Your 10 minute office visit needs 8 people and 45 minutes of work

Your 10 minute office visit needs 8 people and 45 minutes of work

I sat at the checkout desk in my practice last week for the first time and as always, it was a revelation.  If you haven’t worked your check-in and check-out desks recently, I highly recommend it.

An insured patient that I checked out was shocked when I said the charge for her visit was $100.  She said, “But he was only in the room for ten minutes!”  I was briefly at a loss for words.  I recovered, we agreed on a payment plan, I made a note on her encounter form for the billing office and she left.

I’ve been thinking about our conversation, and thinking about what that $100 is supposed to cover…

  1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.
  2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID for red flags.  An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.
  3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief chief complaint, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.
  4. The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
  5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.
  6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.
  7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled.  The chart was filed, and the encounter form was sent to the billing office.
  8. At the billing office the charges and any payment was posted and the claim was filed.  If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.
  9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.
  10. Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient.  If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment.  Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.

I know that patients often say “But he only spent 10 minutes with me.”  Checking back with the provider, I find it was typically longer.  Patients tend to underestimate the time as it goes very fast.

The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller.  It took 8 people, and at least 45 minutes of work to make that appointment happen.  Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services.

The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.

Mary Pat Whaley is board certified in healthcare management and a fellow in the American College of Medical Practice Executives.  She blogs at Manage My Practice.

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  • CG

    You neglected to mention why her bill was $100? Who set that price? You said she was 1) insured, and 2) surprised at the cost – so I am guessing (perhaps incorrectly) that her usual co-pay is not $100, or that she was a new patient and you were an out-of-network provider. Or perhaps you are a specialty provider and so, according to the terms of her insurance, her co-pay was much higher than that of her PCP and she just didn’t realize it? There are so many factors that could go into why she was charged $100..

    I had a last minute (literally “can you be here in 15 minutes?”) visit with my PCP physician yesterday. I don’t know the total number of people involved in the machinations behind the appointment, but I came into contact with 5 different people during the course of my 15 minute visit.

    My bill was my usual co-pay: $20.

    I’m not ignoring all the very valid points you bring up in your email, I guess I’m just trying to make the point that, since she was insured, the issue of why her bill was $100 was more directly influenced by the particulars of her insurance plan, not the costs behind the care you provide. I’m not saying this is right and/or fair to either you or the patient, merely that that is the case.

    • NEMO

      Noted in item 10:

      Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient. If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment. Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.

      • Specialty practice

        WIth all the high deductible plans now the patient’s portion of the bill could easily be $100.

        • Primary Care Internist

          even with high-deductible plans the patient portion is still negotiated (ie. SET) by the insurer. So if the BCBS (emphasis on BS) set fee for a 99213 is around $35 (that is probably the rate for a small suburban NY practice) then that is what the patient is responsible for, regardless of what the doctor billed out. This is yet another way that insurers, through high-deductible plans, manage to avoid paying out claims. If someone has a $3000 family deductible, how many $35 visits do they have to go through in a year before BCBS pays anything? Then even if they had umpteen visits for every member of the family, BCBS will pay $10 after the patient’s per-visit copay of $25. what a friggin’ joke.

  • Laura jodice

    You neglected to say that the visit consumed at least 2 hours of the patients time including travel and sitting in the waiting room and exam room…which was time off from work.

    • pcp

      Do you want to be paid for travel time to see the doctor? Or do you want the doctor and staff to work for free?

      • Laura Jodice

        I do not want to be paid for my travel time, nor do I want the doc and staff to work for free. I just want my time to be respected. I want the staff to say, honestly, the wait is currently averaging an hour, rather than saying, a few minutes. I don’t want to be put in the exam room if I will wait more than 15 min there, unless someone says to me, we are putting you in the exam room, and you will probably wait here for 45 minutes or more because the doc is behind, so if you want to go to the restroom or take a nap, or take out your laptop and do some work, or wear these headphones with music so you don’t have to listen to everything the doc is saying to the patient in the other room, that’s fine. It’s not knowing how long the wait really is that is frustrating and tends to make me anxious and impatient. One of the worst waits is when they have you drink lots of water before an uterine ultrasound, then make you wait extra unknown amount of time before you get the ultrasound and finally let you empty your bladder.

        • Primary Care Internist

          you need a “minute-clinic”

          • Alice

            I love Minute Clinic. I think for the $70 it is a great deal if you do not have to wait too long. My doctor is a better deal…$60 for an hour! Not sure if I am in VIP position or not….but I would pay much more because he is THAT good.

            An even better deal is Olive Garden. I get fantastic service…good food…that had to be delivered, unpacked, put away, sliced and diced, cooked, a waitress to take the order, a hostess, a manager, a cleaner….and it is really affordable. I pay about $20 for an hour of great service.

            Sometimes it is a toss up whether I want to go to Olive Garden for pampering for my money…or a few doctor’s who waste my time and money with routine tests and attitudes.

        • M Camp

          Laura, you make a good point. Communicating a realistic wait time would be the polite thing to do. I understand docs fall behind bc they are dealing w/ all the unexpected things that can occur. Just being honest about the wait time and not leaving the patient in the exam room for extended periods of time would be a step in the right direction.

  • NEMO

    We did this at a solo practice to see how much time and cost is truly in a patient visit for a routine visit, and we used a stop-watch as measure of each step over the course of three days worth of ov’s, to find average time.

    1. 88 seconds to schedule appointment, via telephone

    2. 2 seconds to include appt on day’s schedule the night before (seconds = number total divided by number of pts for day – to pull up, print and walk to doc desk and back to reception)

    3. 64 seconds to pull chart evening before appt

    4. 95 seconds to quickly check chart and add sticky note as to reason why appt is scheduled as reminder to nurse and doc next day

    5. 145 seconds to check pt in upon arrival for appointment

    6. 6 seconds for reception to call pt

    7. 240 seconds for nurse to greet, take weight and BP and walk pt to exam room, place chart in holder on door

    8. 73 seconds for nurse to brief doc on pt in exam room

    9. 720 seconds of doc time in exam room, 720 seconds of nurse time in exam room (male doc)

    10. 210 doc seconds to quickly document and write script, 210 nurse seconds waiting for doc to finish

    11. 288 nurse seconds to follow-up with pt and give instructions

    12. 182 seconds with reception to check-out pt and make another appt

    13. 487 seconds of doc time to completely document in chart, document for billing to have codes to submit claim

    14. 687 seconds billing coder time to review visit and code choices by doc, corrections, creation of claim + electronic submission


    barring denial of the claim by the insurance company, the 12-minute routine office visit in the office required 65-minutes of time from reception, professional staff (nurse), doctor and billing.

    • Specialty practice

      You failed to add the time to verify the patient’s insurance. Not so long if you can verify on line (which most you can but do not give you total benefits) but more time if you have to actually call the insurance comapny.
      Also the time was not added to verify the patient demographic information you have on file. Not just asking the pt has anything changed but going through info because how do they know what info you have on file. WIth identity theft skyrocketing in the medical arena you have to get pt ID to make sure they are not using another persons insurance information.
      How about the time for the pt to sign privacy, financial etc papers that are either required or needed to protect the phys office.

      • NEMO

        Those were the seconds for established patients – and in a rural area, most folks know everyone else, so protocol isn’t always needed – the basic has anything changed usually suffices. But you are right, in larger population areas, those too would add additional time to the patient visit.

  • Gerry Oginski

    Patients need an education in order to understand the true value you provide for their “10 minute” visit. Without educating them, they often don’t recognize all the steps you discussed and simply look at the visit from “Their” point of view and not yours.

    One great way to educate your patients about this is with video that shows them, step by step, what your office does each time a patient calls for an appointment…all the way through the payment process.

    • Alice

      I get the point doctors are driving at…but I think you are in a type of paid for public service that means you need to tread carefully about the type of PR you choose.

