WHEN THE AFFORDABLE Care Act was implemented in 2014, “We realized a lot of people were going to get insurance, but that didn’t confer access to care,” Dr. Laurie Green said. “You would get a ticket, but that didn’t mean there’d be room in the tent.”
But Green had her eye on a way to address that problem.
As one of the first woman OB-GYNs in tech savvy San Francisco, Green had many patients who were starting to talk about the potential of telehealth. As a member of the Harvard Medical Alumni Association, she was part of the nascent virtual health delivery movement and interacted with physicians who launched providers like MDLIVE that offered access 24/7 to medical and behavioral health care.
“There was recognition that in health care, not every patient needed to be seen in person,” Green said. “Especially for populations underserved, to have to go through all the steps to see a doctor, when something could be managed remotely? Who knew the pandemic would strike and make telehealth foundational?
“Remember, this was pre-Zoom. You could phone or email a doctor, but facial expressions matter and a voice is helpful, and when we can both see and listen to a person, it makes all the difference in the world for understanding how sick they are, what help they need, and what their diagnosis might be.”
The force of developing technology, along with health care inequities exacerbated and amplified by COVID-19, coincided with Green’s awareness that a bountiful supply of highly-experienced, retired physicians interested in keeping skin in the game was available to a health care industry relying more and more on physician’s assistants (PAs) and nurse practitioners (NPs).
The result was MAVEN Project, a telehealth service founded by Green expressly to serve the complex patient cases found in remote rural or underserved inner-city communities.
Demand for health professionals rising
“I’ve always enjoyed thinking what might come next,” she said. “When I entered the practice, there was no such thing as shared decision-making with patients. But I learned by listening to patients, to what people want and need. That has caused me to think about innovations in medicine.”
MAVEN — which stands for Medical Alumni Volunteer Expert Network — set out to address what had been estimated by medical experts and scientific researchers would be, by 2025, a shortage of approximately 35,000 primary care doctors and 60,000 specialists. The project uses telehealth, videoconferencing and phone calls to connect volunteer doctors with health providers in underserved communities in 26 states around the country.
Three programs constitute the suite of services: medical consultations offered to frontline providers from expert, veteran physicians; a weekly educational learning video series that allows providers to ask case-specific questions; and one-on-one mentorships in which seasoned physicians contribute private, specific advice on everything from job stress to patient communications. MAVEN volunteer physicians must be licensed and insured, and they are individually vetted for compliance and suitability before joining the team.
One such physician is Berkeley-based pediatric neurologist Dr. Jean Hayward. Retired after 31 years with Kaiser Permanente, the roughly two-hours-per-week contributed to MAVEN is vastly easier than her previous 60-plus-hour work week.
“Pediatric neurology is only a small pocket of the medical world, so there’s less demand,” she said. “What is the satisfaction? It’s fun. I enjoy the puzzle of how to put a solution together for each patient. I hope to provide the medical professional onsite a little training at the same time. It’s intellectual, like doing Wordle. The consults ask what seems like a simple question, and I tailor the answer for each one. I hope the child will benefit from the information.”
“We need investment in teams, advanced clinical education and early intervention with children to limit later, negative outcomes. Honestly, we need all hands on deck.” Laurie Green, MAVEN Project founder
Most often, the issues about which Hayward consults involve headaches or seizures. The patents are frequently uninsured. Many are immigrants who come from countries where medical records are sketchy, or non-existent. “Here in the United States, we’re looking at lab results online before we even see the patient,” she said. “With MAVEN, the group (PAs and NPs) asking questions might not even have background information or not have as much medical training or have seen less pediatric cases than a resident.”
Diagnosis on the run
Recently, a patient with a gait disorder provided extra challenge, even to a doctor like Hayward with decades of experience. She restated the problem for the provider and sent her best advice, then went for a run. “A lightbulb went on and I realized what the condition could be. I wrote back a second response.”
Hayward said the lack of young physicians in the pipeline speaks to the entire U.S. health care system. “I’m 67. With my generation of physicians retiring, they will need to replace each of us with two.”
She said the old system was based on working 18 hour-days, then crashing at home to rest, and returning to work shorter, seven-hour days.
“It was unhealthy for physicians and for patients, and errors occurred.”
But newer, current “shift care” that regulates the hours and number of days a physician works also reveals flaws. “Doctors don’t see the evolution of process, the development of a condition. When the day is over, it’s over. We need more medical schools, medical systems that expand cognitive horizons, more providers who have PAs and nurse assistants qualified to fill the need for front line care.”
Beyond those measures, Green sees a need for even more radical change.
“To improve access to health care for underserved communities, you have to dial back to things that are really upside down, like food insecurity,” she said. “Even in San Francisco, 25 percent of the population is food insecure. Why is colorectal cancer on the rise, especially in minority communities? It’s high-fructose corn syrup that changes the human biome. It’s the reliance on over-processed foods. There’s the misconception that people of limited means will eat only garbage food. But there’s a fascinating study showing that if healthy choices are bundled with prices on them, people buy them because they avoid the embarrassment of running out of money and having to put it back on the shelf.
“We also put things in the health care bucket that are in the social service bucket in other countries. Medical education is free in those countries too. We need investment in teams, advanced clinical education and early intervention with children to limit later, negative outcomes. Honestly, we need all hands on deck.”
Looking ahead to artificial intelligence
For now, though, in terms of recruiting volunteer physicians, MAVEN is a resounding success. By starting with alumni medical associations and asking them to spread the word, a “giant community” revealed itself, according to Green. MAVEN offers credentialed experts trained to address the unique needs of underserved populations in 43 specialties, among them, the four most requested are dermatology, endocrinology, cardiology, and rheumatology. Green says they are often the most complicated conditions to diagnose. Contributing to the complexity, patients who have delayed care due to travel distances, work hour conflicts, or being uninsured, frequently appear in emergency rooms or community health centers in critical condition and multiple illnesses.
Moving forward, the use of artificial intelligence (AI) is most intriguing for Green. “That’s an area where we will have a role. You can look up a medical answer in ChatGPT, but if it isn’t accurate in medicine — we know AI can hallucinate — it can be deadly. We’re looking to how we will make sure answers are accurate. We definitely have a role in AI amplification.
“Psychiatry and addiction medicine is another area where primary care providers must learn how to recognize conditions and help patients. We have a team that can help primary care providers to practice at the top of their license and do the best for their patient population in AI (development) and these top-need specialties.”
In a state like California that she says believes in self-determination, the future for the best health care system will nevertheless require teamwork.
With assistance for accountable care organizations from networks like MAVEN, costs are reduced, quality improves and patient-satisfaction increases. Notably, advanced digital services must never abandon the importance of front-line physicians actually touching and seeing patients.
With real-time, expert angels on their shoulders, Green said the primary medical workforce can practice at the top of their humanity and their licenses.