Why doctors have poor customer service

One of my docs was telling us about a patient’s experience at another practice. Apparently, the parent was at her wits end with her crying baby. She called the  on call doctor to ask for advice and the doctor told the patient, “your baby has colic’s; turn on the vacuum and stop calling.”

It turned out the baby had some gastric condition (not colic) and needed treatment. The patient ended up leaving the practice and ended up at ours.

I do not know what the exact circumstances were. Sometimes patients can tell a story that completely justifies their actions. So in the absence of the complete story, I am not going to rag on the rude doc.

But the fact is we hear stories like this all the time. I’ve encountered people that have been so rude, I actually thought I was on one of those prank shows where the objective is to see how long the customer goes before blowing his lid. No, “You Got Punk’d!” They were legitimately rude.

I think we — and when I say we, I mean the provider side of health care — can all agree that we do a poor job (generalizing of course) with customer service. I mean let’s face it, very few of us could go up against a Southwest Airlines.

Why is that? Why aren’t we better?

I think one of the reasons we have poor customer service is because we are overwhelmed. There are so many patients, and so few of us, that if we are rude to people and they leave, it’s almost a blessing because that is one less patient to worry about.

But it wasn’t always like this. Think back to when the practice was brand new. Think back when you got your first job after residency in a private practice. How did you view the parent then? As a nuance or as an opportunity to help?

The interesting thing is that when practices are just starting, they pull out all the stops for patients. This is also true when numbers are down. I’m sure it happens to the best of us.

It seems to me that the challenge is to have enough patients to keep growing, but not enough where we get too overwhelmed.

Brandon Betancourt manages a pediatric practice and blogs at Pediatric Inc.

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  • http://geekofficesolutions.com/ Geek Office Solutions

    I think one of the biggest issues facing doctors offices (family practice, small offices, and even hospitals) today is a lack of centralized and digitized documentation. Once all of a patient’s medical records can be quickly and easily accessed, I believe it gives the doctor (and patient) the power of data – which is always the best solution for smart and logical conclusions! Just a thought, hoping to hear from others too!

    • Vox Rusticus

      No, I don’t think that is the biggest problem for doctors.. It might be the biggest problem for medical office software vendors, however.

      • http://fertilityfile.com IVF-MD

        Ha ha. Well said VR, and I thought I was bad about straying off topic sometimes. How did a post about customer service get hijacked into an advertisement for EMR? :)

  • Vox Rusticus

    I won’t make excuses for anyone’s rudeness. Even if shortness was provoked, that is still a loss of control in the professional setting, and better responses are called for and need to be applied. Sometimes that is taking a breather, asking to get back with a caller or some other tactic that will allow for appropriate emotional control. Being overtaxed and under-supported is almost a surefire way to wear anyone’s patience, and some settings are more vulnerable to this than others.

    Managing interruptions is an art. Office staff have got to be expected to master this skill and held to account when they don’t..Those without this skill have to be trained and then expected to demonstrate their mastery. Not every call needs immediate attention, and employees and patients have to understand that. Rigorous triage with focused and intelligent query is essential, and generally, if a doctor is in the middle of seeing patients, he is not to be interrupted. Calling back when free, whether between patients or at the end of the morning or day will depend on the urgency. The expectations of everyone need to be managed. Some calls back do have to be done urgently, and others less so. The best way to keep everyone cool is to tell the caller when they may expect a reply. Most will accept this kind of accommodation. For the few who don’t, those for whom every reply must be immediate, a transfer of records form is sometimes necessary.

  • anonymous

    Is it really a case of simply being overwhelmed? Or is the real issue that when business is good, it’s easy to start taking your clientele for granted? I think we’re all guilty of skipping the niceties when a relationship starts to feel routine.

    • Vox Rusticus

      Certainly one has the extra time to be attentive when business is slow, as anxiety-producing as that can be. One wants first to be busy. Once busy, things like over scheduling, interruptions, payment aggravations and other aspects of busy practices become more of an issue.

  • Former timid patient

    As a patient, I would like to add that the rudeness (and lack of listening ) can occassionally be life threatening. I once called an on-call ob/gyn and told him I was hemoriging. The reply was a very rude “Do you know how many women call me and tell me their hemoriging? Go lay down.” Later that day, I was admitted to a ICU with a blood count of three. The rudeness occassionally have severe life threatening conscequences and forever changes the interaction with any medical professional.

  • anonymous

    my vote is for overwhelmed, and part of that is due to the increased sense of entitlement from patients, also due to decreased perception of physicians as experts (thanks internet), and increased regulatory mandates.

    however, i wonder how much of the author’s recollection of boundless customer service was just due to youthful energy and possibly more free time than anything else?

  • Jenga

    You get what you pay for.

  • Matt

    Physicians aren’t in the customer service business. The customer doesn’t pay them, and they’re not rewarded based on how they treat the customer.

    People do what they’re incentivized to do.

    • HJ

      People do what they’re incentivized to do.

      So your only incentive to treat people with respect is money?

      • Kileen

        Did you interpret “only” from Matt’s post? I must be missing something, I didn’t see it that way. If a patient said to me, “So your only incentive to treat people with respect is money?”, based on what I see has transpired in this blog, I would find the comment a little stand-offish. Belligerent? Maybe. Not friendly and building affinity for that person. When I go to my doctor I try to be very pleasant and nice with the staff and the doctor, and they treat me like a VIP so I guess it goes both ways :-)

        • HJ

          Maybe Matt could clarify but it seems to me that he said doctors don’t provide customer service because they don’t get paid to do so.

