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.

Friday, March 21, 2008

Thoughts on Appointment Deposits

Following up on my previous post, I'd like to review some of the thoughts other folks had about charging a deposit to make an appointment with a specialist, and my final formulation for myself.

I completely understand the point about the value of a physician's time and patient responsibilities. I feel your pain; I lose money when patients don't show too. But although the concept seems valid, I have some real problems with it; at least with its execution in this particular case.

First of all, the comparison to placing a deposit for a hotel room doesn't quite hold up. Although deposits are accepted practice in certain industries, they are hardly universal. You don't need a deposit to make a restaurant reservation (last I checked, although precisely the same arguments hold.) Hairstylists don't routinely require payment at the time the appointment is scheduled; neither do car repair shops that accept appointments. Does your lawyer charge you if you don't show for an appointment? (I know, I know; he doesn't have to; he can still charge for phone calls.) At this point in time, I believe it is still generally accepted that the risk of no-shows is considered a business expense for professionals in service industries.

Certain patients will fail to keep appointments, and certain other patients wouldn't dream of it. Reminder calls are an accepted strategy to minimize no-shows. So is charging fees (albeit nearly impossible to collect) after the fact for missed appointments. The problem with charging everyone upfront is that you're assuming the worst; guilty until proven innocent, if you will. Even if you give the check back, what I find insulting is the implication that you don't trust the patient to show up.

What about patients who don't have checking accounts? I suppose it wouldn't rub the wrong way quite so much if it were a credit card number requested instead of a check, but I have some patients who don't have credit cards either. In this case, the free-market argument is that those patients "can't afford" to see those specialists; they're just out of luck, even if they have insurance that would otherwise cover the visit.

Here's the other piece of this that I think slipped past most of my commenters, some of whom said they'd be happy to pay if it guaranteed them face-to-face time with the doctor: the issue of choice. It's one thing if a self-referred patient wants a second (or third, or fourth, or however many it takes to find one that says what they want to hear) opinion. In this case, my patient didn't feel like she had any other option but to comply: I was the one who referred her, therefore she "needed" to see him. In a strange way, I felt guilty. If I were a better doctor -- smarter, better read, more on top of her condition -- then she wouldn't have to see the specialist or pony up the $75 check. Somehow this felt like my fault.

I had actually spoken to the doc about this patient, and we had agreed on a trial of treatment for a month, after which he would see her. At no point in that conversation did he mention anything about this new office policy of his. If nothing else, I could have warned the patient. It sounds weird, but I felt betrayed. Perhaps the policy should be modified for patients when I speak directly to the specialist; perhaps they should have requested a credit card; actually, what they should have done was be more polite about it. My patient felt the appointment scheduler was rude; but again, she didn't feel she had the option not to go.

After much introspection (and appreciation for all the thoughtful comments) here is what I have decided:

I completely support this physician's right to run his practice however he pleases. However as long as this is his office policy, I shall no longer refer patients to him. I just can't do it in good conscience. I haven't decided if I'll call and tell him so (I don't really refer to him all that much as is, so it's not like he'll miss much) but that's how I've decided to handle the situation.


At Sat Mar 22, 12:05:00 AM, Blogger tk said...

Dr. D--You might contact this specialist politely and request a waiver of policy for your patients . . . You never know, he/she might do it for you. If not, you could politely let him/her know that you will refer elsewhere.

At Sat Mar 22, 12:13:00 AM, Anonymous Anonymous said...

The only time I was ever late for a an appointment I was told I would have to reschedule. I was 20 minutes late and even though it was a follow up with an oncologist I got over it. On the other hand I have waited an hour and a half when I wasn't late. Now since I was not charged a deposit I was understanding of the situation but if I have to pay upfront you better see me on time and take care of me right.

That is where my problem is with health care deposits and I feel for you because you were not forewarned . I wonder how this can happen if you are covered by insurance? I thought they mandated the terms when it comes to seeing their patients.

At Sat Mar 22, 12:15:00 AM, Anonymous Anonymous said...

I agree with you. Life by the sword, die by the sword. He instituted a draconian policy (that is completely within his right) so let him feel the pinch in the same way. Assuming of course that you're patients care won't suffer. If patient care is the priority it stays the priority, regardless of his payment policy.

At Sat Mar 22, 09:19:00 AM, Blogger hawk205 said...

On the flip side, when I wait for my doctor for 2 hours and I have paid a deposit. Do I get my deposit back plus compensation for the doctors use of my valuable time? If I've paid a deposit, it does not matter that the doctor was attending to another patients medical emergency.

At Sat Mar 22, 11:54:00 AM, Blogger The Happy Hospitalist said...

