Your 10 minute office visit needs 8 people and 45 minutes of work
I sat at the checkout desk in my practice last week for the first time and as always, it was a revelation. If you haven’t worked your check-in and check-out desks recently, I highly recommend it.
An insured patient that I checked out was shocked when I said the charge for her visit was $100. She said, “But he was only in the room for ten minutes!” I was briefly at a loss for words. I recovered, we agreed on a payment plan, I made a note on her encounter form for the billing office and she left.
I’ve been thinking about our conversation, and thinking about what that $100 is supposed to cover…
- First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.
- When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID for red flags. An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.
- The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief chief complaint, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.
- The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
- He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.
- He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.
- He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled. The chart was filed, and the encounter form was sent to the billing office.
- At the billing office the charges and any payment was posted and the claim was filed. If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.
- If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.
- Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient. If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment. Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.
I know that patients often say “But he only spent 10 minutes with me.” Checking back with the provider, I find it was typically longer. Patients tend to underestimate the time as it goes very fast.
The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller. It took 8 people, and at least 45 minutes of work to make that appointment happen. Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services.
The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable. It’s what we all want. And it ain’t cheap.
Mary Pat Whaley is board certified in healthcare management and a fellow in the American College of Medical Practice Executives. She blogs at Manage My Practice.
COMMENTS
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That is the problem with medicine today is the concern that patients misperception about their doctor's livelihood actually affects the quality and the concern by the doctor. Having a practice with over 25,000 patients over the last 17 years, I can tell you that sick people as group (albeit there are always exceptions) do not concern themselves with ideas that their illness "feeds the beast". If they like thier doctor, they trust their doctor and they are happy with treatment outcomes they do not concern themselves with concepts such as "keep the meat moving". Doctors , as a part of their understanding how to run a business, must also treat their patients as customers and provide excellent "customer" service- which equates to excellent patient care. Patients demand that. Regardless, as I discuss in the book, The Medical Entrepreneur, doctors own well being is often tied to their livelihood which in turn is definitely linked to their ability to be compensated for their time, training, and experience. However, compensation without understanding true costs and approaching the medical practice as a business, is a prescription for difficulties for the doctor. Obviously, I am biased somewhat, but I do agree with you that business of medicine is not quite as important as the practice of medicine but the importance only weighs in favor of the latter slightly. I dont know any practicing physicians today that are not concerned with how to run their business and monetize their efforts and yet at the same time strive to provide excellent care. These efforts are tied hand in hand. The problem is that there was never a book such as The Medical Entrepreneur that really addressed the physician practice as a business and prepared the doctor for the current challengs of running a business. If doctors read this book before finishing residency and before signing any contracts, they will save themselves potential business headaches that commonly afflict physicians.
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Alice Robertson, Homeschooling mom of six....um....:)I think your point about finances is a good one, but disagree that it is equal in importance. It just makes patients think the, "Keep the meat moving" is a truism, and sick people do not like to think their illness feeds the beast.
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Cathy CassettaUnfortunately, the reality is that, without the income there isn't an office to go to...finances are critical to maintain the office.
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As a practicing physician and the author of the business book for doctors, The Medical Entrepreneur Pearls, Pitfalls and Practical Business Advice for Doctors, I can attest to the importance of a physician really understanding what his true bottom line is. Most doctors dont think in these terms whereas all successful businesses do. The "overhead", gross vs. net revenue, and the actual amount the doctor sees from one patient encounter should be understood. My guess is most doctors dont take the time to really drill down on that data. The simplest calculation would be to take the monthly expenses divide it by the number of patient visits per month and then in its crudest form , a doctor would understand how much each patient visit on average costs him or her. The problem really starts from medical school and beyond into residency. There is not enough time to teach doctors the business of medicine as there is barely enough time to prepare them for the practice of medicine. The reality is that the business of medicine is just as important to a doctor's livelihood as is the practice of medicine.
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PhD
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This sounds like this practice likes to relieve the unemployment in the city! I do not really understand why this doc needs an army of assisstants! This is his problem and patients should not be charged for his ideas of grandeur.....a secretary or nurse can easily handle patient visits as is done all over the world...
