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PBS NewsHour

15-minute doctor visits take a toll on patient-physician relationships

Photo by Rebecca Emery/Getty Images

Photo by Rebecca Emery/Getty Images

Joan Eisenstodt didn’t have a stopwatch when she went to see an ear-nose-and-throat specialist recently, but she is certain the physician was not in the exam room with her for more than three or four minutes.

“He looked up my nose, said it was inflamed, told me to see the nurse for a prescription and was gone,” said the 66-year-old Washington, D.C., consultant, who was suffering from an acute sinus infection.

When she started protesting the doctor’s choice of medication, “He just cut me off totally,” she said. “I’ve never been in and out from a visit faster.”

These days, stories like Eisenstodt’s are increasingly common. Patients–and physicians–say they feel the time crunch as never before as doctors rush through appointments as if on roller skates to see more patients and perform more procedures to make up for flat or declining reimbursements.

It’s not unusual for primary care doctors’ appointments to be scheduled at 15-minute intervals. Some physicians who work for hospitals say they’ve been asked to see patients every 11 minutes.

And the problem may worsen as millions of consumers who gained health coverage through the Affordable Care Act begin to seek care — some of whom may have seen doctors rarely, if at all, and have a slew of untreated problems.

“Doctors have one eye on the patient and one eye on the clock,” said David J. Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons.

By all accounts, short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

Shorter visits also increase the likelihood the patient will leave with a prescription for medication, rather than for behavioral change — like trying to lose a few pounds, or going to the gym.

Physicians don’t like to be rushed either, but for primary care physicians, time is, quite literally, money. Unlike specialists, they don’t do procedures like biopsies or colonoscopies, which generate revenue, but instead, are still paid mostly per visit, with only minor adjustments for those that go longer.

And many doctors may face greater financial pressure as many insurers offering new plans through the health law’s exchanges pay them even less, offering instead to send them large numbers of patients.

This fee-for-service payment model, which still dominates U.S. health care, rewards doctors who see patients in bulk, said Dr. Reid B. Blackwelder, president of the American Academy of Family Physicians, who practices in Kingsport, Tenn.

“Doctors are thinking, ‘I have to meet my bottom line, pay my overhead, pay my staff and keep my doors open. So it’s a hamster wheel, and they’re seeing more and more patients … And what ends up happening is the 15-minute visit,” he said.

Struggling For Control

Dr. Richard J. Baron, president of the American Board of Internal Medicine, said that patients and physicians often wrangle over control of that visit – a “struggle for control” over the allocation of time

Sometimes the struggle is overt – as when a patients pulls out a long list of complaints as soon as the doctors comes in.

Sometimes, it’s more subtle. When Judy Weinstein went to see her doctor in Manhattan recently, she knew she would get only 20 minutes with him – even though it was an annual physical, and she had waited nine months for the appointment.

So when the doctor asked if he could have a medical student shadow him, she put her foot down.

“I said, ‘Y’know, I would prefer not. I get 20 minutes of your divided attention as it is – it’s never undivided, ever – and I need to not have any distractions. I need you focused on me.’“

How did visits get so truncated? No one knows exactly why 15 minutes became the norm, but many experts trace the time crunch back to Medicare’s 1992 adoption of a byzantine formula that relies on “relative value units,” or RVUs, to calculate doctors’ fees.

If you must know, the actual formula is: (Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor.

That was a switch for Medicare, which had previously paid physicians based on prevailing or so-called usual and customary fees. But runaway inflation and widespread inequities dictated a change. RVUs were supposed to take into account the physician’s effort and cost of running a practice, not necessarily how much time he or she spent with patients.

The typical office visit for a primary care patient was pegged at 1.3 RVUs, and the American Medical Association coding guidelines for that type of visit suggested a 15-minute consult.

Private insurers, in turn, piggybacked on Medicare’s fee schedule, said Princeton health economist Uwe Reinhardt. Then, in the 1990s, he said, “managed care came in and hit doctors with brutal force.”

Doctors who participated in managed care networks had to give insurers discounts on their rates; in exchange, the insurers promised to steer ever more patients their way.

To avoid income cuts, Reinhardt said, “doctors had to see more patients – instead of doing three an hour, they did four.”

Rushed Doctors Listen Less

How doctors structure the precious 15-minute visit varies – often quite dramatically. Generally, they start by asking the patient how they are and why they came in, trying to zero in on the “chief complaint” — the medical term for the patient’s primary reason for the visit.

