Should Physicians Be Reimbursed for Conversations With Patients?

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.

But Levinson says more communication time should be considered by CMS for payments, particularly in relation to certain illnesses. In addition, the federal government should consider reimbursement for medical students in the last year of school and residency training for communication training, when communication skills are not developed as they should, she insists. Continuing training for physicians also should include communication programs that should be reimbursed, she says.

"It is in the third and fourth years of medical school, during clinical rotations, when students have the most patient contact and face their greatest cognitive and emotional challenges," she writes. "Unfortunately, the teaching of communication skills often receives little attention when compared to the teaching of diagnostic skills and patient management."

"Medicare and other payers have the ability to further increase the demand for patient-centered communication through reimbursement strategies," she writes. "By being procedure-oriented, they aren't well reimbursed.

Reimbursement strategies can be devised to support patient-centered care through the use of patient survey scores, payment codes for patient education and counseling, according to Levinson.

When pressed (by me), Levinson acknowledges CMS already pays a lot for doctors." But, she adds, "If it [were] tied into the whole patient-centered medical home, it can be a vehicle, a new mechanism for paying physicians. It could be linked to the patient centered care, for complicated conditions."

The C-suite also can play a role in improving patient and physician communication, she says.

"Leaders and administrators can model desired communication skills on their interactions with physicians and staff, setting high expectations for effective communication in all interactions," she writes. "Making the importance of communication between physicians and patients and among health professionals part of a medical group's culture can have a profound impact on the degree to which patient-centered care is the norm."

"Increasingly, organizations are looking at the patient experience," she tells me. "If you permeate the culture with views of the patient, this can be transformational. It can change the culture. It can take the c-suite to do that."

The importance cannot be overstated in patient-centered care, and also reveals a gap in communication between physicians and patients that needs to be closed, Levinson says. "When I tell a physician at a cocktail party that I work in healthcare communications, they go "oh" with some disinterest, she says. When she tells patients, they say, "Let me tell you a story," stressing what they consider to be the importance of what they told the physician—and how the physician reacted.

The changes needed to improve communication between patient and physician won't come immediately, and, whether more federal funds are injected or not, won't occur overnight, according to Levinson.

But neither are the possibilities for change "out of reach," she writes. "We have a moral imperative to meet this challenge, because doing so will improve the quality of care."