American Well, a Boston-based start-up that facilitates Internet-based physician “house calls” went live on Jan 15 with its first customer, the Hawaii Medical Service Association.

The archipelago’s sole Blue-Cross Blue-Shield licensee in turn plans to assure the service is available to every state resident, including those who are uninsured.

The service should appeal to those who don’t want to wait to see a physician or waste time commuting to the doctor’s office. It seems particularly well suited for patients needing medication refills or a look-see following surgery, and for elderly folks who are comfortable with computers.

Hawaii seems an ideal first venue for American Well’s online doctor service because island geography frequently complicates access to providers, and because the state lacks providers in remote areas.

During the encounter physicians can, ideally, access patients’ medical histories. For example, a patient using Microsoft’s HealthVault personal medical record can permit the physician to access the information.

Some worry what will happen because physicians can’t detect or assess physical findings using the new medium, but Robert Sussman has been trying it for awhile and has some perspective.

“It’s a tool to help doctors do better, the way a stethoscope is a tool,” he told the New York Times. “You still have to use your common sense.”

And at times it can facilitate triage decisions better than a phone conversation. Physicians for example, can see whether a febrile infant is lethargic and hence needs to be seen or is alert and thus may not have to come in.

In this post, we continue to summarize key findings from a December report by the Commonwealth Fund on the status of retail clinics in the US. An earlier post on the subject appears directly below.

The most common reason (48%) for visiting a retail clinic between 2006 and 2008 was for diagnosis and treatment of a new symptom or illness. Childhood ailments such as earache, sore throats and upper respiratory infections topped the list.

About half as many (23%) retail clinic visitors needed a vaccination and 14% visited the facility to obtain a physical exam required for school, camp or employment.

When asked why they visited a retail clinic over a traditional care setting, 64% of respondents said the clinic’s lengthy hours of operation were a major factor. Roughly the same percentage indicated that the location was more convenient. The ability to walk-in without an appointment was cited by 53%.

Just under half the visitors to retail clinics cited low costs as a principal reason for choosing the venue, while a third indicated they had no other source of care.

It appears that the brief period of unbridled growth in the number of retail clinics has ended. In the first 5 months of 2008 for example, 70 clinics in 15 states were shut down, and the nation’s largest clinic operator, MinuteClinic, announced it would pare back its expansion plans.

That may be so, but the expanding insurance coverage for services provided at retail clinics and rising problems accessing care at traditional venues assure that these convenient providers won’t be disappearing anytime soon.

In its recent report on the status of retail-based health clinics, the Commonwealth Fund suggests that overall utilization remains low, but a recent slowdown in new openings may disproportionately impact uninsured Americans who lack affordable primary care alternatives.

This post and another tomorrow provide a quick update on key findings from the Commonwealth Fund’s report on retail clinics.

Retail clinics are located inside supermarkets, pharmacies and retailers. They provide simple preventive services such as vaccinations and are equipped to diagnose and treat simple health conditions like sore throats and minor rashes.

They are usually staffed by nurse practitioners and remain open during evenings and weekends. Their fee schedules are easy to see and understand, and they tend to keep prices low. They work almost exclusively on a walk-in basis; no appointments are required.

The number of retail clinics exploded from 60 in mid-2005 to more than 1,100 by mid-2008, but virtually all this growth occurred in the first half of this period.

About 3.4 million families have used a retail clinic at least once. That’s 2.3% of all US families. There are wide variations in retail clinic utilization across states however. Minnesota boasts the highest utilization: 6.4% of families in that state have used retail clinics at least once.

Uninsured families (those with at least one member who lacks insurance) comprise 27% of retail clinic users. Overall, 17% of US families are uninsured, meaning that uninsured families use retail clinics more frequently than those with insurance.

Insured families report that half the time their carriers paid for at least some of the fees they incurred during a visit to a retail clinic. Fully 85% of retail clinics now accept insurance, a marked change from the cash-only business model that dominated just a few years ago.

Nearly 20% of breast cancer patients either delayed radiation therapy or did not finish a full course of therapy following breast-conserving surgery, and they experienced worse outcomes as a result, according to a study in Cancer.

