Patients who bill their doctor for being late

by Pamela Wible, MD | in Patient | 392 responses

Meet Elaine.

We lost touch for a while, but caught up with each other recently.

Like most girlfriends, we shared adventures of love, travel, and work. I told Elaine that I left assembly-line medicine. Now I host town hall meetings-inspiring citizens nationwide to design ideal clinics and hospitals.

Elaine shared: “If I’m kept waiting, I bill the doctor. At the twenty minute mark, I politely tell the receptionist that the doctor has missed my appointment and, at the thirty minute mark, I will start billing at $47/hour.”

Wow! I had to hear more.

Elaine scheduled her physical as the first appointment slot of the day. She waited thirty-five minutes in a paper gown before getting dressed, retrieving her copay, and informing the receptionist to expect a bill. The doctor pulled up just as Elaine was leaving.

Prior to her initial visit, Elaine signed the standard agreement outlining no-show and late fees. On follow up, Elaine knocked on the door and discovered her therapist with another client. He apologized for his scheduling error. Elaine sent a bill; check arrived the following week.

Elaine values herself and her time.

When the Comcast guy told her to wait at home between 3:00-6:00 pm, she said, “Expect a $141.00 bill. Is that okay with your boss?” A compromise: The driver agreed to call fifteen minutes ahead of arrival.

I was intrigued. Who pays for waiting?

Cab drivers charge hourly for waiting. Restaurants may provide a discounted meal for the inconvenience. Airlines cover hotel rooms for undue delays. Some physicians apologize. I offer a gift.

Central to medicine is a sacred covenant built on mutual trust, respect, and integrity. What happens when physicians fall into self-interest or self-pity? Or when physicians are so emotionally, physically or financially distraught by their profession?

Patients suffer. And their wait times increase.

So what’s a doc to do?

1. Remember: Respect is reciprocal. If physicians are on time, patients will be on time. If physicians don’t cancel appointments with little notice, patients won’t either. Doctors should stop charging fees they are unwilling to pay themselves.

2. Functional clinics attract functional patients. Patients fall to the level of dysfunction within a clinic. A chaotic, disorganized clinic attracts chaotic, disorganized patients. Take care of yourself; uphold high standards and healthy boundaries.

3. Don’t wait. Doctors should apologize for delays. And if presented with an invoice for excessive waiting, doctors should gladly pay the fee. Fortunately, most patients don’t bill at the doctor’s hourly rate.

My opinion. Share yours:

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care.

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Comments

http://www.yourkycounselor.com Janet Vessels
I have thought about this many of times as I am self-employed and my time is money too! Great idea!
Jeff
Exactly! This is simply a matter of common respect and courtesy. If I fail to cancel an appointment within 24 hours of the appointed time, I expect to be billed for the appointment anyway.
I think this often happens because doctors (or their office managers) overbook their time. And the flip side of this is also disrespectful to patients: Doctors rush us through instead of listening to us, because they’re trying to maintain an impossible schedule. I can appreciate that problem from the doctor’s perspective, but it is not a problem that I created and I should not have to pay for it.

Elaine F
Very well put Jeff; I agree! There are definately two sides to the issues, and overbooking is one of the factors (among others) that can cause delays. Overbooking is a problem with the model that can be corrected and, as you say, isn’t created by patients.
Joe
“I can appreciate that problem from the doctor’s perspective, but it is not a problem that I created and I should not have to pay for it.”
Jeff, perhaps you shouldn’t be so quick to absolve yourself of responsibility. Unless you are seeing a physician in a practice setting that specifically addresses this long-standing issue (a “concierge” type practice, for example), aren’t you tacitly agreeing to see your physician in the “typical” office setting, with all of the rushing, late fees, and impossible schedules? Isn’t that part of the cost, part of the deal, for seeing your physician at a rate set by your insurance company?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
You don’t need a concierge practice to run on time. You don’t need to stop taking insurance to run on time. You simply have to create a humane schedule and generally (barring emergencies) stick to it.
I accept insurance. I do not charge patients any extra fees. And I run on time. Many offices across the country do the same.
Physicians choose to work on an assembly line by designing their schedules that way or working for employers who perpetuate treadmill medicine.
There are many models to choose from. Find one that works for you and your patients. Living as a victim is not caring for one’s health. This is, after all, health care.

