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    It's about time PCPs say enough is enough

    Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Stephen C. Schimpff, MD, a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, and author.  The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

     

    It’s about time—time to recognize that primary care physicians (PCPs) need more time with their patients.  

     

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    PCPs have no time because they need to see too many patients per day to cover rising overhead costs. Short visits, often 15 minutes with even less face time, mean more difficult issues solvable by the PCP get referred to a specialist or lead to a prescription when lifestyle changes could have been appropriate.

    Certainly, 15 minutes is not enough time for an elderly patient with impaired vision, hearing or cognition nor for the patient with multiple chronic illnesses and on multiple prescription medications now presenting with a new problem. It is not enough time for a person whose problem is underlying anxiety who needs empathetic listening. It is not enough time to develop and maintain a trusting relationship—the essential ingredient of the doctor-patient interaction.

    It’s about time to appreciate that primary care is not just the simple stuff like a sore throat or a sprained ankle, but includes wellness, health maintenance, prevention, management of complex chronic illnesses like heart failure and diabetes and care coordination among various providers. When the PCP has the time to give such truly comprehensive care, the costs of primary care do go up, but the total costs of care come down substantially as demonstrated by multiple reports. It’s a good return on the financial investment, reduces physician frustrations, increases patient satisfaction, and of course, means higher quality care all around.

     

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    It’s about time for insurers to recognize that their combined approach of using price controls on reimbursement and of constantly adding extraneous work requirements has led to a serious conundrum. PCPs now see two times as many patients per day but earn the same income (inflation adjusted) as decades ago. But that means short appointments. That’s not adequate. So it’s time for insurers to look at new models, models that grant more time to each patient.

    Next: Time for a real change

    5 Comments

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    • [email protected]
      Great comments Dr McMillan. You have succinctly detailed the problems and the solutions, be they an uphill fight. They will encounter rough terrain when we have large lobbing monies buying politicians. Our precious founders missed term limits because they never envisioned politicians becoming "lifers" and creating gold lined occupations at American's expense. I wanted to add to the DPC conversation our ability to offer discounts, scholarships, and free care. Each of these is now possible under our system. If we have a patient who has fallen on difficult times, we can decrease their costs accordingly or not charge at all. We are free of bondage from insurance companies. The air is certainly fresh in central Indiana! Happiness in medicine has returned! DrBob
    • [email protected]
      Enthusiastically agree, especially with the solution Drbob is using. As a physician board certified in internal medicine and anesthesiology currently practicing spinal medicine and endoscopic spinal surgery, I have seen the destruction of the ethical practice of medicine by these Neanderthals in the suits from the medical and surgical perspective. There is no more innovation, patient advocacy, or personal commitment to optimal outcomes in the current corporate physician employee model of medicine, and some of the PCP's and most of the surgical physicians living under this bondage are miserable. While the long term solution to this carnage is to convince state legislatures to enforce the robust laws currently on the books in most states SPECIFICALLY prohibiting the corporate practice of medicine (CPOM laws), the political realities of getting most politicians to do anything useful are almost insurmountable (e.g. , the Republican congress). The corporate employee business model is straight out of the Mafia playbook; hospitals bribe PCP's who are willing to play the game and sacrifice true patient advocacy with above market salaries, easy hours, plenty of staff, and employee benefits that cannot be earned by independent physicians laboring under an insurance dominated reimbursement structure. Once they have the lazy PCP's, they extort the medical specialists and surgeons who need the PCP referrals to literally survive. Buying the PCP's and their referrals seals the deal for full corporate control. The opinions expressed herein specifically exclude the unique requirements of full-time medical education, and the medical needs of the institutions of society that require a state sponsored medical support framework (state run institutions, nursing homes, emergent indigent care, etc.) For the great majority of patients, a much more timely and remarkably effective way to return to patient centered medical practice is the direct primary care or "concierge" model for PCP's, independent ancillary facilities, and for surgeons to associate with independent surgical facilities (and there are plenty of them) to offer bundled cash pricing arrangements that cost typically 25-30% of what hospitals charge for everything. As you stated, patients may file their own insurance claims if they have out of network coverage that allows it. In many cases, the lower cost of the services provided will be less than the out of pocket costs for comparable hospital based care with high insurance deductibles and co-pays. If surgeons and medical specialists realize that there are enough of these independent referral sources available to support their practices they will leave the corporate employee model in droves. DPC physicians who really want to drive a coffin nail into the beast would be wise to identify and encourage them to associate with their groups. A two-tiered medical system will emerge and be driven by demand from consumers equally fed up with the corporate employee care model, who can afford the alternative, and physicians will again reap the personal and professional rewards of traditional patient centered independent medical practice. My main concern is for the poor people who cannot afford the cost of DPC and cash pay surgery who will be stuck in the corporate swamp. Concern for them, is (allegedly) what keeps some socially conscious PCP's I know implanted in the employee model. Some of these physicians and their corporate handlers also have a deep blood hatred for the medical and surgical pioneers who are shaming them by developing and expanding the DPC and affordable low cost surgery model. The truth is that DPC, bundled surgery, and ancillaries such as lab and radiology in independent facilities actually saves a lot of money and improves outcomes apart from the increased satisfaction it provides for patients and providers. Until real healthcare reform creates a reimbursement climate that allows poor patients and those dependent on government subsidy and/or support to participate in the emerging independent practice models we are discussing, the two-tiered system will continue and ironically, the most vulnerable will suffer most. Health savings accounts and high deductible lower cost indemnity insurance products are a good start, but we need more creative thinking by insurers to offer products that incentivize the utilization of free market healthcare options. It's up to those of us who believe in the free market models to advocate for them as the best way to ensure the very survival of the professional practice of medicine. Medicine is far too important for us to cave in and let these irresponsible, greedy corporate hoods and their lackeys ruin it. Thanks for sharing. Marion R. McMillan MD
    • Anonymous
      For me it was definitely time to say enough is enough. I packed it in at 62. There is no way you can convince the suits in charge that patients are complicated. After all, the experts from Epic tell them in a lunch meeting that it can be done in 15 minutes. Nobody from administration knows what we do behind the exam room door. (And they don't really care.) When you look at the curves on how many physicians have been added versus the number of administrators added over the past decade it tells you the future of medicine. I went to a local CVS today to pick up a prescription and watched the noctor from the minute clinic walk around the store buying snacks. Did she have a jammed schedule? Of course not. The system has to collapse before they give us a seat at the table to help fix it. Until then it is our job to put money on the table for administrators to spend. No more for me.
    • [email protected]
      Dr Schimpff, you again hit the nail on the head;;you are absolutely correct; My partners and I have collectively over a hundred years of practice experience; we have been office based and traditional insurance, forced to see 30 or more patients daily with shorter and shorter visits to maintain any revenue; last year, to the point of back breaking,frustrating burnout, we decided to convert to Direct Primary Care; a huge decision to cut our practice from 6000 to 1500 patients; we decided we would rather be excellent doctors to fewer rather than quit ; with the help of Freedomhealthworks. com we converted and will never go back to the former practice model; we have been "reborn" into the medicine we dreamed of 30 years ago; 10 patients daily, long energizing teaching visits with people who care and want to improve their health; we have time for home visits, after hours seminars, exercise classes for our patients at a local health club, and time to call ,email, and visit with patients every day; we sleep well knowing we are doing a great job; we are at peace,and the staff loves the new style; we do not file any insurance but give statements to whomever would like to file on their own; there is a way to love the practice of medicine again; keep up the great writing;; Dr Habig, westfieldpremier.com; 3178671236

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