Don’t blame the patients for long wait times

Dr. Anthony Youn, a plastic surgeon practicing in Detroit places most of the blame for long office waiting times at the feet of the patients themselves. He comes up with three general categories; patients who arrive late for their appointments, emergencies that require the physician to leave the office, and “oh by-the-way” scenarios:

“Here is a typical scenario: It’s the end of a 10-minute office visit, scheduled as a follow-up for high blood pressure. It’s been 12 minutes, the patient has her prescriptions, and the visit is concluding … The doctor begins to open the door and step out. ‘Oh, doctor, by the way, I forgot to tell you. I had chest pain last night and passed out in the bathtub. And I have bloody diarrhea.’”

Yes, patients can and do many wondrous things. If they did these things in a professional role we would call call their behavior negligent, manipulative, deceptive, non-compliant, selfish, entitled, in-denial, aggressive, and incompetent. But they’re not professionals. They are flawed humans in a very vulnerable and dependent situation in their lives. I don’t expect perfect behavior from my patients. Despite numerous appointment reminders and rules and requirements posted throughout the office there is a constant number who arrive late and forget to bring their medications. This is the nature of the game and is unlikely to change anytime soon.

Don’t blame the patients. Blame the system. A key point in the example above is where Dr. Youn mentions “a 10-minute office visit”.  Think of all the services that take longer than 10 minutes; ordering a meal, getting your car washed, any auto repair, pet grooming, cosmetology, any financial planning, and any legal consultation.  Only in this wacky system of ours is something as critical as health care expected to be squeezed into a 10-15 minute office visit.

At least for primary care providers the main reason that patients are shoehorned into 15 minute slots throughout the day is because of the way we are reimbursed. The vast majority of payments are made only at point-of-care meaning that we only get paid while in the same room as the patient. In that 15 minutes we are expected to perform a proper history and physical, determine the appropriate treatment plan, write prescriptions, order tests, provide explanations and counseling, and thoroughly  document in detail the entire encounter.  Yea, it’s stupid insane.

Actually, the vast majority of instances where I get behind seeing patients is not at all due to late arrivals or “oh by-the-way” scenarios.  It’s because what was supposed to be a straight forward visit for medication refills becomes far more complex. A patient with significant risk factors for heart disease need not wait to the very end of the visit to throw a monkey wrench into a delicate schedule. “Yea doc, I had some chest pain when I was mowing the lawn last week” at the very beginning of the visit is all it takes. Then a brief routine visit to monitor chronic hypertension becomes a frenzied acute care evaluation that includes an EKG, chest Xray, lab orders, additional medications, and an urgent referral to a cardiologist. And the day can be ripe with many other varied scenarios that require far more time than the paltry allotted 15 minutes.

So why not just increase the time allotted per patient? See fewer patients per day? Sure, except that health insurance still pays the same for a 30 or 60 minute visit as it does for a 15 minute visit while the overhead costs remain the same. For an independent primary care practitioner this is just not a realistic option if they want to avoid a further decrease in their income and risk the very real possibility of going out of business. The additional stress, responsibilities, and economic uncertainty of owning their own practice is what has lead more and more physicians to become employees of corporate clinics and practices. But salaried physicians have even less ability to change the scheduling and reimbursement structure of their practices.

The most elegant and obvious solution comes to us from practitioners who have converted to concierge medical practices where patients contract with a provider by paying a flat annual fee in return for unlimited visits and office services. Contrary to claims that physicians are only after more money, the conversion to concierge practice model is almost always done to reduce the demands of 15 minute patient visits while maintaining income. Typically concierge physicians reduce their patient panels from several thousand to only a few hundred and increase allotted patient visit times to 30 or even 60 minute slots. Additionally, concierge practices expand the amount and number of services provided to patients that are simply not reimbursable under the traditional insurance model such as 24/7 direct phone contact to a physician and email and other forms of electronic communication.

While some patients pay upwards of $10,000 – $20,000 per year for these practices it’s becoming more common to see concierge practices change as little as $800-900 per year. The question then becomes, why won’t Medicare, Medicaid, or private insurance companies adopt this reimbursement model if it can improve time spent and overall service for patients? Is it simply because it’s more expensive? Medicare currently reimburses physicians the equivalent of about 1/3 of the annual cost of cable TV for the typical patient with multiple medical problems. Is this a case of being truly too expensive for a $650 Billion per year Medicare program that pays physicians to care for complex elderly medical patients far less than what most Americans pay for cable TV? Seriously?

Or is it because a concierge practice model has not been proven to improve health outcomes and overall patient care? While there is no direct evidence that concierge medicine provides better care there is plenty of evidence that primary care in the traditional model leads to both better outcomes at reduced costs! If we extrapolate this to longer visit times and better access to and communication with providers , there is every reason to expect even better results under a concierge model.  And since when did Medicare start caring about paying more for services without proven benefits? Currently Medicare reimburses surgery performed with robotic assistance several times more than it provides for traditional surgery despite the almost complete lack of evidence that robotic assistance significantly improves outcomes, reduces complications, or reduces long term costs.

This is in keeping with Medicare’s tradition of lavishing reimbursements on any and every newfangled invasive high-tech procedure to come along for specialists while leaving primary care in the dust. But of course, Dr. Youn being a plastic surgical specialist would know all about this.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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  • NewMexicoRam

    Sorry, but the most common reason I get behind are patients who are late.

