by Kenneth Lin, MD
You’ve probably had the experience of going to see a primary care physician and wondering about the many aspects of that visit that just didn’t make sense.
Why is it so important for me to arrive on time when, in reality, I won’t be called back until half an hour (or more) later? What’s the point of waiting for another 20 minutes in a chilly examining room for the doctor to show up? Why does my doctor always seem so rushed? And most importantly, why do they always insist that I come for an appointment for a minor problem that could just as easily be handled by phone or e-mail?
Two articles in the issue of the journal Health Affairs provide outsiders’ perspectives on these issues. The first article, an anthropological “field study” of three general internal medicine practices, describes the primary care experience as separated into three “social silos,” consisting of physicians (”the frantic bubble”), practice staff (”the flexible team”), and patients (”in limbo”). As I’ve described previously, family physicians often feel as if they’re behind from the get-go:
Their days began with a review of what we dubbed the “fictive schedule,” in which the physicians would grab a printed schedule or look at a monitor and see a long string of 15-minute appointments stretching through the morning. They would tap a pen down the list and mutter something like, “This one will take at least half an hour,” or “This one’s a real nightmare …” In addition, many unscheduled patients would need to be “fitted in” to these already tight schedules. The fictive schedule showed uniform, precisely measured blocks of time. The “real” schedule in physicians’ heads was informed by their knowledge of their actual patients.
The authors go on to observe that little or no time is scheduled for already-harried physicians to perform all of the other essential tasks that go into running a practice.
The second article takes the perspective of a Martian (one wonders if the editors who designed this theme issue of the journal recently read neurologist Oliver Sacks’ classic An Anthropologist on Mars) who concludes that primary care physicians’ time would best be spent on longer, “necessary” in-person visits, defined as:
1) for a first visit
2) when it may be necessary to engage in some physical maneuver for diagnostic purposes
3) for specific therapeutic purposes, such as injecting a joint
4) when the patient has problems for which lengthy discussion would be helpful
5) when for psychological or emotions reasons it seems better to see the patient face-to-face
6) when face-to-face visits are necessary to build trust
Even with longer appointment times, the author points out, physicians would still end up with additional time in their schedules to devote to coordinating staff activities (such as health behavior counseling) and supervising population-based preventive health and chronic care improvement activities.
The primary obstacle is that a practice redesigned with these principles would rapidly bankrupt itself, since traditional health insurers almost uniformly pay only for in-person encounters with physicians and do not pay for health education delivered by non-physician staff.
Only integrated health systems such as Washington State’s Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn’t been easy.
Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.
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{ 23 comments }
The only way to “pay” for this type of system is as in Group Health a self-contained cost structure where services rendered are costs rather than sources of payment. In this type of system the opposite incentive is in place, provide the least care, or expend the least resources to provide the care in the most efficient way in order to keep the dollars already spent for health care. Individual practices simply cannot take the risks of full capitation. Some day the US will likely have a national system that looks like Group Health. It’s nickname in the Pacific NW is “Group Death.” I don’t agree with the implications of this, but many patients feel they lack access to in person care, to a primary care physician, and face long delays. The same complaints as in Canadian type systems.
1) It doesn’t have to be either/or. In NZ we have a large proportion of our income capitated and charge the patients a small copayment (eg $20-30) for a visit.
2) Has anyone noticed that the patients who complain the loudest are the ones that arrive with the biggest list of things that they want all attended to in one visit?
Dr. Lin’s remarks are very timely and illustrate the absurdity of the way we practice. A reasonable capitated fee is necessary to improve Primary Care. It could be in addition to fee for service, or a larger sum which would include all services. This would cover reimbursement for emails, increased care-coordination, phone calls, forms, refills and possibly extended hours. I would favor setting aside these dollars from the insurance premiums and letting the patients choose where to spend them.
I personally have experienced exactly what was described, “Why is it so important for me to arrive on time when, in reality, I won’t be called back until half an hour (or more) later? What’s the point of waiting for another 20 minutes in a chilly examining room for the doctor to show up? Why does my doctor always seem so rushed? ”
I don’t like it. I recognize that there are things that some times are going to take more time than expected. But I believe id the Doctor experienced the same when he/she went to a business for a service. They would be complaining to management about the value of their time and very up set. A patients time is valuable to the patient and his employer. Medical practice today is to money motivated.
