Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, January 30, 2007

Taking the Plunge

I did it. I said I was going to do it, and I finally did it.

I sent out a letter to all my active patients: beginning February 1st I am instituting a new office policy: a $20 per person per year Administrative Fee.

Not for medical care. For things like calling patients back with lab results (instead of bringing them back for return visits, like all the other docs do), mailing, faxing and calling in prescriptions, prior authorizations and referrals to the tune of dozens a day (all unreimbursed, and all -- if not part of a face-to-face encounter -- having nothing to do with medical care), for having the phones answered by a person instead of a menu machine* ("Suicide Hotline: press 1 if you have a gun, press 2 if you've overdosed, etc") and for my availability for telephone advice 24/7.

By now the letters have arrived and the phone calls will begin:
  • Do I have to pay if I don't see you in 2007? (No; you don't have to pay unless/until you come into the office.) (But I won't refill scripts if I haven't seen you in a year.)
  • What happens if I don't pay? (I won't call you back with labs; you'll have to come in for every prescription refill; filling out forms without an office visit will cost you $10; etc.)
  • Send me my records.
That last one is obviously the one weighing on me. This could very well be the beginning of the end, I fear in the dark hours of the night. Then I wake up and go to the office and listen to the vast majority of patients I love tell me I'm worth it, whatever it takes to keep me in business, $20 is nothing, and so on.

The problem is that although I clearly provide better service than other practices in my area, none of them have gone to this "prospective payment model" yet. They all charge for things like forms and mailings and records (which I don't) but they haven't yet gone that extra step. It's like a miniature version of "Concierge Medicine," where you pay $1000-2000 a year for the privilege of being a doctor's patient. I have been providing Concierge service at insurance prices. So now I shall begin to charge the nominal sum of $20 per person per year (maximum $100 per family; can be waived for extreme financial hardship) and away we go.

I am not generally on the front end of the innovation curve. I pride myself on being a "late adopter" of drugs and therapies, waiting until the biggest kinks have been worked out by other doctors. More times than not, my patients have benefitted from this approach, and I don't intend to change in that respect. But being the first on the block to try something like this new Administrative Fee is more than a little scary. I shall keep you posted on my progress.


*My father's favorite: "Incontinence Clinic: Can you hold?"

24 Comments:

At Tue Jan 30, 08:41:00 AM, Blogger The Independent Urologist said...

It is a great idea. $20.00 is nada! I would be surprised if you have more than just a little resistance or patient exodus. And I would imagine that most people who leave will ultimatetly return, given the excellent care--both medical and practice management wise--that you provide. If I lived in your malpractice crisis state, instead of mine, I'd come to you as a patient. Congratulations.

 
At Tue Jan 30, 08:56:00 AM, Anonymous Anonymous said...

I'd pay more than $20 if I knew my doctor would take all of the extra steps. I was just thinking the other day that as demanding as things can be I should set up an appointment to chat for fun with my doctor just to allow the doctor to bill some time to cover extras. I don't know how you doctors are supposed to recover for the extras -- got to be a better way to fairly compensate for your time.

 
At Tue Jan 30, 09:17:00 AM, Blogger radioactive girl said...

My doctor is wonderful, and if he told me I would have to pay even $100 a year to have these things, I would gladly pay. I always give my doctors generous gifts during the hoildays because I realize they don't get paid for the extra things they do for me. One extra phone call to me may not seem like a lot, but when you figure in all the patients he does that for, it turns into a lot of extra work for no extra pay. I wouldn't want to do that, so why should you. Hopefully your patients will understand that you need to be paid for the work you do, and $20 a year is still not nearly enough.

 
At Tue Jan 30, 09:23:00 AM, Blogger The MSILF said...

I think you're shorting yourself with $20, by several multiples. How much will that add to your salary? Will it be significant at all? Also, you have to figure in that people may become more demanding because "I paid for it!"

 
At Tue Jan 30, 10:15:00 AM, Blogger Fat Doctor said...

Nifty idea that I will bring up at our next clinic operations meeting. Our patients tend to feel so (artificially) entitled to my time and the time of everyone I work with. Some patients call two to three times a week and take up to an hour of my nurse's time (or worse yet, mine). Maybe even threatening a fee to some of these folks will cut down on the nonsense.

If people leave your care over this, so be it. The vast majority would, as the commenters above have stated, gladly give ten times that amount to keep you around at their beck and call.

Good for you!

 
At Tue Jan 30, 11:20:00 AM, Anonymous difficultpt said...

$20 is more than reasonable. And the folks who are leaving are probably the irritating ones anyhow . . . (I was going to say "difficult," but decided that it was inappropriate, lol)

 
At Tue Jan 30, 11:28:00 AM, Blogger Artemis said...

While I think that $20 is more than reasonable, I can see that some individuals will balk...I agree with your approach that if they aren't interested in paying the $20 up-front, then charging them on an "a la carte" basis for forms, copying, etc. Good luck!
A

 
At Tue Jan 30, 12:22:00 PM, Anonymous Tom P said...

I applaud your decision! My bet is that the only patients you lose, will those that were a bit of an irritant anyway.

Doctors have been giving away too much for too long!

 
At Tue Jan 30, 01:04:00 PM, Anonymous Anonymous said...

Just a heads up- I don't know what state you are in, but where I live it is a felony to charge medicaid patients, so if you have any medicaid patients you may get calls from them.

 
At Tue Jan 30, 01:17:00 PM, Blogger Carol said...

