Friday, July 1, 2011

Paying For Your Time

There has been a lot of Internet/Twitter buzz regarding a recent CNN article "Would your doctor pay for wasted time?" by Elizabeth Cohen.  The premise of the article is that a patient's time is valuable, and if the doctor keeps a patient waiting for longer than anticipated, it should be the doctor that pays the patient, since the patient's time is valuable too.  She describes the story of patient Elaine Farstad waited over two hours to see her physician.

"I decided to bill the doctor," she says. "If you waste my time, you've bought my time."

Farstad mailed an invoice to her doctor based on her own hourly wage, and eventually received a $100 check in the mail.

As mentioned, this story has received considerable attention. Over at the blog Survivor: Pediatrics , Brandon Betancourt humorously counters "Why not bill everybody that wastes our time?" including the movie theaters that make us sit through commercials and previews before the movie we came to see, or even Disney for waiting in those long lines. 

However, the issue of why patients have to wait is an important one. Most patients recognize that emergencies do come up in medicine, which often causes doctors to run behind schedule.  However, medical emergencies are not the main reason why patients spend long waits in doctor's waiting rooms.  The answer can be found in a study published last year and discussed in the New York Times "Study Shows ‘Invisible’ Burden of Family Doctors."  Primary care physicians do a lot more during their day than just see patients.  However, they only get paid for seeing patients.  The actual study, published in the New England Journal of Medicine measured exactly what a group of family physicians did in a given day.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

All of this unpaid work takes an incredible amount of time.  Also, assuming that the doctors were collecting 100% of their $70 per visit, at 18 visits a day, with 60% overhead  (often more for doctors), the doctor only takes home about $120,000 a year in salary.  Now that seems like a pretty good salary, and is certainly much more than most Americans make.  However, it is far lower than many other professionals with equal or less training (lawyers, accountants, dentists, college professors, etc.) and also doesn't take into account the enormous debt that medical students accumulate (in some cases close to $200,000 at graduation, adding up to  well over $1 million if paid over the course of a typical loan).   This is why our medical students are not going into primary care.

All this work can't be done in a given day, and the doctor can't see fewer patients to squeeze in this work because it will lower her salary even further. Another way to put this is that the doctor's time is valuable too, but she isn't get paid for her time. The doctor is getting less than what's it worth from the insurance companies for actually seeing patients and getting nothing from insurance for anything that's not face to face.

Thus, the doctor who is trying to see too many patients in too little time while simultaneously trying to get all the phone calls, lab results, etc. is going to run late. In my practice, with the exception of the first patient of a morning or afternoon session, I start each patient conversation with, "I am so sorry to keep you waiting."  There is only so much that can be accomplished in 15 minutes.   Primary care physicians who need to manage multiple complex medical issues have a choice: be good or be on time.  I choose to do the best job I can, which causes most of my patients to wait much longer than any of them should.

One solution to the problem is to have insurers properly reimburse primary care physicians for all the work that they do.  Unfortunately, regardless of who gets elected in 2012, this seems unlikely to happen.  Another solution is to get the insurance companies out of the mix all together.  This alternative solution is already starting to happen.  Retainer or concierge practices, which charge an annual fee (on average $1500/year) allowing doctors to have a very small number of patients who have instant access and no wait times, are gaining in popularity. Some have suggested that this is one solution for the primary care crisis.

However, many patients can not afford high retainer fees nor necessarily need this level or service.  For these patients, another solution is direct access primary care. Direct access primary care works more like a gym membership, where you pay a monthly fee for all of your basic primary care needs.  You can use your direct access primary care provider as little or as much as needed.  Qliance in Seattle, charges about $75/month.

There are a variety of other models that improve patient and physician satisfaction, and likely the actual quality of care.  However, the key ingredient in all of these models is cutting out the insurance companies to save money, hassle and overhead costs; and collecting money directly from patients to enhance revenue. This combination allows primary care physicians to spend more time with patients, have increased access, and subsequently low to no waiting for patients.

Bottom Line: The current insurance based system keeps primary care physicians on a treadmill, usually forcing them to choose quality of care over patient convenience. Though all patients deserve high quality, patient centered care that is convenient as well, the solution of higher reimbursements and decreased hassles for primary care physicians does not appear to be happening any time soon. Thus, as a patient, you have a choice. If your time is valuable, then you are going to have to pay extra for primary care services. If you choose to (or are only able to) rely on health insurance premiums and co-pays to cover the cost of your care, you should expect to wait. Expect to wait to get a timely appointment with your doctor. Expect to wait for the phone call with results of your recent tests. And, of course, expect to wait in your doctor's waiting room.


ACD22 said...

In the immortal words of "Joliet" Jake Blues, "Do you see the light?"

Please let me know when I can sign up for your new practice plan. I've been ready for a long time to ditch insurance for routine primary care and so have lots of others. Glad to see you coming to the dark side.

Dr. Matthew Mintz said...

If you are in the Washington, DC area, contact me directly and I can give you more specific information about available practices.

Anonymous said...

what is sad is the fact that we equate MONEY with healthcare first, then we think about "Does my insurance cover that?" and then consider throwing in TREATMENT as the next thing we think of

medicine should be about treatment, making the patient better and such, not about money or coverage, but alas that's what healthcare is all about these days, nothing is as sad as that

Dr. Matthew Mintz said...

"medicine should be about treatment, making the patient better and such, not about money or coverage."
Could not agree more. The problem is that health care delivery can not be charity work either. I have been practicing in a not-for-profit, academic faculty practice. Our mission is education, research and service. However, someone has to pay the bills, keep the lights on, pay the staff, etc. The current reimbursement model is not sustainable, at least for primary care. I would be open to any payment system that decreases the hassle factor, and pays a reasonable fee for my time. As long as I got a decent pay check, I would love nothing more than not to worry about money, insurance coverage, etc.

Anonymous said...

Poor doctors. I guess if their job is that hard they can opt out to work at MCDonald for minimum pay. Than they will have no mentioned problems, right?