Why retail clinics will fundamentally change primary care

in Uncategorized | 45 responses

More people are using walk-in clinics for primary care

“‘People are much more consumerist today,’ Dr. Lo said. ‘No one wants to wait two weeks to see a doctor. In fact, no one wants to wait an hour in my waiting room. People are much more concerned about getting things done on demand, and they have difficulty finding a primary care doctor who will see them promptly.’”

Comments

Anonymous
Massive change is coming to your local doctor’s office…and not a moment too soon.
It amazes me that I have to talk to (1) a receptionist with no medical training and tell her why I want to see the doctor; then (2) the front desk nurse (?), who performs triage and would just as soon have you come in next month, unless you can convince her you are about to die; then (3) the nurse in the examining room who wants to know why you’re there and then writes down stuff that when the doctor reads it back to you sounds like someone else altogether. THEN to get test results, the nurse calls and tells me to tell her exactly where I am going to be the rest of the day, and if I’m not at my desk when the doctor calls sometime in the next 6 hours, then I’m SOL [s**t out of luck] because I had my 15 seconds of fame and have to start all over again.
Yes, dears, I know doctors are busy packing as many of us into their day as possible, but that doesn’t make it right. I’m a licensed professional also, and if I made my clients talk to the receptionist and then my secretary and have to tell both of them why they deserve some of my time and have to beg for it, then when I gave them an appointment 2 or 3 weeks hence, made them wait because I was triple booked and made them then tell my secretary all over again what they wanted and then when I arrived in the room to ignore them and read from the notes what they supposedly need from me? THEN made them run the same gantlet again 2 weeks later to get the answers and help they want? Hello?? I wouldn’t have customers/clients very long. Transpose this kind of customer service onto any human interaction, and it appears downright absurd.
There are doctors who treat the patient instead of making us jump through hoops, but they are increasingly harder to find. Indeed this is becoming a ‘customer service’ issue, as it should be. Hey, I still remember when doctors made house calls, and I’m not THAT old. Something’s got to give, and I have to tell you some of the downright nasty, condescending and angry posts I’ve seen from MDs on this site and others make me fear for their patients.
God bless the good docs; the rest of you, deploy your high IQ somewhere else. Please.
jb
Anon:
Please don’t blame your doc for this. She didn’t put herself through 7 or more years of postgraduate training to abuse you like this. You do not state which profession you practice, but odds are you charge your client what both of you believe is fair, and the client pays you directly. Your compensation does not come from a third party that will pay you if it feels like it, if your claim form meets their specifications. You likely do not feel obligated to provide your services for reduced or no fee to a good chunk of your clients, often after hours, and maybe even under the compulsion of losing your ability to practice if you do not take care of these folks. You do not have absurd documentation requirements that make it necessary for you to prove that what you do and say is justified. All of this takes time away from what you justifiably want your doctor to do in exchange for your business. That is why she has all that bureaucracy and (your) time-wasting nonsense.
If your doc decides to practice the way you want her to, charging you directly and dealing with you directly, she will then be denounced as elitist, uncaring, and more interested in making a dollar than caring for the less fortunate.
Anonymous
The clinics have regular hours, they take no call, they participate vith few or no insurances, sure as hell not Medicaid, they have no hospital burdens, they expect to be paid at the time of service.
Sounds like a good deal, I’m going to turn my office into a walk-in. I’ll throw away my pager, I’ll tell my Medicaid recipients to show up with a credit card or go somewhere else.
Anonymous
Dear jb, I also didn’t put myself through 4 years of post graduate work to abuse my clients, not the way too many docs act these days. Since when does having gone to school for a long time justify treating people badly, the same people you supposedly want to help? Look at the initial post on this, quoting a Dr Lo saying with disdain or dismay (hard to tell which, maybe both) that people just don’t want to wait any more, even an hour in his waiting room. Damn straight. Why is HIS time more valuable than mine? Docs seem to think that since we’re talking about my health I’ll be willing to put up with just about anything for a few minutes of their time, but really shouldn’t it be the other way around — since it IS my health and not an oil change, shouldn’t I be treated BETTER at the doctor’s office and the hospital than I am at the mechanic?
You say: “You likely do not feel obligated to provide your services for reduced or no fee to a good chunk of your clients, often after hours, and maybe even under the compulsion of losing your ability to practice if you do not take care of these folks.” Not true; not true; and not true.
You also say: “You do not have absurd documentation requirements that make it necessary for you to prove that what you do and say is justified.” Not true.
You then say: “All of this takes time away from what you justifiably want your doctor to do in exchange for your business. That is why she has all that bureaucracy and (your) time-wasting nonsense.” And that means I get treated badly why? I know docs who backed away from the 3-minute limit per patient, in a variety of creative ways, and they are a joy to work with. I don’t get the attitude that just because you decided to go through many years of school your time and attention can be ladled out in teaspoons. You can’t have it both ways: you can’t be bitchy and be a saint at the same time.
You’re getting pinched by the system? Well, so are the rest of us, and spending an hour in Dr Lo’s waiting room is cutting in to our ability to keep a job to pay your damn bills and the health insurance premiums.