stitch
And what have you chosen to do that allows you to operate this way? Do you run extended hours? Do you have less staff than the average? Do you pay staff benefits like healthcare?
I live in the jurisdiction with the lowest, yes, the absolute lowest, reimbursement for professional fees. And traditional private practitioners are few and far between, who have solo offices that can run on a regular schedule and maintain the overhead, including staff.
You make it sound so easy. Gee, wish you’d give up some more of your secrets.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
The secret is low overhead. I used to have out-of-control overhead working at my favorite factory job. Now I have a no staff solo/solo model. I lease a small office space for $322/month rather than a huge building, streamline operation costs with IT etc. . .
And I have “activated patients” who have a sense of ownership of the practice since they designed it themselves.
Before opening this community-designed ideal practice I actually held several town hall meetings inviting citizens to share their idea of a dream clinic. I collected 100 pages of testimony, adopted 90% of feedback, and was open one month later.
More on how to do this on my website: IdealMedicalCare.org and hey, call me anytime.
I’m here to help. . .
My YouTube Channel features examples of other docs who have done the same:
http://www.youtube.com/user/pamelawible?feature=mhum#p/u
Call me: 541-345-2437. Seriously.
Pamela

nimo
On your next appointment when you come in with a “trivial” complaint that leads to an hour workup that is life saving, remember your doctor will be billed by the next patient for being late. Do you prefer a 15min appointment that can barely take care of pleasantries or a proper check up?

http://regrounding.wordpress.com Lori
It’s not an either-or. When scheduling my appointments, when something unusual comes up I let the scheduler know so that extra time can be booked if necessary. In the event of a more urgent need, I will readily take a late-in-the-day appointment of the day so that, while I may be frustrated by the wait (if there is one), I’m not part of backing someone else up. If I am running late, I call ahead and offer to move into a slower time or reschedule altogether. While I applaud the idea that patient’s time is just as valuable as a doctor’s time, I am trouble by a generally punitive answer to an issue that should be, at it’s heart, about a partnership.

http://www.drmintz.com Matthew Mintz
Agree that a patient’s time is valuable. However, what causes most patients to wait is the over-booked doctor’s schedule. The schedule is over-booked due to the low reimbursement from insurance companies.
Please see my post on this
http://drmintz.blogspot.com/2011/07/paying-for-your-time.html

http://drmaliareckons.posterous.com/ Timothy Malia, MD
Dr. Mintz –
I think that is a truth that very few patients really understand. Thanks for mentioning it.
I also am not sure folks understand that doctors and their staff are working for many patients’ sake during the day and not just the appointments scheduled. I covered some of those issue, too, in my post at:
http://drmaliareckons.posterous.com/waiting-in-doctors-offices-supporting-relatio
–Timothy Malia, MD

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Overbooking is disrespectful to patients and doctors. Great point Jeff.
http://www.facebook.com/sparkspeds.nv kevin m. windisch md, fapp
You are right, respect demands respect. I guess I’ll start demanding that patients no longer have seizures in my office because that throws me behind. I will also no longer allow patients to book appointments for vomiting when in fact they are a pregnant teenager with pelvic inflammatory disease whose mother does not know she is sexually active- these cases also throw me behind and I can’t have that. While I’m at it, no more suicidal teens, that always makes me run behind. Also no more suspected child abuse cases, I don’t really like those anyway and they put me behind.
Give me a break, this isn’t mcdonalds, it’s healthcare.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
We can have health care and mutual respect.
Most patients just want an apology and an update.
Excluding emergencies, why doçtors are late
for scheduled appointments:
PATIENT CAUSED:
Misrepresent real reason for visit
Add-on complaints & “oh by the ways”
Add-on family members (mom brings several sick kids in for one slot)
Arrive late to office/poor time management
Unprepared (No insurance card, ID, paperwork)
Inattentive (on cell phone)
PHYSICIAN CAUSED
Unrealistic schedule
Overbooking
Socializing with staff
Personal phone calls
Drug rep interruptions
Arrive late to office/poor time management)
Consulting with other doctors
SYSTEM CAUSED:
Third party interference (insurance hoop jumping etc. . ) **
EMR/IT breakdown
Physicians functioning as social safety net
Uninsured/underinsured delay care then clog system
** Since PHYSICIAN signed contract with interfering third party
and PATIENT paid monthly premium this is a PHYSICIAN & PATIENT-CAUSED delay.
Pamela Wible MD

