It\’s not our Fault

Dear Patients:
I know you get frustrated with our office.  We make you come in for visits when you think we should handle things over the phone.  We seem more focused on your chart sometimes than on you.  Sometimes you may even wonder if money has become more important than patients. 

To this, I say: I\’m Sorry.  It\’s not our fault. 

We are part of an insane system that requires us to do things in a way that makes life harder for us both.  We would love to practice medicine differently, but we simply can\’t.  Here are some examples:

1.  Making You Come in All The Time

I would love to handle your simple problems on the phone or via e-mail.  The problem is that if I do this, I am giving free care for which I am liable.  People are being sued for nearly everything.  If we give you a medicine without seeing you, we are actually more at risk than if you come in.  Plus, the only way we can get paid is to bring you in.  Insurance won\’t pay me for handling your problem any other way.  Even if we both agreed, we couldn\’t have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.*

2.  Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right?  Well, according to our government, I am actually committing fraud.  That\’s right, fraud.  You see, I can\’t offer anyone a discount that I don\’t offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients.  Ridiculous, isn\’t it?

3.  Getting lost in notes

Why do we spend so much time taking notes and not talking to you?  Is it so that we can do better medicine?  No, we actually think that all this charting is stupid too.  The problem is that we don\’t get paid to see you, we get paid to chart about you.  We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more.  If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4.  Obsessing about money

When you get your bill from us, you may wonder what all those charges are.  And why are we forcing everyone to pay up front and sending people to collections?  The problem is, while healthcare insurance premiums have gone up and inflation has raised everyone\’s cost of living, our reimbursement has dropped.  We get paid less and less for taking care of you, so we have to become much stricter in how we run our business.  The practice of medicine has turned into the business of medicine.  We didn\’t do that, nor do we like it.  But we have to stay in business, so we do what we must.

5.  Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don\’t see adult patients in the hospital.  Believe me, we hate that as much as you do.  It is very hard to give your care over to others who see you as \”another patient.\”  They don\’t know your history like we do and are often too busy to answer your questions.  We try to communicate with them, but it is just a hard thing to do.

The problem is that we can\’t afford to see patients in the hospital.  The amount of time it takes for the money we get is just not worth it.  It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less, or see our salaries drop.  As PCP\’s we are not paid enough to let our salaries drop, so we chose our families.  It was one of the hardest choices we ever made.

6.  Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem?  Why are you treated like a criminal if you ask for pain medications?  The answer?  Lawyers.  Lawsuits are so rampant in our culture and so it makes us practice \”defensive medicine.\”  This means that we can\’t do what makes sense, we must do what minimizes risk. 

And if we are ever thought to be giving pain medications too liberally?  We can lose our licenses and even go to jail.  It\’s a dangerous business we are in, but we don\’t want to do anything to make it more dangerous.

 

I am truly sorry for the state of things as they are.  Perhaps better days are ahead of us.  Some politicians are actually talking about paying primary care doctors more.  Some people are suggesting that they stop paying just based on charting, but actually reward better work.  And some people are even talking about limiting malpractice rewards. 

These all sound promising, but remember who it is that is making the decision:  It isn\’t the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff.  Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!

Sincerely,

Dr. Rob

*In response to some of my comments here, some insurance companies do pay for this type of visit.  We are allowed to charge people and even collect with private insurance, but few (we have found) pay for them.  If we charge Medicare and Medicaid patients, we not only won\’t get paid, but it would be illegal to collect the unpaid balance from the patient (even if they agreed to pay it).

62 thoughts on “It\’s not our Fault”

  1. ARE YOU SERIOUS that you’re not allowed to charge for phone calls and emails and such?A former pediatrician (who we did not get along with) has started charging $15 for each email and $20 for each phone consultation.
    I kid thee not.

    He has serious ego problems …but … I didn’t know you weren’t allowed to do it …

    tee hee … word captcha …” his frightens ” …

  2. ARE YOU SERIOUS that you’re not allowed to charge for phone calls and emails and such?A former pediatrician (who we did not get along with) has started charging $15 for each email and $20 for each phone consultation.
    I kid thee not.