          When I interact with people, I don’t need any money to be respectful.

          If you continue reading Kevin’s blog, there was advice a few weeks ago to be the “squeaky wheel.” Maybe the squeaky wheel is told to “turn the vacuum on and stop calling.”

          I would guess you get treated like a VIP because of your profession. In my experience, politeness just gets you shoved to the back of the line. I am always treated like I am in the way and would rather get my information from the internet

          • Matt

            If you make more money by seeing more patients – what are the vast, vast majority of people going to do? Move them along.

            They may not be rude, but they may be efficient and brisk. Many people take this as rude. But most of those people aren’t paying for their care out of pocket, and don’t value the time. When you hire any other professional, like a lawyer or architect, I promise you’ll care about the time far more than whether you get the requisite coddling.

            Now, whose fault is it that physicians don’t get valued for their time? Well, everyone’s, including physicians. If you want them to pay more attention to you, work to change the payment model to something other than flat rate per encounter.

    • Dr.Z

      Can’t post a reply to Matt’s Oct 8/0955am post.

      Quoting his last para:

      “Now, whose fault is it that physicians don’t get valued for their time? Well, everyone’s, including physicians. If you want them to pay more attention to you, work to change the payment model to something other than flat rate per encounter.”

      First, reimbursement is not a “flat rate per encounter”. Reimbursement is based on the procedure codes performed. CMS designed the fee for service model over the objections of AAFP membership. Insurance carriers jumped on it as a way out of the maze following crash of the HMO adventure.

      But to his first comment: “If you make more money by seeing more patients – what are the vast, vast majority of people going to do? Move them along.”

      You don’t make more money seeing more patients. You make more money doing more procedures for as many patients as you can. The capacity is full. There is a line out the door, down the block, and around the corner.

      Did you know that Mayo Clinic’s Arrowhead Family Medicine Clinic in Glendale, AZ terminated services to over 3000 Medicare patients effective 1 Jan 2010 due to the continuing losses that Medicare patients were causing Mayo Clinic … not just its PCP clinic … but its MC in Phoenix too. The 2-year test program eliminating Medicare patients from being serviced will be evaluated and a decision made to take the same action Mayo Clinic wide (Minnesota, Florida). There is no shortage of people wanting to see a PCP.

  • anon

    Come on.I am sorry but, being overwhelmed is no excuse for being rude to patients or anyone. Most jobs that I know of are stressful and overwhelming, especially ones that pay a good salary and carry a lot of responsibility. What if we all decided to lower our standards, because we couldn’t handle our jobs and responsibilities? Patients deserve our respect, and our livelihood depends on our patients. Let us not forget.

  • BladeDoc

    Here’s the problem from the standpoint of a surgeon:
    1. Almost none of the problems I get called with at night are life threatening.
    2. Those that ARE obviously life threatening usually don’t generate a phone call, they generate an ambulance ride to the ED.
    3. Generally speaking I can’t do anything about it over the phone anyway whether life threatening or not.

    Which is why, generally speaking my answers go something like this. Blah, Blah, Blah go to the ED.

    Except last week at 2 am when I got a call asking if someone that had a minor operation 2 weeks previously could have sex. Of course I said no and that having an orgasm within 6 months of surgery would cause immediate death (not really, but it was tempting).

    • HJ

      “Which is why, generally speaking my answers go something like this. Blah, Blah, Blah go to the ED.”

      After surgery, a patient is usually given a piece of paper with instructions. Those instructions usually list a set of symptoms that need to be address right away. Somewhere on the paper, there is a phone number on who to call when these symptoms occur. So if you are going to send all questions to the emergency room anyway, why waste everyone’s time with that piece of paper? Perhaps your discharge instructions could say, “I can’t help you over the phone so just go to the nearest emergency room with your questions.”

      • Jackson MD

        Call that number and make an appointment.

      • Mudpie

        Perhaps your discharge instructions could say, “I can’t help you over the phone so just go to the nearest emergency room with your questions.”

        Because sometimes the patient interprets what they’re experiencing as a life-threatening issue when it’s not and that can often be resolved on the phone to the doctor and reduce the use of the ED. For example, the other night my husband received a call at 10PM, from a patient who’d had surgery four days prior – the question was related to her feeling off, a bit of cramping and continued bleeding….she was starting to feel dizzy and worried she’d lost too much blood. DH asked a bunch of questions and assured her she wasn’t dying (she wasn’t), told her to come in to see him in the AM and to eat something….turns out she’d not eaten for over 24-hours since the pain meds were making her feel yucky, hence her feeling off and dizzy. Next day she went in and she was fine. That call saved an unnecessary trip the the ED and reassured the patient that she wasn’t dying.

  • anon

    Blade Doc,

    I would be willing to bet that you are not a surgeon, judging by your unprofessional comments. Or perhaps you are a lousy one, and only envy the ones that CAN help a patient by answering questions and addressing concerns over the phone. After all, you probably made a lot of money doing the patient’s surgery. You shouldn’t be whining about a few phone calls that come with the job.

  • http://fertilityfile.com IVF-MD

    When we get patients who were seen at another center and who describe in detail a legitimate gripe about something unsatisfactory over there, this can be used constructively in many ways.

    1. We can take that information and shape how we do things to avoid making that same mistake.
    2. We now have a patient for whom to try our best and give them something totally different from their experience at “that bad place” Sure, if we fail, they will go elsewhere and complain about us. But, if we succeed, they will spread the good news and bolster our reputation. That is pretty strong incentive for us.