Jo
You forgot the most time consuming reason of all and that is the practice that must be taken care of outside of Patient visits that patients expect but is totally unreimbursed by insurance companies and that is the 100s of messages and prescription refills that must be answered in a timely manner and the coordination of care after the visit is done. Like one staff member stated, “if patients don’t get their meds (refills) they get spasmodic”.
This is being done in between visits, after hours and on weekends, utilizing staff to do the call backs after you have reviewed the medical record and given the answer. If you have more than 1500 patients this is why most doctors run late.
Our office is also a Family Medicine Medical Home and every visit, every patient record is checked for last labs, physical exam etc to be monitored to make sure all chronic illnesses are being addressed appropriately, we also update and reconcile all medications as some are seeing multiple specialists. We keep same day appointment slots open for acute illness and work patients in the morning and also in the afternoon.
Most of the patients are roomed within 5 minutes of arriving and are seen by the physician within 30 minutes of being checked in, and before the Dr walks in their records are updated by the nurse and refills pulled into the A&P and our MAs (2) scribe in the EMR during visit.
Most patients are willing to wait for such service and are offered water and kept up to date if the physician is running behind.
In our practice it would be an insult after that kind of care for a patient to then state they feel we owe them “money for their time” when they only paid a $20 co-payment and the reibursement for the longer visit they were given after their wait, due to them bringing up multiple medical problems will only be about 60 cents on the dollar.
No practice is cooker cutter and should not be lumped into the same type of category, what works for you does not work in our patient population.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Prevent all refill headaches:
I highly recommend doing refills during appointments only. I give 1-12 months of meds depending on how stable condition is and whether patient needs monitoring or not.
Now I have NO pharmacists calling or faxing which use to be a third of all calls. And no more whining patients begging for emergency refills because they “just took their last pill.” We all need to be proactive and respect each others’ time.
BTW, pharmacists have been ECSTATIC because I tell patients straight out not to burden pharmacists or physicians with emergency requests because they forgot to keep track of how many pills they had left.

ninguem
That’s one of the top ten complaints, is people expecting unlimited refills of meds. You’re abusing your monopoly on prescribing authority you evil capitalist.
Though I never could understand that. This is Oregon, anybody can be a healthcare professional in some capacity. I think my dog has prescribing privileges.
But you’ve got to get from point “A” to point “B”. I find it hard to believe there weren’t people angry that you insisted on the visit, for whatever financial arrangements you have. Heck, I get that with Medicaid patients who have no financial responsibility.
You’re making it sound like they were all happy about it.
I’m in the other Oregon, that parallel universe where Mr. Spock has the goatee……..

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Oh, some patients bitch about coming in. One woman wanted her antidepressant filled over the phone and got pretty vicious when I told her she would need to be seen. I fit her in the same day. By the time she left the appointment she was thanking me for getting her out of the house and gave me a hug.
I’m sure there are other patients who don’t feel like giving me a hug. Hey, I gotta stand my ground.
Anonymous
Having read all of the comments so far, I’m intrigued at how many commenters seem to misconstrue what the issue is about.
As I understand it, it’s not about lateness per se (whether by doctors, patients, plumbers or other ‘service’ or ‘delivery’ providers), but about _communication_ between provider and receiver (or receiver and provdier). This communication can be through notices, statements, questions, texts, or indeed other forms that haven’t yet been posted here.
Even these posts and replies are forms of communication, albeit often very angry, accusatory, and defensive. Often doctors don’t seem to understand what it is like for people in ‘patient’ positions who are undergoing medical systems (which often seem to implicitly expect patients to be there, and be available, for doctors when doctors become available. This is generally more true in hospital ‘clinics’ than in primary care, but can still apply in primary care _when no communication systems about timing of appointments are in place_, which is when unspoken assumptions come into play – on all sides: doctors, office staff, and patients; all of these have been written about or represented amongst the comments. Busy providers feel (and are) under various kinds of stresses and easily become defensive or attacking when they perceive comments as criticisms; office staff are often caught betwixt a rock and a hard place (but can still be managed differently by their employers); and patients are caught between the historical training in passivity and gratitude, vs the more recent, more empowered ‘partner in one’s own health care’ position. It was helpful to be reminded in some of the comments of the kinds of issues which can lead doctors to give more time to patients (though not to hear the angry accusatory tones the information was delivered in!), and perhaps some of this could be incorporated in routine signs / handouts at reception about ‘appointments running late’. This is respectful of everyone’s positions and situations.
As a patient, I am learning to be more proactive and to ask staff when I might be seen – I ask on arrival, and after 10 / 20 / 30 minutes’ wait; if I’m pressed for time, I ask about rescheduling if the wait is more than I can cope with on that occasion. Sometimes if early for an appointment, I have been offered to be fitted in before the scheduled time of my appointment. When I’m under pressure (as a patient or as a practitioner) is when communication is least likely to be civil, respectful, and kindly; but I try to learn, because my respectful question can bring some lightness and civility into the office system, which is always beneficial for me and whomever I am communicating with. Simple questions like ‘Are appointments running to time just now, or how late are they running?’ gives me information, leaves me feeling less helpless and angry at waiting, and helps me plan what I want to do in the face of delays. Sometimes the doctor apologises for the delays; it helps if there is a sign up at Reception about delays and causes of delays. Over time one can learn whether there are patterns to the times of day when appointments are likelier to keep to time than others. I’m not saying it’s the patient’s responsibility, but simply recognising stressed systems and how to navigate or surf them more comfortably for all concerned.
It is much easier for me to do this as a patient, now that I am retired and no longer a harried professional and parent having to get back to one or another of my many then-responsibilities. But my time is still important, even though my stress level is lower. I have experienced medical care on three different continents and 4 different countries, under a variety of public/private systems. The fact that one _needs_ a doctor or a plumber is no reason for being left to passively wait through unexamined and/or _unexplained_ delays. I’ve heard people be as irate about ‘tradespeople’ as about doctors or electricity meter readers.
It’s about how we humans, in stressed systems, leading busy lives, can still somehow manage to be aware of both sides of the equation (provider and recipient) and maintain civility and communication despite all the stresses we are all living and seeking and providing services under.

