Why Do I Only Get 10 Minutes With My Doctor?

Good question. You call for an appointment and are told it will be about 20 days. You arrive on time only to sit in the apt named waiting room for 40 minutes. Finally you get to see your primary care doctor (PCP). You begin to explain why you came in but are interrupted within about 23 seconds even though it would have only taken you about 6 more seconds to finish your “opening statement.” The doctor asks a few questions, does a brief exam, gives you a prescription, suggests you see the specialist and off you go, all within 8-12 minutes. At the exit desk you are told you owe a $30 co-pay. “Visa or MasterCard please.” And in no time at all you are out the door.

No time for delving deeply into your issues. No time to build trust. No time for compassion. No time for actual healing.

Why so quick? It is all in the numbers. At the risk of being boring, here they are. They might surprise you.

According to the New York Times a PCP earns on average $150,000 per year. A survey from Medscape pegs it at $170-180,000. That is about what a newly minted law student gets if he or she can land a job at a prestigious large firm or a just graduated MBA gets if hired by a big consulting company. But how does our PCP actually earn that money?

If the PCP has a private practice, in order to earn $150,000, he or she needs to bring in about $350,000 to also cover office expenses. Given what insurers like BlueCross, Aetna, United Health Care, Medicare and Medicaid pay per visit, the doctor needs to see about 25 patients per day. That is $30 to the PCP’s pocket for each visit. No wonder the visit is so short.

Said a different way, the PCP has to see 15 patients to cover expenses. Any patients over 15 and the income goes to him or her. So the PCP works for others until about 2pm.

It was not always this way. A PCP today earns about what a PCP earned (in today’s dollars)   few decades back but, in order to earn it, must see almost twice as many patients per day.

The typical PCP takes 24 phone calls per day, 17 emails, processes 12 prescription refills (above those handled during visits, ) and reviews 20 laboratory reports, 11 X-ray reports and 14 specialist consult reports. These are all done outside of the visit and obviously take substantial time. This work is clinically relevant but then there is about an hour a day – least – of time spent of dealing with insurers. And a recent report suggests that the PCP spends an nearly an extra 1 hour per day with the electronic health record (EHR.)

Look at the numbers a different way. A PCP who worked for a well-known HMO in California earned $140,000 and was assigned a panel of 2200 patients, a large percentage quite ill. That is $64 for each patient for the entire year. That is probably less than you spend taking your car for a twice yearly oil change and checkup. If each patient came in three times per year then each visit was worth $21. This PCP found herself highly stressed, unable to keep up to the level she thought appropriate and went home exhausted only to ignore her family and “crawl into bed realizing  it would start all over again tomorrow.”

On the east coast, a highly regarded PCP told me that “I thought I was going to die, literally, if I kept this up. I could not give the type of care and attention that I felt was best for my patients, I could not be compassionate. All the things I treasured doing as a doctor had vanished.”

The answer is straight forward. Pay the PCP more. Not more in total (although that might also be appropriate) but more per visit and have the PCP take care of substantially fewer patients.

There are many ways to approach this. Increase the fee for service payment in return for more attention to, at least, those with chronic illnesses who need close care coordination. At least one example of this with a Blue Cross program has worked well in the fee for service setting. In a capitated system, an insurer could assign fewer patients but pay the same total amount to the PCP. Maybe 1000 patients instead of 2200 for that $140,000. Or if the population in the pool is high risk with either mostly elderly people or those with multiple chronic illnesses as in a Medicare Advantage program, set the capitation rate so that it works with just 300-500 patients. There are good examples of this being highly effective as well.

Yes, in each of these examples the amount of money going toward primary care per capita is increased but the total costs of care comes way down. It comes down because high quality primary care takes care of most issues, offers better preventive care and coordinates the care of those with chronic illnesses. This means less referrals to specialists, less unnecessary testing and prescriptions and fewer trips to the ER or the hospital.

For PCPs in private practice, they can switch to retainer or membership models where the patient pays directly (direct primary care) by the visit or on a monthly or annual basis for all primary care in a setting where the PCP only has 500-700 patients, offers same day appointments, access to his or her cell phone 24/7, and perhaps reduced cost laboratory testing and even generic medications. Many of these practices are quite affordable - “blue collar.” And the savings on drugs can often offset the membership fee.

