Multiple-Problem patient visits

To the editor:

Flocke and colleagues¹ presented some important findings about the nature of family practice that are applicable to primary care in general. Because primary care physicians do not have the procedural approach that many other specialists have, it has always been difficult for health insurers to understand the scope and the value of their work. The misguided environment created by managed care has only made it worse. Some physicians are so preoccupied with having charts that will pass muster in case of an insurance audit that a “clean” chart has undermined their approach to treating patients. Maintaining a humane perspective and a compassionate outlook under today’s working conditions has become an increasingly difficult task.

I have been a family practitioner for more than 25 years, and it is common for patients to come in with one or more problems. Sometimes the add-on problem is more important than the scheduled visit for that patient. Most of us in general practice (family practitioners and general internists) are familiar with patients who come in for a sore throat and as they are leaving mention incidentally that they noticed blood in their stools or that they have been having funny chest pains when they work in the garden; there are also patients who come in with a family member and ask if we would mind just looking him or her over. These added demands consume physicians’ time and energy. Unfortunately, there is no billing code that rewards physicians for responding to these requests. In fact, those physicians who make themselves most available to their patients in situations like these are the ones who are least compensated for their efforts by the health care system.

But getting compensated for seeing multiple problems in the office does not only have to do with the misperceptions of health insurers. Because most patients get to see their physicians for only a small copay, they have become silent partners in the process of turning physicians into commodities. Perhaps primary care physicians need a different system of compensation that does not depend on the inappropriate concept of productivity. For example, why not have patients assume responsibility for all of their primary care office visits with the exception of expensive tests and procedures? This would make patients more aware of the valuable time that their physicians are spending with them. If they do not think that they are getting their money’s worth, they could shop around for another physician. The present system of billing is no longer adequate. It makes all primary care physicians interchangeable and rewards them all equally. It is time to look for different ways to reimburse primary care physicians.

Edward J. Volpintesta, MD
Bethel, Connecticut

REFERENCE

1. Flocke SA, Frank SH, Wenger DA. Addressing multiple problems in the family practice office visit. J Fam Pract 2001; 50:211-16.

Editor’s note: Dr Flocke and colleagues declined the opportunity to respond to this letter.