Our healthcare system is broken her in the United States. I have great hopes that the Affordable Care Act with help… and great fears that it will only make things worse.
A huge part of the problem is the bureaucratic nature of medicine. Many patients don’t realize is what is expected of medical providers, and when they are asked to shoulder some of the burden of our messed-up system, they get understandably angry. Let me explain.
It takes a huge time and energy commitment to become trained in medicine. Even if you take the route of less years of formalized training, as I did when I decided to become a physician assistant, it requires putting much of “life” on hold for years. Many medical students get divorced during medical school – did you know that? Quite simply, it’s very difficult to have any balance in your life when you are studying. It’s also extremely expensive. To put it in perspective, if I were able to pay on all my loans at once, I might pay them off around the time I retire. However, I can usually afford to pay on only 2 or 3 (of the several loans I have) at a time. Don’t get me wrong – I am eternally GRATEFUL for the financial assistance I was given. It allowed me to pursue my dreams and gave me the qualifications to do work I love and find very fulfilling (most of the time, anyhow… *grin*).
Fast forward. When a provider begins medical practice, it can be a rude awakening. Often, appointments will be scheduled every 15 or 20 minutes, all day long. (I worked in one practice right out of school that was scheduling 5-6 patients an hour on my schedule.) Because life (and medicine!) are unpredictable, things come up that are unexpected. A patient comes for a simple bladder infection and lets you know that she can’t pee and has been up all night with a fever. Then, she happens to mention that she has had chest pain for 2 weeks and passed out yesterday. Suddenly your “quick” acute care visit turns into an extended encounter for a high-risk patient.
And then there are the “one-more-thing” encounters: someone who came in for a cold will want to have a prescription refilled. Okay, no biggie – happy to help. Then, the patient will ask if the advice in the media about taking fish oil regularly is a a good idea. Still on track – happy to give a brief recommendation. Then, “I just have this weird mole… can you take a quick look at it?” Sure… shouldn’t take more than a couple seconds… Then, “My left toenail has been hurting, would you mind taking a quick peek to see if I have an ingrown toenail?” Okay – won’t take long. What that patient doesn’t realize is that for every “small” item, I need to document what I found and the advice given, even if it was just “reassurance.” If you were scheduled for a 10 or 15 minute acute care visit, I’m now behind… because even if all that take only 7 minutes, I have to write everything down and order any prescriptions and tests. I am happy to do it – patient care is why I do what I do… but now I’m behind, and if this happens multiple times, patients wait. And I work through my lunch hour.
The strain of juggling a LOT of thoughts cannot be overstated. I (usually) do it with relative ease at this point in my career – but believe me, it is a skill that has taken years to develop – years after my formal training was completed. All bets are off if the patient has a condition I am not familiar with or a puzzling set of symptoms. I once read an article written by a doctor about the number of considerations running through her head during a routine office visit – not even a complex one; it was kind of overwhelming to see it all written out like that. I found myself nodding my head through the entire read. I will post a link if I can find the article…
The end of the day comes in a flash – on my feet and busy all day long, I finally sit down to fill in the gaps on my documentation (a complete progress note usually isn’t done during your office visit – personally, I usually make sure to document just enough to jog my memory so I can finish the complete note later, which allows me to move on to the next patient in line sooner…). That actually gets put on hold as I check through my telephone messages first – addressing what seem to be most urgent, then the ones that appear to be time-sensitive, then whatever else I can manage in the time I have left. It is usually 6:30 p.m. or later by this time. Then I work through the test results (labs and imaging) in a similar manner – addressing the most urgent, by this time watching the clock and wondering if I’ll get home before my daughter’s bedtime; balancing the needs of anyone who is sick enough to need action tonight or first thing in the morning with the fact that I haven’t seen my family all week. If there’s any time left or any energy left by the time I get through those vital tasks, then I return to my unfinished progress notes.
By the time I get home, it has been anywhere from 9 to 11 hours, often without a lunch break (depending how “crazy” the morning was). There is no downtime - no quick checks of Facebook, no coffee breaks. A chat around the water cooler is rare indeed. And on a busy day, I find myself strategizing how I will get to the ladies room. Every patient gets my undivided attention, 15 or 20 minutes at a time, all day long. If there is a cancellation or a no-show on a busy day, I am grateful for the extra few minutes to check on a few of those things that typically wait for the end of the day (see above) – or I breathe a sigh of relief, as I realize the person who has been waiting for 20 minutes won’t be forced to wait another 15 or 20 minutes on top of that.
