No Substitute For Time

In his second installment in a series that originally appeared on KevinMDDr. Stephen Schimpff discusses the ways in which primary care physicians adjust their workflow in order to compensate for insufficient time.

By Stephen Schimpff, M.D.

Previously in this continuing series on primary care, I described a patient with a straightforward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, no resolution of her symptoms and no physician exploring the underlying causes of her symptom – guilt related to a family issue. Why did this happen? Because the doctor had only 15 minutes, not enough time to listen, think or delve into her psyche.
 
Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. For years, Medicare has reimbursed at a low rate for regular office visits to a primary care physician. Commercial insurance follows Medicare’s lead. Reimbursement rates have remained fairly steady for a decade or more – though Medicare has now begun to raise rates as a result of the Affordable Care Act – but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding staff, accounting and legal needs, malpractice and disability insurance, health insurance for the staff, supplies and rent and utilities for the office.

With costs rising and income steady, the doctor tries to make it up with volume. This means seeing more patients per day, usually about 24-25, often more. In order to see that many, the doctor no longer sees patients in the hospital or emergency room and has shortened the time per visit — most about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat test, a blood pressure medication check or diagnosis and treatment of Lyme disease. But it is not enough time to deal with a more subtle problem. It’s not enough time to explore the family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness.

The situation is compounded when the doctor has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses such as diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis are difficult to manage, persist for the patient’s lifetime and are expensive to treat. These patients need close attention and often need a team approach to their care. The diabetic patient, for example, will need an endocrine consult, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist at the least.

Every team needs a quarterback, and this should be the primary care physician. But here again, care coordination requires time. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total health care system perspective, this is critical because chronic illnesses consume 75 to 85 percent of all claims paid by insurers.

Many doctors take action by sending the patient to a specialist. According to the Archives of Internal Medicine, about nine percent of all doctor visits result in a specialist referral, much higher than necessary. This is up from about five percent a decade earlier, with 41 million referrals per year as compared to 105 million in 2010.  The push for accountable care organizations, medical homes, population health and a switch from fee-for-service to a salaried or capitated system are noble, but unless the doctor is given time, and enough of it, these changes will prove valueless.
 
Meanwhile, fewer medical school graduates choose to enter primary care. They are smart and see that doctors are busy and frustrated. They know that given the doctor’s average income, it will take many years to pay off their high educational debt load. Doctors are looking for ways out of this dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital, but the hospital wants the physicians to earn their keep. This still means 24 to 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, government insurances (Medicare, Medicaid) or the Affordable Care Act. It will come from the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care.

To start, many doctors need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technology. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some doctors have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection, they can charge a reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or a set amount for all care for the year. In each of these models and others, the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and begins to ask questions and in general bring down the costs of care, all while receiving a higher level of quality, greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by doctors today to overcome the current non-sustainable business model so they can not only give better quality of care but also reduce their sense of frustration and increase their patients’ satisfaction.
 
Stephen Schimpff, M.D., is former CEO of University of Maryland Medical Center and the author of The Future of Medicine – Megatrends in Health Care and The Future of Health Care Delivery - Why It Must Change and How It Will Affect You. This post originally appeared on KevinMD and then his own blog.

Further reading on the "seven-minute visit."
Posted by Sonya Collins on Jun 17, 2014 9:36 AM US/Eastern
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