They observed 33 primary care general internists in 20 different practices in the New York metropolitan area during a full workday. They found that, on average, physicians spent 20 percent of their office time (1.6 hours per day) in patient care activities outside of office visits.
These activities included phone or e-mail communication with patients who did not have appointments, filling out charts, following up on diagnostic studies and arranging complex patient care plans with specialists.
The physicians perceived these activities saved five potential visits per day to the doctor's office or ER. Each activity was performed in a quarter of the time that a face-to-face office visit took, thus saving time and expense for everyone -- the patient, the doctor, and the insurance company.
Why is this important? Because despite all the good it does, physicians are generally not reimbursed for their out-of-office work in the current fee-for-service payment system. Not getting paid for this kind of work makes some doctors less enthusiastic about doing it.
"This study confirms what good primary care physicians know. They spend a great deal of time doing things for patients outside of office visits," says the study's senior investigator, Dr. Lawrence Casalino, chief of the Division of Outcomes and Effectiveness Research in the Department of Public Health at Weill Cornell Medical College.
"Unfortunately, primary care physicians are paid only for seeing patients face-to-face, so they have no financial incentive to spend time outside office visits helping patients.
The study's lead investigator, Dr. Melinda Chen, feels primary care physicians should be compensated for their out-of-office work. "This kind of work is extremely valuable in potentially substituting for office visits. Changing payment incentives to support care coordination outside of office visits might reduce unnecessary visits and costs."
Dr. Chen is a recent graduate of the Agency for Healthcare Research and Quality (AHRQ) fellowship in the Division of Clinical Epidemiology and Evaluative Sciences Research in the Department of Medicine at Weill Cornell Medical College.
Getting someone else to do this non-compensated work isn't an option, either. The doctors in the study felt that only 15 percent of the out-of-office work they did could be performed by non-physician support staff.
"While extremely valuable, these activities are time-consuming and frantically squeezed in between office visits in a system that assumes but rarely accounts for this often invisible care coordination," said Chen.
She says that several new reimbursement systems are now being discussed that could compensate physicians
for this work, including monthly care coordination payments and pay-for-performance.
Additionally, in the proposed "patient-centered medical home," non-physician staff could assist with chart reviews and other work normally undertaken by physicians.
"It might be possible to incorporate elements of all of these approaches to get the best of each different strategy," said Chen.
Chen thinks reimbursement to physicians for the invisible work they do on behalf of patients may help forestall steadily increasing attrition and shortages in primary care, which is a cornerstone of health care in the U.S.
The researchers say theirs is the first direct observational study they are aware of that evaluates the value of the patient care that primary care general internists provide outside of office visits.
Dr. Chen was funded by a grant from the Agency for Healthcare Research and Quality during the time in
which this work was conducted.
Other authors of the study are Weill Cornell Medical College researchers Dr. James Hollenberg and Janey
Peterson, Ed.D., R.N., and Dr. Walid Michelen, of the Generations +/Northern Manhattan Health Network.