    This rewards us with more job satisfaction for helping the patient in a way that betters their life and earns her gratitude and it also of course helps support our practice financially. Win/Win.

    What Matt correctly said about “Physicians aren’t in the customer service business. The customer doesn’t pay them, and they’re not rewarded based on how they treat the customer.
    People do what they’re incentivized to do.”
    only specifically applies to when third party payers intrude into the doctor-patient relationship.

    • HJ

      “only specifically applies to when third party payers intrude into the doctor-patient relationship.”

      When a friend of mine hit my car, someone from her insurance called me…very polite and helpful…an insurance adjuster came to my home to inspect the damage…very polite and helpful…the autobody shop gave me an estimate and coordinated with the insurance to make sure everything was covered…very polite and helpful…when I brought my car back to the autoshop because there was a problem, they fixed it…very polite and helpful. Since I was not the one paying the bill, what incentized these people, paid by a third party, to be polite and helpful?

      Perhaps the third party is not the barrier to customer service, it’s the shortage of available health care providers and the guarantee of payment regardless of outcome or satisfaction. If I have no recourse for not getting quality service and there are so many customers that walking away doesn’t matter, why would a doctor bother being polite and helpful?

      • Vox Rusticus

        They were polite to you, a stranger, because they are hired and trained to be polite. Her insurance was on the hook for your damages. They were the carrier that would have to pay generously if you filed a whiplash claim. They were nice to you because making you upset or angry might have prompted you to make more expensive claims.

        Did you stop to wonder how nice the same company was to their own insured in this incident?

        If you ran your car into a tree or guardrail, and were turning to your own carrier to pay the body damage bills, they wouldn’t have to be so nice to you. They might pay the claim, but then they might also drop your coverage to get rid of you as well.

        How do you come from the third party barrier to the availability of doctors conclusion? Let me put it another way, since payment is not guaranteed by the insurer (and it isn’t; I don’t know why you think it is) what incentive is there for me to make you “satisfied” (as if I were a retail clerk)? None. You wouldn’t pay me a penny more for satisfaction, and for that matter you don’t expect to pay me at all, except for a token co-payment. And suppose there was a flood of new doctors to the market, it would seem your demonstration of satisfaction would be to go to one you think satisfies you more and leave the one who satisfies you less. But that new doctor will eventually be busy enough that he can’t see any more patients and then what? What then does he get for doing more for you? You wouldn’t pay him anything more. He could replace you with another hopeful patient if you left.

        The third-party system as practiced now does work against customer service, because it restricts payment. Only the cash-pay patient and the out-of-network patient escape the third party control.

        • Alina

          How does the third party payer restricts payment? My insurance company doesn’t really seem to care at all about how much they’re paying. After all it’s not their money they’re wasting. Just out of curiousity I called them to find out the code for my 10-min visit for which the doc billed $210 and got $145. I wasn’t able to get that information.

          • joe

            Here we go again:
            A little math
            $145 dollars per 10 minute visit X 6 visits/hour X 8 hours per day X 4.5 clinic days per week X 48 weeks per year = $ 1.5 million per year.

            Well docs, how many of you (especially PCP’s) are grossing 1.5 million a year?

            Conclusion: You have an amazing cadillac insurance compared with everyone else or something is just not adding up here.

        • HJ

          “They were the carrier that would have to pay generously if you filed a whiplash claim.”

          I was not in the car at the time of the accident.

          ” Only the cash-pay patient and the out-of-network patient escape the third party control.”

          The out-of-network patient gets ripped off.

          “what incentive is there for me to make you “satisfied” ”

          And that’s really the question, isn’t it.

          • HJ

            “The third-party system as practiced now does work against customer service, because it restricts payment.”

            So if a insurance company paid $200 for a 10 minute visit, and I paid only $50 as a cash paying customer, would you feel the same way about the insurance companies?

  • http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD

    This discussion is hilarious because the answer is so simple.
    Patients who use insurance for your healthcare: you are NOT a doctor’s “customer”
    You forfeited that right when you chose the “comprehensive plan” from your “insurance co.” to ration your care.
    The insurance-based doctor’s customer is the INSURANCE COMPANY, not you. That’s reality. Want customer service? Deal with your doctor DIRECTLY. Demand from your doctors price transparency. You may be pleasantly surprised with what you find out.

    • Alina

      I may be missing something. Do you treat the insurance companies or you treat the patients? Even though the third party may pay the MD’s bill, in most instances they are nothing more than an administrator of someone else’s money.
      Without patients doctors would not be in business, hence patient = customer. It’s that simple.
      You have a concierge business so I can see why you’re promoting this type of practice. Even though I’ve seen a lot of complaints about how insurance companies don’t pay doctors that much, I am yet to see an EOB with a rate of $60-70 as some mentioned on this site. My recent doctor’s appt was $145 for 10 minute consult – no major medical decision and nothing complex. Further the “rack rate” was $210. I didn’t have to pay more than my $15 copay for this, but I find this price totally outrageous and irresponsible on both sides, doctor and insurance company. Then we’ve wondering why the healthcare cost is so high!

      • Vox Rusticus

        So as a “customer,” you would not pay anything more than your $15, no matter how good the service?

        BTW, consults cost more because of extra correspondence to the requesting doctor. (Unless you are under Medicare, where they cost more but don’t pay any more, go figure.)

        If your insurer pays $145 for a ten minute consult, tell me what that carrier is, because I only get that level of payment for a much longer encounter, no matter what the “rack rate.”