I think this is pretty typical for primary care providers (and many specialists). In fact, some have even more to do – if they are hospitalists as well, they must find time to see their patients in the hospital. Many doctors and providers also take call – either to see sick patients in the ER or hospital after hours or to be available to patients by phone.
In today’s medicine, the general practitioner (GP) – your primary care provider (PCP) – must know and retain an astonishing amount of information and know how to apply it practically and individually. And the learning is never done. I actually like this about my job – I like learning, I like that new and exciting information is coming out every single day. I like fitting the puzzle pieces together and helping a patient figure out what will work best for him or her. Specialists also must know an astonishing amount of information, but typically they must know only the information that applies to their specialty. Primary care providers – good ones, anyway – know a good amount about a LOT of things. It’s true that the depth of my knowledge in any particular specialty usually does not match that of a specialist (that’s why we have them, after all!) – but the breadth of my knowledge must be quite comprehensive. At a minimum, I need to know when the best care is likely by referring to a specialist – and which one. As medicine and technology advances, the humble GP must know more and do more – it’s not your great-grandfather’s doctor you are dealing with today. In addition, it is the PCP’s job to coordinate all your care. We must doggedly pursue notes and records from all your specialists, we must ask questions about who is doing what, and we must fill in the gaps whenever necessary.
Despite the reality of the above statement, generally speaking, compensation for your PCP is typically the lowest of any doctor or medical provider you see. I suspect this is because insurance companies got their start when specialists were the ones with the greatest depth AND breadth of knowledge in the medical community. The family physician handled the most common, least complex stuff and referred the rest to specialists. (It’s also true that procedures tend to get reimbursed at a much higher rate than consults, and this is another reason most specialists are compensated better than PCPs. It’s crazy, but I make more money for the practice when I take 2 minutes to freeze off a benign skin lesion than when I work with a brittle diabetic for 30 minutes to ensure he doesn’t end up in the hospital.) GPs now manage chronic and complex conditions every day. If my day were full of sniffles and bladder infections alone, with the occasional serious condition that I could refer to a specialist, the current pay structure might be reasonable. But I manage every common chronic condition, spanning multiple specialities, and I work with patients who have multiple complex conditions, all of which must be considered when prescribing something as common as an antibiotic. This is why, quite frankly, primary care providers are becoming scarce. Who wants to make the sacrifices involved in becoming a doctor, only to be overworked and underpaid?
And those who own primary care practices are forever trying to figure out how to manage their overhead – professional (utilities, realty, medical supplies, electronic medical records system, licensing, malpractice, staff, etc.) and personal (loan payments, for starters). Many have resorted to less-than-ideal options – seeing as many patients as possible in as little time as possible, extending hours, cutting benefits for staff (if they ever existed in the first place). We try to implement productivity strategies that help us accomplish more in less time. Some practices are quite good at this, some not so good. And a lot – a LOT – of practices close their doors within 10 years of starting up. Read what this doctor has to say about why primary care is not sustainable.
What has taken me years to learn (and I’m still learning) is that if I don’t guard my wellness, I will burn out. And then I will want to quit medicine and find another way to make a living. By the time I feel that way, I know things have gotten out of hand.
The insurance industry can be quite arbitrary in what they decide to pay for and how they determine what the medical provider’s time and resources are worth. This is a for-profit business, and while they have plenty of warm fuzzy commercials airing that try to convince you otherwise, they do not care about you or your health – they care about their bottom line. They care even less about your doctor.
This is the first step in what I feel is an important revolution that needs to happen in this country as we work toward solutions in healthcare: we need to acknowledge that if we want to be well, we cannot rely on the insurance industry to get us there. We need to be aware of the fiscal and human costs of medicine, and we need to be willing to take responsibility for these costs for ourselves and others. While we accept that our auto insurance won’t cover oil changes and new tires, we get angry over the idea that we should have to pay anything over our premiums when it comes to our health care. It’s true that the abuses of the insurance industry should be reined in, but I also believe that we need to consider reining in our attitudes about what the insurance companies “owe” us, as well as what is reasonable to pay them for their (sometimes quite limited) services.