But most patients have more than one issue to discuss, said Dr. Alex Lickerman, an internist who has taught medical students at University of Chicago and is director of the university’s Student Health and Counseling Services.

“The patient is thinking: ‘I’m taking the afternoon off work for this appointment. I’ve waited three months for it. I’ve got a list of things to discuss.’

“The doctor is thinking, ‘I’ve got 15 minutes.’ There is almost a built-in tension,” Lickerman said.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them; Only one in four patients got to finish his or her statement. Medical schools drill patients in the art of taking a careful medical history, but studies have found doctors often fall short in the listening department. It turns out they have a bad habit of interrupting.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them; Only one in four patients got to finish his or her statement.

A University of South Carolina study in 2001 found primary care patients were interrupted after 12 seconds, if not by the health care provider then by a beeper or a knock on the door.

Yet making the patient feel they have been heard may be one of the most important elements of doctoring, Lickerman said.

“People feel dissatisfied when they don’t get a chance to say what they have to say,” he said. “I will sometimes boast that I can make people feel they ‘got their money’s worth’ in five minutes. It’s not the actual time or lack of time people are complaining about – it’s how that time felt.”

Studies show that doctors’ visits have not gotten shorter on average in recent decades and may actually have gotten a few minutes longer. The mean time spent with a physician across specialties was 20.8 minutes in 2010, the latest year available, up from 16.3 minutes in 1991-1992 and 18.9 minutes in 2000, according to the National Center for Health Statistics; that includes visits with internists, family docs and pediatricians, which all increased by about two and a half minutes.

In 1992, most visits – about 70 percent — lasted 15 minutes or less; by 2010, only half of doctor visits were that short (the data is from the National Ambulatory Medical Care Survey, an annual nationally representative sample survey of visits to physicians).

This doesn’t necessarily mean the patient experience is improving. Medical schools drill students in the art of taking a careful medical history, but studies have found doctors often fall short in the listening department. It turns out they have a bad habit of interrupting.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them; only one in four patients got to finish their statement. A University of South Carolina study in 2001 found primary care patients were interrupted after 12 seconds, if not by the health care provider then by a beeper or a knock on the door.

Yet making the patient feel they have been heard may be one of the most important elements of doctoring, Lickerman said.

“People feel dissatisfied when they don’t get a chance to say what they have to say,” he said. “I will sometimes boast that I can make people feel they ‘got their money’s worth’ in five minutes. It’s not the actual time or lack of time people are complaining about – it’s how that time felt.”

This KHN story was produced in collaboration with USA Today. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Do free samples influence the way doctors prescribe drugs?

Photo by Flickr user ep_jhu

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HARI SREENIVASAN:  If you ever felt lucky that you got a free sample of a prescription drug from a doctor, it may actually be costing you in the long run. A new study from Stanford University’s School of Medicine found that doctors who are allowed to hand out free samples, often prescribe those expensive drugs versus doctors who don’t have access to free samples. We’re joined from California by Professor Alfred Lane, who teaches pediatrics and dermatology at Stanford and is a senior author of the study. So you looked specifically at the practice of dermatology, what did you find?

DR. ALFRED LANE:  Yes, we found that those physicians across the United States who use samples are much more likely to write for higher prescriptions. The average cost of a first visit for acne or rosacea was over $450 for medication for the physicians that use samples. And we compared it to our clinic where we have no samples where the average cost was only 200-hundred dollars. So at least twice as more expensive were the prescription costs from the physicians who use samples.

HARI SREENIVASAN:  And now this was focused on dermatologists and these particular types of medicines. But how does this translate out – is this a wider practice that’s happening in different fields as well?

DR. ALFRED LANE:  Well, the reason for the study is I noticed in my practice once we did not have samples that I was writing for more generics and the patients referred from dermatologists were on more expensive medications. And so we tried to look at it, and in the data we found that it is true that dermatologists are using samples more than other specialties over the last ten years. And a lot of that has to do with the use of what’s called branded generics or generics that now are under brand name, and they’re very expensive.

HARI SREENIVASAN:  So now, the drug companies would come back and say listen, don’t these free samples help the poor who might not able to afford the medications or help them get immediately on the drug?

DR. ALFRED LANE:  That’s what dermatologists and that’s what physicians will often say, but the data is very clear that the poor patients are not the ones who usually get the samples. We didn’t look at that in our study, but that’s been shown in other studies.

HARI SREENIVASAN:  And so is there a connection between the amount of money the drug companies now spend – is this basically, are free samples essentially the marketing right off?

