Curbside Consult with Dr. Jayne 9/19/16

A reader clued me in to this great piece in Forbes that discusses the 15-minute office visit. It ties the origin to Medicare’s RVU (relative value unit) formula and its attempts to standardize the calculation of physician fees. The RVU formula factors in geography, practice expenses, liability insurance, and a Medicare “conversion factor” in an attempt to level the playing field for physicians. Translating the average visit’s RVUs using the American Medical Association’s then-current coding guidelines resulted in an average 15-minute office visit.

The RVU formula came into being in 1992. We’ve been through some cyclic changes in healthcare with the rise of managed care, a frenzy of hospitals purchasing practices, the subsequent divestiture of the practices, then back to integrated delivery systems and hospital ownership of physician practices. The change has recently been fueled by the rise of Accountable Care Organizations and other risk-sharing programs as well as the regulatory pressures stemming from HITECH and resulting incentive (now penalty) programs.

Medicine has changed considerably in the last 24 years. Decision-making has gotten more complex. Many patients are more empowered and take an active role in their healthcare. These visits often require more time due to detailed discussions of the pros and cons of various treatment options or diagnostic maneuvers. Unless physicians are coding based on the face-to-face time spent in counseling or coordination of care, it’s hard to get insurance payers to adequately pay for the time spent on those visits. Payers often ask for loads of documentation to justify the visit code, which results in additional work and expense to the practice.

Payers have created lists of codes they won’t pay, regardless of the medical realities. Case in point: I recently diagnosed a patient with a skin infection, most likely from time spent in a hot tub with inadequate cleaning procedures. The patient required antibiotics and I had to take a detailed history to make sure I was selecting the correct drug based on the likely infectious agents. It probably lasted less than 15 minutes, but I was rewarded a week later with a denial because the insurance company refuses to pay for a diagnosis of folliculitis. My staff had to handle the request, then send it to me for potential re-coding, and then we had to submit the claim again. Knowing how much time had already been wasted, I slapped a couple of potential diagnoses on the chart in the hopes that I’d hit the jackpot with one of them and would actually be paid.

Why is that OK? The patient had an actual problem, it required thought to diagnose, antibiotics were needed, and the visit was legitimate. Counseling on hot tub hygiene was given. The problem wasn’t self-limited and was unlikely to resolve without medical attention. I see dozens of people who come in with issues that could be easily handled by a well-trained Scout with a first aid kit and I get paid for those, but this time the insurance decided they just weren’t going to pay for that particular diagnosis.

Whenever physicians complain about everything they’re trying to cram into the 15-minute office visit, the first answer is that maybe we don’t need physicians to provide the care. Nurse practitioners and physician assistants should be used as well as various care team members with a range of clinical training experiences. Regardless of who is delivering a given level of care, it still takes time to deliver it, document it, and make sure the patient understands the steps they need to take prior to the next episode of care.

In many states, nurse practitioners and physician assistants practice independently. We just had a mini-revolt in our practice when we tried to credential our physician assistants to work without a supervising physician. The maneuver was intended to lower the cost of care, but several PAs refused to take part, reminding our leadership that their title was “physician assistant” rather than physician and that they went into the field to assist physicians rather than to try to be interchangeable with them.

I often practice alone, without a second clinician to jump in if the office gets busy. Those 15-minute visits become shorter and shorter when we have six or more patients streaming into the waiting room every hour. Most come because either they can’t get after-hours care from their primary physician or because they don’t have a primary physician. Our mission is to address their issues as completely and compassionately as possible, and knowing that payers can just decide not to pay for our services really puts a shadow over the whole concept of what we’re trying to do.

The editorial mentions that of the typical 15-minute office visit, physicians may spend 37 percent of the time doing paperwork. I’m fortunate to work for an organization that values physician time and staffs the practice with scribes during peak periods so that physicians and our independently-practicing PAs can focus on patients and not paperwork. Most of the time my notes and orders are complete before I walk out of the exam room, which is truly a beautiful thing. Patients appreciate our focus, but having a qualified scribe doesn’t come cheap. A good number of our scribes are students and recent graduates who are applying to medical school and who are looking for experience. It continues to amaze me that people would still consider a career in medicine after what they see in the trenches.

Using a figure of 37 percent leaves eight minutes for the actual office visit. The piece breaks down the patient activities that must fit into that time slot: social constructs like saying hello, disrobing if you didn’t change already, explaining why you’re seeking medical attention, being examined, etc. It suggests that patients shouldn’t take more than two minutes to tell their story, likening the time slot to that of a commercial break during broadcast television. “If four companies can get you to buy things in two minutes, surely you can tell your whole story.” That works if patients have focused or prepared, which is a rarity. Usually when I ask how long something has been going on, patients have to work through a series of cues to figure out the timeline. “Well, it started when I went to Michigan for Dean’s wedding, that was in the spring, no maybe it was early summer…” and there you have it.

I don’t blame patients who haven’t prepared – they should expect more than assembly line care with physicians running on the hamster wheel. They’re seeking care, not auditioning for a play or interviewing for a job. However, as long as insurance companies (including government payers like Medicare and Medicaid) are intermediaries and patients aren’t able to understand the full cost of care, things aren’t going to change. Patients who are actually paying for the physician’s time are going to demand his or her full attention, not an overly-truncated excuse of an office visit.

Building a patient-physician relationship takes time and medicine isn’t something that’s practiced by following a cookbook approach. Technology can help,but it’s not the be-all, end-all solution for healthcare’s problems. However, it seems to get most of our focus. Patient-empowerment movements have helped raise awareness of the need for greater partnership and shared decision-making in healthcare, but no one wants to pay for it. Cost control will continue to be a downward pressure with clinical and emotional consequences for both patients and caregivers. Eventually something has to give.

When will we reach the boiling point? Have ideas on how to fix things? Email me.

Email Dr. Jayne.