I do not chronicle my professional life to complain. I’m writing this today because of the concerns I hear from patients. Until patients understand how medicine in the U.S. works, they will have no idea what needs to be done to move towards solutions – and if the patients don’t understand and insist on change, I truly believe we can’t expect change to magically happen on it’s own. It’s not enough to leave this to politicians and industry experts.
Patients are frustrated and financially squeezed – I don’t blame them for their frustrations (as a patient, I share them). But I also have little sympathy for those who expect that the burden will be shouldered wholly by the doctors and medical providers who are just as stuck in a broken system as they are. Don’t get me wrong – some docs have become burned out and no longer care to do what is required to take optimal care of patients. Some never had great motivations to begin with and got a hell of a wake-up call when they discovered what medicine entails. I’ve known several of these types, both as a patient and as a working physician assistant. I sympathize with them – boy, do I ever! But if you can’t do good work, get out of medicine. It sounds harsh, but it’s a standard I hold myself to, as well.
I hear comments and read comments regularly that indicate to me that many people have no comprehension of how the healthcare industry is set up. Either that or they are unwilling to take responsibility for themselves or make reasonable demands on their doctors’ time and resources. In many cases, both. What job-hopping this year has also shown me is the variety of ways that practices deal with the onslaught – the great need and the low resources, trying to do their best with customer service yet drawing appropriate boundaries. There is no one way to do it, but most practices are working very hard to find the balance. And most doctors, for all the drawbacks and failures of the current system, are really quite interested in taking care of patients in as optimal a way they can manage.
So, let’s get to patient concerns. I’d like to address them directly – not to make excuses for medical providers and practices, but to shed some light on WHY certain decisions have been made and boundaries have been established.
The office practice of having patients call themselves to check on what is covered on their insurance is a pain.
Yes, that is a pain. However, insurance is a contract between the patient and the insurance company. Billing your insurance at all is a courtesy that has become an industry standard (although more and more doctors are opting out and requiring that patients pay them directly and submit their own reimbursement paperwork). Most doctors take several different kinds of insurance, which allows them to offer their services to more people, as most people rely on insurance to cover costs. Each insurance company has several plans, and each plan has different coverage for various things. Given what I’ve shared about about what needs to be considered and done during even a brief visit, can you imagine what it would take (if it were even possible) to check on coverage for every test and exam recommended? Personally, I am aware of a couple of things that are generally not covered by certain companies – but it changes all the time, and it’s just not reasonable to expect your doctor’s office to verify your coverage. It’s also not reasonable to blame your doctor’s office if your insurance declines to cover something you feel you are entitled to.
Wouldn’t it be nice if medical providers could simply recommend what they believe to be of greatest benefit to patients instead of wondering if the insurance company will agree? Well, that’s not the world we live in at present… until then, the division of responsibility is as follows: it is the provider’s job to take the best care of you that he or she can with available resources; it is the patient’s responsibility to manage the details of how the provider or practice is compensated for his or her time and expertise.
Medicine is the only profession I can think of where patients commonly expect they should not have to pay a professional for her services. Try telling your lawyer that you don’t think you should have to pay for her services. See what she says. All in all, I think most practices do quite a lot to assist the patient as much as they reasonably can – and most doctors wait for payment, regardless of who is footing the bill. You’d be furious if you had to wait weeks or months for your services to be reimbursed, yet this is not unusual for your doctor.
My husband was charged for 4 different office visits just to have a yearly physical. One charge to establish him as a patient, one charge for the physical, one for labs and one because he discussed more then what is allowed during the physical.
Most offices will do your annual physical, send you to the lab for the required lab tests and phone you with the results. This office requires two separate doctors appointments, requiring two co-pays and additional costs for the insurance company.
My doctor refuses to speak with me on the phone! I always have to send messages through staff.
