Going to a new place for convenience

My family likes to go to Primary Restaurant for great food. We know the food is high quality and the chef takes special care to make everything just right with healthy ingredients. The staff gives great service, always making sure we have what we need. Because there's always room for improvement, they encourage quality development and the restaurant staff works to make things right to the best of their ability if a problem is identified.

Image source: Wikipedia

But one night we decided to go to Convenience Cooks. We were hungry and Convenience Cooks was on the way home. Were we starving to death? No. We had food at home we could have eaten, but Convenience Cooks was, well... convenient. Their menu was limited compared to what we are used to, but we were able to order something that was decent. While we were waiting, I decided to call Primary Restaurant to see if it was a good choice or if we should leave and go to their restaurant. They said since I made the choice and was already waiting, I should just stay at Convenience Cooks. The food wasn't the quality we were used to, but we ate it. I had second thoughts at the end of the meal, so I called the Primary Restaurant to see what they thought. The staff who is usually so helpful wasn't of any use helping me decide if what we ate was good for us or not. Since none of us felt satisfied and left still hungry, I feel like Primary Restaurant should deliver food to our home, but they refused. They said we should go to Primary Restaurant to eat if we want their food. Why? I already paid Convenience Cooks and had most of a meal there. Weeks later I get a bill from Convenience Cooks and am surprised about the cost of convenience, so I call Primary Restaurant to see if it's usual for Convenience Cooks to bill added fees.

In another scenario, you really want a good BBQ. Primary Restaurant specializes in All-American food, but don't offer slow-cooked BBQ, so they refer customers to BBQ-R-Us. But BBQ-R-Us is busy and requires reservations. Since you are used to same day seating at Primary Restaurant, you ask if they can get you preferential seating at BBQ-R-Us. After several phone calls back and forth with staff at each location, you realize you can be put on a waiting list, but no one was able to change your initial reservation. When that time finally comes, you enjoy the ribs, but leave with questions. Instead of asking the BBQ specialists, you call Primary Restaurant to ask if you should have gotten the burnt ends or the ribs. Even later you call Primary Restaurant to complain about the bill you got from BBQ-R-Us. You were surprised that the creamy corn was extra and they charged a seating fee.

Most people can see just how crazy it is for a restaurant to "fix" the problems with quality, cost, or service at another restaurant, yet many (MANY) people want their primary care physician to do just that after trips to convenience urgent cares or after we refer to a specialist. The scenarios above are based on real phone calls about medical care.

Convenience Cooks = Urgent Cares

I'm sure I'm not alone when I get frustrated at the number of calls asking me to give an opinion of treatment received elsewhere, or to fix a problem that wasn't fixed at an urgent care. I am glad that patient families feel so comfortable with my office that you will call to ask for help, but if I am not a part of the evaluation, I can't help.

Many problems seen at urgent cares can wait. I know it's easier to get your child in tonight so they can maybe go to daycare/school tomorrow, but many of these things are viral and just take time. Even if it's strep throat and they start an antibiotic at 8pm, they can't go to school in the morning. If you would have called my office before going to the urgent care (or looked on our website for advice), chances are the issue could have waited until office hours by using some at home treatments to make it through the night. The cost savings of staying out of an emergency room or urgent care can be substantial with many insurance plans. And my office would be available to help answer any questions that arise from that visit. (Note: sometimes when the symptoms change we still need to see a child again, but we are more likely to be able to help over the phone if we were the ones who saw the child than if they were seen anywhere else.)

If your child was having an issue that did need to be seen ASAP after our office hours, we would have referred you to an urgent care that has quality pediatric providers we trust and sends us a written report of what happened. Even with that, sometimes we need to see a patient on follow up to ascertain if a treatment plan is working or if it needs to be changed.

If you call us because your child is having an allergic reaction to a medicine someone else prescribed, we will tell you to call the place that prescribed the medicine. We cannot manage what someone else prescribed. Often we hear that "they're not open yet" or "they don't do phone calls, they want us to come back." Sorry. We will want to see your child before we treat him for this issue.

