Talk About Bullying With Your Kids

Bullying. Fist fights. Cyberbullying. Mean girls. Playground scuffles.

There are many labels and many variations on the same theme. Kids aren't always nice. Even nice kids get caught up in mean behaviors. We all remember being young and getting picked on. Or maybe we were the instigator of trouble. Chances are we've been on both sides of the line. Whatever roll we had, we know that this is not new behavior. But that doesn't make it any easier for parents to watch their kids suffer at the words and actions of other kids.

photo source: Shutterstock

We all need to talk with our kids often about their lives: what they are doing, how they feel about things, what they are looking forward to, dislikes, and more. Many kids clam up when it's time to open up, and sometimes the best thing for a parent to say is simply, "I'm here if you want to talk later."

Sometimes a general talk about bullying behaviors is a good idea, whether you suspect some bullying is going on or not. As with most things, a little prevention is worth a pound of cure.

If you see your own child saying or doing something that could be interpreted as mean, pull them aside and point it out as soon as possible so the memory is fresh in their mind. Children and young teens often don't even realize what they've said or done can be taken in a negative way. Don't punish or yell at them for the words. Don't belittle them. Making them angry will only block their mind to seeing another point of view. Use this time as a teaching moment to point out what was said. They might not get it right away, but later you can role play and see if they can understand better in a different situation.

I've put together things to use as talking points. Don't try to tackle this all in one sitting. Talk about one subtopic at a time, but talk often.

What else would you add?

• A small comment that seems to not be so bad to you can make someone else feel awful, even if you didn't intend for it to be. Those comments often come out of the blue and you don't give it a second thought, but the other person can dwell on its negativity for a long time. Even worse are the comments that are repeated over time. 
• You cannot change what others do or say, but you can change how you respond to what they do and say. 
• If you did or said something hurtful, it can't be taken back, but you can ask for forgiveness.

• If you know you're tired or in a bad mood, try to be extra careful before you say anything. 
• Don't send texts when you're angry, sad, or tired. 
• Don't reply to a text that makes you angry, scared, or sad. Show an adult if it is a threatening text or if it really upsets you.
• If you have negative thoughts, keep them to yourself. This might mean that you think someone got something they didn't deserve, someone's a teacher's pet, or their hair is awful. Whatever. Nothing good comes from sharing a negative opinion. In the end, people will see that you are negative and won't want to be around you as much if you share those thoughts. 
• If in doubt about saying or sending something, save the thought overnight and see if you still think it needs to be said. Think about the wording to make it constructive and not destructive if it does need to be said. Talk to an adult if you're not sure.
• If you wouldn't say something to someone's face, don't say it at all.
• If you hear someone saying something negative, tell them to stop. Let them know you don't like hearing negative comments. This might teach them what they are saying is hurtful, because sometimes people don't realize what they are saying. They can learn to be a nicer person- what a great friend you can be to help them in this way! If they don't change their behaviors over a few days or weeks after being told what they are doing (depending on how severely or intentionally they are being hurtful) then you need to tell an adult. Doing nothing or agreeing with them puts you down to the level of being a bully, even if you didn't start it. If you don't feel comfortable telling them to stop, leave. If you stay, you’re part of the cruelty. Leaving means you refuse to be part. If they don't have an audience they won't continue.
• If you realize that something you said was hurtful to someone, talk to them about it. If you have a hard time talking face to face, a nice note can work. Have a trusted adult help you wordsmith what you will say so the words don't get twisted. You must be careful to not put blame back on the person or put them down again when you apologize. It can be tricky to find the right words, but it is possible. 
• Texting is a dangerous way to communicate emotional or sensitive issues. It is great for simple questions and answers, but short phrases in texts can easily be misunderstood or incomplete. If you are disagreeing with someone, do not use texts to talk it out. Remember that anything shared electronically is public and permanent. Even if you think you are sending it to just one person, there are many ways for it to be seen by others. These words and pictures can be very hurtful. Never send anything you wouldn't want to put on a sign on your front door for all to see.
• Kids are often afraid to tell adults things for many reasons. It is okay to tell an adult if you are trying to help someone or yourself, but not if you are trying to get someone in trouble. Think about it. There's a difference. 

Positives drown out the negatives...

• Every day write down (or discuss as a family) one thing that you really appreciate or are grateful for. It can be anything, but think of things that really mean something to you. It can be as simple as a person said something really nice when you were feeling down, or you did well on a test you studied hard for. It doesn't have to be a huge thing like winning the lottery, but it should be something that you really feel thankful or happy about. Focusing on the good things really helps keep life in a healthy perspective. It can help protect you from the negative effects of other people's behavior.
• Smiling really can make you feel better, so try it.  
• If you see a friend struggling because negative things have been said, say kind words to him or her. Be extra nice to him or her so they know they aren't alone.
• Praise people when they say nice things. Recognize the kindness. Make it contagious!
• Try to do something nice or say something nice to at least one person each day. Notice the response over time in yourself as well as others.

