Letters To The Editor: The 15-Minute Doctor-Patient Relationship; Issues Of Costs, Medical Debts And Unnecessary Procedures; Physicians’ Examination Skills; And Other Thoughts

Jun 05, 2014

Letters to the Editor is a periodic KHN feature. We welcome all comments and will publish a selection. We will edit for space, and we require full names.


The recent story, 15-Minute Visits Take A Toll On The Doctor-Patient Relationship (Rabin, 4/21), triggered a range of comments. Here's a sampling:

Mary Cooley; Ashburn, Va.

Great article about the challenge of providing a better patient experience (feeling) and patient outcome (improved health) while trying to work for severely discounted rates. The Affordable Care Act should not have decreased the amount payers can spend to reimburse providers. Everyone should see the benefit and the curse of the increased number of patients, some of whom are sicker. The payer should not be able to manage the increased risk to the detriment of the patient and provider.

Rich Sensenbach; Rochester, N.Y.

I found [this] article … totally missing the real issue. Yes, doctors are spending less time with patients and that is a real concern, but why didn't she mention that this is being driven by the health insurance plans. They withhold a portion of what they reimburse the doctors as an incentive to meet the insurance companies' goals. If the doctors meet these goals, they get the withheld funds back. A large part of those goals are how much time a doctor can spend with a patient. The really disturbing issue here is that non-medical people are making medical decisions.

Molly Ciliberti, R.N.; Sammamish, Wash.

Perhaps you could publish an article on the difference between our current health care system, which is actually a sick care system, and a real health care system, which is primarily preventive health care. We are rapidly going down the rabbit hole. [It's] time to stop the money going for procedures, and having the money going [instead] into preventing injury and disease or controlling a chronic disease.

Another article, Doctors Overlook Lucrative Procedures When Naming Unwise Treatments (Rau, 4/10), drew this response:

Daniel B. Wolfson, ABIM Foundation executive vice president and chief operating officer; Philadelphia, Pa.

This type of analysis is a critical part of the transparent, honest dialogue about the issues of unnecessary medical care that we have sought to encourage. … That said, we think it is unfortunately shortsighted to measure the success of Choosing Wisely based on whether the physicians involved have cut their own income. Since the campaign launched just over two years ago, more than 50 medical societies have answered this unprecedented call and released lists of tests or procedures to question within their own fields. … The article also questioned whether one medical society should identify tests or procedures done by a different medical specialty as unnecessary. When physician groups provided recommendations that crossed in to other areas of medicine, it demonstrated the interconnectedness of our health care system. … Of course, while important progress has been made in starting this dialogue on waste, we agree that more work needs to be done. The article questioned whether the physician groups identified some of the most lucrative health care procedures as wasteful. The question is valid, although the usefulness of a medical test or procedure should be gauged by the outcomes it achieves for patients, not the income it generates for the health system. As resources in our health care system are stretched, we need to ask ourselves hard questions. Does the health care community have the fortitude to stop ordering costly tests and performing procedures that are not supported by evidence? Will patients stop asking for them?… Only by … challenging ourselves to identify unnecessary care can we truly achieve a goal of reducing wasteful practices ingrained in our system.

In regard to the following story about medical debt collection, With Medical Debts Rising, Doctors Are More Aggressive About Payments (Gold, 4/25), a reader offered the following:

Herbert L. Drayton III, vice president and health services administrator, Carolina Center for Occupational Health; North Charleston, S.C.

I think we all agree the business model of medicine is broken. Carriers play games, consumers are not informed and medical providers think they are forced to participate in the dysfunction. The current business of medicine is like visiting Walmart, loading up a cart with things I want and the cashier then asking if I want to pay now or later. Our communication with the consumer should include educating the consumer. This is about economics, not just vitals and procedures.

Meanwhile, Medicare Seeks To Stop Overpayments For Hospice Patients' Drugs (Jaffe, 5/1), triggered various comments like this one:

Donald Wechsler, Peoria, Ariz.

With this deficient process, Medicare has introduced an adversarial situation. Why should those otherwise entitled to chronic condition meds be singled out because of their failing health? In this heavy-handed approach to a perceived problem, Medicare created a conundrum for those already burdened.

