Primary Care Clinician-Patient Face Time Trending Down, Treatment Inequities Continue to Rise

In the last 40 years or so, American have gotten more face time with their physicians, expanding from 40 minutes of annual outpatient time to 60.4 minutes.

It sounds like good news for patients getting care and for doctors getting paid. But a new study found there are nuances in the minutes:

• Since 2005, annual face time with primary care physicians decreased about 10% because the number of visits fell.
• Annual face time with specialist physicians is increasing.
• White patients average at least 70 minutes of physician face time a year, more than Black patients (52.4 minutes) and Hispanic patients (53 minutes).
• That equity gap has gotten worse over time, largely due to Black and Hispanic patients spending less time with specialist physicians and having fewer medical visits.
• Among patients aged 65 years and older, racial and ethnic disparities were minimal. They have nearly universal coverage under Medicare.

The findings were in “Trends and Disparities in the Distribution of Outpatient Physicians’ Annual Face Time with Patients, 1979-2018,” published June 6 in the Journal of General Internal Medicine.

The figures are not a guess-timate. Authors Adam Gaffney, MD, MPH, David U. Himmelstein, MD, Samuel Dickman, MD, Danny McCormick, MD, MPH, Christopher Cai, MD, and Steffie Woolhandler, MD, MPH, examined more than 1.1 million patient visits in the National Ambulatory Medical Care Survey, a database maintained by the US Centers for Disease Control and Prevention.

Medical Economics discussed the results with Gaffney, corresponding author and a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance. The following transcript was edited for length and clarity.

Medical Economics: Five, 10, 20 minutes over the course of a year does not sound like a lot of time. Can you explain why time together is so important for physicians and patients?

Adam Gaffney: Time has been called the currency of primary care by a notable general practitioner, Julian Tudor Hart, but time is really the currency of all medical care. In a sense time is what physicians use to diagnose illness, to perform a physical examination, to collect data, to provide counseling, to perform procedures, and to formulate a carefully thought-out treatment plan. Time is really of the essence when it comes to the practice of medicine, time is necessary to provide high quality medical care. And although this study does not examine outcomes or health, ultimately it does matter how much time a patient has a year to spend with physicians. And that's why we look at this. That's why we found it interesting.

ME: The study found that overall face time with office-based physicians has increased over the past four decades. But racial and ethnic disparities in face time have widened. Can you explain what that means?

AG: We tracked the total minutes that Americans of all ages spend with physicians, not just per visit, but over the course of the year. What we found is, there was a rise over the last 40 years, from about 40 minutes to about 60 minutes, a 50% increase. Now, what that seems to be driven by is the fact that the number of physicians per capita has also risen. As a result, the amount of time that patients receive has gone up, even though the amount of face time provided per physician has basically stayed level throughout that period. So that's the total amount of time that is supplied, that is available, that is given in visits.

But that's a different question than the distribution of that time. For a variety of reasons, it does not seem that that time is being distributed, allocated among different populations, equitably. At the start of the period, there were differences by race and ethnicity, specifically, Black individuals and Hispanic individuals received less annual face time relative to White individuals. And that absolute gap in minutes has actually gotten larger over the last 40 years. And we think that probably stems from a variety of different factors. Despite a lot of progress that has been made in expanding the proportion of the U.S. population that has some form of health coverage as a result of the Affordable Care Act, there still are big racial and ethnic disparities in uninsurance. So Black and Hispanic individuals are uninsured at higher rates. Other factors could also keep patients from coming into the doctor, things like co-pays or deductibles. Another factor might be geographic accessibility – we do know that there is less U.S. healthcare infrastructure in minority predominant areas. The history of racism, of course, and past and present discrimination may also deter some individuals from seeking care. What I will say is that in the current day, at least, we didn't find a big difference in the number of minutes per visit, that was received by people of different racial and ethnic backgrounds. What really is driving the finding of overall face time disparities is differences in the number of visits.

ME: Are there any means or measures you would suggest for the health care system overall to reach out to Black and Hispanic patients who are not scheduling those same number of visits?

AG: There's a lot of things that we need to do to work toward mitigating and solving these sorts of disparities, which are obviously present in many parts of our health care system, unfortunately. From a policy perspective, I think there's some things we can simply fix, right? So cost barriers, uninsurance. If everyone had health insurance, I think it wouldn't solve this problem, but I think it would help. We know that people who are uninsured just don't show up to the doctor because they're afraid, understandably, of big bills, that they get in an emergency room and then suddenly they could face bankruptcy even. So uninsurance is a part of this problem that we can fix. Obviously, we need national health care reform to do it on a national level. There's certainly incremental steps that can be taken. States that have not expanded Medicaid, of course, could in fact do that, or other kinds of incremental steps that could reduce the number of uninsured. National health care reform is needed to cover everyone. We also need to think more about the use of high deductibles and high co-pays as a tool for cost control. Those tools do not seem to have really controlled costs in the big perspective over the last 20 years. But they do deter use and they do disproportionately impact disadvantaged populations, so we need to think more about ending those kinds of financial barriers. Those are things we can do on a systems level. We need to think more about geographic access, if that's a driving factor, making sure we have providers in the localities where we need them, where patients are. The ongoing rural hospital closures, which we know also cause physicians to leave areas, are something that we just need to take a careful look at, and the manner in which that can be contributing. I do think health care providers and health care systems also need to take steps in terms of active outreach to patients who might not be coming in for various reasons, ensuring that adequate language interpretation services are available, because that also could be keeping some patients, Hispanic patients particularly in our study, from care. So there's things on both a state, a federal, but also on a provider level that could make a difference.

