Are Longer Office Hours Cost Effective? - NYTimes.com

When a colleague of mine announced her retirement recently, she said she was going to miss her patients ? but not the pressures of running a practice, nor the plethora of new insurance regulations and initiatives to improve the way doctors run their offices.

Unlike her colleagues still practicing, she would no longer have to heed measures like Medicare?s ?meaningful use? regulation, which pushes doctors to use electronic health records with a financial incentive at first, then a penalty later if they do not. She could ignore the new pay-for-performance plans that linked reimbursement to quality measures with little proven effect on patient outcomes. And she could choose to overlook the hullabaloo surrounding the so-called medical home, a strategy to reorganize doctors? offices so that patients have access not just to their familiar doctor but also to a team of nurses, physician assistants and other medical assistants, with minimal delays, and on weekends and evenings if needed.

?Where?s the proof?? she asked tensely, forgetting for a moment that she was retiring. ?Why is it that I can?t prescribe a medication without studies to back me up, but we doctors must overhaul our practices without data to show that the changes will actually make a difference??

She is not the only doctor asking that question.

In blogs, discussion forums and private conversations, a growing number of doctors are voicing serious doubts about the new schemes to improve medical practice. All agree that change of some kind is necessary, but many doctors feel trapped by a reform process that links ?voluntary? changes to reimbursement. Others are overwhelmed by the amount of effort and financial investment required. Still others worry that patient care will end up suffering.

All of these doctors share a common concern: that the changes won?t work because the assumptions underlying them are, well, just assumptions.

Now a study in The Annals of Family Medicine confirms that these doubting doctors may be right.

The study analyzed a central assumption of one proposed change to medical practice: that patients who enjoy regular access to their primary doctors cost less, since they are less likely to go to an emergency room or to require hospitalization than patients who are unable to see a doctor regularly. Continuity of care is a central goal of primary care improvement efforts, because it is assumed that physicians? offices operating as medical homes, with office hours during weekends and evenings, will yield better health outcomes, improve patient satisfaction and save money.

To test this assumption, researchers from the University of California, Davis, School of Medicine in Sacramento analyzed the records of more than 30,000 patients, only some of them enrolled in a medical home. As expected, patients whose doctors offered extended office hours had total health care costs that were at least 10 percent less than patients who could see their doctors only during standard business hours. There were no significant differences in mortality rates.

But when the results were analyzed more closely, it turned out that the savings was not a result of fewer emergency room visits or hospital stays. Rather, costs were lower because doctors offering extended hours tended to prescribe fewer expensive drugs, blood tests, X-rays and other procedures commonly associated with normal office visits.

In other words, the doctors who offered extended hours were, over all, just more cost-conscious than those who did not.

?Offering extended office hours could be a marker for doctors who tend to adopt cost-savings measures in general,? said Dr. Anthony Jerant, the study?s lead author and a professor in the U.C. Davis department of family and community medicine.

The study also raises the broader issue of whether certain proposed policies have the potential to offer more bang for the buck than others. Mandating extended office hours, for example, might be a less effective way of holding down expenditures than creating new ways of rewarding doctors for being cost-conscious in the exam room.

?It might be that what we need to do is teach and reward cost-effective decision-making,? Dr. Jerant said. ?But that?s going to be a hard sell as long as doctors are incentivized to do more. They get paid to do and order more.?

Currently, studies that analyze and test the assumptions underlying proposed initiatives to improve care, particularly those involving primary care, are rare. But Dr. Jerant and his fellow investigators believe that such research could have important implications, particularly as politicians and policy makers attempt to institute changes. Such studies could not only assess the strength of proposed policies, but also provide the evidence that practicing physicians need to get on board with changes.

?We have a golden opportunity right now,? Dr. Jerant said. ?We?re scrutinizing health care and practices as never before.

?Why not choose to do what make the biggest difference for practices and their patients??

Source: http://well.blogs.nytimes.com/2012/10/25/how-extended-office-hours-save-money/

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