BBQ-R-Us = Subspecialist Referrals

As for specialist referrals, I know it's hard for people to wait for appointments, but I really can't get people in any quicker than a schedule allows. If it is a real emergent or urgent need, I can talk to the doctor to see options, such as admitting to the hospital so they can be consulted, or having someone go to the ER, where they might stop by to see the patient. But usually it isn't really that urgent from a medical standpoint, and waiting for the appointment is just what happens in the specialist world. I'm not saying that's a good thing, it's simply reality. Please don't beg me to call them to get you in sooner. I cannot invent time and I can't alter their schedule. Despite what the scheduler tells you, if the primary care doctor calls the specialist, the specialist rarely can get the appointment changed. I've done this frustrating scenario many times-- often when I really want the child seen sooner than scheduled. Unfortunately, it usually doesn't significantly alter the appointment time.

After your appointment I cannot tell you if the treatment plan they propose is the best for your child. Once I refer, it is usually because it is out of my knowledge base and needs specialist care. I can learn along with patients, but I rely on the specialist to know the latest and greatest in their field and they can give better advice than I can. I also don't like to "step on toes" if I refer. If they are driving the bus, they need to drive. Back seat drivers can cause problems on the road.

Expect higher fees any time you use a hospital based facility, whether it's for an office visit, a lab, or a procedure. They not only have charges for the physician's time, but they have facility fees to cover the costs of running the hospital. Of course the primary care physician cannot affect the charges incurred at any other clinic or hospital. We recommend researching costs prior to care, but we know that this is very difficult unless you know exactly what will be done at every visit. We cannot tell you what another physician will do... I can't even predict what I will do at a visit if you call me ahead of time. If your child has a fever and cough, I might send you home with at home treatment instructions without any expensive tests if the exam supports that. I might order labs or a CXR, prescribe a medicine, or admit your child to the hospital for treatment if the findings support that. It is hard to anticipate costs, and that is a problem with our healthcare system. I know that, but it is not in my control to fix that. We try to help by keeping a list of all our most common charges in the parent book in each exam room, but that doesn't help plan before the visit. I understand how that's frustrating, but I can only help with what is in my control. I cannot control how our billing and insurance system works and another office's charges are in no way under my control.

Medical Billing and a Restaurant

Medical insurance and billing is a mess. That is one thing I think most people would agree upon. The difficult thing is to find a solution that most people agree upon.

photo source: Shutterstock

Since our office has started a new financial policy that includes sending credit card information for secure storage to be used for payment of money owed, we have been encouraged by many people. They realize that businesses must have a means to collect payments owed. Many businesses use a credit card storage system. For instance, when someone books a hotel room they must have a credit card on file with the hotel. That protects the hotel in case people never show up (so the hotel can collect per their cancellation policy), if they damage the room, or otherwise build charges for which the hotel needs to collect payment. Because the hotel industry has been doing this for so long, most people don't question the practice when booking a room. There have been a few (but vocal) people who are upset by our new financial policy. I am hopeful that they can begin to see from our perspective just why this is a much needed policy.

We see most collection issues with high deductible plans but can't pick and choose which patients need to give a credit card. It must be the same policy for everyone. If you never owe money, we will never charge your card. If you owe money, you owe money. Your insurance company lets you know how much after they make their adjustments on the Explanation of Benefits (EOB). That amount is not up to us. It is per your contract with your insurance company. We will save you time in processing the bill by submitting it to your credit card if it's under the amount stated in our policy. If it's a higher amount owed, out of courtesy we will contact you to alert you to the charge. If you need to work out a payment plan, we're happy to work with you. But you still owe the money for services already rendered. It's that simple.

Where else does someone make a purchase, but only find out how much it will cost them weeks later? That is exactly what happens when someone goes to the doctor or has a lab or procedure done. You don't know the cost to you (and neither does the office) because it depends on how your insurance adjusts the bill and what portion they pay versus what they state is expected from you. It is not my system nor my office's system. It is the insurance system.

Our office does have a "menu" of codes representing common procedures, vaccines, and more with the associated charges, but it doesn't really tell people how much they will owe. This menu is in every patient room and can be given to parents if requested. The charges listed are our charges, but the amount any family will owe depends on how their insurance company adjusts and pays for things. I think it would be ideal for people to have access to a standard set of codes on their insurance company website, with a clear depiction of how much their portion will be for each code. But this would be difficult since there are so many plans, people who owe a percentage that varies based on if their deductible is met or not, etc. It varies even to the point that your employer has a different contract with your insurance company than the next employer has with the same company.

When we get the adjustment report from the insurance company and there is a portion left to be paid by the patient, it is typically already weeks after the service was provided. We then are responsible for collecting that money from the family. Many practices (including my own) are starting to hold credit card information to help with collecting payments. We simply can't afford to track down the high volume of patients that owe money. It is often small amounts, sometimes so small that it would cost more to send the bill than the amount owed. But to simply not collect small amounts from hundreds of people adds up to a business in the red.