And your parting shot: “If your doc decides to practice the way you want her to, charging you directly and dealing with you directly, she will then be denounced as elitist, uncaring, and more interested in making a dollar than caring for the less fortunate.” And that’s my problem why? and justifies the treatment patients get as I described above why? You don’t want to be denounced as uncaring, so you treat your patients rudely? Come again?
I have docs who DO walk on water, some of them, but there are too many out there who should have gotten a PhD instead of an MD and think the rest of us owe them a secure, comfortable, stress-free, fault-free, wealthy lifestyle while claiming to dispense grace and favor. Let them eat cake, as the Dr Marie Antoinette reputedly said.
Meaning: if you think the patients are the problem, then you need another job.
Anonymous
You’re quite frankly INSANE if you don’t think that patients, and the entitlement mentality that has been inculcated by our culture over the years, have a LOT to do with the new doctor/patient dynamic. Don’t kid yourself, and please don’t act as if all (or most) patients are saints, and all (or most) physicians are jerks.
Anonymous
“You do not state which profession you practice, but odds are you charge your client what both of you believe is fair, and the client pays you directly. Your compensation does not come from a third party that will pay you if it feels like it, if your claim form meets their specifications. You likely do not feel obligated to provide your services for reduced or no fee to a good chunk of your clients, often after hours, and maybe even under the compulsion of losing your ability to practice if you do not take care of these folks. You do not have absurd documentation requirements that make it necessary for you to prove that what you do and say is justified. All of this takes time away from what you justifiably want your doctor to do in exchange for your business. That is why she has all that bureaucracy and (your) time-wasting nonsense.”
Jb, you’re exactly right, all of those are the biggest problems in your lives, at least according to the blogosphere. So why is the only organized legislative action you take tort reform, which only benefits insurers? You’re all backing Bush on that issue, which makes no promises, while he cuts your reimbursement rates.
Anonymous
“You’re quite frankly INSANE if you don’t think that patients, and the entitlement mentality that has been inculcated by our culture over the years, have a LOT to do with the new doctor/patient dynamic. Don’t kid yourself, and please don’t act as if all (or most) patients are saints, and all (or most) physicians are jerks.”
Gee, thanks for the speedy and inexpensive diagnosis of my mental state. ‘Entitlement mentality?’ ah, you must mean the DOCTOR’s entitlement mentality, and yes, that is indeed a big problem here: to be entitled to screw up without responsibility while making a lot of money and looking down on the sine qua non of the income [patients]. No, some docs don’t make a lot of money, but there seems to be an assumption among too many posting MDs that they are entitled [there's that word again] to make a cool half million a year and treat patients as an inconvenience in the widget factory. These are the docs who bitch-post that all that’s needed to fix the system is to cap med mal damages. You know why I post here? Because I can’t tell my unpleasant doctors how I feel, because they would take it out on me. Now THAT’s a problem.
Bob Vineyard, CLU
Sorry, but I just HAD to weigh in on this . . .
As one who has been involved in the third party payor side of health care for quite a few years, I have seen the good and bad of the health care delivery system. I try to remain objective, but sometimes I can’t help myself.
Docs no longer have the luxury(?) of making house calls and taking unlimited time with pts. This may sound like I am old enough to have ridden on the ark with Noah, but when I was small I can recall our ped coming to the house, attending to my fever, writing a script (which he dropped off at the local pharmacy), and then having that med delivered to our door in short order.
Years later, and managed care came along and transformed us into “bean counter” medicine. In the last few years the pendulum has shifted back toward dead center where there is more of a balance of costing against the need for personal attention. I don’t anticipate we will ever get back to the Marcus Welby days, but I do believe we are better off now than say, even 5 years ago.
It is this sense of entitlement that has stirred me. Are some medical providers horsey? No doubt. But from my perspective it is the pt who should wear this crown most often.
Insured plans, particularly those offered through employers, come with low copays on routine items that encourage over-utilization. Pts have no idea what it costs to see a doc, or fill a script beyond the $20 or so that comes out of their pocket.
Many of my clients are those who left the security blanket of the corporate world and are now looking for “affordable” health insurance. Of course they still want those $20 copays, low major med deductibles and they want their plan to include dental, vision and a host of other goodies.
Did I mention they only want to pay about $200 a month for family coverage?
When they had an employer plan it was a game they played each month to make sure the claims they filed equaled or exceeded their payroll deduction.
Funny how things change once they are paying for services out of pocket. Seems they become more discriminating in their demands and don’t have the sense of entitlement that occurs when one receives coverage for free (or nearly free) and only pays $20 to see a doc.
I could go on, but I won’t. The WIIFM (what’s in it for me?)syndrome is pervasive from the consumer standpoint. Yes, my time is busy, and I deplore going to see a doc and having to wait an hour or more.
I can also see the frustration in the medical providers who are reduced to practicing assembly line medicine.
We don’t have a perfect system, but it sure beats whatever is second (Canada comes to mind) by a long shot.
Anonymous
Well, anonymous, posting above, why are you wasting your time posting here and cooling your apparently overheated heels in your doctor’s office? Please put your money where your mouth is or at least where you think it will buy you what you want. Paying with any kind of insurance is not paying with cash. It is the company scrip’ of the present age, and unfortunately it isn’t exactly negotiable, as you seem to conveniently forget.