ME: The study says primary care is the bedrock of quality care, but that access may be deteriorating. Can you discuss that finding?

AG: In addition to looking at trends in annual face time, by race, ethnicity, age group, we also looked at primary versus medical specialty, versus surgical specialty care, and we divided into those three groups. What we found was interesting. First, the racial and ethnic disparities I'm describing in time, were actually seen in specialty care, but actually not in primary care. Second, we found that although over the last 40 years, there's been an increase in total face time, there's been differential trends by specialty, such that in the last 15 years or so, there's actually been a decline in the number of minutes spent by Americans with a primary care physician every year. And that's been counteracted by a rise in the number of minutes spent with specialists a year. So even putting aside the racial disparities question, overall, Americans are spending less time with primary care physicians. That seems to track in our study with a decline in the number of primary care physicians. So again, it's not that primary care doctors are working any less, it's just that the total number of minutes is fixed. That's a very concerning trend, because we know that so much of the life-saving efficacy of the health care system comes from primary care. And I can say that in part because I'm a specialist, so I'm not digging anyone, but it's absolutely the case. In recent years, there's been some troubling trends in health. Some of that is factors that are sort of outside medical care to an extent, things like the opioid epidemic, which is a medical problem, but it also reflects other social issues. But recent analyses have found declining control of hypertension as well as diabetes in the United States in recent years. And these are conditions that are commonly treated by primary care physicians. So it does raise questions. We didn't examine that association, to be clear, so I'm speculating. But that's one concerning factor here. So yes, the decline in time spent with primary care physicians worries me both from a health perspective, but also from an equity perspective, because as I said, there does seem to be greater equity in the allocation of primary care physician time.

ME: What are some practical tools that physicians can use to maximize the time they spend with patients? Do they need more schedule flexibility, more staff, better technology?

AG: It's a very difficult question and I would not presume to be in a position to sort of tell primary care physicians how to better use their time. I do think we need systematic solutions. A lot of time is being siphoned into the electronic health record. Some of that is important, some of that's going to the charts and learning about your patient's history, but some of that is not very valuable time. It's time spent putting a lot of codes in as part of billing. It’s documentation that's driven not necessarily by what you feel like you have to write down, but what you have to document to meet certain billing requirements. So I do think that we need to think about reforms, in addition to the things I've talked about in terms of insurance coverage and provider supply. We need to think about reforms that would allow providers to spend less time interacting with the electronic health record, more time interacting with patients and thinking about patients. That is something that I think as a society, we really need to be focusing on and talking about more.

ME: The Association of American Medical Colleges has forecasted a coming physician shortage, up to 124 000 doctors by year 2034. If that holds true, do you predict that physician face time will decrease for patients further?

AG: Ultimately, the deciding factor in face time is a very simple calculus. It's really the number of physicians per capita, right? The amount that physicians are working can't change that much, physicians are already working pretty much full schedules. So really, the ultimate determinant of face time is the number of physicians per capita, and what I said earlier, which is, well, how much of our day can actually be spent on patients? How much time on desk work and paperwork? I am worried about face time trends in the coming decades, not just because of projections about physician shortages, but because of increasing time spent with inboxes and with electronic work.

Even now, we seem to have an imbalance in terms of specialties where it seems the field is tilted towards specialists away from primary care. We can talk about number of physicians per capita, but I think probably as important, if not more important, is the question of the kinds of physicians and the specialties and where they are within the country. You can expand the physician workforce and that wouldn't necessarily translate into more primary care physicians, or not necessarily translate into more physicians in areas that need physicians. We have to be very careful when thinking about supply. Health care supply is a complicated phenomenon and we know that we can actually have both shortages and surpluses in the same place or at the same time in the same country. Those are the kinds of economic issues that have to be dealt with, both through the coverage system, but also the workforce policies that people are talking about.

ME: What would you like to add or what else would you like people to know?

AG: Really the takeaway here is that we need change, if we're going to do something about these problematic trends, both in terms of the undercutting of primary care in the United States, as well as the big cities. We can talk about it, we can study it, I can do papers, but it's really not going to change things until we see policy change and that's going to really require action at the governmental level.