Tag Archives: waiting times

From the Patient’s Point of View-Why will they be Miserable?

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 The 15-minute visits also take a toll on the relationship of the patient-doctor relationship. The patient who sits patiently in the exam rooms waiting patiently for the doctors to arrive for their visit and to finally speak with their physician. They have already seen the administrative secretary and the nurse, but they came here to see their physician. So, now the physician presents his or herself. Based on my complaint he or she looks in my mouth, throat and up my nose, said that my throat was inflamed and told me to see the nurse for a prescription and that I was suffering from a sinus infection with inflammation of my throat from posterior pharyngeal drip.

When I protested the drug that he wanted to prescribe he cut me short and told me to see the nurse……and he was out of the exam room. It must have been a visit that lasted for a total of 9-11 minutes, if that.

This story is becoming increasingly common. The patients as well as the physicians are feeling the time crunch as never before. The doctors and nurses feel like “running” office hours on rollerblades. Doctors have to see more patients and perform more procedures to make up for the discounted, flat or declining reimbursements.

This problem will worsen with the Affordable Care Act (ACA). Remember, millions of consumers who are gaining healthcare through the ACA begin to seek care, many of whom have never, or very rarely, have seen a doctor and therefore this patient population presents with a list of untreated problems. Often in the primary care as well as in other specialties, the patient is seen for only one diagnosis per visit. This is very inconvenient for the diagnostically/multiple disease patient. They then don’t get the comprehensive care with continuity associated with the individual patient. This is happening today as evidence by one of my patients with complex endocrine disease (diabetes and thyroid disease) who has been frustrated by these short visits with the results that her complex disease is out of control. I quickly referred her to an endocrine specialist.

In today’s world it seems that the doctors have one eye on the clock and the other on their laptop computers, typing away to capture the correct amount of “points” for the highest reimbursement for the visit.

As Roni Caryn Rabin stated in her article in WebMD, short visits take a toll on the whole relationship of the doctor –patient, which I have already stated in an important part of the good care equation. As I presented last week, we have to have a change in behavior in both the doctor as well as the patient. The office visit and the physician-patient relationship represents missed opportunities for getting patients more actively involved in their own health care. Research and the surveys show that there is less of a dialogue between the patients and their doctors, which increases the odds that patients will leave the office frustrated. Also, the shorter visits also increase the likelihood that patients will leave the office with a prescription, instead of discussion about behavioral changes like trying to lose a few pounds by going to the gym/exercise.

The physicians also don’t like to be rushed either, but for the primary care physicians and now even with specialists, time is is, quite literally money. Primary care doctors are paid mostly per visits with only minor adjustments for those that go longer than the time allocated for the diagnostic codes. Specialists who do procedures also need to see an increasing number of patients to generate a proportion of patients an increased number of procedures to compensate for the decreasing/discounted reimbursements for those procedures. The struggle is getting worse and worse with doctors thinking about meeting the bottom line, paying the overhead, having to pay staff and keep the doors open.

The pressure becomes even worse between both physician and patient when the patient has waited 9 months for his or her appointment and when the doctor comes in the exam room the patient pulls out a long list of complaints. Remember, the patient is thinking that they have waited sometimes a few months for the appointment and I’m going to try to get the most of my time that I have taken off from my work or have had to get paid childcare so that they could get to the appointment.

The situation became worse when doctors started participating in managed care networks where the doctors gave the insurers discounts on their rates in exchange for the promises to steer more patients to their office. Therefore, to avoid a cut in income the doctors had to see more patients.

In medical school the students are drilled in the art of taking a careful medical history, but studies have found that the doctors are falling short and that they have a bad habit of interrupting. A 1999 study of 29 family care practices found that doctors let patients speak for only 23 seconds before redirecting them and that only four patients got to finish their statements. Today the technical doctor of the present is often, and the interview is interrupted by the physician’s beeper, their cell phone or an email notification as their typing in the patient information on their laptops.

Communication between the physicians and their patients is important and making the patient feel they have been heard may be one of the most important elements of the healthcare equation. People are feeling dissatisfied when they don’t get a chance to say what they have to say, when they don’t get their questions answered, that they got their monies worth.