      Surely patients see the medical assistant, receptionist, etc. They are not blind nor ignorant (but I can imagine some are petulant). I think when doctors do their job well….most patients do not mind paying for a job well done…and it can prevent lawsuits. Patients do not sue doctors they love. I know I would not want to see a video justifying the expense.

      Build communication with your patients…do something for free to show it is not all about money….and the patient’s will respond. Even if it is just what my dad’s neurologist does…he would walk you to the desk and give you a compliment. His staff cried when he found another job at a different hospital. He is loved and missed.

      In the movie Waiting for Superman the documentary shows what happens to students when teachers with tenure just show up for work. They are so into routine they are impotent and of very low productivity. The charter schools teach differently. The students can call the teacher until around 10 p.m. if they have questions (the school provides the professional phone for each teacher). The results of the hands on caring are magnificent. Lives are changed. Teachers have student debt like doctors, but make a lot less money…but some manage to change lives…what a way to use your knowledge and giftedness. The example has many ideas doctors should use. Building patient trust stops a lot of complaints, and….like teachers you may find that beyond the physical the metaphorical heart is healed.

  • Jan

    The US seems to have an amazing health care system. Despite it being one of the most expensive systems in the world, it is certainly far from the best (ranked 5-10 depending on the research). And that is true for those who are insured only, not for the 40M or so non-insured people. I live in The Netherlands. This would cost around 40 $….. NL health care ranks higher on the scale than the US (Sweden at the top I believe) and BTW, everybody is insured.. Glad to be a European

    • workflowdx

      Jan, I think you’re right — we should shift the entire cost burden to the taxpayers and place the administration of our mammoth healthcare system (with a population 20 times that of your country) in the hands of the federal government. That will make all of these inefficiencies seem pale in comparison.

      • Alice

        LOL. I still like the O,Rourke quote in the WSJ (during the Clinton Administration healthcare fiasco): If you think healthcare is expensive now….just wait until it’s free.

      • gzuckier

        Right; it’s axiomatic that a dozen different bureaucracies are more efficient than one.

        Just as it’s axiomatic that the US can’t possibly succeed at something that every other Western industrialized country has done; that’s why we are the Best Country In The World.

    • Alice

      I do not agree with how the outcome of these quoted stats were arrived at. Google Sally Pipes…one of the top 30 experts in the world about this. European countries and others feed off our innovation, and keep their own costs down. America can be proud of the lives we have saved through research around the world…and other countries should thank us for…basically…our donation to mankind. We have our problems, and the stats are tweaked a bit too much for my liking…and socialized medicine in other countries feeds off our research while their citizens often falsely believe they are receiving a type of world class care…not realizing so much innovation came their way for free via the States. Canada is a prime example. They gain by saving oodles of money because we are the sweat equity of the meds they can buy in bulk cheaply. They get the recipe for free while we pay for the test kitchen and supplies.

      • Jan

        Ah common.. you cannot truly believe that, do you? It strongly reminds me of an interview I saw during the cold was. They asked Americans what would happen if Europe was blown up because of the US/Russia war.. One respondent said that of course America would be very happy to re-populate Europe. What an arrogance. You may not like the stats, but you really must understand that top healthcare is good in the US (not even the best, despite your conviction) and that in European countries the cost of healthcare (Again FOR EVERYBODY, we do not cut out 20% of our population) is 1/5 of the cost (of course compared to the number of inhabitants). BTW, also we have far less people on drugs, far less murders, far less teen pregnancies, far less people in jail, far less people in (western) poverty. I have lived in the States, I work for an American company, I have American managers, I spend vacation in the US and I like the country. But I am so glad to live in Europe…. Yes we talk a lot, but we achieve something together.. w edo not shoot people we do not like because of the crazy political polarization…Enough… Have fun..

        • Alice

          Umm………..referring to a troubled man who shoots people isn’t helpful…..I seem to remember some mass shootings in your part of the world too……and lynch mobs…..etc.

          I have lived in the UK……America is one of the most generous countries in the world……we are the kind neighbor. We rebuilt Europe…..but, hopefully, we won’t duplicate your socialistic ideologies that you are trying to dig your way out of. Government just doesn’t run things well and it creates less rights for the common man.

          I know what your gun control stats are and people get shot in Europe. Maybe not at the same rates as we do here…..but it happens. Ever go to a soccer game in Europe? Hooliganism? Where they play darts with the opposing teams head, or flip your car, or trample some people to death on the way in? Violence isn’t an American nationality problem…….it’s within us all. We just act it out differently. People are people…..we have tendencies that are not cultural. That said……I live in the best nation on God’s green earth. When I come home from Europe I want to kiss the ground we land on.

          • Jan

            Alice, it is good that you want to kiss the ground you land on. I thought that was for Popes only, but fine. I also have issue with faith, especially in the US as in a number of states/counties schools are forbidden to teach evolution. I would like to correct your view that you rebuilt Europe. Unless you mean it is like rebuilding Iraq, Afghanistan, Vietnam and many other place that were very generously gifted with war. And sure, Europe also has issues with violence, but magnitudes lower than US. And socialistic ideology.. big words. When we take about socialism, we mean compassion for other people, which is indeed very different here and results in a better life (and insured) for the common man. Anyhow, I feel the US view of the rest of the world is a very patronizing one, which is not justified (anymore).

          • Alice

            Jan….to not teach evolution would mean you lose taxpayer funding. Do you really believe creationism is taught in our schools? I pay for private education where evolution and creationism are taught….I pay thousands of dollars to get the truth into my children…not one taxpayer dollars goes to this school. The textbooks are filled with error, and we can choose the most rigorous and truthful curriculums. Ever compare textbooks? There is website that does so.

            The Pope’s ring is kissed by others….and saying I feel like kissing the ground is patriotic symbolism.

            You believe stereotypes and offer no facts. Just your supposed statements of correcting show you have not studied history.

            Defenders of socialism always tell us how wonderfully kind they are…but they hurt others. Socialism cannot be sustained without harm….and when done well it can lead to communism…..the utopia of the purist socialist. I can go into factual details if you wish. I have taught every subject, so I tend to like debate.

            I will end by suggesting you do some research and see the funding we have sent to other countries in the last 80 years, and what other countries spend on research and innovation. And next time you fill your prescription…you, too, may want to kiss some American or our soil! :)

          • Jan

            Alice, I honestly believe people should believe in their country and love to live there. I do. Here some public statistics to put things in perspective.

            Sources: WHO, UN and other international agencies

            HEALTH RELATED
            Health system and performance: US ranks: 72
            Total expenditure as % of GDP US ranks: 2
            Healthy life expectancy (HALE index): US ranks: 24
            Preventable deaths in health care: US ranks 14 (of 14 western countries researched)
            Number of physicians, US ranks 23 (they must earn a lot as US is ranked 2 in expenditure)
            Quality of death US ranks 6 one would expect superb healthcare would give rank 1… )
            Obesity index US ranks 18 (this may sound OK, however, the first 17 are countries such as Tonga, Samua, Nauru. The next western country is at rank 38)
            Child well being: US ranks 19
            Infant deaths, US 20% higher then European average
            Life expectancy US ranks 48

            Education score of students: US ranks 33 on reading, 27 on math, 22 on science, all well below OECD average
            Literacy rate US ranks 24

            CRIME RELATED
            Murder rates. US ranks 78 (5.6 times that of other developed European countries like Germany, Netherlands)
            Death sentences: US ranks 5 (between Saudi Arabia and Yemen, and a bunch of 40 other (non civilized) nations)
            Prison population per capita: US ranks 1 (first other civilized country ranks around place 50)
            Corruption index US ranks 22

            Environmental index. US ranks: 23 (1 is best)
            Carbon footprint: US ranks 16 (twice the footprint of Europe)

            Arms delivery: US ranks 1 (over 100 B USD, almost 3 times as much as number 2.)

