A clinic patient recently told me he wanted to return to the “good old days” when primary care physicians were the “quarterbacks” for patients.
He said he remembered that primary care doctors not only referred their patients for health screenings, tests and referrals, but they also ensured that their staff scheduled those necessary tests and specialist visits for their patients. He said he recalled when doctors themselves were diligent about following up on the outcomes.
As a cardiologist in a busy cancer center practice, I listen to patients making similar comments about all physicians in general.
Until last year in our cancer center, health care staff scheduled tests and referrals for patients at check-out; ideally creating less stressful scheduling for patients. However, recently, staff now give patients resources to make their own appointments.
Hospitals and health care providers in the U.S. have recently shifted from practices of the past to managed care, meaning a managing company monitors a patient’s health care treatment. Based on the number of individuals covered by the plan, the managing company sends the health care provider a set amount of funding each month.
These companies require that physicians reduce health care costs as much as possible and spend more effort on preventive services. The emphasis shifts to primary care with less emphasis on referral and subspecialty services.
The overall result is that doctors have to be as efficient as possible in caring for patients. While efficiency is certainly a great attribute, the ultimate cost could sometimes be reduced quality of health care where doctors can miss subtle patient factors necessary for diagnosis.
In order to be more efficient while simultaneously cutting costs, doctors see more patients in shorter periods of time. For example, a typical primary care doctor could see return patients every 15 minutes; and could ultimately see up to 30 to 40 patients a day. A typical cardiologist like me has allotted 20 minutes for each return patient.
The large volume of patients affords physicians less time to follow up on each patient’s referrals and tests and to ensure staff schedule them. They also have to be able to do more for patients with less staff.
Many faculty physicians in academia and group practices use the Relative Value Units model to achieve efficiency in seeing patients. These RVUs are a model unique in the United States as a Medicare reimbursement formula for physician services.
Hospitals and administrations tie bonuses and sometimes salaries to these value scales, intended to incentivize physicians to increase their productivity by seeing more patients and doing more procedures. This can lead to reduced quality of care for patients.
For this reason, in order to improve quality of care, more hospitals and medical organizations, groups and the Medicare and Medicaid Services are moving toward a value-based payer system for health care providers, focused on the quality of care. Even though this model comprises a small percentage of physician compensation, many are optimistic it could grow to become the main model of physician compensation.
For instance, at the hospital where I practice, administrators modified a recent policy about fees for no-shows to clinic appointments to exclude patients who are Medicaid, Medicaid Managed Care, and Charity Care recipients. The fees policy overall includes only those who miss their clinic appointments without notice to the clinic or cancel within 24 hours of the appointment.
To be sure, efficiency is necessary for improved quality in health care. Patients sometimes knowingly or inadvertently add to these inefficiencies. Patients also miss referral appointments even after the clinic staff spends time coordinating these visits.
Yes, in the good old days, each physician saw fewer patients and spent more time with each one. Doctors were better able to establish meaningful relationships with each patient and more easily refer patients to specialists and follow up as needed. The system, however, was not so efficient.
Today with the focus on preventive services, the health care system may be overall more efficient. Yet with this grueling emphasis on efficiency, the system needs to move towards providing an excellent quality of health care, in order to create good new days for all patients.
Dr. Tochukwu (Tochi) Okwuosa is a board-certified cardiologist, Associate Professor of medicine at Rush University Medical Center. She is the Director of the Cardio-Oncology Program at Rush and is the onsite cardiologist at the Rush University Cancer Center.