http://www.mdwrites.com MD
Remember that your doctor may be rounding on sick patients in the morning before your appointment and may have had an emergency or an especially sick patient. He may have had a sick patient or emergency during the day which may have run his schedule late. If this is not a pattern, then cut your doctor some slack. There may be a good reason for it. A doctor is not a comcast guy or your plumber.

http://www.womeninpainawareness.ning.com carol
My one doctor’s sec’t told me as she wrote out an appointment slip “We triple-book.” When I look aghast, she modified her statement “I meant double book.” Neither should be acceptable. There needs to be a mutual contract, I will not overbook (and pts need to understand that some patients do go overtime.)
That being said I once waited 10 hours (not a mistype ten) and was very angry but when I finally saw her i was so impressed I was no longer angry.
Carol Jay Levy, B.A., CH.t

Dave
Believe it or not many physicians start work before their first office visit. Sometimes mourning rounds at the hospital take longer, especially with complex patients. If you really want what is described in the article there will be no more hospital visits resulting in a loss of continuity of care. Also, expect to get kicked out and told to cone back in a week if your problem takes longer than scheduled. Likewise expect to pay for whatever was scheduled even if a problem ends up minor.
http://www.medicalmissions.org Steven Thiltgen
How would a person feel if, during their exam, the doctor looked up and abruptly left because they couldn’t be late for their next patient?
The allotted time might work for most patients but perhaps your condition requires a more thorough exam…should your visit be cut short and a second appointment scheduled for you the doctor can’t be late for the next appointment or face being billed?

Penny
I totally agree with your comment Steven. Such selfish patients would surely not be desired by most doctors. If I were that patient’s doctor I purposely be late on every appointment to drive her to another doctor.
I once went to a surgeon who had a huge sign in his office that went something like this: “We strive to keep waiting time as short as possible, but please understand that some cases take longer than others and if you should find yourself in that situation you will be given the same consideration.” The surgeon was as warm as his sign.
My guess is that the patients who complain about waiting times are also the same types who demand unreasonable time themselves when they get in. Like you indicated, how would she have liked it if she or another member of her family developed a serious condition that was extremely traumatizing and he said, “sorry but your five minutes are up and my duty is not to console or deal with serious issues, but rather to keep selfish, unreasonable, and impatient patients happy?”

Elaine F
Hi Penny,
I’m the selfish, undesirable, unreasonable, and impatient patient/customer to which you refer. In terms of mutual respect in the client/patient relationship,
is how you conduct yourself in your practice? Would really use your practice to retaliate on an patient who “dares” to bill you as you state?
I’ll say thank you for presenting yourself as an example that goes to the heart of what many doctors and patients are working to eliminate. And as I customer I will avoid you.
- Elaine

Penny
That would be quite wise, since I’m not a doctor.

Ross
Penny,
Awesome! That was so funny.