        By your argument, you object to the payment made, $145, not because of the service but because of the time required (or not required.) Are you suggesting paying an hourly rate? Tell me, how much of a board-certified medical doctor’s time do you think you ought to have for your $15?

        • HJ

          “you would not pay anything more than your $15, no matter how good the service?”

          I believe you signed a contract that said you can’t accept more money from me. Maybe you could put a tip jar by the receptionist’s desk.

          My doctor also receives $125 for an appointment that takes about 15 minutes. Many times the doctor is in and out of the room in less than 15 minutes. My former PCP at the big box medical center received $285 dollars for a 10 minute visit with a nurse practitioner. Perhap you should reconsider where you practice medicine if you want to make more money.

          “Tell me, how much of a board-certified medical doctor’s time do you think you ought to have for your $15.”

          So what about the cost of premiums? Medicare/Medicaid taxes? Employers raise prices to cover the cost of insuring their workers. All the money you receive comes from consumers. Did you think the money materialized out of thin air?

          • joe

            Yet again:

            285 dollars/10 minute vist X 6 visits/hour X 8 hours/day X 4.5 days/week X 48 weeks per year = 2.95 million per year.

            Tell me docs who many of you (especially PCP’s) are grossing almost 3 million per year.

            This is simply not the reality of the equation.

        • Alina

          So why is the customer in quotation mark? Who are you providing that consultation for? Is United or Aetna or Cigna or the likes bringing their company to your office and you examine their buildings, or are you examining the patients?

          If you could read my statement correctly you would find what I actually said, which is $145 for 10 minutes is way, way too much.

          “No matter how good the service”….I’m not sure that I would call that good service. The guy was quite clueless, which exacerbates the issue with the high payment. If you can’t even treat a sore throat, then what can you really do? And please don’t tell me any of that non-sense that I didn’t get what I wanted because I didn’t ask for anything. My throat is still sore after almost one month and now I have to go to yet another doctor to see what’s going on.

          “If your insurer pays $145 for a ten minute consult, tell me what that carrier is, because I only get that level of payment for a much longer encounter” It’s a national carrier (not United or Anthem).
          “Tell me, how much of a board-certified medical doctor’s time do you think you ought to have for your $15?” Don’t understand why you keep harping on the $15 copay when that’s not all the doctor got. In total he received almost 10 times that amount…have you missed that part?
          Since I remember you once mentioned that you are in Maryland, Medicaid pays $29.50 and Medicare $45.27 (this is for the metro DC which is higher than the other two areas listed). This fee would be for a new patient, 10 minute visit. The Medicare fee is adequate.
          Was your comment regarding the board licensure suppose to impress me? This along with the whole education debacle is overused and not doing much for your argument.
          “….doctor’s time..” – is there a reason why some doctors think of themselves as above everyone else? In terms of education, quite frankly you do less than someone with a PhD which actually requires a bachelors, and most times a masters to even enter the program. For a med student you only need 90 credits to apply. In terms of the residency, you do the 3 years but you get paid for it, so it’s more like an entry-level job.

          • Vox Rusticus

            “For a med student you only need 90 credits to apply.”

            Where? Not at my medical school. Everyone had to have a bachelor’s degree and many had master’s degrees as well. With the typical science pre-requisites, the bachelor’s degree required at least 132 credit hours, well in excess of the minimum number of credits required for that degree. Oh, and you had to do well; you wouldn’t be competitive without degree honors.

            “In terms of education, quite frankly you do less than someone with a PhD which actually requires a bachelors, and most times a masters to even enter the program. ”

            Wrong. Medical school is four years after completing a bachelors, just as long as a Ph.D. generally would take with the Masters degree in course, unless you were unable to complete your dissertation on time. Why do you write such things when you ought to know that medical students are in universities along with graduate students in Ph.D. programs? We know very well how much work is involved in graduate degree programs, and it is less in terms of hours of work than for an M.D. A lot less.

          • Alina

            Vox

            I’m replying here because there was no option for your comment.

            George Washington University Medical School states that entrance requirements is 90 credits, so you do NOT need to have a bachelors to apply. Columbia University states 3 full years – again, no bachelors degree needed. I bet that if I would to do the research on all med schools I will find the same trend. So your comment “Everyone had to have a bachelor’s degree.” is just not true. What school did you go to? BTW, try studying in Europe where you go to med school for 6 years straight from high school. This is pure med school, none of the “liberal arts” and other unrelated stuff that some docs go for prior to med school in the US.

            “With the typical science pre-requisites, the bachelor’s degree required at least 132 credit hours” Here is a thought – incorporate the science classes into the 90 credits you need to go to med school. Why you’re saying you have to do anything extra? It’s juts not how it is.

            “We know very well how much work is involved in graduate degree programs, and it is less in terms of hours of work than for an M.D. A lot less.” Really? So the PhD in chemistry, math, or physics is less demanding than med school? Who usually discovers the life saving medicine that doctors use to treat their patients, which otherwise they couldn’t do by themselves? I think that this kind of talk about how doctors are the smartest is really counterproductive. There are some good ones out there, but there are also some very lousy ones. Just like in any other profession. Having an MD after your name doesn’t guarantee that you’re smart or good at what you do. In my experience, the good doctors are also the humble ones, while the arrogant ones couldn’t do their job right if their life depended on it.

            I wonder why people post things that are not accurate when they are easily disputable by a simple research. What is there to gain from this?

