Why (non-DPC) Doctor’s Visits Feel Rushed
Why Doctor's Visits Feel Rushed
If you’ve ever felt that your visit to the primary care doctor was rushed, you're not alone. Many patients are frustrated by medical appointments' increasingly brief and impersonal nature. Let's delve into the reasons behind this and what it means for patient care, acknowledging the shared frustration.
Mal-aligned Incentives
In recent years, the healthcare landscape has shifted significantly. Large corporate entities, aka healthcare systems, have bought out many independent practices. These healthcare systems emphasize profitability and efficiency more than patient-centered care. The predominant reimbursement model in the US Healthcare system is “Fee-For-Service”(FFS). This model incentivizes volume (seeing more patients) over the quality of care. In this model, insurances reimburse for direct care or patient visits. Some systems will counteract this by tacking on additional metrics to incentivize providers to improve “quality of care” (i.e., financially rewarding those who achieve a specific target percentage of patients above predefined metrics annually). The metrics vary yearly, but commonly measured things include the percentages of patients with controlled diabetes, controlled blood pressure, or the percentage of your panel up to date on colon cancer screening. You may think this sounds good until you consider that a doctor with a panel size of 3000 patients (or more) likely has much less influence on those numbers than expected. Quality metrics, short patient visits, and large panel sizes are a recipe for failure. Improving outcomes requires time and trust.
There is a push to re-align incentives with patient outcomes more comprehensively; however, this, too, has its limitations. “Value-based care” (VBC) is a newer payment model that incentivizes providers to focus on quality outcomes rather than the quantity of services rendered. In VBC, the emphasis is on the overall health of the patient, rather than the number of visits or procedures. The potential benefits of VBC include improved patient outcomes, reduced healthcare costs, and a shift towards a more patient-centered approach. “The Centers for Medicare and Medicaid Services (CMS) has set a goal to have 100% of all Medicare beneficiaries tied to quality or value by 2030. Yet 40% of Medicare payments are still tied to Fee-for-Service as of 2020.” (Ahmed) Implementing VBC requires significant upfront financial and technology investments. Though it does stand to lower overall healthcare costs, it partially does so by limiting patient choice. Kaiser Permanente is an example of a healthcare system that has implemented VBC.
The Impact on Patients
Most of my patients come from FFS-based systems, so they are accustomed to 15-minute face-to-face visits (regardless of the patient issue) and long appointment wait times. When I left my healthcare system, I had a panel of 3000 plus patients and a 3-6 mo appointment wait time. Most appointments are “limited to “ your top 2-3 concerns; otherwise, schedule another appointment. Don’t think about bringing up new or chronic issues during your annual physical either; you get slapped with another co-pay for that visit (which is not always the doctor’s doing). This rushed atmosphere can lead to mistrust, overlooked symptoms, and a feeling of being unheard. It certainly does not leave room for lifestyle counseling and education.
The Impact on Doctors
Systematic time constraints place significant pressure on doctors. Because schedules are booked so far in advance, there are few slots for acute or simple patient visits. Thus, most doctor schedules are packed with chronic conditions, complex medical cases, or comprehensive physicals. These tight schedules leave little time during the “work day” for paperwork, patient correspondence, and administrative tasks. The result? Work spills over into the evenings and weekends, and despite sacrificing sleep and time with your family, the work never ends. Doctors in these environments must adapt to becoming cogs in the wheel or face moral injury.
Lack of Continuity and Personal Connection
Another significant downside of the corporate medicine model is the lack of continuity in care. Patients are effectively not assigned to doctors; they are assigned to an office with a team of doctors and providers. There is certainly room for teams in medicine, however, not at the expense of the doctor-patient relationship. Fragmented care, sparse visits with your doctor, and time constraints lead to a lack of personal connection, making patients feel like just another number. Doctors feel the pain of this, too.
A Way Forward
Direct primary care and other forms of independent practices are unlikely to meet the primary care needs of the whole population. However, I hope that by pushing the envelope and setting a new standard for primary care—quality over quantity, longer appointment times, and prioritization of the doctor-patient relationships—healthcare systems will have no choice but to change their practices. Maybe, just maybe, more students will choose primary care.