JohnMD
I assume this is the same kind of patient that EXPECTS me to spend 30 minutes of a 10 minute appointment explaining the side effects of her Yaz to her after she was scared by a comment on CNN , thus making me 20 minutes late for my next appointment. Yeah – she can stuff her invoice where the sun don’t shine!
I am almost never late and when I am , I always apologise and there is always a good reason. Very few doctors mean to be late , but sometimes patients need extra time and that makes lateness unavoidable. This morning a 55 year old logger cried on my shoulder (literally) for 40 mins of a 10 minute appointment he made ostensibly for a med refill – his teenage son died. What was I supposed to tell him? Make another appointment , Elaine is waiting to discuss her worried well symptoms? If she presented me with a bill for “excessive waiting” I would encourage her to find another doctor. I would pay the “invoice” when hell becomes a ski resort. Sometimes I am late for the first appointment because when I do rounds at 6 am when Elaine is still getting her beauty sleep , my patients are sick , crashing or dying and that can unfortunately result in a bit of a delay. This kind of attitude incenses me from a culture that is happy to sit in their car for 20 minutes at the Starbucks drive through to get a latte- try presenting them with an invoice!

Elaine F
Don’t worry JohnMD, I won’t be visiting your office.
- Elaine
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
JohnMD ~ This is about ending the double standard of charging patients for missed/cancelled appointments, but if the doctor screws up and misses/cancels a patients visit he or she is not held to the same contract.
Elaines signed forms agreeing to pay physicians if she screwed up and missed an appointment. Respect goes both ways.
Besides, most patients (Elaine included) respond very well to a simple explanation and a sincere apology. Patients only bill doctors as a last resort when they have experienced excessive waiting AND disrespect.
While attending a risk reduction course with my malpractice carrier we were told that patients do not sue doctors they like even if there is a legitimate case. Be likable and patents will like you. Mutual respect goes a long way.
Please do not vilify Elaine. The doctors she billed were not with crying loggers or rounding in the hospital. They were in the wrong and would have expected Elaine to pay up had she committed the same error.
Let’s be understanding and fair with one another.
Please.

http://deleted pcp
“If I’m kept waiting, I bill the doctor”
Doesn’t sound like a last resort to me.
Penny
I never noticed before your comment that the doctor hadn’t been looking after “crying loggers”. While I realize that’s “just a “term”, how was she able to prove that, and how were you able to verify it? The fact that the proof hasn’t yet been documented (as far as I have noticed anyway) is the only thing that makes it hard for readers to understand.
I don’t think anyone is trying to vilify either Elaine or you. It’s just that people don’t want her to hurt herself. Some don’t think it’s fair to vilify her doctor without concrete proof either.
She’s also harming herself, I think more than she realizes, by continually saying, “I won’t be seeing you as a doctor, or you or you or a hundred others.” By gradually eliminating herself from a large pool she may soon find it hard to book a doctor at all.
Worse yet, if notes were to be put in her medical records stating that she’s highly demanding and unreasonable that too could hurt her for the rest of her life by causing any future doctor to have a negative attitude toward her before he even meets her.
The billing could also work against her too, possibly causing herself to be labelled as “neurotic.” (No, I’m not saying she is; I’m just saying that some doctors might define her that way in her records). Surely most doctors would refuse to pay something like that unless she could legally prove in court that they were bad doctors.
She’s hurting herself in so many ways that it might help her if you can make her understand that. The stress of allowing herself to become so angry over something so trivial can also cause disease serious enough to make her one day realize that her health really is more important than her money. For that reason alone, it might be better for her to arrange her appointments on days when she doesn’t have extremely important appointments, and then she can simply take along an enjoyable book to read. Rage has a way of eating away the insides of the beholder and it can not only harm her, but kill her many years before her time.

Elaine F
Penny,
Thank you so much for your concern for me. I am so highly demanding and unreasonable that not only will no doctors see me but I have no friends at all. Now if you will excuse me I have some puppies to kick..
Penny, I invite you to re-read your post and see how humorously you have exaggerated this issue. It keeps me from being able to take you seriously at all.

Penny
My gosh, we actually both feel the same about something. It was amusing that you found my posts as ridiculous as yours but nice that we could arrive at common agreement on at least something.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Matthew, it is the doctor that signed the contract with the third party who is destabilizing his or her practice so isn’t the doctor partially at fault?

Vox Rusticus
The patient has a choice here, accept delays caused by insurance or pay cash for the privilege of not having insurance become an issue. The doctor isn’t at fault if the insurance company is delaying, he didn’t contract with the insurance company for them to impose delays, he contracted in order to allow patients to be seen without having to front the money. But that all can be changed.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Doctors who sign with abusive third parties sign up for the abuse. Don’t like it? Terminate the contract.

