Cognition takes time, we must pay for time

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Category : Medical Rants

A recurrent theme here is time.  One must take enough time to take a history, do a physical exam, and consider the problem.  Cognition does take time.  Cognition can save money.  If we paid cognitive only physicians for their time, perhaps we would need less tests.

One of the many reasons for increased health care costs comes from our current payment system.  We get paid the same regardless of the time spent (I do understand there are some exceptions).  Family physicians and internists often see too many patients each day, because our payment model pays for the visit rather than time.  Too often we substitute tests for time with the patient.

This post addresses the issue partly – Why cognitive doctors need to be paid more

Perhaps these data will help make the case – Direct Primary Care Practice Model Eyed to Trim Health Care Spending

For example, the affiliated medical practice, Qliance Medical Group, analyzed internal data from 2009 and found that its direct primary care model lowered emergency department visits by 62% and hospital days by 26% for patients on its plan, when compared with regional averages for the same year, Dr. Bliss said. The group also cut specialist referrals by 55% and advanced radiology services by 48%, compared with regional averages.

“Insurance really doesn’t work for primary care; it’s meant to protect you from catastrophic events. It just adds a whole lot of administrative cost, not only on the doctors’ office side but also on the insurance side,” Dr. Bliss said in an interview. “Primary care is 90% of what people need, and we can provide that.”

The direct primary care practice model resembles the concierge medical practice model, but – unlike concierge practices – direct primary care practices cater to a lower-income demographic and attempt to provide almost all necessary care for a flat monthly fee. Many concierge practices charge a monthly or annual retainer, but also bill for services provided to the patient.

The direct primary care practice model also follows some of the same principles as the patient-centered medical home model. However, the direct primary care model does not team physicians with other health care professionals, such as social workers and pharmacists.

The wonks are trying, but they do not seem to understand the doctor patient interaction.  They forget that good medical interactions take time.  Inadequate time leads to diagnostic errors.  Inadequate time leads to unnecessary shortcuts.

Our society has an obsession with tests.  Our society has an obsession with the latest technology.  But tests and technology represent one part of a physicians toolkit.  Relying solely on testing handicaps the diagnostic process.  

The best diagnosticians use both intuition and analysis – the so-called dual process theory.  We need physicians who can take time with patients, and who know when to spend time.

Or we can just order too many CT scans – Medicare Claims Show Overuse for CT Scanning

We need out of the box thinking.  Our current system discourages spending the extra time to think.  Why would we expect such a payment system to lower health care costs?  Unless we pay our physicians to take enough time with patients, we will continue with our never-ending upwards cost spiral.

The answer really is that simple.  We just need to invest our moneys in the most component in the health care system – the brains of cognitive physicians.

Comments (3)

What has happened ot cognitive medicine fits with the more costly paradigm of using newer techniques, fancier equipment, and more costly diagnostic testing.  Good primary care practitioners would save bundles of money by cutting diagnostic testing and specialty referrals, but our entire system has been rigged to encourage the application of the most expensive treatments rather than the most cost effective.  Primary care is undervalued because it satisfies the interests of all the major players in medicine; specialist (who benfit from more referrals from overwhelmed PCPs), hospitals (who benefit from more admissions and readmissions), and diagnostic and device manufacturers (who sell more of their product).  There is no countervailing pushback against this onslaught of influence and lobbying to work for a more cost effective and value based health care system.  Instead of strengthening primary care with better training experiences (why do most training programs still spend the majority of time in a hospital?), we are told that most of our job can be adequately performed by NPs and PAs with half the training!
In other words, harried and overwhelmed primary care docs are just what all the other components of the health care system want.  More referrals, more hospitilizations, more tests are the result, and under our current fee for service system, this is what is rewarded with ever more profits going to these sectors.  Hopefully the new health care law will change all this, but watch out for those entrenched interests to react asnd attempt to change aspects of the health care law as they are enacted.

"Hopefully the new health care law will change all this"
 
Many of us think the push for ACOs will make the situation much worse very quickly.

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