DR. ALFRED LANE: Yeah, so it looks like there’s at least over six-billion dollars a year that are spent by pharmaceutical companies in sampling. And so that cost eventually has to be paid by someone. And the price of the generic drug may be quite a bit less than what’s called brand name or branded generic. And it’s only the branded generics or the branded drugs that are sampled. So those are the ones that the dermatologists are channeled into writing prescriptions for.

HARI SREENIVASAN: And what about the argument that samples are the way to get the most recent medications into the hands of doctors?

DR. ALFRED LANE: Well, sometimes that’s not the best thing. There are studies with cardiovascular disease that sometimes the recent medications are not studied as well, and the risk of death or dying from the use of samples can be there. In dermatology, we don’t see that. But the other problem is that the recent medications have not been proven better than the generic in most situations.

HARI SREENIVASAN: So the six-point-three billions dollars, those are essentially costs passed onto the consumer?

DR. ALFRED LANE: That’s exactly right. And one of the focuses of our study was for the dermatologists to realize that although they think they’re helping the patients, they are really being manipulated to write for more expensive medications with no proven benefit of those medications over the generic drugs.

HARI SREENIVASAN: All right, Professor Alfred Lane joining us from Stanford, thanks so much.

DR. ALFRED LANE: Thank you.

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New clinical trials underway for advanced lung cancer patients


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HARI SREENIVASAN: Another medical story that caught our attention this week. Word of what’s described as a pioneering clinical trial for patients with advanced lung cancer. What’s novel is not necessarily the drugs being used, but how many and how they’re being targeted. Dr. Mark Kris, an oncologist at Memorial Sloan Kettering Cancer Center, joins us. So what are they doing in the U.K. with this clinical trial? What’s so interesting about it?

DR. MARK KRIS: They are taking a discovery that was made here almost ten years ago now where specific genes are damaged in lung tumors. And the damage brought on by those genes makes those cancer cells very susceptible to medications. So if you find one of these genetic changes and give a patient a drug targeting that, almost surely their cancer will shrink and normal tissues are not affected. I mean it’s exactly what oncologists hope to do. What they’re doing now in the U.K. is developing a nationwide program partnering with pharmaceutical companies that are developers of these drugs to do the testing in a much more generalized way and to test for many of these different gene mutations at the same time. So in essence a patient might have ten chances to find something in the tumor that’s in their body. Ten chances to get a medication. And also the pharmaceutical companies supplying drugs to go along with the discovery of those genetic markers and help individual patients.

HARI SREENIVASAN: And that’s different because we’re used to clinical trials that are one drug at a time or one gene at a time.

DR. MARK KRIS: Exactly. And also ten years ago before these mutations were discovered, everyone with a lung cancer got the same chemotherapy. Sometimes it helped, sometimes it didn’t. And we always wanted to know what is it that makes an individual’s cancer shrink or not. And this genetic information is the way we can do that, and we can really move much toward this goal of what we call personalized medicine. The right drug for the right patient.

HARI SREENIVASAN:  So if this personalized medicine trial, so to speak, happens successfully in the U.K., does that mean something like that can happen here on a larger scale in the U.S.?

DR. MARK KRIS: Well, it’s actually happening all over the world right now. And we have already completed a program here in the U.S., the Lung Cancer Mutation Consortium, where 14 hospitals did something very much like this. There are programs in France as well. It’s a whole world-wide movement. And the fact that the U.K is doing it, they’re a little sometimes slower to embrace these new technologies and new drugs. And the fact that they’re doing it says that this technology, that this idea, is becoming more and more mainstream. And it’s really going to accelerate progress.

HARI SREENIVASAN: And so tell me about how this is going to make this larger shift in terms of personalized medicine, almost on a genetic level, targeting each patient with a specific drug that could cure their cancer.

DR. MARK KRIS: So the way that it is happening now is that when the cancer is first discovered, these genetic tests are done. In the panel we have at Sloan Kettering, MSK Impact, we test for 340 different genes. And then what we try to do is find the drugs that are most likely to help a person whose cancer is driven by these genes. These genes make a cancer cell horribly dependent on the proteins that these ankA genes produce. They call it ankA gene addiction, In other words, Achilles’ heel has been the term that’s been used. So if you find that arrow to go after the Achilles’ heel, the cancer cells die. And the beautiful thing about it is these drugs are much less destructive to normal people. The other thing is if you know this person’s cancer cells don’t have this medicine, then we wouldn’t recommend that medicine to a patient. Previously, it was one size fits all. Every person with the illness got the same medicine.

