Background Many believe that managed care creates pressure onphysicians to increase productivity, see more patients, andspend less time with each patient.
Methods We used nationally representative data from the NationalAmbulatory Medical Care Survey (NAMCS) of the National Centerfor Health Statistics and the American Medical Association'sSocioeconomic Monitoring System (SMS) to examine the lengthof office visits with physicians from 1989 through 1998. Weassessed the trends for visits covered by a managed-care orother prepaid health plan (prepaid visits) and non-prepaid visitsfor primary and specialty care, for new and established patients,and for common and serious diagnoses.
Results Between 1989 and 1998 the number of visits to physicians'offices increased significantly from 677 million to 797 million,although the rate of visits per 100 population did not changesignificantly. The average duration of office visits in 1989was 16.3 minutes according to the NAMCS and 20.4 minutes accordingto the SMS survey. According to both sets of data, the averageduration of visits increased by between one and two minutesbetween 1989 and 1998. The duration of the visits increasedfor both prepaid and non-prepaid visits. Non-prepaid visitswere consistently longer than prepaid visits, although the gapdeclined from 1 minute in 1989 to 0.6 minute in 1998. Therewas an upward trend in the length of visits for both primaryand specialty care and for both new and established patients.The average length of visits remained stable or increased forpatients with the most common diagnoses and for those with themost serious diagnoses.
Conclusions Contrary to expectations, the growth of managedhealth care has not been associated with a reduction in thelength of office visits. The observed trends cannot be explainedby increases in physicians' availability, shifts in the distributionof physicians according to sex, or changes in the complexityof the case mix.
There is a wide consensus that managed care has substantiallyreduced the length of patients' office visits with physicians.1,2,3,4,5,6,7,8,9Kenneth Ludmerer, for example, expresses this view:
Perhaps the most extraordinary development in medical practiceduring the age of managed care was that time, in the name ofefficiency, was being squeezed out of the doctor-patient relationship.Managed care organizations, with their insistence on maximizing"throughput," were forcing physicians to churn through patientsin assembly line fashion at ever-accelerating rates of speed.. . . By the late 1990s, the pressure on doctors to see morepatients in less time showed no signs of abating, and many doctorswere staggering under the load.1
These observations are supported by physicians' responses tosurveys.10,11 In a 1991 survey of young physicians, approximately84 percent of respondents felt that they had the freedom tospend adequate time with patients. In 1997, a follow-up surveyfocused on young physicians in the 75 largest metropolitan areasin the United States, and only 32 percent reported that theycould spend sufficient time with patients.10 A comparison ofthe responses of young physicians in California in 1996 withthose of an age-matched group of physicians from the 1991 surveyof young physicians found an almost 14 percent drop in the proportionwho thought they had the freedom to spend sufficient time withpatients; among primary care physicians the decline was evengreater (24 percent).11
Physicians have been vocal about their dissatisfaction withthe changes in medical care, the growth of managed care, andtheir loss of professional autonomy. We report on two sourcesof national data that permit a more rigorous assessment of changesin the length of office visits with physicians between 1989and 1998, a period characterized by the rapid expansion of managedcare.12
Methods
National Ambulatory Medical Care Survey
We analyzed data from the National Ambulatory Medical Care Survey(NAMCS) of the National Center for Health Statistics from 1989through 1998.13,14,15,16,17 These surveys involve multistageprobability samples of visits to office-based physicians, excludinganesthesiologists, pathologists, and radiologists. The rateof response to the survey varied from 68 percent to 74 percentover the 10-year period. A systematic random sample of visitsto each physician was selected during one randomly chosen one-weekperiod. The number of visits sampled per year ranged from 24,715to 43,469. The estimates we present were calculated with theweighting used by the NAMCS to adjust for nonresponse and torender estimates nationally representative.
