Are Apps, Not Humans, Making Your Specialist Referrals?
The QC (quality control) deficiencies frequently appearing in our consumption-driven economic system have insinuated themselves into the health care marketplace. And if you’re wondering why this matters, it raises the essential question of continuity and reliability of primary and specialist medical care. Are recommendations for each individual’s ongoing healthcare based on his/her medical history? Are they subject to any genuine QC? Or are they more of a knee-jerk by a digital algorithm without that analysis of medical history and other pertinent patient data?
Simply stated, it goes like this. Patient takes a blood test or other diagnostic test, and primary care practitioner lists questionable or incorrect diagnosis. Computer algorithm picks up diagnosis, automatically generates inappropriate referral, then schedules appointment with specialty without informing patient. Neither algorithm nor any human picks up the faulty diagnosis based on that blood test. It’s simply passed-over — and monetized by the for-profit system.
Because I know all the details with certainty, I’m using a personal example, making it unnecessary to cite hearsay experiences of friends or acquaintances.
My latest annual blood test data showed that I had a slight deficiency of lymphocytes (a type of white blood cell) in what’s known as a differential count. The clinical terminology is lymphopenia. But amid the throes of the confusion and overwork of a pandemic, my primary-care practitioner (PCP) had a brain fart and entered the opposite — lymphocytosis. Too many lymphocytes. I caught the error because some app chewed on that diagnosis and spat out a snail-mail referral to oncology, providing a phone number and instructing me to schedule an appointment. An appointment that made no sense. The concern in this situation is that too many lymphocytes might signal lymphoma, a type of cancer. After two email exchanges, the PCP admitted that brain fart and apologized profusely for hastily entering the opposite of the correct diagnosis.
Should’ve been the end of it. But not when a piece of software is playing the role of deus ex machina. Not only had it knee-jerked the referral, but it had scheduled an oncology appointment. Without informing me. Moreover, without any entity — human or machine — checking the appropriateness of the entire process.
Only reason I discovered that oncology appointment was a system-generated email instructing me to check the insurer’s online portal, in order to fill out a questionnaire about COVID-19 before showing up at the hospital cancer center. What the email did instead was to alert me to an appointment I had no notion of. And for which there was no biomedical reason.
Trying to shield the PCP from reprisals, I simply canceled the oncology appointment online. I was fairly sure that the initial diagnostic error was precipitated by a system that squeezes PCPs by overbooking patients into skinny 20-minute time slots. It’s likewise a system regularly unable to sustain adequate levels of primary care. Because multiple local insurers divide up the available PCPs into their usually non-overlapping private networks. And because the system tends to overwork and underpay the individuals it places into those primary-care positions. There’s been plenty written about the unwillingness of newly minted MDs to enter primary-care family medicine rather than pursue a more lucrative specialty like dermatology or cardiology. As usual in a for-profit system, money talks loudest. It also illustrates the recently prominent awareness that the most essential workers are often paid the least. Tiers of managers paid progressively more than in-the-trenches workers. Specialist physicians paid far more than their primary-care counterparts.
Despite my understanding of the strictures under which PCPs function and my desire to protect this practitioner, I also felt the need to post this short piece to inform readers that the types of algorithms being used in this arena may well not promote the QC essential for quality healthcare. And frankly, I take umbrage at being manipulated by a digital device whose understanding of my physiology is rather obviously inferior to my own.
And yeah, I’m a cell biologist who’s taught extensively — to pharmacists, nurses, pre-meds and pharmacology grad students — in most areas of human physiology, particularly immunology and (ironically) oncology. So I was able to navigate through these murky waters and set things straight. But had I been a more typical patient in my age range, I’d have undoubtedly suffered a ton of anxiety — cancer! — and been poorer by a $50 specialist copay. And have wasted my time and unnecessarily exposed myself to infection by keeping that oncology appointment at a hospital during a pandemic.
Moreover, I was initially reluctant to post this story. Let sleeping dogs lie. But about a week after I canceled that oncology appointment, I received a phone message from an RN telling me that they’d scheduled ANOTHER ONCOLOGY APPOINTMENT, one I was forbidden to cancel online; I would need to call them. My immediate reaction was, to say the least, “fuck this!” My more important reaction is connected to the confirmation that there is, indeed, no QC. No one has bothered to check the reason for the diagnosis, which would immediately inform them of the reason I canceled the initial oncology appointment, i.e., there isn’t any lymphocytosis, no reason to suspect cancer.
I am now largely convinced that getting me in for a high-copay, high-Medicare-reimbursal specialist appointment is and has been a prime motivator of my “healthcare” system’s MO. Then again, as I alluded to earlier, what can one expect from a market-based economy fueled by product/service PR that is so regularly hyperbolic, so frequently flat-out mendacious. And sure, I’ll be ditching this insurer come October . . . if I can find a primary-care doc who’s accepting new patients. But can I really anticipate that it’ll be better somewhere else? I’m not nearly that naive.
A final, but certainly not the least important issue is the use of patient feedback by practitioners. In theory, the patient is one source of data in diagnosis. So it’s important to understand that practitioners who develop a knowledge of their individual patients will be well-informed as to the reliability of each patient’s feedback, based on both a particular individual’s knowledge and expertise and their emotional responses to illness. When I was a kid with a solid family-physician relationship, this was indeed the model. In today’s rushed-for-profit, ultra-fragmented system, I see far too much evidence that many docs don’t care enough about or don’t have time to consider their patients’ perceptions of their own health.
This entire system seems to be structured as theater pretending to be genuine healthcare, camouflaging its primary function of profit-making. Managerial-class efficiency and profit optimization, sure. But good for patients? Imagine the most scornful laughter you’ve ever heard. And please spare me the American-exceptionalism angle, which insists that the U.S. has the world’s best healthcare. Because if you subscribe to that delusion, you’re living in a reality that hasn’t existed for at least a century. If it ever existed at all.
Moreover, simply transitioning to a single-payer system like Medicare-for-all isn’t going to rectify this type of shortcoming. Not without a concerted effort to do so. The entire beast needs to be restructured. And only removing the profit motive will allow that. Healthcare as business, healthcare as human right: as incompatible as two electrons occupying exactly the same quantum orbital in an atom.