            Gender cap index (gender equality): US ranks 27
            Olympic medals per GDP US ranks 67
            Olympic medals per capita: US ranks 46
            Global privacy index US ranks 43
            Freedom of press US ranks 24 (yeah, surprising isn’t it?)
            Home ownership US ranks 7 (and still able to completely disrupt global economy with it’s almost criminal Mortgage plans)

          • Alice

            Umm… is not patriotism, but the truth about where I would seek care….along with the very rich. Did you know out of the 20 top colleges in the world America has 17 of them? Now that said we stink at math! And our public schools need to switch to charters and give parents more choice and competition for the schools. I am more than willing to point out flaws….and the flaws of other countries, but our main problem at this point is half of our expenditure here is from our tax money (our GDP on medical is about 17% with Canada spending about 9%….hence why they have waiting lists, denials, need for newer equipment and therapies and research dollars they do not spend helps keep costs down….and it is worse in Britain where I believe the PM just made 80/20 cuts across the board. That means more people are hurt and die. But Canada is single payer…I think only Canada and North Korea are single payer while others are public option. I like neither…and actually believe America is almost at the public option level because the government is paying Medicare, Medicaid, VA, and state children’s insurance. I would like to see more free market…not less…..but less government….limited).

            I was listening to a video from the former Canadian Sally Pipes. I find her riveting and maligned by Michael Moore and his untrue documentary, Sicko. She sorts through the crap. The bottom-line is this….people who pay cash and need the best medical care in the world use America or our foreign hospitals. (i.e. Cleveland Clinic is in the Middle East [Abu Dhabi] now and their doctors go there to train the doctors.

            I can get my children and husband free care in the UK. No thanks! I will pay out of pocket for cancer treatment here if I have to. It has nothing to do with patriotism…and everything to do with the fact that she will get the best care without waiting lists. I know there are problems…my child’s cancer spread because a lousy doctor did not read the lab notes….yet….the system here usually works far better right here with better outcomes. Some of the stats quoted here are too slanted. I can think of nowhere else in the world I would/could get better care…..look at Sicko film maker ….Michael Moore…his doctors are right here in the U.S.

      • gzuckier

        How exactly does my paying ten times as much as a Japanese citizen for an identical MRI from the identical machine contribute to research? Is the extra 90% I pay going for research? That’s not only generous, but how humble of the folks involved to do it anonymously.

        Similarly, when I pay $500 for a office procedure that costs $100 in Canada, is the other $400 going for research? Not sure I can Follow The Money here.

        And as I’ve mentioned before, Sally Pipes has demonstrated her ignorance of comparative health statistics and, worse, her willingness to make statements that contradict these statistics (without any apparent knowledge they exist, let alone explanation of their supposed error) if they support her cause.

        • Alice

          I am back home and can type a bit better. I just think the comparison to Japan is a poor one. No free market, complete government control to the point many employers can no longer pay the premiums of the insurance (which cost the average Japanese citizen about 1/3 of their bill out of pocket which makes the typical American co-pay look good…..and insurance is mandatory). Hospitals can’t make a profit so again they feed off of our dollars.

          If you are an American is this what you want (below)? Where you are refused treatment at the ER and because there is no space they have to refuse treatment to needy people? Mandatory insurance and still having to pay so much out-of-pocket and no appeals? Captialize cast aside will not make for better healthcare. I simply can’t understand why people want the government to run healthcare. As the government gets bigger we get smaller……along with smaller paychecks.

          There is more, but it’s late and I am rushed.
          ***** Japan has about three times as many hospitals per capita as the United States[6] and, on average, visit the hospital more than four times as often as the average American.[6] Due to large numbers of people visiting hospitals and doctors for relativity minor problems space can be an issue in some regions. More than 14,000 emergency patients were rejected at least three times by Japanese hospitals before getting treatment in 2007, according to the government survey for that year. In some of the more publicized cases an elderly man was turned away by 14 hospitals before dying 90 minutes after being finally admitted.[7] In another case a pregnant woman complaining of a severe headache was refused admission to seven Tokyo hospitals. She later died of an undiagnosed brain hemorrhage after giving birth.[8] The manga “Team Medical Dragon” shed light on this issue and the Japanese public used this as a cry for change. The Japanese government has somewhat broken down and started admitting patients, including some who may have been denied under old policies.[citation needed]
          Interior of standard ambulance

          Public health insurance covers most citizens/residents and the system pays 70% or more of the medical or drugs costs with the remainder being covered by the patient (upper limits apply).[9] The monthly insurance premium is paid per household and scaled to annual income. Supplementary private health insurance is available only to cover the co-payments or non-covered costs, and usually makes a fixed payment per days in hospital or per surgery performed, rather than per actual expenditure. In 2005, Japan spent 8.2% of GDP on health care, or US$2,908 per capita. Of that, approximately 83% was government expenditure.[10][11]********

  • chewableman

    It takes a chef, one or more waiters, a front-door greeter, and almost 2 hours of total time, including most likely 5 – 20 minutes of cooking time, to produce one steak for you at a steakhouse, but this costs nowhere near $100. But it would if a doctor was the one to hand it to you.

    • Taylor

      Well last time I checked a chef didn’t go through eight years of school, take out tons of loans, and have to pay malpractice insurance. It’s so funny when people try to compare what doctors do to other professions. They DO NOT compare. If the steak comes out overdone and the customer is not happy it’s quite simple to correct the problem. If a patient comes in with a complaint and it’s misdiagnosed or there is no diagnosis, well that’s just the beginning of a long road, which can result in the doctor’s insurance paying out a huge claim

    • pcp

      How many people are eating simultaneously at a steakhouse? I’ve never seen a doc put 150 people in one exam room.

    • NEMO

      With your $40 porterhouse meal, if it takes you two-hours – you also had to have an appetizer or salad (in fine restaurants these are not included in the meal), the establishment prays you drink something alcoholic since it’s their profit center….and you’ll be expected to fork over an appropriate tip because they’re not paying staff even minimum wage. The cook, if he’s lucky, is paid around $15 an hour.

      • Alice

        Egads…I should have read the whole thread before my Olive Garden analogy…but as far as management there may be something to learn. Although, Taylor’s comparison needed to go a step further. The comparison is not fair unless he/she compares the student and business loans of the restaurant owner…not just the chef…unless the chef is the owner.

        The years in college doesn’t entitle you to such extreme wages (doesn’t the average doctor make 3 to 5 times what their average patient makes? Are all your patient’s uneducated? ). My friend with a PhD makes under six figures. Should he out earn you?

        That said…the training and the ability to save lives means I think a good doctor is worth a million dollars a year…emphasis on “good” (and “worth”…i have homeschooled my six kids with no monetary benefit…and teach literature for free….my pay? When kids learn to love the gift that literature gives,,,,the gift of dreaming…that is priceless…but I am not paid what I am worth) which in my personal, unscientific research….using Moi as a subject means “Two!”. That’s how many doctors I have met who are worth a million a year. A few should not be practicing medicine. They are useless…and choose the wrong field…and I do not care if they went to school for 15 years. Then there are the rest of them…the average docs who are probably worth their pay….thinking….about the tip statement. I tip 20% because I think waitresses are some of the hardest working people I know… exceptional doctors would be worth the same percentage…but we ran up a quarter million dollar bill……yet, there are doctors out there who some patients feel like giving the tip of their boot to!:)

        I do try to tip the workers though. The receptionist for my doctor got a Starbucks coffee card, the nurses we loved were offered Starbucks drinks when we would go down to eat, etc.

