Comments on: Good medical care requires time – h/t @efalchuk http://www.medrants.com/archives/5688 Internal medicine, American health care, and especially medical education Sat, 11 Feb 2012 15:15:48 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: medrecgal http://www.medrants.com/archives/5688/comment-page-1#comment-535400 medrecgal Fri, 30 Jul 2010 13:16:01 +0000 http://www.medrants.com/?p=5688#comment-535400 You hit the crux of the problem straight on, Dr. Centor, and completely explained the oddity of being both a patient and a coder....I see the lousy reimbursement rates for primary care and totally understand why physician bloggers rant and rave about them so often. It signals that our system of payment for health care needs a total overhaul, but there are so many reasons why an acceptable solution is unlikely to come about any time in the foreseeable future. Much of the emphasis in our system is on specialists with fancy procedures and equipment that don't get used until the patient is much further along in a disease process than they would be if they showed up for regular visits with a primary physician; it SHOULD be on preventive care, which would save our system tons of money even if they started reimbursing physicians on a more appropriate scale for what I call "cognitive medicine", i.e., where a provider uses their enormous bank of knowledge to counsel and educate patients on ways they can work together and improve health/stave off disease. (And for those who already have complicated problems, time to explain the use of their 6 different meds and what they can do to prevent more problems from developing.)  Yes, TIME is a huge factor here; it needs to be part of the payment equation in a way that doesn't wind up punishing physicians who have patients that require more of their time individually. Don't know what the answer would be, but our current system is far from it. You hit the crux of the problem straight on, Dr. Centor, and completely explained the oddity of being both a patient and a coder….I see the lousy reimbursement rates for primary care and totally understand why physician bloggers rant and rave about them so often. It signals that our system of payment for health care needs a total overhaul, but there are so many reasons why an acceptable solution is unlikely to come about any time in the foreseeable future. Much of the emphasis in our system is on specialists with fancy procedures and equipment that don't get used until the patient is much further along in a disease process than they would be if they showed up for regular visits with a primary physician; it SHOULD be on preventive care, which would save our system tons of money even if they started reimbursing physicians on a more appropriate scale for what I call "cognitive medicine", i.e., where a provider uses their enormous bank of knowledge to counsel and educate patients on ways they can work together and improve health/stave off disease. (And for those who already have complicated problems, time to explain the use of their 6 different meds and what they can do to prevent more problems from developing.) 
Yes, TIME is a huge factor here; it needs to be part of the payment equation in a way that doesn't wind up punishing physicians who have patients that require more of their time individually. Don't know what the answer would be, but our current system is far from it.

]]> By: DrB http://www.medrants.com/archives/5688/comment-page-1#comment-535391 DrB Fri, 30 Jul 2010 01:01:04 +0000 http://www.medrants.com/?p=5688#comment-535391 I find it interesting....  tonight on KevinMD's blog there are several post about the tribulations of the"Medical Home" (a term that already seems to be circling the drain.) why??  because Family Medicine (the major player pushing this concept) has missed the point.   it's ALL about TIME. it's what we need.  it's what makes primary care good. and, it's what patients WANT! Patient satisfaction is not good with PCMH projects because it sill does not give the patient what they want... time. if we could just get AAFP and ACP to understand this.  stop kidding ourselves by trying to play nice with the system and demand what is needed.  more time for patients and doctors to develop the relationship they desire.   stop messing around with PMCHs and change the focus to being the patients Advocate.  not just their doctor.  thats what patients want.  An advisor, confidant, and advocate to help them through the system. that is the change that will save primary care. I find it interesting….  tonight on KevinMD's blog there are several post about the tribulations of the"Medical Home" (a term that already seems to be circling the drain.)
why??  because Family Medicine (the major player pushing this concept) has missed the point.  
it's ALL about TIME.
it's what we need.  it's what makes primary care good. and, it's what patients WANT!
Patient satisfaction is not good with PCMH projects because it sill does not give the patient what they want… time.
if we could just get AAFP and ACP to understand this.  stop kidding ourselves by trying to play nice with the system and demand what is needed.  more time for patients and doctors to develop the relationship they desire.  
stop messing around with PMCHs and change the focus to being the patients Advocate.  not just their doctor.  thats what patients want.  An advisor, confidant, and advocate to help them through the system.
that is the change that will save primary care.

