This discussion of how current reimbursement practices limit a doctor's time with each patient is very interesting. Physicians who I know personally are greatly upset by the limitations on the amount of time they can spend with their patients. Abraham Verghese's discussion of the importance of understanding a patient in order to provide appropriate care seems spot on. But how should the payment system be re-organized to encourage longer consultations without involving financial loses for the doctors?
This issue reminds me of a similar concern I learned of while studying abroad in England. The NHS has a major emphasis on primary care, and has small primary care trusts (PCTs) in different regions that are staffed with a number of medical practitioners. However, when a patient comes to the PCT, they don't choose which doctor they see. Accordingly, there is a loss of the type of interpersonal relationship found between a patient and their long-term doctor. The service makes primary care easily available, but limits the ability to form strong ties that can be beneficial to both patient and provider.
On a somewhat related note, the first doctor quoted, Abraham Verghese, is also an excellent writer. I just read his most recent novel entitled "Cutting for Stone," and it was an excellent story with a great deal of medicine involved. I highly recommend it if anyone can find free time.
This post has efficiently underlined an important aspect of physician-patient relationship in practicing medicine. This reminds me of similar discussions I had with a family physician at University based hospital in NY, whom I was shadowing for a couple of months. He had his private clinic too in the area and described how differently he has to practice medicine at both sites. The "payment system" guided hospital practice requiring them to see a specific number of patients in a given time frame on one hand and "morally" guided private practice where he sees same number of patients in twice as much time on other hand (discounting the fact that he has the busiest practice in area). However in a capitalist or profit driven rigid market it is difficult to practice "moral" medicine. Some of the reasons for the immalleable nature of market is its lacking of being "free" and far from being patient (consumer) centered. I think what is required is a consumer-centered health reform that challenges policymakers to redesign the basic rules of the health care market to create new incentives for all of the actors in the system to put the interests of consumers and patients first rather than third party payment arrangements. Let the patient decide how much they want to pay a physician who has been taking their care for decades compared to surgeon performing appendectomy. On that note, we have to also consider the shortage of primary care physicians that US health care system is facing which is posing a huge patient burden on existing primary care physicians who are not able to devote adequate time to each patient. Although the number of medical school seats have been increased to address this problem still there is no change in medicare supported residency training seats which are stationary since 1996.
This post reminds me days when I was a nurse. Each Monday on the regular meeting hosted by the head nurse, we were receiving education on the patient-center medical practice, such as quality control, medical errors prevention, satisfaction improvement on service. There are plenty of documents or rules released by the board of hospital or government for us to study. I am not sure how much of such education physicians and nurses can really keep in mind when practicing medicine or nursing. But it seems that our policy makers are beginning to consider this issue seriously. From this point of view, this is initially good news for patients.
According to one of these policies, there will be a new fee of 3 Yuan on health education per week for each patient. This fee will appear on their medical bills when they are discharged. Besides, both physicians and nurses’ salaries will be directly correlated to the results of the service satisfaction questionnaire each month randomly distributed by the administrative office. I valued these two rules as strong incentives to encourage more individual specific medical service and interaction among patients, physicians, and nurses. However, when I was assigned to be responsible for the health education in my clinical ward, I found I could hardly successfully achieve this job by only allowed 2 hours for educating more than 60 patients about healthy life style, most of who suffered from chronic disease. Every time I would love to sit down and share some ideas that may helpful for better recovery or compliance toward treatment, I would be asked to do other things that was told to be of more “efficient”. For example, I might be asked to take care of newly arrived patients who will be prescribed a dozen of diagnosis examinations that might cost them 400-500 Yuan, but less than 20 minutes for nurses to show them the right way to do. Is it still surprise to see people focus on providing so many kinds of “procedures” rather than on those time- consuming services?
I do agree with Chintan that it might be difficult to make the provision of health service morally in nowadays’ for-profit society. In this aspect, health reform is not just modification within the realm of healthcare itself. It is something sensitive enough to induce dramatic change within the whole society, something related to values and beliefs. Equity or efficiency, which should be weighed more? As in my point of view, I always believe that health is one of the basic human rights that each person should be eligible for. It is unreasonable to guarantee that everyone should get a perfect mattress from Sleep City, but it does make sense to promise each of us get what we need to fight with diseases and survive.
I also agree that it is our payment system that should be mainly responsible for the difficulty of practicing “moral” medicine. And patients should have more freedom in choosing physicians. But I don’t think it will be a good idea to let patients decide who they should pay to and how much. More than 10 years professional training on medicine will always leave the gap of knowledge among physicians and patients exists. It is also unfair to evaluate physicians’ efforts predominately by someone who don’t know medicine at all. I might wonder that whether we could apply a fixed payment system to drive our health system more morally. Since so far, and maybe in the long term as well, we still live in an adaptive health system that mechanistic approaches will not work in most situations. For services that engage with rigid individual specific and long term continuous care, such as primary health care, physicians and nurses could be paid by regular salaries from government plus bonus determined by patient outcomes and response.
Never drive our physicians to survive by earning money from us! Give them stipend regularly like us, bonus and prizes for their success in saving lives and promoting health, right to be chosen by patients, and ways to let voice be heard!
