Physician No Show Appointments Demoralize Doctors

I’ve had two jobs since I completed a fellowship is gastroenterology over 20 years ago. For the first decade, I was a salaried physician. Afterwards, I promoted myself to private practice. Each model has its advantages and drawbacks, but for me the private practice model wins out. The climate in Cleveland is extremely inhospitable to private practice, because of two mega-medical institutions that incinerate private practices as their boiling lava flows across the region. So far, our practice is still viable, but the prospects for its long term health and welfare are questionable.

One of the advantages of working for a straight salary is that income dies not depend upon productivity. (My employer maintained that we had a productivity bonus, but in reality there wasn’t much the physicians could do to adjust their salaries in either direction.) One of the disadvantages of private practice, particularly where I practice, is the need to hustle aggressively for patients, a task I neither enjoy nor do particularly well. In my present professional world, an empty schedule means empty collections.

So, when a patient decides to miss an appointment, the ramifications are quite different for me now than it was during my first job. At least when I was reading The New York Times during a gap in the schedule while I was on salary, my paycheck didn’t change. Not so these days.

My partners and I are forever lamenting the empty spaces in our schedules when patients do not show up or call in advance to notify us that they will not be coming.

These acts hurt us economically and forfeit an appointment slot that another patient would have happily occupied. Moreover, not showing up is downright inconsiderate. Sorry, if some readers find this latter view to be harsh, but I don’t wish to sanitize it as a venial sin.

Of course, sometimes life happens and an appointment is missed or forgotten. As a member of the human species, I get this. However, many of the patients who are AWOL at appointment times have been contacted a day before by a living, breathing member of our superb staff. Here, the absence is inexcusable.

Should these patients be assessed a fee for failure to appear? If a patient does call to cancel, how much notice is reasonable? 24 hours? 10 minutes? What if their insurance companies prohibit us by contract from charging patients these fees? Then, what leverage do we have?

Should we leave a heartfelt flyer in the waiting room pleading for cooperation on this issue? What good would that do? The ones who really need to read it aren’t there.

Electronic Medical Records Save Money! (Never Mind)

Electronic medical records (EMR) were supposed to rewire the medical grid.  It would increase efficiency, reduce redundancy, improve quality and reduce costs.  On  these measures I offer a grade of 0 for 4.  Ask any practicing doctor how EMR has impacted on his practice and be prepared for some remarks that differ from the government’s Kool Aid talking points.  EMR, thus far, hasn’t been ball bearings for the system.  More often, it gums up the works.

The EMR Maze - Enjoy!

The government spent billions of dollars with cash payments  to induce hospitals and doctors like me to jump on board the EMR express.  The Rand Corporation helped to fuel this euphoria in 2005 when it predicted exaggerated benefits of EMR.   By the way, this study was financed in part by EMR companies whom, I politely suggest, had a vested interest in the study’s conclusion.  Rand denies that they were unduly influenced by their backers, and I don’t claim that they caved on their principles.  Nevertheless, the propriety of taking money from folks whose survival may depend upon the study’s outcome is ethically problematic.  But, Rand was wrong and has publicly admitted it now.  The Rand folks are now back flipping across the countryside with new and improved pronouncements stating that EMR has added to medical costs and hasn’t delivered on its other rosy promises.

This wasn’t an epiphany.  Many folks in 2005 didn’t swallow the Rand bait.   The Whistleblower was blowing hard but apparently the frequency was above what human ears can perceive.  EMR is a money pit that has made many companies rich.  EMR systems are expensive, clumsy to use and do not communicate easily with other EMR systems.  Patients have the notion that the hundreds or more EMR systems out there can easily communicate with each other.  They can’t.  I have a few posts on EMR, and they’re not pretty.

The point here transcends the EMR mirage.  How many other promises of Obamacare will crumble in the years ahead?  Again, this won’t be a revelation.  Many of us were shouting about this on day 1.  No one could hear us above the din of health care reform.   Will these reformers, like Rand, admit that they were wrong as the evidence piles up?  Wouldn’t that be the fair and balanced thing to do? 

We’re in the Era of Medical Ridiculousness.  Call it EMR.

A U.S. Marine's Gift to a Doctor

I saw an elderly patient a few months back for a gastrointestinal issue that fortunately led to a benign outcome.  He was a modest man who spoke softly and used few words.  As has been my custom for as long as I’ve sat across patients, I was interested to learn something of the man beyond the issue that brought him to see me.  Indeed, it is these vignettes that I regard as the gems of my practice.  Without them, I would be left only with the practice of medicine, and this would not be sufficient.

