Fri 19 May 2006
An article in the May 1 issue of Time, titled “Q: What Scares Doctors? A: Being The Patient“, struck a chord with me. While a lot of it was about things specific to the situation of doctors being patients, there was a quote that really got my attention.
Specialists are typically paid much more to do a procedure than the family doctor who takes the time to talk through the treatment options. A doctor who does a biopsy may be paid as much as $1,600 for 15 minutes’ work, notes Dr. Jerome Groopman of Harvard Medical School. “If you’re an internist, you can easily spend an hour with a family where a member has been diagnosed with Alzheimer’s or breast cancer, and be paid $100. So there’s this disconnect between what’s valued and reimbursement.”
And yet sometimes, talking is the more important and certainly the safer treatment. Ten more minutes spent taking a family history can reveal clues that prevent a misdiagnosis or an unnecessary test…
One of the reasons this resonated with me is because I went to see my primary care physician (my “PCP”) recently. Some recent events in my family convinced me that the “I’ll quit smoking… soon” I kept saying needed a date put on the “soon” part.
During my visit, we didn’t just discuss my desire to quit smoking. We talked about various things I’m doing to improve my health and quality of life, how they’re coming along, and where they’re going. I probably took about 20 minutes of his time and I greatly appreciated the time he spent with me.
When the doctor in the Time article said “you can easily spend an hour with a family… and be paid $100,” that’s because the office visit with your doctor is basically considered a “procedure”. My doctor gets the same amount from the insurance company whether we talk for for 5 minutes or 20 minutes.
And because the doctors, whether a surgeon or a primary care physician, get paid by procedure, this creates a situation in which their income doesn’t depend so much on the quality of care as the speed of care. If a doctor can get away with giving each patient 10 minutes, instead of 20, he doubles his income.
It just feels wrong, doesn’t it? But if the insurance company paid by the hour… doctors would be looking for patients who were die-hard sports fans. Why? Because if insurance companies paid by the hour, the most profitable question a Seattle doctor could ask would not be “is anything else bothering you?” The most profitable question would be “how about those Mariners?”
A system that pays by the hour is ripe for abuse and would probably drive insurance costs even higher. Yet a system that pays by procedure financially punishes the doctors who take the time to care for the whole patient, not just the latest symptom. And since taking that time can “prevent a misdiagnosis or an unnecessary test” it seems like consumers are left with a choice of what they want raising their insurance rates:
1: The insurance companies paying for tests and issues caused by doctors not being able to take the time to talk with patients as much as they should.
2: The insurance companies paying doctors to listen to what’s wrong with the Mariners’ batting order.
Raising the rates the insurance companies pay for an office visit might solve some of it. Some doctors would see it as an encouragement to give their patients more time. Other doctors, especially if they have kids in private school and a car payment higher than my mortgage payment, would see it as a windfall.
Once again, I’m left asking “what’s the answer?” How do we structure a system that rewards doctors for asking the right questions, regardless of how long it takes, but doesn’t give them an incentive to ask “how about those Mariners?”
I’m stumped. If you have an idea, please post it in the comments below.
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