Think of it like this: "Pay Later Restaurant" doesn't have people pay immediately after dinner. They send the bill to one of the people who enjoyed the meal. About 2 - 4 weeks later, the restaurant receives a payment, but the customer first adjusted the bill down 80% because they have a contract that states they can. But even that payment of 80% of the bill doesn't all come. Since the payment will come from multiple people at the table, only a portion of that discounted price is paid. The remaining portion of the discounted price is owed by someone else at the table. That person wants to see the bill and have it explained to them. They still take a few weeks to pay because they didn't know they were going to pay for their portion of the bill. They thought it would be covered by their dining partner. During all these weeks of trying to decide if the diner really does owe the restaurant, the restaurant still has to pay their rent, pay salaries to their employees, buy new food to sell, and otherwise pay business expenses. How can they continue to stay in business if they don't collect? Businesses in the red close. This is exactly how medical offices must operate.

We want to keep seeing patients, so we need to collect money owed us to be able to pay our bills.

In my perfect world the insurance company would pay the office the full contracted amount owed, and if the patient had a responsibility for part of that fee, the insurance company would charge the family. This keeps it clear that the money is due per the insurance contract because the bill would be to the insurance company, not the doctor's office. This helps the doctor-patient relationship continue to be about medical care, not payments. The insurance company also would have the benefit of withholding coverage if patients don't pay their bills. That encourages people to stay current on payment of their fees. When patients owe the doctor, the doctor has little to do to collect payment other than send the patient to collections and discharge them from the practice - which is really hard for physicians who want to care for people, not worry about paying bills. But we need to think of the business bottom line. If we don't collect payments, we cannot pay our bills. Then we close (or sell to large hospital systems, as many offices have done) and we can't take care of patients the way we want.

My friend, Suzanne Berman, MD, FAAP, of Plateau Pediatrics in Crossville, Tennessee, has written this list of similarities between a restaurant and medical care. It might just help clear up some of the issues we have with competition of walk in clinics, office scheduling, billing, and collecting.

1)      A meal at Hardee’s is different than a meal at the Palm, in many ways (including costs).

2)      Sometimes it’s just cheaper to eat at home.

3)      Most restaurants are a la carte.   The more you order, even if you don’t eat it all, the more you pay. 

4)      Yes, some restaurants are all-you-can-eat for one price, but drinks are still extra.

5)      Just because you had to wait for a table doesn’t entitle you to a free meal.

6)      Some places bring you chips for free.  Other places charge for chips.

7)      Plate sharing and corkage fees have legitimate reasons behind them, even if you don’t like the idea of them.

8)      Just because there are no prices posted on the menu does not mean that the chateaubriand is free.

9)      Your total does not include tax.

10)   Your total does not include tip.

11)   Liquor is always a very expensive add-on relative to the wholesale price of spirits. 

12)   Even if you don’t like how the shrimp makes your pasta taste, you’re still obliged to pay.

13)   Do you treat your own house like you treat our establishment?

14)   If you want a soufflé, you need to declare that BEFORE you order your meal.  Adding on an “oh by the way” does not work with soufflés.

15)   We can help you split the bill and decide which party owes how much, but before you leave the restaurant, the bill must be paid in full by SOMEONE.

Challenges to remain a financially stable medical practice

I recently posted Top 10 challenges facing physicians in 2014 and was pleasantly surprised to see that it was one of the more clicked-on posts that day. Business Facebook pages allow administrators to see  total reach (yellow), post clicks (blue), likes/shares (pink). (The post with the overall largest was of course a cartoon of the hazards of shopping at Target... cartoons and memes are always popular.)

Why was I pleasantly surprised? Because I want people to know more about insurance issues and our office financial concerns. I don't know if people made it through the entire 10 concerns, so thought I'd summarize them.

Why do I want to spend time blogging about this?