See a doctor who gives you the time you think you need and deserve, and be prepared to pay in full for that in turn. It sounds as if you are the ideal patient for a concierge-type private practice. Squealing and moaning about not getting all the attention you want while not being willing to pay out isn’t exactly acknowledging your own responsibility in the exchange.
CHenry
Anonymous
The massive change is more likely to mean that insurance can walk. When a doctor’s office can expect to collect in full rather than only a small portion of the charge, a copay that doesn’t come close to covering even the overhead costs, then patients can expect to be inconvenienced less. There won’t be the need to determine eligibility,(some patients are also criminals who knowingly present false or expired insurance cards)or the need for referrals (sorry, but if you dear patient won’t be paying, I have to make sure someone is), or other time-wasting and costly administrative requirements. And there won’t be the need for time-consuming posting and collections tasks. I am all for it, patients pay in full, deal with their insurers themselves if they want, and practice gets simpler.
jb
Gee, it seems like I touched a nerve here. All these anonymous posters jumping on my post, all these non-sequiturs, all this anti-MD hostility that just has to be worked out.
Anon 12:29-None of us wants our patients to wait forever, and I agree that there are some docs that never seem to be able to run on schedule. In my office, I aim for 30-45 minutes door to door, and when I can’t keep to this, it’s generally because of a true emergency or unforeseen circumstances. Since many of my patients started out as these types of urgent cases, they generally understand that medicine and surgery do not run like their beauty shops or dentists, where timing is much more predictable. If your doc persists in abusing you by keeping you waiting, you can manage him by calling before you go for your visit to see if he’s running late so you don’t waste your time. Or you can find another doctor. Or you can keep going back for more abuse and then complain about it here. It’s your choice. You respond to my statements with the pithy retort:”Not true.” I’m not yet convinced, but might be if you provided a few more details, like what it is that you do, and how the federal government controls your revenue, and how the government tells you that you have 30 minutes to respond to an emergency under pain of 5 figure fines, and how your hospital requires you to operate on illegal aliens at 2am at zero compensation but definite risk of getting sued if things don’t turn out right. By the way, one of the reasons that you might have to wait to see me is that I am operating on one of those emergencies. But it’s not your emergency, so you feel abused if you have to wait. I read through my post again to see where I said that I think that the patients are the problem. It’s not there. I suspect that you are the one who thinks that the patients are the problem, all those troublesome other patients that take up your doctor’s time when he could be more usefully listening to your complaints.
Anon 1:15:You are correct that docs are agitating for tort reform, but the concept that it will only benefit insurers is a Trial Bar Talking Point, totally unrelated to the facts on the ground, and not worthy of discussion. The rest of your post is a nice example of the logical fallacy of “I don’t know anything about it, so it does not exist.” If you think that “the only organized legislative action you take tort reform,” (sic) you are either ignorant of organized medicine’s vigorous actions in other spheres, or again are reading from the Trial Bar’s Talking Points. Doctors have successfully sued large insurance companies to make them stop interfering in our relationship with our patients. Doctors assist state legislators in every state and in D.C. on all manner of health-related legislation and policy. We are trying to change the projected Medicare payment decrease scheduled for next year. You may think that we are only trying to line our pockets by doing this, but if it costs $70 to see a Medicare patient in the office, and reimbursement goes from $60 to $50, what do you think that will do to a doc’s willingness and ability to take care of grandma?
Anon 1:50- I don’t make anywhere near a cool half million a year; that’s 2-3 times the average doc’s income, but why not exaggerate when you are trying to make a point? And why not invent “the docs who bitch-post that all that’s needed to fix the system is to cap med mal damages,” since you will never find any doc in the real world who has said that. Sure, it’s something that a lot of us have said will help, but “all that’s needed to fix the system”??? It will take a lot more than that, and inventing straw men to make your argument will not advance the level of discourse.
Mr. Vineyard: Thanks for your post. An even better example is comparing the behavior of Medicaid patients, who pay $3 per visit in my state, to those who have invested in their care by paying premiums and copays for their care. Many of the Medicaid folks show up when they feel like it, and rarely call to cancel their missed appointments. Before the Anons begin bleating about how the poor folks can’t afford phones and have transportation problems, I will point out that mine seem to have access to nice rides and all have cell phones. It’s all in the attitude.
To those of you who are undecided: Many out there have a great deal of hostility towards their physicians. You are unlikely to get good results if you dislike, distrust, or resent your physician. Please find another. If you run into a series of docs who all seem incapable of meeting your expectations, maybe the problem is you. If you expect your doc to run on schedule all the time, and take as much time with you as you feel necessary, there will not be one available when you have an unexpected urgent problem. Most of the time, we do not have unexpected urgencies, so we complain about waiting, but nobody ever complained about me showing up to take care of their kid’s ruptured appendix, no matter how many people I keep waiting in the office. When I explain to the folks I have kept waiting why I’m late, they invariably say they understand and we go on with the visit. So far, no one has accused me of thinking that my time is worth more than theirs, at least not to my face.