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L Faith Birminghamepatientgr:
Your response indicates a substantial lack of familiarity with the multiple regulations required of a medical practice, the workload imposed by insurance companies in order to file a claim on behalf of the patient and to handle every increasing prior authorizations (for medications, a number of diagnostic studies and/or referral to a specialist when needed). It is hardly for "ideas of grandeur" (what a hostile, prejudicial comment to make!) but to meet the substantial requirements imposed in order to practice medicine in the US.
A recent study in the journal Health Affairs: http://content.healthaffairs.o...
identifies the substantial differences between US and Canadian medical practices. "US nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans—nearly ten times that of their Ontario counterparts."
Perhaps you would like to reconsider your remark? -
DWow...I don't know where to begin...
Thank you Mary for attempting to explain why things work the way they do in a doctor's office. I would like to give my insight on this blog since I know how things work on our end as a solo surgery practice, as a patient as well since I work directly with patients all day every day in the office, and as a medical family since it is my husband's practice. As shown in many of these posts, unless someone is in the medical field, there really is no clue how our system works.
As a medical practice, I can assure all of you that if we could eliminate any of the steps we take, we would. We are working with computers, and as one person commented, the computer does a lot of work. I would like to point out however, computers can only process what information it is given. Think about the information you are asked as a patient to fill out. In many offices, this needs to be entered into a system. Those demographics, symptoms, medications, past history, etc. all need to be entered. In addition, many patients do not answer fully, so additional time needs to be taken to interview the patient and confirm. In our instance, not only does the doctor need to review this information, but he needs to review the information and testing that has brought the patient to our office. Only then does he meet with the patient. After answering all their questions and fully explaining options, there could be as much as an additional 30 minutes spent with ordering additional testing or setting up surgery. Once these items are scheduled, it could take as little as 10 minutes or as long as a hour checking approval policies for the patients insurance plan, and getting the approval if needed. In the meantime, the doctor does not finish with the visit when he walks out the door. He writes his note, fills out orders if necessary and walks the patient to the check out desk. We then have the follow up of testing and getting the patient the results, making sure all the necessary physicians get the notes, etc. This doesn't even include the billing which is made more difficult by the insurance companies. Btw, specialists get paid the same fees per office code that a primary care doctor gets paid.
I do understand the frustration of patients sitting in the room for long periods of time. We do try and wait until we think the doctor will be out of the other room, however there are times where we need to go in and apologize because he has been held up with another patient. It is important for patients to remember that most physicians are not on a coffee break while you are waiting. Especially in our office, another patient may be getting a cancer diagnosis or are being put at ease with answers to questions about their surgery that is needed. Be sure that you will also get that extra time when needed, even when there are patients waiting behind you.
Lastly, I can assure you Alice that we live in a neighborhood with plumbers, police officers, teachers, etc. While we are able to afford to go out to dinner, or a movie, the days of getting paid an enormous amount of money as a physician are long gone. This is partly due to patients who no longer feel it necessary to pay their portion of the bill, and partly due to the minimal amount insurance pays as compared to overhead costs. For example, we can get paid $427 for hernia surgery, which means someone is actually cutting you, fixing you, putting you back together, and seeing you after the surgery for 90 days for free. If the insurance pays 80% or about $340 and the patient doesn't pay their portion, you've just made very little for a skill that not many people have. And honestly, I've paid $75 for my plumber to unclog my shower. Payment was due on the spot and there wasn't a guarantee that he would come back free of charge for three months if it clogged again.
As a side note, we have many patients who come to us from Canada and Europe. They are willing to pay out of pocket to get care. Telling of what they think their options are at home. -
gzuckierI was so impressed by my deep thoughts that I forgot my original point, which was that the ten minute office visit is some sort of convenient fiction (convenient for whom, is another matter). A serious medical professional can't do anything in a ten minute visit that is really worthy of their time, along with the additional fixed time and effort attached to a visit of any size, as pointed out in the article. Just because the procedure code and the reimbursement pretends that 10 minute visits are a thrifty and effective way of dispensing health doesn't mean anybody else has to. Either you do nothing and get reimbursed or you do something and get underpaid for the time you do put in. Reminds me of the good old capitation days, where you never saw a big chunk of your patients and got reimbursed as though you saw them for an hour a year, and you spent hours and hours with another chunk of your patients and got reimbursed as though you saw them for an hour a year.