HARI SREENIVASAN: Dr. Mark Kris, an oncologist at Memorial Sloan Kettering. Thanks so much.

DR. MARK KRIS: Thank you.

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What’s keeping less expensive biologic drugs from the U.S. market?

Technician working with biosimilars and biologic drugs.

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EMILY SENAY: Philip DeLuca is enjoying retirement after working decades on the Long Island Railroad.  The 71 year old stays busy with his ten grandkids, but lately it’s been difficult to keep up.

How has your energy been?

PHILIP DELUCA: Low. I can’t do the things I did, you know, ten, 12 years ago.

EMILY SENAY: Patricia DeLuca is his wife.

PATRICIA DELUCA: He became more tired, more frustrated with not being able to do the things he normally could do.

EMILY SENAY: DeLuca found out his bone marrow wasn’t producing enough normal red blood cells, and if the levels dipped too low it could be life-threatening. So the doctor gave DeLuca two choices: blood transfusions or medication that would boost his red blood cell count.  He chose the medication.

PROCRIT AD: Too tired to do the things you used to do? Talk to your doctor about Procrit.

EMILY SENAY: DeLuca’s medication, Procrit, is known as a biologic, a relatively young and revolutionary class of drugs. Other popular biologics include Humira or Enbrel used to treat rheumatoid arthritis and Lucentis for macular degeneration.

Unlike pills used to treat common conditions like high blood pressure or high cholesterol that are made from chemicals, biologics are more complex.  They’re made in living organisms, resulting in proteins.

They’re often considered more effective because biologics work with the body to normalize its immune system in a way chemicals don’t.

GEOFFREY EICH: We will see more biologic medicines.

EMILY SENAY: Geoffrey Eich is Amgen’s executive director of research and development policy. Amgen is one of the largest manufacturers of biologics, including the drug DeLuca takes.

GEOFFREY EICH: I think everyone is very excited about what the future holds in terms of our ability to treat diseases like high cholesterol, or diseases like Alzheimer’s and fighting cancer, but also for disease where a patient will have a chronic lifelong disease.

EMILY SENAY: Since DeLuca’s condition is chronic every Monday morning he goes to the hospital for an injection of Procrit. The biologic medication has helped, the DeLucas say, but it’s also extremely expensive.

EMILY SENAY: When you heard the price of the, of the shot can you tell us what your reaction was?

PATRICIA DELUCA: I was shocked.  I had no idea that this could cost this much.

EMILY SENAY: Had you seen a medication that has cost that much before?


EMILY SENAY: According to a bill DeLuca showed us a single injection costs $1,500. Under his insurance plan his copay ended up being $196. And remember, he was going to the hospital every week.  So the copay turned out to be nearly $800 a month.

PATRICIA DELUCA: It’s financially difficult.  We’re on a pension.  And $196 a week extra, coming out of that pension, is a lot of money for us.

EMILY SENAY: Can you afford it?

PATRICIA DELUCA: Can I afford it?  I have to afford it.  I have to pay it.  It’s a bill.

EMILY SENAY: But why is it so expensive?  Some critics say that’s because there’s no system in place in this country that would make “generic” biologics available.  But they are sold overseas and at a much lower price and have been for nearly eight years. There they are known as biosimilars.

STEVE MILLER: If you look at Europe with there are already biosimilars on the marketplace the discount is somewhere between 30 and 50 percent.  So, we’re talking about tens of thousands of dollars of savings annually for each and every patient.

EMILY SENAY: So Europe is already using these biosimilars?

STEVE MILLER: Much of the world is way ahead of us.  So Japan, Canada, much of Europe already has biosimilars in their marketplace.  And patients are already benefiting from both the great products and the discounts.

EMILY SENAY: Steve Miller is the Chief Medical Officer at Express Scripts, which negotiates drug prices with pharmaceutical companies for employers, unions as well as the department of defense.

Patients like DeLuca are forced to pay much more for their biologics because there’s no competition in the U.S. in Europe there are at least 5 versions of DeLuca’s biologic where according to manufacturers they’re sold for up to 30 percent less than the brand name biologic.

So why aren’t less expensive versions of DeLuca’s drug or any biosimilars available in this country?  That’s because when Congress passed the Hatch-Waxman bill nearly thirty years ago creating generic drugs, biologics barely existed.

