The physician is about to close the door, and the patient blurts out, "I have these chest pains."
Shouldn't that statement have been mentioned at the beginning of the visit?
Wendy Levinson, MD, chair of the department of medicine at the University of Toronto, and her colleagues called it the "oh, by the way?" moment in a paper they wrote in the 1990s. In the piece, they describe how sometimes things go wrong in whatever words are exchanged between patient and physician, which leads to their failure to really discuss what matters until the end of the visit.
Recently, Levinson brought up her article, written years ago, in a conversation with me about physician and patient communication, which is a continuing, if sometimes stumbling, journey of discovery for both sides. She mentioned the article because she's broadening her arguments about the need for improved communication in patient-centered homes. As healthcare reform gets going, communication is more important than ever—with the need for broader federal reimbursement, and C-suite involvement, she says.
Levinson's bottom line: Doctors should be paid more for their conversations with patients—and the result may be improved patient care.
"Complicated conversations such as breaking bad news or disclosing medical errors could be reimbursed as complex procedures," Levinson writes in "Developing Physician Communication Skills for Patient-Centered Care" in the July issue of Health Affairs, with co-authors Cara S. Lesser, MA, director of foundation programs for the ABIM Foundation in Philadelphia, PA. and Ronald M. Epstein, MD.
Under current procedures, the Centers for Medicare & Medicaid Services (CMS) pay for more than 7,000 types of physician services, identified in codes developed by the American Medical Association. But the term "complicated conversations" doesn't apparently come up.
The codes could include "face-to-face" encounters between physicians and their patients, but that's when the physician usually takes the patient's medical history, performs appropriate examinations and makes decisions about course of treatment or management of a patient's health, says Ellen B. Griffith, spokeswoman for CMS. When appropriate, the codes also can be used to pay for the time a physician spends with a patient or caregivers discussing the patient's condition and other concerns.
Recognizing that physicians may not be aware of these options, Griffith says, CMS published a 2009 Caregiver Initiative guidance that says physicians seeking reimbursement may spend as much as 25 minutes counseling a patient and family out of a 40-minute visit.