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?

Related posts:

1. Primary care payment – is win-win possible?
2. Primary care – money is the answer
3. Dazed and Confused – Levels of primary care?
4. Universal health care will require fair pay for primary care
5. Why health care reform should focus on primary care

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