Why Your Doctor Appointment Is So Short
There’s an invisible price tag influencing your doctor visit. But that could be about to change.
If you’ve ever wondered why your doctor lingers with some patients and seemingly whisks others out the door, you probably chalked it up to individuals’ differing medical needs.
That may be true, but there’s another factor: Every patient enters the exam room with an invisible price tag.
“It’s a business,” says Jeff Gorke, managing director of the health care practice consulting firm Stout, “and it’s also about the delivery of quality care.”
Both aspects have gotten more complicated recently.
Today, doctors appointments are brief: about 13 to 16 minutes long, according to 2016 data. Dr. Saul J. Weiner, professor of medicine, pediatrics, and medical education at the University of Illinois at Chicago, recalls how the system used to work. “Especially if you knew a patient well, you could just write afterward something concise like, ‘Patient is doing fine, continue present management,’” he says.
That informality has mostly vanished as more oversight has been implemented. The shift came as a response to what were seen as abuses of the “more care, more money” model of fee-for-service payment, which has been a part of U.S. medicine for centuries. A 1980s-era analysis of physician payment helped set the stage for the advent of a blizzard of new rules. While in theory, fee-for-service can “reward those physicians who are efficient, hardworking, and attractive to patients,” wrote researcher Bruce Rosen, the reality was that without “control mechanisms,” physicians can easily “bill for procedures not carried out” or assign procedures “to the more lucrative billing codes.”
Medicare, as the nation’s largest payer of medical bills, decided in the mid-1990s that those “control mechanisms” desperately needed a revamp. The Medicare program instituted computerized billing codes analogous to the fare codes on an airline ticket. Each “evaluation and management” code corresponded to a set of clinical requirements, an estimated doctor visit time (from 10 minutes to an hour), and a payment. Medicare’s criteria were promptly adopted by private insurers, too.
“Sometimes, doctors check the boxes indicating they’ve asked all sorts of screening questions when they didn’t. They may send the patient out the door, and they haven’t even spent the allotted 15 minutes.”
Then, beginning in 2008, incentives from federal legislation for digitization of health information pushed computers into the exam room and, inevitably, made documentation just one more job for a doctor suddenly trying to balance being a clinician and being a typist. The changed patient-doctor dynamic has resulted in some physicians spending more time with the electronic health records, logging services, than face-to-face with patients. Physicians struggle to balance “checking the right boxes” on the computer and maintaining patient eye contact, turning “the doctor-patient duet into a ménage à trois,” as one frustrated physician wrote last month for STAT News.
In theory, payment criteria should ensure certain quality standards while also protecting a block of time. In reality, though, your doctor could be billing for the equivalent of an aisle seat with extra legroom, while your exam experience more closely resembles a middle seat in Basic Economy.
Consultant Gorke wrote of one physician who claimed to have seen 90 patients in a day, all for the three most time-consuming levels of care — a physical impossibility.
Similarly, Weiner, whose research involves recording and analyzing doctor-patient interactions, says he frequently finds a discrepancy between the documentation in the medical record and what’s on the audio.
“Sometimes, doctors check the boxes indicating they’ve asked all sorts of screening questions when they didn’t,” said Weiner. “They may send the patient out the door, and they haven’t even spent the allotted 15 minutes.”
The same pattern has surfaced even in patients with advanced cancer. Dr. Cardinale B. Smith, director of quality for cancer services at New York’s Mount Sinai Health System, arranged visits with a diverse group of oncologists for people with advanced breast, prostate, and other solid-tumor cancers. The purpose was to discuss the patient’s latest scan results and their impact on the patient’s goals for care. As part of a research project, the results were recorded.
Smith, a hematologist, found the results “disconcerting.” Appointments were scheduled for 40 minutes, but the median time oncologists spent with patients was just 17 minutes. Worse, black and Hispanic patients received significantly less time than whites, likely due to the problem of “implicit bias” attracting growing attention in health care.
Moreover, both primary care physicians and oncologists were quick to step in and direct the conversation. The physician’s interview of the patient has been called “the most powerful, sensitive, and versatile instrument available to the physician,” yet recent research found doctors listen to patients for just 11 seconds on average before interrupting.
Smith attributes the quick interruptions to physicians’ “take charge” training and the abbreviated visits to “a system that sets up success as the number of patients you see in a day.”
