Why Your Doctor Needs a Bigger Waiting Room: Making Health Care Efficiently Absurd
If health care is going to get serious about efficiency, it might have to start with bigger waiting rooms.
According to proposed changes in the 2027 Medicare Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS), a bill for a visit and a procedure can both qualify for payment, but CMS proposes paying the higher-valued service at 100% and the lower-valued service at only 50%. According to CMS's rationale, doing both services together "creates efficiencies and may otherwise duplicate payment." In other words, if a doctor evaluates a problem and fixes it during the same visit, CMS considers that work less valuable simply because it happened efficiently.
What does this actually mean for patients? Imagine this: you come into your doctor's office, wait in the waiting room, and finally get to see your doctor, who diagnoses one of any number of immediately treatable conditions. Maybe it's a skin lesion that needs freezing or a joint that could be injected for pain relief. Under CMS's proposed rules, your doctor would only receive partial payment for one of those services. For many practices, fitting a procedure into the same visit already requires finding extra time, staff, supplies, and room availability. Often the reason to do it immediately is simple: it saves the patient from having to come back.
Medicine already has plenty of examples where solving multiple problems during one encounter creates a complex-looking bill. This proposed rule takes that tension a step further by directly reducing payment when certain services are performed together.
CMS may be trying to lower the cost of the individual service, but patients, employers, families, and the health care system still bear the cost of creating another encounter. A second appointment can mean more time away from work, another commute, childcare arrangements, delayed treatment, continued symptoms, and possibly progression of the medical problem. The cheapest health care encounter is often the one that never needed to happen.
Medicine isn't just an economic transaction. Consider someone waiting for a biopsy, the drainage of a painful lesion, or an injection for joint pain. The cost of waiting another week isn't captured on the Medicare claim, but there is a significant human cost. People worry: "Is this cancer? Am I going to get worse? How long am I going to have to suffer?" Even if the eventual outcome is identical, uncertainty has a cost.
To be fair, nobody at CMS is telling your doctor to make you come back next Tuesday.
But reimbursement has a remarkable ability to teach health care systems what Tuesday is worth.
CMS is trying to avoid paying twice for overlapping work. That seems like a legitimate objective, but how would performing two services together make one of them worth half as much? Imagine how much busier your doctor's office will have to be if every simple procedure now requires a separate visit. Patients have a right to feel like this is ridiculous. Health care occasionally looks ridiculous because the clinical question and the financial question are being answered by two different people. Organizations build workflows around payment rules. Financial incentives rarely stay in the billing department. Eventually they find their way into the exam room.
One of the things I appreciate most about direct primary care is that CMS is no longer sitting in the room with us deciding how the encounter should be structured. If I can evaluate a problem, explain it, and safely take care of it during the same visit, most patients would call that efficient health care. They might even call it good service. CMS may soon call part of it 50% off.
Dr. Sharma is a board-certified family medicine physician and the founder of HealthWinds, a virtual-first family medicine practice serving DuPage County and the surrounding Chicago suburbs. He comes with over 11 years of experience specializing in family medicine with Duly Health and Care and Loyola Medicine's MacNeal Hospital, among others. He sees patients ages five and up, with longer visits and direct access built around a membership model rather than insurance.
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