Anonymous
“You are correct that docs are agitating for tort reform, but the concept that it will only benefit insurers is a Trial Bar Talking Point, totally unrelated to the facts on the ground, and not worthy of discussion.”
Sorry, Jb, but the facts on the ground are that this is the third “crisis” in 30 years, and is occuring even in states with tort reform. What’s more, each crisis coincides with an economic downturn. It may not be worthy of discussion because you’re not interested in learning about it, but then you haven’t been on the receiving end of someone like the Dr. Death mentioned below. You’d probably care a lot more if you and yours were.
As for the rest, if you think even 1/10 of the effort putting into denying the patients of Dr. Death compensation are put into the rest of the legislative efforts, you’re fooling yourself (which if you’re a supporter of caps is something you’re probably used to doing). But that’s mainly because the insurers don’t have a stake in the rest
Anonymous
By the way, I don’t know how much you know about illegal aliens, but they’re about the last people who go into court with a claim for ANYTHING. They are far more likely to just disappear back across the border. That’s why they’re so popular with unscrupulous employers.
Can’t you post anything on this subject without the overdone scare tactics? You’d think you worked for an insurer.
Anonymous
Whew, a lot of these nasty doc retorts assume facts not in evidence, as Perry Mason would say. You assume I think I should pay $10 copay and get gold plated service; I’ve been self employed for many years without access to those employer plans you dislike so much. My gripe with the original Dr Lo post was his off hand remark that patients don’t like waiting ‘even an hour’ — the implication being that (1) we should not mind, and (2) waits of an hour or longer are routine in his office. But somehow you skipped over that and focussed on me, the patient, being the problem.
I should just shut up, huh? My heels are not over heated, to use your phrase — these are real gripes I have. Why not address the idea of ‘pay as you go’ urgent care alongside doc appointments for ongoing medical conditions; that would let patients like me see a doc for a sore throat without having to negotiate with the receptionist of the likelihood of my imminent death. But can I find an urgent care in this town? No. Why not? I don’t know, and it’s a question I would like to hear you docs weigh in on. This IS a customer service issue, and if you care so much about your patients, then please address it — it doesn’t mean we are whiny bitchy people, it means we patients don’t think we’re well taken care of when we are treated like a major inconvenience instead of the reason for your practice.
I’ve said over and over here that I’ve been treated extremely well and had my life saved by wonderful docs, but why should that take away permission for me to say what I don’t like? The reaction here has been ‘If you don’t like it, tough cookies.’ Why is that the reaction? Doesn’t that tell you there’s a basic lack of respect for patients? I am by the way a very good patient. I never bitch about being kept waiting, I never complain about the bills, I pay everything on time, I say please and thank you to the doctor who spend nanoseconds with me and to the techs and the receptionists and nurses, I don’t cancel at the last minute, I often wait for weeks to see docs, I don’t demand the latest pharmaceuticals on TV, I follow docs’ orders slavishly, I stay away from the doc’s office except when I’m really sick and wait for a while when I do get sick to see if it goes away. I am grateful for medical care. But when I point out what is not working, I am called an ingrate.
Docs who feel this way: there is a problem with your attitude. Please soul search and come up with some productive solutions instead of complaining at and about everything and everyone.
And…it’s interesting that I’m not the only ‘anonymous’ who’s been posting here — so if you tire me out, you should realize I’m not the only one who feels this way. And you wonder why you get sued. When patients feel marginalized and ignored, that’s when they are inclined to sue. I don’t feel ‘entitled’ to anything, but some of you docs out there sure do…and you’re the ones I’m talking to. Are you listening?
jb
Thanks to all the Anons who have posted responses that prove my points. All I have seen is responses to arguments not made, references to some mythical “Dr. Death,” and resentment over being told to “shut up,” when that phrase was never used. I merely recommended that you find another doc more to your liking. Chenry was more pointed but was referring to the undisputable fact that any care that you receive under BlueCross, Cigna, United, Aetna, or any government plan is heavily discounted from the doctor’s standard fee, and that there are practices out there, known somewhat derisively as “concierge practices,” that will give you what you say you want- all the time and attention you expect. These are the practices that I referred to in my original post as being referred to as elitist, etc.
Insurance companies really will not benefit much from medmal caps. The most that they can pay out from a lost suit is whatever the policy limit is, generally a million dollars. The doc has to worry about the judgement over his policy limits, as that can lead to loss of his savings and possessions. Most docs spend considerable time and money on otherwise wasteful asset protection plans to protect ourselves from such lawsuits. The benefit from caps is that that they lead to more realistic settlement offers and fewer suits initiated when the prospect of a lottery judgement is off the table.
Bob Vineyard, CLU
Those who claim there is no med mal crisis either are ignoring facts or have no idea how to interpret loss ratio’s.
Capping awards for general damages will have some affect but not as much as some would believe. Most med mal suits are settled out of court and many fall short of even the policy limits.
Two things that can reduce payout, and have a leveling effect on med mal are better self policing by the medical profession of their own. Removing the few “bad” apples can improve conditions for the rest.
The other thing is to somehow discourage or limit the number of med mal claims. As long as juries in some areas view docs & carriers as deep pocket lotteries the game of suing the doc will continue.