Insurers should consider paying the retainer for those who buy a high deductible insurance policy since quality primary care substantially reduces the total costs of care. And at a minimum, they should allow the retainer/membership fee to go against the deductible.  Employers could either buy the retainer or place an equal sum in an HSA for the employee who takes out a high deductible policy through the company. Alternatively, the company might initiate its own in house primary care clinic designed so that the employed/contracted PCP has only a reasonable number of employees to care for. In any of these models, the use of health coaches can further improve wellness, maintain health and assist with illness care.

The result: More time with the doctor. More time for the PCP to listen, more time to think, more time to diagnose and treat, more time to coordinate care for those with chronic illnesses and more time for better preventive medicine. So better care, better health, less frustrations, more satisfaction and much reduced total costs of care. Now you will no longer be wondering why the doctor allots you so little time.

Medicare and the Continuing Loss of Primary Care Physicians

Primary care physicians (PCPs) have been marginalized by Medicare for decades with low reimbursement rates for routine office visits which has led to the 15-20 minute office visit with 10-12 minutes of actual “face time” and a panel of patients that well exceeds 2000.  

Is there a good solution to the Medicare cost and quality issues? Setting aside either the Democrats’ approach to basically enact price controls by ratcheting down reimbursements or the Republican’s plan to re-structure Medicare to a defined contribution plan, albeit not for ten years, are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reducing costs? There are, but in this Part 6 of my Medicare series, we first need to understand one of the major issues facing Medicare today – the crisis in primary care.  

A 10-12 minute interaction means no time for the PCP to truly listen, no time to prevent, no time to coordinate and no time to just think. This has in turn meant that whenever a patient has a slightly more complex issue, one that is not easily recognized in a short time frame, then the PCP is quick to refer to a specialist. It is this very act that dramatically drives up expenditures with added tests, imaging and procedures along with the specialist’s fees. Medicare has been exceptionally short sighted in this regard and as a result is the prime culprit in the rapidly rising costs of care.  

Further, this lack of time being reimbursed means that two critical quality care needs area left largely unattended. The first is offering extensive preventive care and the second is coordinating the care of the patient with chronic illness. Recall that 85% of Medicare enrollees have at least one chronic illness and 50% have three or more. These are mostly the result of years of adverse behavior patterns but it is never too late to begin preventive care so time spent here is valuable for better health quality and ultimately reduced costs. And those with a chronic illness need to have their team of caregivers coordinated – every team needs a quarterback and the PCP is the obvious choice. But Medicare does not reimburse for this critical function which when done correctly means less reliance on specialists, tests, procedures and prescriptions. The result of this low reimbursement for routine visits and lack of reimbursement for either extensive preventive care or chronic care coordination over the years is a PCP shortage, many current PCPs no longer accepting Medicare, and the remaining PCPs trying to see 24 to 25 patients or more per day, each for 15 minutes despite the patient’s complex problem list. And this means less than stellar patient care in many instances. 

The result is a real problem facing Medicare right now - the rapid loss of primary care physicians (PCPs) who will no longer accept Medicare. In 2009 there were 3700 physicians that opted out of Medicare; the number rose to 9500 in 2012 according to CMS in a Wall Street Journal article; this on top of the shortage of PCPs across the country, with no end in sight. The ACA does include an extra 10% increase to primary care providers but this will probably be too little, too late. And if the mandated 27% across the board physician cut in reimbursement is ever implemented by Congress (it probably never will be but Congress refuses to clarify itself) then it is reasonable to expect that there will be a mass exodus from accepting Medicare reimbursements by all physicians, not just PCPs. 

What is the fix? As long as fee for service predominates in the payment system, Medicare needs to increase its reimbursement of PCPs in a manner that ensures that they will offer the patient more time per visit. Time to listen, to prevent, to coordinate and to think. And in a capitated system, Medicare (or its agent) needs to pay enough per patient per month/year to insure that each PCP does not have more than a maximum of 1000 patients (even fewer if the practice is largely geriatric) so that there can be adequate time per patient encounter. 

The next post will highlight some specific recommendations for Medicare to enact that would improve quality and reduce costs.