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Alice Robertson, Homeschooling mom of six....um....:)How exactly does my paying ten times as much as a Japanese citizen for an identical MRI from the identical machine contribute to research? Is the extra 90% I pay going for research? That's not only generous, but how humble of the folks involved to do it anonymously. [end quote]
Are you Canadian? They are highly defensive like the Brits, but there was an honest Canadian on another board.
When you save tons of money from research it is just as I said. We run the test kitchen they get the recipe for free. Would you like to invest tons of time and money to develop...oh let's....a secret recipe and advertise it etc. then have someone duplicate without the work and expense and profit without sweat equity? That's why generic medicines are not available for years. It gives time to recoup the expenses. But the Canadians run a generic type of system that is effective at times, cost saving always (which is troublesome), and a leech at our expense. But that's alright......if it's helpful....but at least admit they are the beneficiary of a rich inheritance they didn't sacrifice for. -
gzuckierAgain, how does the money I'm paying the providers get to support research? Is my cardiiologist doing experiments in his basement without any research funding? Are those doors in the clinic that I don't get to go through leading to fully equipped labs run at the clinic's expense? Or does the NIH funding come not from general taxes, but from taxes on doctors and hospitals? That's certainly not fair. Or maybe it is.
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AliceIf I was not on a cellphone I would show you what yiou failed to study. Just because you disagree with her, does not mean she is wrong. For those interested in the truth her research is fascinating. The stats are not on a level playing field. The comparisons are incorrect. If you just want to complain about America and not truly study that is fine to on an emotional level.
So. G what country do you want to duplicate? You mentioned countries that are taxpayer funded, government run with waiting lists, no research so again you wait. If you had a bad diagnosis you would really want treated in Japan? They think Americans and our diets and lifestyle produces a land of butterballs. They have government mandated waist measurements. You like mandates...little choice...believing doctored stats? Some people like living in denial....they thrive on romantic notions and kick the American system. There is room for improvement but in my heart I do not know one person who would opt for care in Canada far less Japan. -
gzuckierIn all honesty, the actual work done at this visit
"The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her."
could be as easily done by the case management nurse and/or software that will undoubtedly go over the treatment plan and confirm it at the insurance plan. In which case the question arises, why can't it be done by a nurse and/or software in the first place? (Except for the exam, which couldn't have been a real workup given the total ten minute visit) The rest of the effort listed is merely to avoid screwing up this redundant visit.
I'm quite sympathetic to the argument that "turning the valve cost $5, knowing which valve to turn cost $500" as the joke goes, but that by definition doesn't apply in the quasi-routine stuff that makes up the majority of the work; Pareto principle and all that. If medical practitioners are to justify their charges on the basis of the specialized knowledge and skill they possess and the effort and cost it took to get that knowledge and skill, they have to be applied to cases which actually utilize them.
On the other hand, I'm well aware that undoubtedly the majority of the population are incapable of coping without the authoritative presence telling them what to do (an maybe not even then). But me? I've just had minor surgery. Went very well. I could easily remove the stitches myself and it was obvious there weren't any complications, but OK, let's stipulate a followup anyway. But now, another followup in the pipe to make sure it continues to do well. Believe me, I will definitely make a visit if it fails to continue to do well; on the other hand I don't need the doctor to tell me it's doing well (this doesn't involve any fancy tests or diagnostics, mostly just the doctor looking at it and asking me how it feels). For some folks, this may be of value, but personally, I don't see it as super productive. However, since all it costs me personally is the copay, I'll go along with the game.
Finally (as many readers realize), note how much of that list of activities would be deleted under a system like the Canadian one; where you just fill out one simple identical form for each encounter and at the end of the month you just stuff them into an envelope and a check arrives. No need to check whether the patient is covered or not covered or whether coverage lapsed or whether the copay was paid in advance or whether the patient will need to pay the entire fee as part of the deductible or whether you will end up having to put a lien on the patient's house to get your $100. -
Ronnie,
I am curious how you would "compare" your typical "10 minute" experience with the experience described by the diabetic patient in the video found at this web address below. I am curious how authentic the woman in the video sounds... Is her experience typical of other diabetic patients?
www.healthecommunications.word...
