Primary Care Dystopia

January 19, 2030

Whitney Payson, a 50 year-old-man, comes to an urgently scheduled visit with a general internist. He has two concerns. The first is a cough that has persisted for the last month after an upper respiratory infection. The second is a 3 cm adrenal lesion that was discovered on the screening MRI that he had the week prior.

The doctor, Frank McGraw, fresh out of his two year medical school curriculum – a shortened curriculum championed by one Vinay Prasad – and an 18th month primary care, internal medicine residency – approved urgently by the ABIM in 2027 when not a single IM resident entered primary care – interviews and examines the patient. 

He finds him to be well, with scant expiratory wheezes on his lung exam. He diagnoses him with post-viral reactive airway disease and prescribes a combination long acting beta agonist/corticosteroid inhaler. At the patient’s insistence, he also orders a chest x-ray, which is, of course, normal. (He has trouble saying no to patients, probably related to the fact that his abbreviated training only included six clinic sessions.)

“What about the adrenal lesion?” asks Mr. Payson. “The MRI interpretation suggested removal.”

“Mr. Payson, you must know that insurance doesn't cover me consulting on ‘non-symptom connected problems.’ If you want my input, there is an extra fee — I can actually do Apple Pay right in the room now — or you can use our free AI consultant. If you go ahead with a resection of the adrenal lesion, you will be responsible for the cost of the procedure and any downstream costs — unless the pathology shows that the tumor was life-threatening.”

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January 10, 2032

“Mr. Payson, I haven’t seen you in a couple of years, what brings you in?” asks Dr. McGraw.

“I’m so glad you could see me doc. I’ve had some belly pain for the last two days. I’ve had no appetite either and I’ve been throwing up all day.”

“Have you been moving your bowels? Have you passed gas today?”

“I haven’t had a bowel movement in a few days and, come to think of it, I haven’t passed gas since yesterday.”

A brief physical reveals fever, tachycardia, and a tense, distended abdomen. 

“Mr. Payson, have you ever had abdominal surgery?”

“Yes. After I saw you last, I had surgery for the adrenal lesion. It turned out to be benign, thankfully.”

“OK. I'm pretty sure you have a small bowel obstruction. I'm going to send you for an x-ray to verify the diagnosis and call one of the general surgeons. Assuming I'm correct about the diagnosis, she'll take you directly to the operating room.”

“I was kind of expecting this was something serious. Do you think I'll do okay.”

“You should do fine. The only problem is this is going to be very expensive. Because this is ‘more likely than not’ to be a result of a non-symptom connected problem, the evaluation, procedure, and all postoperative care will be an out of pocket expense…”

“Huh?”

“This small bowel obstruction is a late complication of the surgery you had for the adrenal lesion, which you only had because you paid for an MRI.”

“Oh, I get it. That’s OK. After the surgery my wife convinced me to buy supplemental insurance that covers 80% of the downstream costs of any non-symptom connected healthcare that I purchase. I’ve been trying to convince her that we can’t afford the policy, along with our regular health insurance, but I haven’t gotten my act together to cancel it yet.” 

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February 2, 2035

“Mr. Payson, what brings you in?”

“I took an Uber.”

“No, I mean why are you seeing me?”

“Well it's been a couple of years since I saw you and I just feel like I should have a good going over. I've been putting it off because it took a while to pay off the bowel obstruction surgery. Even 20% of the cost was quite a hit. We had to drop the supplemental policy.”

“Yes, I'm sorry. The rules regarding non-symptom connected care are very stringent. They date back to the “Mandrola Laws” that went into effect on January 1st 2030. The insurance companies, Medicare, and Medicaid were really struggling to pay the downstream costs of all the senseless screening tests that people were getting. The laws were controversial at the time but, I have to say, they have had their intended effect. Most people are now very conservative about medical testing.”

A history and physical examination are unrevealing. 

“Well you're definitely looking good. Given your age I'd recommend a colonoscopy, prostate MRI, blood work, the Shingrix vaccine, and your 27th covid vaccine. Irrespective of test results I’ll also prescribe you a statin, a GLP-1 RA, and metformin. Are you okay with that?”

“I'm not sure, that sounds pretty expensive.”

“No worries, since all of those tests have an A, B, or C rating from the USPSTF, and the medications an A or B rating from the USPTTF, they are all fully covered.”

“What about a screening stress test?”

“We still don’t do those.”

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February 6, 2040.

“Whitney, how are you today? Can you believe we’ve been seeing each other for 10 years? I never thought I’d last this long in primary care. I owe my longevity to the “Cifu Rule” that guarantees that primary care visits will be at least 8 minutes long — not including time spent discussing the cost of healthcare.”

“Dr. McGraw, I'm a mess. I had a screening MRI and there's a 2 cm pancreatic lesion. The AI read says there is a 40% chance it's an adenocarcinoma and a 45% chance it’s an IPMN. There's no evidence of lymphadenopathy so if it's an adenocarcinoma, the reading says it is resectable.”

“That's going to be a tough call about what to do.”

“But what do you think?”

“You know the rules, I can't counsel you on a non-symptom connected problem without an extra fee. What I can tell you is that if you go through with a Whipple and the tumor turns out to be malignant you will be reimbursed for the cost of the procedure. Obviously, in that case, downstream treatment costs would be covered too. If it turns out to be benign, though, you will be stuck with having to pay for the surgery.”

“ Yeah, I already read up on this a bit.”

“One thing I can suggest, without getting into trouble, is that we do a hemoglobin A1C today. If it's elevated, then insurance will pay for your insulin post pancreatectomy even if the pathology is benign. Of course if the A1C is normal, and the pathology is benign, not only will you have to pay for the surgery but you'll have to pay for the necessary insulin and pancreatic enzyme replacements for the rest of your life.”

“That makes sense. I am so appreciative of your insight and honesty. I guess I'll hope I have diabetes now and go into the surgery hoping this turns out to be pancreatic cancer.”