Our present system rarely compensates providers for being punctual, but neither are patients successfully penalized for being late or not showing up for an appt. There is no incentive for punctuality. But it isn’t as if docs want their patients to wait, to be cold and to be fuming mad when they start the encounter.
Also, there often isn’t more compensation for time spent on patient paperwork, laundry lists of questions, what they saw on TV, what was done elsewhere and about medications and other bureaucratic issues.
It’s got to be money motivated, or it won’t survive. A splinter removal generates more RVUs (insurance reimbursement) than your average primary care visit! If people don’t like the waiting times because doctors squeeze in patients, they need to talk to their representatives about changing reimbursement models.
Not surprisingly, there is a bit of a money issue. If you see a coupla pts in the morning and a few in the afternoon and give them superb, patient-centered care, with all the time they want, so that you can answer every single little single question they might have, and then perchance you can answer a few emails from the worried well in a dignified and unhurried fashion and putter with the computer a bit, well sir, at the end of the day you will be puzzled and disappointed to find that you have not earned enough money to pay even half the utility bill, let alone the bill for your brand-new state -of -the -art EHR, or your own salary and benefits and those of your employees.
America, if you don’t want to be treated like cattle, kindly pony up the $1000 per year or so and get a concierge doc. Or have the government raise your taxes so they can pay family docs enough to think that they are not damned fools to get into the field in the first place. Otherwise, take a number and clap your trap.
In the same vein, every primary care physician who complains about medicare/private insurance hassles and low reimbursement should “clap his trap” and become a concierge doctor.
As indeed many are. See below posts….
I’ve been with a concierge doc for three years. Reading this post takes me back to why I made that choice. I experienced every single one of the visit issues the author describes.
I got the straw that broke the camel’s back after a serious illness in which my former PCP sent me to a hospital where he had no privileges and never called my spouse or me (or the doctor into whose care he signed me off) to see how I was doing. Upon my discharge, the hospitalist and specialist both told me I had to see my PCP within 7 days of discharge and get some follow-up tests. The only way I could even get in was because I demanded it and they worked me in (which meant an hour’s wait). His panel had 5,000 patients.
My concierge doc is signed on with my insurance for the purpose of making specialist referrals, but otherwise the fee covers all visits. No visit is less than 30 minutes, and the annual physical is a couple of hours because we go over everything in detail and do all the preventative tests. I can reach him or his nurse any time of day or night by cell, text, or email, which saves a lot of time and anxiety on minor matters. There are no barriers between staff, doctor, and patients.
In short, it’s everything medicine should be, and the fee is very reasonable. If it were much more, honestly it would be a hardship, but I think my doctor has priced his services reasonably for the community in which I live.
Something–in this case, more time with your un-harried doctor–that is better costs more. This fact seems obvious to most authors (and readers) of this site.
And in real-life, higher cost for higher quality is assumed.
But this truism is not so in health care in America today, for a too-numerous-to-list number of reasons. I hope that the simplicity of the tenets of concierge medicine take hold. It would be good for all, patients and doctors alike.
Wow, sounds great.
How much is the yearly fee and what do you think is the panel size of your concierge doc?
I have a frail old man in the practice. Unfortunately, he comes to be accompanied by several very strange daughters. I tend to dread the appointments. Old man is fine, it’s the daughters. I do my best with them.
Thing is, he came to me from the VA system. ( for benefit of New Zealand reader, VA = Veteran’s Administration ). He’s a WW-2 veteran. Daughters did not like large, impersonal government-run healthcare.
Veterans use their VA healthcare to a varying degree. Most don’t use it at all. Some, with true service-connected disease, use it extensively. My father, also a WW-2 veteran, uses the VA as a giant pharmacy. Goes to the VA for an annual checkup. Otherwise, he gets nearly all of his care privately. Doctor at VA simply approves what private doctor did, and my father gets a free second opinion, certain preventive checks for free, and free medicines for a year. Everything else, he pays privately. This frail old man in my practice, he chose to get 100% of his care at the VA. It’s free, but disadvantage is impersonal cattle-car atmosphere, and good luck getting any acute care done if a problem comes up. “Our next opening is in three months, see you then.”
