Jan. 17, 2001 -- The frustrations -- real or perceived -- confronting patients and doctors by managed care have provided comedians with material for a month of stand-up routines:
Question: What do you call a visit to an HMO doctor for a flu shot?
Answer: A drive-by shooting.
Question: What are some ways to know you've joined a cheap HMO?
Answer: To avoid a time-consuming throat culture, the doctor French kisses you.
And by now many web-browsing patients and doctors have seen the widely circulated memo by a fictitious squinty-eyed claims administrator offering a cost-effectiveness analysis of a famous unfinished Schubert symphony: "If all redundant passages were eliminated, as determined by the utilization review committee, the concert would have been reduced to about 20 minutes, resulting in substantial savings in salaries and overhead. In fact, if Schubert had addressed these concerns on a cost-containment basis, he probably would have been able to finish his symphony."
The jokes attest to a pervasive anxiety about the transformations of American medical care in the last 20 years. And they speak to the widespread belief -- disseminated as conventional wisdom -- that managed care has drastically reduced the amount of time a physician can spend with a patient.
But now national survey data have turned up a startling finding: The average duration of physician office visits actually increased between 1989 and 1998.
"It is important for patients to understand that the rhetoric about managed care is not necessarily true," lead author David Mechanic, PhD, director of the Institute on Health, Healthcare Policy, and Aging Research at Rutgers University, tells WebMD. "They have to evaluate their care on the basis of their own experience and on good data that is increasingly available."
Using information from two nationally representative data banks, Mechanic found that the average duration of a physician office visit increased between one and two minutes from 1989 to 1998. The length of office visits increased for patients in both prepaid HMOs and non-prepaid managed care plans, according to the report, published in the Jan. 18 issue of The New England Journal of Medicine.
How is it possible that such widely received wisdom can be stood on its head?
Mechanic, who says he himself initially accepted the conventional wisdom, believes the popular media is a culprit, peddling anecdotes about managed care horror stories based on isolated patient experiences without objective confirmation.
In fact, he says, objective data reveal great variability among managed care companies. "We get fixated on anecdotally built theories that divert us from the really important policy issues of access to health insurance, appropriate ways of organizing long-term and chronic care, and quality of care," he says.
And Mechanic suggests that because of the backlash against managed care, many managed care organizations are increasingly focused on patient satisfaction. "Doctors know that a key to patient satisfaction is the time they spend with them," he says.
Edward W. Campion, MD, deputy editor of The New England Journal, who authored an editorial accompanying the study, believes the increasing number of doctors is a crucial element. "There has been a 21% increase in the number of physicians per capita," he tells WebMD. "That has to have an effect."
He also believes that the increasing complexity of medicine, and the number of informed patients who come to an office visit with questions about complicated topics, has driven up the time doctors spend with patients. "The study is an example of how useful it is to get objective data rather than relying on intuitions that can be misleading," he says.
Others suggest caution in interpreting the data. Jerome Kassirer, MD, professor of medicine at Tufts University School of Medicine, points out that the survey did not take into account the age of patients. While physicians may be spending more time with older, sicker patients -- and thereby increasing the overall average time spent -- they may be spending substantially less time with younger patients, Kassirer suggests.
"We know older people take more time, and there are more older patients," says Kassirer, who is also associate research scientist at Yale University School of Medicine and editor-in-chief emeritus of The New England Journal of Medicine. "What we may be seeing is an artifact of the aging population."
Kassirer also notes that the busiest doctors may not have participated in the survey. He also points out that it is not possible to independently verify the record keeping for patient visits, which may be done by assistants and secretaries.
"Managed care organizations are looking for doctors who will spend time with patients regardless of the restrictions, and so assistants or secretaries may be keeping track of time differently than they did in the past," he tells WebMD.
Neither Mechanic nor Campion believes the frustrations expressed by doctors and patients with managed care are completely fabricated. While the actual number of minutes a patient can spend with a doctor may be increasing, continuity of care over time may have deteriorated, resulting in a loss of trust that feeds misperceptions, they say.
"Trust between a patient and a doctor is built iteratively across visits," Mechanic tells WebMD. "That is why continuity of care is so important."
According to Campion, patient perceptions of a doctor visit can be influenced by a variety of factors. "If you are hassled and under pressure, that is not going to seem like a comfortable visit," he says. "The quality of a visit can be affected by how long a patient has to wait. If a patient has to wait 90 minutes, it is going to be an unsatisfactory visit no matter what."