Value, money and time

I always wonder how can the insurance companies decide payment on a few codes and numbers? I am known to spend extra time with my patients. Most of my younger patients do not want to be in the office longer than 10-15 minutes for established visits. In contrast, most older patients like 20+ minute visits. I find that I get initial bill rejections for some of the 99214 visits, until I send in copies of my office notes. I think most insurance companies are interested in keeping the payments low from the insurance standpoint, while outpatient copayments keep increasing. To meet overhead, each physician has to see a certain number of patients. Once the overhead is met, then the physician can decided on the personal compensation.
It may take me 30 minutes to do a thorough H&P and then go over old records, labs, and studies, but good luck trying to code above a 99214. If I just saw the patient a week ago, I may only be able to get covered a 99212 or 99213, even though time based coding is allowed. The insurance companies routinely reject codes, if there are done too frequently, even though I spend extra time with the patients.
During my first few years in practice, most IM/FPs in the area would ask me how many patients I would see daily? My reply is that I see a reasonable number of patients. My income is above the national avg for FPs. To the hospitals and other employers of primary care doctors in the area, a good primary care doctor is one who sees 40 or more patients each office day for maximum revenue to the employer. One local FP doctor is known to see over 50 patients daily. High revenue does not necessarily equate with quality of care, and his former patients often tell me that he never laid a stethoscope on them.
On the flip side, most insurance companies are starting to track quality measures, with payments tentatively adjusted to pay better producing doctors who meet quality standards. This will encourage physicians to discharge noncompliant patients. This year I was dinged on some cancer screening tests that my patients failed to do, secondary to multi thousand dollar deductibles.
The point of all this is that our current medical system is tied to becoming efficient physicians and doing more paperwork/tracking of quality while limiting reimbursement for the time spent caring for patients. The only current way to maintain salaries in a fixed reimbursement system is to see more patients, which equates to less time spent directly caring for patients. Add in the hours spent dealing with preauthorizations, mail order medications, handicap placard applications, patient phone calls, and other unpaid time, and you have a system that is in a downward spiral for quality of care.
The current system suggests that physicians cannot exist without insurance companies, as patients are afraid to pay more than the copay to see a physician. Thousands in premiums are paid to insurance companies, and insurance companies spread fear that patients won’t be seen without insurance. The dozens of insurance companies simply duplicate the same services for almost the same price. The simple solution to the current inefficient system is to switch to a flat fee national system, with adjustments for geographic location and to eliminate insurance companies.

Extra time can allow higher quality care I don’t think many people will argue that. But if we paid for time, Wouldn’t that allow physicians to take advantage of being paid for time but not really doing anything helpful? Like a doctor saying he spent all morning with a patient, and all they did was gossip, or the doctor lied ans saw the patient for 30 min and took a very long lunch break?