Elizabeth
Doctors are starting to terminate these contracts with insurance companies that won’t respect the doctor’s time. But this just means there are fewer and fewer doctors left on that insurance panel, creating worse backlog and overbooking. I agree, we as doctors shouldn’t put up with this, but until doctors and hospitals stand up, en masse, to these “abusive” practices (for both patient and doctor) will continue.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yes, a collective movement is best. I’m thinking along the lines of the civil rights movement.
At a “create your ideal practice” keynote address I gave to a few hundred docs several years back a doc asked what to do about insurance companies that keep you on hold for 15 minutes and provide horrible customer service.
Answer: If we all terminated contracts with abusive third parties they’d be forced to go out of business or raise the bar on their behavior.
We gotta stick together.

Sharon
my ex father in law was a business person. he informed his doctors up front that if they were late more than 5 minutes he reverses the bill. this isn’t a new idea but its rare, i think, because people are afraid of “God, i.e. their own doctors.” I think its time we stop being afraid.

Vox Rusticus
Be prepared to back up your assertiveness with a willingness to pay; if I can pay by the minute, so can you. I certainly would not pay any patient for waiting, although I know they very rarely do wait. If there is a wait, it is usually obvious, someone has unexpected problems that can’t be accommodated in the usual appointment slot.

ninguem
Father-in-law is free to say that.
I’m also free to say “find another doctor”, and I’d likely tell a patient like that to go elsewhere, from the get-go.
There ARE practices that cater to the VIP’s. I mean that in the best way. The very famous types where their appearance in a doc’s waiting room would be in the newspapers the next day. Papparazzi and all that.
The doc will open his entire day to that VIP’s visit.
And charge accordingly.
Go for it.

http://www.womeninpainawareness.ning.com carol
(just an anecdote: I was in the exam room, the doc starting the app’t with me, already began our dialogue when he was told there was a VIP patient who wanted to see him, now. He got up and left the room. I sat in that exam room for over 30 additional minutes while this VIP person was treated. As a peon, and insurance covered patient, I just didnt matter. )
As for it being obvious as Vox Rusticus writes “If there is a wait, it is usually obvious, someone has unexpected problems that can’t be accommodated in the usual appointment slot.” Not always so. I have seen pharmaceutical reps be ushered in and doc talking with them as I sit and wait (I like to have door kept open so I can see there is still a world outside the closed exam room.) I have overheard parts of phone conversations where doc is laughing with a buddy or relative about some anecdote or another and this conitnues til end of call, no medical discussion going on but I am required to wait until they finish. When I worked I was not allowed to take personal phone calls or visit with people who were there for reasons other than the work (and pharma is not work that should be done during pt hours, I am sorry, but it should not be.)
Carol

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Mutual respect needed on both sides.

http://www.twitter.com/HomeOfficeMommy Adelaide “Home Office Mommy’ Zindler
The dad of a friend of mine was a pediatrician way back in the day. She tells me that patients who took care of their children’s health even got free visits. Those that didn’t had to pay him out of their own pockets. HMO’s had not taken over our land yet. Have you ever heard of such a thing?
The real trip is that he did quite well. My friend Nancy even had her own seamstress, maid… I’m talking lifestyles of the rich and famous. We’re into retro, vintage and recycling. So why not throw back to the days when families still believed in healthcare? I just love me some Dr. Wible yal!
MassachusettsPCP
Poor practical idea with overwhelming populist support.
First, I will preface that I detest running late. It stresses me out and I don’t want to stay at work even later than I have to already (due to paperwork, prior auths, EMR notes). I also start my day on time and do not overbook. My secretary is not allowed to fit 3 people into one space. And I agree that respect between doctor and patient, including for time, ideally needs to be reciprocal. But I cannot promise it or pay financially for breaches that happen time to time (I am not one of those doctors who run habitually late – that is altogether another matter, be it scheduling or not showing up on time)
But yes I sometimes run late. Here are the reasons I can identify, and what my solution will be if patients start sending me bills for the inconvenience.
1. Patient needs same-day appt for really urgent issue. I have already allocated 50% of my spaces to “same day” slots but I’m full. Patient doesn’t have time to go to ER and wait hours, it costs more, and they will be just rushed through. I work them in. Next patient sends me a 10 minute bill. Solution: no you can’t be seen today.
2. Johnny fell, has a cut on his knee and elbow and needs stitches. A complex repair as one of them isn’t linear. Johnny’s mom also detests the wait at the ER, the copay, and wants Johnny home by supper. I could do it, but then I will run behind on the next scheduled patient. I do it. Next patient (and cascading, the next 5 as I will run late from that point on) send me bills. Solution: no, I don’t sew stitches anymore as it inconveniences several patients when I run late so you will have to go to ER. Sorry Johnny’s mom.
3. Elderly patient shows up with family. She hasn’t been seen in months, just got out of 6 week rehab stay and 2 week hospitalization. Lots of med changes, confusion about meds, followups, why isn’t she eating? She was supposed to followup next week but hospital only gave her 1 week of meds (some of which are unfamiliar to patient and family) and needs refills. Also family needs you to review what happened to her and answer their questions. Solution: See patient, then once 10-15 minutes runs down the clock, apologize that you must be on your way and book a followup appt to take up their questions. Apologize personally to the Janet the daughter who had to take a day off work because her 80-year old mother will not remember my directions, but Janet will have to take another day off because I can’t run late and answer everything patiently, compassionately, at the family’s level and wishes, and not be late for the next patient.
I could give more examples that happen very regularly. With primary care medicine in particular, there are so many things that can and do happen that I can’t guarantee every 15 minutes I cut off. I am not a financial advisor. Nor a psychiatrist (they cut you off, albeit gently). Nor a dentist (at least they know how long a filling or crown takes, and any new problems are rescheduled, not addressed that day and patients do NOT usually object).

