by Richard Reece, MD
I would like to introduce you a remarkable article by Edward J. Volpintesta, MD, a 65-year old solo primary care doctor in Bethel, Connecticut. Dr. Volpintesta is a veritable writing machine and has been published in The Wall Street Journal, the New York Times, medical journals, and other publications. His articles cry for a deeper understanding of primary care dilemmas.
In the October issue of Connecticut Medicine, Dr. Volpintesta hits the primary care dilemma on the head by simply recording a “typical day” in his office, in this case, a “half-day,” lasting 9 hours. The power of his entry is the simple recording of events of his day – including details of 7 office visits, 9 telephone conversations, and reviewing, signing, or taking care of some 25 documents, faxes, referrals, and other paperwork.
What struck me about his chronicle is how many of his activities were non-reimbursable. In Denmark and other countries, these activities tend to be reimbursed through a combination of management fees for serving a patient panel, fees for responding to telephone calls and emails, and fee for-service during office visits. Not being paid for telephone calls, which can take up to one-third of a doctor’s time, is a particularly egregious example of what should be paid for any reform measure to have impact in the clinical trenches.
Keep in mind doctors like Dr. Volpintesta are the workhorses of our health care delivery system. These physicians, which deliver most of initial care in this country, are generally in independent practice, are underpaid compared to specialist peers, represent a threatened species, and are short by 50,000 doctors, scheduled to reach 160,000 in a decade.
I have long maintained pundits like myself and health reformers in Washington should spend a day in the office of busy solo practitioner. Only then can we begin to appreciate travails of primary care – the hours spent on such non-reimbursable activities as paperwork, phone calls, and prescription writing and renewals.
These activities require knowledge possessed only by the physician. In my opinion, these activities, because of the time and know-how required, ought to be reimbursed. That would make primary care more rewarding and would close the satisfaction and monetary gap between primary care and specialty care.
The next big health reform crisis will be lack of access to primary care physicians. This will occur when 78 million baby boomers turn 65 in 2011, and, if and when, Obamacare reforms propel 25 to 30 million uninsured into the market in 2012 or thereabouts.
Primary care doctors, already overworked, will be swamped, and waiting times to see doctors will escalate. Waiting times have already grown to twice to three times the national average in Massachusetts, now three years into its universal coverage plan.
Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.
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{ 9 comments… read them below or add one }
Obamacare, the cure, may be worse than the disease.
Dr. Reece certainly points out clearly one of the many significant problems in the provision of health care. It seems that the demands of primary care providers steadily grows as the rewards steadily diminish. I believe many of the problems of health care could be greatly lessened with significantly better pay for the primary care provider, whether it be more for the services performed now or whether pay for presently unpaid services, such as use of email or telephone consultations. Personally, I believe that phone and email provision of services should be reimbursed. There are a few companies that do so now.
Is it possible to post a link to the original article?
Thanks
Also, 78 million baby boomers will not turn 65 in 2011.
The only voice for primary care physicians that will be heard and acted upon will be footsteps of those leaving practice.
Expect more federal expenditures with no real cost control or improvement in the practice hassles for PCP’s. The solution will be more corporatization of medicine. Walmart, or its equivalent will come to the rescue and offer “health care for less” – outsourcing and all.
The cure will not be worse than the disease, but we may need a second cure soon after the first.
We should outsource diagnostic radiology and use that money to support primary care doctors. Diagnostic radiologists are over paid anyway.
I don’t know how much longer you can expect primary care physicians to stay in practice.
Two trends are:
Insurance companies constantly reducing compensation (they all do it, but GHI, United Healthcare and Blue Cross are the worst). This leads to physicians having to take on greater patient loads and having less time to evaluate and treat patients. Patients can help by either switching to private fees, a better insurance plan or having a written list of issues ready for the doctor. This trend also makes the physician the chaser of payment, a very bad use of precious resources. Insurance companies have been saying recently that their profit margins come out to only 2-6%, this is an attempt to mislead. The companies pay out 100s of millions to billions in compensatio to their executives and then give their shareholders paltry returns of 2-6%. Their profits are in the 30% area and don’t let them mislead you. Also the executives taking huge amounts of compensation is a problem throughout all public companies, not just healthcare, and so you should be very careful investing your money/
Government constantly adding requirements that all sound nice on paper but the government never provides funding for those requirements. This means that physicians have to expend more time and money to comply.
There is the constant fear among physicians that one mistake/bad outcome can ruin the physician’s career forever. This is a real and palpable fear and a problem for a physician which almost no one who is not a physician is aware of or relates. The trial lawyers will throw out figures which say that judgements in malpractice are small compared to total healthcare expenditures. What they fail to mention are all the settlments that are done so that physicians or insurance companies avoid going to court. Also they fail to point out how much weight and damage the fear instilled by malpractice lawyers and malpractice insurance does to the psyche of the physician.
There is an upper limit to how many patients a day we can see and provide quality treatment. Once you cross that 8 minute per patient line there is a severe reduction in quality. Primary care physicians have not choice, they must see a patient every 8 minutes to pay for all overhead.
The rest of the day is uncompensated work like dealing with 20 refill requests + 5-10 prescription adjustments due to patient wants cheaper med since insurance won’t pay for the one prescribed, 4-5 clearances (usually on an immediate need basis since the patient makes the appointment with the specialist and then informs that they need clearance tomorrow), 25 diagnostic reports (labs, radiology and specialist consults), 4-5 discussing abnormal results and the usual 10 “I would like to talk to the doctor requests”.
PP
You nailed it. Primary care practice is on it’s death bed. It takes me 8 hours for uncompensated administration work for every 40 hours of patient care. Requests for disability and power wheelchairs that require multiple forms and letters. We need to move to charging for our time involved in nonclinical tasks and stop giving out tine away.
I also think PC is in a death spiral. A lot of people don’t realize how much tougher it has gotten in terms of the paperwork. Twenty years ago, when I got our of residency, my clinic’s pt population was much younger and healthier. Not much paperwork. The old and sick increase our administrative burden exponentially and the population is aging. Also, with medical progress there is more to be done on each pt.
I read a comment on the internet a couple months ago by an Oregon ER doc, something like ” if you’re smart enough to get into med school,how could you be stupid enough to go into primary care.” Harsh, but some truth to it.