Evanston RoundTable, Nov. 21, 2024

Editor’s note: The first part of this series explored the supply-and-demand dynamics that help explain difficulty accessing doctors nationwide, and the concerns of local patients and physicians. This part looks at some initiatives underway to remedy the problem.

That it is increasingly hard to access doctors for even acute conditions is widely acknowledged as one of the most pressing problems of our health care system. Many experts say a shrinking physician workforce, combined with increased demand from the aging baby boom population, create something like a perfect storm of conditions that prevent people from accessing practitioners in a timely fashion.

“If there’s a suspicious mammogram and you’re worried it might be cancer, waiting six weeks? That’s a serious problem for sure, not what we would hope for families,” observed Dr. Gaurava Agarwal, vice president and chief wellness executive at Northwestern Medicine and associate professor at Northwestern University’s Feinberg School of Medicine.

So what can be done?

Home-based care

Dr. Mustafa Alavi, who is co-site medical director of Erie Family Health Center in Evanston and second vice president of the Illinois Academy of Family Physicians, said more innovative approaches are needed. One such approach is returning to the age-old practice of seeing patients at home, which is enormously helpful for those unable to get to a doctor due to infirmities and other problems.

Alavi referred me to the website of In-Home Physicians, one of 17 Illinois medical practices that in 2022 joined together in the Illinois House Call Project, a three-year effort “building on their track record of caring for the state’s most vulnerable residents — homebound adults with chronic conditions.” As of July 2022, the website states, “nearly 200,000 residents who require home-based primary care (HBPC) are not receiving this critical medical service.”

Another organization, the Home Centered Care Institute based in Schaumburg, provides primary care training and support for doctors who visit patients at home. According to HCCI’s website, the organization has trained 3,200 professionals and supported 1,000 practices across all 50 states. Its mission is to “address the unmet need of over 5.9 million people in the U.S. who are homebound, home-limited, or living with serious illness and do not yet have access to best practice house call programs.”

“Home-based medical care has been shown to be one of the best care models for keeping medically complex patients out of the hospital,” HCCI President and Chief Operating Officer Julie Sacks told me. “It improves health outcomes and reduces the overall cost of care.”

Getting patients to doctors can also be a challenge. Thanks to a grant from Uber, Alavi said, Erie is now using the ride-hailing service to transport patients to the Evanston clinic.

Care as close as your phone

Telehealth can also help patients access care. “I’ll do a phone call visit to check on diabetes care, monitor blood pressure problems and address hypertension issues,” Alavi said. “Patients appreciate the service. And we’re finding more and more ways to utilize telemedicine to tackle chronic health conditions.”

Another innovative approach is a concierge-type model for accessing care, known as Direct Primary Care. In DPC, patients pay by the month, quarter or year rather than by the health care episode. “This fee covers all or most primary care services, including clinical and laboratory services, consultative services, care coordination, and comprehensive care management,” the American Academy of Family Physicians website says, also noting that the typical monthly fee ranges from $20 to $49 for children and $50 to $100 for adults 65 and under. Alavi called it an alternative to the traditional fee-for-service billing model. “Some people refer to it as a concierge model for primary care,” he said.

Alavi said there are also training programs designed to encourage residents to go into primary care. One is The Teaching Health Center Graduate Medical Education program. The center’s website says it “helps communities grow their health workforce by training physicians and dentists in community-based settings with a focus on rural and underserved communities. This unique training model changes the physician training paradigm by providing the majority of training in community-based outpatient settings where most people receive their health care.

“The program aims to increase physicians and dentists trained in community-based settings, improve health outcomes for members of underserved communities [and] expand health care access in underserved and rural areas.”

AI at Endeavor

Endeavor Health is also exploring and implementing artificial intelligence to improve medical outcomes. Leading the system’s AI program is infectious disease specialist Dr. Nirav S. Shah, along with Dr. Nadim M. Ilbawi, a family medicine physician who is also on the innovation team.

“AI is a tool now being integrated into health care nationwide and here at Endeavor in a variety of ways,” said Shah, “including note-taking in the doctor’s office; identifying risks of disease; helping practitioners make real-time recommendations and informed decisions to optimize patient outcomes; as well as improve early disease detection.”

Added Ilbawi, who leads the “ambient documentation” initiative at Endeavor: “Ambient AI is a tool we use to listen to the conversation between clinician and patient at the doctor’s office to parse out non-clinically relevant information and create a note that goes into the patient’s medical record. Documentation is one of the leading causes of burnout among physicians nationwide, so this program promises to help facilitate accurate and efficient note-generation so clinicians can focus on connecting with the patient and their care.”