]]> By: DrB http://www.medrants.com/archives/5688/comment-page-1#comment-535389 DrB Fri, 30 Jul 2010 00:10:42 +0000 http://www.medrants.com/?p=5688#comment-535389 bkulow   chicken or egg..... how would you ever expect to have physician supply meet demand when there is NO incentive for that to happen???   im sorry....  it's a poor excuse not to effect change.  If we demand real change the improved work conditions for primary care doctors would improve the supply.   care will continue to be mediocre until the system is fixed.  so... our healthcare is headed for a huge split.  doctors and patients willing to accept the mediocre and what the governement has dictated..... and the other doctors and patients that demand more and better.... and are willing to pay for it. bkulow
 
chicken or egg….. how would you ever expect to have physician supply meet demand when there is NO incentive for that to happen???
 
im sorry….  it's a poor excuse not to effect change.  If we demand real change the improved work conditions for primary care doctors would improve the supply.
 
care will continue to be mediocre until the system is fixed.  so… our healthcare is headed for a huge split.  doctors and patients willing to accept the mediocre and what the governement has dictated….. and the other doctors and patients that demand more and better…. and are willing to pay for it.

]]> By: rcentor http://www.medrants.com/archives/5688/comment-page-1#comment-535382 rcentor Thu, 29 Jul 2010 18:20:16 +0000 http://www.medrants.com/?p=5688#comment-535382 If the payment model works better, then we would likely have more outpatient physicians. The problem we are trying to address in these rants is that physicians are choosing to forgo outpatient practice. While we have a physician shortage, more important is a physician maldistribution. If the payment model works better, then we would likely have more outpatient physicians. The problem we are trying to address in these rants is that physicians are choosing to forgo outpatient practice. While we have a physician shortage, more important is a physician maldistribution.

]]> By: Evan Falchuk http://www.medrants.com/archives/5688/comment-page-1#comment-535380 Evan Falchuk Thu, 29 Jul 2010 16:56:01 +0000 http://www.medrants.com/?p=5688#comment-535380 First, Dr. Centor, thank you very much for your kind words. I suspect most patients would be shocked to learn that their doctor only gets fifty bucks for seeing them.  It's about what it costs to get your car detailed.  It doesn't make any sense. I'm sure it's a big reason why there aren't enough doctors.  Who wants a job where you train for years to use your judgment but end up being treated - and paid - like you were an assembly line worker.  As you suggest, policy wonks don't get this, which is why they keep trying to come up with ever more clever ways to treat medicine like a rote process, when it's nothing of the sort. Evan Falchuk First, Dr. Centor, thank you very much for your kind words.
I suspect most patients would be shocked to learn that their doctor only gets fifty bucks for seeing them.  It's about what it costs to get your car detailed.  It doesn't make any sense.
I'm sure it's a big reason why there aren't enough doctors.  Who wants a job where you train for years to use your judgment but end up being treated – and paid – like you were an assembly line worker. 
As you suggest, policy wonks don't get this, which is why they keep trying to come up with ever more clever ways to treat medicine like a rote process, when it's nothing of the sort.
Evan Falchuk

]]> By: bkulow http://www.medrants.com/archives/5688/comment-page-1#comment-535378 bkulow Thu, 29 Jul 2010 16:39:31 +0000 http://www.medrants.com/?p=5688#comment-535378 You've talked many times on the need to change the payment model and I really like your thoughts. One thing you neglect to address is the consequence of switching to a time model. If doctors are paid the same for seeing less patients, then patient demand will skyrocket due to the lack of supply of physicians. I see this being the single greatest deterrent in moving forward. There simply aren't enough doctors currently, nor being trained to meet the future demand even under the current payment model. How could you expect them to change it? You won't see changes in Medicare payment until the supply of doctors meets the demands of patients. You've talked many times on the need to change the payment model and I really like your thoughts. One thing you neglect to address is the consequence of switching to a time model. If doctors are paid the same for seeing less patients, then patient demand will skyrocket due to the lack of supply of physicians. I see this being the single greatest deterrent in moving forward. There simply aren't enough doctors currently, nor being trained to meet the future demand even under the current payment model. How could you expect them to change it? You won't see changes in Medicare payment until the supply of doctors meets the demands of patients.