For each visit selected, the physician or a member of the physician'sstaff provided information about the characteristics of thepatient, the duration of the visit, the reason for the visit,any diagnoses made, and any tests and procedures performed.From 1989 through 1996, "prepaid/HMO [health maintenance organization]plans" was listed as one option for the response to a questionabout the expected source of payment. In 1997 and 1998, thesurvey asked if the patient belonged to an HMO or if the visitwas covered by a capitated insurance plan. If there was a positiveresponse to either question, the visit was classified as "prepaid."Our analyses were limited to visits during which the patientsaw a physician. The duration of the visit included only thetime that the physician spent in face-to-face contact with thepatient. Duration was examined for visits to all physicians,for visits to primary care physicians (those in general or familymedicine, internal medicine, and pediatrics), and for visitsto specialists. Duration was also examined separately for newpatients and established patients.
The primary diagnosis was coded according to the InternationalClassification of Diseases, 9th Revision, Clinical Modification,18and we examined changes in the duration of patients' visitsfor general medical examinations, for the five most common primarydiagnoses in 1998 (upper respiratory tract infection, hypertension,routine checkup for an infant or child, normal pregnancy, andarthropathy and related conditions), and for the diagnoses associatedwith the leading causes of death in 1997 (heart disease andmalignant neoplasms).19 We examined changes in the provisionof the 34 services — including diagnostic tests, examinations,and counseling — for which there were data from at leastthree years.
American Medical Association Data
The Socioeconomic Monitoring System (SMS),20,21,22 an annualsurvey conducted by the American Medical Association (AMA) anddesigned to collect nationally representative information aboutphysicians' practices, provided corroborating data. The populationsampled was non–federally employed physicians who wereengaged primarily in patient care and who were listed in theAMA's Physician Masterfile. The rate of response varied from72 percent in 1989 to 52 percent in 1998. The estimates wereweighted to adjust for nonresponse.
The average duration of an office visit was estimated by dividingthe average number of hours the physician reported spendingwith patients in his or her office each week by the averagenumber of patients the physician reported seeing per week. Theduration of the visit excluded the time spent by the physicianin caring for patients in other settings, performing administrativetasks, consulting over the telephone, engaging in professionalactivities, and performing such tasks as interpreting laboratoryresults or x-ray films. Questions regarding these activitieswere not asked of psychiatrists, radiologists, anesthesiologists,or pathologists.
The SMS and the NAMCS cover different, although overlapping,populations of physicians, and data from the SMS surveys permitonly crude approximations of the length of visits. However,to the extent that patterns reported in the SMS data are similarto those found in the NAMCS, we can have additional confidencein the validity of the results.
Statistical Analysis
For the SMS estimates, we used published standard errors tocalculate confidence intervals. SUDAAN software23 that adjustsvariances to account for the complex designs of the surveyswas used to calculate standard errors for the NAMCS estimates.We used t-tests to assess the differences between the mean durationof prepaid visits in a given year and the mean duration of non-prepaidvisits in that year. For the NAMCS estimates, regression analyseswere used to test for significant linear trends, and we presentthe beta coefficients for the time variable (year of survey),along with the corresponding P values. For trends that appearedto be nonlinear, we computed regression models that added theexponential term for year. In no instance did adding this termimprove the fit of the model; therefore, the results of thesecomputations are not presented. Because the samples were large,even small changes are statistically significant in analysesthat involve data from all 10 years. Therefore, we also constructedconfidence intervals around the differences between the estimatesfor 1989 and those for 1998 in order to show the magnitude ofchange. Intervals that include zero indicate that the differenceis not significant; confidence limits that approach zero indicatethat the difference is not substantial.
Results
The NAMCS data indicate that the number of visits during whichthe patient met with a physician increased significantly byabout 120 million (95 percent confidence interval, 43 millionto 196 million), from 677 million visits in 1989 to 797 millionin 1998. The rate of visits per 100 population increased from278 in 1989 to 296 in 1998 — an increase of 6.5 percent— although this increase was not significant (difference,18 visits per 100 population; 95 percent confidence interval,–12 to 48).
