Can we deliver high value care with one eye on the clock and the other on the screen?

Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice.

It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.

Doctors need time to listen and think. General practice’s inherent time pressures, interruptions and the need to record information on computers can be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.

This is not rocket science and has been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.

In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.

Increasing complexity

In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.

It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.

It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.

Health Care Homes

Is block funding such as proposed in the Federal Government’s Health Care Homes model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.

Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.

This article was originally published in newsGP.

11 thoughts on “Can we deliver high value care with one eye on the clock and the other on the screen?

  • I agree Edwin. The way we structure our clinics, consultations times and payments probably needs a revamp. We need to consider innovation and not tying all our fees to MBS item numbers. General Practices will need to focus on promoting quality and more quantity, demonstrate effectiveness, and quality outcomes. The limitations here are what patients can afford to pay for this, particularly the disadvantaged populations. I would happily spend an hour with my patients however I doubt they could afford the cost that would reflect 4 x level b consultations. Once we can prove quality care, we then advocate for patients to be reimbursed more of their out of pocket costs.

    Liked by 1 person

    • Good points, thanks Ash. The MBS for GP is a bit outdated indeed (and will be reviewed in the coming months). I think the effectiveness of general practice has been well demonstrated, here in Australia as well as overseas. Let’s be careful with KPIs, ‘quality indicators’ and performance management as this is not backed by evidence (eg in the UK it has led to drs focusing on meeting their targets instead of patient needs). There is of course always room for quality improvement, and in-practice quality assurance activities should be facilitated & encouraged.

      Liked by 2 people

      • Yes the idea of ‘QI’ and measuring effectiveness can get people nervous about a UK style system. This is certainly not what I meant.

        However we can’t ignore that we need ongoing evidence of quality that policy makers can understand and feel confident in. Choosing the most appropriate activities is key.

        Liked by 2 people

        • Agreed Ash, we shouldn’t shy away from in-practice quality assurance. We need clever, safe ways to maintain quality and demonstrate that we have the right processes in place.

          Liked by 1 person

  • Reblogged this on Dr Thinus' musings and commented:

    So true – especially it is those long consults with frail and complicated, often elderly, patients that we are most likely to end up bulkbilling.

    You can only work the system with add-ons like Careplans and Health Assessments so far – after that it becomes a loss maker for the business

    Liked by 3 people

  • As a comorbid chronic condition patient and a CPA (so I understand the business/profitability/KPI aspects) I agree. You already knew I would, though. 😊

    I deliberately book long appointments for the core reason you raise: I want my doctor to have time to THINK.

    Invariably I will have more than one issue: I have skin issues from my meds, I have vanishing iron, etc etc etc. For the doctors here for context, hyperactive thyroid/Graves/MNG and AI arthritis (RA or PA or both). Photosensitive eczema (from meds) and a host of lumbar structural issues. I’m not going in for a work certificate for a sniffle and I’m trying really hard to retain/maintain normal function. My leg press is 160 kg and I swim – not as much as I used to, only 1 km a session now.

    I am also well aware I’m one of the healthier chronic people – many WAY worse off than I who would need more time.

    Just as I can’t fix your software in 10 minutes, nor do I expect a doctor to be able to do his/her job in 10 minutes.

    Yesterday I did book a 10 minute appointment because all I was needing was a pathology request. I am involved enough in my own care to know the GP was most likely going to agree with my thoughts on the current situation.

    The old adage of “We get what we pay for” rings true, I believe. If I want to keep my conditions managed, my doctors have to have time to think. Thinking is a critical skill in the medical profession.

    I worry greatly about being a pensioner and not being able to afford the care I currently get. As I’m 62, that’s not far away.

    As a CPA, I am well aware of the need for medical practices to cover running costs and enable doctors to earn a living (i.e. profitable practices). Doctors need to be able to invest in CPD – yes, I want you to keep up-to-date, because that will impact on my care.

    Oh dear, this is getting to long.

    I could have just setlled for “I agree”. 😁

    Liked by 4 people

  • Medicare does offer patients with chronic disease/s, mental health issues, and many other complex issues an increased rebate for increased time with the doctor.

    It is our duty as professionals to offer this time to our valued patients and know the MBS such that they can access these rebates.

    We can also charge a private fee.

    There are many ways to meet the challenge of complex patients as professional clinicians without expecting bureaucrats to manage it for us!

    Thanks for a great thought provoking post Edwin.

    Liked by 2 people

    • Agreed Nick, that’s what I try to do. However will those item numbers exist in 20yrs? Part of looking at risk in business (whether we like it or not, medical practices are businesses) is future sustainability of funding. Where will the money come from if these items are rolled away for block funding only?

      This is I believe the essence of Edwin’s piece. That in future funding to enable patients to access affordable medical costs from cost effective quality General Practice there needs to be recognition of the need for this at a federal level.

      It’s up to us as a profession to not only rely on past data but to continue to prove that funding for patients and is essential and worth it. 🙂

      Liked by 3 people

  • A small classic of General Practice in my day ( and still pertinent) was The Doctor -Patient Relationship. Browne K, Freeling P. Churchill Livingstone 1976.
    Says it all. One case is about a lady that has made 300 short consultations in 3 years, to little avail. Paul Freeling spends an hour with her and she reverts to one or two consults a year.
    The cardiologist (physician) hour is now 6-8 minutes, The psychiatric hour is now 20 minutes and the initial orthopaedic consultation is 3 minutes (look at the MRI). The actual ophthalmologist consult and treatment is 2 minutes and 90% of corporate GP on-line bookings are in 5 and 10 minute blocks. Time is money.
    Julian Tudor Hart was a big name in the world of British General Practice . When I told him that RACGP surveys showed that 80-90% of Australian Patients were happy with GP he replied:” They obviously don’t expect very much”.

    Liked by 1 person

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