]]> By: rcentor http://www.medrants.com/archives/5688/comment-page-1#comment-535366 rcentor Thu, 29 Jul 2010 12:56:21 +0000 http://www.medrants.com/?p=5688#comment-535366 Just reading your description makes me ill. Why should anyone develop arbitrary timing for visits? Why not have patients pay for our time? If our main commodities are our knowledge, our time and our patient interaction, let the marketplace pay us for that time. Why should a brand new internist receive the same payment as a 30 year experienced internist? The payment system is byzantine, arcane and overly complex. Thus too many physicians game the system and too many administrators encourage that gaming. And that is my point. Just reading your description makes me ill. Why should anyone develop arbitrary timing for visits? Why not have patients pay for our time? If our main commodities are our knowledge, our time and our patient interaction, let the marketplace pay us for that time. Why should a brand new internist receive the same payment as a 30 year experienced internist?

The payment system is byzantine, arcane and overly complex. Thus too many physicians game the system and too many administrators encourage that gaming. And that is my point.

]]> By: david mitchell http://www.medrants.com/archives/5688/comment-page-1#comment-535362 david mitchell Thu, 29 Jul 2010 12:25:25 +0000 http://www.medrants.com/?p=5688#comment-535362 Fifteen minutes is a standard level 3 outpatient visit, 1-3 concerns.  Most primary doctors see at least 4 patients/hour on average, with some pushing 7-8 patients/hour at the level 3.  Established level 4 visits average 25 minutes, as per the AMA CPT coding guidelines, such as the patient with T2DM, HTN, and hypercholesterolemia with medication changes.  New patient level 3 visits average 30 minutes, and new patient level 4 visits average 40 minutes.  I spent 40 minutes on a new, uncontrolled T2DM patient.  She told me her other primary care doctor had never looked at her feet, never done the monofilament testing for neuropathy, and never had spent a total of 40 minutes in the last 3 years with her.  What happens is established docs can game the system to document a level 3 visit and perform it rapidly in 5-8 minutes or a level four visit in around 10-15. An average level 3 visit reimbursement in my area is $56.  We often blame the insurance companies for the system, but it is a combination of the poor reimbursement for outpatient office visits and the AMA guidelines on CPT coding for levels of care with average times that hurt outpatient medicine which together leads to irritated physicians and patients. Fifteen minutes is a standard level 3 outpatient visit, 1-3 concerns.  Most primary doctors see at least 4 patients/hour on average, with some pushing 7-8 patients/hour at the level 3.  Established level 4 visits average 25 minutes, as per the AMA CPT coding guidelines, such as the patient with T2DM, HTN, and hypercholesterolemia with medication changes.  New patient level 3 visits average 30 minutes, and new patient level 4 visits average 40 minutes.  I spent 40 minutes on a new, uncontrolled T2DM patient.  She told me her other primary care doctor had never looked at her feet, never done the monofilament testing for neuropathy, and never had spent a total of 40 minutes in the last 3 years with her.  What happens is established docs can game the system to document a level 3 visit and perform it rapidly in 5-8 minutes or a level four visit in around 10-15. An average level 3 visit reimbursement in my area is $56.  We often blame the insurance companies for the system, but it is a combination of the poor reimbursement for outpatient office visits and the AMA guidelines on CPT coding for levels of care with average times that hurt outpatient medicine which together leads to irritated physicians and patients.

]]> By: Tweets that mention Good medical care requires time – h/t @efalchuk — db's Medical Rants -- Topsy.com http://www.medrants.com/archives/5688/comment-page-1#comment-535359 Tweets that mention Good medical care requires time – h/t @efalchuk — db's Medical Rants -- Topsy.com Thu, 29 Jul 2010 11:15:55 +0000 http://www.medrants.com/?p=5688#comment-535359 [...] This post was mentioned on Twitter by Robert Centor, John Mandrola, MD. John Mandrola, MD said: RT @Medrants: Good medical care requires time - h/t @efalchuk http://is.gd/dQxuT >If only every day was like a snow day: http://ow.ly/2idki [...] [...] This post was mentioned on Twitter by Robert Centor, John Mandrola, MD. John Mandrola, MD said: RT @Medrants: Good medical care requires time – h/t @efalchuk http://is.gd/dQxuT >If only every day was like a snow day: http://ow.ly/2idki [...]

]]>