Health Care News & Discussion
Between the Office Visits
02/04/1997 1:05 PM
The office visit has been the best deal in medicine–but that was when it lasted 15 minutes. Reduction to 10 minutes was a bit tight. Now Chicago University Professor Richard Epstein states he heard a rumor that managed care office visits in California were down to 5 minutes–about 300 seconds. He suggested perhaps that was not enough time to generate empathy and trust, but should be long enough to look into a pair of ears or to check for a sore throat. Physicians are paid for the time they spend with a patient; their technical training is the expensive input. Epstein holds that their psychological insight can be duplicated by others whose hourly rate is far less.
Professor Epstein goes on to say that technology allows the design of new diagnostic tests that can be applied across the board. The better the test, the less interpretation and evaluation is required. The physician becomes ancillary to the dominant sources of knowledge, and empathetic intuitions are pushed aside by hard data. To have a physician chat with patients for five minutes out of an hour may not seem like much, but over a year it amounts to a month of time.
The distinguished professor continues by saying that allowing physicians to order additional tests increases the need for space, laboratory technicians, record keeping services, and the like. Indeed, to allow physicians to give free care after hours is also expensive, if heat, electricity, insurance, and record keeping are accurately reckoned in the bill.
Under Professor Epstein, the essential services are both transformed and preserved, but the nature of the doctor-patient relationship will be changed, unless and until it can be shown that the traditional doctor-patient relationship controls costs, detects disease, or both. Although the process becomes more impersonal, patients do not leave the system because they value the savings more than they fear the costs. Physicians do not leave the system because the patients will not follow them.
He points out that any change will produce a fair share of losers who will try to recapture some of their gains through politics. Physicians, he states, often lose when HMOs insist on complete control over the physicians who join their staffs. Thus, excluded physicians have secured the passage of “any willing provider law” which requires any plan to agree to work with physicians who are willing to abide by its rules. This makes the health plan work like a common carrier for its physicians. No other business is forced to expand its roster of employees in quite this fashion. Professor Epstein concludes that the state regulations of HMOs has brought with it a host of unintended consequences, mostly bad. It has brought about a level of dependence that places the welfare of the general population in Mortal Peril, which is the title of his book.
Although we may think this philosophy harsh, cold, and unkind, it may be the prevailing opinion of our profession. We best take note, evaluate our profession, and plan damage control. Meanwhile the train continues onward, if not upward.
The non-professional medical entrepreneurs who are now advising us on every front don’t have any idea what could go wrong with their suggested approach. Perhaps they don’t care. Epstein is not sure that traditional doctor-patient relationships even detected disease. So in his understanding, just about anything is better than the traditional practice.
A managed care executive mentioned that primary care physicians should reduce the number of office calls; if currently four a year, try for three; if currently two, try for yearly. But this leaves many problems unattended between visits or delegated to others who may or may not be qualified. Family physicians tell me they work two hours after the office closes, or during their compensatory afternoon off, or spend an extra 8-10 hours on the weekend to complete their charts, make phone calls, fill out forms, complete referrals, and do dictation. Perhaps since he or she is not seeing patients and if the electricity is not used, it won’t disturb Professor Epstein as adding too much to the costs.