  • stargirl65

    Agree most on call phone calls are not emergency. Most are:
    1. I ran out of medicine and will you call it in. This is usually because they missed their last appointment. With EHR I can access the record at home and determine this. Giving you a prescription because you don’t want to come in is not an emergency.
    2. I’ve been sick for a week and didn’t have time to come in and will you call something in. Not an emergency.

    That is 99% of phone calls. I might be rude if you wake me for this.

    • healthcareProf

      When I used to take call, it was one of the duties of my job. And I was actually compensated very well to be on call. Yes there may have been times when these call didn’t seem like an emergency to me, but it didn’t kill me to do my job and answer the question. If I ever found myself whining about my job, I would have been told to find a new one.

      • JRB

        @proff, Back when I was doing it we used to walk both ways in the snow, uphill….

        My priest gets people coming to his house late at night asking him to baptize their nine year old kid or bless their house that they lived in for three years already. He and I were venting to each other and he said he wanted to tell people, “Why does your lack of foresight and planning constitute and emergency for me?”

  • Ralph

    If I got paid to do call I wouldn’t mind the nonsense calls. I feel Pt’s take for granted healthcare since they feel that they paid for it already. All they paid to was the insurance. company, not to the Dr. I get about 50 cents on the dollar as reimbursement. Would Pt’s pay extra for calling a Dr after hours for a callback??

    • family practitioner

      I agree with Ralph.
      Why do patients call after hours for inocuous reasons?
      Answer: because they can. It costs them nothing extra. It’s convenient. They get what they want, ie free advice, a scrip called in, etc.

      In the olden days, before primary care was squeezed and triangulated by the third party payor system, this was part of relationship betwixt doctor and patient. As this relationship has become more strained, however, the privilege of calling your doctor after hours has been abused. Similarly, because primary care doctors feel taken advantage of, this has become a more and more difficult part of the job.

      • a med student

        Why don’t more Family Docs go into the Ideal Medical Practice / Direct Pay / Affordable Concierge model??

        The most common and most understandable reason (which most docs don’t want to admit to) is the risk averse nature of doctors. It takes guts to switch, but many have done it, why don’t you?

  • Ralph

    my favorite calls are when I call back the pt and they are not at the number they left for me to call at. Unfortunatly I feel pt’s think that Dr’s get paid for many things that we don’t

    • healthcareProf

      Who are you kidding? Doctors get paid quite well compared to the general popuation. Any accountant who has done taxes for an MD would agree. We must all earn our keep
      in this world.

      • Vox Rusticus

        Who cares? I have a level of education, training, vetting and acquired expertise far greater than any example from the “general population.” (Are you writing from prison?)

        Any accountant who has done taxes charges by the hour, or at least any accountant who has done taxes for me has done that. Chit-chat on the phone is no problem; one can charge by tenths of an hour as well.

        Yes indeed, we must all earn our keep, which is why I find it surprising that someone calling himself “healthcareProf” has such difficulty understanding why a doctor should expect to be paid for professional advice, whether given face-to-face or over the phone. Any accountant could understand that.

  • guest

    Doctors may get paid “quite well compared to the GENERAL population” but that is very misleading since the vast majority of people don’t go through the same hardship. You would have to compare them with people that are as intelligent and hard-working; engineers, PhD’s, etc.

    In regards to physical hardship, I would much rather by humping a 40 pound back pack over 20 miles than doing 30 hour shifts for years. Of course, not everybody love physical pain.

  • Bruce Hopper Jr MD

    Alina,
    You see, I don’t treat “insurance companies” anymore because I don’t take private insurance. Thus, I’m free to care for patients directly.
    “Without patients doctors would be out of business”
    Your logic defies reality.
    Mine does not as I’m finding out with my “concierge” practice.
    I’m building it from scratch, and, I’m happy to say, it’s growing…. because I use technology wisely to communicate with my patients…
    and because they have fantastic access to me…
    and because I don’t make them wait an hour for a 6 minute visit…
    and because I coordinate all other care and services they need…
    and because my prices are transparent and affordable…
    and because I deliver a personalized service.
    I do agree with you that the pricing is both “outrageous and irresponsible” in your example. But don’t blame only “doctors and insurance companies”. YOU are an active participant in this dysfunctional system.
    A little math… In your scenario the doctor collected $15 + $145 = $160 for 10 minutes. You forgot some details, however. A primary care doctor’s office carries about 70% overhead. So, $160 X 0.3 = $48. Your’e also assuming the transaction is clean, does not have to be resubmitted, etc.
    Too bad, if you saw me 10 minutes would cost you $40 if you were a member ($35/month, with additional perks, including 2 “free” urgent care visits.) or $50 if you were not a member. You would have saved the “system” ~ $110 – $120. But, then again, you probably only look at your own out of pocket costs ($25 – $35 bucks more).
    You can’t have it both ways.

    • Alina

      You stated that my logic defies reality because I said that without patients doctors would not be in business. How is that? You provide a service to someone. If that someone is not in the picture who are you providing your service to?

      All these services that you listed you do, isn’t that what you suppose to do as a doctor in the first place? There are some physicians who seem to think that they are entitled to charge people an arm and a leg just to do their job. I’ve seen your fees are they are more moderate, but there are other concierge businesses who charge the patient an average of $1,200-$1,500 per year on top of the usual visit fees (copays and insurance payment). I’m by no means a fan of the insurance companies, but I find these concierge businesses offensive and completely immoral!

      You’ll always going to find some people that make more than others in any business setting. If one is only motivated by money they will never be satisfied, no matter how much cash you throw at them. Incidentally such individuals are also the least competent and the laziest bunch.