Everyone needs a circle of respect. You don't have to like everyone, but you need to treat everyone with respect.

• Respect yourself enough to do what is right. Eat right. Exercise. Get 9-10 hours of sleep each night. Don't take unnecessary risks, such as smoking or drinking alcohol. 
• Respect others. Say kind words and keep negative thoughts to yourself. Don't make anyone else do something they aren't comfortable doing. Don't make fun of people. 
• Be sure people respect you. If someone says or does something that you feel is disrespectful, let them know. If they don't change their behaviors, avoid them and find other people to have fun with. Get away from people who make you uncomfortable or scared immediately. Find new friends if your friends repeatedly disrespect you. Get help from an adult when needed.

Teal Pumpkins for Non-Food Items at Halloween

Teal pumpkins have a new meaning this Halloween. Displaying one means that your home has non-food items available for the little goblins and superheroes as they come looking for treats.

Some might wonder why this is important.

Because what child likes to be left out of the fun of Trick or Treating?

And what happens if that child has severe food allergies, diabetes, or another condition that limits the types of foods the child can eat? Or what about all the parents who worry about the excessive intake of sugar this time of year?

Show parents that you are giving kids the option of a safe treat by displaying a teal pumpkin. There are many non-food treats that kids would love ~ stickers, pencils, glow sticks, bubbles, plastic jewelry, vampire teeth, pencil toppers, hair pieces, magic trick cards, and many more. Be sure you have some that are safe for toddlers.

Non-food items are better than nut-free, because kids have allergies to all kinds of things, and it is impossible to know in advance what all those allergies are. And for kids who must limit their overall sugar intake, non-food treats rule.

We put together some reusable teal pumpkins at the office. My initial plan was to spray paint some plastic pumpkins, but decided to use Duct tape to cover plastic pumpkins instead. Less smell, no time waiting for them to dry, and if we ever want to use them outside, they will be fairly weather-proof.

Pretty cute, huh?

And yes, plenty of people have asked if they are to celebrate our KC Royals. Not exactly. But hey, we can double their duty during Blue October!

Share this idea with your neighbors and friends. Use social media. Put a note in your neighborhood bulletin. Share with your school nurse. Ask stores to display a flyer.

Get the word out!

For more information and a free printable flyer (like the one pictured in our office above), see the original post where I learned about this great idea: The Teal Pumpkin Project

Why We Should Cherish the Gift of ADHD

Ok, so I know most parents of children with ADHD will read this title and think I'm crazy. Kids with ADHD wreck havoc on family life. Spouses with ADHD can do the same. How in the world can we cherish ADHD? It involves impairments in executive functioning... how can anything causing a broken executive functioning system be cherished?

photo source: Shutterstock

First, we must realize that everyone has gifts. ADHD has many variables in the way it shows up, so people with it also have many variations in gifts. But they do have gifts. I want parents, spouses, siblings, grandparents, aunts, uncle, neighbors, teachers, and more to understand the value of these gifts and help children (and adults) recognize the benefits that people with ADHD can have. I'm not saying life for them is easy. It's not. They struggle with many things other people can easily manage. But they still have gifts. I want kids to grow up building their confidence by using their gifts, not by measuring their failures when they don't conform to norms.

People with ADHD tend to think outside the box. They have lots of energy. They are often very creative. We all think of their inattention and poor focus, but they also hyper focus on things they love. If they become passionate about something, they can sustain attention and work on it for long periods of time. If they use this hyper focus wisely (with setting time limits so they can do other daily activities) they can become an expert in that area. For young children the hyper focus tends to be on "kid" things, like trains or video games, but as they get older, allowing kids to experience activities that interest them will give the opportunity to find a life passion that could turn into a fantastic career.

"ADD people are high-energy and incredibly good brainstormers. They will often happily work 12 to 15 hours by choice. The business community should not fear ADD. Instead, they should see that they have a potential gold mine here.” - Dr. Kathleen Nadeau, psychologist

With all that good, we are more quick to see the negatives. Kids can lose their drive and ambition if they are not supported along the way. School is not favorable to kids with ADHD. Kids must follow rules. They need to color in the lines. They need to do all the steps in the order the teacher wants. Doing things someone else's way is not easy for kids with ADHD.

