Days of the short-order doc Health: Managed-care plans push physicians to shorten visits to the point where some worry that patients will suffer.

March 05, 1996|By Richard A. Knox | Richard A. Knox,BOSTON GLOBE

If you're feeling rushed in the doctor's office, join the crowd. Prodded by health care managers, physicians are trying to squeeze more patients into every hour, to the point where many worry that care is being seriously shortchanged.

"Doctors appear to be under a lot of stress," said Carlton Anderson, 63. "Whatever you have to say to them, you'd better get it out right away because they have so many other patients."

Mr. Anderson's complaint is notable because his primary physician is Dr. Sheldon Greenfield of New England Medical Center in Boston, a leading authority on the drive to streamline medical practice and how it affects patients. Dr. Greenfield acknowledges that he is not immune to the pressures on doctors across the nation to be more "productive."

"The other day a patient asked a sensitive personal question at the end of his visit, and I could feel the tension in me," Dr. Greenfield said. "He wanted to discuss it with me, but I couldn't do it. The clock was ticking."

Like an increasing number of doctors, Dr. Greenfield and his colleagues were recently told to meet a "productivity target" that holds new patients to 40 minutes for a first visit and others to 20-minute visits.

This is actually on the liberal side of such targets. "At the University of Pittsburgh, their internist volume targets are 15 minutes per patient," Dr. Greenfield reports. "That's a big comedown. They're used to spending 30 minutes." In some managed-care systems, Boston-area physicians say, doctors are expected to cram a patient encounter into 10 or even eight

minutes.

"Eight minutes is not a workable time. It's ridiculous. [But some] groups and some health plans expect that," said Dr. Barbara Stewart of Beth Israel HealthCare in Boston.

Research by Sherrie H. Kaplan, Dr. Greenfield and their colleagues at New England Medical Center indicates that 20 minutes is about the minimum needed for a doctor-patient encounter that is truly productive.

The most effective care, Ms. Kaplan and her co-workers believe, is "participatory," meaning that the doctor presents treatment options, discusses pros and cons, elicits patient preferences, and with the patient reaches agreement on a treatment plan.

In a series of reports from the Medical Outcomes Study, a project involving nearly 8,000 patients in Boston, Chicago and Los Angeles, Ms. Kaplan's group found that participatory decision-making produced better outcomes. They measured such factors as diabetes control, blood pressure, arthritis severity and functional status among patients with chronic diseases.

An update of that study published Friday in the Annals of Internal Medicine documents that when doctors are too rushed, lack control over their schedules or lack training in participatory decision-making, there is also a cost in patient satisfaction and loyalty.

One-third of patients who rated their doctors as low on a scale of participatory style changed physicians in the following year, twice the proportion among those with high-participation doctors. Having a high-volume practice accounted for almost half the difference in doctors' "participatory" rating scores.

Another cost, Ms. Kaplan said, is "unhappy, dissatisfied doctors who may not be providing the kind of care Americans want."

Ms. Kaplan and her colleagues defined a high-volume practice as having more than 70 patient visits a week, a level others say is becoming an industry standard in the fast-growing and highly competitive managed-care marketplace. At Harvard Pilgrim Health Care, New England's largest health maintenance organization, "the target is for roughly 80 patients a week," said Dr. Joseph Dorsey, the plan's corporate medical director.

"The visits are generally in the range of 15 or 20 minutes," Dr. Dorsey added. "But patients who come in with a sore throat or a quick blood pressure check may need five minutes. Then there are others with a significant chronic illness, a high level of anxiety or a new illness. We try not to have the doc feel boxed in to 15 minutes."

Dr. Dorsey says a 20-minute minimum visit is uneconomic. "They could not survive in running a health plan if they set a 20-minute minimum," he said of Dr. Kaplan's group. "Society would not pay for it. That's not to say that the average shouldn't be around 20 minutes."

Pub Date: 3/05/96

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