The healthcare landscape has changed over the last 20-25 years.  Primary care physicians used to manage overall patient care, coordinating with specialists for care that was outside their training and expertise.  Now, it seems that the primary care physician sees the patient a few times a year and might even request labs or perform a well-exam.  These exams have been greatly watered down over the years due to government red tape, ill advice from the U.S Preventive Services Task Force and declining reimbursement.  What used to be a true 40-minute history and physical has become a 10-to-15-minute checklist of things that the patient’s insurance company will likely reimburse the physician for providing.  The list of what won’t be done is longer than the list of things that will be done.  For specialty care, I notice that patients are increasingly arranging for care on their own, which often leaves the primary care physician out of the loop.

Primary care physicians used to have a trusted network of specialists to whom they could refer for evaluation and management of concerns outside of the primary care physician’s scope of practice.  A simple phone call once served as an introductory transfer of the patient from primary to specialty care.  Progress notes and polite thank you notes followed upon returning the patient to the primary care setting.  Today, insurance regulations and paperwork have become the primary focus, while the actual diagnosis and treatment of the condition(s) have become a distant secondary focus.  Medicare starts something and commercial insurers follow their lead, whether the policy is beneficial or harmful to their beneficiaries.

Referrals can be difficult to obtain, even for large academic medical centers.  In certain instances, the return of the patient to the primary care setting is delayed or halted altogether, with the specialist’s employer or accountable care organization assuming the role of the primary care physician.  Communication between offices has become something of a nightmare due to absent consultation notes in the patient’s chart.  In years past, referrals could be arranged quickly and easily.  The tides have changed over the last 20-25 years, with referrals becoming increasingly more difficult to obtain.  Due to insurance participation/non-participation, arranging referrals may take quite a while, and the patient’s condition might have worsened during the waiting period.

It is the author’s belief that the healthcare system is still recovering from the COVID-19 pandemic.  Preventive care was delayed to re-focus on the medically complex.  Patients who were not taking an active role in their care are now of higher acuity and require more resources to return to a more optimal state of functioning.  Referrals to specialists in large healthcare systems are still being impacted to due continued care for those medically complex patients who never fully recovered during the pandemic.

Referrals can be hard to come by, even in large cities with more than one major healthcare system.  Timeframes to obtain referrals varied for the author: 2 weeks for urology; 2 months for otolaryngology; 4-6 months for pulmonary evaluation after 1 round of COVID-19 and three rounds of pneumonia; 9-12 months for cardiology; and 24-36 months for a routine colonoscopy with gastroenterology.  For three of the above referral requests, the author was told there just weren’t enough good providers in San Antonio to see all the patients.  That waters down the prospects of finding a great provider to treat one’s medical conditions.

Is this the best we can do?  Is the status quo good enough?  While I share the same sentiment as my cardiologist and pulmonologist, “Healthcare as we once knew it is dead,” I say that we can do better, and the status quo isn’t something we should brag about.  While I’m grateful for the providers on my care team, I am disappointed that the healthcare system has changed for the worse.  I see patients being treated like numbers rather than human beings, band-aids being applied until the next care episode arrives, less emphasis on preventive care and fewer people taking part in their own care plans.  Will healthcare return to the glory days of 20-25 years ago?  Probably not.  However, I believe that if enough patients and providers start protesting the state of the current system, we could return to a better state within the next 5-7 years.

By Scott J. Grandjean, LFACHE