      Overhead for primary care is between 45% – 55%. It appears that you have not seen on EOB, otherwise you would know that it even lists the payment date and there were no resubmissions. You will notice that I asked the insurance company what the procedure code is b/c I suspect the doctor might have more time than he actually spent. It’s not unheard of you know.

      You say that I’m at fault as well b/c the insurance company paid so much. Not quite as I don’t work in the benefits area for my company. If they would do their job right they would also check on the rates the insurance company has negotiated with the providers and would not accept such fees. Perhaps is another one of this people that “doesn’t make that much” so they don’t care….

      If I would have looked only at my cost as you put it, I wouldn’t have done the research in the matter. You seem to conveniently overlook the fact that we also pay a monthly premium. This on top of the employer’s share, which also affects the employees benefits as well as job security. It’s a vicious circle.

  • http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD

    Alina,
    We agree. Indeed, it is a vicious cycle. Angry patients, angry doctors. Yet, 3rd parties love how we bicker amongst each each other. “Insurance” does NOT equal customer service service, despite contracts.
    Overhead for primary care between 45-55%??? What are you smoking?
    Go to http://www.einsurance.com. Do some research. Don’t know your given situation. I suggest high deductible, catastrophic coverage plan. Find a good direct, cash primary care doctor. We are growing nationally. Feel free to contact me directly at brucehopperjrmd@gmail.com. Maybe I can steer you in the right direction. Otherwise, good luck with a primary care doctor you find through your traditional “insurance” plan.

    • patient

      http://www.ehealthinsurance.com is what you meant to write.

    • Alina

      “Yet, 3rd parties love how we bicker amongst each other.” I totally agree and I actually posted the same thing some weeks back for a different article. I believe that insurance companies are a waste of money and I posted this several times. It’s ridiculous that their CEOs make so much money off of all of us and don’t even offer decent insurance to their own people who all they have is these horrible high deductible plans. With the profits they make every quarter (billions of dollars) we could offer care for a lot of people that are left out of the system. What’s sad is that the new law also favors the insurance companies, rather than to actually help people. Politicians on both sides of the isle are to blame for this.

      We have to adopt a bottom up instead of the top down approach that we currently have. What this means is that doctors and patients have to work together to change this system.
      At the same time I don’t think that the solution is to have a concierge business that is exclusive to some people that can’t pay these extreme fees (not in your case, but in most). Even though your fees are moderate and many people may be able to pay, there are still out of reach for some and I don’t agree with discarding anybody like they’re an old pair of shoes. Also, besides your fees people would still need coverage for hospitalization, specialists, tests, etc so what should they do?

      Other countries offer health care to everyone, why can’t we? Don’t we say in the US that we are the best, the strongest, the brightest? Why is this not the case when it comes to caring for people’s care?

      If doctors would refuse to do these 5-10 minute “visits” and would instead plan, things could change and they would still make money. Patients would also have to be engaged and take some ownership for their own health, but we have to first give them the tools to do so. Sure it would take a bit of effort initially to make the transition, but it would be well worth it.

      “Overhead for primary care between 45-55%??? What are you smoking?”

      It comes from the physicianspractice – here you go – click on the overhead spreadsheet

      http://www.physicianspractice.com/display/article/1462168/1625176

      “Do some research.”

      Guess what, I actually do a lot of research..some for my job and the rest because I feel very passionate about this whole healthcare issue.

      “I suggest high deductible, catastrophic coverage plan.” Why, I have insurance. I detest this type of plans and I would actually not sign up for one if given the option. They cost as much as a traditional plan and don’t give you much of anything before you actually meet that deductible. They’re nothing but garbage.

  • Ralph

    Alina you may be finding new stats for upcoming med school students but most of us (like myself) who have been in practice for greater than 10+ years needed 4+ years of an undergrad in a heavily influenced science background program. Even then it was still very competitive to get into any MD/DO school in the US. I’m sure it’s different in Europe but everything is including malpractice. Try being a Dr where you can’t make a mistake or have a pt not like an unexpected outcome for fear of being sued. That is a Huge difference from any PhD.

    • Alina

      I can’t say that I know how it was 10+ years ago. If it was different, it’s interesting that schools (and good ones) would lower their standards nowadays…

      I’ve met doctors with humanities and other unrelated course work prior to them completing their med education and being from Europe I thought that was strange. Back there the general education is all done in high school, so once you go to college you study your chosen subject – that’s it.

      “Try being a Dr where you can’t make a mistake”

      Yet there are plenty of mistakes made every year, some that actually cost people’s lives. How much do you think one’s life is worth? Nothing at all? What if it’s someone in your family that is dear to you?

      If competency would increase I bet that malpractice insurance would be much, much lower. Do you think about that?

  • a med student

    Alina – you are correct, some* medical schools allow accept students who have not technically earned a Bachelor degree – these are unique programs and are the exception, not the standard. These schools accept exceptional students to enter Med School after their Sophomore or Junior year in College. Pointing to exceptions does prove your point that such exceptions exist, but does not prove anything about Medical Education in the U.S.

    Making assumptions that PhD’s are the ones who create great products doctors use is also purposeless and is it really true? Did you have research to back up your statement? Sure, it makes sense on the surface but is that really true? Are PhD’s really the ones who have made the biggest/most contribution to medicine? Again the answer to this question is purposeless to the overarching discussion.

    One thing I want to ask you, in your response to BruceHopperJrMD you stated that you find his type of practice immoral, why is that? From my understanding his practice charges a monthly or yearly fee, the patient has access to their doc via cell/email/text, no waiting lines, next day appntmnt, web-based phr, web scheduling. I have never found any medical office that does the same, have you? I have never seen a doctor that encourage me to call/text/email them, have you? So, if this doctor offers all these extra services, why is it wrong for the doctor to charge extra for them?

