Your 10 minute office visit needs 8 people and 45 minutes of work
COMMENTS
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?
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.
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.
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.
"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.
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
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?
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.
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
“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.
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
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.
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.
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.
I will say my cellphone provider has such great customer service I doubt I will ever switch.
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*
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. .
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.
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.
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
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.
"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;-)
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