        • Praying Man

          The main point is in our modern society, what you do (however noble and selfless you think it is) it’s worth nothing, so you are paid nothing . If what you did had tangible value, then you would be able to bill it to someone. Otherwise, even the most useless, bottom of the heap doctors you mentioned are worth more to the general public than you, because at least they have some capacity to save lives based on their knowledge and training. I do not mean to be so harsh, but this is the reality and it is time you dug your head out from under the sands as you so persist in quoting facts and figures willy-nilly which seem taken out of context and illustrate further the fact that you have no idea what you’re talking about. Your patronising attitude towards the rest of the world is, to be frank, disdainful. In closing, I urge you not too feel too badly about this censure and in fact to take comfort in discussing this issue with your next pro bono literature class. I’m sure it will be…priceless.

          • Alice

            Well…..just for the record your diatribe was not offensive because it had nothing factual….but it is quite alright to express yourself for free. So, if my opinion is worth nothing….we’ll… is your own.

            But…I just wanted “Prayingman” to know I send my own messages on a wing and a prayer….I do not know who you are…but God does….I’m prayin’ for ya!

    • Alice

      I was just browsing the posts and have to say some of the anonymous names here add some nice humor amidst such serious posts. I mean really……..”Chewableman” posting about steaks. Really funny……I like it! On another thread an anonymous lawyer posted under an odd name….he had named himself after the fiercest of sharks…..and then just shut up when asked about it. Too busy surfing I assume.

  • PM

    The first thing that comes to my mind is “how can we make the system more efficient?”.

    When I go out for dinner, many people are involved: the receptionist who took my reservation, the waiter, the bus boy, the chef, the dishwasher, and so on. Shouldn’t I be paying $100 a meal too then? The number of people involved is not an excuse to justify this inefficient system.

    Yes, I agree that many people don’t take administrative time into account. In that respect, it is “educational” for them. However, doctors, healthcare workers, and insurance providers should also look at themselves and ask “why are the patients unhappy with the service they get?”.

    I can choose to go out for a meal, but I have no choice when it comes to healthcare. My insurance does have $50 co-pay and some hospitals even slap on a $100 “facility charge” on top of that.

    From a patient’s point-of-view, this needs to change. I am eager to discuss and work something out with other healthcare-related professionals. Now, are you willing to put yourselves in our shoes?

    • rswatkins

      I’d like to hear what you specifically think “needs to change.” Most docs feel like they are powerless in face of the demands and power of the insurers, and see going to an all-cash practice as the only option.

    • Primary Care Internist

      we are ALREADY in your shoes! we, and our families, are also exposed to the inequities and challenges of the healthcare system when we get sick, injured, need a hospital ER or physician etc. And we are as powerless as you are to change it.

    • Alice

      I think $50 is fair, and so is the $100 for ER visits. If it helps keep costs down, and keeps our system the way it is without socialized medicine I am grateful for co pays. It sure beats waiting lists, and old equipment or therapies. I was on catastrophic care. I would support it before socialized medicine, but it was worrisome when you needed to go to the doctor. You could be looking at huge bills that make the copay look line a blessing.

  • Aaron Seacat

    Next time I’m at a restaurant I’ll make sure to walk back in the kitchen and interview the staff, check their years of schooling, apply an apptitude and IQ test to see which one I would like making my health care decisions.

    • Alice

      Is there an arrogance vaccine?:). IQ? Are doctors now a large percentage of Mensa? I only know one brilliant doctor and these days with the Information Revolution many patients are more up to date than doctors. Yes, we need you…but you need us and insurance companies. And…most of us went to college…have student debt for ourselves or our children….and our aptitude and IQ are just fine, doctor!

      The IQ rant is amusing?
      How about a humble, “Thank you!” to the staff? You must be a riot for a server?

      My doctors do not make my healthcare decisions for me….they suggest, discuss, then I make the decision. I love my humble doctors.

  • Mary Pat Whaley

    Thanks for asking for clarification. The charge for the visit was $100, her responsibility was the co-pay, which she was unable to pay at time-of-service as it was a same day visit and she said she was unprepared to pay. I directed her to speak with the billing office who would set up two payments for her. Since I wrote this article, the practice is now collecting co-pays prior to the visit.

    This is amazing information! Thank you so much for sharing.

    @Gerry Oginski
    An excellent idea! Most people are not aware of the complexity of a visit and most likely would enjoy a peek behind the scenes.

  • weezy

    I’m always and STILL quite disappointed in how this process is so inefficient considering the importance of it.
    - the patient is responsible to find who he/she wants to see or go and make an appointment.
    - office verifies patients information in their COMPUTER DATABASE, schedules the appointment and explain what is needed for the visit(at this time, the associate should explain the billing so the patient can be prepared)
    - Patient comes in at the appointed time and verifies/checks in with the front desk associates using the COMPUTER DATABASE(5 min max)
    - Nurse escorts and do the usual chores
    - Doctor sees patient and prescribes medication or suggestions.
    - Patient returns to the front office or exit office pays co pay, DONE.

    But instead, patient is always confused of what is to be paid, don’t know what the hell is going on after they make an appearance. I’ve waited for 30min before for a scheduled appointment. SAD!

    • stargirl65

      Sadly most doctor’s offices have a hard time even knowing what they are going to get for the visit. The insurance companies control prices and don’t like to share them with you. How much you owe depends on: 1. Which insurance plan do you have? 2. Do you have a deductible and have you met it? (BTW the patient never seems to know this answer and you generally get a blank stare). 3. If so then how much is your copay? 4. If not then you are responsible for the amount the insurance company says you are responsible for after they adjust for their contracted price which varies over time.

      I have been computerized since 2000. Insurance companies have no interest in making things better for us. If I want to confirm a patients insurance then I have to go online to their website to check. For an emergency work-in this has to be done as they come in. Photo IDs are getting pushed by the government to avoid identity theft of health care dollars.

      Same day appointments of established patients can be easily scheduled as we leave appointments open. I run my office with me and one support person. We try to rely on technology.

      • Joyce Hilbun

        I have been doing billing for 16 years… There’s also a loss the physicians take from patients who do not pay their bills. Physicians who are not employed live and die by what insurance companies set as their fee schedules. When patients don’t pay their portion or can only pay minimum amount monthly, you still have to pay your staff and utilities/overhead.

  • Kelly Merrick

    Mary, I think this is a very important post. Thank you for writing it. I think this can be applied to nearly all professions. Whether it’s a marketing agency, a doctor’s office or a restaurant, there is always work done behind the scene that the patient/client/customer doesn’t see and therefore doesn’t always appreciate. And because we have had clients (often those with a limited budget) express surprise at how much a particular service costs, I try to remember that when I am paying for services that it’s important to recognize the value of the services being provided and not always get caught up with how much it costs.

    • Educated Patient

      I agree, Kelly. The fault is not on either side. It’s about understanding BOTH perspectives and treating the opposing side with more respect after having gained insight. Cost is important, and as consumers we should always be aware of what it is that makes up the cost of the goods and services we choose. But it’s not the only factor.

      I liked your comment.

      – E P

      P.S.: Author: **Mary Pat, not Mary :-)

      • Kelly Merrick

        Right! I realized that after I hit “submit.” And thanks for the reply. I don’t comment on posts often, but this one really resonated with me.

  • Jackie

    I see now why the appointment with my oncologist is often the last one scheduled for the day – my appointment usually lasts more than 20 minutes.

    Wondered if there could be a self-check in/out system available like the ones available at the grocery store. For the four major surgeries I’ve had in the past 20 years at the same hospital/clinic, there’s always some kind of insurance issue involved even though we’ve always had adequate insurance.

    The more pressing issue is the time doctors spend with their patient. My oncologist of seven years is very patient and thoughtful. Only this year did I find out that he’s also board certified in Internal medicine and has had special training in pharmacology as well.

    • surgical resident

      All oncologist completed a residency in internal medicine and all doctors take pharmacology…. I’m glad you like him/her.

    • Alice

      Minute Clinic has self check in. At one point it was just the NP doing it all, but now she has a medical assistant. Almost every minute is patient intensive care. So far, I love it! Very caring and knowledgeable….but much more limited than a doctor’s office (treatment wise),

  • J Adams

    I am sure that customer would have appreciated and seen more value in the visit if she spent more time with the doctor.

