Our office hasn’t been able to stop talking about Michael Stein’s essay in last week’s Washington Post. In his piece, Dr. Stein details the negative pressures today’s fee-for-service medicine system places on him – namely, the push to see as many patients as possible in a given day.
The essay provides various reasons for this pressure: Dr. Stein’s status as an employee of a large medical group, where he is instructed to conform to the assigned length of the patient visit; a need to react to the acute problems of the patients who come into the office that day instead of acting proactively; and the (well-intentioned) desire to accommodate patients who want same- or next-day appointments.
But the fundamental issue with this approach is captured by Dr. Stein towards the middle of his essay. He writes, “[t]he origin of the 15-minute visit is capitalistic, money tied to a clock…[the length of the average primary-care visit] remains driven by arbitrary 20th-century insurance service codes, based on diagnostic complexity, that dictate physician payment.”
The issues detailed by Dr. Stein are familiar for far too many primary care physicians – myself included. Working in fee-for-service medicine, I often found myself behind schedule, pressed to make up time during a “less complex” visit that may turn out to be every bit as nuanced. It is my privilege to spend a few extra moments with a patient to delve into the potential underlying environmental or personal causes of her condition, or tease out connections that would lead to more coordinated, more effective, care. But these extra moments are not always mine to give, and inevitably inconvenience the patients who follow.
In this way, the 15-minute visit structure sidelines the patient-physician relationship and becomes a zero-sum game – any excess time spent trying to improve one patient’s health through communication or a comprehensive approach to care means a patient later in the day might not receive the same attention, or might hold back explaining a problem, frustrated at having been kept waiting.
Accountable care in general – and our approach in particular – aims to keep physicians’ focus on patients, not the clock or computer screen. While value-based arrangements can’t completely eliminate the time crunch felt by doctors, shifting emphasis from the number of services delivered to the outcomes achieved reorients how doctors can approach daily appointments and a population of patients. In all of our Aledade ACOs, we implement initiatives designed to provide the space for physicians and their teams to avoid the situations detailed by Dr. Stein:
- Team-Based Care: All Aledade partner practices elevate team-based care and re-examine what can be accomplished by capable physician assistants, nurses, and other support staff. Engaging nurses and medical assistants as partners in quality care leads to fewer missed flu shots, improved coordination of care, better reconciled medication lists, fewer errors – and more time for the Aledade doctor to connect meaningfully with the patient.
- Medicare Annual Wellness Visits: When a practice joins Aledade, one of our highest priorities is working with the physician and staff to bring in eligible patients for Medicare Annual Wellness Visits (AWVs). AWVs, fully covered by Medicare with no costs to patients, leverage team based care and provide an opportunity for a doctor and patient to discuss a patients’ risk for falls, depression, and a host of potentially significant health issues, and develop personalized care plans for problems before they become serious.
- Focusing on high-risk patients: We work with our partner practices to proactively identify – through EHR and claims data analysis – the highest-risk patients in a doctor’s population. For these patients, we explore wrap-around approaches to care, examining external factors affecting health and integrating social services.
Each of these initiatives empowers doctors to spend more time thinking about the best way to care for patients, instead of worrying about the next appointment. As Stein writes, “[A] hurried, task-oriented approach doesn’t accommodate the meandering, overlapping, widening issues of patients.”
We want our doctors to be focused on exactly that – the complex ecosystem that each patient represents. So we’re working to change the equation, and add a few extra minutes to the clock.