For example, kids need to learn the steps to solve a mathematical problem. They need to solve the math problem the way the teacher did it and show their work. They lose points if they get to the right answer but didn't show their work or if they get there a different way. The teacher might assume they cheated to get the answer, but some kids just skip steps. To me that might just show brilliance. They can skip steps. Their brain just "gets" to the right answer. I never could figure math out without being told how to do it, but there are kids out there who can. What a gift! Unfortunately they feel dumb if they can't show the steps just like the teacher taught. And it would be quite typical for a child with ADHD to have a brain that thinks this way if math is that child's gift. What a shame that our schools tend to make these kids feel inferior because in the end they might resist working on math and will never reach their potential.

For a fun look at ADHD that will continue to show you the better side of the diagnosis, check out this short documentary, A.D.D & Loving It. I promise it will have you laughing, but you will get a lot of great information from respected ADHD experts.

If your child struggles with the diagnosis, consider reading about real people who have done well despite (or due to) ADHD (link with many articles about successful people with ADHD and other learning disorders). Have them read Percy Jackson (link to a book review). He's a fictional character with ADHD and dyslexia that kids can look up to.

Throughout history many successful people have had ADHD. Your child with ADHD can also become a leader, an inventor, an artist, or an otherwise excellent contributor to society. We just need to help them find their gifts and work on their challenges so that they can flourish. Support them so they do not lose self confidence. Celebrate what they do right more than harping on what they do wrong. Encourage them to develop their talents. Help them find ways to accommodate for their struggles and to learn tools to help with some of the executive functioning problems they have. Cherish them!

Heart Screenings for Athletes - Are they worth it?

In recent years I've been getting more and more reports of athletic heart screenings. The schools and sports clubs locally are offering for athletes to get a heart work up for a relatively small fee.

Why are they offering this? Because sudden cardiac death in athletes has been in the news a lot over the years, and we all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk. Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator. (Side note: if you've not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow "A B C" so it is very different. CPR is recommended for all teens and adults.)

Is the cost of a heart screen worth it?

A new report, Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology, is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation and is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD). Complex issues from the Statement linked above:

1. the low prevalence of cardiovascular diseases responsible for SD in the young population
2. the low risk of SD among those with these diseases
3. the large sizes of the populations proposed for screening
4. the imperfection of the 12-lead ECG as a diagnostic test in this venue 

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: To do an ECG screening on all athletes is not inheritantly unwarranted nor discouraged, but it isn't recommended either.

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is available below.

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time, so one normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so. The evidence does not support mass required screenings.

If however, your child has identified risks based on the questionnaire, a more thorough testing should be done.

These 14 points are listed in Table 1 of the above linked statement:

The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history* 
  Personal history
    1. Chest pain/discomfort/tightness/pressure related to exertion
    2. Unexplained syncope/near-syncope†
    3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
    4. Prior recognition of a heart murmur
    5. Elevated systemic blood pressure
    6. Prior restriction from participation in sports
    7. Prior testing for the heart, ordered by a physician
 Family history
    8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
    9. Disability from heart disease in close relative <50 y of age
    10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination
    11. Heart murmur‡
    12. Femoral pulses to exclude aortic coarctation 
    13. Physical stigmata of Marfan syndrome
    14. Brachial artery blood pressure (sitting position)§

AHA indicates American Heart Association.
*Parental verification is recommended for high school and middle school athletes.
†Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
§Preferably taken in both arms.
Modified with permission from Maron et al.3 Copyright © 2007, American Heart Association, Inc. 

How long will a cough or cold last?

How long will a cough or cold last?

I get this question all the time. Most people want it gone now. Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.

Unfortunately our area has been hit with Enterovirus D68, which seems to cause prolonged symptoms compared to many respiratory viruses.

I don't hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I've been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can't make them better faster.

We have our standard instructions:

• Fluids (water)
• Rest
• Saline washes to the nose
• Blow the mucus out. If a child's too young to blow his nose well, parents can suck the snot right out.
• Honey for children over 12 months of age
• Prop the head up during sleep
• Prevent spread

But then we still have the original question: How long will a cough or cold last?

One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960's, but since we don't have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.

Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren't going down fast at that point, they both seem to linger. 

A more recent review of medical studies showed that the many symptoms of illness linger for much longer than parents want to accept. From this study:

* Earache range 7-8 days, Sore throat 2-7 days

Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away. That is an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis. It isn't the color of the mucus (really!) We don't want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.

So if you're struggling with cough and cold symptoms in your house, follow these instructions. To help determine when your child needs to be seen:

Urgently or emergently: If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children. 

Routine office visits: If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.

More reading:

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature

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Swollen Eyelids: Causes, Treatments, and When to Worry

There are many causes of swollen eyelids in kids (and adults). The good news is that the most common ones are usually not serious. Some swellings herald warning though and should be properly evaluated and treated by a doctor. Warning signs include vision changes, pain, protrusion of the eye, fever, difficulty breathing, abnormal eye movements (or loss of movement), foreign body that cannot be removed, or signs of anaphylaxis (swollen tongue or throat, difficulty breathing, hives). Any warning signs deserve prompt medical attention.