Thanks,
Steve Wilkins -
xyzAll the people will one day get sick some will end up being critically ill with major organ failures: a reality of life. At that time you want a well trained, unhurried, well paid, dedicated and compassionate and intelligent MD. That does not come cheap. I hope the people realize that. I work in an ICU and see it everyday.................
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Alice Robertson, Homeschooling mom of six....um....:)That's a good argument against socialized medicine. Good medicine...really good medicine is expensive. Quite frankly...even with all it's flaws I hope I never get sick abroad...I want treated right here in the USA.
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WThe part of this I question is "NEEDS" 8 people, 45 min.
I'll pay high prices for health care without complaint as long as I'm not paying them primarily to support inefficient, overly bureaucratic systems that no one questions or strives to improve.
Last October I had a routine colonoscopy. No polyps, no biopsies. Provider was in-network, and both the physician group and insurance company are owned by the hospital where the procedure was performed. What could be easier, right?
About 6 weeks later I received a statement from the insurance company, summarizing the anticipated cost (no itemization) and what they would cover of that estimate (100%). A week or so after that I received a statement from the hospital, summarizing its anticipated charges (no itemization) and what they expected the insurance to cover (100%). The hospital's sum, not surprisingly, exceeded that which the insurance statement estimated.
A week or two later I received a $14 check from the physician group, with no explanation other than that the insurance company had negotiated a lower co-pay (at this point I'd still received no bill for the colonscopy and had actually paid nothing).
Shortly after that, I received an actual bill from the hospital for approx. $300 that was not being covered by the insurance. No itemization. FIne with me...check went out the same day. Less than I had initially expected.
Last week I received a statement from the insurance company that, finally, itemized charges and how much they covered for each.
This seems like an awful lot of paperwork to me for a routine procedure with no additional tests or complications. Should I assume there's a "need" for this bureaucracy and be happy to pay for it? Or should I expect the providers (insurance companies and health care centers both) to work together toward a better system? -
Alice Robertson, Homeschooling mom of six....um....:)The paperwork is partly the problem of the doctor's predecessors and colleagues who bilked insurance companies and the government. Their behavior has constrained the practice of true medicine, but the days of easy money may be over....but there is still money to be made despite all the burdens. Their past behavior problems have hurt the image of doctors. There is a website titled, "Doctors Behaving Badly" and they try to expose these issues.
The Internet opened up patient advocacy...doctors are so much more accountable, and I know they feel like we do...that they are swimming through sewage...but I tend to think the real vision of the patient is improving....yet, it can be a painful process on both sides of the fence. -
imdocNEMO is right. One needs to factor in opportunity cost. It is too easy just to look at income alone. Anyone who has run a small business knows this. I know docs who are diversifying into restaurants and other small ventures because it is a better business model.
Also, let's not forget there are very capable business people who have created great service delivery in other fields. Why does medical care service continue to be an open sore? Hmmm. Despite many MBA's being involved I don't see a clear standout in any healthcare system.
Doctors are not business experts. Apparently the business experts even in large systems can't solve it either. Kinda' makes me think something else is going on that the service levels don't reach expectations.
Alice:
"I think $50 is fair, and so is the $100 for ER visits." Please go set up an ER and charge these levels. Everyone (except the investors and the bank) will love it. Good luck -
AnnRWe own a building that is outfitted for a resturant. It is a LOT of work and they fail with alarming frequency. A doctor would be a fool to get involved with one.
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Alice Robertson, Homeschooling mom of six....um....:)Alice:
“I think $50 is fair, and so is the $100 for ER visits.” Please go set up an ER and charge these levels. Everyone (except the investors and the bank) will love it. Good luck [end quote]
But, again, the comparison is wrong. How does the ER make money? From the government (taxpayers) and insurerance companies. You couldn't survive on cash only, so why the comparison? Are ER doctors now on the dole too? Where can we send our charitable contributions? :) I hope your children received Christmas gifts this year.......it's a real dog-eat-dog world out there. Sigh!