The data from both the NAMCS and the SMS indicate an upwardtrend in the duration of office visits to physicians (Figure 1).Data from the SMS indicate that the average duration ofvisits increased by 1.1 minutes (95 percent confidence interval,0.1 to 2.1) between 1989 and 1998. Data from the NAMCS indicatethat the mean duration of visits in 1998 was 2.0 minutes longer(95 percent confidence interval, 1.4 to 2.7) than in 1989. TheNAMCS data also show a nonsignificant decline of about 1 minute(95 percent confidence interval, –2.1 to 0.1) between1995 and 1998.
Figure 1. Mean Length of Office Visits to Physicians, According to the Socioeconomic Monitoring System (SMS) of the American Medical Association and the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics.
For the NAMCS estimates, regression analyses were used to test for significant linear trends; the beta coefficient for the variable for year was 0.27 (P<0.001).
Data from the NAMCS indicate that the number of prepaid visitsmore than doubled over the period studied, increasing from 102million in 1989 (95 percent confidence interval, 85 millionto 119 million) to 261 million in 1998 (95 percent confidenceinterval, 232 million to 290 million). Consequently, the proportionof visits that were prepaid grew from 15.4 percent of all visitsin 1989 to 33.1 percent in 1998 (difference, 17.7 percentagepoints; 95 percent confidence interval, 13.9 to 21.4).
Data from the NAMCS (Figure 2) also indicate that over the 10-yearperiod, the length of prepaid visits increased by 2.5 minutes(95 percent confidence interval, 1.4 to 3.5) and the lengthof non-prepaid visits increased by 2.1 minutes (95 percent confidenceinterval, 1.3 to 2.9). In 1989, prepaid visits were about 1minute shorter (95 percent confidence interval, 0.03 to 1.96)than non-prepaid visits (t=2.15, P=0.04). By 1998, this gaphad shrunk to 0.6 minute (95 percent confidence interval, –0.65to 1.93) and was not statistically significant (t=1.63, P=0.11).
Figure 2. Mean Length of Office Visits to Physicians According to Whether the Visit Was Covered by a Prepaid Insurance Plan, 1989 through 1998.
Data are from the National Ambulatory Medical Care Survey. Regression analyses were used to test for significant linear trends; the beta coefficient for the variable for year was 0.30 for non-prepaid visits and 0.28 for prepaid visits (P<0.001 for both betas).
The NAMCS data indicate that the mean length of prepaid visitsto primary care physicians increased by 2.0 minutes (95 percentconfidence interval, 0.7 to 3.3), although the upward trendwas not consistent in all the years studied (Figure 3). Similarly,the mean length of non-prepaid visits to primary care physiciansincreased by 2.6 minutes (95 percent confidence interval, 1.5to 3.7). The mean length of prepaid visits to specialists increasedby 2.6 minutes (95 percent confidence interval, 0.8 to 4.3);the increase in the length of non-prepaid visits to specialistswas 1.6 minutes (95 percent confidence interval, 0.5 to 2.7).Between 1995 and 1998, however, the length of non-prepaid visitsto specialists declined significantly by 2.7 minutes (95 percentconfidence interval, 1.1 to 4.3).
Figure 3. Mean Length of Office Visits to Physicians According to Whether the Visit Was Covered by a Prepaid Insurance Plan, for Primary and Specialty Care Visits, 1989 through 1998.
Data are from the National Ambulatory Medical Care Survey. Regression analyses were used to test for significant linear trends; the beta coefficient for the variable for year was 0.29 for non-prepaid specialty care visits, 0.26 for prepaid specialty care visits, 0.29 for non-prepaid primary care visits, and 0.26 for prepaid primary care visits (P<0.001 for all betas).
Only for psychiatrists does there appear to have been a downwardtrend in the length of visits. Between 1989 and 1998, the lengthof non-prepaid visits to psychiatrists declined by 4.5 minutes(95 percent confidence interval, –0.5 to 9.5), althoughthe confidence interval includes zero, indicating that the differenceis not significant. The samples were too small in the earlyyears to allow reliable estimates for prepaid visits to psychiatrists,but the reduction in the length of visits appears to have beenminimal (37.7 minutes vs. 36.7 minutes).