Allergies can make the eyelids puffy due to the histamine reaction. This is usually accompanied by itching, red eyes that are watery. Treatment involves either oral allergy medicines, topical allergy medicine (eye drops) or a combination of both. Washing the face, hair, and eyes after exposure to allergen can also be an important part of treatment.

Anaphylaxis is a more serious allergic reaction. It involves swelling of the eyelids, throat, and airways. This is a medical emergency. If epinephrine is available, use it. Call 911.

Blepharitis is an inflammation of the eyelids that can cause swollen lids, often with flaky eyelid skin and loss of the lashes. This chronic condition should be managed by an eye care specialist.

Bug bites are the most common cause of swollen eyelids we see in our office. Usually there is a known exposure to insects and there may be other bug bites on the body. Bug bites on the eyelid tend to itch rather than hurt despite the significant swelling they produce. There should be no fever or other signs of illness. The eyeball should move freely in the socket. (See "orbital cellulitis" below.) Treatment of bug bites involves cool compresses and oral antihistamines. Occasionally oral steroids are required for significant swelling, but they require a prescription. If the swelling is concerning to you or your child, bring him in to be seen.

Conjunctivitis, also known as pink eye, causes inflammation of the surface of the eye ball and sometimes a puffy appearance to the eye lids. It can be from bacteria, virus, or allergies. Bacterial conjunctivitis causes the whites of the eyes to look red and includes a yellow discharge from the eye. Viral conjunctivitis causes the white of the eye to look red, but there is no yellow discharge. Allergic conjunctivitis is described above under "allergies." If unsure which type your child has, or if it is probably bacterial, see your doctor.

Contact lenses can contribute to swollen eyes if they are dirty or damaged. See your eye doctor in this case.

Crying can cause the eye lids to become puffy. The lacrimal glands produce an overflow of tears, so the fine tissues around the eyes absorb the fluid, causing them to appear swollen. This is compounded by the autonomic nervous system increasing blood flow to the face during times of strong emotion and rubbing the eyes to wipe away the tears. This cause of swelling is short lived. Cool compresses and avoidance of rubbing can help decrease the swelling.

Graves' disease can cause swelling of the eyelids and protruding eyes. Sometimes a drooping eyelid or double vision occurs. It is caused by thyroid problems, which also can cause problems with appetite, fatigue, heat intolerance, and more. These symptoms should be evaluated by a doctor.

Kidney problems can lead to fluid retention. If the eyes are puffy along with puffiness of the ankles or swelling of the abdomen, kidney problems should be considered. Children can develop this suddenly from infections, like certain diarrheal illnesses or Strep throat. The urine may look tea colored or like it has blood in it. This is a medical emergency and you should seek care immediately.

Sinus infections can cause puffy eyelids. Congestion, runny nose, headache, postnasal drip, and cough are typical symptoms. See your doctor if you suspect sinusitis.

Styes look like a swelling at the edge of the eyelid, often red or pink with a small white central area. It is caused by a blockage in one of the small glands in the eyelid. Another swelling from blockage of oil glands of the eyelid is a chalazion. Both a stye and a chalazion can start as painful bumps, but after a few days they no longer hurt. They can cause the whole eyelid to swell. Applying warm packs to the area several times per day often helps treat styes. Chalazions more often need to see an ophthalmologist for treatment. If a stye persists beyond a few months or the lid swells to cover the pupil, see your doctor.

Trauma of the eye or nose, like any trauma, can cause swelling. A broken nose can cause swelling and bruising to the eyelids. Any significant trauma to the eye or nose should be seen by a doctor. Symptoms may include vision changes, chemical exposure, foreign body in the eye, blood in the eye, severe pain, or nausea or vomiting after injury.

Ocular herpes is an infection of the eye by the herpes virus. (Not all herpes infections are sexually transmitted!) It can appear initially like a blister or cluster of blisters near the eye. It can lead to permanent damage to the eye, so prompt care by an ophthalmologist is important.

Orbital cellulitis is a potentially serious infection of the eyelids. The infection can extend behind the eyes, causing meningitis. It is suspected when there is painful swelling of the upper and lower eyelids, fever, bulging eyes, vision problems, and pain with eye movement (or inability to move the eyes). This is a medical emergency and if suspected, prompt medical attention is warranted. Treatment involves iv antibiotics. To assess the extent of swelling or to differentiate between pre-septal cellulitis (which is not into the deep tissues) and orbital cellulitis, imaging is often done.

Ptosis, or drooping of the eyelid, can look like a swollen lid. There are many causes and this should be evaluated by a doctor.

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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.