Medical Practice Models:
How Patient Care Is Delivered

Traditional Medical Practice

There are various ways in which a physician can choose to offer patient care. The most common and traditional method of medical practice is to establish an office or clinic where patients come in for regular or urgent visits. There will often be hospital rounds to do in the morning or in the evening or both. In the beginning when the patient load is small and growing, this is not a problem. However, as s/he acquires a significant patient base, it becomes less fun.

The doctor usually will allow about fifteen minutes for each visit. This is adequate for managing relatively simple problems like an upper respiratory infection, a blood pressure check or a diabetes checkup. However, if the visit is at all complicated by two or more active problems requiring increased time for history-taking or physical examination, ordering tests, explaining things to family members or arranging hospitalization, the schedule is pretty much ruined for the rest of the day.

Patients in the waiting room become frustrated, the doctor becomes rushed and harried, and as much as the doctor and staff try to do a good job for each of the following patients, the time pressures don’t allow for very personalized care. At the end of the day, patients, staff and physicians are all unhappy and dissatisfied with this situation.

In order to try to improve these conditions, the physician may try to increase the duration of visits to 20 or 30 minutes or maybe even eliminate the hospital work, allowing the growing number of hospitalists to take over that portion of the load, even though patients become upset about the lack of continuity of care. This makes the day go a little easier most of the time, but the doctor is obviously less productive; it becomes more difficult for patients to get an appointment; and the doctor’s income gets cut by 25-50%.

The doctor may try to raise his fees to compensate for this, but his/her income won’t increase at all because reimbursement for each patient is severely regulated by Medicare, Medicaid and other insurance companies. The office overhead increases because of inflation; and the doctor has to cut salaries, employees or benefits to make ends meet. So at the end of the day, week or month, the patients, the staff and the doctors are still not satisfied and all are increasingly unhappy.

This medical practice model provides the least favorable environment for practicing the type of patient care that is promoted in the other pages of this website. It is not impossible however, because many physicians have been able to do it, but it’s not easy.

Hospital-based Medical Practice

A growing number of physicians coming out of internal medicine residencies are becoming aware of these problems and are deciding to go into hospital medicine as a career. The rapid growth of this trend attests to the severity of the problems associated with trying to survive in an office practice. The main advantages of this medical practice model are the reduction in time pressure to see each patient at a certain time, significant reduction in overhead and a greater variety of the types of patients seen. The disadvantages are the greater stress associated with taking care of sicker patients, the decrease in continuity of care between office and hospital, and the long and difficult nights on call covering new admissions and consults. From the patients’ point of view, with all the newer doctors becoming hospitalists or subspecialists, there are fewer primary care doctors to provide the general overall care and attention to preventive care that they need. So access to health care suffers even more.

Concierge Medical Practice

A new trend has developed over the past decade that is gaining in popularity and is also driven to a large extent by the multiple problems described in the traditional model. In this model of concierge or “boutique” medicine, the number of patients accepted into the practice is kept low so that the physician has more time to devote to each patient. Special services can be offered like house calls, comprehensive physical exams, better continuity of care between office and hospital, same day appointments and faster prescription renewals, easier and more direct access to the physician and in general much more personalized care. Many patients feel a great deal more satisfied with this model of care and are willing to pay for it – as much as $100 to 20,000 per yr in some cases depending on the area and the type of services offered. Many patients unfortunately don’t feel they can afford to join this type of medical practice, which has led to some controversy and concern that this will lead to a two-tiered medical system – one for the wealthy and one for the poor. Nevertheless, patients, staff and physicians appear to have a greater amount of satisfaction with the services, benefits and income respectively received in a concierge medical practice model.

Whatever the controversies, the fact is that the second two models are driven by the failure of the first model. As I see it, the only way to make the first model better is to either increase reimbursement to those physicians through the existing insurance programs or, even better, decrease the severe regulation and restrictions forced upon physicians by those same insurance companies (Medicare. Medicaid, and other managed care plans), or both. In addition, there has to be better tort reform, so that physicians don’t feel forced to practice defensive medicine.

The only way for this to happen is for lawmakers to realize that increasing health care costs are not the result of greedy doctors. In fact, doctors’ fees are only a very small part of this country’s expenditures in medical care.

If physician reimbursements were improved and regulations were lifted and if better tort reform were instituted, the market would help solve the inequalities in access to care by allowing more incentive for students to become primary care physicians. With a greater number of PCPs, the doctors’ charges would be controlled by the market. The medical practice of defensive medicine would dissolve with better tort reform and with a movement to improve systems of care rather than blaming individuals for the inevitable occasional bad results. With less defensive medicine, health care costs would plummet. We will still need mechanisms to weed out incompetent physicians and laws to prevent fraud, but there would be less incentive to commit fraud if the first model above were not so impractical and unsatisfying.

Also with deregulation of physician reimbursement, the money that is being spent on health care administration would decrease sharply. There would be no need for managed care organizations (which time has shown don’t really save costs anyway, just shift it around). The huge costs associated with regulation of physicians’ fees by Medicare and Medicaid would dissolve as well.

Well, now that we have that problem solved, we can move on to other things.

Right.

Just my 2 cents…

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