Med mal premiums for some professions are their largest single outlay, exceeding staff payroll in many cases. Some specialists are paying 40% of their gross revenue for med mal premiums.
OB’s are opting out of baby catching and reducing their practice to GYN only. Others are leaving pvt practice and joining HMO’s for the limited hours and med mal cover that is afforded them by their employer.
Is there a crisis?
Absolutely, but this is entirely off topic. This thread has been interesting but it has also digressed.
Anonymous
Regarding the 3.05 post :
I think we did but I am not sure we’ve walked in each other’s shoes. I had three surgeries. As a doctor, I patiently waited one hour to see my obstetrician, for two pregnancies in a row. But I was happy that at 2 a.m. when I needed a C-section, he was there.
I worked for an assembly line type of practice for several years. I was always late because I had to see four patients every hour, most of them were managed care and the amount of papers I had to fill was unbelievable. Later, I quit and opened my own practice with the goal of seeing only 15 patients daily, answering calls directly, making house calls when needed and all the good stuff you were dreaming of. The reality is that I had to give up Medicaid, some of the HMO’s and probably soon will have to limit Medicare as well. By the time you retire, you will be able to see me right away and be treated with perfect dignity but your Medicare may not be of much help. My rent is 30.000/year and malpractice 10.000. The part-time help I have costs me 20.000 (after counting Uncle Sam’s fees). I am doing everything else by myself (including billing and cleaning the space- do you have to mop your office and clean the toilets ?). I do value my patient’s time and most of them are my friends but I know that if I would make a mistake their families would probably have no mercy in suing me. Because people are like that, not just patients but people in general.
The truth is that every human being deserves all those things you were talking about but everybody wants to avoid paying for it.
I remember once we did some physicals at church, for people without insurance. The agreement was that we won’t charge but everybody will donate something to the church. they donated between 5 and 10 $ each and then went to Bennigan’s for lunch…
I can make a suggestion : if you don’t have a walk-in clinic, why doesn’t the community rent the space and then hire a doctor to do the type of medicine they want ? It is a free society, or not ?
Anonymous
And another idea I forgot : it is true that doctors don’t care about their patients as much as they used to but it is also true that patient’s don’t care about their doctors the way they used to. Doing all things “the right way”, I also remember a patient who “loved me” but changed her PPO. Since I was not a member of the new one, she had to pay out-of-network fees to see me. It was maybe a 10-20 $ cost increase. What do you think she did ? Found somebody else who was in-network, one of those factory-type clinics. She will have what she paid for. And she was not poor, either !
Anonymous
“A physician is one upon whom we set our hopes when ill and our dogs when well.”
The Devil’s Dictionary by Ambrose Bierce (1911)
Ambrose Bierce described people’s expectations of physicians quite accurately. Even Marcus Welby got half an hour to solve the world’s problems.
As for me, I do take the time with my patients, run on time (usually), and give extra attention when needed. Which is most of the time.
I’m thinking of changing my name to “Dr. Obytheway” because that’s what they call me after I’ve spent 20 minutes with them and I’m trying to see the next patient.
The price for this is, I accept no Medicaid, no Medicare, few private insurances, and expect my patients to pay for services rendered.
Of course, what I get for this is criticism for “rejecting the poor”. Actually, I have a lot of people who have no insurance and pay cash. They’re my best patients, and I find ways to make their healthcare affordable. Those with the entitled mentality well…….there are clinics directed toward that population in my area.
They get the “assembly line” treatment.
Running a “pay as you go” acute care practice and a chronic care “appointment” practice is not possible from the billing standpoint. You are either in Medicare or you’re not. You either accept Medicaid or you don’t. You are not allowed to see some Medicare recipients in the Medicare system and others on a “cash” basis.
The walk-in clinics that provide ongoing primary care are doing all of it on a “pay as you go” basis.
Anonymous
Maybe medicare and medicaid should run their own clinics.
Anonymous
In a way, they do something like that with “critical access” clinics in rural areas, and similar setups in urban areas.
In reality, all they manage to do is find ways to extract more payment from the government for the same service a private doctor does for less payment.
As such, since they’re being paid more than I to see the same patients, I say, more power to ya.
When they call my office I send the Medicaid recipients to those clinics nearby.
This is frequently followed by abuse directed at me for not offering them the personalized attention and forcing them to go to the “factory”.
Ambrose Bierce lives.
Anonymous
Hallelujah, some rationale and thoughtful suggestions. I like this idea that if you are paid for by the govt, you see govt docs. It works for the VA, yes? And used to for the military preCHAMPUS. When you mail a letter at the post office, you don’t expect Fed Ex to deliver it overnight for 37 cents.