Elaine F
I can appreciate your points, and I understand that the healthcare model includes not knowing how long a patient will need. For me, as a patient, it would go a long way towards mutual respect if I received a phone call from the doctor’s office letting me know the doctor is running late. That way, I can choose to come in when he can see me (i.e. after he has cared for those before me), or reschedule.

Joe
Elaine,
You say that you appreciate and understand the limitations of the system, as provided by MassPCPs points … and then you request something which completely ignores the chief limitation!
A physician’s office accepting third-party payment must keep their schedule fully booked and schedule patients for shorter periods of time than are sometimes necessary or the practice would quickly be insolvent. The overhead costs related to internal monitoring of the physician’s timeliness and calling patients when the physician is running late, not to mention the potential losses due to allowing last minute rescheduling would quickly devour whatever slim margins currently exist. The net result is the same as patients billing their physician for time spent waiting, and the “solution” would be just as MassPCP described.
As others have stated, you seem to be asking for a service that already exists – just not in the setting or at the price point you are expecting it.

Elaine F
Hi Joe,
Help me understand the comment “you seem to be asking for a service that already exists.” I’m not currently receiving ‘running late’ phone calls from any of my doctors.
I challenge your assertation that having such calls made would “quickly devour whatever slim margins currently exist.” Data behind the assertion would help make it more believable.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Joe – Traditional offices can provide the service Elaine expects at the price point she expects it. Some offices drop particularly abusive third parties with pitiful reimbursement and high administrative burden to allow excellent customer service for everyone else.
Doctors don’t have to suffer.

Joe
What if Elaine has particularly abusive third party insurance with pitiful reimbursement and high administrative burden? Is Elaine not allowed to expect phone calls and other perks in this case? I thought your post attempted to make the case that physician’s should do these things in the interest of basic mutual respect. Why did you write a post about Elaine being upset with her physician and not a post about how your helped your friend find a practice that suits her needs?
You’re right. Doctors don’t have to suffer – if they can find a well-paying cohort. Patients don’t have to suffer either – if they have well-paying insurance or the means to pay cash. What happens to the rest?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@Joe below: If we all collectively stopped accepting the abuse as a normal part of receiving health care then some insurance companies would be forced to raise the bar on their behavior or go out of business. Other no-value added intermediaries would do the same. Be respectful and add value or get out of the exam room.
I made a video about Elaine because I was fascinated by her approach. The media picked it up immediately. Elaine knows how to find a new practice with a doctor who respects her time.

Joe
I’ll agree in theory, but with the realization that such a plan would create a tiered system. You are fortunate to be able to cater to those patients who, in one way or another, have the means to reward you adequately for your time. A universal shift to your type of practice would require many more physicians and many, many more dollars.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Joe ~ if we collectively stop accepting abuse it does not create a two-tiered system. We all benefit.
ninguem
Joe – “…..I’ll agree in theory, but with the realization that such a plan would create a tiered system….”
There already is a tiered system. There is no place on the planet tat does NOT have a tiered system.
Elaine F
Hi Joe,
Again, I find myself quizzing your bold statement “A universal shift to your type of practice would require many more physicians and many, many more dollars.” How many more physicians? How many more doctors? Please refrain from making statements that sound outrageous as it makes it hard to take you seriously.