He wore a military baseball style cap, emblazoned with a U.S.M.C. label.  To those who do not immediately recognize what these letters stand for, then I suggest that you apply to medical school, become a physician, see patients so you also will have the opportunity to learn stuff that really matters.

I learned that he served in the Pacific theater in World War II and asked him about his service there.  While my father served in the war for 39 months, he remained in the United States, far from harm’s way.  As he was so mechanically incompetent, perhaps the government kept him home as they were fearful of placing a firearm in his hand.  He was stationed in California and likely would have been deployed to Japan had President Truman not ended the war in August 1945.

My patient described how he was shot in the head, with the bullet piercing the front of his helmet and then exiting out the rear.  No vital structures were injured.  He described the event as casually as one who had sprained an ankle in the parking lot.  I find that older veterans are characteristically modest and understated, two virtues that I wish were more contagious.

When I learned that he served on Iwo Jima, my eyes flickered wondering if he had witnessed the scene that has become America’s most iconic military image.  Yes, he had witnessed the legendary flag raising on Mount Suribachi.  I felt as if I were in the presence of an important man, though he would likely dispute that.

I saw this man back in the office recently, and at the conclusion of the visit, he gave me an envelope containing a gift.  It was his U.S.M.C. pin that he wore throughout his service.

“I want you to have this, doctor,” he told me. 

I accepted this important gift from an important man with deep appreciation.

We give what we can to our patients.   They have just as much to give back to us.

Semper fi, Elmer. 

The Cost of Colonoscopy: A New Payment Model

There is a steady push to change the way that physicians are paid.  No compensation model is ideal.  The fee-for-service (FFS) model has become Public Enemy #1 as it is felt to be responsible for overtreatment generating excessive costs and utilization.   Salaried physicians may be freed from the FFS conflict of interest, but it has other drawbacks including a diminished incentive to provide exemplary service to patients and to referring physicians.  Since physicians did not initiate compensation and health care reform decades ago when we should have, we are now being squeezed hard by external forces that will overcorrect on the system’s deficiencies.  It’s always better to fix your own house.  There should be a lesson here for other professions who are in need of some reform and repair.  Teachers, in my view, were dragged into the education reform arena, and will suffer because of it.  Attorneys have been smug and cavalier about the legal profession’s obscene excesses and I believe that they will rue their inaction.

What do patients think about how their doctors should be paid?

I’ve done over 20,000 colonoscopies.  As I have written in this blog, I’m not even sure how much I charge for the procedure.  It’s not simply because I have little interest in the business of medicine.  It’s also because colonoscopies are like air travel.  No two passengers pay the same price.

Which system would you favor for pricing a colonoscopy?

(1)    Flat fee for the procedure for every insurance carrier.

(2)    Hourly rate.  If a colonoscopy is tough and takes twice as long, the physician should get double the dough.

(3)    Graduated rate depending upon experience.  Should a 20 year gastro veteran be paid the same as a green newbie?

(4)    Airline model.   We now know that various airline seats have been designated as premium seats because they afford an extra centimeter of leg room or the oxygen mask actually works.  Similarly, certain colonoscopy time slots could be subject to a surcharge, such as the first appointment of the day when the physician is energized and not yet running behind.  The 5 pm  slot, in contrast, would be discounted as the physician is fatigued and is trying to make a 6 pm dinner reservation. 

(5)    Name your own price model as is done with air travel, car rentals and hotel rooms.  Patients offer an on-line price in advance and the GI practice decides to accept this or wait for a higher bidder.  This adds a fun element to the colonoscopy adventure.

(6)    Patients decide after the procedure to pay the doctor what they feel the training, knowledge, experience and judgment are worth.   Some patients, I fear, may valuate the colonoscopy only by the 10 minutes duration.   This is not quite fair.  Once in Cape Cod, I saw a beautiful sand sculpture of a mermaid.  I asked the artist how long it took him to create the art.  His response was ’30 years and 7 hours’.  Get the point?

(7)    Barter system as functioned well historically.  One colonoscopy = 6 Box seats at sporting event = set of luggage = last year’s iPhone model = 1 hour plumbing service = 5 car gas fillups

(8)    No charge at all.  You can’t put a price on your health, and we shouldn’t try. 

While I’ve never regarded myself as business savvy, perhaps I’m onto something here.   What do readers think?  Is it time to take off the rubber gloves and wear suits and ties or should I keep my day job?