mw
I have read these postings with some interest and not a little amusement. Most physicians are also patients but obviously most patients are not physicians and therefore don’t see the issues from both sides. Admittedly the physician patient often gets priority treatment, but this is not universal. Anonymous #1 is correct in his complaint that it is often difficult to navigate the front office – it is true that in many offices the receptionists and even the triage nurses see themselves as protectors of their doctors’ time. That is unfortunate and those offices need to change. But it is also very true as jb and others stated that unlike an oil change or even a psychologist’s visit (the first of which has been worked out to the minute long ago, and the second is strictly time limited- “when gong sounds, your appointment is over”), medical visits cannot be entirely predicted. As a primary care physician, I don’t know if “ear ache” is going to be a routine ten minute visit or the beginning of a laundry list of complaints. I don’t know if a routine 10-year-old checkup is going to be that or the opening salvo of “I think he has ADHD.” Sometimes the extra time is not warranted, but the patient who has paid the co-pay, wants everything included in the visit and does not want to pay another $10 to come back in a week for the longer issues, when they can be appropriately scheduled. And many visits are medically warranted and must run over. From time to time we make up time because some visits are truly very quick. And there are always broken appointments that gain time. And as jb pointed out, there are emergencies. Not only surgeons who are called out for emergencies, but pediatricians called to the delivery room for a sick newborn or a C-section, internists and family practitioners who are called to chest pain patients. If anonymous #1 is complaining about the docs who routinely double and triple book and then run behind, I have no argument there. That is not acceptable. Occasional double booking is necessary, to fit a sick patient into an already full schedule, but these should be rarities. As far as “making our cool half million,” well my salary is about a quarter of that, thank you. The problem lies with managed care and the insurance mentality that has driven up usage, driven charges up astronomically (to cover the cost of maintaining a complete billing staff, absorbing the “allowed” payments the insurers make, coping with the delays in payment, the increase in non-payment, and the everpresent government intrusion. Perhaps a medical savings/checking account coupled with hospital (“catastrophic”) insurance, where the patient pays at the time of visit (but from a cash fund provided in lieu of enormous premiums, the result of savings due to the catastrophic plan rather than the HMO plan) would dramatically cut the medical office costs and thus the charges, and return medicine to a doctor-patient relationship and not a doctor-patient-insurer triangle.
Anonymous
“. The doc has to worry about the judgement over his policy limits, as that can lead to loss of his savings and possessions. Most docs spend considerable time and money on otherwise wasteful asset protection plans to protect ourselves from such lawsuits. The benefit from caps is that that they lead to more realistic settlement offers and fewer suits initiated when the prospect of a lottery judgement is off the table.”
Sorry JB, but you’re just wrong.
I’d like you to tell a patient who is looking at the kind of injury worth $250,000 plus that they are playing the “lottery.” That they should just take that lesser number because it would be unjust. Explain to the parents of a child who you’re only willing to give $250,000 for a lifetime of pain and suffering. And then tell them that you make that in under 2 years.
And the real kicker is, after the next economic downturn, tell them how your rates have skyrocketed again. Or will your short term memory loss rear its ugly head again?
But at least your precious assets will be protected, eh? I mean, it would just be too much trouble to go incorporate. That’s just wasteful. Never mind the tax benefits that come with incorporation for the small businessman. You must not work for yourself.
By the way, if you’d read the site at all, you’d see the references to “Dr. Death” just a couple of posts below this one.
Bob, juries aren’t as dumb, or as vindictive, as you think. You’ll be hard pressed to find an award that would be effected by caps that was out of proportion to the injury suffered.
jb
Sorry back at you, but I’m not “just wrong.” I’m not even wrong.
It’s not my job to tell a patient that he’s playing the lottery by filing a lawsuit. It’s his lawyer’s job to tell him that, depending on where he is in the process, he has somewhere between 1/100 and 1/5 chance of recovering any money at all, and less than 1/1000 of recovering big money. I’m sure that any similarity between this situation and your state lottery are entirely coincidental.
I have done several thousand surgical operations in my career, and not one of my patients has asked a priori for details of potential recovery in the event of malpractice litigation. If any one had, I would tell him that his maximal recovery would be gross $1million (my policy limit), less his attorney’s expenses (probably considerable), less his attorney’s fee (typically 30-40% of the total), less his own federal and state tax levy (another 30-40%). If he asked further, I would tell him that I had gone to considerable trouble to protect my family’s assets from his attorney, so he could forget about any additional recovery. I would then tell him that if he preferred that I not proceed further with my plan of care under those circumstances, it would not hurt my feelings one bit, and I would gladly provide him with a list of other physicians in our region that he could consult. I would then, absent anything emergent about his condition, ask him to leave my office and not return, as I do not provide non-emergent care to people who are thinking along those lines from the start. To simplify it further, I would have no trouble telling any patient that it is possible that he, or his child, will suffer an injury as a result of my care that he will value at millions or even billions of dollars, but that all he will be able to recover is the million, gross. It’s his choice to proceed or not.
Your statement that incorporating will protect my assets is the one that is “just wrong.” A physician (or other professional) cannot protect his assets by incorporating the way a hardware store owner can. Incorporating my practice protects me against slip-and-fall litigation, but not malpractice. Ask any competent attorney. BTW, I do work for myself, and the tax benefits are nice but not as great as you might think, after subtracting the extra costs involved.
The urban legend relating malpractice premiums to economic conditions refuses to die, but doesn’t stand up to examination. How does that explain the discrepancy between neighboring states, such as Illinois and Indiana, or California and Nevada, for the same specialties for the same year? Are their economies that much different, or is it the different legal climates that exist in these states?