    He has serious ego problems …but … I didn’t know you weren’t allowed to do it …

    tee hee … word captcha …” his frightens ” …

  3. Wow. Kudos for tackling a subject that medical education just sweeps under the rug. What do you think of the “pay for performance” measures that some insurance companies are instituting? I’ve heard concern that they will lead to cherry-picking and aggressive medicine, to the detriment of the patient.

  4. Wow. Kudos for tackling a subject that medical education just sweeps under the rug. What do you think of the “pay for performance” measures that some insurance companies are instituting? I’ve heard concern that they will lead to cherry-picking and aggressive medicine, to the detriment of the patient.

  5. 99% of patients want to see you anyway, don’t need the discount, don’t see the notes (and never will), understand the need to run a business, will not be in hospital for more than an x-ray and understand your desire to be paranoid (and will ignore it). Part of the problem is with the colleges and legislators that facilitate the abuse of the system by the 1%.

  6. 99% of patients want to see you anyway, don’t need the discount, don’t see the notes (and never will), understand the need to run a business, will not be in hospital for more than an x-ray and understand your desire to be paranoid (and will ignore it). Part of the problem is with the colleges and legislators that facilitate the abuse of the system by the 1%.

  7. some dude named steevo

    Good post, but I don’t even argue with people anymore, I don’t have the energy. About a year ago I had an irate wife who was upset we couldn’t tell her over the phone that her husband had a hypoglycemic attack. She was mad and I just told her to call her congressman — that was all I could do.
    I charge for some phone calls. If you take a relatively detailed history and prescribe a treatment, or a change of current treatment, you can charge for a call. The only time I usually do this is when I get called at 2am for a rash or a cold the patient has had for a week.

  8. some dude named steevo

    Good post, but I don’t even argue with people anymore, I don’t have the energy. About a year ago I had an irate wife who was upset we couldn’t tell her over the phone that her husband had a hypoglycemic attack. She was mad and I just told her to call her congressman — that was all I could do.
    I charge for some phone calls. If you take a relatively detailed history and prescribe a treatment, or a change of current treatment, you can charge for a call. The only time I usually do this is when I get called at 2am for a rash or a cold the patient has had for a week.

  9. Mornin’, Dr. Rob. Coupla quick comments/questions:
    1) Why can’t you charge for those who want consults/information via phone or email, but not through insurance? They could choose to pay. My endo does that. I love the email communication.

    2) Have you seen this month’s AARP magazine? (I know…I’m telling my age…) It has a great article, actually, on the shortage of PCP’s and why.

    3) Ok…make it three: Dr. Ian McCuthcheon of M.D. Anderson has written a great article mostly geared to OB/GYN doctors about detecting pituitary tumors from symptoms. It is great for any physician to read, though, and I have it on my blog, but it was originally posted on the Pituitary Network Association site. Either place is a great place to read it. It’s a good read.

  10. Mornin’, Dr. Rob. Coupla quick comments/questions:
    1) Why can’t you charge for those who want consults/information via phone or email, but not through insurance? They could choose to pay. My endo does that. I love the email communication.

    2) Have you seen this month’s AARP magazine? (I know…I’m telling my age…) It has a great article, actually, on the shortage of PCP’s and why.

    3) Ok…make it three: Dr. Ian McCuthcheon of M.D. Anderson has written a great article mostly geared to OB/GYN doctors about detecting pituitary tumors from symptoms. It is great for any physician to read, though, and I have it on my blog, but it was originally posted on the Pituitary Network Association site. Either place is a great place to read it. It’s a good read.

  11. This post should be emailed to every healthcare administrator, politician and health insurance company employee every hour, on the hour, for the rest of their lives, or until they do something sensible about it!!

  12. This post should be emailed to every healthcare administrator, politician and health insurance company employee every hour, on the hour, for the rest of their lives, or until they do something sensible about it!!

