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Report: 15-Minute Visits Take Toll on Doctor–Patient Relationship

Time is money for PCPs and hospitalists

According to a new report from the Kaiser Family Foundation, it’s not unusual for primary care physicians’ appointments to be scheduled at 15-minute intervals, and some physicians who work for hospitals say they’ve been asked to see patients every 11 minutes.

And the problem may worsen as millions of consumers who gained health coverage through the Patient Protection and Affordable Care Act (PPACA) begin to seek care — some of whom may have seen doctors rarely, if at all, and have a host of untreated problems.

The Kaiser report concludes that short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

Shorter visits also increase the likelihood that patients will leave with a prescription for a medication rather than for behavioral change — such as trying to lose a few pounds or going to the gym.

Physicians don’t like to be rushed either, but for primary care physicians, time is money. Unlike specialists, they don’t do procedures such as biopsies or colonoscopies, which generate revenue, but instead are still paid mostly per visit, with only minor adjustments for those that go longer.

And doctors may face greater financial pressure as many insurers offering new plans through the PPACA’s exchanges pay them even less, offering instead to send them more patients.

This fee-for-service payment model, which still dominates the U.S. health care system, rewards doctors who see patients in bulk, said Dr. Reid B. Blackwelder, president of the American Academy of Family Physicians.

No one knows exactly why 15 minutes became the norm, the Kaiser report says, but many experts trace the time crunch to Medicare’s 1992 adoption of a complicated formula that relies on “relative value units” (RVUs) to calculate doctors’ fees. The formula is: (Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor.

That was a switch for Medicare, which had previously paid physicians based on prevailing “usual and customary fees.” But inflation and widespread inequities dictated a change. RVUs were supposed to take into account the physician’s efforts and the cost of running a practice, not necessarily how much time he or she spent with patients.

The typical office visit for a primary care patient was calculated at 1.3 RVUs, and the American Medical Association coding guidelines for that type of visit suggested a 15-minute consult. Private insurers, in turn, added Medicare’s fee schedule. Then, in the 1990s, “managed care came in and hit doctors with brutal force,” according to Princeton health economist Uwe Reinhardt.

Physicians who participated in managed care networks had to give insurers discounts on their rates; in exchange, the insurers promised to steer more patients their way.

To avoid income cuts, Reinhardt said, “doctors had to see more patients — instead of doing three an hour, they did four.”

Medical schools drill students in the art of taking a careful medical history, but studies have found that doctors often fall short in the listening department. It turns out they have a bad habit of interrupting.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them. Only one in four patients got to finish his or her statement. Further, a University of South Carolina study in 2001 found that primary care patients were interrupted after 12 seconds, if not by the health care provider then by a beeper or a knock on the door.

And yet making patients feel they have been heard may be one of the most important elements of doctoring, said Dr. Alex Lickerman, director of the University of Chicago's Student Health and Counseling Services.

“People feel dissatisfied when they don’t get a chance to say what they have to say,” he remarked.

Source: Kaiser Health News; April 21, 2014.

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