Why primary care physicians are seeing fewer patients

Prior to the launch of the Affordable Care Act (ACA), policy experts predicted that a wave of more than eight million newly insured patients would flood an already strained primary care system. However, those predictions have not yet been borne out.

The 2014 Medical Economics Physician Practice Study found that both family physicians and internists saw a significant dropoff in their average number of patient visits per week, despite the number of hours worked remaining steady.

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Family physicians and general practitioners reported an average of 89 patient visits per week. That’s down from 99 visits per week in 2013. Internists reported a drop from 93 patient visits per week in 2013 to 85 visits in 2014.

This year, the median number of hours worked per week by family physicians was 51, while internists reported 52 hours. That’s consistent with the median hours worked per week in 2013, when family physicians and internists reported 50 and 52 hours, respectively.

Experts say the slump in patient volume may be due to several factors, including changes in patient insurance and rising deductibles, the struggles of adapting to electronic health records (EHRs) and increased administrative burdens that are falling on physicians.

Next: Administrative burdens

Administrative burdens
Primary care physicians face an increasing level of administrative burdens throughout their workday that distract from patient encounters. The most time-consuming of those tasks may be prior authorizations which, according to the American Medical Association, consume an average of 20 hours per week. Walker Ray, MD, vice president of The Physician Foundation and chairman of its research committee, says these tasks wear the most on physician morale.

“Face time with patients is so important to physicians,” Ray says. “Patient relationships are the primary reason why doctors go into medicine. This is why doctors give up their 20s and come out with $150,000 worth of debt. This is the premier aspect that gives docs the most professional satisfaction.”

A recent survey from The Physician Foundation found that 81% of physicians feel over-extended.

“The physician is the only person in the practice that does not have a job description,” says Elizabeth Woodcock, MBA, FACMPE, CPC, a healthcare consultant and author with Woodcock & Associates. “The bottleneck is the doctor, because all of this work is being pushed onto him or her. The physician needs to step back and say, ‘I have to figure out how to make the best use of my time.’ ”

Woodcock says the other benefit of treating the physician’s time as a practice’s most important asset is that it puts the focus back on patient care. “That’s a very patient-centric approach, because they want the doctor’s time most of all,” she says.

Leistikow says when administrative pressures build up, she concentrates on why she went into medicine in the first place. “When I get frustrated, I remember that I am good at taking care of patients, and try to not to focus on that other stuff,” she says.

Next: High-deductible plans

High-deductible health plans
While millions of patients gained access to coverage through the ACA, high-deductible insurance plans were prevalent throughout the healthcare exchanges. H. Christopher Zaenger, CHBC, president of Z Management Group in Elgin, Illinois, and a Medical Economics editorial consultant, says patients with those plans may think twice before actually using their insurance.

“When you’re paying for all of your ambulatory care out of pocket, you only really go [to the doctor] when you need to,” he says.
For 2014, the maximum out-of-pocket limit for all policies purchased through the ACA is $6,350 for individuals and $12,700 for families, according to the Kaiser Family Foundation. In 2015, that cost will increase to $6,600 for individuals and $13,200 for families. In California, patients who purchased bronze-level plans on the state’s insurance exchange had $5,000 deductibles and paid $70 copays for office visits, reports Kaiser Health News.

David Cohen, DO, an independent physician in Oakwood, Georgia, says his practice is seeing fewer patients, a drop-off he attributes to patient confusion regarding insurance plans, higher deductibles and copays.

The Medical Economics study found that physicians in the Western region of the country saw the largest dropoff in patient visits from an average of 89 patients per week in 2013 to 83 in 2014. By contrast, physicians in the South saw average weekly patients fall  from 98 to 94.  
Practice management consultant Judy Bee says high-deductibles are designed to limit the amount of healthcare services patients use, so it’s not surprising that patient volume would decline. She believes the real drain on physician productivity is EHRs.
documentation struggles.

A recent study in Health Affairs found that eight in 10 office-based physicians have adopted an EHR system. But with that new technology comes the challenge of documenting patient encounters and attesting to meaningful use.

“What we have are EHRs that are collecting in some cases ridiculous data that is required and that takes a long time to put in, especially when you’re new at it,” Bee says. “There is so much information on the page that it actually slows down the encounter as the physician tries to wander through it.”
To compensate for the added documentation, many physicians have extended their appointment times, in some cases to as long as 30 minutes per patient. Physicians are then left with two options.

“One of the options is to schedule fewer patients. The other is to hire a scribe, and that person is responsible for entering everything during the patient encounter,” Bee says. “But in primary care there’s not a lot of extra money for hiring scribes, especially when you just paid for an EHR.

Corrine Leistikow, MD, the assistant medical director for family medicine at a clinic in Fairbanks, Alaska, says that family physicians in her clinic are seeing fewer patients per day since her clinic started using an EHR.

“The main complaint from my family docs is spending so much more time on the EHR instead of seeing patients, that if they didn’t have the EHR, they could see more patients,” she says. “There are really good things about EHRs. They are not all bad. But nobody has figured out a way to make it work for doctors.”

Next: Retail clinics

Retail clinics
The decrease in patient visits also corresponds to an increase in the number of retail clinics and urgent care centers.Zaenger says these new competitors are eating into some of the marketplace. “The focus is to keep patients out of the emergency room, so practices are now competing with urgent care centers for primary care services or in some cases Walgreens, Walmart, or CVS MinuteClinics,” he says.

With increasing pressure to build their patient volume, Zaenger says some urgent cares are having patients return for follow-up appointments, rather than referring them back to their primary care physician.

To stay competitive, some practices are extending hours and opening on weekends, but that requires investing in staff, including hiring more nurse practitioners and physicians assistants to carry the patient load. Zaenger says he expects the patient volume of midlevel providers to continue  increasing, as physicians learn to delegate tasks and take on the more complex cases.

While some physicians fear the extra competition, Bee says retail clinics have been around a long time. For well-established practices, it’s unlikely that clinics will contribute to a more significant decline in patient volume.

“They serve a purpose,” she says. “If you’re nothing special, if you have rotating doctors and nurses, long waits, and not patient-friendly hours, you’re not giving [your patients] a whole lot of consumer incentives to come back. Teach your patients when it is appropriate to use them and when it is not.”

Changing productivity
Bee is skeptical as to whether productivity levels will begin to trend upward in the coming years. As the healthcare industry shifts to more collaborative care models, including the adoption of patient-centered medical homes, she says physicians may intentionally schedule longer appointments and reduce their patient panel size, in order to provide more comprehensive care.

However, Reed Tinsley, CPA, CHBC, president of the National Society of Healthcare Business Consultants, says he has already seen an increase in patient volume.

As long as the fee-for-service model persists, Tinsley says, primary care physicians in private practice can’t rely on established patients to bring in more revenue. They will have to see more patients within the day if they want to remain financially viable.

“It’s an issue of reimbursement and having to see more patients just to maintain a bottom line,” says Tinsley. “Any physician that’s just going to show up and sit on their hands and maintain the status quo is guaranteed to take a pay cut. The winners are the proactive practices, and the losers are the reactive practices.”