I fear that people presume we will always be there for them, but historically bills often aren't paid by families for various reasons. In the past we at least collected from the insurance company and a smaller percentage was patient responsibility. With the higher number of high deductible plans this year, we are at serious risk of not collecting payments or having delayed collection of payments at a time that our practice is forced to spend significant money on government mandated things. We will be implementing new billing policies soon to help protect the financial stability of our office. I know we will hear complaints because no one wants to think about money when they are worried about the health of their child, but the reality is we need to implement these changes so that we can continue to be around to take care of your children. If I could have a wish granted, I would ask that all money is paid to insurance companies, from the policy charge for the insurance itself (like we pay now, often with the help of our employer) to the money owed to the physician or hospital for services rendered. This would allow doctors and other medical professionals to stay out of the money game. I hate having the money conversations when parents think they shouldn't have to pay something. We submit a bill for services rendered to the insurance company and the insurance company ultimately decides what the patient family owes, based on your contract with them. If we don't then bill you that amount, it is a contract violation on our part. If you don't pay that full amount (that may have already been discounted by your insurance company) you are violating your contract with them. The system is not good because we bill something that is due based on your contract with a third party. It would make sense if they had to collect all the money and they paid all the bills. That is my dream...

But I'm getting off track. I want to summarize the very long article referenced above and point out how it affects our office. You will find that many of their points interlink with each other, which seems redundant, but they are so intertwined, it is hard to separate them out.