I pay a $100 copay to go to the ER, and if it's not an emergency I pay the whole thing out of my own pocket. I think that's fair. And I think it should be duplicated with Medicaid. Some kind of copay to keep them from using the ER for office visits. I have a relative who has been taken by ambulance for the fourth time this week and there is nothing wrong with him. They run the same tests every single time, and he owes nothing. The government should let the free market run Medicaid. -
StephanieAnother perspective of the ER visit: My insurance will not pay for an ER visit unless I am admitted. The only time that I ever went to the ER was with a temperature of 105° (after taking both ibuprofen and tylenol) that lasted for four days. I went to the ER on day four when I couldn't reach my doctor, who was closed for a long weekend and had no service or anyone on call. Turns out that I had cellulitis and, according to the ER doctor, definitely needed to be seen, but I did not get admitted; therefore, the cost was mine. My problem here is with the insurance company, but also with my doc, who was unavailable for so many days without anyone covering her patients. Am I unreasonable to expect my doctor to be available or to at least have someone covering them for just such situations?
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Stephanie,
Two things you may pursue: one is that every insurance contract I've ever signed requires the provider to state how they will cover the patients 24/7. Does your insurance company have a contract with your provider?
Second, it is unreasonable IMO to expect you to bypass the ER if your physician is not available. I would appeal the charges being your responsibility if your provider could not be contacted. Most insurance companies pay for emergency services if no other option was available.
Mary Pat -
Alice Robertson, Homeschooling mom of six....um....:)Am I unreasonable to expect my doctor to be available or to at least have someone covering them for just such situations? [end quote]
Stephanie this is a valid and reasonable question. I do think your doctor should have had someone in her office return your call. A lot of patients ask the same question. My doctors are part of a huge hospital (Cleveland Clinic) and they now have a 24 hour nurse you can contact.....because of this exact complaint.
My question though.....is would it have been possible to to an urgent care center? They are often much cheaper. That's what I do because I know if I have to pay they won't run the same tests as the ER. I go to my insurer's website and get the few names of the ones I am allowed to go to. -
FinnI suspect that the patient works for an hourly wage and estimated that the doctor was making $600 an hour or $4800 a day, without taking into account all the expenses involved in running a medical practice that mean the doctor is clearing far less than that.
One fairly obvious money-suck: the amount of time listed in NEMO's comment for the billing coder's work is nearly equal to the doctor's time spent with the patient, and this is probably the expense that the patient never considered since she's probably not aware that the billing coder even exists. If we could figure out a way to slash the amount of time needed for this part of the process, doctors could spend more time with patients and/or charge less per visit. Unfortunately, it seems that no one has enough power to force insurers to alter or simplify the amount of hoop-jumping and paperwork needed for doctors to get paid. -
Alice Robertson, Homeschooling mom of six....um....:)As long as doctor's standard of living is so much better than the patient's they will think about the house they are building for a doctor that they will not be able to afford. I think you deserve to live well....but what that ultimately says to the patient is that even if you have 50 assistants that need paid you are still living well and most of your income comes from insurance companies. They will rightfully, assume the payments are fair because you are not living in a trailer on food stamps.
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NEMOIn various cost analysis I've done with doctors, one consistent finding is that the doctor's are not making as much as one might perceive. In fact, most are making less per hour than their RN on staff. The reason is simply because they tend to work the equivalent of two full-time jobs in hours each week, whereas their staff usually works a normal 35-45 hours.
So when doc is working 80-hours and making even $200,000, he's making about $50 an hour as his salary. Most solo doc's are not able to pay themselves that much in small-to-medium population areas, but usually can and do in larger population areas due to sheer volume.
Private practice doc's also have additional financial obligations that academic doc's don't - most notably having to meet the "employer" side of social security and medicare - so an additional 7.65% on their income up to 106,000 + an additional 1.45% on all income above 106,000. Due to IRS regulations, depending on how the practice is structured and the state they're located, they often pay out of pocket for life insurance, disability insurance and health insurance - while still able to provide such to their employees through the practice.