    • NEMO

      Why? If the doctor can complete his work with her, why does he need to spend more time? The issue above wasn’t the time spent, it was the amount that was going to be billed – then the time was an issue.

      The time is irrelevant if that patient complaints have been addressed and the patient has no more questions or needs from the doctor.

      • Alice

        I thought one of the big bones of contention is patient’s wanting more time and doctors claiming an inability to give it?

        • Praying Man

          Yes! More time with each patient is what’s needed. Especially when there’s a waiting room of sick people impatient to be seen. Meanwhile, they are all thinking, “wow, what a great doctor, to be spending half an hour with that woman who just walked in, who frankly seems to have a common cold. you would think that a “great and brilliant” doctor would be able to diagnose that on sight!!!” Unbeknowst to them, the woman is actually having a great debate with the doctor, because she’s already self diagnosed herself with Lyme disease and insists that she has all the symptoms as listed by WebMddotcom. Suffice to say, she is humored..after all, the most important thing is not to actually cure, but to let her think she’s had her money’s worth. And give her time to vent on all those other lousy physicians who couldn’t figure out her illness because she exaggerated all the symptoms. Yes, let’s just give her what she wants…more time in the doctor’s office and also, what the heck, she knows her body best so let’s go with her diagnosis and let her CHOOSE what medicines she wants/doesn’t want. HAHAHAHAHA.

          • Alice

            I imagine this was directed at me….. I will defend a few doctors ad nauseam… if they are worthy and of few ours are…particularly one. You assumed much that is not true and used the keyboard to paint a false picture, so I will use the cyber eraser in an effort to clean up the mess. My doctors sometimes read my comments (I e-mail with a link sometimes, also).

            No one waits for me in the waiting room…..that’s an irresponsible assumption to even suggest without asking me first. I was told to schedule at the end of the day or beginning (i.e. the one doctor comes in early and once spent two hours with me doing a test and chatting….his choice….his time). They aren’t paid anything extra for staying after because they are salaried. Here is a tip….be nice to your doctors……engaging, even entertaining……and they may stay longer for you too. Work it Praying Woman…and you, too, may get some superior service and personal time from your doctors……because they will care about you on a personal level. You will become more than a patient….at least that’s what they told me. One gives updates to his children who care. I will miss them…..but I desperately want there to be a time when I can move away from this dark cloud that entered my life…….and their kindnesses.

            Imagine…..someone who knows me personally liking me. Sorta nice, huh?

  • Ronnie the poor diabetic

    As with everything else in this world, money becomes the key motivator for everything we do. As a diabetic, the 10 minute semi annual rush fest given by my doctor is simply not adequate but I cannot afford the extra five minutes and the doctor has flagged me as a difficult patient because, I will keep asking questions until I get clarification and or understanding and yet this is the best a health system has to offer.

    • NEMO

      Your semi-annual as a diabetic patient is supposed to be a level-3 appointment – about 30 to 40 minutes scheduled….it could be as few as 20, or as many as 45 minutes – it may not all be with doc (should be at least 20 minutes with doc) and may include time with the nurse and/or dietitian and/or other CDE’s. You should not accept a 10-minute hussle in and out of the exam room. When you schedule your appointment, ask to have a time slot appropriate for the level of time you’re supposed to have with your doctor for diabetic management..

      • Ronnie the poor diabetic

        I have been a diabetic for 13 years now and most of the time my annual check ups are considered routine, which is the proverbial 10 “minute” slot and the rest CDE, Nutritionist and the rest are not scheduled unless deemed necessary after the appointment.
        Most of the time I take the 10 minute visit because it means I am on track and everything is fine but it might seem familiarity or for some other unknown reason but it seems more and more I am getting the 10 minute visit and have to force a longer visit if I have additional questions or concerns.

    • Alice

      Your doctor should allow you to leave the written questions behind, or let you email them? Doctors here claim this isn’t feasible. Kevin manages just fine!:). My extremely busy doctors claim I am the only patient emailing them. They encourage me…..only God knows why!:)

  • KH

    Thanks for the post – it’s important to know what goes on behind the scenes. I also like Gerry Oginski’s idea of a video to help with transparency. The health care system is complicated and, I find, not intuitive to patients (this would include me).

    I think perhaps this is the larger point behind the 10 minute comment – health care for patients is perpetually a surprise. The surprise could be the shortness of an appointment, or the cost, or the way the billing process works, or the diagnosis, or any number of things (especially if your medical visits are more longterm), none of which help the patient feel in any way empowered, all of which cause stress. Many of us would love more transparency, more empowerment, less surprises.

    There is too far a divide between patients and doctors, their experiences and their view points need to be better represented to the opposite group. Mutual respect in itself would make navigating the medical system better for all involved. Too much “us” versus “them” mentality currently prevails.

    Patients should educate themselves. Doctors should also. This means realizing what each navigates to make an appointment possible. Doctors: the long hours, the loans, medical school (enough pain in itself), the broken lawsuit system, administrative work that occurs around patient face-time. Patients: lost work hours and pay (patients also have careers which may require long hours, loans, school, and risk), time (OUR administrative work; understanding and paying medical bills, appointment scheduling, notifying work of absences or applying for vacation days, transportation, waiting), emotional and financial stress.

    Let me repeat: mutual respect. It’s SO important.

    • M Camp


      “Mutual respect in itself would make navigating the medical system better for all involved. Too much “us” versus “them” mentality currently prevails.”

      You are spot on! Great comments & I couldn’t agree more.

      Why can’t we all just get along;-)

  • Mary Pat Whaley

    What a great discussion!

    Office visits are categorized by codes that are designed and maintained by the AMA. The code that is tied to the charge describes what happens during the visit, not how much time was spent, although there are some general guidelines as to how much time it might take for the level of work described.

    The visit I described was scheduled for 20 minutes, as all established patient visits are at this primary care practice. The physician could have been in the room for 10 minutes, or it could have been 25 minutes. Nevertheless, the patient perceived that he was in the room with her for 10 minutes.

    What mattered from the standpoint of the coding and documentation required by the insurance is that the physician performed the duties associated with the code he chose. What mattered from the standpoint of the patient (I think) is that she did not believe the service she had received had a value of $100. What the practice ultimately received from the insurance and the patient together (if she paid her co-pay after the fact) was probably around $60.

    Does anyone ever pay $100 for that service in that practice? No. Never. So why is the charge $100? Well, that’s a whole other post. I’ll start writing.

    Mary Pat

  • workflowdx

    Mary Pat,

    Great job of breaking down the process for everyone to see what goes on behind the scenes, before the visit and after the visit, just to put one visit in the books. I’m exhausted after reading it and have new-found sympathy for people like yourself who work in this system day-in, day-out. I think we might have a major awakening — like the one your patient had — if we reviewed each step and assigned a “value-added/non-value-added” descriptor to it, examining each from the standpoint of the patient (and the practitioner/nurse/staffperson, if you like). The patient pretty much stated what the only value-added portion was to her — time with the doctor. Everything else, she could take it or leave it. So, 35 of the 45 minutes of this end-to-end time — a whopping 78% — was of no value to the patient (there may be a little wiggle room when we add in the billing of insurance, since nobody likes to deal with them). There’s the source of her complaint. This is the supreme challenge we have in healthcare: maximizing the value-added components, and minimizing the opposite. Studies estimate that at least half of every dollar spent in healthcare is consumed by non-value-added elements such as redundant processing, unnecessary care/tests, administrative red tape, fraud and other types of waste. We certainly have no shortage of opportunities.

  • Steve Wilkins

    Mary Pat and everyone,

    Excellent post and excellent discussion! Those of you who say that the patient has no knowledge of what goes into to producing a 10 or 15 minute visit are absolutely correct. I have been involved in the health industry for many years and this is the first time I have ever seen these kinds of numbers!

