Family Medicine / Direct Primary Care / Same-Day Appointments

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Have you ever considered the origins of the "15-minute office visit" and how we arrived at it as the benchmark for a health care visit?

In my earlier days as a primary care doctor working in a traditional medical clinic, I recall receiving a productivity report every month.  This report ranked every doctor in the group by the volume of patients seen, the total fees charged, and most importantly, patients seen per hour.  

Productivity Report


Doctors ranking near the bottom saw less than three patients an hour, those in the middle ranged between the three to four, while those at the top would see a dizzying five to even six patients an hour! In other words, the average doctor was seeing a patient every 15 to 20 minutes, while the top-ranked doctors were seeing one every 10 minutes.

The purpose of this report was quite clear to those of us in medical practice:  It was informing us in a not-so-subtle way that to be successful we had better produce both volume and charges (fees).  These reports used financial indicators as the ultimate benchmark of success--spending time with the patient was never mentioned.  

A “good” doctor in this system was one who churned and burned, not one who listened, learned, understood, and diagnosed his or her patient correctly.  Of course, not every condition requires that much time. Patients with simple upper-respiratory tract infections, sinusitis, strep throat, or urinary tract infections take very little physician time to diagnose correctly.  (It is this understanding that has led to the more recent explosion of nurse practitioner-only clinics, because physicians are not necessarily needed to diagnose these conditions.)

Invariably though, a far more complex patient would come into the office.  That person could take three or even four times more time to diagnose and manage than someone with a simple medical problem.  In those cases, a doctor was free to take more time, but if he or she had too many of those patients, it would harm him or her financially.  

So what was the end result?

The outpatient primary care system shifted its preference to treating uncomplicated patients.

If a clinic could prioritize the “simple” patients while shifting sicker, more complex patients to other doctors, then that clinic was rewarded financially.

This shift had occurred gradually since 1992, when Medicare adopted the Relative Value Unit, or RVU, system of paying doctors.  Based on its formula, a typical office visit equaled 1.3 RVUs which translated into 15 minutes using the American Medical Association coding guidelines.  Presto! The 15 minute office visit was born!

After a while, primary care physicians who were still committed to taking care of older and sicker patients noticed a trend: Their incomes started falling and they began having trouble meeting their overhead.  Dr. Ariel Cole, M.D., a geriatrician who focuses on the care of elderly patients said it best: "Geriatrics is the only specialty where you do more training to make less money. The truth is, I can see three 25 year-old women with UTIs in the time it takes me to see one 85 year-old with the same problem."

This change in the financial landscape led to an equally dramatic shift in the healthcare landscape:  Primary care physicians begin selling their independent practices to large health systems and hospitals.

With this movement, primary care physicians lost their autonomy to traditional business administrators of the larger systems.  These business administrators viewed primary care physicians as "engines" who referred lucrative patients "downstream" to the health system's most valuable physicians, such as surgeons, cardiologists, and others who perform expensive, well-reimbursed procedures.  They pushed their primary care physicians to see as many patients as possible to increase the referrals and consequent revenue to the system. In the end, all patients became a 15 minute office visit, whether their problems were simple or complex.

Now, 26 years later, the traditional family doctor and general internist is nearly extinct.

While there are still plenty of good doctors out there, they are invariably handcuffed and shackled to the goals and priorities of the health systems they work for.

In the end, a bad system will generate bad results. Good physicians forced to work in a bad system will eventually cease to practice medicine the way they would prefer to practice it.  The financial pressures of the system that emphasizes volume over quality and time eventually leads to physician burnout. Others choose to give up all together as many older physicians are choosing to retire early rather than continue to struggle in the current system.

Now more than ever, we need direct primary care.  

Direct primary care returns autonomy back to the physician and emphasizes the doctor-patient relationship once again.  It allows primary care physicians to spend time with their patients--as it properly should be--so that they get to know them and understand their health concerns.  

At the risk of self promotion, let me close by saying that I think you owe it to yourself to try direct primary care and experience the difference for yourself.  You too might find yourself shocked and surprised as if you had stepped back in time to the "good ol' days" of medicine, when you were more than a number and felt that your doctor and nurse truly cared about you.