It’s true that some offices will just call you with your test results. Personally, if the results are normal and the patient does not have any chronic conditions that need to followed more closely, I will usually ask staff to call the patient with normal results (even better if the practice has a web-based patient portal – then I can send the results to the portal, and the patient can review them there, making a follow-up appointment if there are any questions or concerns). There is a cost associated with this, but it is minimal if it is a simple courtesy call (and, in my opinion, should be covered by the fee associated with the original visit). Often, the patient will have a “quick” question for the doctor or mention that they have a concern or a problem for which they do not want to schedule an appointment “since I’ve got you on the phone anyway.” At that point, boundaries have to be drawn… or the practice chooses to eat the cost of the ensuing messages back and forth and time entailed for the staff. I’ve seen practices do it both ways, and that’s a personal choice. However, patients should be aware that time on the phone is time that is not compensated. In other words, that is time your doctor’s office is working for free. If the practice is gracious enough to offer this service, be gracious enough to appreciate it and recognize that you are receiving a free service.
An important consideration when evaluating the “fairness” of such policies is recognizing that most practices are reimbursed by insurance. Insurance has set the rules, and the reality is that your medical provider and the practice he or she works with do not get reimbursed for telephone consultations. And most insurance companies will not reimburse anything “extra” we do in any encounter. They consider a well check or a physical just that. If I uncover something that indicates you are not “well,” or if you bring up a specific complaint, I can appropriately bill for it – but it’s not likely the insurance will pay for it. Some insurance companies go so far as to deny the claim for the preventive care (physical) if there’s any acute compaint or chronic condition billed. If I have time, I can address it – as long as you understand that you may receive a bill – the insurance will pay for either the preventive “well” care OR the acute complaint/chronic condition management, but not both.
As one doc I’ve worked with says, “We didn’t make these rules. If you have chosen to use insurance, you have chosen to accept the way they do things. And we don’t – we can’t – work for free.” This comment is actually quite telling. It has helped me feel more comfortable drawing appropriate boundaries, and it also sometimes justifies a different approach with cash-pay patients, who have either opted out of or cannot obtain insurance. (Frankly, if everyone paid in cash and/or processed their own insurance claims, medical care would cost a lot less – you’d be shocked how many people employed at your doctors office deal with insurance-related tasks… imagine how much the cost of running a practice would go down if a biller wasn’t needed, if there wasn’t a requirement for referrals or insurance paperwork… I’m not saying this is the optimal solution, but it’s something to think about.)
I cannot take good care of patients if I don’t have the time to discuss their test results with them. Even simple, non-urgent issues often generate questions for the staff member calling, and some patients expect the provider to call them and discuss the nuances of the test results over the phone. Refer to my description of my typical day, above. Tell me, how would you feel if you were asked to work – for free – at the end of 9-11 hours of continuous work, at the expense of getting home to see your family and a much needed rest so you can do it again the next day? How would you feel if this happened repeatedly because someone you are attempting to assist feels that you are “only trying to get more money out of me”? It’s true that it may only take “a minute” (well, okay, this is often NOT true – “a minute,” for some patients, turns into 10 or 20), but multiply that by the number of patients I see in a week – somewhere between 60 and 80 most weeks (for many docs, it is 80-100). Let me put it this way – it takes the better part of an hour, at times, just to read and respond to all the messages waiting for me at the end of the day – and that’s just to look at the information, determine what needs to be done, and send a message to the appropriate staff member to call the patient the next day. Can you imagine what would happen if I called each patient and managed everything over the phone? I would be there until midnight… for a few months. And then I would burn out and either quit medicine or practice in a way that wouldn’t resemble anything I consider to be good medicine. (We won’t even get into the fact that burnout contributes to medical errors and the fact that physicians are at higher risk of suicide than the general population….)
Don’t get me wrong, if the situation is unusual or the patient is very frightened or the news is serious, I will call. That is the human part of medicine. But I will not call you to discuss your low vitamin D level or your mild anemia – you will get a call from a member of my staff (that’s what they are there for) and/or you will be asked to follow up to discuss recommendations/treatment. And if I diagnosed you with the flu, a viral illness for which antibiotics are not effective, and you call for an antibiotic the next day, you WILL be asked to follow up if you feel your illness is worsening.
I waited 45 minutes for labwork today before I asked to reschedule. I watched as 4 other people left in frustration because they had waited so long. I think I am going to look for another family practice office that values their patients’ time.
