The volume issue is such a downward spiral. Not only does a doc trying to “make it up on volume” run him/herself ragged in clinic and deliver substandard care, but the oversized patient panel generates even more paperwork, phone calls, emails, pre-authorizations, etc. than a “right-sized” panel would.

So the doc can’t keep up in clinic because he’s seeing too many patients, which then creates more follow up work than he can handle because he’s seeing so many patients, which creates even more follow up work, and on and on…..

Madness, really. (and a perfect recipe for burnout)

[...] DB on retainer practices again: I will state again, that as a physician, my primary responsibility is to provide the highest quality of care to my patients. If I have to choose between providing mediocre care to 1500 patients, and outstanding care to 500 patients, then I believe that I should take the latter approach. (. . .)I suspect that an excellent internist should see no more than 16 patients each day, but would not be surprised if the number is less. Regardless of the exact number, we can all agree that we would like our physician to be seeing the appropriate number of patients to provide the highest quality care. Once the physician exceeds that number significantly, care suffers.Many physicians adapt to patient overload through several mechanisms. First, they become more controlling of the patient visit, minimizing open ended questions, and not addressing extra issues. Second, they more quickly consult. Consultations save the generalist time. Third, they order expensive diagnostic tests rather than take a careful history. Additionally, such physicians rarely answer telephone calls and shun email communication.My support of the retainer model stems from my desire to see patients receive the best possible care. I believe that retainer physicians likely do a much better job with each patient.   [...]

I’d like to comment on two things:

1) Excellent medicine- although the evidence is scant and speculative, I’m pretty sure that retainer medicine will improve patient-physician interaction and both physician and patient satisfaction. Whether it will improve quality of medicine is a completely different question, but I am willing to concede that for those patients in a retainer practice, that is probably true. I also think that if physicians want to practice retainer medicine, let them.

But what I wanted to really comment on is db’s argument that his “support of the retainer model stems from [his] desire to see patients receive the best possible care” (For one thing, best possible care does not mean excellent care). I don’t doubt his desire. But Db argues that time is an issue. There is nothing stopping physicians from seeing less patients a day under the current model– there’s a pay cut if the physican does so, but he or she won’t be impoverished. It seems more likely that retainer medicine is driven is some part by economic incentive and satisfaction for the physician (there’s nothing wrong with that).

2) The speculation that retainer medicine will change internal medicine. I also don’t doubt that there will be a small portion of retainer practices, but I strongly doubt that it will change internal medicine unless physician and patients influence third party payers for the simple reason that not everyone can afford to have “excellent medical care”. Do you really think that the proportion of patients will pay out of pocket for medical care will be substantial enough to transform internal medicine? American have often thought of medical care as a right (or at least an entitlement), and this will not change because of a few scattered retainer practices. I’ve no doubt retainer practices will grow. I have no problem treating medical care as a privilege to pay for, just the idea that retainer medicine will impact the health care industry enough.

3)db’s continued rejection of public health is odd. How can someone who cares about the welfare of physicians (by his support of retainer medicine) and care about his patients (or at least the patients of those retainer practices) disregard the impact on patients of other physicians. The argument that retainer medicine will provide patients with better care with retainer medicine but then not care about the health of patients (who form the public) doesn’t make sense. It is exactly this disregard of externalities or political concerns that put us here (physicians lack of political activity and not sitting at the table when third payers stepped into the picture). In case you haven’t realized, health care form a large part of the GDP, and we’d be stupid to forget politics.

Retainer physicians have much lower overhead than those in the typical current practice, because they don’t bill insurance plans. AND, their panels of patients are small, so some may work with just an assistant or aide.

I reject the public service argument against retainer practices because of the way in which physicians are educated and trained in this country. Young people devote their best years of young adulthood to pursuing a medical educations; they work long hours (really, even 80 hours a week is pretty long!!); and go into tremendous debt to earn the priveledge to join the medical profession. I believe all AMERICANS should be good citizens and human beings and help the less-advantaged in our country; I don’t see that a doctor has an additional duty under the present system. Sure, doctors should be professional, competent, and compassionate, and when they breach professional norms of behavior and competence they should NOT be allowed to practice medicine.

steve, some insurances will not fee for service or allow billing to occur if the patient pays a retainer. especially if the service is purportedly covered by the insurance.
one recommendation being made to patients under retainer care is that they have a high deductible policies for emergencies to make sure they can get high cost care when necessary.
we’ll have to see what the insurance companies allow and whether people are willing to forego their insurance in favor of a retainer arrangement if this system is to be tested widescale.

[...] than primary care of the indigent, so in that sense, the question was specious. And, as I said yesterday, if retainer practices turn out to in fact cut down on admissions and overall health care costs [...]

A retainer system will also remove the disinsentive to communicate with patients by email. In addition to convenience, it would end up reducing the workload at the office. Physicians can take advantage of free online services such as http://www.housedoc.us, that provide for HIPAA compliant email communication with patients.