Dr. Amy Tuteur has a brilliant guest post on KevinMD -Is an efficient physician necessarily a good doctor?
The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.
Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster.
And that’s not efficiency.
For years I have advocated time based payments for medicine. I do understand the potential problems with time based payment, but I cannot think of another way to properly value spending adequate time with each patient.
Patients who enroll in cash only practices willingly pay fees based on time. Patients join a variety of retainer practices primarily because physicians devote adequate time to them.
I have heard friends complain about how quickly physicians come in and out of the office or the hospital room. Patients understand the value of time.
The suits respond to a poorly conceived payment system that values the visit regardless of the time needed. If you pay for visits, then suits want you see see more patients – hence more payments. This system runs counter to best medical practice. I believe that our dysfunctional payment system has much to do with decreasing physician satisfaction.
Kudos to Amy for an excellent explication of this problem. If you did not click on her link, please do so – it will be worth your time.
{ 3 comments… read them below or add one }
After having worked in pharmaceuticals, I have to say the same problems exist in medicine production. In the lab and on the production floor we had a saying, “There is never time to do it right, but there is always time to do it twice.”
That reflects the amount of rework that had to be done because of the incessant pressure of efficiency and volume of output. I do not mean to demonize the work or the workers, because they were very diligent, intelligent people. But, they are employed under a management that only values the revenue they bring in.
Why do you think the payment system based on visits and procedures is the product of “suits”? That system was set up for doctors by doctors in the advent of Blue Cross/Blue Shield, the original insurer completely controlled by medical interests.
Don Berwick discussed this a decade ago in his Escape Fire talk.
The AMA and their CPT codes influence visit times. A 99213, the most commonly charged established outpatient visit, averages 15 minutes. In the definition, time is part of the factor, but complexity also is included. An “efficient” physician can see 5-6 patients hourly at 99213 to maintain revenue. If the AMA would revise time and the insurance companies would pay better, as the pay range for a 99213 from private plans averages around $50 in my area, more time could be spent with the patient. The next code up at 99214 only adds around $15-$20 for another 10 minutes work. 2-3 99214 visits/hour versus 5 or more 99213 visits an hour equates to less time spent with the patients to make more money.