The Office Visit - The Best Bargain in Medicine 11/97
by Del Meyer, MD
The standard office visit has devalued over recent years--reduced in time spent with the patient and in remuneration to the doctor. And still Managed Care Organizations (MCOs) steadily try to reduce the length of a routine examination. One physician reported that her HMO tried to cut the office exam time from 12 minutes (5/hour) to 10 minutes (6/hr). Because of physician uprising, the latter did not occur--they continue with the 12-minute office visit.
When I went into practice in 1970, I interviewed at the Houston Diagnostic Clinic, the largest internal medicine clinic in the country. The interviewing process took me into the administrative office of Mr Mercy for an hour as he expounded on the philosophy of this referral and primary care center. Among other things, he mentioned why they allowed one hour for each new patient and half an hour for each return patient. He said, "Our internists arent any smarter than other internists. We just give them more time so they make fewer mistakes." I hate to think such sound administration has become extinct only 25 years later, but the current trend suggests it.
A primary physician noted in the staff lounge he received word from his HMO that future office calls would be reimbursed at $13. He did not sign the agreement and tossed it in the circular file next to his desk. He did the same with the proposed contract the following month and on the third month was given a letter of termination. He had already notified his patients and all but one had been able to make the appropriate changes to keep him as their personal physician. These patients stated that they had received word from the HMO that their physician had resigned.
The office exam is routine--and the routine is easily devalued. But the lowly office exam is the backbone of the medical care industry. And it is still a patients greatest bargain--or in current lingo in which the patient is removed from the purchase of his own care, the office call is the insurance carriers or the governments greatest bargain.
In the 1970s when office calls were $20, and Medi-Cal was in serious financial straits (as is the way of government programs), our internal medicine leaders agreed to the $19 office call. During the same month, the standard hip replacement fee went from $1800 to $2400. Surgeons have less difficulty than primary care medical practitioners in determining the value of their services.
In the past 27 years one would have expected a doubling of the fee for an office call every 7-10 years just to keep pace with inflation; the $20 visit should have gone up six-fold to $120. However, I stopped at $60 a decade ago since no one was paying me $60 anyway. If my fee is greater than what Medicare, Blue Cross, and Blue Shield pay, the patient looks at this as dishonest over-charging and gouging the sick, no matter how just the charge.
Just what do we accomplish in a short office visit? My office visit may range from 15 minutes to 45 minutes or more if required. It is always difficult to judge how much time an unknown medical problem may take. The time it takes to handle a medical problem also depends on patient expectations and desperation.
When I was in the Internal Medicine Clinic at Mather AFB in 1967, I was called out for a cardiac arrest in the operating room. After a successful open-chest cardiac resuscitation, since it was near noon, I called back to the Internal Medicine desk and asked the receptionist to reschedule all patients with routine or stable problems, and I would see all the urgent and really sick problems during my lunch hour which I would forfeit. All my diabetics, cancer, heart, and emphysema patients rescheduled. What I gave up my lunch hour for were patients with headaches, back aches, leg aches, and total body exhaustion of 10, 15, or even 20 years duration. They were in lifelong medical crises but had actual hopes that their crises would be solved that day on an emergency lunch time basis. These patients had already had numerous tests done and duly recorded in massive medical files. It would have been easy to order another test and take only 5 minutes, but by being frank with the patient over 15 to 20 minutes, they assessed their chronic conditions with more realistic expectations for the future and left with a better understanding of their physical and mental health. I truly felt the office visit during my missed lunch was more valuable to the patient than the thousands of dollars worth of testing the weight of the medical chart represented.
I remember an alpha one antitrypsin emphysema patient who was deeply cyanotic despite oxygen and maximal therapy. He was stable and I suggested that the office visits could perhaps be spread out to every other month or even every third month. He said he needed to come in every month or he would have to go to the hospital. So he came in every month until he died at home, saving tens of thousands of dollars in hospital costs for the price of a few dozen office calls. What a bargain to Medi-Cal & Medicare.
Do doctors still order tests to shorten office calls? Staff room discussions suggest it still happens today. One internist mentioned that he obtained some expensive testing because it was the best alternative to his time frame, would convince the patient and allay his anxieties, and allow the doctor to see his allotted patients.
The office call is still the best bargain in medicine--but its only the best bargain if its thorough enough to do the job. It takes time to greet a patient in a humanistic manner; exchange a few pleasantries, even if for only 90 seconds; inquire about previous medical problems and if they have resolved or require further attention; determine the current issues; do a brief physical examination; discuss the treatment plan; write out the requisitions and prescriptions; wish the patient the best of health; and then dictate or write a note. A 720-second office call wont do the job. Medicine is not a horse race, and a stop watch is not the right measure. Even at only 150 to 240 seconds for each of the seven items listed, we are already at 1500 seconds or past 20 minutes.
Maybe Mr Mercy was right. It takes about half an hour to do a good job and minimize mistakes. The fact that insurance carriers and their HMOs and the employers who purchase the plans overlook obvious savings should not deter our professional obligation. Our service is to the patient, not to insurance companies and administrators. The challenge is how to accomplish this service in a cost-effective manner. We must deal first with our patients and not with the insurance carriers, their HMOs, or the employers to whom they sold the policy. Doctors are the cream of the crop of college graduates; surely we can figure out how to solve the problem better than those who flunked out of pre-med and went on to get their MBAs.