Anonymous
>>But at least your precious assets will be protected, eh? I mean, it would just be too much trouble to go incorporate. That’s just wasteful. Never mind the tax benefits that come with incorporation for the small businessman. You must not work for yourself.
Incorporation is a speed bump if there’s a devastating lawsuit, it’s simple to “pierce the corporate veil”. Not much practical advantage to incorporation for a small practice. I did it anyway, for the small advantages that it offers, knowing that malpractice defense is not one of them. So what’s you’re point?
Anonymous
It’s simple to pierce the corporate veil? Tell me, how many times have you done it?
It’s only easier (it’s never simple) if you violate the corporate form and don’t treat the corporation as a separate entity – paying your home mortgage out of corporate funds, buying family Christmas presents out of the corporate account, etc. Other than that, it’s very difficult.
If you have that much of a misconception about corporations, what makes you think your assessment of the insurance and legal industry are correct anywhere else?
Anonymous
“The urban legend relating malpractice premiums to economic conditions refuses to die, but doesn’t stand up to examination. How does that explain the discrepancy between neighboring states, such as Illinois and Indiana, or California and Nevada, for the same specialties for the same year? Are their economies that much different, or is it the different legal climates that exist in these states?”
Surely you’re not arguing that these “crises” haven’t occurred everytime there has been a significant economic downturn in the last 30 years? Or that they are occuring in states that have caps? Be serious.
California can be easily explained – insurance reform. Different premiums in different states can be caused by a lot of factors. These can include anything from the number of payouts to the competency of the executives running the company and where they invest. Why did two Pennsylvania insurers go under and others didn’t? Those two made poor financial decisions and in one case they simply looted the company. To suggest it’s a matter of caps v. non-caps is simplistic at best.
Anonymous
By the way, jb, I like your full disclosure of your coverage. Would you also give full disclosure of adverse results in your practice? References of satisfied customers?
I’ve seen the proposal of waivers of liability bandied about the blogosphere, to go to more of a contract basis for malpractice. Would you also advocate more information about you and how you rate as a physician being made available to the public so they can make a more informed decision?
Considering that you would reject a patient who dared ask about malpractice coverage, I suspect that you would not. Interesting how physicians expect patients to fully understand that “you’re not God” and “bad things happen” but if a patient dare ask a question about your ability to compensate for your own negligence you fire them.
Perhaps the only contractual arrangement physicians want to enter into is one where they hold all the cards and can’t be held accountable for anything. Nice work if you can get it.
jb
Yes, I do give information about “adverse results” in my practice. Every time I discuss surgery with a patient, I inform her about the more likely and significant potential complications, and whenever I can, the percentage of cases that they are likely to occur. I compare my complication rates to these published rates, and so far have fortunately not had to tell anyone that my complication rate differs from published standards. If my rate were higher for a particular procedure, I would probably stop doing it. Even before HIPAA made it a federal crime to discuss one patient’s care with another, I did not provide “references of satisfied customers.” I rely on word of mouth for much of my new business, but it does not come from me or my office.
I would have no problem having my “report card” available for public view. The people who object to that should be patients who would find doctors unwilling to care for them if they are sicker or harder to work on than usual (obese, multiple previous procedures, hard to control diabetes, heavy smokers), for fear that their report cards would reflect these unfavorable outcomes.
I do not fire patients who want to discuss complications; in fact, as I wrote above, I initiate the discussion and occasionally make it clear to some who are wavering that it is entirely their choice to take the risk of the operation or live with whatever medical condition that brings them to my office. Firing a hypothetical patient who wants to discuss malpractice compensation would be a risk management tool. I am not perfect, nor are my outcomes, but it is a well established fact that a poor outcome in a patient who is predisposed to sue is the most likely scenario for a lawsuit. I can’t eliminate poor outcomes, but minimizing my exposure to lawsuit-disposed patients is a way for me to minimize my risk of being sued.
I hope that none of the young docs who read this blog believe the nonsense being proposed that incorporating your practice will protect your personal assets from a malpractice claim. It just ain’t so. Ask a competent lawyer. Just think: incorporating costs a few thousand in most states, and a few hundred bucks per year to maintain. Why not just do that and blow off the malpractice premium? Answer: they will take your house, your car, your savings, and your furniture, depending on state law. In my state, the house is protected because I’m married, but that’s not true everywhere. As I said, talk to a competent lawyer who is versed in asset protection.
Anonymous
Amen jb.
Find a COMPETENT lawyer, tell him/her you want to incorporate your practice to protect your assets in a malpractice suit, judge the answer for yourself.
I’m sure it varies from state to state. What they tell me in my state is it protects from some smaller “slip and fall” kinds of claims, but is of no use whatsoever in a malpractice suit. I did incorporate, but with the knowledge that the advantage for me was small.
Anonymous
Actually, as any COMPETENT lawyer will tell you, your house and car are almost certainly protected in bankruptcy, even with the new bankruptcy law. The house has limits, which you might surpass, but don’t worry – it won’t be any worse than trying to live on $250,000 for a lifetime despite the fact you have to breathe through a tube.