    Thanks!

    • Alina

      “…some* medical schools allow accept students who have not technically earned a Bachelor degree – these are unique programs and are the exception, not the standard”

      Let’s see, who these some are: I already mentioned Columbia, GWU, and here are a couple more that are ranked in the top 10 for primary care programs:

      University of Michigan – #4
      http://med.umich.edu/medschool/admissions/apply/requirements.html

      Duke who is #8
      http://dukemed.duke.edu/modules/ooa_applicant/index.php?id=21

      “Making assumptions that PhD’s are the ones who create great products doctors use is also purposeless and is it really true? Did you have research to back up your statement? Sure, it makes sense on the surface but is that really true?” LOL….So we’re talking about starting with the ABC – you need to do some research on your own. I suggest you take a look at job postings for pharma jobs and try reading about drug development. Guess what, it’s true. People that work on developing medicines do have a chemistry PhD.

      “One thing I want to ask you, in your response to BruceHopperJrMD you stated that you find his type of practice immoral, why is that?” Being a med student you should already know why that is. This of course would presume that you actually decided on this career for the right reasons, you know to help people maintain or improve their health. Do you think it’s okay to exclude some people and leave them without care just so you can make 900k per year (600*$1,500)? Then, how is a doctor like this different from the insurance executives? Being a physician is not a right, but a privilege which means that there are some standards that you agree to in return for the license that you receive.

      “the patient has access to their doc via cell/email/text, no waiting lines, next day appntmnt, web-based phr, web scheduling. I have never found any medical office that does the same, have you?”

      Who cares about access to my doc’s cell phone and email? I settle for competency which quite frankly is in short supply these days. I think this is non-sense and we’re putting the cart before the horses. People should concentrate more on improving their skills and knowledge, and only after that we should talk about electronic anything.

      Same day appt yes, I did get that before I moved to a new area not too long ago. My former doc also spends an average of 20 minutes with all their patient (no payer discrimination there) and you know what, he actually does very well and can also be a human and compassionate being at the same time. It doesn’t have to be exclusive you know.

      If you want to be successful I suggest that you don’t believe the first person that comes along, but rather surround yourself with positive and trustworthy individuals and do your own research on all these matters. Also a big factor in any profession is to be passionate about the chosen field; otherwise that you’ll never be happy no matter how much money you make.
      Good luck to you.

  • a med student

    Alina – thanks for your insight.

    I agree with you, competency in a medical doctor is very important, and that is a must. No one is arguing about this point. And sure there may be many doctors who you or others would consider less competent. Let’s not forget, as Atul Gawande pointed out, even doctors are on a Bell Curve with most in the middle and few at either extreme. So again, arguing competency will get us nowhere. It simply must be there.

    In regards to practicing in an Ideal Medical Practice…I must disagree with you. Many, many people value email, value cell phone, value web enabled phrs. You seem to be concerned about skills and knowledge, why is this? Why do you think it is lacking?

    You say it is immoral to earn a certain amount of money, in your example it was 900k/ year. So let me ask you, what annual income for a doctor is moral enough? What figure is too much? Where is the cut-off?

    Furthermore, many Ideal Medical Practices are the primary source of healthcare for the “Working Poor” – those who work but don’t have any insurance at all(think bartenders, hair stylist, baristas, etc). I know this because I witnessed it first hand working with an Ideal Medical Practice doc. They frequent such practices because prices are transparent, cost are provided before the appointment and the doctor has no incentive to perform unnecessary tests or refer you to some specialist.

    Agree, being passionate is a must, hence my participation on this forum…

    Thank you for clarifying that the amount of money I make will never make me happy, at this stage of my life I was still unsure about the answer to that question, but you have finally answered it.

    Your thoughts are appreciated.

  • Dr.Cosmo

    Being on call should be for emergencies…not free advice anytime a patient feels like it.We are frequently abused when on call and yes its overwhelming because we are also handling real emergencies.And fro the woman who states she always interacts well with people………its different when you are on call fro a 72hr weekend( for no pay) and you are being abused .

    • Stephanie

      Chiming in here as a patient…..I agree with Dr. Cosmos that calling a doctor after hours should be for emergencies. My pediatrician charges $25.00 for those calls, paid up front over the phone with credit or debit care info taken by the service.

  • imdoc

    “All these services that you listed you do, isn’t that what you suppose to do as a doctor in the first place? There are some physicians who seem to think that they are entitled to charge people an arm and a leg just to do their job. I’ve seen your fees are they are more moderate, but there are other concierge businesses who charge the patient an average of $1,200-$1,500 per year on top of the usual visit fees (copays and insurance payment). I’m by no means a fan of the insurance companies, but I find these concierge businesses offensive and completely immoral!”

    So…Alina are you suggesting that all business which charges what you consider to be “a lot” is immoral or is just the idea of profit altogether reprehensible? The standard here is fuzzy. How do you get paid? My guess it derives somehow from others in society.

    • Alina

      ” you suggesting that all business which charges what you consider to be “a lot” is immoral or is just the idea of profit altogether reprehensible?”

      Businesses in general set up their pricing on a value-based model. They take into consideration many different things, with product/service attributes, differentiation from competitors offerings, customer’s ability and willingness to pay being at the top of their list. The medical profession is among the very few that we see that actually doesn’t follow these principles.

