Doing More Doesn't Mean Spending More Time With Patients

The results of a recent study by the American Academy of Family Physicians seem to confirm a widely held belief that physicians who spend more time with their patients keep them healthier and reduce healthcare costs.

The study, published in a recent issue of Annals of Family Medicine, found that patients were 35% less likely to incur a hospital stay if their family doctor was very comprehensive as opposed to minimally comprehensive. In addition, physicians performing a wider range of services led to reducing patient costs by 10-15%.

In other words, doing more saves more. But what exactly is doing more? Ralph Nobo, Jr., MD, an OB/GYN in Bartow, Florida and a board member of the Physician's Foundation, offers an interesting perspective on that.

“Listening to the patient is number one,” Nobo says. “If you listen to the patient you will learn more about that patient and you may not have to order so many tests, and you may not have to refer to another physician or specialist.”

Important Distinctions

Nobo puts a premium on listening because with reimbursements declining, physicians are under pressure to see more patients. That means spending more time with patients is not always possible, or feasible.

“Twenty percent of the time we spend is on paperwork, it’s not on patients,” Nobo says. “It’s trying to do Meaningful Use, which I call meaningless, but it doesn't take care of the patient. It’s just for statistics.”

Given that there are only 24 hours in a day, and nobody wants to work 24 hours, Nobo says it’s not a question of how much time is spent during an office visit, it’s about what physicians do with the time allotted.

“If you truly want to save money, what you need to do is follow up with the patient,” he says.

For example, a patient who is diabetic comes in for an office visit. The physician does a hemoglobin A1C and finds that the patient’s numbers are not coming down, but doesn’t take the time, or have the time, to find out why. Why is the patient not taking her insulin? Why is the patient skipping the diet instructions she was given?

In just such a case, a woman was unable to control her diabetes. Extensive follow-up and questioning during a visit to a federally qualified health clinic revealed that she did not have a refrigerator. The issue, therefore, wasn’t that she didn’t want to follow the physician’s advice, but rather that she did not have the means to refrigerate her insulin.

“It’s about following up to make sure someone is taking their medication, to make sure that when you’re supposed to do something you do it,” Nobo says. “People stop taking their blood pressure medication and then they get a stroke that they could have avoided if someone would have been guiding them.”

To Refer or Not

The AAFP study also found that family doctors who are judicious about referring patients to specialists can help realize cost savings. In fact, Nobo says that many insurance companies are incentivizing primary care physicians to do just that. Then, at the end of the year, the physician receives a bonus based on the savings realized by not referring patients.

But that strategy, Nobo points out, is a double-edged sword.

“As an OB/GYN a lot of times I see women who have been to a primary care physician and often when it comes time to do the pap smear and the pelvic exam and looking at the vaginal issues, [the primary care physician has] their PA or nurse practitioner do it while they go see another patient,” he says.

The problem, Nobo explains, is that the patient may have a pre-cancerous cell. And the nurse practitioner, despite all good intentions, does not have the experience to diagnose as a specialist would.

“We have to be very careful,” Nobo says. “We don’t want to give incentives to primary care physicians to interfere with the care of a patient.”

Collaborative Effort

Nobo reiterates that doing more is not as black and white an issue as simply doubling the time spent with a patient. Follow up is key, and this is where he suggests insurance companies can play an important role in a collaborative effort.

“Insurance companies have the capability of reaching out to the patient,” he explains.

Insurance companies can contact a patient and ask why they did not fill the prescription for hypertensive medication that their physician prescribed. The insurance company then lets the physician know that the patient is not adhering to their medication regimen. The physician then follows up to find out why.

“And then you can bring that patient back and explain to them the importance of saving her from going to the ER,” Nobo says. “That’s where the savings is.”