Frustration at the apparent waste of money in the United States’ health care industry by federal and state governments, insurance companies, and some commercial providers is nothing new. Increasingly, however, patients and doctors are growing frustrated by the industry’s waste of a more precious resource: time.
Most patients are keenly aware of the contrast between the hours they invest in visiting their doctor’s office and the few minutes they spend with their doctor during an exam.
On average, patients enjoy a paltry eight minutes of face time with their doctor during appointments. Doctors often spend the remainder of the patient’s 12- to 20-minute appointment on administrative tasks, such as meeting burdensome electronic health record (EHR) reporting requirements issued by the federal Centers for Medicare and Medicaid Services (CMS).
The up-to-20-minute block of time an average patient spends in an exam room receiving care from a doctor is often a fraction of the time patients spend on the premises of their doctor’s office. Patients spent an average of 84 minutes at clinics per visit in 2010, according to a 2015 study published by the American Journal of Managed Care (AJMC).
To these 84 minutes, add 44 percent, or an average of 37 minutes, of travel time per visit, rounding out the average total time patients spend on each doctor appointment to just over two hours–121 minutes–the AJMC study states.
Patients who live in rural areas and who need highly specialized care must travel farther and longer. “For multiple sclerosis, there’s very few specialists … in Georgia,” telemedicine provider Dr. Jeffrey English, director of clinical research at the MS Center of Atlanta, told me in an August 4 episode of the Health Care News Podcast. “They’re only in Atlanta, so I would have patients who would travel four hours each way … and I would spend 20 minutes with them.”
In contrast to doctors, patients don’t bill for time spent at appointments–but patients’ time still carries a price tag above and beyond their out-of-pocket costs (not to mention costs of car fuel and maintenance or other transportation). “Opportunity costs added 15 additional cents in indirect costs to every dollar spent in physician visit reimbursement,” the AJMC study states.
An extra 15 cents per dollar may not sound like much, but extrapolating these pennies across all patient visits yields a staggering figure.
The total dollar value the study assigned to the time patients spent on doctor appointments was $52 billion among America’s adult population in 2010. This includes, among the employed, $25 billion in the lost productivity of 1.1 billion hours spent on doctor appointments.
On the other side of this equation is doctors, many of whom suffer from the prevailing system’s inefficiency almost as much as patients do.
Doctors mired in the mainstream third-party payer system–i.e., who primarily bill patients’ insurers, Medicare, or Medicaid–typically must treat 2,000 to 3,000 patients across 6,000 to 9,000 doctor visits per year in order to earn at a level acceptable to them. At that pace, minutes are scarce, and EHR reporting requirements enforced by CMS make time scarcer.
“I see thirty patients each office day,” Dr. William Strinden of Memorial Hospital in Lufkin, Texas, told the American Medical Association for a Break the Red Tape event, Becker’s Healthcare reported in October 2015. “If I wasted only three minutes per patient, that would add up to an extra hour and a half of work. I have a [registered nurse] and three employees who have been with me at least 12 years and do a good job and are well-compensated. It would cost me at least $100 per day extra just in lost time.”
Becker’s reported that Dr. James Smith, a practitioner in Lawrenceville, Georgia, tried to save time by inputting history and orders while talking to patients. “I could tell that they felt I was very detached and more focused on this,” Smith said–so he hired a scribe to facilitate EHR reporting. “That has alleviated a portion of that and allows me to sit at the bedside and be more engaged with a patient, but that’s now at a cost of between $25,000 and $30,000 a year out of my pocket.”
Laws like the Affordable Care Act, and CMS regulations like EHR reporting requirements and restrictions on telemedicine reimbursements, purport to increase patient access to affordable, high-quality health care. Their success is doubtful, as evinced by Republicans’ and Democrats’ renewed calls for vigorous, although different, government responses to the current health care landscape.
Our government programs fail to keep pace with the opportunity cost of a single patient’s doctor appointment. No government program can keep pace with the opportunity cost of confining free-thinking patients and enterprising doctors to a centrally planned system.
Michael T. Hamilton ([email protected]) is The Heartland Institute’s research fellow for health care policy, author of the weekly Consumer Power Report, and managing editor of Health Care News, an online and print newspaper read by market-minded health care professionals, policy analysts, and 56 percent of lawmakers.
IN THIS ISSUE:
Late Monday evening, health insurer Aetna confirmed a major pullback from Obamacare’s exchanges for 2017. The carrier, which this spring said it was looking to increase its Obamacare involvement, instead decided to participate in only four state marketplaces next year, down from 15 in 2016. Aetna will offer plans in a total of 242 counties next year — less than one-third its current 778. Coupled with earlier decisions by major insurers Humana and UnitedHealthGroup to reduce their exchange involvement, Aetna’s move has major political and policy implications …
Over the weekend, in a report on premium increases for 2017, the New York Times noted that for one Pennsylvania health plan, nearly 250 individuals incurred health-care costs of over $100,000 each — “and then cancelled coverage before the end of the year.” While the administration has proposed some minor tweaks to minimize gaming the system, they will not solve the underlying problem: It takes tens of thousands of healthy enrollees to even out the health costs of 250 individuals with six-figure medical expenses, and Obamacare plans have failed to attract enough healthy individuals. …
The Wall Street Journal noted that Aetna’s pullback means that some areas in Arizona now have no health insurers offering exchange coverage. Individuals there who qualify for insurance subsidies will have nowhere to spend them. President Obama faced a self-imposed crisis in the fall of 2013 when millions of Americans encountered a double whammy: Cancellation of their pre-Obamacare policies was coupled with much higher premiums for exchange coverage to replace it. …
How would a President Clinton get out of the box that her predecessor has gift-wrapped for her? …
As I previously noted, Aetna’s “solution” to the exchange problem is simple: Place taxpayers on the hook for their losses — in short, a permanent taxpayer bailout. …
SOURCE: Chris Jacobs, National Review
Hospital boardrooms are beginning to sound more like those on Wall Street, with talk of upside and downside risk, capitation and a hefty addition of new acronyms.
