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What is the Value of Clinical Time?

Posted by Simone Isadora Flynn, PhD, NPA Project Manager-Leveraging Social Media September 17, 2014 at 12:21 PM

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In his provocative NYT piece, “Busy Doctors, Wasteful Spending,” Dr. Sandeep Jauhar tackles an issue addressed in NPA’s July 2014 policy brief, Value and Values in Health Care. NPA leaders have endorsed the principle that clinicians needs more time to understand patients better and to create and maintain healing relationships.

Does Jauhar nail it or not? Read his op-ed below and tell us what you think. Your responses to NPA blog posts help us refine our communications about important issues and influence the choice of initiatives we undertake.

“Busy Doctors, Wasteful Spending”
By Dr. Sandeep Jauhar, a cardiologist,
New York Times, July 21, 2014

Of all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients.

Racing through patient encounters, we practice with an ever-present fear that we will miss something, hurt someone and open ourselves up to legal (not to mention moral) liability. To cope with the anxiety, we start to call in experts for problems that perhaps we could handle ourselves if we had more time to think through a case. The specialists, in turn, order more tests, scans and the like.

And therein lies the sad irony of the health cost containment paradigm in this country. There is no more wasteful entity in medicine than a rushed doctor. For the full op-ed, click here.

Do you agree with Dr. Jauhar?

Total MissI Think NotMehGenerally In The ZoneNails It (4 votes, average: 5.00 out of 5)
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6 Responses to “What is the Value of Clinical Time?”

  1. Ken Frisof, MD says:

    “Rushed” is only a partial description of the problem. Deeper causes are fee-for-service and lack of collegiality. Too often a referral is made because it generates specialist income (as well as further studies) when a ‘curbside consult’ would have been able to answer the technical question on the clinician’s mind. As long as volume is the primary source of income, “rushed” will be the name of the game.

  2. Hillary Clinton recently stated, “The fee-for-service model, which made a lot of sense for a long time, may not make sense for physicians, for hospitals, or any other providers and may not make sense for patients and other payers.” Dr. Jauhar is correct about the waste in healthcare that results from a doctor being rushed. It takes time to take a history, do an exam, and then explain to the patient the ‘working diagnosis’ and ‘differential diagnosis’ and the benefits, if any, of ordering tests to reach an ‘accurate diagnosis’. With the present fee-for-service model, many physicians and mid-level providers take the easy road and look for the answer through a plethora of labs and imaging studies. Osler said, “One of the first duties of the physician is to educate the masses not to take medicine.” I would add to that by saying one of our first duties is to listen to the patient story and only resort to ordering tests when absolutely necessary and only when the tests will be used to determine the next step.

  3. Jeffrey Jaeger says:

    I agree with the other 2 posters that the problem here is not “rushed” physicians, but a fee-for-service payment system that makes no sense for patients, payers, or providers. I admit to having an understanding of healthcare economics that is not good enough to understand why capitation and accountable care cannot be adapted to work for the best interests of those three groups. As long as you have FFS, payers will try to cut their expenses by paying less per service, and providers will ramp up the # of services provided.

    But it makes no sense to complain about being rushed. The real problem is the way you are paid — you are choosing to rush to sustain what you believe to be a reasonable reimbursement. As long as you and the payer disagree on what that should be — you will feel rushed.

    Look to the recent (and soon to be reintroduced) report of the National Commission on Physician Payment Reform (http://physicianpaymentcommission.org/) for clear guidance on how we can move past FFS and get to a future where we again have some control over the service we provide, the costs, and the outcomes.

  4. Thomas Pretlow, M.D. says:

    I agree with Dr. Juahar’s views as expressed in the editorial. His book, “Doctored…” is really impressive. His renunciation of the complicity of many physicians and administrators in the needless extortion of money from patients may not make him popular in some circles. As one who (a) entered medical school fifty years ago this month and (b) is retired, the most important point that I would like to make is that the older patients whom I know personally are often very discouraged by what they have experienced in medical care to the point that they delay in seeking needed medical help because it has become such an unpleasant experience. Delays can often cause exacerbation of disease patients resulting in greatly increased medical expenses.

    I should comment on Dr. Juahar’s observation that “One option is to hire doctors as employees and put them on a salary, as they do at the Mayo and Cleveland Clinics, which takes away some of the financial impetus to cram more and more patients into a workday.” As one who worked as a full-time academician for his entire career, I do not regret the fact that I was paid a salary without bonuses. I would point out that friends of mine who practice at the Cleveland Clinic tell me that they get very significant bonuses annually. Some of them think that these bonuses are related to the amount of money that they generate at the Cleveland Clinic. Upon his retirement I was told by an internist specializing in infectious diseases at the Cleveland Clinic that, if he spent fifteen minutes with a patient, an administrator came and knocked on his door. When I repeated this to another friend who is a Cleveland Clinic clinician, his response was: “Fifteen minutes for Clinic patients: nine minutes for Kaiser.” In short, even when clinicians are paid salaries, they can be manipulated by a variety of other approaches including generous bonuses.

    When relating to patients, physicians need time to observe the patient during the history and physical examination, time to think, time to discuss the patient’s condition with the patient. These activities are considered by some to be “unproductive,” i.e., unreimbursable.

    As a single payer enthusiast, I would suggest that there are many ways to save money on administration, insurance, and pharmaceuticals without harming patients.

  5. Jim Scott says:

    I hear from many colleagues about the feeling that they’re on a treadmill, focused on ‘production’ and the speed keeps getting turned up. We need to re-define ‘production’ from RVUs to relationships, healing. RVUs don’t measure value, they measure activity.

  6. I agree wholeheartedly that more time with patients is essential, but I think that fixing this issue goes far beyond simply paying doctors for their time and abolishing fee-for-service; a siloed and physician-centric model of healthcare is simply unsustainable and sometimes harmful to patients. We need to focus on means of care delivery that give more power to patients and their communities, including community health workers (which I’ve written on before: http://afpjournal.blogspot.com/2014/06/guest-post-future-of-family-medicine-20.html & http://mereorthodoxy.com/beyond-pink-police-state-community-health-workers/). This is going to take sacrifice from doctors– sacrificing the easy patients on our schedules so we can spend our time and energy helping the really sick ones. It will take some power sacrifices and financial sacrifices as well. But we have to lead the charge in humbling ourselves or else these things will be taken away from us by the cost cutters.

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