  13. Regarding phone messages, we have tried charging for them and have never gotten paid. Since collecting on unpaid charges from Medicare and Medicaid patients is not legal, and since our capitated contracts would not allow it either, there is no real good reason to continue doing this. We can charge, but we can’t collect on most of those charges.

  14. Regarding phone messages, we have tried charging for them and have never gotten paid. Since collecting on unpaid charges from Medicare and Medicaid patients is not legal, and since our capitated contracts would not allow it either, there is no real good reason to continue doing this. We can charge, but we can’t collect on most of those charges.

  15. Very well written and sooo true. The piece would be more marketable if the *it’s not our fault* part is removed….

  16. Very well written and sooo true. The piece would be more marketable if the *it’s not our fault* part is removed….

  17. Very well said post. There are so many ways in which the delivery of health care could be so much more efficient and effective, but the bureaucracy of the health care system is so enormous and entrenched that it stiffles any innovation.

  18. Very well said post. There are so many ways in which the delivery of health care could be so much more efficient and effective, but the bureaucracy of the health care system is so enormous and entrenched that it stiffles any innovation.

  19. More paperwork and lower reimbursement. How do they get away with paying less when the cost of living (and practicing) increases each year? And if they’re paying less, why do they keep raising insurance premiums? Ours went up ~ $2000 this year. What a racket!

  20. More paperwork and lower reimbursement. How do they get away with paying less when the cost of living (and practicing) increases each year? And if they’re paying less, why do they keep raising insurance premiums? Ours went up ~ $2000 this year. What a racket!

  21. Well said, Robbo.
    Here’s an article you might find interesting, too, somewhat along the same lines.

    PS: haven’t been here in a while. I see you dropped the complex calculus. Still a challenge for me, though.

  22. Well said, Robbo.
    Here’s an article you might find interesting, too, somewhat along the same lines.

    PS: haven’t been here in a while. I see you dropped the complex calculus. Still a challenge for me, though.

  23. According to this article there are now CPT codes for email and phone conferences. Does this mean it depends on the providers acceptance of them? Is that not true for all the CPT codes?
    I think it is important those of us who are patients to understand the roadblocks, and thus the questions. Thanks for your help.

  24. According to this article there are now CPT codes for email and phone conferences. Does this mean it depends on the providers acceptance of them? Is that not true for all the CPT codes?
    I think it is important those of us who are patients to understand the roadblocks, and thus the questions. Thanks for your help.

  25. Yes, Robin. There are lots of non-reimbursed CPT codes. The ones paid for and not paid for are often only discovered by trying them. There is no simple way to figure this kind of thing out. We just bill and see if they pay. One of our docs tried to bill for phone calls, but nobody paid and the patients all got mad.
    I have a friend who started charging a yearly fee and a charge for each phone consultation, but he had to first drop Medicare (and Medicaid, I presume).

    Sid: Good to have you back. I saw your most recent rant.

  26. Yes, Robin. There are lots of non-reimbursed CPT codes. The ones paid for and not paid for are often only discovered by trying them. There is no simple way to figure this kind of thing out. We just bill and see if they pay. One of our docs tried to bill for phone calls, but nobody paid and the patients all got mad.
    I have a friend who started charging a yearly fee and a charge for each phone consultation, but he had to first drop Medicare (and Medicaid, I presume).

    Sid: Good to have you back. I saw your most recent rant.

  27. Ok…now, what can those of us who have insurance do to make this better? I want to be able to use email and phone calls with my doctors. And I want them to get paid. As a consumer, it is in my best interest, also, to be able to do this.
    And my endo does not deal with insurance or Medicare. I pay him up front for any service. (I can do this online.) However, I can submit his bill (which I’ve already paid) and get some reimbursement from my insurance. Frankly, I’ve saved money this way and prefer it. I know not every provider does/will, but I know that I am getting the service I need without paying umpteen dozen co-pays to get nowhere with various doctors.

    In other words, he’s worth it. And I’m worth it.