Hospitals, health systems and physician groups are now in the process of deciding which of the two possible reimbursement paths they will take under the Medicare Access and CHIP Reauthorization Act, which replaced the rarely implemented sustainable growth-rate formula for determining physician pay.
“This is not practice as usual,” said Aric Sharp, vice president of accountable care at UnityPoint Health, based in West Des Moines, Iowa. “This is not what we’ve done for the past 10 to 20 years in group practice. This is a whole new world.”
There was much rejoicing in April 2015 when Congress replaced Medicare’s extremely unpopular SGR formula with an overwhelmingly bipartisan vote. The focus, however, was far more on the joy of getting rid of the annual doc fix to payment rates and all of its frustrations than it was on the system now set to replace it–MACRA.
Under MACRA, providers will use either the Merit-based Incentive Payment System, known as MIPS, or an alternative payment model. Under MIPS, physician payments will be based on a compilation of quality measures and the use of EHRs. HHS will announce the eligible measures, and providers will have some options on which to report. More on how this will work is expected in the final rule, which is likely to be published in November.
About 90% of physicians are expected to take this path.
MIPS consolidates three highly unpopular incentive pay programs: the Physician Quality Reporting System, or PQRS; the Physician Value-based Payment Modifier; and the electronic health record meaningful-use program. Providers will now be graded on quality, resource use, clinical practice improvement and meaningful use of certified EHR technology. Medicare revenue would be affected by as much as 4% in 2019, the first year the payment changes take effect, and increase to up to 9% in later years.
Most providers will choose MIPS because they are not ready to take on the other option, a qualifying alternative payment model that requires a hefty amount of risk. Many don’t have the capital to set one up or to risk losing money with subpar performance. Although MIPS requires putting some profits on the line, it is much less of a gamble than heading into an APM without experience and confidence that quality measures are high. …
SOURCE: Shannon Muchmore, Modern Healthcare
Dr. Lorraine Page, believe it or not, makes housecalls.
One place she makes calls on is the home of Ann Caponio. …
Besides the housecalls, Page provides a little more than Caponio could expect from the primary care service she’d get through Medicare. Page, for instance, has aided her patient with a number of safety issues, including helping her find someone to rig up a chairlift on those stairs. Now, she can sit on a seat at the top and get ferried to the bottom.
“It opens up a whole new world for me,” Caponio says. …
A whole new world is what Dr. Page herself has been experiencing, ever since she left the traditional clinic setting to try something different. She does have a small office, but prefers to visit most of her patients in their homes.
She’s one of a growing number of doctors who have cut loose from what she calls the “assembly-line, volume approach” and is now using a health care delivery model called direct primary care. She has scaled back the number of patients she sees and takes longer with the ones she does. She doesn’t take insurance and deals mostly in cash; she charges each time she sees a patient, but most direct primary care doctors charge a monthly fee for unlimited visits.
In her previous practice, Page says, the pressure to see more patients in less time wore her down, as did the need for an army of support staff to process the copious paperwork required by insurance companies.
“At our office, we had six full-time doctors. And we had seven full-time insurance people,” she says. “So [that’s] more than one full-time person trying to get reimbursement for patients I was seeing.”
She ticks off the benefits of leaving that bureaucratic load behind: more time with patients; shorter days from seeing fewer of them; and doing the kind of family-care medicine for which she was trained.
“And I enjoy it a lot more,” Page says. “Let’s not minimize that.” …
SOURCE: David Gorin, KQED Science
Blue Shield of California is shutting down for the four days after Labor Day to reduce its payroll-related liabilities, citing losses in California’s Covered California Obamacare exchange and other commercial and individual lines of business.
The move will affect most of its 6,000 employees in California, except about 1,000 who work for Care1st, which it acquired last fall for $1.2 billion, and some staffers in customer service and related areas who will remain on the job. The exact number of workers involved hasn’t yet been tabulated, according to the San Francisco-based insurer.
“This is certainly not normal for us,” said spokesman Steve Shivinsky. “We’re definitely seeing some income challenges as of mid-year,” with claims in the individual and other markets “greatly exceeding the revenue we’re taking in.”
The move could save Blue Shield an estimated $4 million, by reducing its liabilities for paid time off.
Staffers are being required to use paid-time-off from September 6 to 9, Shivinsky confirmed. He said health plans nationally are facing challenges in the individual market and on the Obamacare exchanges, and some have said they plan to exit or cut back their participation, but Blue Shield isn’t taking that step. …
SOURCE: Chris Rauber, San Francisco Business Times