Charles Whitney was burning out. In the six years since the primary-care physician left the U.S. Air force for a civilian practice, Whitney and his partners at the University of Pennsylvania practice were trying to make up for declining reimbursements by seeing more patients and working longer hours. In fact, Whitney was so overworked he had taken to sleeping on the office sofa to get an early jump on the previous day’s paperwork. It was during one of his office overnights in 2003 that Whitney had his epiphany.

“I remember laying there unable to sleep thinking ‘This is ridiculous. I’m sleeping on the couch to get work done.’ I didn’t have any emotional energy left for my family,” he recalls. “First we cut out the fat, then the meat, and then the organs of what we did. The amount of time we could spend with each patient was shrinking and the priorities were the sickness. I was practicing ‘sick care.’ Something had to give.”

Luckily something gave. A few months later, the university offered Whitney an opportunity to work in a pilot practice designed to promote preventive care. He was so intrigued by the practice’s concierge model that after the sponsorship ended, he bought it. Today the practice, Revolutionary Health Services, has 200 patients and is growing, and Whitney finally feels he is practicing medicine the way he should be.

Whitney’s radical change in the very nature of his practice worked for him. But you don’t necessarily have to do what he did to get a more preventive care-focused practice. Even within the standard fee-for-service practice model, preventive care is still alive and profitable, if you’re willing to make some changes to your work habits.

There are ways to find the time and get reimbursed. The trick is knowing what quagmires to watch out for and what to do about them. Here’s our guide.

Where did the time go?

No doubt there is a problem out there. Physicians everywhere are scrambling to see more patients each day, but does that really mean preventive services are the first to go? Well, that could depend on how you define “preventive healthcare.”

For our purposes, let’s clarify that preventive healthcare refers to evidence-based treatments, screenings, and counseling proven to keep people healthier by detecting illnesses earlier, tracking disease progression more closely, and helping patients avoid behaviors that lead to problems in the first place. Everything from colonoscopies to nutrition counseling to diabetic foot exams would fall into this rubric. We’re not referring to so-called “alternative” treatments that people may find helpful to their general sense of well-being but whose actual health benefits have not been well established.

According to a 2003 Duke University study, “Primary Care: Is There Enough Time for Prevention?,” preventive healthcare services, which largely include quality-of-life indicators such as skin cancer screenings or diet and behavioral counseling, would take 7.4 hours a day to provide, leaving only 30 minutes a day for critical and chronic disease care. And that’s not a realistic balance considering the number of patients with chronic care needs, says Whitney. “[Doctors] need adequate time to do preventive medicine. Most people need at least an hour for a physical — not the half hour they usually get.”

But still others argue that providing preventive services needn’t take a lot of time. Michael Parkinson, primary-care physician and past president of the American College of Preventive Medicine, contends the answer isn’t spending more time per patient, but rather properly utilizing the time you do have.

“The evidence is that patients aren’t really looking for an hour-long lecture from a doctor about nutrition, exercise, or whatever. They’re looking for brief interventions that show the physician cares, that they listen to what [the patient] says, and then follow up,” says Parkinson. It may be just a matter of increasing pre-exam organization, sticking to what’s been proven, and then referring patients to specially trained nonphysician providers for more detailed counseling.

“Counseling needs take up a lot of time. Doctors haven’t been trained to do the intensive behavioral counseling that is needed to quit tobacco, for example. It would be totally unreasonable to put that burden on our doctors,” says David Grossman, a pediatrician and medical director of Group Health Cooperative, a Seattle-based multispecialty practice with more than 900 physicians. Instead, the practice refers patients to its wellness classes for such behavior counseling.

Small practices, though, don’t necessarily have access to a bevy of nutrition counselors, smoking cessation support groups, and wellness classes. Still, there are ways to create those extra minutes that can make a big difference in keeping patients healthy. Here are some suggestions:

Create flow sheets for chronic conditions. Make a list of “Five Things I Need to Check During an Exam” to use with patients who have diabetes or asthma, for example. Better yet, suggests practice consultant Elizabeth Woodcock, make a list of “Five Things I Need to Do Ahead of Time” before you see a patient with a chronic condition.

Schedule appropriately and realistically. Make sure your schedulers are giving you extra time to see new patients, those with chronic conditions, and others who fall into certain pre-defined risk categories.

Deal with no-shows gracefully. If you have a no-show, don’t stand around gnashing your teeth — just move on. That time now belongs to you and your other patients. Also, if you have patients who are chronic no-shows (and for whatever reason you won’t let them go) consider only scheduling their appointments during your lunch hour. If they show up, so be it, you’re eating on the run. If they don’t, you get to have lunch.

Use your staff. Don’t put all the burden on yourself; make sure your nonphysician staff is trained to do everything they’re capable of so that you’re making the best of use of your own time with the patient. Peter Anderson, one of three physicians at Hilton Family Practice in Newport News, Va., developed in 2003 his Family Team Care plan, which utilizes specially trained nurses and medical assistants to do thorough patient histories. Since turning these duties over to his staff, Hilton Family Practice sees almost 40 patients a day, up from 24; doctors work an average of 45 hours a week, down from 50; and Anderson says his income has increased by $70,000 a year.

“I’ve been practicing for 25 years and I’ve never given this type of quality. … [Family Team Care] allows all the nurses to spend the time that leads to that annual physical, which is an extremely important part of good care.”

Money woes

Dwindling payer reimbursements are real and they are a large reason physicians across the nation are sprinting to see more patients. According to the Physicians Practice 2008 Fee Schedule Survey, the national average for commercial insurer’s reimbursement rates is now only 10 percent higher than what Medicare pays for E&M codes. The average reimbursement for a 99213 (a mid-level established office visit) is $71.67, compared to Medicare’s $59.80. For a 99214, the average reimbursement is $97.36 compared to Medicare’s $89.89.