Less time, more patients: The perverse incentives of medicine

As the Affordable Care Act continues to impact millions of Americans through its second year of implementation, many things have become clear to both patients and health care providers alike: nothing is as it seems. While the ACA has provided health care to millions of previously uninsured Americans, it has also robbed many patients of their doctors and has forced others into higher premium, lower service plans. Even those with insurance are finding that they have little choice. Many health care systems and providers are finding it impossible to accept the Exchange insurances and many long time Medicare providers are also opting out. Why is this happening? Didn’t the Obama administration see this coming?

Of course not! In the words of the legendary Nancy Pelosi: “We have to pass it to find out what is in it.”

Well, now that we are more than a year into the program, we are all learning exactly what is in it; more accurately, we are finding out what is not in it.

Physicians have found the ACA to provide significantly lower reimbursements and Medicare continues to make further payment cuts. If you carefully look at the way incentives within the Medicare code are structured, you begin to see that they are not in the best interest of either the patient or the physician.

For example, a 10-minute office visit is reimbursed in some areas at $50, and a 40-minute visit is reimbursed at $140 — with the reimbursement for each block of time reduced. While physicians would much rather spend more time with each patient — working on prevention and goal setting and actually developing lasting relationships — Medicare and other government based health care plans seem to incentivize the opposite. In order to remain financially viable, a practice must see more people in less time — reimbursement favors larger numbers of short visits rather than fewer, extended, more productive visits. Overall health care costs are not impacted because we are not able to spend needed time on preventative efforts. Patients are not engaged, and outcomes suffer.

Medicare bureaucrats and federal health care regulators say that they would like physicians to emphasize patient education, patient engagement and patient inclusion in decision-making yet they are unwilling to compensate doctors for the time these activities require. In fact, the current system pushes the opposite: mass production of patient visits with limited time for questions and lifestyle modification discussions. Health care providers are actually negatively impacted when they spend more time with patients — often to the point of not being able to remain open and independent without selling out to large health care systems in order to meet the demands of business overhead.

Most disturbing, however, is the negative impacts these regulations and perverse incentives have on patients and overall patient care. Patients depend on doctors to advise them and to help them make health care choices. While patients are much better informed now — mainly due to the availability of information on the Internet — they still need to have quality, non-rushed, personal interaction with a physician. Many patients feel lost and abandoned when they realize that the time that they now get with their doctor is significantly limited or eliminated altogether (as many physicians substitute allied health professionals for themselves during routine office visits).

Ultimately time will tell. It is my hope that we can somehow reverse the course of Obamacare in the years to come. We must find a way to insure and care for all Americans in a way that also allows doctors to be healers rather than government automatons. The practice of medicine remains a privilege; we must all work to ensure that the sanctity of the doctor-patient relationship is preserved in the future. We must reform both the ACA as well as the often perverse Medicare code in order to allow physicians to provide what is most important to patients and families alike: time and personal attention. Only then will we have a system that actually works.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.