This is an archived article that was published on in 2013, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.

It annoys me to no end whenever I hear economists talk about healthcare as if it's a commodity.

They seem to think that if healthcare costs patients nothing, we'd all be lined up for appendectomies the way we line up for iPads. The truth is that cost, while major, is only one factor in access to care.

For many, geography correlates far more with what kind of care they get than health insurance status. As someone who has lived and practiced almost exclusively in large urban centers where sub- sub-specialization is standard, it was sobering to see what healthcare is like for the millions of Americans who live in rural, underserved areas.

While on vacation near what the guide book asterisk noted was "the most remote place in continental U.S.," we met an older couple from the area. They told us how, when they needed specialist care, they twice had to drive several hours each way to be referred to a shoulder surgeon for rotator cuff repair. First a doctor, then physical therapy and, finally, surgeon referral.

When the couple finally did see the surgeon, they were surprised to find it was merely a consultation. So they had to return yet again for the actual procedure.

"It took us four trips!" she said. "I thought, 'Do you know where we live?'"

No, we don't, is what I realized.

I could explain to them why no surgeon would operate on someone, sight unseen, without a consultation. The specialist might disagree that surgery is needed, or think a different kind of surgery is necessary, or appraise surgery as too risky, or decide that more testing might be needed to determine the above.

But still. For all our talk about patient-centered care, our system is not set up to accommodate these patients. We ask them to drive hours, wait in the office for our appointments to get the short consultation.

They likely have to spend the night in distant places and drive home, then come back a week or two later.

Who could possibly manage that much time off work, that much money on hotels and restaurant meals, that much travel when you're not feeling well, even if you are insured?

The Mayo clinic has a model for delivering quaternary-level care for complex patients. People fly from all over the world to Rochester, Minn., or the other Mayo locations, and upon arrival they receive an itinerary centered around getting their entire workup in the same trip. People do not fly in for a consultation only to fly back a few weeks later for the procedure or tests.

The kind of care that is delivered in Salt Lake City to residents from places like Elko Nev., or Idaho, Wyoming and southern Utah — places where our patients have to drive for hours on slippery roads in wintertime snow, would benefit from a similar patient-centered program.

If you have to drive more than one hour to see doctors, perhaps all your visits could be coordinated in that one- or two-day visit. If a procedure might be needed, you can see the specialist one day and schedule surgery the next. If the surgeon wants you to see a cardiologist or pulmonologist first, do that on the afternoon of the first day.

This type of patient-centered service requires the kind of coordination of care and providers that we are already aspiring to.

Perhaps thinking of our rural patients can help all of us get there sooner.

Denitza P. Blagev is a pulmonologist in Salt Lake City, where she blogs at