EMILY SENAY: If these biosimilars could be sold would people have access to something they don’t have access to now because it’s just too expensive?

STEVE MILLER: So just like when you use a generic drug and you often have, you know, a four-dollar payment or ten-dollar payment, the same thing would happen with biologics in that you would have a much lower co-pay.

EMILY SENAY: In 2009 the federal trade commission reached a similar conclusion that “competition is likely to lead to an expanded market and greater consumer access.” In other words lower prices.

Geoffrey Eich of Amgen says his company is open to competition but cautions that biosimilars cannot be approached the same way as traditional drugs.

GEOFF EICH: They’re different, right.  These are, these are different than drugs and different than chemicals.  And the prevailing assumption is that you have a brand medicine and you have generic medicines and generics are all the same and they’re also the same as the brand medicine. In the world that we’re going to in the future though, because they’re expressed in living cells, each medicine will have its own particular profile.

EMILY SENAY: That means biosimilars will never be identical to the original biologic.

According to the New England Journal of Medicine, “given the complex nature of biologics, it’s unlikely that a “one size fits all” systematic assessment of biosimilarity can be developed.”

But Miller says the U.S. should simply look to the European Union as a model. The European medicines agency, which is the equivalent of the F.D.A., has been approving biosimilars there for eight years.

STEVE MILLER: There has actually not been a single episode with a biosimilar in Europe that has risen to the point of concern. And they’ve had a great track record.

EMILY SENAY: In an email to NewsHour a spokesperson for the European Medicines Agency wrote, “biosimilars have a good safety record since introduction” in 2006.

Still, Eich says new procedures have to be in place before biosimilars hit the u-s market.

GEOFFREY EICH: You really have to have a program in place that gets them from the law that enables them to be approved to the FDA approval, to the way they’re going to be used in health care.

EMILY SENAY: The affordable care act passed in 2010 authorized the FDA to set up an approval process for biosimilars. But in the four years since, not a single biosimilar has hit the U.S. market.

What’s taking the FDA so long?

In an email to the NewsHour an FDA spokeswoman wrote:  “congress deliberately set a very high bar for a biosimilar product approval…when these products go to market, they will meet the standards of safety, efficacy and high quality that everyone expects and counts on.”

But Miller says the FDA has been impeded by biologic companies that have extensively lobbied congress and state legislatures to stall competition. He says the strategy is designed to protect the huge profits they make off their biologic drugs.

STEVE MILLER: If you think about just the drug erythropoietin which is made by Amgen, their profit’s a month over $100 million for that product.  That product came out into the market in 1989.

EMILY SENAY: Eich says the high price of biologics is justified.

GEOFFREY EICH:  They are expensive to manufacture.  The workforce is made up of PhD scientists who on a daily basis, are managing the production of these medicines, so there’s a tremendous amount of investment that goes into making and manufacturing high-quality biologic medicines.

EMILY SENAY: Some people say that Amgen is able to charge $50,000 a year for a particular medication because it can. Because it’s able to.  There’s no regulation. And when those issues come up, a company like Amgen has been very successful at lobbying to prevent any– movement in terms of price.

GEOFFREY EICH: I’m not, I’m just not familiar with any of the pricing information.  But what I can tell you is that I mean, we’re a company that’s focused on the future. So if there are revenues here, we want to invest in clinical studies for new clinical trials and for new medicines.

EMILY SENAY: In fact Eich says if the company were so against biosimilars it wouldn’t have its own plans to start selling them.

EMILY SENAY: One of the points that Amgen makes is that they too are getting into the biosimilar marketplace.  They don’t see anything they’re doing as, as a roadblock to getting biosimilars on the market.  Is, is that fair?

STEVE MILLER: The reality is that they actually are well positioned to make biosimilars, but they probably make more on their branded product than they’ll make on their biosimilars.  So, it makes sense every, every month they can delay makes a lot of money for them.

EMILY SENAY: Now these medicines that would be very similar to the one you’re taking would require that the FDA, and the regulatory process, and the states, and the companies move very slowly to make sure that these are safe.  Isn’t that what we want?

PATRICIA DELUCA: How long does it take?

PHILIP DELUCA: And if they are being used in Europe, and if they’re standing’, and if they’re still surviving, and if they’re in better shape?  Then obviously it must be, it must be working and it must be safe.

EMILY SENAY: Philip DeLuca’s doctor recently added another biologic drug to his treatment regimen. He’s waiting to find out how much that one’s going to cost him.

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