In his fifth decade as physician, healthcare executive, educator and infectious disease/cancer researcher, Dr. Stephen Schimpff is one of the world's foremost experts on healthcare. An author of 6 books, including Fixing the Primary Care Crisis, and Longevity Decoded, he is the former Chief Executive Officer of the University of Maryland Medical Center, which includes the world's preeminent trauma center, an NCI certified cancer center, and one of the country's largest kidney transplant programs. Dr. Schimpff also is a professor of medicine at the University of Maryland School of Medicine where he teaches residents and fellows in oncology and infectious diseases and is a former professor of public policy at the University of Maryland, College Park.
Below are snacks from the show.
Hunter: So what, what happened to get us into this situation?
Dr. Schimpff: Yeah, there's a lot of steps in there, but if you go back in time when various insurances first came about, including Medicare and including, uh, commercial insurance, uh, through your employer, primary care was not included. You paid for that yourself. And that was just an expectation. And then over time, um, I don't want to make it sound like I'm blaming the unions, but anyway, unions pressured for adding that in. And so it was, but of course for everybody, and, uh, Medicare was pressured pretty heavily, so they added it in. Uh, so then Medicare, sorry, then the insurance is paying for it, but insurers don't want to pay too much. Uh, they're in their own problems. They're trying to reduce costs. And so to them, how do you reduce costs? Well, one of the best ways to do it is to just say I'm going to pay less.
And so primary care gets the short end of the stick. The insurance system is weighted towards folks who do a procedure. Whether that's surgery or cardiology or gastroenterology or whatever, and as weighted against the, the physician who spends a lot of time with the patient developing a long, very detailed history, understanding, nuances and so on. So, what's happened then is that the physician has to see more and more patients in order to make things work out. I guess I should back up for a second. Um, how to say this clearly, simply, uh, so if you're earning less money from the insurer, but your costs have gone up. So why have costs gone up? Well, the costs have gone up because you need a, you need to hire people to do the billing and coding. It's just not simple anymore. And every, every insurer has a different billing system.
You have to have people from know each different insurers what they need, what they want. So it doesn't just keep bouncing back and forth. That's one issue. It's costs a lot more money now because of the, the billing process. Second thing is, uh, the insurers and from the Medicare, especially Medicare, put out all sorts of regulations and requirements that you have to follow. And this is another time sink. So there's two ways they're, they're taking time away and adding costs while at the same time trying to hold them the revenue string. So what's the doc gonna do? Well, it's the old line of make it up with volume. You make it up with volume by seeing more patients per day. And how do you see more patients per day? Well, you can stop seeing your patient in the hospital as has been the tradition for, you know, hundreds of years.
You can stop going to the ER when your patient's in the ER. You don't have time for that anymore. So now you've just saved some time. Uh, used to be the doctor, go to the hospital, you know, early in the morning and see patients and then get back and start office hours. Well now if you don't go to the hospital, you can start office hours a little earlier and can get a few more patients. But then the big thing is to reduce the time per patient and if the doc seeing like say 24 patients a day and let's assume an eight hour day, that's three patients an hour, 20 minutes a piece. But there's other things that doc has to do. He has to answer the phone. Has to look at reports and so on and so really getting 15 minutes, but it's not all with you. You're probably getting eight to 10 maybe 12 minutes. So what I'll call face time with the doc and that's a pretty short time. Certainly too short for comprehensive quality care when the patient has something more than let's just call the simple issue.
Hunter: You just said something.
Dr. Schimpff: Probably a longer answer than you wanted.
Hunter: No, no. I think it's important for people to understand something you just mentioned and that is the comprehensiveness of primary care. I'm going to latch onto that in a little bit. So yeah, it's, I'll set it up by basically saying, I see a lot of ignorance, and keep in mind that since I live in Panama, and I have a whole bunch of ex-pat friends from all over the world. So I get exposure to many different medical systems and perceptions of care. And I guarantee you the person who comes in from Spain has a completely different perception of care than a person from the U S, and so you get, you get ex-pats arguing over what is great care and they really aren't defining the care. So, bottom line is in Spain they have terrific primary care. In fact, they focused on it starting in 1986 so there's a lot of ignorance driving the perception that primary care is only for simple things.
Dr. Schimpff: You know, a big part of medicine, good medicine is that interpersonal relationship between doctor and patient or maybe I should say between patient and doctor. Um, it's absolutely crucial and it's crucial one because it's important in order to elicit information with the patient, they have to feel that they can trust you, and trust comes with time, and with energy and with, uh, again, a sense that we're working together and not just going in and quickly saying something and you know, getting sent out for a bunch of tests or sent out to the specialist. And I really should stop at that point meant to talk about that. If the primary care doc doesn't have time to dig into a problem, what's going to happen? They're going to say, you know, let's send you off to the cardiologist or send you off to the gastroenterologist or send you up to the pulmonary doc or whatever when, if they had the time. Again, it's all about time. They could perfectly adequate and take care of the problem. So the issue more than anything else is get some time between doctor and patient.
Hunter: If you as a primary care doctor have more time with the patient time to really do what Dr. William Osler said. You know, the good doctor treats the disease, the great doctor treats the patient with the disease you're really dealing with the psychological factor and enabling them to get better, uh, easier. But you're also reducing the need to spend to send people to a specialist in the first place. Or second place.
Dr. Schimpff: Well that's right.
Hunter: The primary care physician has time to deal with things and primary care covers all the systems in the body. So they have a broad view.