If only I could communicate to you how awful I feel when a patient has to wait an extended period of time. If you’ve read my description of a typical day, above, you’ll understand a bit more about why this happens. Primary care providers are usually the least compensated doctors in the business, as I’ve mentioned. For that reason, the schedule has to remain full. If your doctor isn’t working at a reasonable capacity at all times, the overhead involved with running a practice can overwhelm receipts. And there is always – always – a wild card factor. We can draw boundaries around the “one-more-thing” patients (although I often flub this, as I don’t realize that “one-more-thing” has turned into 5 “one-more-things” and now I’m behind for the waiting patients), you simply can’t predict the patient who comes in for back pain and mentions signs of a heart attack. You can’t account for the time it may take to give some compassion to a patient who is very frightened or whose case turns out to me more complicated than the soundbite “reason for appointment” would suggest. If this happens once or twice, it’s easier to recover and get back on track. If it is a “perfect storm” kind of day, as I like to call them, I stumble from room to room all day long, thanking patients for their patience (ha!) and apologizing for delays. I can assure you that if I’m not with you yet, it’s because I’m working hard for someone else, and when it’s your turn, I will give you the same consideration.
My doctor didn’t even look at me and only spent 10 minutes with me. All these doctors care about is money.
I heard this one while eating out with my husband – the guy in the next booth was quite dissatisfied with his experience with his doctor. (And I’ve heard variations on this complaint many times.) This is unfortunate and, as a patient, unacceptable. If you’ve read what I wrote above about the pressures of primary care, it’s easier to understand why doctors become burned out or lose sight of what they are ultimately there to do – take care of patients. Sometimes, moving from room to room every 10-15 minutes becomes the only goal, and I believe we’ve probably lost many talented clinicians (or never allowed them to develop) because of this. However, I must say, I don’t find these reasons acceptable. As a patient, I expect my doctor to take care of me, to care about what I’m saying, and to look me in the eye and express some compassion and concern for my quality of life. I’m quite opinionated about this – if you can’t do that, hang it up and find a different line of work. What I wanted to say to this patient I overheard at the restaurant (I didn’t, of course – can you say intrusive?!) is: “You may have to choose. If you want a medical provider who gives you the time and human compassion you need, recognize that he or she will give that to other patients as well, and that means that sometimes there will be a wait. Sometimes you will be asked to follow up for another appointment when you don’t particularly want to because you think you should be able to receive advice over the phone. But keep on looking, buddy – because you deserve more than what you got.”
This place is a money pit. They offer so many services that are not covered by insurance!
There are several possible reasons for offering services that don’t have good insurance coverage. One is that the doctor has determined that there are methods of treatment that can be very useful in helping patients become and remain healthy that have not yet been accepted by insurance as worthy. This is true for some cutting-edge medical technologies, as well as for most “alternative” treatments, including acupuncture, chiropractic, Reiki, soft tissue manipulation (e.g., Rolfing or similar techniques) herbal medicine, and even clinical nutrition (if you don’t have a “qualifying condition,” such as diabetes).
I do understand that, as a society, we are paying an awful lot for our health insurance and expect to get more value from it. However, a good doctor will give you options for treatments that may be helpful, regardless of whether your insurance company is willing to cover it. It then becomes a question of the patient’s ability to afford the treatment, and sometimes it’s just not something the patient can afford. However, just as often (or more often!), I see patients simply do not want to prioritize their health or do not wish to evaluate their spending elsewhere. I have ZERO judgement for this – it is up to each person to determine their priorities and how they choose to spend their money. And I certainly don’t expect anyone to take my word for something that is going to cost them more money than they anticipated spending – which is why I usually ask patients to think about my recommendations, do some research, and know that it is available for them if they choose.
Choice is important; while I recognize and share the frustrations involved in paying out money to a company that has its own ideas about how your health should be managed, I do not advocate allowing that company to dictate your choices in how you will approach your own health and well-being. Regardless of your insurance coverage (or lack thereof), your health is YOUR responsibility. A good medical provider will provide you with options and work with you to make things as cost-effective as possible. We hand way too much power over our health to insurance companies, and that’s something I’d like to see come to an end. Take the coverage where it exists if you choose to carry insurance, but be prepared to think carefully and make decisions about how much you’d like to prioritize your health in those cases where a treatment or test may not be covered.
Another reason cash-pay services might be offered is that there are times when patients are willing to pay out of pocket for services. We’ve seen the rise of the “med spa,” and various cosmetic medical treatments such as Botox, microdermabrasion, and prescriptions for Latisse have been driven by consumer demand. Many weight loss programs (and some prescriptions) are also cash-pay services.