So, they decided to send him to me. I’m private, solo, independent primary care. I see him on average about four times a year. He gets an acute problem, he gets seen.
Now, the people who complained about impersonal treatment, now complains about my wanting to see him more frequently (four times a year?). Since last visit, three new issues, five questions, I want an extra visit or two to sort things out.
They resent it.
“Why do you want an office visit just to refill Dad’s prescription?”
“Because I didn’t prescribe this. It was prescribed by the doctor at the hospital, when your father was admitted for a new problem. I’d like to make sure the medicine is really helping, that it’s enough, that you’re not having side-effects. No, I didn’t see your father at the hospital. You admitted to a hospital I don’t work at, it’s convenient to you, but far away from me, and more to the point, I didn’t know he was in the hospital in the first place. No one told me he was in the hospital. Staff at hospital probably had no idea who his primary care doc was in the first place, as you didn’t tell them. They don’t read minds. So in addition to everything else, I’d like to see you, and the records I now know to search for, to make sure I know what happened to you in the first place, and make sure…….it’s better, being treated properly, make sure you even need the medicine in the first place. Sometimes I get asked to refill medicines a doctor did not intend to use for a long time. Short steroid bursts and ophthalmic steroids come to mind.
They resented it.
The “inconvenience”, despite their hovering over their father (is it just a show for me? They can hover here as well as at home.). Maybe they resent the Medicare copay, with their private cover, and their Medicare, their out-of-pocket is less than the New Zealand numbers described.
Of course it’s not fair to say it applies to everyone, but I sure do see it a lot. They come to me from the VA, from the city and county health department, large clinics set up for the poor, Medicaid, uninsured. The public clinics locally are actually quite nice, superficially. Big, clean, spacious. But still, a cattle car atmosphere.
So they come to me for more personalized attention. Telephones are answered, phone calls returned, time taken to explain things. The basics.
And then they resent paying for it. And I’m not describing astronomical fees, this is primary care. The big box places charge far more than me, and I’ve seen their fee schedules, having worked at some of them.
So, only a limited amount of sympathy.
Very well said ninguem. People will pay for haircuts and smokes but think your time and effort should be free to them.
The future is clear to see. We ain’t seen nothin’ yet as regards “inconvenience.” The PCP shortage is starting to bite big time. Five or ten years from now it will be much worse, and pts will be incensed by the cost and ineffectiveness specialty care. They’ll look back at this decade as the good ole days. The new PCPs and a few well heeled pts will be livin’ the good life in the world of concierge, and it’ll be the cattle call for the rest.
We told you so, America.
At this point, my PCP is more of a referral service. I haven’t ever had a PCP that helped me live the good life-OK in my twenties I had a great GYN. There aren’t any good ol’ days for me to be nostalgic about.
One word, HJ: concierge.
I don’t understand # 6 on Dr. Lin’s article: “6) when face-to-face visits are necessary to build trust.”
Aren’t many visits required to build the “necessary trust”? Doesn’t transfering care to another person like an NP damage and somewhat negate the need for that trust in the physician, and create a need to trust the mid-level practitioner? Lastly, if #6 were carried out appropriately, would it truly free up any time from the physician?
“……Only integrated health systems such as Washington State’s Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn’t been easy…..”
Does Group Health’s data actually support this statement? At least with regard to cost savings?
http://www.kevinmd.com/blog/2010/06/medical-home-save-primary-care-money.html
Some years after the whole delivery model implodes, some ivy league school will do a ’study’ and begin promoting the novel idea of a well-trained generalist physician….
What if docs had posters on their waiting room walls: 1) “The real cost of treating diabetes for a year is $___,” with a rough breakdown of that cost. Likewise for other chronic conditions.
