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15 Minutes

By Dr. Nilesh Kalyanaraman
. 2 Comment(s)

My third patient of the day came in for the first time in three years. She had lost her job during the economic meltdown of 2008, and with it her health insurance.  For the past three years she’s been going to the ER for her any urgent health care issues. Then, a few months ago, she got a new job and with it health insurance so she came back to see us.

She had a list of issues she wanted to address: high blood pressure, fatigue, joint pain and obesity. Most of my overweight patients don’t want to talk about their weight so when someone comes in and says they want to lose weight I try to focus on that as much as possible. The difficulty, if not impossibility, is how I can address diet, nutrition and exercise in 15 minutes while also addressing her other concerns.

Most of my patients have multiple issues that they want to discuss during their visit. After all, it took them a week to get in to see me and they want to get as much done as possible. The problem is that if I don’t stick close enough to our 15-minute visit time, by the end of the day I’ll be running an hour behind.

So why is the standard primary care visit 15 minutes? No patient ever thinks it’s enough time. No doctor ever thinks it’s enough time. Yet, the industry standard (trust me, we’re an industry) is the 15-minute primary care visit. I suspect it’s related to the relatively low reimbursement rates for primary care physicians. Someone, somewhere, figured out that given the reimbursement rates for primary care services, a certain number of visits a day were required, usually 22 to 24, to maintain an income in the high one-hundred thousand dollar range.  In order to see that many patients, appointment times had to be 15 minutes a piece so that schedules could be made that make sense. And thus was born the 15-minute visit.

In order to allow more time for patient visits we need to change how we compensate our primary care doctors. As it stands, current reimbursement rates allow me to make almost twice as much money for two visits of 15 minutes each than for one visit of 30 minutes. Given such an incentive structure, it’s not surprising that the 15-minute visit is so entrenched. But, in this push for quantity we lose out on quality. For my patient who I mentioned earlier, all I was able to do was go over an exercise plan with her and manage her blood pressure and the visit still took 20 minutes.

We as a society are starting to realize that the business of medicine is getting in the way of the actual practice of medicine. To address this, changes such as free preventive care visits and patient centered medical homes are being instituted around the country. The next change that needs to be made is to kill the 15-minute visit. 

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  1. Omada Idachaba

    Excellent article. I agree. For a lot of my chronic disease patients, 15 minutes is just not enough. It takes 15 minutes for some of them to walk back to the exam room! I don't like doing an incomplete job and I don't like being behind. No benefits to either. What I do now, as I wait for the revamp of the healthcare system, is prioritize problems and chip away at them at a reasonable pace. If I can only effectively take care of one problem at this visit, so be it. I will continue to see patients on a frequent basis until we both feel that all concerns have been addressed. Is it an inconvenience to the patient? Probably. Do I have much of a choice - no. Not if I want to provide superior care.
  2. Andrew Johnstone

    One OTHER problem is that if you see Medicare or Anthem patients, you don't have the OPTION of that 30 minute visit instead of two 15 minute visits, or one 45 minute instead of three 15 minute ones. You WILL be 'audited', if you dare try coding 99215's, even though they lose you money vs. three 99213's (which fragments care, wastes patient's time, takes employees off work, means multiple co-pays costs the patient more money, and - even costs the insurance companies more money). I put 'audit' in quotes because the process involves a one-sided even where the insurer can simply change the rules and/or interpret them as they wish, so you simply cannot win despite 'thorough' documentation.

    Every day at the end of the day I have to go through all my charts for the day, pull out the Anthem/Medicare ones, and down-code the visits. Of course to me, this seems like fraud, which it would be if I did it to make ME more money, but I guess lying about what we do vs. bill for is not fraud if it's the government's pet Medicare-carrier making the extra money.

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