Scientists at Weil Cornell Medical College studied 7,791 patients who were at least 66 years old and had been diagnosed with Stage 1 breast cancer between 1991 and 1999.

They found that 16% experienced a delay in the onset of radiation therapy of at least 8 weeks following surgery, and 3% did not complete a full course of therapy, defined as less than 3 weeks instead of the usual course of 5-7 weeks.

 African-Americans were 50% more likely to delay treatment, and women living in high poverty areas were less likely to complete their treatments.

Women who delayed radiation therapy for at least 8 weeks were 40% more likely to experience a recurrence of breast cancer. Those who waited more than 12 weeks were 4 times more likely to experience a recurrence.

Patients who did not complete their radiation therapy had a 32% higher mortality.

“One of the big problems is that care has to be coordinated to avoid these kinds of delays and lack of completion, especially for patients from a lower socioeconomic status,” study leader Heather Taffet Gold told the New York Times.

That’s easier said than done.

In a survey of chronically ill adults in 8 affluent countries, US patients were the most likely to forego care due to high costs and rate their care as inefficient and error prone.

This according to Cathy Schoen and her team, who surveyed 7,500 adults chosen at random in France, Germany, Netherlands, Canada, Australia, New Zealand and the US. The study was published in Health Affairs.

Participants had at least one chronic illness such as arthritis, diabetes or heart disease. They had rated their health as fair or poor, or reported that they had recently sustained a major illness, undergone major surgery or required hospitalization.

Overall, US patients viewed their health system more negatively than any other country. One-third said it ought to be rebuilt from the ground up and only one-fifth said it worked well. Dutch patients viewed their system most positively, followed by the British, French and Canadians.

54% of Americans reported at least one cost-related access problem in the previous year, such as skipping medication doses, not filling prescriptions and not seeing a physician during an illness. This was highest among the 8 countries.

Only 7% of Dutch participants reported that costs were a barrier to accessing medical services.

41% of Americans indicated they incurred at least $1,000 in out-of-pocket medical expenses in the last year. That happened to just 5% of French and 4% of British respondents.

One third of US respondents reported experiencing a medical error, receiving an incorrect medication or dosage, delays receiving test results or receiving incorrect test results. That was higher than any other country.

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Just when it starts to look like we might finally expand health coverage and access in this country, we get word that 49% of physicians responding to a recent survey say they plan to reduce their panel sizes or quit practice altogether due to poor working conditions.

The Physician’s Foundation sent the survey to 250,000 primary care physicians and 50,000 specialists. It received 12,000 responses.

The results showed widespread frustration—particularly among primary care physicians—due to burdensome administrative responsibilities, reimbursement delays and governmental regulations.

- 94% said time spent on clerical duties increased in the last 3 years
- 63% said this caused them to spend less time with patients
- 82% said their practices would be unsustainable with further Medicare cuts
- 60% said they would not recommend medicine as a career
- 17% said their practices’ financial position was healthy and profitable
- 45% said they would retire today if they could

“Going into this project we generally knew about the shortage of physicians; what we didn’t know is how much worse it could get over the next few years,” said Lou Goodman, President of the Physicians’ Foundation. 

News of PCP dissatisfaction is not lost on students preparing to graduate US medical schools, where only 2% have indicated plans to enter primary care. That’s down from 9% in 1990.

The American Medical Association used this and other data to estimate that the US will be 35,000 PCPs short by 2025.

And strung-out PCPs don’t want to hear it but we’re more likely to empower nurse practitioners, utilize new provider venues like retail clinics and recruit more foreign medical graduates than we are to fix the fundamental issues raised by the surveys.

The Great Economic Crisis of 2008 is taking a bite out of personal health spending, and we’re not talking about Botox and liposuction.

There’s the Texas woman for example, who showed up in an ER with back pain. Physician Doug Curran found cancer on her X-ray. “She’d had a lump in her breast for awhile, but things were tight and she said she couldn’t get it looked at,” Dr. Curran told the Washington Post. “We’re going to see more of that.”

Indeed. The number of Americans that skipped a doctor visit, didn’t fill a prescription and paid for health care using retirement savings all rose this year, according to a survey by Time Magazine and the Rockefeller Foundation. Ten percent of respondents said they had postponed their children’s check-ups during the year to save money.