I’m sure I’ll have much more to say on this topic in coming days, online and off. Feel free to leave your comments – this is something we are all in together, and I know there are as many ideas about how things should be done as there are people to voice those opinions. I wrote this post to give some background based on my experiences alone. If we work together and shift our thinking, I know we can eventually get ourselves out of this mess – and seeing the full picture is part of informing ourselves so that we can work towards solutions.
ADDENDUM: I did think of one more irksome thing that tends to happen to patients at a doctor’s office – it’s hard to get a straight answer about what a visit will cost if you are paying cash or have a high-deductible plan. There is a reason for this, and some of the reason goes back to insurance. When I see a patient, I must bill a visit code at the end of every visit, and the code I choose depends on the complexity of the visit, the exam I performed, the questions I asked, and the amount of time I spent.
Contrary to popular belief, time spent is not the only deciding factor – in fact, it’s not even the primary factor. (Although if your office visit is extended, time becomes more of a factor – after I spend 40 minutes with a patient, I will typically code for time.) Even if I “only” listen to your chest when I examine you, I am also silently assessing your cranial nerve function, your eyes, your speech, your exposed skin, your gait and how you are moving around the room, whether your breathing is labored, your demeanor and attitude (Do you appear uncomfortable or ill? Is your affect flat? Do you appear listless? Are you irritable?), etc. If I am seeing you for an upper respiratory illness, add on what your ear canals and tympanic membranes look like, your dentition, your uvula, your tongue, your lymph nodes, your sinuses, your nasal and oral mucosa, etc. If I suspect mono, add on a full abdominal exam.
All of that is documented, even if it only took me 2-5 minutes to make those observations and determine if they were normal or concerning. Earlier in my career, I didn’t have the skill to make so many assessments in such a short period of time. I had to slow myself down and think about it more carefully. But experienced clinicians will assess more than you know in a very brief period of time. It can come off like we don’t care enough to evaluate you thoroughly, and unfortunately, some clinicians are not as thorough as they should be. If a patient is concerned with my diagnosis, I tend to explain what my opinion is based on: “I see no signs of bacterial illness, so an antibiotic will not help you and may be harmful. This is based on the symptoms you have reported to me, your skin temperature, the appearance of your mucous membranes, palpation and illumination of your sinuses, the sounds of your lungs, etc. I don’t have a crystal ball, so of course if new symptoms develop or present symptoms worsen, please follow up so we can take another look at you. It is possible for a secondary bacterial infections (such as sinusitis or pneumonia) to develop after a viral illness, so we would like to see you back if you feel you are not improving in the next [x number of] days.”
Based on all these factors, I code the office visit, which is necessary to bill insurance. Even if you are a cash-pay patient, the system I use requires the code before I can close your chart. Most offices have discounted rates for cash-pay patients, but there’s no way to tell what the provider will code until the visit is complete. And if tests were ordered, you can expect an additional cost, either from the office (if they processed the test) or from an outside lab or imaging facility. If you received an injection, that will carry an additional charge. Although I can tell you a chest x-ray outside of the office should cost somewhere in the neighborhood of $30-35, I cannot guarantee that price nor price check for you. You will need to do that yourself. I will usually guide patients towards businesses that have better cash-pay rates in general, if I am aware of them.
Personally, I prefer offices that have flat fees for different types of visits. I currently do not carry insurance, and I like to have a general idea of what I will be charged. The doctor’s office I use now charges something like $125 for a visit to establish care, somewhere around $175 for a well-woman exam with Pap processing included (a smokin’ deal since that Pap test has typically cost me close to $200 in the past – on TOP of the cost of the exam, which usually is somewhere around $125-150) and $70 for follow-ups. However, the office I am currently working for bases it on the coding, and I believe a level 3 visit (which I will code for many simple acute care visits) is less than $60. ALWAYS mention to your provider if you are a cash-pay patient. I have worked in offices where the prices are not discounted but the providers are allowed to “downcode” by one level for cash-pay patients – if your provider doesn’t happen to look at your billing screen (I know I usually do not go into that part of the chart), he or she won’t know, and you may not get as good a rate.