This should probably be #1–a statement of my philosophies about healthcare availability, such as “I believe everyone deserves BASIC healthcare.” And/or “I have care plans suited to those with chronic conditions, to adults who are generally in good health and to those who have an acute episode, such as an accident or injury, and children ages birth through 18. Ask at the front desk for details. You will receive a written care plan from my triage nurse or nurse practitioner. Be assured, however, that I am always ready to individualize your care”.
2) There are more basic ways of taking care of your health than taking medications. There is prevention and there are lifestyle changes. The real cost of medical care for a person taking care of their health in a personally responsible way is $___- ___(this is a range). (Rough breakdown includes a yearly visit to your doc, the cost of vitamin supplements, the cost of a good pair of walking shoes and weekly healthy grocery costs for a family of 3. Or whatever else the individual doc would like to see on this list, such as gym membership.
3) The “basics” are these things: _________. For a child: _________. For my older patients: ________(Patient education.)
4) These cultural practices can undermine your health: _____. (Individual doc fills in the blank with such things as “fast food,” “x-amount of alcohol,” “sitting in front of a screen–TV or computer–for x-number of hours/day,” “recreational drugs,” etc.)
5) Insurance costs and reimbursements are NOT in line with real costs. Negotiate with your insurance company, altering your plan for your individual health needs and means, and consider direct payments for basic care (concierge plans) with catastrophic coverage from insurance companies.
6) As a primary care physician, I am altering my relationship with insurance companies and hospitals in these ways:
________________ (i.e., use of hospitalists, relationship with Medicare/Medicaid, # of minutes per visit, communication via phone/email v face-to-face visits, health coaches/triage nurses will contact you, “medical home” practice, etc.).
7) Don’t count on either insurance nor government plans to safeguard your health and address your needs. Take personal responsibility for your health.
I’m an internist, in the process of leaving my clinic practice at Kaiser for a more doable job in long-term care. I have been running my IM practice at Kaiser very differently than the norm as described by Dr Lim above, for the past 3 years. I have based my practice on the medical home and what I perceive health care to be like in Sweden. I start with my day’s schedule (and upcoming days and weeks’ schedules) and scrutinize each appt and what i know about each patient, and determine if an MD-level appt is truly needed or not, in my opinion. For those that are not needed in my view (approx half), I have a skilled triage RN with a flair for this type of work, call those folks and say that I asked her to call to get more info. I outline some options for the RN to offer (RN & MD advice with MD appt in few days if no imorovement), direct-access PT, redirect to the specialist they’ve already
seen for same issue, etc). Thus about half or more of my appts are handled this way. I see about 6-8 pts per day and spend the rest if my worktime doing emails with pts (20-30 per day) and discussing test results with pts either via written comments or email. I have 1400 pts, 80% of whom are avid emailers. i have shifted all the non-MD work, including appts that don’t need to happen, to other team members. My quality scores are among the top 10% in Kaiser nationally, and my patient satisfaction scores are 89% delighted or more. It has all been working brilliantly. Problem is, the folks who run the insurance side of Kaiser are not supportive of doing things this radically, and I have to beg for the level of RN support needed for doing things this way; there is no system-wide cultural support for me, I’m considered “ahead of my time” and there is resentment amongst team members for my shifting work to them. There is no actual time carved out of
my day for me to do emails with 80% of my patients, the
expectation is that i will get it done on my own time in the evenings. Doing tjings this way works great if I am on top of things 24/7, but if I take any time off, it all becomes nightmarish and not doable once again, like for all my colleagues all the time.
I have been a patient at Mayo Clinic Primary Care in Jacksonville for about 8 years. I have only on very, very rare occasions had to wait for my physician. The majority of the time he is in my room within minutes after I undress and is apologetic if I have to wait five minutes for him.
I will say however, that it is made known to you that you are expected to arrive on time for your appointment and if you are late, your appointment will be cancelled. C’est la vie. It happened to me once, I got stuck in traffic, was late, and that was life, I rescheduled. They were very nice about it, but it’s my responsibility to be on time an appointment time is not a suggestion.
nguem: I think the answer is- go work or the VA. The pay differential is not that much between private and va docs and benefits are good.
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