  28. Ok…now, what can those of us who have insurance do to make this better? I want to be able to use email and phone calls with my doctors. And I want them to get paid. As a consumer, it is in my best interest, also, to be able to do this.
    And my endo does not deal with insurance or Medicare. I pay him up front for any service. (I can do this online.) However, I can submit his bill (which I’ve already paid) and get some reimbursement from my insurance. Frankly, I’ve saved money this way and prefer it. I know not every provider does/will, but I know that I am getting the service I need without paying umpteen dozen co-pays to get nowhere with various doctors.

    In other words, he’s worth it. And I’m worth it.

  29. Mental health clinicians face the same challenges. Our reimbursement, which was nothing like MD’s to begin with, have also dropped. and although we are not responsible for physical health issues we do have certain life and death responsibilities such as suicide, severe substance abuse and reckless impulsive decisions. We assess how safe our self harming clients will be each night. We have liability and lawsuits to contend with. We have clients with legal problems who would like us to do all sorts of things on their behalf during their court processes that we will likely never be reimbursed for. We too take calls in the middle of the night, return emails and see pro bono clients all of which we are also not reimbursed for. We are burdened with excessive amounts of paperwork – something I was never adequately prepared for in graduate school. The ongoing frustrations and changes in managed healthcare impact many professionals and sadly our clients as well. However, that rant having been said I wouldn’t change what I do for anything.

  30. Mental health clinicians face the same challenges. Our reimbursement, which was nothing like MD’s to begin with, have also dropped. and although we are not responsible for physical health issues we do have certain life and death responsibilities such as suicide, severe substance abuse and reckless impulsive decisions. We assess how safe our self harming clients will be each night. We have liability and lawsuits to contend with. We have clients with legal problems who would like us to do all sorts of things on their behalf during their court processes that we will likely never be reimbursed for. We too take calls in the middle of the night, return emails and see pro bono clients all of which we are also not reimbursed for. We are burdened with excessive amounts of paperwork – something I was never adequately prepared for in graduate school. The ongoing frustrations and changes in managed healthcare impact many professionals and sadly our clients as well. However, that rant having been said I wouldn’t change what I do for anything.

  31. The only docs that may have it worse than PCP’s are psychiatrists. No question about that. There is no way to up your volume and the payment is generally poor. As a PCP I LOVE the good psychiatrists in town. They keep me from having to do amateur psychiatry.
    Robin: Talk to your HR people at work and ask if they can pressure the insurance companies to allow/promote e-visits. It is VERY much in a business’ best interest because people miss less work. The people insurance companies listen to the best are businesses.

  32. The only docs that may have it worse than PCP’s are psychiatrists. No question about that. There is no way to up your volume and the payment is generally poor. As a PCP I LOVE the good psychiatrists in town. They keep me from having to do amateur psychiatry.
    Robin: Talk to your HR people at work and ask if they can pressure the insurance companies to allow/promote e-visits. It is VERY much in a business’ best interest because people miss less work. The people insurance companies listen to the best are businesses.

  33. some dude named steevo

    I use email in my personal life. It is simple and effective.
    However, I will NEVER use email in my medical practice. Unless it was only a one-way email (doctor to patient) for lab results and other things. Then I could have my assistant do it. I will never communicate with my patients through email, it is just a horribly inefficient way to talk to someone.

    That being said, I do use it for deaf patients. That is an efficient use of email.

  34. some dude named steevo

    I use email in my personal life. It is simple and effective.
    However, I will NEVER use email in my medical practice. Unless it was only a one-way email (doctor to patient) for lab results and other things. Then I could have my assistant do it. I will never communicate with my patients through email, it is just a horribly inefficient way to talk to someone.

    That being said, I do use it for deaf patients. That is an efficient use of email.

  35. God, I didn’t think things were that bad. Anyways, I never blamed you guys, I suspected about bureaucracy as much. I have always respected doctors for what they did, and I think the system repays them very poorly.

  36. God, I didn’t think things were that bad. Anyways, I never blamed you guys, I suspected about bureaucracy as much. I have always respected doctors for what they did, and I think the system repays them very poorly.

