Paying for primary care – side effects


Category : Medical Rants

Recently I visited my octogenerian parents. My mother was gushing about her new internist. She told me that he takes the time to sit down, talk and listen. She told me that he is really a good doctor.

I love my mother, and I suspect that the physician is quite good, but she really gave me no information on which to make an independent judgment. She based her opinion (it seemed to me) on his bedside manner and her perception that he devoted enough time to her concerns.

My mother is not alone. As I have conversations with friends and relatives who are not medical professionals, I hear similar endorsements often. Patients want a physician to listen to their concerns. They want explanations.

Our current system of paying for primary care does not reward this activity. Now those who love to attack our lack of a health care system in the US may interpret the previous sentence as a criticism of US health care specifically. But I meant the criticism to include Canada and Great Britain (the two other systems that I understand the best.)

The attribute that many patients value the most runs counter to any system which encourages (or demands) that physicians see more patients to make more money. In essence these systems do not value physician time, but rather value throughput.

The natural side effect of these payment systems is to shorten visit time. If you are paid for the total number of patients in your panel, you will try to increase the number of patients, and limit their visits (both in number and duration). If you are paid by the visit, of course you will do your best to shorten visit times.

We know that shortening visit times must impair quality. Now I am using the term quality in a larger sense then the bean counters. For my mother, quality starts with a physician who sits and converses. For me quality implies that the physician has enough time to think about all of the patient’s issues and how they interact.

This side effect explains the appeal of retainer medicine and cash only practice. In these new systems, the physician can charge for his/her time. The patient can pay for more time. Both patients and physicians have a higher probability of satisfaction.

Medical students and residents understand these issues – even if they do not usually explicate the details. They do not view primary care choices positively, because of the dissonance between how one should practice primary care and what the payment system imposes.

This problem is not specific to primary care. Hospital medicine has a similar issue. I have had hospitalists tell me that they really should not follow more than approximately 17 patients each day. Yet many hospitalists will see more patients, and I suspect care suffers.

While I have not read all the presidential candidates plans for health care reform, I wonder if any of them are addressing this issue. They are worried about insuring the entire population (a worthy goal) but unless we have enough primary care providers, what value is that insurance?

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Comments (7)

Good point. I was a more than a little surprised to find the American Cancer Society will be spending its budget on promoting politically correct universal coverage, not antismoking or other lifestyle changes to promote a healthy lifestyle. The Mayo Clinic has also jumped on the band wagon.

I wonder who will take up the cause of promoting an increase in generalist?

Steve Lucas

OK, I agree with you on this one 100% (it does occasionally happen). As of now we are torn between the business case (seeing 40 pts/day) and the compassion and good care of our patients (seeing 15). I am hopeful that the political pundits actually do seem to realize that primary care is a good thing and that it also is an endangered profession. Will that translate to good change for us? Well, trusting a politician is bad enough, but trusting a bunch of them is even worse.

I moved to another state, found, on the recommendation of my doctor, a family practitioner and saw him initially for a small problem. He really was very nice, took care of the problem very well and efficiently without seeming to rush me. But he didn’t seem at all interested when I offered to get to him (by paying for them myself) my previous medical records. That worried me.

Actually, we DON’T know that a longer visit is better than a shorter visit; we just think that it ought to be because it “sounds” as though it should. I know a doctor who is famous for his 2-minute visits who is trusted and beloved by his patients. As for the other comment about the physician who was uninterested in “previous medical records”, that’s because he’s not going to look at them–so why bother receiving and filing them in your patient chart. He’s going to look at HIS chart. No physician wants a new patient to show up with a wheelbarrow full of moldy records. Your medical past maybe fascinating to you–but it’s not to her/him.

DB, great post-I think we’re on the same page ( see my post at

@Darrell, I respectfully disagree re previous medical records. It is a HUGE PITA to read through old records, esp if they’re handwritten and illegible. However, you very often strike gold there. It’s another good example of exactly what DB is talking about–if you were paid for your time, you might take the time to read through those old records–but since you’re not, you don’t unless you have an explicit question to answer. As a part-time primary care pediatrician, I very much understand this trade-off. As a part-time ID specialist, I know that there is unexpected treasure in old records, and that a chart biopsy is the least invasive procedure you can do; you just don’t get paid well for it.

Nice post. What about the potential for mid level practitioners to provide some of the ‘high touch’ care that patients prefer more cost effectively?

I know I’m late to this but anyway here goes. Patients SAY that that they want “high touch” care but aren’t willing to pay for it. Well I want to be a triathelete — just not enough to go jogging. Put up or shut up.

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