Another innovation, online portals, has become something of a two-edged sword. These portals give patients a fast way to text their health care providers, and have been in place nationwide for many years, according to Advanced MD. But when the pandemic reduced or eliminated visits to doctors’ offices, portal volume soared, slowing response time and creating additional communication burdens in doctors’ offices.

“Since COVID, demand for medical advice through NorthShoreConnect [Endeavor Health’s portal] has nearly doubled for some clinicians,” said Ilbawi. “There has been a tremendous increase in NorthShoreConnect messages. When patients can’t visit their doctors, they write in, which results in doctors spending extra hours every week answering questions and addressing concerns. It becomes a bit of a chicken-and-egg problem, but this additional in-basket volume adds to non-patient-facing work.”

A hot topic in medical circles is physician burnout, with practitioners cutting hours or exiting the field altogether, which since COVID has worsened the current shortage of doctors. “When health care workers are feeling burnt out, the implications are serious for the health care system,” said Northwestern Medicine’s Agarwal, citing increased medical errors and lower patient satisfaction.

He referred me to a 300-page report titled “Taking Action Against Clinician Burnout” published in 2019 by the National Academy of Medicine, which promotes a holistic approach to improving clinician well-being. The report urges health care leaders “to prioritize the creation of positive, healthy clinical work and learning environments in all settings, and thereby mitigate clinician burnout and foster professional well-being across all disciplines.”

“At Northwestern Medicine, we recognized the importance of our workforce’s well-being even pre-pandemic and have been on a journey to provide a superior work environment that promotes well-being,” Agarwal told me. “We believe three solutions are key: developing wellness-centered leadership, promoting high-functioning teams and integrating technology to remove administrative burden. These solutions enhance the inherent meaning and purpose clinicians find in serving their patients.”

Medicare for All?

Might universal health care in the U.S. also help? Evanston resident Dr. Peter Gann is a member of Physicians for a National Health Program, which supports a Medicare-for-all approach, a single-payer system “similar to what many other developed countries have,” he said. “That would give us the opportunity to change priorities, by bringing more people into primary care by allowing more autonomy. It would work such that there wouldn’t be an intermediate insurance company that has the ability to deny the test or drug you ordered.”

Many studies show that the U.S. health care system itself is not very healthy. Americans pay far more for health care but have far worse outcomes than people in other developed countries.

A recent report from The Commonwealth Fund that compared 10 developed nations found that “The U.S. continues to be in a class by itself in the underperformance of its health care sector.” Though the United States spends more than 16% of its gross domestic product on health care, far more than the other nations studied, the report noted that “life expectancy is more than four years below the 10-country average, and the U.S. has the highest rates of preventable and treatable deaths for all ages.”

“Our health care system is built to generate profit, not to help people,” Gann told me, describing it as “a sickness system, basically, not a health care system.”

(When I point out that universal, government-supported health care — so called “socialized medicine” — in countries such as Canada and the United Kingdom has been historically associated with extensive delays in accessing care, he replied that the U.K.’s National Health Service is a different model than Medicare for All would be in the U.S., since the British government not only pays for health care but also employs the practitioners. In any case, he claimed, the English, Canadians and residents of other countries with universal medicine “would not trade places with us.”)

I put it to Gann bluntly: Is the U.S. health care system in crisis? Do we need shock therapy like socialized medicine, which would be hugely controversial given the embedded interests of hospitals and insurers to maintain the current system?

“I think we’re on the brink of an implosion, frankly,” he replied. “We’re looking at a shortage of primary care doctors, particularly with the aging of the baby boomer generation, where needs are going to increase dramatically. It wouldn’t surprise me at all if we start seeing more efforts by doctors to unionize, to try to improve conditions. I believe we are looking at a very, very serious possibility of a major crisis. Morale among health care workers now is lower than I’ve ever seen it. It’s very scary.”

To test how scary the situation is, I tried scheduling a visit with my longtime internist for a persistent and potentially serious problem. How soon could I get in to see him? Not long at all, as it happened: just three hours!

Turns out I had lucked into a late cancellation. Better yet, my prognosis was fine. But had I been referred to a specialist, I might have a different story to tell, the same as the many others who experience long, frustrating and sometimes alarming delays.