  37. nzou.com » Blog Archive » The Business of Primary Care Medicine

    […] It’s Not Our Fault by Dr. Rob. […]

  38. And how is the current system better for doctors than Europes? Why do doctors fight universal care so hard when they get a worse deal from the insurance companies than European doctors get from the governments?

  39. And how is the current system better for doctors than Europes? Why do doctors fight universal care so hard when they get a worse deal from the insurance companies than European doctors get from the governments?

  40. I came here from Dr. Kevin MD. This entry of yours addresses some concerns I’ve had for a long time, and I appreciate your explaining the problem to me.

  41. I came here from Dr. Kevin MD. This entry of yours addresses some concerns I’ve had for a long time, and I appreciate your explaining the problem to me.

  42. Hang in there, Rob!
    @Larry, universal coverage would be fine by me. It’s single payer I’m afraid of. The govt is already the biggest culprit re: soul-destroying paperwork and ticky-tack regulations that create more work without more pay. But my worst fear is that under single payer we as docs could be pressured (even more than we are now) to put the interests of “society” ahead of our patients’ interests. At least right now nobody is leaning on me to euthanize my sick elderly patients to save money and calling it “end of life care.”

  43. Hang in there, Rob!
    @Larry, universal coverage would be fine by me. It’s single payer I’m afraid of. The govt is already the biggest culprit re: soul-destroying paperwork and ticky-tack regulations that create more work without more pay. But my worst fear is that under single payer we as docs could be pressured (even more than we are now) to put the interests of “society” ahead of our patients’ interests. At least right now nobody is leaning on me to euthanize my sick elderly patients to save money and calling it “end of life care.”

  44. A few years back, I asked my then ‘primary care’ doctor if I could pay out of my own pocket to have a more thorough physical exam, above the level and few minutes of time allowed by the insurance company.
    She said by her contract with the insurance company, she wasn’t allowed to do that. She quit being a doctor not long after that, the third doctor I’ve had in a row who quit practicing after expressing frustration with insurance rules.

    On the other hand, I’ve started asking medical people what they personally would do about routine screening examinations, annual tests, and so on. Mostly they say they don’t bother with that stuff. And statistically they’re no worse off, I gather.

    I once talked with a pathologist at some length and he told me that one conclusion he’d come to after years of work is that he always avoids elective surgery of any sort.

    I’m starting to agree.

  45. A few years back, I asked my then ‘primary care’ doctor if I could pay out of my own pocket to have a more thorough physical exam, above the level and few minutes of time allowed by the insurance company.
    She said by her contract with the insurance company, she wasn’t allowed to do that. She quit being a doctor not long after that, the third doctor I’ve had in a row who quit practicing after expressing frustration with insurance rules.

    On the other hand, I’ve started asking medical people what they personally would do about routine screening examinations, annual tests, and so on. Mostly they say they don’t bother with that stuff. And statistically they’re no worse off, I gather.

    I once talked with a pathologist at some length and he told me that one conclusion he’d come to after years of work is that he always avoids elective surgery of any sort.

    I’m starting to agree.

  46. I wish I had discovered your blog while I was dating my last boyfriend – a pediatrician. It’s just helped me understand the pressures of the profession in a way he never could. Thanks.

  47. I wish I had discovered your blog while I was dating my last boyfriend – a pediatrician. It’s just helped me understand the pressures of the profession in a way he never could. Thanks.

  48. A great post, but you didn’t explain how the nutty fee for service pay schedule, which is responsible for much of the problems you note, was imposed on us by Medicare, with the acquiescence of nearly all managed care organizations and health insurers, and is a product of Medicare’s collaboration with the mysterious AMA-sponsored RUC (RBRVS Update Committee). See:http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html

  49. A great post, but you didn’t explain how the nutty fee for service pay schedule, which is responsible for much of the problems you note, was imposed on us by Medicare, with the acquiescence of nearly all managed care organizations and health insurers, and is a product of Medicare’s collaboration with the mysterious AMA-sponsored RUC (RBRVS Update Committee). See:http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html

  50. Doc, I think there was a new ruling from CMS that allowed charging (and collecting) for phone calls. I would have to do some digging to find it, but I”m pretty sure I didn’t hallucinate it.