    It kind of reminds me of the “economic education” we all got about what it cost to build a car in the US as GM was going down the tubes prior to the bailout.

    Mary Pat’s comment about the patient’s not feeling like she got $100 of value from the appointment is worth exploring. Since the patient presumably based her “opinion” upon the quality of time spent with her physician, I suspect the problem lie in the quality of the conversation between the doctor and patient. My research has shown a direct correlation between patient-centered communications and pt. satisfaction. Engaged, satisfied patients are much more likely to report “spending longer times with the doctor” (even though their face- time with the doctor was no longer than anyone else). Contrast that with unengaged and dissatisfied patients who are more likely to report just the opposite. .

    • pcp

      I’m sure that the doctor did not feel she was giving $100 of value, either. She knew her fee schedule, and probably calculated that she gave $50 or $60 worth. Unfortunately, the patient doesn’t determine dollar value when a third party payer is involved.

    • NEMO

      What’s interesting is I’ve done these types of cost analysis in various industries…most are absolutely shocked to learn just how much time and money goes into something when they don’t “see” it in the process.

      One state gov’t freaked when they realized ordering a stapler was costing them $45 (retail was $5) due to their burdensome approval process and centralized distribution of supplies order.

      A travel industry giant was shocked to learn toilet paper was costing them $3 a roll due to their business processes.

      A banking institution was dumb-founded when they realized their ATM processes were costing them more than their tellers, by 65%.

      And, other doctor offices have come in at or above the example above. This particular practice was open to making some changes, but at the end of the day, the changes only amounted to shaving off about 3-minutes (180 seconds) off the processes since so much above is literally beyond their control (checkin verification time and billing especially and the need to check and double check before filing the claiim). As a male solo doc, he also couldn’t eliminate the chaperone for female patients, so the exam room time is always going to be, for this practice, a double-hit for cost.

  • Muddy Waters

    Doctors are the most HIGHLY trained, dedicated, and compassionate professionals you will ever write a check to. No, we are not perfect, but we also deal with so much more complexities in our workdays. Next time you pay several hundred dollars in profit margins to your plumber, electrician, car dealer, cell phone provider, grocery store, etc, consider this fact and stop complaining when doctors are reimbursed for their considerable expertise and overhead.

    • Alice

      Your comparison is not on a level playing field. A plumber and electrician come to your home…with equipment…make a diagnosis…go back out and buy parts. When my doctor does this then I can have a better comparison. And speaking for some of the skilled tradesmen I know they do a four to five year apprenticeship with college. Some have four year degrees….and receptionists, insurance, license fees, warehouses, trucks, etc.

      I will say my cellphone provider has such great customer service I doubt I will ever switch.

      • Praying Man

        You’re right Alice. It isn’t even the same playing field. Doctors deal with life and strive to keep it going despite your best efforts. Get that through your thick skull. And I’m sure your physician will appreciate the fact that you equate his skill with that of your common tradesman. You be sure to think of that when you’re a menopausal woman suffering a heart attack. Let’s see how well your Minute clinic serves you then. I pray that at least a plumber is around to unclog your pipes er..arteries. Whoops.

        • Alice

          Well…….Praying Man…I prayed and I think it’s been revealed you are a menopausal woman…..well at least a woman.

          Okay…..once more……I said Minute Clinic is limited….but great at the small stuff……and a good deal.

          Guess what? When I met my husband he was in an apprenticeship in Scotland to become…….what else….a pipefitter/plumber. I shouldn’t share this……but I must brag…..he is the pipe cleaner I know! *wink*

  • Finn

    I suspect that the patient works for an hourly wage and estimated that the doctor was making $600 an hour or $4800 a day, without taking into account all the expenses involved in running a medical practice that mean the doctor is clearing far less than that.

    One fairly obvious money-suck: the amount of time listed in NEMO’s comment for the billing coder’s work is nearly equal to the doctor’s time spent with the patient, and this is probably the expense that the patient never considered since she’s probably not aware that the billing coder even exists. If we could figure out a way to slash the amount of time needed for this part of the process, doctors could spend more time with patients and/or charge less per visit. Unfortunately, it seems that no one has enough power to force insurers to alter or simplify the amount of hoop-jumping and paperwork needed for doctors to get paid.

    • Alice

      As long as doctor’s standard of living is so much better than the patient’s they will think about the house they are building for a doctor that they will not be able to afford. I think you deserve to live well….but what that ultimately says to the patient is that even if you have 50 assistants that need paid you are still living well and most of your income comes from insurance companies. They will rightfully, assume the payments are fair because you are not living in a trailer on food stamps.

      • NEMO

        In various cost analysis I’ve done with doctors, one consistent finding is that the doctor’s are not making as much as one might perceive. In fact, most are making less per hour than their RN on staff. The reason is simply because they tend to work the equivalent of two full-time jobs in hours each week, whereas their staff usually works a normal 35-45 hours.

        So when doc is working 80-hours and making even $200,000, he’s making about $50 an hour as his salary. Most solo doc’s are not able to pay themselves that much in small-to-medium population areas, but usually can and do in larger population areas due to sheer volume.

        Private practice doc’s also have additional financial obligations that academic doc’s don’t – most notably having to meet the “employer” side of social security and medicare – so an additional 7.65% on their income up to 106,000 + an additional 1.45% on all income above 106,000. Due to IRS regulations, depending on how the practice is structured and the state they’re located, they often pay out of pocket for life insurance, disability insurance and health insurance – while still able to provide such to their employees through the practice.

        For a financially savvy person, standard of living isn’t necessarily proof of a level of income. I know folks who are middle earners living a better lifestyle, whom are debt-free before 50…..and I know folks making 250,000 or more a year struggling to get by. Wealth isn’t a product of income (though it can help), it is a product of planning and investing well.

        • Alice

          But you are giving exceptions. There will always be people who gain through inheritance, or stocks, etc.Our friend inherited a castle! Good on him! But as a whole doctors live much better than the average bear! Good on you! The patients just want you to earn it well! The golf course, four day week style of your colleagues needs to change of you want public perception to change.

  • imdoc

    NEMO is right. One needs to factor in opportunity cost. It is too easy just to look at income alone. Anyone who has run a small business knows this. I know docs who are diversifying into restaurants and other small ventures because it is a better business model.
    Also, let’s not forget there are very capable business people who have created great service delivery in other fields. Why does medical care service continue to be an open sore? Hmmm. Despite many MBA’s being involved I don’t see a clear standout in any healthcare system.
    Doctors are not business experts. Apparently the business experts even in large systems can’t solve it either. Kinda’ makes me think something else is going on that the service levels don’t reach expectations.

    “I think $50 is fair, and so is the $100 for ER visits.” Please go set up an ER and charge these levels. Everyone (except the investors and the bank) will love it. Good luck

    • Alice

      “I think $50 is fair, and so is the $100 for ER visits.” Please go set up an ER and charge these levels. Everyone (except the investors and the bank) will love it. Good luck [end quote]

      But, again, the comparison is wrong. How does the ER make money? From the government (taxpayers) and insurerance companies. You couldn’t survive on cash only, so why the comparison? Are ER doctors now on the dole too? Where can we send our charitable contributions? :) I hope your children received Christmas gifts this year…….it’s a real dog-eat-dog world out there. Sigh!

      I pay a $100 copay to go to the ER, and if it’s not an emergency I pay the whole thing out of my own pocket. I think that’s fair. And I think it should be duplicated with Medicaid. Some kind of copay to keep them from using the ER for office visits. I have a relative who has been taken by ambulance for the fourth time this week and there is nothing wrong with him. They run the same tests every single time, and he owes nothing. The government should let the free market run Medicaid.

