In a comment on my Rules post, swdoc commented:

I wish people in this thread sat in my waiting room!  Our patients do not seem to have the same understanding of the time issues, and I’m not sure would really want to see a rule book.  Everyone is busy, and it takes time away from other tasks to go in to see the doctor; patients often feel their time is not “respected” by the physician, because physicians typically are not  able to stay on schedule.  My patients do not want to make several appointments for several issues – they want them all handled during their 15 minute time slot – though do not think it is appropriate to be delayed because every other patient feels the same way.
Patients are consumers of healthcare, and understandably want to get the most for their money.  I am not a mechanic, and may think the tune-up is more important that the brake job, and would really appreciate the opportunity and understanding from not only the patients, but more importantly, those insurance companies with their rules books!

Do patients want everything handled in fifteen minutes?  No.

Do patients want everything handled in a single appointment?  Yes, whenever possible.

So if it’s not feasible, explain why.

It would be much better to stretch that appointment to 25 or 30 minutes than to have to make a separate trip another day.  Patients assume that a 30 minute appointment will cost more than a 15 minute appointment.  That would be reasonable.  I expect my doctor to be paid for his work.  I honestly thought that he could deal with any number of health problems at a time, then bill my insurance to receive fair compensation for the time and complexity involved.  I was shocked when I learned that’s not the way it works.

I think most people assume that the doctor’s bill will reflect what is owed.  I don’t understand why, if my physician takes time to listen to me and address all my concerns, he isn’t paid for that.  If he has clearly documented four distinct problems, the insurance company should pay for the handling of four problems.  Instead, my doctor gets the same amount of money for a one-problem fifteen minute appointment as he does for a multiple-problem appointment that takes an hour.  That’s wrong!

If I were the one doing four times the work for exactly the same amount of pay, I’d be highly resentful.  It’s no wonder that so many doctors in the blogosphere feel pressured and unappreciated.

Maybe the solution is to be very clear that there are different kinds of appointments so that patient expectations are realistic.

When patients realize that their insurance will only pay for one problem at a time, they might be a lot more understanding of the external forces at play.  I certainly am.

Insurance should pay (for example) $100 for a single-problem visit, $170 for a two-problem visit, and $240 for a three-problem visit.  Don’t get hung up on round numbers, because that’s beside the point.  The point is that it’s less work for the doctor and his staff to handle everything in one appointment instead of in three, so a discount for extra problems handled at the same time is reasonable.  It takes less of everyone’s time to handle multiple things at once.  In a system that permitted this, patients would be explicitly asked how many problems they wished to discuss, and a corresponding amount of time would be scheduled.

Instead, insurance pays for one problem, so doctors only schedule for a single problem.  Patients who don’t understand how this works (because the rule book is a secret) get frustrated.  Insurance companies won’t tell what the rules are because it makes them look like money-grubbing cheapskates.

Insurers try to weasel out of paying fairly.  They greatly discount the doctor’s fee, they play games trying to discourage doctors from ordering needed tests, and make it nearly impossible for patients to get needed treatments.  Well, I can play games, too.  Since my insurance company doesn’t value my doctor’s skill or time, nor do they value my time, I can make it cost the insurer extra.

By planning my appointments carefully, I make it cost the insurer as much as possible and get my doctors more money.  Instead of trying to squeeze three problems into a single appointment, I intentionally schedule separate appointments so that the insurer is on the hook for three times the amount of money.  Some people might point out that I owe an extra copay when I schedule extra appointments.  While this is true, 1) the cost is small compared to the full fee for an office visit, and 2) if I schedule appointments with multiple doctors on the same day, I only owe a copay to one doctor; insurance picks up the full cost of the other appointments.  In the long run, it’s a wash.

Patients expect that their insurers will pay doctors fairly.  It seems as though the first rule patients need to know is that this simple expectation is not met.


Be Succinct

Anonymous Doc provides a hilarious peek into the exam room.  “Ah, patient histories.  Consider this a crash course.”

“So, what brings you in?”
“I’ve been getting up every 45 minutes or an hour to urinate during the night.”

“You get up five, ten times during the night to go to the bathroom?”
“Well, maybe not five or ten. Three. Two or three. Most nights.”

“Okay. How long has this been going on?”
“The past couple of years, maybe four years.”

“Wow. That’s a long time. What brings you in now, specifically?”
“Oh, I have a rash.”

“You have a rash on your–”
“No, no, not there. On my stomach.”

“And you think this is related to the nighttime urination?”
“I don’t know.”

“Okay. Let’s talk more about the rash. How long have you had it?”
“About a month.”

“And you’re first coming in now because–”
“I had microscopic blood in my urine.”

“Yes, very small amount. I could barely see it.”

“Okay, that’s definitely concerning. And this was this morning?”
“No, no, 1996. It was because of a weight loss pill I was taking. I stopped taking it.”

“Okay. So what changed today that you came in to see me?”
“My sleep has been very poor.”

“Because you keep having to get up to use the bathroom?”
“Yes, and because of my leg.”

“What’s wrong with your leg?”
“Well, I think have the rash because I’m not showering as much as I used to. I have trouble balancing in the shower. So I think I keep getting food on my stomach and that is causing the rash.”

“And the trouble balancing–”
“That is my leg.”

“So you’re having trouble balancing, or trouble standing?”

“Which one is it?”
“I don’t know. My mother had an infection on her leg a few years ago.”

“Do you think I could have the same thing?”

“I don’t think you caught an infection your mother had a few years ago, no. Whether you have an infection in your leg is something I can’t tell without examining you. I’m just trying to isolate exactly what’s going on now that we need to be most concerned about. Is the trouble balancing a new thing?”

“Is the leg pain new?”
“I don’t have leg pain, no. I have a rash.”

“On your stomach?”
“And my leg.”

“And it burns when I urinate.”

“It does not burn now. Only when I urinate.”

“When is the last time it burned?”
“In the night. I don’t urinate during the day.”

“On purpose?”
“I don’t know. But do you think it has to do with my mother’s leg infection?”

Clearly explain to your doctor the purpose of your appointment.  Maybe explain it to yourself first, so you know what you hope to get out of it.