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.


4 thoughts on “Expectations

  1. Very stimulating post. As a patient, I expect to pay the physician’s fee myself. Radical strategy! I have a high deductible Health Savings Account (HSA). It reaffirms my shopper/ consumer role in the relationship with my physician(s) and the medical system. I know I’m worth the investment.

    They agreed to accept reimbursement from me at a lesser amount based on a percentage of Medicare charges (even though I’m not on Medicare, they are used as the baseline for fees in most physician contracts with insurance companies).

    As a physician, I expect that the patient is paying the bill themselves. Most aren’t paying themselves, so they are in collusion with the confusion. Why did so many people decide to assume that someone else should pay something for them? That’s radical, too!

    And it went downhill from there. Trying to retain the system in which someone else makes the rules and the payments. Folks, it’s time to start over. Take back your health and health care from the night.

    Short-term strategy until you do that: Always ask for an extended visit if you have a chronic disease (e.g., RA, diabetes, obesity) because you’ll tack on two extra problems once you get to the waiting room that you want attended to even though you didn’t plan ahead well enough to schedule the doctors time for them. (What the heck, s/he’s got nothing better to do than care for people who have difficulty planning ahead about things of importance to them like their health). But you’ll be considerate and s/he will love you forever.
    If you’re sharp enough to use Warmsocks planning forms (see her previous posts) you’ll be prepared to deliver the best information and questions at the right time and right place comfortably in the allotted time. The next five patients will cheer you for your organization and timeliness and ask to borrow WS forms so they can do likewise. Then the office will run smoothly and everyone in town will transfer their care to your efficient doctor and love will flow everywhere. Radical again!
    Doctors have four blanks on the insurance billing form,if the extended service includes a lot of thinking,four or five issues they can easily send in a bill for four diagnoses and a high evaluation and management code (99215). Your extended visit starts at a low of about $110 while the four dx may hit $175-$195, for which we get about $109-155 depending on the deal with your insurance company.

    • There’s a lot of information here. Thank you.

      I haven’t investigated high-deductible HSA’s much, mainly because we have insurance. It sounds like HSA’s are a step toward getting back to insurance being protection against a calamity, rather than something that’s used for routine medical care. That’s a good thing. But they’d have to lower their rates from what I saw last time I checked prices.

      I believe that people should take responsibility for themselves, and see many problems with medical insurance. Returning to a cash system has a lot of merit for many people.

      The problem I see is that it’s not just (healthy people checking in with their doctor every couple years for a routine checkup) or (major problem leading to a hospital admission).

      When you’re healthy and see your doctor once every year or two for a routine check-up, it would be much more cost-effective to pay cash for that single appointment instead of buying insurance. My family pays approximately $1000 a month for insurance. Up until a few years ago, if we’d paid cash instead of buying an insurance policy, we’d probably have spent less than $1000 a year most years. We could have saved a lot by not having insurance. The insurance company made a bundle on my family for a long time. We grumbled a bit, but paid so that the coverage would be there in an emergency.

      And it’s a good thing we did. Now I see the other side. Ongoing medical care gets expensive very quickly. My PCP charges $100 for most visits; 1-2 times a year can be worked into our budget, but 4-5 gets tough – that’s the most affordable part of my care. My rheumy charges much more ($213 or $385) and wants to see me more frequently (usually every 6, 8, or 12 weeks, depending on how I’m doing). My labs usually cost $150 every six weeks, but last month a couple extra tests were ordered and the bill was $935. The cash price on my meds is just over $2500 a month. Then there are x-rays ($1600), MRIs($3K), ultrasounds ($500), PT ($135 twice a week), plus a possible shoulder surgery looming. I don’t think I could justify impoverishing my family so that we could postpone the inevitable.
      What a depressing line of thought!

      I didn’t realize it was possible to request an extended appointment. I’m looking forward to a good discussion with my doctor the next time I see him.

  2. Warmsocks and Dr. Synonymous make clear that a significant cause of the problem getting competent medical care lies with the insurance companies. It’s a tail wagging the dog scenario in which doctors and patients are being crammed into a system that was designed with shareholder profits the dominant goal — not patient health or reality.

    I’m glad Dr. Synonymous pointed out that insurance slips (the receipts cash paying patients also receive) typically contain check offs for four different levels of doctor office visits based on how involved/time consuming the visit is. As a cash payer, I was always charged the hefty full price rate corresponding to how much time the visit took, and for specialists the fee was in the $500-$600 range! The fact that many insurance companies refuse to acknowledge reality just goes to show how devoid they are of caring at all about patient welfare.

    With the current insurance reform looming, I can already envision insurance company lawyers coming up with all kinds of ways to skirt the new laws. It’s difficult for me as an American to believe there is nothing that we citizens, patients and doctors, consumers of health care, can do to correct this.

  3. How about if we could send in problem lists by e-mail, say a week ahead of time? Then get as many answers as possible back via e-mail, and then the scheduler adjust the length of the appointment to address the problems that require laying on of hands or blood draws? I don’t know about y’all, but many of my questions don’t really need a face-to-face.

    Also, that interim history? Well, I have copies of all my docs’ interim history forms that they want me to fill out. I scan them into Paperport, and then annotate them. If I have a lot of interim history, I use a smaller font. It’s still easier to read than my hen-scratching would be. OR, you can just write up your answers and print out on a separate piece of paper, then attach the printout to the form.

    Seems to me we aren’t using the electronic possibilities very creatively. Nurse practitioners could answer a lot of the more basic questions. They can also print out the prescriptions you need and put them in the chart for the doc’s signature the day you come in.

    We need to add that to the “rules!”

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