The $40 Call

One of  the local HMOs has been heavily advertising their nurse practitioner diagnostic line. It caught my attention because the radio ad was focused on wood tick season, and it suggested the diagnosis and treatment of Lyme disease could be rapidly made over the phone and that it could require e-mailing in a picture of the rash or tick.

I used to teach a course in medical diagnostics and diagnostic reasoning and one of the examples I used in that course involved expert diagnosis of rashes from photographs.  An important part of medical diagnostics is pattern recognition. There is probably no better example than the diagnosis of rashes and it should not come as a surprise that experts in rashes or dermatologists do a much better than physicians who are not experts. That is true both in terms of making the actual diagnosis and in the total amount of time that it takes to arrive at that diagnosis.

When I heard about this new service to diagnose Lyme disease based on photographs I went to Medline to see if I could find anything written about it. Managed care organizations and HMOs frequently advertise the fact that they are evidence-based organizations. I really cannot find any studies done on using the Internet or telephone consultation for the diagnosis of rashes or Lyme disease.

I think that this new service has implications for how the business models are impacting the practice of medicine. With all the talk about transparency it would be useful for the public to know the false positive and false negative rates for this diagnostic service. That certainly would be consistent with the literature on the misdiagnosis of Lyme disease.

From a purely economic perspective, it is interesting that the cash charge for this service is on par with the most common cash charge for seeing a psychiatrist in person. As I have previously posted, there is a wide range for the psychiatric charge and it is conceivable that this telephone service generates considerably more cash than a psychiatrist does sitting in a clinic, seeing patients, and doing all of the associated administrative work.

The next logical step for this telephone service is to have patient's complete a number of rating scales and be treated for depression. Whether it is Lyme disease or depression the diagnosticians with the greatest pattern matching and pattern completion capabilities are taken out of the loop.

George Dawson, MD, DFAPA