What happens when the patient doctor relationship suffers? Well, the patients lose trust in their caregivers and don’t fully engage in their care. How then do you change the patient’s behavior leading to better care, a healthy patient that leads to a more sustainable health care system?

It is predicted by this writer and physician, that with the increased numbers of patients forced into a system with less and less physicians that this relationship between the physician and their patient will get worse and worse. So, the middle class will get poorer healthcare and have to pay more for it.

Good Behavior and Bad Behavior-How do we reward or penalize behaviors?

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As I suggested weeks ago, that in order for the Accountable Care Act(ACA) to work or become sustainable as a health care system for the USA, we need to have behavioral changes take place.

These behavioral changes need to come from both the patient as well as from the physician and the health care delivery system. We can reward the physician as well as the health care delivery system by increasing reimbursements or payments for the patient interaction, i.e. patient visits, patient care, surgical procedures. We negatively affect the physician and health care system by assessing penalties or decreasing what the ACA pays out for patient interactions or surgical procedures. We can also penalize health care providers by denying them licensing to practice or increasing their malpractice premiums. This way we weed out the bad players in health care, as well as bad behavior.

But how do we encourage good behavior for patients involved in their care, improving their health? How do we penalize the patient who does not want to participate in their care, persisting in their bad behavior, with no improvement in their health? In fact these patients get sicker and the demands financially and the man/woman-power investment become unrealistic.

The patients that pay their insurance premiums, we can increase the premiums, increase their deductibles, penalize them on their taxes, whether federal of state taxes. But what will the results be? Increasing their deductibles discourages the patient from seeking medical care because the majority of cost is now out of pocket. So, how does this encourage good behavior?

Increasing the premiums for patient’s bad behavior and decreasing their premiums and deductibles for good involved compliant behavior makes a lot of sense. But increasing their premiums or assessing tax penalties will not work, especially in the fully subsidized person or persons who will not feel the true effect.

In fact, will any of these ACA health care strategies work if we can’t change the overall behavior of the patients who are going to still delay their care, resulting in the continued use of the most expensive form of health care….. the emergency room (ER) for their routine care. This is a problem because using the ER sets the system up for failure due to the increase expense and the level of care needed for the patients who wait until it is often too late to for preventive care and then often result in the need for interventional costly procedures.

In a survey that I completed I had a number of participants want to deny coverage altogether for these noncompliant patients. Really? How does this contribute to a system, which is designed to provide health care for all potential patients blinded to their financial status?

Unfortunately, we are truly stuck in that we can not really penalize bad behavior in the portion of the demographic segment of patients who are completely subsidized by the government health care system or those who pay no taxes.

But we can reward good behavior. Here is the answer, I believe, to this dilemma. If they already have subsides like SNAP cards, can we increase or bonus them for good behavior? I think this is a workable solution. We may have to put on our thinking caps and design creative rewards so that these “bad behavior” patients are converted to patients who participate in their care lowering their blood sugars, their weight and who will stop smoking.

I love the idea of the British system, utilizing consumer taxing to subsidize their system, i.e. the Value Added Tax (VAT), which is being increased from 17% to 27%. Heck, raise the tax on cigarettes to 50-75% as well as increasing the tax on alcohol as well as on “bad” non-nutritious foods.

We need to be very careful in that we don’t proceed down the murky path of true social engineering. Do we deny hip and knee replacements for the obese noncompliant diabetics? Why not? They are the patients who will have the highest complication rates, costing the system a true financial burden.

Do we extend this thinking to the noncompliant patients who don’t take their blood thinners, medications for high blood pressure and heart medicines? Why not? Here we will eventual see these patients dying out and therefore decreasing the “bad” patient population. Wow, should we really conceive these strategies? Think about it. In the European system where the necessary surgery waiting times are often weeks to months, aren’t they also culling out the “bad” behavior patients? Sure, the high-risk patients and noncompliant patients then die from their underlying premorbid diseases or go elsewhere for their care. I truly cringe when I just mention these potential strategies. But what options do we have?

So, what are your solutions to these difficult problems? We have to consider these problems and come up with solutions otherwise the system will eventually fail or result in a multi-tiered health care delivery system.