1. Payment for medical services. Payment structures are moving more toward an outcome based system. If our patients get quality care and we can prove it with metrics, we will be payed at a higher scale. While in theory this is good, it is really hard for physicians to prove that they do good care. It takes staff time and money to run reports. And we have no ability to make patients follow recommended care. A popular metric to measure is asthma, since it is a common pediatric condition. I get insurance warnings routinely that a patient isn't filling preventative medications on schedule. Sometimes that is because they are using it as told because of overall good control and my desire to use as little medicine as needed for good control, but that is less than the twice/day general recommendation. Unfortunately, sometimes it is because the co pay for the medicine is too much and the family uses it less than needed because they can't afford it.  With new plans that have higher deductibles, I see that more often. I can direct patient families to programs that help with drug costs, but I can't buy their medicine for them. When they end up suffering with more asthma symptoms, they use ER and office visits for sick visits, and then I'm dinged by that same insurance company that set their rates too high for families to afford the best medicine.
2. Government mandates. This year the coding and billing system that has been around for years is completely changing. This means that the computer systems on our end need to be updated and the computer systems on the insurance company end need to be updated. We will be required to use the new system, ICD 10, starting October 1st, but surveys are showing that it is very likely that insurance companies won't be able to accept those codes yet. This will delay processing of all bills submitted. Various experts say that payments may be delayed 3-6 months. How can any business survive if they make no money for that time? Not to mention the conversion costs to our practice. Estimates range from $83,000 to $2.7 million. Our practice is mid-sized, so will probably be somewhere in the middle of that. Where will this money come from? We are fortunate that we started using electronic health records (EHR) many years ago. That was a huge financial cost at the time, but I am glad we don't have to have that added expense now. (I'm not sure if EHRs will directly be required, but they certainly make it easier to meet all the other requirements now mandated.)
3. Payer headaches, and the fine print. Physicians are being dropped from insurance panels at a time when there are more insured patients. This will make access even more difficult. Insurance companies are requiring more prior authorizations than ever for tests and treatments. This takes staff and physician time. That time is not reimbursed by the insurance company. 
4. Time. I love to spend time with my patients, but with all these numbers adding up, I might have to schedule more visits per hour so that I can pay our office bills at the end of the month. This means less time with each patient. I don't know how that can be done and still provide good care, so altering my schedule will be one of the last changes I want to implement. 
5. Technology costs. Many practices starting a new EHR will not be able to see the same patient volume due to the added time documenting in a new charting system. As I mentioned before, I am thankful that we took that plunge and ate those costs years ago. But we still have IT costs on a regular basis and are looking forward to more this year with all the changes, both described elsewhere here and things like Microsoft is no longer supporting the version of Office that we were on, so we have to upgrade. This upgrade is not as simple as it sounds because it alters the way our EHR interacts with it and some of our computers are older and must be replaced to support the new software.
6. Staffing and training. We have been moving up the ladder in Patient-Centered-Medical-Home certification. Several staff members have put in significant time over the last few years building and implementing new practice policies and generating and reviewing reports. Our EHR has not always been able to generate the needed reports, so we had to find a company that could use data from our EHR to build them. Several times that we almost meet a metric, they update the rules, meaning new reports need to be generated. It has been a frustrating process, to say the least. I find that most of the things they want us to prove we were doing already, it's just that proving those things can be difficult. We are fortunate that we have a very low staff turnover rate. I hope all of our employees know how much we appreciate them!!!
7. Putting control back in the hands of physicians. Physicians generally go into healthcare to help others, but with all the stresses described here, many are dissatisfied on the job. Some are leaving patient care and finding other employment. Some still practice, but their dissatisfaction probably impacts the care they give. Many are fearful of all these stressors and leave private practice to be an employed physician. I have friends who used to love their doctor, but now can't get the access they used to have because of the bureaucracy of the new office management. Our local children's hospital has wonderful physicians, but I hear complaints often about the problems with access and other business themes. If these same physicians were self employed, they would be able to control these problems more easily on a smaller scale. As more physicians become employed, I think these problems will magnify.
8. Changing patient populations. More patients are opting for high deductible plans, meaning payment must first come from patients. This means the regular income physicians get from insurance companies won't happen until patients meet their deductibles. Most patients hope to never reach their deductibles. Now we will be relying on patients to pay their bills in a timely fashion. I personally hate talking money with patients. I want to provide the care that is recommended. While I think that having patients invested in their healthcare can make them more informed consumers and has the potential to help them make better healthcare decisions, it can also be a roadblock to good care. There is also the problem that I can't easily tell a parent how much it will cost. We can tell them what we bill, but their insurance will probably discount it. It might be covered in full by the insurance company and not cost the patient a dime. I don't know the patient's insurance payment requirements, and finding out information from the insurance company is difficult. We can provide the code so the parent can call the insurance company and ask, but at the time of service there simply isn't time to spend on hold with the insurance company to find out before the visit is over. Some parents have smartly called us ahead of time to ask what will be billed, but our staff can't know exactly what the physician will order at any visit. They can make best guesses based on the type of visit, such as an 18 month old well visit will have standard physical, vaccines, and autism screening. But if the child is tugging at an ear and there is wax obstructing the ear drum, we will remove the wax and diagnose either ear pain or ear infection plus impacted ear wax. None of that could have been anticipated based on the well visit scheduled. (Adding separate visits to a well visit is another topic entirely, since the well visit is often covered entirely by insurance, but the ear issue would be separate and fall to patient responsibility.) Using asthma again as an example (but it also goes for autism screenings, cholesterol screenings and more): I don't want to skip the spirometry for my asthmatic patient because the parent doesn't want to pay for it. That means I won't meet the metrics for asthma care, which puts me at a lower pay scale because I'm not a "quality" doctor. And more importantly, I'm not doing what I know is best for the patient's asthma management. How can I ethically treat patients with the standard of care I believe in only if they can afford to pay it? Should I lower the standards if they want to cut corners? That is a slippery slope I don't want to travel!
9. Primary care's changing role. Primary care physicians are going to be more accountable for being the central member of the health care team. As part of the Patient Centered Medical Home, we will continue to offer full scale preventative healthcare as well as management of most illnesses. We are also required to follow up to be sure patients got into the specialist we referred them to, or that they did the labs as ordered. We must have easy access for same day visits and extended hours. We must show that we follow practice guidelines. Although my practice already does these things, we must prove that we do, which takes even more uncompensated staff time.
10. Work life balance. This has always been a tricky thing for physicians. We cannot expect to work a 40 hour work week unless we are employed and there are shifts without any call requirements and all charting, follow up phone calls, review of labs, etc can be done while on the clock. Those of us who also own a practice must do business things when we aren't seeing patients. Either we cut our productivity and do business during business hours, or we see patients during business hours and do other business things after hours. This cuts into our family time. But we must be able to pay the bills... This explains the high rate of physician dissatisfaction and burnout. Physicians have a higher suicide rate than the general population-- up to 4 times the general population for male physicians by some estimates. This rate cannot support a healthy healthcare system, and with all the added issues with the 2014 changes, more burnout or sell out is to be expected.

In summary, there are many things that worry me and other physicians about our current healthcare climate. I still love my job, at least the parts where I get to take care of patients to improve their health and well being. I just wish we didn't have to worry about how to keep our office financially viable. Any time money comes into the equation, it can impact healthcare. I hope that all these changes help people take charge of their own health in new ways and that they can find ways to pay for all their healthcare needs. I also hope that all the regulations really do improve healthcare outcomes and help physicians provide better care, not just more documentation of care.

P.S. I'd love to meet you on Twitter. Stop by and say "hi"!

P.P.S. If you've enjoyed this blog, go to the top of the page and enter your email address so you will get future posts direct to your In Box!