      • Stephanie

        Another perspective of the ER visit: My insurance will not pay for an ER visit unless I am admitted. The only time that I ever went to the ER was with a temperature of 105° (after taking both ibuprofen and tylenol) that lasted for four days. I went to the ER on day four when I couldn’t reach my doctor, who was closed for a long weekend and had no service or anyone on call. Turns out that I had cellulitis and, according to the ER doctor, definitely needed to be seen, but I did not get admitted; therefore, the cost was mine. My problem here is with the insurance company, but also with my doc, who was unavailable for so many days without anyone covering her patients. Am I unreasonable to expect my doctor to be available or to at least have someone covering them for just such situations?

        • Alice

          Am I unreasonable to expect my doctor to be available or to at least have someone covering them for just such situations? [end quote]

          Stephanie this is a valid and reasonable question. I do think your doctor should have had someone in her office return your call. A lot of patients ask the same question. My doctors are part of a huge hospital (Cleveland Clinic) and they now have a 24 hour nurse you can contact…..because of this exact complaint.

          My question though… would it have been possible to to an urgent care center? They are often much cheaper. That’s what I do because I know if I have to pay they won’t run the same tests as the ER. I go to my insurer’s website and get the few names of the ones I am allowed to go to.

        • Mary Pat Whaley


          Two things you may pursue: one is that every insurance contract I’ve ever signed requires the provider to state how they will cover the patients 24/7. Does your insurance company have a contract with your provider?

          Second, it is unreasonable IMO to expect you to bypass the ER if your physician is not available. I would appeal the charges being your responsibility if your provider could not be contacted. Most insurance companies pay for emergency services if no other option was available.

          Mary Pat

    • AnnR

      We own a building that is outfitted for a resturant. It is a LOT of work and they fail with alarming frequency. A doctor would be a fool to get involved with one.

  • W

    The part of this I question is “NEEDS” 8 people, 45 min.

    I’ll pay high prices for health care without complaint as long as I’m not paying them primarily to support inefficient, overly bureaucratic systems that no one questions or strives to improve.

    Last October I had a routine colonoscopy. No polyps, no biopsies. Provider was in-network, and both the physician group and insurance company are owned by the hospital where the procedure was performed. What could be easier, right?

    About 6 weeks later I received a statement from the insurance company, summarizing the anticipated cost (no itemization) and what they would cover of that estimate (100%). A week or so after that I received a statement from the hospital, summarizing its anticipated charges (no itemization) and what they expected the insurance to cover (100%). The hospital’s sum, not surprisingly, exceeded that which the insurance statement estimated.

    A week or two later I received a $14 check from the physician group, with no explanation other than that the insurance company had negotiated a lower co-pay (at this point I’d still received no bill for the colonscopy and had actually paid nothing).

    Shortly after that, I received an actual bill from the hospital for approx. $300 that was not being covered by the insurance. No itemization. FIne with me…check went out the same day. Less than I had initially expected.

    Last week I received a statement from the insurance company that, finally, itemized charges and how much they covered for each.

    This seems like an awful lot of paperwork to me for a routine procedure with no additional tests or complications. Should I assume there’s a “need” for this bureaucracy and be happy to pay for it? Or should I expect the providers (insurance companies and health care centers both) to work together toward a better system?

    • Alice

      The paperwork is partly the problem of the doctor’s predecessors and colleagues who bilked insurance companies and the government. Their behavior has constrained the practice of true medicine, but the days of easy money may be over….but there is still money to be made despite all the burdens. Their past behavior problems have hurt the image of doctors. There is a website titled, “Doctors Behaving Badly” and they try to expose these issues.

      The Internet opened up patient advocacy…doctors are so much more accountable, and I know they feel like we do…that they are swimming through sewage…but I tend to think the real vision of the patient is improving….yet, it can be a painful process on both sides of the fence.

  • xyz

    All the people will one day get sick some will end up being critically ill with major organ failures: a reality of life. At that time you want a well trained, unhurried, well paid, dedicated and compassionate and intelligent MD. That does not come cheap. I hope the people realize that. I work in an ICU and see it everyday……………..

    • Alice

      That’s a good argument against socialized medicine. Good medicine…really good medicine is expensive. Quite frankly…even with all it’s flaws I hope I never get sick abroad…I want treated right here in the USA.

  • Steve Wilkins


    I am curious how you would “compare” your typical “10 minute” experience with the experience described by the diabetic patient in the video found at this web address below. I am curious how authentic the woman in the video sounds… Is her experience typical of other diabetic patients?

    Steve Wilkins

  • gzuckier

    In all honesty, the actual work done at this visit
    “The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
    He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.”
    could be as easily done by the case management nurse and/or software that will undoubtedly go over the treatment plan and confirm it at the insurance plan. In which case the question arises, why can’t it be done by a nurse and/or software in the first place? (Except for the exam, which couldn’t have been a real workup given the total ten minute visit) The rest of the effort listed is merely to avoid screwing up this redundant visit.

    I’m quite sympathetic to the argument that “turning the valve cost $5, knowing which valve to turn cost $500″ as the joke goes, but that by definition doesn’t apply in the quasi-routine stuff that makes up the majority of the work; Pareto principle and all that. If medical practitioners are to justify their charges on the basis of the specialized knowledge and skill they possess and the effort and cost it took to get that knowledge and skill, they have to be applied to cases which actually utilize them.

    On the other hand, I’m well aware that undoubtedly the majority of the population are incapable of coping without the authoritative presence telling them what to do (an maybe not even then). But me? I’ve just had minor surgery. Went very well. I could easily remove the stitches myself and it was obvious there weren’t any complications, but OK, let’s stipulate a followup anyway. But now, another followup in the pipe to make sure it continues to do well. Believe me, I will definitely make a visit if it fails to continue to do well; on the other hand I don’t need the doctor to tell me it’s doing well (this doesn’t involve any fancy tests or diagnostics, mostly just the doctor looking at it and asking me how it feels). For some folks, this may be of value, but personally, I don’t see it as super productive. However, since all it costs me personally is the copay, I’ll go along with the game.

    Finally (as many readers realize), note how much of that list of activities would be deleted under a system like the Canadian one; where you just fill out one simple identical form for each encounter and at the end of the month you just stuff them into an envelope and a check arrives. No need to check whether the patient is covered or not covered or whether coverage lapsed or whether the copay was paid in advance or whether the patient will need to pay the entire fee as part of the deductible or whether you will end up having to put a lien on the patient’s house to get your $100.

  • Alice

    If I was not on a cellphone I would show you what yiou failed to study. Just because you disagree with her, does not mean she is wrong. For those interested in the truth her research is fascinating. The stats are not on a level playing field. The comparisons are incorrect. If you just want to complain about America and not truly study that is fine to on an emotional level.

    So. G what country do you want to duplicate? You mentioned countries that are taxpayer funded, government run with waiting lists, no research so again you wait. If you had a bad diagnosis you would really want treated in Japan? They think Americans and our diets and lifestyle produces a land of butterballs. They have government mandated waist measurements. You like mandates…little choice…believing doctored stats? Some people like living in denial….they thrive on romantic notions and kick the American system. There is room for improvement but in my heart I do not know one person who would opt for care in Canada far less Japan.

  • Alice

    How exactly does my paying ten times as much as a Japanese citizen for an identical MRI from the identical machine contribute to research? Is the extra 90% I pay going for research? That’s not only generous, but how humble of the folks involved to do it anonymously. [end quote]

    Are you Canadian? They are highly defensive like the Brits, but there was an honest Canadian on another board.

    When you save tons of money from research it is just as I said. We run the test kitchen they get the recipe for free. Would you like to invest tons of time and money to develop…oh let’s….a secret recipe and advertise it etc. then have someone duplicate without the work and expense and profit without sweat equity? That’s why generic medicines are not available for years. It gives time to recoup the expenses. But the Canadians run a generic type of system that is effective at times, cost saving always (which is troublesome), and a leech at our expense. But that’s alright……if it’s helpful….but at least admit they are the beneficiary of a rich inheritance they didn’t sacrifice for.