For a financially savvy person, standard of living isn't necessarily proof of a level of income. I know folks who are middle earners living a better lifestyle, whom are debt-free before 50.....and I know folks making 250,000 or more a year struggling to get by. Wealth isn't a product of income (though it can help), it is a product of planning and investing well. -
Alice Robertson, Homeschooling mom of six....um....:)But you are giving exceptions. There will always be people who gain through inheritance, or stocks, etc.Our friend inherited a castle! Good on him! But as a whole doctors live much better than the average bear! Good on you! The patients just want you to earn it well! The golf course, four day week style of your colleagues needs to change of you want public perception to change.
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Muddy WatersDoctors are the most HIGHLY trained, dedicated, and compassionate professionals you will ever write a check to. No, we are not perfect, but we also deal with so much more complexities in our workdays. Next time you pay several hundred dollars in profit margins to your plumber, electrician, car dealer, cell phone provider, grocery store, etc, consider this fact and stop complaining when doctors are reimbursed for their considerable expertise and overhead.
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Alice Robertson, Homeschooling mom of six....um....:)Your comparison is not on a level playing field. A plumber and electrician come to your home...with equipment...make a diagnosis...go back out and buy parts. When my doctor does this then I can have a better comparison. And speaking for some of the skilled tradesmen I know they do a four to five year apprenticeship with college. Some have four year degrees....and receptionists, insurance, license fees, warehouses, trucks, etc.
I will say my cellphone provider has such great customer service I doubt I will ever switch. -
Praying ManYou're right Alice. It isn't even the same playing field. Doctors deal with life and strive to keep it going despite your best efforts. Get that through your thick skull. And I'm sure your physician will appreciate the fact that you equate his skill with that of your common tradesman. You be sure to think of that when you're a menopausal woman suffering a heart attack. Let's see how well your Minute clinic serves you then. I pray that at least a plumber is around to unclog your pipes er..arteries. Whoops.
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Alice Robertson, Homeschooling mom of six....um....:)Well.......Praying Man...I prayed and I think it's been revealed you are a menopausal woman.....well at least a woman.
Okay.....once more......I said Minute Clinic is limited....but great at the small stuff......and a good deal.
Guess what? When I met my husband he was in an apprenticeship in Scotland to become.......what else....a pipefitter/plumber. I shouldn't share this......but I must brag.....he is the pipe cleaner I know! *wink* -
Mary Pat and everyone,
Excellent post and excellent discussion! Those of you who say that the patient has no knowledge of what goes into to producing a 10 or 15 minute visit are absolutely correct. I have been involved in the health industry for many years and this is the first time I have ever seen these kinds of numbers!
It kind of reminds me of the "economic education" we all got about what it cost to build a car in the US as GM was going down the tubes prior to the bailout.
Mary Pat's comment about the patient's not feeling like she got $100 of value from the appointment is worth exploring. Since the patient presumably based her "opinion" upon the quality of time spent with her physician, I suspect the problem lie in the quality of the conversation between the doctor and patient. My research has shown a direct correlation between patient-centered communications and pt. satisfaction. Engaged, satisfied patients are much more likely to report "spending longer times with the doctor" (even though their face- time with the doctor was no longer than anyone else). Contrast that with unengaged and dissatisfied patients who are more likely to report just the opposite. . -
NEMOWhat's interesting is I've done these types of cost analysis in various industries...most are absolutely shocked to learn just how much time and money goes into something when they don't "see" it in the process.
One state gov't freaked when they realized ordering a stapler was costing them $45 (retail was $5) due to their burdensome approval process and centralized distribution of supplies order.
A travel industry giant was shocked to learn toilet paper was costing them $3 a roll due to their business processes.
A banking institution was dumb-founded when they realized their ATM processes were costing them more than their tellers, by 65%.
And, other doctor offices have come in at or above the example above. This particular practice was open to making some changes, but at the end of the day, the changes only amounted to shaving off about 3-minutes (180 seconds) off the processes since so much above is literally beyond their control (checkin verification time and billing especially and the need to check and double check before filing the claiim). As a male solo doc, he also couldn't eliminate the chaperone for female patients, so the exam room time is always going to be, for this practice, a double-hit for cost. -
pcpI'm sure that the doctor did not feel she was giving $100 of value, either. She knew her fee schedule, and probably calculated that she gave $50 or $60 worth. Unfortunately, the patient doesn't determine dollar value when a third party payer is involved.