This discussion of how current reimbursement practices limit a doctor's time with each patient is very interesting. Physicians who I know personally are greatly upset by the limitations on the amount of time they can spend with their patients. Abraham Verghese's discussion of the importance of understanding a patient in order to provide appropriate care seems spot on. But how should the payment system be re-organized to encourage longer consultations without involving financial loses for the doctors?
ReplyDeleteThis issue reminds me of a similar concern I learned of while studying abroad in England. The NHS has a major emphasis on primary care, and has small primary care trusts (PCTs) in different regions that are staffed with a number of medical practitioners. However, when a patient comes to the PCT, they don't choose which doctor they see. Accordingly, there is a loss of the type of interpersonal relationship found between a patient and their long-term doctor. The service makes primary care easily available, but limits the ability to form strong ties that can be beneficial to both patient and provider.
On a somewhat related note, the first doctor quoted, Abraham Verghese, is also an excellent writer. I just read his most recent novel entitled "Cutting for Stone," and it was an excellent story with a great deal of medicine involved. I highly recommend it if anyone can find free time.
This post has efficiently underlined an important aspect of physician-patient relationship in practicing medicine. This reminds me of similar discussions I had with a family physician at University based hospital in NY, whom I was shadowing for a couple of months. He had his private clinic too in the area and described how differently he has to practice medicine at both sites. The "payment system" guided hospital practice requiring them to see a specific number of patients in a given time frame on one hand and "morally" guided private practice where he sees same number of patients in twice as much time on other hand (discounting the fact that he has the busiest practice in area).
ReplyDeleteHowever in a capitalist or profit driven rigid market it is difficult to practice "moral" medicine. Some of the reasons for the immalleable nature of market is its lacking of being "free" and far from being patient (consumer) centered. I think what is required is a consumer-centered health reform that challenges policymakers to redesign the basic rules of the health care market to create new incentives for all of the actors in the system to put the interests of consumers and patients first rather than third party payment arrangements.
Let the patient decide how much they want to pay a physician who has been taking their care for decades compared to surgeon performing appendectomy.
On that note, we have to also consider the shortage of primary care physicians that US health care system is facing which is posing a huge patient burden on existing primary care physicians who are not able to devote adequate time to each patient. Although the number of medical school seats have been increased to address this problem still there is no change in medicare supported residency training seats which are stationary since 1996.
This post reminds me days when I was a nurse. Each Monday on the regular meeting hosted by the head nurse, we were receiving education on the patient-center medical practice, such as quality control, medical errors prevention, satisfaction improvement on service. There are plenty of documents or rules released by the board of hospital or government for us to study. I am not sure how much of such education physicians and nurses can really keep in mind when practicing medicine or nursing. But it seems that our policy makers are beginning to consider this issue seriously. From this point of view, this is initially good news for patients.
ReplyDeleteAccording to one of these policies, there will be a new fee of 3 Yuan on health education per week for each patient. This fee will appear on their medical bills when they are discharged. Besides, both physicians and nurses’ salaries will be directly correlated to the results of the service satisfaction questionnaire each month randomly distributed by the administrative office. I valued these two rules as strong incentives to encourage more individual specific medical service and interaction among patients, physicians, and nurses. However, when I was assigned to be responsible for the health education in my clinical ward, I found I could hardly successfully achieve this job by only allowed 2 hours for educating more than 60 patients about healthy life style, most of who suffered from chronic disease. Every time I would love to sit down and share some ideas that may helpful for better recovery or compliance toward treatment, I would be asked to do other things that was told to be of more “efficient”. For example, I might be asked to take care of newly arrived patients who will be prescribed a dozen of diagnosis examinations that might cost them 400-500 Yuan, but less than 20 minutes for nurses to show them the right way to do. Is it still surprise to see people focus on providing so many kinds of “procedures” rather than on those time- consuming services?
I do agree with Chintan that it might be difficult to make the provision of health service morally in nowadays’ for-profit society. In this aspect, health reform is not just modification within the realm of healthcare itself. It is something sensitive enough to induce dramatic change within the whole society, something related to values and beliefs. Equity or efficiency, which should be weighed more? As in my point of view, I always believe that health is one of the basic human rights that each person should be eligible for. It is unreasonable to guarantee that everyone should get a perfect mattress from Sleep City, but it does make sense to promise each of us get what we need to fight with diseases and survive.
I also agree that it is our payment system that should be mainly responsible for the difficulty of practicing “moral” medicine. And patients should have more freedom in choosing physicians. But I don’t think it will be a good idea to let patients decide who they should pay to and how much. More than 10 years professional training on medicine will always leave the gap of knowledge among physicians and patients exists. It is also unfair to evaluate physicians’ efforts predominately by someone who don’t know medicine at all. I might wonder that whether we could apply a fixed payment system to drive our health system more morally. Since so far, and maybe in the long term as well, we still live in an adaptive health system that mechanistic approaches will not work in most situations. For services that engage with rigid individual specific and long term continuous care, such as primary health care, physicians and nurses could be paid by regular salaries from government plus bonus determined by patient outcomes and response.
Never drive our physicians to survive by earning money from us! Give them stipend regularly like us, bonus and prizes for their success in saving lives and promoting health, right to be chosen by patients, and ways to let voice be heard!