I know how much my PCP gets paid by my insurance company. I read my EOBs. It is disgusting. My mechanic gets paid better. I have actually suggested an administrative fee to my doctor because I value his time and his personal interest in my mental and physical health. In six years I've called after hours once - for Phenergan because I didn't want to go to the ER for the stomach flu. I always make an appt. for RX refills or referrals because it is the only way I can contribute to his income - it would be unethical for him to simply accept an "I really appreciate you!" check. I hope he can convince his partners to adapt an administrative fee. I would pay it happily! And I think $20 is paltry. Maybe set it at $50 or $100 and have the business manager review financial hardship patients. With only a $15 co-pay I can certainly write a check for $100. I paid more than that to take my dog to the vet clinic yesterday.

 
At Tue Jan 30, 01:28:00 PM, Blogger Bohemian Road Nurse... said...

An interesting idea, I'll be interested in seeing how it works out.

 
At Tue Jan 30, 01:40:00 PM, Blogger Flea said...

My practice is 40% medicaid. Would this fly here?

best,

Flea

 
At Tue Jan 30, 03:06:00 PM, Anonymous Cheryl Fuller, Ph.D. said...

That's a great idea! I have a small charge which I assess monthly for responding to patient emails, something I almost always manage to do in less than 24 hrs. It lets them have access when they need it, frees me from the phone more and keeps me from feeling unpaid for real wortk, which answering these emails is.

 
At Tue Jan 30, 05:27:00 PM, Anonymous Mary Lu said...

Dino, It's an excellent idea. I'm really interested in seeing how this idea floats for your practice. Keep us posted, please. My Hubs is a Clinical Pharmacist, and there are times I wish he could charge for all the time spent dosing, changing drugs, counseling, teaching and phone calls. But if you think you patients howl at the price of an Rx co-pay, they'd go orbital if he charged an extra $20 for adminstrative fees.

 
At Tue Jan 30, 07:06:00 PM, Blogger Sarah said...

I recently spent $3000 to have my bariatric surgeon at my beck and call for the REST OF MY LIFE. Insurance just doesn't pay enough anymore. And I am now safe in the knowledge that I will have one of the best bariatric surgeons a phone call away should I have an emergency related to my condition. Well worth the money spent.

 
At Tue Jan 30, 07:28:00 PM, Anonymous Anonymous said...

Won't there be patients who, because they pay this (phenomenally small) admin fee, will feel free to call you continually? Maybe those already do!

 
At Tue Jan 30, 07:29:00 PM, Blogger Narya said...

Is there some way you can offer a sliding scale up front? Because some people simply may not be able to afford it, and may not want to question it (or may be embarrassed to say they can't afford it).

 
At Tue Jan 30, 09:34:00 PM, Blogger Sid Schwab said...

A bold move, which seems more than reasonable. With respect to the last response you got: this may have the effect of pruning away those patients who don't fully appreciate what you do. Not entirely a bad thing.

 
At Tue Jan 30, 10:03:00 PM, Blogger Cathy said...

I think it is a good idea. I wish my doc's did this! They charge for every little thing imaginable and paying 20.00 per year for getting all these extras sounds good to me.

 
At Tue Jan 30, 11:09:00 PM, Anonymous Bruce Small said...

I'd gladly pay that to our wonderful doc, and much more.

 
At Tue Jan 30, 11:44:00 PM, Anonymous Anonymous said...

I'd be confused and unhappy if my doctor did this, if only because I only see MY medical needs: visit once a year, get my bcp prescription re-upped, answer questions about whether I use a seat belt, get my heart listened to, etc. And get a little card in the mail in a couple weeks saying that my pap is normal.

The last time I noticed, my insurance paid $59. for a supposedly 15 minute visit with a nurse. (bcp check)

So if you asked me for an extra $20, in addition to the money taken out of my check every month for my part of the health insurance (in addition to the money my employer pays the insurer instead of me), I wouldn't see it making sense, and would probably leave rather than argue about it. But then my view would be really limited compared to most, I guess.

It would only be worth the $20 if I really could get the refill without wasting my time waiting in rooms full of baby propaganda and then answering stupid questions from a form.

How many patients? 1000? so an extra $20K a year. 3000? Hey, I could more than double my annual salary. I wish I could do that with my job.

 
At Wed Jan 31, 12:56:00 AM, Blogger SeaSpray said...

I think that is a great idea! I wouldn't hesitate to pay that fee and more for the good doctors that I have.

I agree with Carol - do a financial review for hardship patients if charging significantly more. If families had several doctors that did this I could see it being difficult for some depending on the amount charged. $20.00 - how often do we all waste $20.00 on nothing?

I've said it before - my urologist and group is amazing with their follow-up care and the office staff is wonderful.

Like radioactive girl - I also gave the office a sizable food gift - twice! In July - I gave them a big fruit salad in a watermelon, yogurt for toppings and other stuff. Then for Christmas I baked and added other assorted stuff. I had fun both times and it was my way of saying thank you for EVERYTHING! Also - they have a lot of employees and I wanted to be sure that everyone got something.

You doctors are so valued by your patients. I know not everyone appreciates you or what you do but I think most do. :)

 
At Wed Jan 31, 11:20:00 AM, Blogger Detail Muse said...

Re: the responses of "Send me my records" -- perhaps we'll see the longer versions of some of these as bonuses in the FOAD? :)

 
At Wed Jan 31, 02:49:00 PM, Anonymous Anonymous said...

anonymous who is "confused and unahppy" explained very well the economic problem of a third party (Insurance Co) being involved. The monthly premiums paid by her employer and herself do not go to the Doctor! I get the idea fromher comments that she is young, and healthy-she would be better off to have a high deductable,catastrophic plan and pay her annual check up cost out of pocket.

 

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