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Mary Pat,
Great job of breaking down the process for everyone to see what goes on behind the scenes, before the visit and after the visit, just to put one visit in the books. I'm exhausted after reading it and have new-found sympathy for people like yourself who work in this system day-in, day-out. I think we might have a major awakening -- like the one your patient had -- if we reviewed each step and assigned a "value-added/non-value-added" descriptor to it, examining each from the standpoint of the patient (and the practitioner/nurse/staffperson, if you like). The patient pretty much stated what the only value-added portion was to her -- time with the doctor. Everything else, she could take it or leave it. So, 35 of the 45 minutes of this end-to-end time -- a whopping 78% -- was of no value to the patient (there may be a little wiggle room when we add in the billing of insurance, since nobody likes to deal with them). There's the source of her complaint. This is the supreme challenge we have in healthcare: maximizing the value-added components, and minimizing the opposite. Studies estimate that at least half of every dollar spent in healthcare is consumed by non-value-added elements such as redundant processing, unnecessary care/tests, administrative red tape, fraud and other types of waste. We certainly have no shortage of opportunities. -
What a great discussion!
Office visits are categorized by codes that are designed and maintained by the AMA. The code that is tied to the charge describes what happens during the visit, not how much time was spent, although there are some general guidelines as to how much time it might take for the level of work described.
The visit I described was scheduled for 20 minutes, as all established patient visits are at this primary care practice. The physician could have been in the room for 10 minutes, or it could have been 25 minutes. Nevertheless, the patient perceived that he was in the room with her for 10 minutes.
What mattered from the standpoint of the coding and documentation required by the insurance is that the physician performed the duties associated with the code he chose. What mattered from the standpoint of the patient (I think) is that she did not believe the service she had received had a value of $100. What the practice ultimately received from the insurance and the patient together (if she paid her co-pay after the fact) was probably around $60.
Does anyone ever pay $100 for that service in that practice? No. Never. So why is the charge $100? Well, that's a whole other post. I'll start writing.
Mary Pat -
KHThanks for the post - it's important to know what goes on behind the scenes. I also like Gerry Oginski's idea of a video to help with transparency. The health care system is complicated and, I find, not intuitive to patients (this would include me).
I think perhaps this is the larger point behind the 10 minute comment - health care for patients is perpetually a surprise. The surprise could be the shortness of an appointment, or the cost, or the way the billing process works, or the diagnosis, or any number of things (especially if your medical visits are more longterm), none of which help the patient feel in any way empowered, all of which cause stress. Many of us would love more transparency, more empowerment, less surprises.
There is too far a divide between patients and doctors, their experiences and their view points need to be better represented to the opposite group. Mutual respect in itself would make navigating the medical system better for all involved. Too much "us" versus "them" mentality currently prevails.
Patients should educate themselves. Doctors should also. This means realizing what each navigates to make an appointment possible. Doctors: the long hours, the loans, medical school (enough pain in itself), the broken lawsuit system, administrative work that occurs around patient face-time. Patients: lost work hours and pay (patients also have careers which may require long hours, loans, school, and risk), time (OUR administrative work; understanding and paying medical bills, appointment scheduling, notifying work of absences or applying for vacation days, transportation, waiting), emotional and financial stress.
Let me repeat: mutual respect. It's SO important. -
M CampKH,
"Mutual respect in itself would make navigating the medical system better for all involved. Too much “us” versus “them” mentality currently prevails."
You are spot on! Great comments & I couldn't agree more.
Why can't we all just get along;-) -
Ronnie Gregory M, Ronnie Gregory is a diabetic blogger with the poor diabetic blog and an activist for the online diabetes community.As with everything else in this world, money becomes the key motivator for everything we do. As a diabetic, the 10 minute semi annual rush fest given by my doctor is simply not adequate but I cannot afford the extra five minutes and the doctor has flagged me as a difficult patient because, I will keep asking questions until I get clarification and or understanding and yet this is the best a health system has to offer.
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