  • Joshua Dawalt

    Great blog and very well put. We have become brainwashed into believing we need to see 30-40 per day in order to be considered a valued doctor. All I know is that 30-40 is a number and has zero value in the health of an individual nor the physician’s abilities.

  • http://warmsocks.wordpress.com/ WarmSocks

    You said, “health insurance still pays the same for a 30 or 60 minute visit as it does for a 15 minute visit while the overhead costs remain the same.”
    This is just not true. Insurance payment for office visits varies greatly, and it’s directly tied to how complicated the doctor claims the visit was. Level 5 visits pay more than level 1 visits. They don’t pay five times as much, because doctors are not paid by the hour, but if you are getting the same amount for a 15 minute visit as for a 60 minute visit, there is something wrong with your office procedures.
    As for the remainder of your analysis, consider that the reason 15-minute med checks get longer is that patients don’t know the rules. Nobody tells us how to play the game. There’s never any “Welcome To The Practice” brochure to let patients know that there are different types of visits and that insurance does not pay by the hour, but according to the type of visit. I believe that many patients would respond favorably if someone would bother to explain the system.

    • NewMexicoRam

      If a doctor doesn’t know how it works (as you are claiming here), then how are they going to explain it properly to their patients?

      • http://warmsocks.wordpress.com/ WarmSocks

        I wasn’t saying that the doctor doesn’t know how the system works, only that what he stated about payment is inaccurate. I don’t make any claim to knowing why he was inaccurate. Maybe he doesn’t know, but it’s also possible that he intended to say that payment for one 60-minute appointment is less than the sum of the payments for four 15-minute appointments. True, but not what he said.
        Or maybe he’s had instances of only getting paid for a 15 minute level-2 visit when the patient was really there for a whole hour (but the doctor only billed for a level-2 visit). The short-term solution is for the doctor to figure out how to bill that visit at a higher level so he gets paid for the complexity of the visit.
        I honestly believe that patients would respond favorably to knowing how the system works. When making appointments, we would be better able to articulate the purpose of the visit. We would know that if we have two separate issues to discuss, we need to book a double-appointment (and might need to pay a second copay), and that it’s due to the insurer’s rules, not because doctors want it that way. We would recognize better how a medical office works, and be able to conduct ourselves in a manner that didn’t typically make our appointments run longer than scheduled. We might even be more understanding when the doctor is running late.

        • rswmd

          You don’t know what you’re talking about.

          Under most fee schedules, a doc is paid for a 60 minute visit less than half what she would be paid for four 15 minute visits. Actually, the best thing for the doc to do financially is not see any patients at all and just supervise medical assistants doing 99211s. That pays way more than a 60 minute visit.

          It’s against all contracts to collect two co-pays from one patient on the same day, so you’re stuck with a 10-15 minutes visit.

          The system sucks. Deal with it.

          • http://www.capko.com Laurie Morgan

            It seems to me that warmsocks is at least partly right — he/she isn’t saying “adjust the schedule and take more 60 minute visits,” just that it’s not true that a physician will never be paid more if the visit is 30 minutes than if it’s 15. Your point about double copays is of course correct (although perhaps warmsocks meant that the patient would have to come back on another day?), and of course there may be modifiers that reduce the reimbursement for the extra service, but if a longer, more complex visit occurs than was planned, there is often some way to get additional reimbursement.

  • JPedersenB

    I left one practice because the doctor was always 1-2 hours late. In one case, all the examination rooms were filled and the doc was talking with drug reps…

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    As a general internist we used to see 15 patients per day in the late 1970′s early 1980′s. That was until the insurance companies kidnapped the patients and the profession and sold the patient panels back to the doctors and hospitals at 75 cents or less on the dollar. The consultants followed with the suggestion to see more volume to make up the difference. Each year you added 3 patients per day per year to stay in the same place as insurers ratcheted down payments and increased overhead with additional bureaucratic rules to get the care done. The solution, add more patients per day.
    Doctors fall behind because patient problems do not fall into 5, 10, 15 or 20 minutes schedules. Sometimes the acuteness of an issue or the angst it is causing the patient require attention. Doctors fall behind when a nurse calls with a question about a patient in the hospital or when a colleague collaborating with you on a patient’s care calls with a question or to discuss the case. Doctors fall behind when their stomach rumbles and they need to take an unscheduled bathroom break. Doctors fall behind when their life partner or child calls with a problem that requires immediate attention and will not wait until the end of the day. Doctors fall behind because the need to schedule so many patients into such short visits doesnt work and is insane but is required to meet overhead and follow the business plan created by insurers who own the patients. Yes sometimes patients late arrivals and needs cause delays but if the schedule had built in slack or down time for this it would be far kinder to the patients and the practitioners

  • rswmd

    Don’t blame the docs, don’t blame the patients. Blame the system.

  • Peggy Zuckerman

    Few patients probably realize that their appointment is a 10 minute event. Fewer patients would think that having two issues–in the same body!–should be handled in two separate appointments, as Warm Socks says, “We (doctor and patients) would know that if we have two separate issues to discuss, we need to book a double-appointment”. Since when do symptoms or chronic conditions present themselves in neat boxes?

    Patients do not understand the rules, since they have never had a role in making those rules. Being excluded from the creation of the system which they support may be a root cause of much of the dysfunction that exists in the medical system. Let the patient be part of the system, not just a party to be acted upon, as their will be a better outcome for all.