As a primary care physician practicing in Portland, Oregon, I've experienced firsthand the problems that our health care system creates for patients and doctors—especially in a traditional clinic setting.
During a three-and-a-half hour period (a half day), I'd go straight from visit to visit without checking my computer to review notes from incoming phone calls, incoming lab results or patient email messages. Although each visit was scheduled to be about 20 minutes long, they'd inevitably take longer—after seeing ten patients, I'd be running over an hour behind. Then I’d sit down at my desk to review calls, emails and lab results, as well as finish visit notes for everyone that I saw.
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By the end of the day, I often felt like I’d been hit by a truck. And worse than that, I felt like I needed to apologize constantly for inadequately meeting the needs of patients.
I’m not the only physician who feels this way: In 2010, a group of doctors in Philadelphia published a study that described their work in the New England Journal of Medicine. On average, the doctors in that practice took 24 phone calls per day; wrote 17 emails a day; processed 12 prescriptions per day (not including those made during visits) and reviewed 20 lab reports, 11 imaging reports and 14 consultation reports from specialists each day. This was all in addition to a full day of patient visits.
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Unfortunately, but not surprisingly, the United States has a shortage in the primary care workforce—as well as a shortage of primary care doctors in training. At the same time, as the Affordable Care Act is implemented and more people have access to health care, demand for primary care will only increase.
Why Are Doctors So Rushed These Days?
Most doctors in the U.S. are paid on a fee-for-service basis either by insurers, Medicare or Medicaid, which means that they receive payment only for face-to-face visits. This poses a challenge for three reasons:
- The payment amount is such that primary care offices have to limit visits to 15 or 20 minutes in order to schedule enough visits in a doctor’s day to cover the expense of running a practice, which includes staff salaries, rent and other overhead.
- The fee-for-service method does not pay offices for responding to phone calls or emails. For this reason, most practices reserve a small amount (if any) time on physicians’ schedules for non-visit care. Of course, physicians have to review lab results and contact patients about them, but explicitly allotting doctor time for such things would take away from the face-to-face visits that pay the practice.
- No time is reserved for another essential aspect of patient care: the documentation required in order to bill the payer. Electronic records have actually made that more cumbersome and time-consuming. Some documentation can be done during the visit: With practice, most of us can learn to look at the patient while typing, but the majority of the documentation simply must be done afterward—for instance, checking boxes for a certain number of physical exam findings, selecting numeric codes that represent problems, typing up a plan, etc.
Because of the fee-for-service method of payment, patients often find that they are asked to come in for many things that could be handled by phone or email. They also discover that, although they may have several concerns to discuss, the doctor may say to them (as many are trained to do): “We have time for one or two problems today. What’s on your mind?"
The reason my practice can allot time for things that don’t pay the bills: We charge insurance AND we have a membership fee.
How Membership-Based Practices Can Fix the Problem
My job today at a membership-based practice is much different from my old one. In a half day now, I have four to six 30-minute visits, plus a small amount of time set aside for phone calls and emails. And since visit times are longer, I can even fit in a call or email response between patients. Nowadays, I finish most clinic days feeling like I did an adequate job—which is great!
The reason my practice can allot time for things that don’t technically pay the bills: We charge insurance and we have a membership fee. It's typically called a “per member, per month” fee, and it covers all the work that insurance doesn’t. Individual patients either pay for it or their employers do, and the price, which is based on age, ranges from $120 annually for minors up to $756 for those 70 and older.
There are other practices like ours, such as One Medical, which has offices in San Francisco, New York City, Washington, D.C., Boston and Chicago. A lot of pilot programs from both insurers and public payers are also moving in the same direction:
- Medicare’s Comprehensive Primary Care Initiative (CPCI): This is a pilot program in which Medicare pays its usual visit fees and an extra pmpm fee, which gives some flexibility to primary care practices to lengthen their visits, as well as pay for doctors or team members to be in contact with patients between visits. In return for extra payment, Medicare expects the participating practices to track their quality of care, and reach out to patients with chronic illnesses or those who have been recently hospitalized. For example, practices would need to show that lab tests are up-to-date for people with diabetes or that people who were discharged from the hospital were seen by a primary care doctor in a timely manner. If successful, the Medicare pilot programs, which have been running for four years in seven states, could be quite influential because the Medicare payment structures have historically set precedent for regular insurers.
- Medicaid: Several state Medicaid programs are trying to change the primary care patient experience, as well. For instance, Oregon’s Medicaid has been reorganized into coordinated care organizations, which put all hospital and clinical health care providers under one umbrella and have them work together to treat people and keep them out of the hospital. Medicaid in Oregon may eventually move away from the fee-for-service method of payment.
- Concierge Medicine: A number of practices are innovating without partnering with insurance or payer programs by just charging a pmpm. That gives them incentive to have a lot of phone and email contact with patients, taking as much time as necessary to solve patient problems. These kinds of practices can make sense for people with high-deductible plans.
The Future for Physicians and Patients
The term “patient-centered medical home” is sometimes used loosely to describe the above innovations. The term can also refer to an actual certification that practices can get to show that they do things like track quality of their care and use electronic records.
The hope is that, eventually, being a patient-centered medical home will qualify practices to receive extra payment—resulting in longer visits, care between visits via phone and email, and other benefits.
I'm encouraged by these innovative patient-centered pilot programs, and by innovations in private clinics like mine. But doctors and patients should also advocate for longer visits, as well as phone and email contact outside of regular visits. If serious primary care reforms are successful, in the future, your primary care doctor will seem—and feel—less rushed.
Dr. Stacie Carney is an internal medicine physician who practices at GreenField Health in Portland, Oregon.