According to the NAMCS data, there was an upward trend in theduration of office visits for both established patients andnew patients (data not shown). The mean length of non-prepaidvisits for established patients increased by 2.2 minutes (95percent confidence interval, 1.4 to 3.0), and the increase fornew patients was 2.8 minutes (95 percent confidence interval,1.2 to 4.5). For prepaid visits, the increase was 2.5 minutesfor established patients (95 percent confidence interval, 1.5to 3.6) and 4.2 minutes for new patients (95 percent confidenceinterval, 2.2 to 6.2).
The duration of visits for patients with common and seriousprimary diagnoses either increased over the 10-year period orremained stable (Table 1). There were no significant declinesin the length of visits for patients with these diagnoses.
Table 1. Mean Length of Office Visits to Physicians According to Primary Diagnosis at Prepaid and Non-Prepaid Visits, 1989 through 1998.
We inspected trends in the provision of 34 services orderedor performed during office visits over the 10-year period, andwe present illustrative results. Only the frequency of blood-pressureexaminations increased by more than 5 percent. As shown in Table 2,there were declines in the proportion of visits during whichurinalysis was ordered or weight-reduction counseling was given.
Table 2. Percentage of Office Visits to Primary Care Physicians That Included Selected Services.
Discussion
The data we examined did not support the view that the lengthof visits to physicians has declined significantly in recentyears. Although the data from one source did suggest a slightdecline since 1995, that decline was more pronounced for non-prepaidvisits than for prepaid visits. Given the widespread impressionthat the length of office visits has been decreasing substantially,we might remain skeptical of these findings, but our two verydifferent data sources present much the same picture. Therewere similar findings in other analyses of visits to primarycare physicians between 1978 and 199424 and in reports thatused data from the AMA.25 Dissatisfaction is often generalizedand may affect the way surveyed physicians answer many typesof questions.26,27 Dissatisfaction with the length of visitshas long been a concern to physicians28 and can now be attributedto managed care. There are several plausible explanations forwhy the length of visits has not declined.
Between 1989 and 1998, the number of office-based physiciansengaged in patient care per 100,000 population increased 21percent overall, 18 percent for primary care physicians, and22 percent for specialists.29,30 During the same period, therewas only a 17.7 percent increase in office visits. Thus, itmight be assumed that physicians have more time for each patient.The SMS data indicate that in 1989, the average number of officevisits to a given physician per week was 79.1, and that thisaverage had declined significantly, by 3.9 visits (95 percentconfidence interval, 0.9 to 6.8), by 1998. Between 1989 and1998, the average number of office hours held by office-basedphysicians increased nonsignificantly, by 0.1 hour (95 percentconfidence interval, –0.7 to 0.9). The small decreasein the number of patient visits per week may allow longer averagevisits but cannot explain the trend we observed.
Female physicians spend more time, on average, with patients.31,32,33,34,35The increase in the number of female physicians in the workforcemay counter any effect of managed care on the length of visits.Female physicians may be more attuned than male physicians toissues of communication and psychosocial issues,32,33,36,37more likely to treat new patients, or more likely to treat womenpatients who have more serious health problems.38 The proportionof physicians in office-based practice who are women increasedfrom approximately 12.9 percent in 1989 to 20.5 percent in 1998.29,30Data from the 1989 NAMCS indicate that visits to female physiciansare about 1.2 minutes longer, on average, than visits to malephysicians. Data from the AMA suggest that the average numberof weekly office visits for male physicians is about 35 percentgreater than the average for female physicians (Gonzalez M:personal communication). If we make projections on the basisof the 1989 data, taking into account differences in caseloadsand the sex-related difference in the length of visits, theincrease in the proportion of physicians who are female wouldaccount for an increase in the average duration of an officevisit to 16.5 minutes in 1998. The mean duration observed in1998, however, was 18.3 minutes, suggesting that changes inthe sex distribution of physicians are unlikely to account formuch of the upward trend.