      For one, many doctors seem to think that their customers are the insurance companies, not the patients. In turn, what this means is that they look to provide value to the insurance companies, rather than their patients.

      Second, we don’t currently have a value-based model in this health”care” industry. We reward physicians based on their coding skills more so than on their medical skills or the value they provide to their patients. The whole CPT system, which by the way was invented by the American Medical Assn, is based on the time spent with a patient, not so much on the skill and expertise, or on the actual outcome of that visit. I’ve seen many doctors who practice the 5-minute visit all the time and try to pack in patients like they are on the assembly line. Now what can you possibly discover in that 5 minutes? What kind of value do you provide to your patient during such a short time? And it terms of outcomes we’ve seen what this system means as we are after all #37 in the world in terms of quality. Yet we spend more than anyone else. This answers part of you question…I hope.

      For the second part, I would like to put the onus on you a bit and have you give us an answer.

      Consider someone that makes $35,000 per year (gross). This person would not qualify for Medicaid or Medicare. His/her doctor decides to close the traditional practice and instead open a “concierge” business. The “membership” fee is $1,200 per year and the doctor would only take 600 patients (the remainder of let’s say 1,400 patients would have to go somewhere else).

      1. In your mind is it feasible for that person to pay this fee only for the PCP membership? Let’s not forget that many also charge the regular fees that they charge under the traditional practice and still bill insurance companies for this. So there is still a copay or coinsurance involved on top of the $100 per month that the patient has to pay. That is if the patient even has insurance. If not they would be stuck with paying rack price for any visit, as most docs don’t really offer a discount to their cash paying patients. Should the patient forgo his daily food so the doc can now make $900k – $1M per year because this doc feels entitled? If the patient needs tests or medication, (as the doctor can’t do it all by himself just on his expertise alone) should this person also become homeless so they can pay for these extra items?

      2. Is the physician even worth this much? After all the membership fee alone is $720k per year, this on top of all the regular visit fees. What kind of value does a physician like this provide? The patient would get the doctor’s cell phone and email and have access to the doc 24/7? If the doctors is good would the patient even need to have these “extras”? If the doc is not even knowledgeable, what good would that email be to the patient and why would the patient have to pay this extra fee? If the doctor couldn’t provide value before what would make us think that he/she could do that now? This would be like an employee who doesn’t pull his/her weight so let’s pay them more, a lot more, and they will now do a fantastic job. Highly unlikely! And it’s not like the doctor made an insignificant amount previously. On average PCPs make $186k per year, so not exactly destitute.

      As I stated earlier in this post, being a doctor is not a right, but a privilege. If you became a doctor just so you attach MD to your name or to make $900k per year, then you did it for all the wrong reasons and you don’t understand the meaning of the profession.

      “How do you get paid?” I get paid for the work I produce, aka my own competency. When you have confidence in your skills and abilities, this is actually the model you would want to be compensated on.

      • a med student

        Alina –
        How about the doc that charges $35/mo instead of $1500/year, that would be reasonable right? If anyone can afford Cable at $80/mo they should be able to pay $35/mo for a PCP.

        You say PCPs make 186k/yr avg. Does that seem fair and reasonable to you? Especially since specialists get paid 3 – 5x that amount?

        Why would any medical student want to do primary care given that drastic difference in reimbursement? It is silly, a Dermatologist spends the same amount of time in residency as a Fam Doctor but at the end Dermatologist’s work is compensated at a significantly greater amount! Sure medicine is not about making tons of money, but $3million difference in pay over a lifetime is just ridiculous.

        The Direct-Pay model balances this out.

  • imdoc

    “Businesses in general set up their pricing on a value-based model.”

    A market-based system allocates business based on value (Price/Quality), but I would tell you business charges what the market bears. Saying you get paid for your “work and competence” seems to imply others don’t. We could go on and on about the societal worth of any number of individuals, the fact is in a capitalist society, ideally the consumer is the final arbiter of price. The problem in medicine in the U.S. is that the third party system usurped market forces of physician pricing. Were it actually free market priced, ordinary earners could afford it.

  • http://yourpractice-yourbusiness.blogspot.com mds-mdmba

    While it doesn’t necessarily qualify me as an expert, I’ve given invited lectures to physicians (nephrologists) on the broader topic of Practice Management, starting with defining who we are, how we want to be perceived by our stakeholders, what our purpose for existing is, etc. This leads to a more in-depth discussion of Strategy, and how important it is for any organization to think and be clear about how it wants to gain competitive advantage in its market. This competitive differential advantage is typically based upon either quality, service or price. Thus most physician practices are more likely to successfully gain an advantage over their competitors by providing superior customer service, as quality and price are less likely to be relevant differentiators to those customers. For example, how often does a patient seeking a primary care physician choose one based upon the physician’s class rank in medical school, or where they did their residency training? And since most costs are paid by insurers, differences in cost to the patient are typically negligible. Quality is arguably becoming a more significant factor, as pay for performance initiatives take hold, and outcomes data become more accessible. Will it become a potential strategic differentiator, too? Perhaps. Back to the customer: we of course need to define who the customer is before we expend resources on office operational processes and market ourselves to support such a strategy. Betancourt’s lament that service has perhaps gone the way of the typewriter is thus critically relevant. If more physicians thought of their practices as businesses to run and become (and remain) prosperous, they would not ignore customer service, and in fact would embrace it as much as Southwest Airlines and others do.

    Please feel free to see more of my comments and post your own at http://yourpractice-yourbusiness.blogspot.com/2010/10/whatwho-constitutes-your-market.html