These trends will worsen as the Crisis drags into 2009. “An economic downturn drives more people to be uninsured,” the New America Foundation’s Len Nichols told the Washington Post. “They lose their jobs, they lose their income and their insurance.”

“Many times in health care there’s a lag of three to six months before it really hits hard, added Donald Fisher, President of the American Medical Group Association who spoke with the Post about health seeking behavior during economic downturns. “If they have a problem, they get it fixed while they still have health insurance. Then we see a decline in elective procedures, and then we really see a drop-off.”

In a stunning policy turnabout made possible by its swollen coffers, China announced that it will cover health care costs for 90% of its population by 2010 and implement universal coverage by 2020.

The plan has global implications given China’s enormous population, its questionable capacity to address epidemics of communicable diseases such as avian influenza and SARS, and its troubled pharmaceutical and food processing industries.

For 35 years after Mao Zedong assumed control of China, the government employed physicians and owned, funded and operated China’s health care system. During this time, China achieved dramatic improvements (albeit from a very low baseline) in life expectancy, infant mortality and other measures of population health.

Then in the early 1980s, in what appears to have been collateral damage from a larger effort to privatize its economy, China essentially dismantled its health care system overnight, replacing it with nothing. Central government spending on health evaporated, leaving overwhelmed provincial and local authorities to coordinate care, physicians to fend for themselves and normal citizens with no choice but to pay for health services out of pocket.

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Revered health care economist Victor Fuchs has said that America will never achieve serious health care reform until there is a depression, a war or civil unrest.

Well, we’ve pretty much hit the trifecta in 2008, and it’s an election year no less. We might just be staring at the best opportunity in generations to overhaul our cockamamie health care system.

That’s the conclusion of Dr. Ezekiel Emanuel, Chair of the Department of Bioethics at the National Institutes of Health, whose editorial on the subject appeared in last week’s Chicago Tribune.

Emanuel argues that people are desperately concerned about financial security, and to achieve that we must control health care costs. As for businesses, things have gotten so bad lately that that tens of thousands of them, big and small, will be wiped out if they can’t off most or all these costs, and soon.

And whether Republicans like it or not, a new era of interventionist government has arrived. In fact thanks to recent (and necessary) interventions by a Republican administration, you and I now own US banks. We own insurance companies. We own mortgage lenders like Fannie and Freddie, and we may soon own housing securities.

Now to be sure, even the most radical single-payer plans do not suggest that the US government should own health care in the same way. No one proposes that we employ physicians or that we own hospitals, drug stores and pharmaceutical companies, so let’s knock-off the scurrilous, fear-mongering rumors that comprehensive health care reform means socialized medicine.

In one day a few weeks ago, US politicians committed $700 billion to shore up the banking system. It would take about a third as much to overhaul the US health system so that it covers everyone while delivering a higher level of quality than it does now. The upfront spending would include IT platforms and quality measurement systems that position us to save hundreds of billions of dollars down the road while continuously and forever improving health system performance.

Has anyone proposed legislation that could do this? Actually, yes. The Healthy Americans Act (S. 334), also known as the Wyden-Bennett health care bill  has bipartisan support and is awaiting action by the Senate Finance Committee. It calls for more sweeping changes than the plans proposed by either candidate for president.

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Thanks to an acclaimed state initiative, 439,000 more Massachusetts residents have health insurance now than in 2006. Ironically however, many of them cannot find a doctor.

Massachusetts didn’t have enough primary care doctors to begin with, but the flood of newly insured people means that Bay Staters have to wait as long as 100 days to see a PCP. Those who have urgent problems or who are OK seeing a nurse practitioner can get seen sooner, but others have resorted to ER visits, which is what they did before they obtained insurance in the first place.

Legislators have approved many new laws to alleviate the problem. One allows UMass Medical School students to waive tuition in return for a promise to work as a PCP in the state for four years. The state has also agreed to repay medical school loans for PCPs who work in underserved areas for two years. Inexpensive housing loans are also available for PCPs in the state.

Unfortunately, these “initiatives have a long lag time,” says Bruce Auerbach, President of the Massachusetts Medical Society. Auerbach believes that increased payment and reduced administrative burdens would more effectively address the state’s PCP shortage.