The average length of an office visit may have increased ratherthan declined because the case mix of office-based physicianshas become more complex and therefore more time is requiredfor each visit. There are no data available that would allowa direct evaluation of this hypothesis, but the explanationappears unlikely. The average number of annual contacts a personhad with a physician increased only slightly between 1989 and1996 (from 5.3 to 5.8).12 Thus, it is unlikely that the averagepatient's care is more complex. Moreover, the upward trend holdsboth for new and established patients, for the most common diagnosesand for the diagnoses associated with the highest mortality.The age of the patient can be used as a proxy for the complexityof care required; physicians spend more time, on average, withelderly patients.39 However, according to the NAMCS, the proportionof visits in which the patient was 65 years old or older increasedonly from 22 percent to 24 percent during the period studied,and in 1998 the average visit with an elderly patient was only0.3 minute longer than the average visit with a younger patient.
Physicians are expected to do more now than they were in thepast during each visit with a patient. Stafford and colleagues,24using NAMCS data, suggest that primary care physicians havean increased responsibility to offer preventive services. Unfortunately,the types of services that the NAMCS recorded for each visitvaried from year to year during the period studied. Moreover,they include both services that are ordered and those that areperformed, allowing no way to establish who provided the servicesor whether they were delivered during the course of the visitwith the physician.
Our analyses could not identify any clear patterns in the servicesthat were performed or offered that can explain the trend towardlonger visits. There is partial evidence (i.e., an increasein the frequency of blood-pressure examinations) that more servicesare being delivered. It is also possible that the number ofservices provided during each visit increased between 1989 and1998. With increased numbers of treatments available, the growthof managed care, and patients who ask more questions, physiciansmay also spend more time explaining their decisions about treatment.
The data from the SMS provide only indirect evidence on whetherphysicians are spending more time on administrative tasks, whichmight inflate their reports of the length of time they spendwith patients. The average number of hours spent per week inall professional activities (patient care, indirect care, administrativetasks, conferences, and other activities) declined significantly,by 2.2 hours (95 percent confidence interval, 1.4 to 3.0), between1989 and 1998.20,22 Since 1996, the AMA has published separatedata on indirect patient care activities (such as reading x-rayfilms, interpreting laboratory tests, and consulting over thetelephone); the time spent in such activities declined nonsignificantly,by 0.1 hour (95 percent confidence interval, –0.2 to 0.4),between 1996 and 1998.22,40 Data from the AMA also indicatethat in 1990 there were 1.7 full-time–equivalent administrativestaff members per physician, as compared with 1.8 in 1997,22,41although the 1997 estimate is based on the sum of full-timeand part-time positions and is therefore not identical to the1990 measure.
Health plans seek to reduce attrition. Physicians understandthat the time spent with patients is a factor in patients' satisfaction42and helps to retain patients in their practice. Health plansincreasingly monitor patient satisfaction and may exclude physiciansfrom their network if too many patients complain.43,44 Becauseof such increased pressures, physicians may perceive that theyare providing patients with less time than they need, despitespending as much time with them as they have spent in the past,or more. Increased competition provides a credible explanationfor the lack of a decline in the length of visits, but we donot have the necessary data to test it empirically.
In summary, the data fail to support the belief among physiciansand others that the growth of managed care has substantiallyreduced the duration of office visits. Growing competition andan increased range of services offer plausible explanations.Limitations to our study include imperfect rates of responseand the possibility that the busiest physicians were less likelyto participate in the surveys. Moreover, the degree of precisionwith which physicians record or report the length of visitsis uncertain. Nevertheless, the fact that there are consistenttrends in the data from two very different sources increasesour confidence in the patterns we observed.
Supported by an Investigator Award in Health Policy Researchfrom the Robert Wood Johnson Foundation (to Dr. Mechanic) andby the Healthcare for Communities study funded by the RobertWood Johnson Foundation. The views expressed in this paper arethe authors' and imply no endorsement by the Robert Wood JohnsonFoundation.
We are indebted to Robert Krasowski and Iris Shimizu at theNational Center for Health Statistics for assistance with data;to Don Hoover for statistical consultation; and to Peg Polanskyfor assistance with the figures.
Source Information
From the Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, N.J.
Address reprint requests to Dr. Mechanic at the Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 30 College Ave., New Brunswick, NJ 08901, or at mechanic{at}rci.rutgers.edu.
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