Isn't it amazing, when it's your own money at risk, a deposit becomes a huge deal.

I shouldn't have to pay a deposit to see the doc. And the doc shouldn't make me wait an 1 1/2 to see him/her.

The only difference is, I can assure you that if you were paying cash for your appointment at agreed upon rates, over booking would disappear and service would return to the market place. You would not wait 1 1/2 hours because you would go somewhere else with better service.

Right now, insurance rules the office visit, and because of that, wait times will only get worse as volume continues to escalate.

You get what you pay for.

At Sat Mar 22, 06:03:00 PM, Anonymous Anonymous said...

if i read the description right, it is not paying anyone anything as long as you show up. if you show up, the check is returned.
no one is paying for face to face time or attention. they are paying for missing an appointment.

that said, i agree with you dinosaur. it is an accepted cost of business. i find the patient repsonses interesting--no i would never miss unless there was a dire emergency, no i can't understand why i have to wait, but in fact every day there are a number of missed appointments and people arriving late and still expecting to be seen with the same quality as if they had been on time. they don't have the well if i have to wait, at least it is good for society mentality anymore either. (not to say that physicians also have their heads in the sand about such stuff). do these patients have a suggestion as to how to minimize these missed and late appointments?
the longer we book an appointment so that you feel less rushed during your visit, the more the pain of the missed visit. apparently the wait time is already several weeks.
i am sure the rheumatologist is just trying to make sure people keep their appointments, not trying to bag $75 a couple times a day. well, i would hope that.

nonetheless, i think it is an interesting idea. certainly you have the right to not send them patients dinosaur. good luck with things.

At Sat Mar 22, 10:46:00 PM, Anonymous Anonymous said...

I suspect that there are several issues here. Rheumatologists, by the nature of the specialty, attract many patients that primary care physicians just don't do well with (i.e. fibromyalgia, chronic fatigue, back pain, chronic pain, unexplained symptoms, etc.). Unfortunately, many of these patients are not the most reliable people and shop around for doctors, making multiple appointments. The initial new patient appointment for the rheumatologist is probably 30 to 45minutes, and other than joint injections, rheumatology is primarily an "E&M" specialty without a high fee procedures. This rheumatologist is probably reacting to experience with too many no-shows, and I don't blame him a bit for his policy. There is quite a nationwide shortage of rheumatologists, and I don't think he will be hurting from your decision not to refer to him.

At Sun Mar 23, 10:21:00 AM, Blogger #1 Dinosaur said...

Just for the hell of it, let me point out that one of my blogging techniques for rendering patients and situations anonymous is to alter certain identifying details. Because some of the comments have been overly specific, allow me to state that the specialist involved in this case was not, in fact, a rheumatologist, nor was the patient having issues with autoimmune disease. Nevertheless, I feel it sufficiently conveys the context of the situation, whether it was a neurologist, endocrinologist, pulmonologist or any other medicine subspecialist you care to pull out of your hat.

I agree the specialist involved will not be hurting for business from my lack of referrals. However I am beginning to feel he has the right to know my feelings about his policy. No, the patient doesn't actually end up paying anything extra; still, the whole thing just rubs me the wrong way.

At Sun Mar 23, 01:12:00 PM, Blogger ccinnkeeper said...

I encourage you to call the specialist and inform him of your decision not to refer to him any longer because of his deposit policy. You may not cause him to see a drop in his business, but this sort of peer-to-peer feedback is valuable. He may reconsider his policy, he may grant your patients a waiver or he may not do anything but if he does not know there has been a possibly unintended consequence of his policy then he has no opportunity to adjust it.

I also thought you should know that certain restaurants in New York City do take a credit card number from you when you make a reservation and if you fail to show up they will charge you $100 (or possibly more) as a penalty. While it is not a deposit, it is an incentive to either keep the reservation or cancel it in advance. Other reservations call you a day ahead to confirm, much like a doctor's office. The no-show rate at restaurants is extremely high - much higher, I would suspect, than for a medical specialist - and for those restaurants where it is known you need to make a reservation 2 - 4 weeks in advance they stand to loose a lot of money on no-shows.

Great, informative post, by the way.

At Sun Mar 23, 03:04:00 PM, Anonymous Anonymous said...

There's no reason for the deposit to be as high as $75. The Harvard University student health services started charging $10 for missed appointments last year, and it had a huge impact on the number of people showing up late or never. Just $10 can make a big difference. No need for $75.

At Sun Mar 23, 05:31:00 PM, Anonymous Anonymous said...

I think $25 would be more in line with increasing the chance that a patient shows up for that initial visit.