  51. Doc, I think there was a new ruling from CMS that allowed charging (and collecting) for phone calls. I would have to do some digging to find it, but I”m pretty sure I didn’t hallucinate it.

  52. CPT 2008: A Glimpse of the Future of Family Medicine?
    Cindy Hughes, CPC

    Fam Pract Manag. 2008;15(1):16-18,21. ©2008 American Academy of Family Physicians
    Posted 03/13/2008

    Introduction
    This year’s CPT update won’t dramatically affect the way you code the services you provide in face-to-face visits. However, it does recognize new ways of delivering health care services. The addition of codes for telephone and online evaluations reflect a reality anticipated in the Future of Family Medicine report – one in which “interactions will not be limited to traditional, individual, face-to-face encounters between the patient and the family physician.”[1] Time will tell whether health insurers share this same vision; at press time, it was unclear whether any of the major plans would provide reimbursement for the services these codes represent.

    A table summarizing these and other changes most likely to affect family physicians is available at http://www.aafp.org/fpm/20080100/cptchanges2008.pdf.

  53. CPT 2008: A Glimpse of the Future of Family Medicine?
    Cindy Hughes, CPC

    Fam Pract Manag. 2008;15(1):16-18,21. ©2008 American Academy of Family Physicians
    Posted 03/13/2008

    Introduction
    This year’s CPT update won’t dramatically affect the way you code the services you provide in face-to-face visits. However, it does recognize new ways of delivering health care services. The addition of codes for telephone and online evaluations reflect a reality anticipated in the Future of Family Medicine report – one in which “interactions will not be limited to traditional, individual, face-to-face encounters between the patient and the family physician.”[1] Time will tell whether health insurers share this same vision; at press time, it was unclear whether any of the major plans would provide reimbursement for the services these codes represent.

    A table summarizing these and other changes most likely to affect family physicians is available at http://www.aafp.org/fpm/20080100/cptchanges2008.pdf.

  54. Rob: This is a great post…you speak for probably the majority of practicing physicians, particularly in primary care! I have been aware of the CPT codes for e-mail and phone services and think that Doctors or one of our organizations should band together to post which insurance companies do and do not pay for these codes (and any others for that matter). I’ve heard that this might be called collusion and might cause anti-trust stirrings. I beg to differ….we need to have access to this information and so do our patients. We should figure out a way to do this in order to hold insurance companies accountable.

  55. Rob: This is a great post…you speak for probably the majority of practicing physicians, particularly in primary care! I have been aware of the CPT codes for e-mail and phone services and think that Doctors or one of our organizations should band together to post which insurance companies do and do not pay for these codes (and any others for that matter). I’ve heard that this might be called collusion and might cause anti-trust stirrings. I beg to differ….we need to have access to this information and so do our patients. We should figure out a way to do this in order to hold insurance companies accountable.

  56. Re Robin’s comment above:
    I suppose online communication could be viewed as relatively new. I guess email has been in general use since the mid-1990s, and the internet really got going around 10 years ago.

    Doctors have been communicating with patients via telephone since when? – the 1940’s . That isn’t even close to new.

    So I suggest that this demonstrates how absurd CMS’ approach (now driven by the RUC) to paying generalist physicians is. That it took, what? – 60+ years to even consider whether physicians’ time on the phone taking care of or in support of patients ought to be paid is just ridiculous.

  57. Re Robin’s comment above:
    I suppose online communication could be viewed as relatively new. I guess email has been in general use since the mid-1990s, and the internet really got going around 10 years ago.

    Doctors have been communicating with patients via telephone since when? – the 1940’s . That isn’t even close to new.

    So I suggest that this demonstrates how absurd CMS’ approach (now driven by the RUC) to paying generalist physicians is. That it took, what? – 60+ years to even consider whether physicians’ time on the phone taking care of or in support of patients ought to be paid is just ridiculous.

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