Behind schedule: Examining the underreported consequences of reducing patient encounters

Compare today with the late 1960s and 1970s, when the medical profession recognized the advantages of collective operation, and group practices experienced rapid growth. It once had been suggested that medical practices represented one of the last bastions of free enterprise.

Physicians developed and managed their practices with the help of medical practice managers and occasional consultants. Quality of care was accepted as a given based on extensive physician training, licensing and medical society oversight. Malpractice lawsuits were minimal. Physicians, by virtue of their chosen career, had a passion for optimal outcomes, and strong patient relations developed.

Patients were financially responsible for services rendered, and collection ratios typically exceeded 90%, with expense ratios under 50%. Most notable, medical records were easily maintained in an abbreviated format as a convenient reference in patient care.

Today, we observe physicians practicing in a completely new world in which they are subjected to demands by government, insurance companies, health plans, employers and unions. Of the many new pressures, transition to electronic health records and proof of quality care are the most onerous as the time demanded for data entry grossly exceeds the time needed for similar work 40 to 50 years ago. Primary care physicians report adding at least two hours to their already busy day.1 For physicians to enjoy a work-life balance, reduced patient schedules are frequently the alternative to avoid physician burnout.

Little recognition has been given to the consequences and economic aspects associated with reduced patient scheduling, including the four mentioned here:

1. Financial — Reduced schedules translate to loss of equivalent revenue. Subtract new costs to process, including scribes, IT upgrades and relatively inflexible overhead. This results in reduced margins before considering physician compensation and benefits — not a good outcome, with many physicians electing employment rather than private practice. An article in the July 22, 2019, issue of Modern Healthcare reports an average annual loss of $240,000 per employed physician.2 Some of this may be due to hospital systems’ accounting methodology, which can differ from that of private practice, but the balance is being absorbed elsewhere as rapidly increasing healthcare costs are a major concern.
2. Access — Reduced schedules mean more limited availability for established patients, and in some locations, it’s difficult to identify and equate. Are the conveniences of commercial and hospital system urgent care and “docs in a box” resulting in increased costs in comparison to the fundamental patient continuity of care?
3. Patient concerns — We’re hearing more than the complaints of, “I can see my doc when I’m well, but I’m unable to get in when I’m sick.” We also hear, “My doc is so busy on his computer, there’s no time to talk!” While harder to ascertain, any diminishment of the provider-patient relationship is sure to have profoundly negative impacts on the business’ bottom line in time.
4. “Whom do I work for?” — Are physicians seeking alternatives to private practice in hospital employment offering compensation guarantees without the headaches associated with compliance and adhering to new external practice demands? Some physicians have tried and are returning to private practice financed by new private equity firms. Are we seeing a repeat of the ill-fated practice management companies in the late 1980s, only to fail in the 1990s?

It doesn’t seem believable to suggest that changing appointment schedules can result in major consequences for physicians, but this is the case.

In any industry, a major responsibility of leadership is to identify that which supports maximum productivity, and then assure that no obstacle negates optimum results. There is something missing in healthcare today when priorities seem out of balance.

Quality and cost of care have always been a top priority, so why do we require 100% validation? The patient consumer never seemed unhappy; it’s those now controlling the purse strings who are creating the problem. In other words, I recall the phrase, “Do we have a dollar chasing a nickel?” Maybe it’s time to place docs back in control of their own profession. It worked before, why not today?

Notes:

1. Sinsky C, Colligan L, Li L, et al. “Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties.” Ann Intern Med. 165:753–760. doi: 10.7326/M16-0961.
2. Johnson SR. “Physician pay rebounds in 2018 after flat 2017.” Modern Healthcare. July 20, 2019. Available from: bit.ly/2kMnBIQ.