That being said, the deposit-or-no-appointment policy doesn't sit well with me. It would leave me with the impression that the doctor cares most about money, above all else. Perhaps that isn't the intention of the doctor, and he actually trying to open up slots for new patients, and keep his scheduling under control. If this is the case, then that needs to be explained to each new patient at deposit-request time. And it's not helping the doctor to have a rude clerk administering the policy. (Ah, rude health care office workers! The one that I do not miss about my 18 years in Philadelphia.) The way the policy is set up now, it assumes that anyone is a potential time waster, and treats everyone accordingly.

What I would do is this: If a person misses an initial appointment, they cannot schedule another one and so lose any chance of being a patient at that practice. If an established patient misses two appointments in a row, then they are dismissed from the practice, with no chance of coming back. Post the policy clearly in the office and on paper. Sounds draconian, but at least this way, only the time wasters are effected, and everyone else is left alone.

The above did happen to my elderly father. Unbeknownst to us, he was making appointments with his dentist, then forgeting to go. He was dismissed from the practice, until my brother called and promised to drive my dad to the appointments, which took care of the problem.

Just my thoughts.

At Tue Mar 25, 06:22:00 AM, Anonymous Anonymous said...

What I am troubled most in this series are the comments containing phrases such as “I just can not do it in good conscience (refer to this rheumatologist)” and “I would never have the audacity to conceive of such behavior…”

Several people seem to have set themselves up as the moral elite, and turned a shared problem among physicians that we should all be trying to solve into a conflict among physicians. In such a case I would propose to look into the mirror and apply the same standards. The number one complaint against primary care physicians is the lack of time spent with the patient, the inability to obtain appointments (a patient of mine was recently told there would be a 4 month wait for a pre-operative physical), and feeling rushed.

I hope that Dr. Dinasour never has patients who feel rushed, who can’t obtain timely appointments, or with whom he spends less than 15 minutes. If he does, I wonder how he can practice in good conscience.

We all face similar problems, and are trying to come up with solutions. I noticed Dr. Dinasaur is from the “malpractice state.” Perhaps this judgmental environment is affecting him. It sounds like the rheumatologist gave him some free advice over the phone; he doesn’t sound like such a bad guy.

At Tue Mar 25, 07:06:00 AM, Blogger #1 Dinosaur said...

Anon 6:22 --

Yeah, as it happens I'm walking the walk as well as talking the talk.

Time to first available appointment for new patient: 1-2 days.

Time to first available appointment for established patient: same day for calls before noon; next day for pm calls.

Average time in waiting room: 0-5 minutes (when people show up as scheduled. Otherwise it can be up to 1/2 hour, with the person who's late doing the waiting.)

Average time spent with new patient: 45-60 minutes.

Average time with established patient: 20-30 minutes.

I understand that we're all trying to cope with the same problems. Remember, it took me a lot of time trying to figure out what was bothering me about the specialist's policy. I'm still not even sure how well I can articulate it. All I know is that if I tried something like that, my practice would disappear faster than you can say "Everyone into the tar pit!"

It just feels wrong, and all I can do is act on that (which is what patients do all the time.)

At Wed Mar 26, 07:04:00 AM, Anonymous Anonymous said...

I am the precious poster and I am impressed by your statistics. I stand corrected by assumptions I made.

I will say that I cannot find anyone in my referral area who offers those same services.

This is my point.

We are all faced with decreased reimbursement, increased expenses, and increasing administrative complexity. We are all trying to figure out ways to take care of patients while having a successful business.

In my environment, primary care docs solve this problem with increased volume. This occasionally means patients feel rushed, and occasionally means people are referred for problems which might have been solved if more time was spent with them. I do not begrudge this or sit in judgment.

As a rheumatologist, I want to make sure new patients with conditions like vasculitis and lupus get the time they need. But, no-shows are an enormous problem. I am still trying to figure out what to do about it. For example, if someone no-shows a new patient visit once, do they get a second chance, or a third? How many return no-shows will get a person discharged? I don’t know the answers, but it is a problem and as I try to find a solution I would appreciate if others to not begrudge or sit in judgment of me. I would welcome constructive feedback and suggestions instead of judgmental blogging of my behavior on the internet.

Since you’ve taken a decent amount of time to blog about this, my advice to you would be to call the rheumatologist and let him know the feedback you have received. Maybe you should get his side of the story. What is his waiting list, what was his no-show rate before and after the policy, has he tried other policies. What is the financial impact of his no-shows compared with his profit margin? If after getting his side of the story you disagree and choose not to use him, I have no problem with that, and you’ve done your part by letting him know the impact of his policy. Currently, it sounds as if you solicited free advice (for which he is legally liable) being courteous to him on the phone while at the same time disparaging him behind his back. Most importantly, you’ve done nothing to have a positive impact on the situation.


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