Incorporation can easily protect your non-medical assets if you do it. It’s not difficult. If you own rental homes, for example, place them in a corporation or LLC. Again, as any COMPETENT lawyer would tell you.
It is interesting to see that physicians wouldn’t want to work on more difficult patients. Although I guess I shouldn’t be surprised.
Anonymous
I think my state’s homestead laws protect the family Bible, 40 acres and a mule, too.
Gee, it’s so easy to protect assets. Why bother with insurance? I think I got one of your mass mailings last week. Is there a seminar coming soon?
Anonymous
Then move to a different state or advocate for a change in the bankruptcy laws.
What are you going to do when the rates don’t fall? Where will you turn next for “relief”? Or will $250K all the sudden not be enough, just as $500K wasn’t for Missouri?
I hope your memories of this “crisis” last longer than your memories of the last one. It’s a lot easier learning the fallacy of tort reform that way than having to learn it by being a victim. Of course, what with your indestructability, that’s probably not an issue for you.
Anonymous
The cap in Missouri wasn’t enough, not because of the dollar value, but because the cap could be lifted in so many exceptions that it was useless.
This time round, they got a hard cap, which was what they wanted in the first place.
http://msma.org/cgi-bin/cgiwrap/msmaorg/htmlos.cgi/003169.5.2288874789915668050
Anonymous
And when this cap isn’t enough? Where will you turn then?
Or will you even remember 10 years from now during the next economic downturn? Or do you just figure that you’ll be retired, so screw the injured patients?
Anonymous
Try retiring on that $250,000 for a lifetime your jury award got knocked down to for having the wrong kidney removed. Or being disfigured for the rest of your life as a result of a burn.
Anonymous
I’d sue my lawyer for not getting my economic damages addressed.
Anonymous
Sorry, but if you don’t have any lost wages (ie, you’re not employed), you don’t have any extra money to retire on.
You’ve got money to pay your caregivers and medical bills. That’s it. You’re not even going to make it to the beach in Mississippi on $250,000 for a LIFETIME.
Anonymous
glory be, I finally got you to admit your lie that noneconomic damages are all the injured party gets.
We’re getting somewhere.
Anonymous
Actually, it is all they “get”. The rest goes into the pockets of caretakers. If your mama gives you $20 to go to the store and get $15 worth of goods and you can keep the change, you didn’t get $20. You got $5.
If a child gets a $25 million award in a state with caps, then all but $250K of that will end up in the hands of caregivers. That’s it.
Although your statement does serve to further illustrate the fallacy that caps will have any effect on insurance premiums (it will have plenty of effect on victims). It’s a tiny percentage of cases that will even be affected by caps.
That’s why these insurers and Medical Association reps made the following statements:
“While MICRA was the legislature’s attempt at remedying the medical malpractice crisis in California in 1975, it did not substantially reduce the relative risk of medical malpractice insurance in California.”
~James Robertson, Assistant Vice President and Associate Actuary, SCIPIE Indemnity Company (California’s second largest medical malpractice insurer), in written testimony responding to a question from an administrative law jugdge who is overseeing a case in which SCIPIE has requested a 15.6 % rate hike. April 30, 2003.
“Non-economic damages are a small percentage of total losses paid. Capping non-economic damages will show loss savings of 1.0%.”
~GE Medical Protective regulatory filing with Department of Insurance (TDI), October 30, 2003. The revelation was contained in a document submitted by GE Medical Protective to explain why the insurer planned to raise physicians’ premiums 19% a mere six months after Texas enacted caps on medical malpractice awards.
Anonymous
You can’t eat money. My “mama” gave me twenty bucks, I got food.
The person didn’t “get” the money in that it went to the caretakers.
The person “got” care. To say the person got nothing is just another lie.
The person with “no income” either magically found a way to live on nothing, or had some source of income to pay the rent and put food on the table before the accident. He continues to have that. If the income had come from savings and was exhausted, that’s economic damage.
You’re good at twisting words, the fact remains that economic damages should be paid. To the extent that they’re not paid, it’s a failure of the plaintiff lawyer.
Now throw out your bag of quotes. It’s time to change the subject again.
Curious JD
A child has no income, his sole source of income is his parents.
I used direct quotes from your allies. Sorry you didn’t like them, but they certainly weren’t twisted. You can verify them for yourself – I told you where they were published. It must really suck to find out they are contradicting everything they’ve told you when they are under oath and trying to raise rates.
Anonymous
Is this conversation still going on, being April, 11, 2007 or is this old and has stopped?
TY,
PD
Brandy
Healthcare is a joke. I lost my job and therefore my health insurance and then found out I was pregnant. I had to go on medicare because I don’t have $10,000 to pay for having my baby. Let me tell you, being on medicaid is not fun. I hate going to my doctor visits because the staff treat me like I’m a piece of crap that’s just a waste of their time, all for being on medicaid. No one greets me with a “hello” no one asks “how are you?” nothing. I get, “get on the scale!” and “Go give me a urine sample!” and that’s it. Basically I’m less than human and ignored, I don’t count, I don’t exsist, and they act like they’re doing me a favor by seeing me. I hate doctors/ nurses and the whole healthcare system. I’m just so sorry you doctors aren’t making all that much off of me.

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