Readers also reacted to the story, Telemedicine Policy Draws Opposition From Patient Advocates, Health Care Providers (Gillespie, 5/2).

Lynn Bailey, consulting health care economist; Columbia, S.C.

Aren't we once again making the perfect the enemy of the good enough. Rural patients would prefer to have human, face-to-face physician contacts. … There simply aren't enough health professions to make this happen. I doubt there will ever be because health demands are unlimited and resources are finite. So if you're willing to deal with an ATM or talk with an attorney over the phone or by email, a physician telemedicine appointment may not be prefect but it might just be good enough.

Jean Rawlings Sumner, M.D.; Wrightsville, Ga.

The policy does not limit telephone conversations between a patient and doctor. It limits to some degree prescribing for total strangers by random doctors using only a telephone conversation as a basis for using a drug or giving a recommendation. Why settle for substandard medicine? The individuals who reference rural health always live in cities. Rural citizens deserve the same quality of healthcare that those living in urban areas receive.

Meanwhile, readers drew on first-hand professional experience to comment on the story, Patients Lose When Doctors Can't Do Good Physical Exams (Boodman, 5/20).

Barry M. Lamont, M.D.; West Roxbury, Mass.

As a radiologist, I have seen the same phenomenon (loss of clinical diagnostic skills) first-hand. When a patient arrives at a busy ER, the residents make a quick clinical assessment and refer the patient for "appropriate" imaging tests. When an imaging test shows their clinical assessment to have been wrong, rather than try to develop and polish their skills at physical examination, they throw up their hands and say, "We'll never be as good as a CT scan. The patient is going to get a CT anyway, and we don't have time." The result is that the function of the ER often seems to be to decide whether a patient needs a CT of the head, a CT of the chest, or a CT of the abdomen and pelvis. Unfortunately, the usual proposed solutions -- cuts in reimbursement for imaging services, and so-called "bundled payments," which were soundly rejected by the public in the 1990s when they were known as capitation -- will simply shift the medico-legal and financial risk to the physicians without, in any way, protecting them from the inevitable consequences of a demand for less testing. It's always easier for politicians to blame those evil, greedy doctors than to explain to the public how much good medicine costs -- even when it is done the old-fashioned way, by hand.

Stephen Blythe, D.O.; Machias, Maine

As a physician who was trained in a "hands-on" approach to medicine, I concur that "when in doubt, examine the patient" is a good approach! But the technology and rushed atmosphere today makes it very difficult. I see young ER doctors so over-use CT scans it scares me - belly pain with a normal exam and a normal CBC still gets a CT scan. When I trained I learned "Cope's Early Diagnosis of the Acute Abdomen" at least enough to have the self-confidence to know when reassurance or watchful waiting was appropriate. Many of our young doctors and medical students seem afraid to touch the patients. When I teach students and we are evaluating skin lesions they seem surprised when I insist that they feel the lesion! And I cannot count the times when patients have told me that they were less than impressed with a previous doctor whom, they felt, "seemed like they were afraid to touch me." Even placing a hand on the patient's shoulder while you auscultate their heart lets the patient know you care about them as a person.

Another physician offered his thoughts on Some Colorado Doctors May Be Overcharging Medicare For Routine Visits (Whitney, 5/22).

Christopher Stanley, M.D., M.B.A.; Denver, Colo.

Love this topic and the article … looking at coding practices. I'm a physician who spent a total of 10 years working as a health plan medical director and am now with a large health system. I echo the caution, but also the serious concern, about overcoding. I've seen many, many examples of this in my clinical and administrative careers -- and physician colleagues are usually all-to-eager to justify to themselves or others that their patients are (all) sicker and therefore should be billed at the highest level. I don't agree with them. While not a hard-and-fast rule, a level 5 visit (99215) visit is broadly expected to require 45-60 minutes of face-to-face time with the physician while a mid visit (99213) typically takes about 15 minutes. Another metric that can be used is to multiply the number of cases per day (or week or month) by the number of minutes to see if it's reasonable for a physician to provide care as billed. For example, I've seen many situations where a physician would have spent more than 24 hours each day seeing patients (such as 40 patients per day, all billed at 99215 levels). I encourage further reporting and transparency of this issue that drives increased cost to health care.

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