Finding a better way
There were nearly 900 million office-based physician visits in 2016, according to the latest data available. But increasingly, the traditional visit is changing under pressure from the same technological, social, and economic forces affecting other areas of U.S. life.
Some of the most visible differences reflect the public’s desire for more convenient access to care. For example, in many places, you can guarantee quick access and longer visits by paying a fee ranging from $50 a month up to as much as $25,000 a year to a concierge medicine practice, with $135 to $150 a month being the national average. This, obviously, is a solution for the few, not the many.
Or you might skip the traditional route altogether and visit a worksite clinic, now offered by a third of firms with 5,000 or more employees, or a retail clinic in stores such as CVS or Walmart (typically staffed by a nurse practitioner or physician assistant). Or you might use telehealth. Insurance coverage for all these options varies.
That said, office-based doctor visits still rule. The number of patient visits to convenient care clinics in roughly 20 years, as recorded by an industry trade group, equals less than 5% of the total U.S. office visits in just one year. Similarly, while telehealth is growing rapidly (SSM Health, for instance, recently began offering a $25 virtual doctor visit), the total remains small. From 2005 to 2017, telehealth visits amounted to less than five-hundredths of 1% of annual U.S. office visits, according to a JAMA study.
These niche efforts are better seen as one part of a broader movement to replace “the more you do, the more you’re paid” paradigm with payment linked to achieving specific goals related to care quality, cost, and the patient’s experience. The effort to change the way doctors have been paid first began to take hold with the passage of the Affordable Care Act in 2010, and it has continued with rare bipartisan political support and buy-in from private insurers.
The catchphrase for the health care cognoscenti is “value-based payment.” That’s short for, “We (those paying for services) want to get more value for all that money we’re spending.” Because six in 10 American adults have a chronic condition such as diabetes or heart disease, according to the Centers for Disease Control and Prevention, and four in 10 suffer from two or more conditions, one focus of “getting our money’s worth” has inevitably turned to how doctors treat patients with chronic disease.
Helping someone with diabetes or asthma avoid a trip to the emergency room is an area where getting better care, less expensive care, and improving the patient’s experience all come together. The two-pronged, “value-based” response relies on outreach. It starts with holistic strategies to keep people healthy and out of the doctor’s office altogether, something fee-for-service doctors never emphasized. The second part of the outreach strategy is making sure that when something does go wrong, the patient is brought into the health care system for treatment as quickly as possible.
Some of the tactics being deployed include same-day access to a clinician, home visits, remote monitoring, artificial intelligence-enabled predictive analytics, health coaches and behavioral health specialists. You can see different mixes of these new approaches being offered by entrepreneurial start-ups such as Aledade, Cityblock, Forward, Heal, Iora Health, Oak Street Health, and others, that sometimes compete and sometimes partner with the traditional system. But you can also see everyday care changing in places like the offices of Dr. José Peña, an internist practicing in Texas’s Rio Grande Valley, just a few miles from the Mexico border.
Peña co-founded the RGV Accountable Care Organization (ACO) in 2012 to participate in a new value-based payment program from Medicare. If an ACO meets the annual quality, cost, and patient experience goals for its patient group, it can keep part of the money Medicare calculates was saved.
Under fee-for-service, said Peña, volume was the key for him and his colleagues. “The more patients the better. We were very, very proud when we saw more than 30 patients per day,” he says. Today, with Medicare and many of his privately insured patients on value-based contracts, volume is down by a third, but the focus has changed.
In the old days, “there was no time to talk about vaccinations, talk to a family member, talk to the whole group of people around the patient,” says Peña.
But under value-based payment, “I cannot let that patient go without a very clear understanding of everything involved. I need to actually listen better to the patient, unpack further conditions, discuss problems differently.”
Medicare recently announced that it’s streamlining its billing and coding system, in part to encourage physicians to spend more time with patients who need it. Private insurers seem likely to follow.
The altered incentives could be significant, says Dr. Robert Berenson, a physician payment expert and Institute Fellow at the Urban Institute. Still, Berenson worries that the individual doctor’s commitment to help a patient no matter how long it takes is being eroded by bureaucratic metrics.
“The core function of a doctor is to be there for a patient in need,” he says.