    • gzuckier

      Again, how does the money I’m paying the providers get to support research? Is my cardiiologist doing experiments in his basement without any research funding? Are those doors in the clinic that I don’t get to go through leading to fully equipped labs run at the clinic’s expense? Or does the NIH funding come not from general taxes, but from taxes on doctors and hospitals? That’s certainly not fair. Or maybe it is.

  • gzuckier

    I was so impressed by my deep thoughts that I forgot my original point, which was that the ten minute office visit is some sort of convenient fiction (convenient for whom, is another matter). A serious medical professional can’t do anything in a ten minute visit that is really worthy of their time, along with the additional fixed time and effort attached to a visit of any size, as pointed out in the article. Just because the procedure code and the reimbursement pretends that 10 minute visits are a thrifty and effective way of dispensing health doesn’t mean anybody else has to. Either you do nothing and get reimbursed or you do something and get underpaid for the time you do put in. Reminds me of the good old capitation days, where you never saw a big chunk of your patients and got reimbursed as though you saw them for an hour a year, and you spent hours and hours with another chunk of your patients and got reimbursed as though you saw them for an hour a year.

  • D

    Wow…I don’t know where to begin…

    Thank you Mary for attempting to explain why things work the way they do in a doctor’s office. I would like to give my insight on this blog since I know how things work on our end as a solo surgery practice, as a patient as well since I work directly with patients all day every day in the office, and as a medical family since it is my husband’s practice. As shown in many of these posts, unless someone is in the medical field, there really is no clue how our system works.

    As a medical practice, I can assure all of you that if we could eliminate any of the steps we take, we would. We are working with computers, and as one person commented, the computer does a lot of work. I would like to point out however, computers can only process what information it is given. Think about the information you are asked as a patient to fill out. In many offices, this needs to be entered into a system. Those demographics, symptoms, medications, past history, etc. all need to be entered. In addition, many patients do not answer fully, so additional time needs to be taken to interview the patient and confirm. In our instance, not only does the doctor need to review this information, but he needs to review the information and testing that has brought the patient to our office. Only then does he meet with the patient. After answering all their questions and fully explaining options, there could be as much as an additional 30 minutes spent with ordering additional testing or setting up surgery. Once these items are scheduled, it could take as little as 10 minutes or as long as a hour checking approval policies for the patients insurance plan, and getting the approval if needed. In the meantime, the doctor does not finish with the visit when he walks out the door. He writes his note, fills out orders if necessary and walks the patient to the check out desk. We then have the follow up of testing and getting the patient the results, making sure all the necessary physicians get the notes, etc. This doesn’t even include the billing which is made more difficult by the insurance companies. Btw, specialists get paid the same fees per office code that a primary care doctor gets paid.

    I do understand the frustration of patients sitting in the room for long periods of time. We do try and wait until we think the doctor will be out of the other room, however there are times where we need to go in and apologize because he has been held up with another patient. It is important for patients to remember that most physicians are not on a coffee break while you are waiting. Especially in our office, another patient may be getting a cancer diagnosis or are being put at ease with answers to questions about their surgery that is needed. Be sure that you will also get that extra time when needed, even when there are patients waiting behind you.

    Lastly, I can assure you Alice that we live in a neighborhood with plumbers, police officers, teachers, etc. While we are able to afford to go out to dinner, or a movie, the days of getting paid an enormous amount of money as a physician are long gone. This is partly due to patients who no longer feel it necessary to pay their portion of the bill, and partly due to the minimal amount insurance pays as compared to overhead costs. For example, we can get paid $427 for hernia surgery, which means someone is actually cutting you, fixing you, putting you back together, and seeing you after the surgery for 90 days for free. If the insurance pays 80% or about $340 and the patient doesn’t pay their portion, you’ve just made very little for a skill that not many people have. And honestly, I’ve paid $75 for my plumber to unclog my shower. Payment was due on the spot and there wasn’t a guarantee that he would come back free of charge for three months if it clogged again.

    As a side note, we have many patients who come to us from Canada and Europe. They are willing to pay out of pocket to get care. Telling of what they think their options are at home.

  • epatientgr

    This sounds like this practice likes to relieve the unemployment in the city! I do not really understand why this doc needs an army of assisstants! This is his problem and patients should not be charged for his ideas of grandeur…..a secretary or nurse can easily handle patient visits as is done all over the world…

    • L Faith Birmingham

          Your response indicates a substantial lack of familiarity with the multiple regulations required of a medical practice, the workload imposed by insurance companies in order to file a claim on behalf of the patient and to handle every increasing prior authorizations (for medications, a number of diagnostic studies and/or referral to a specialist when needed). It is hardly for “ideas of grandeur” (what a hostile, prejudicial comment to make!) but to meet the substantial requirements imposed in order to practice medicine in the US.

          A recent study in the journal Health Affairs:
      identifies the substantial differences between US and Canadian medical practices. “US nursing staff, including medical assistants, spent 20.6 hours per physician per week interacting with health plans—nearly ten times that of their Ontario counterparts.”  
         Perhaps you would like to reconsider your remark?

  • PhD

    This is probably what has people upset the most:

  • Steven M Hacker, MD

    As a practicing physician and the author of the business book for doctors, The Medical Entrepreneur Pearls, Pitfalls and Practical Business Advice for Doctors, I can attest to the importance of a physician really understanding what his true bottom line is. Most doctors dont think in these terms whereas all successful businesses do. The “overhead”, gross vs. net revenue, and the actual amount the doctor sees from one patient encounter should be understood. My guess is most doctors dont take the time to really drill down on that data. The simplest calculation would be to take the monthly expenses divide it by the number of patient visits per month and then in its crudest form , a doctor would understand how much each patient visit on average costs him or her. The problem really starts from medical school and beyond into residency. There is not enough time to teach doctors the business of medicine as there is barely enough time to prepare them for the practice of medicine. The reality is that the business of medicine is just as important to a doctor’s livelihood as is the practice of medicine.

  • Alice

    I think your point about finances is a good one, but disagree that it is equal in importance. It just makes patients think the, “Keep the meat moving” is a truism, and sick people do not like to think their illness feeds the beast.

    • Cathy Cassetta

      Unfortunately, the reality is that, without the income there isn’t an office to go to…finances are critical to maintain the office.

  • Steven M Hacker MD

    That is the problem with medicine today is the concern that patients misperception about their doctor’s livelihood actually affects the quality and the concern by the doctor. Having a practice with over 25,000 patients over the last 17 years, I can tell you that sick people as group (albeit there are always exceptions) do not concern themselves with ideas that their illness “feeds the beast”. If they like thier doctor, they trust their doctor and they are happy with treatment outcomes they do not concern themselves with concepts such as “keep the meat moving”. Doctors , as a part of their understanding how to run a business, must also treat their patients as customers and provide excellent “customer” service- which equates to excellent patient care. Patients demand that. Regardless, as I discuss in the book, The Medical Entrepreneur, doctors own well being is often tied to their livelihood which in turn is definitely linked to their ability to be compensated for their time, training, and experience. However, compensation without understanding true costs and approaching the medical practice as a business, is a prescription for difficulties for the doctor. Obviously, I am biased somewhat, but I do agree with you that business of medicine is not quite as important as the practice of medicine but the importance only weighs in favor of the latter slightly. I dont know any practicing physicians today that are not concerned with how to run their business and monetize their efforts and yet at the same time strive to provide excellent care. These efforts are tied hand in hand. The problem is that there was never a book such as The Medical Entrepreneur that really addressed the physician practice as a business and prepared the doctor for the current challengs of running a business. If doctors read this book before finishing residency and before signing any contracts, they will save themselves potential business headaches that commonly afflict physicians.

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