Dr. Anthony Youn, a plastic surgeon practicing in Detroit places most of the blame for long office waiting times at the feet of the patients themselves. He comes up with three general categories; patients who arrive late for their appointments, emergencies that require the physician to leave the office, and “oh by-the-way” scenarios:

“Here is a typical scenario: It’s the end of a 10-minute office visit, scheduled as a follow-up for high blood pressure. It’s been 12 minutes, the patient has her prescriptions, and the visit is concluding … The doctor begins to open the door and step out. ‘Oh, doctor, by the way, I forgot to tell you. I had chest pain last night and passed out in the bathtub. And I have bloody diarrhea.'”

Yes, patients can and do many wondrous things. If they did these things in a professional role we would call call their behavior negligent, manipulative, deceptive, non-compliant, selfish, entitled, in-denial, aggressive, and incompetent. But they’re not professionals. They are flawed humans in a very vulnerable and dependent situation in their lives. I don’t expect perfect behavior from my patients. Despite numerous appointment reminders and rules and requirements posted throughout the office there is a constant number who arrive late and forget to bring their medications. This is the nature of the game and is unlikely to change anytime soon.

Don’t blame the patients. Blame the system. A key point in the example above is where Dr. Youn mentions “a 10-minute office visit”.  Think of all the services that take longer than 10 minutes; ordering a meal, getting your car washed, any auto repair, pet grooming, cosmetology, any financial planning, and any legal consultation.  Only in this wacky system of ours is something as critical as health care expected to be squeezed into a 10-15 minute office visit.

At least for primary care providers the main reason that patients are shoehorned into 15 minute slots throughout the day is because of the way we are reimbursed. The vast majority of payments are made only at point-of-care meaning that we only get paid while in the same room as the patient. In that 15 minutes we are expected to perform a proper history and physical, determine the appropriate treatment plan, write prescriptions, order tests, provide explanations and counseling, and thoroughly  document in detail the entire encounter.  Yea, it’s stupid insane.

Actually, the vast majority of instances where I get behind seeing patients is not at all due to late arrivals or “oh by-the-way” scenarios.  It’s because what was supposed to be a straight forward visit for medication refills becomes far more complex. A patient with significant risk factors for heart disease need not wait to the very end of the visit to throw a monkey wrench into a delicate schedule. “Yea doc, I had some chest pain when I was mowing the lawn last week” at the very beginning of the visit is all it takes. Then a brief routine visit to monitor chronic hypertension becomes a frenzied acute care evaluation that includes an EKG, chest Xray, lab orders, additional medications, and an urgent referral to a cardiologist. And the day can be ripe with many other varied scenarios that require far more time than the paltry allotted 15 minutes.

So why not just increase the time allotted per patient? See fewer patients per day? Sure, except that health insurance still pays the same for a 30 or 60 minute visit as it does for a 15 minute visit while the overhead costs remain the same. For an independent primary care practitioner this is just not a realistic option if they want to avoid a further decrease in their income and risk the very real possibility of going out of business. The additional stress, responsibilities, and economic uncertainty of owning their own practice is what has lead more and more physicians to become employees of corporate clinics and practices. But salaried physicians have even less ability to change the scheduling and reimbursement structure of their practices.

The most elegant and obvious solution comes to us from practitioners who have converted to concierge medical practices where patients contract with a provider by paying a flat annual fee in return for unlimited visits and office services. Contrary to claims that physicians are only after more money, the conversion to concierge practice model is almost always done to reduce the demands of 15 minute patient visits while maintaining income. Typically concierge physicians reduce their patient panels from several thousand to only a few hundred and increase allotted patient visit times to 30 or even 60 minute slots. Additionally, concierge practices expand the amount and number of services provided to patients that are simply not reimbursable under the traditional insurance model such as 24/7 direct phone contact to a physician and email and other forms of electronic communication.

While some patients pay upwards of $10,000 – $20,000 per year for these practices it’s becoming more common to see concierge practices change as little as $800-900 per year. The question then becomes, why won’t Medicare, Medicaid, or private insurance companies adopt this reimbursement model if it can improve time spent and overall service for patients? Is it simply because it’s more expensive? Medicare currently reimburses physicians the equivalent of about 1/3 of the annual cost of cable TV for the typical patient with multiple medical problems. Is this a case of being truly too expensive for a $650 Billion per year Medicare program that pays physicians to care for complex elderly medical patients far less than what most Americans pay for cable TV? Seriously?

Or is it because a concierge practice model has not been proven to improve health outcomes and overall patient care? While there is no direct evidence that concierge medicine provides better care there is plenty of evidence that primary care in the traditional model leads to both better outcomes at reduced costs! If we extrapolate this to longer visit times and better access to and communication with providers , there is every reason to expect even better results under a concierge model.  And since when did Medicare start caring about paying more for services without proven benefits? Currently Medicare reimburses surgery performed with robotic assistance several times more than it provides for traditional surgery despite the almost complete lack of evidence that robotic assistance significantly improves outcomes, reduces complications, or reduces long term costs.

This is in keeping with Medicare’s tradition of lavishing reimbursements on any and every newfangled invasive high-tech procedure to come along for specialists while leaving primary care in the dust. But of course, Dr. Youn being a plastic surgical specialist would know all about this.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.