Chad
I work in an undserved area and overbooking is a way of life. We have actively been recruiting for more physicians in the practice for the past 2 years. We seem to lose out over more urban locations in a cognitive specialty that has a workforce shortage already.
I would love to book a reasonable schedule and I mean no disrepect to my patients when we have days scheduling 30-40 patients. And somedays we are 30-60minutes behind. But if you wait you will be seen. The delima for this physician in the trenches is which patient to deny access so that patient’s might have a better chance of not waititng or so that my day would be less harried.
With the physician shortage looming ahead, I would look for more wait times. On the other hand, I don’t bill late fees or fees for missed appointments. I figure the 3 month wait to get back into the schedule is punishement enough.
Of course, if you wage capacity is $50 dollars an hour as in the example above, then you can probably afford the retainer of a concierge physician – at least your problem would be solved.
AnnR
I think trying to bill the doctor would not be the way to have a good relationship with the doctor and/or his/her office staff. When you suddenly need a refill and can’t come in or call in with a question you will not be the person they bother to make an effort to help.
If you’ve been to see someone 4-5 times and they don’t meet your needs for timeliness it’s better just to find someone else. If they’re a super-duper specialist and there is no one else then plan accordingly.
Smart Doc
Buh bye, Elaine.
Colin
Don’t bite the hand that heals you.
http://deleted pcp
“Meet Elaine.”
No, thank you, I’d rather not.
BladeDoc
1. I have not agreed to that arrangement so no legal duty to pay your “invoice” applies.
2. If you don’t pay for your healthcare directly, you are not the customer, your insurance company is. I guarantee the insurance company rep doesn’t wait on the phone. If you want to actually be the customer actually pay the bill yourself.
3. Have you guys noticed that there is a lack of PCPs and internists? If your physician is continually overbooked, running late, and getting an appointment is difficult do you really think that s/he will be distraught if you go someplace else? This BTW is the usual effect of price caps and 3rd party payors.
Good luck with your billing endeavors. I personally would respond with a nice certified note apologizing along with a list of other providers in the area and an offer to take care of any emergencies for the next 30 days.
Max
The problem is, the doctor did not sign a contract with that patient agreeing to her billing while she did in fact sign a contract with the physician. Her bill is neither binding nor appropriate. I’d shred her bill and tell her “show me where I signed the contract with you agreeing to your fee schedule?”.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Mutual respect in the patient/physician partnership will make these one-sided office policies obsolete in the near future.

Alan
It truly is about respect, and much of the patient discontent is about the lack of respect patient’s receive from the physician’s office staff. When my children where babies, I had purposely scheduled well baby visits for the first appointment of the day. After waiting over 30 minutes (and no sign of the doctor) I proceded to leave and ask for a reschedule. I was given no explaination for the delay and told, “Sir, you have to understand that the doctor is a very important person and other priorities come up.” The doctor arrived at the office at the end of this discussion. I kept the appointment, and told the doctor about the exchange. She explained that there was an emergency at the hospital, but did not appologize for the staff’s disrespect, as it implied that my time is not valuable, and I am not important. Upon check out I asked for copies of my childs medical records as we were not coming back. This is no different than other service based businesses. Yes things will go not to plan, but be upfront with the customer, appologize, and acknowledge the inconvenience. In this case the customer is the patient, and how the office staff interacts has as much an impact on the outcome as the doctor’s words.
Max
For the present, my argument stands with no legal recourse by the patient who bills their physician. Your prognostication is just that and you offer no facts to back up your claim. With far more patients than physicians, the loss of the patient who bills from a practice is merely an annoyance filled by another more appreciative patient.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@Max – Since there are so many patients out there we can continue to behave disrespectfully?
Elaine F
Reading your comment, Max, makes me even more appreciative of Dr. Lippin’s comments about the “demise of paternalism in Organized Medicine.” I look forward to practices with attitudes like yours becoming a thing of the past.

Bladedeoc
Yeah, because the ever turning ratchet towards single payor will improve practice incentives. Just like at the DMV and the IRS and the TSA!

http://mommyblawg.blogspot.com The Mommy Blawger
Patients understand that doctors sometimes run late. But some common courtesy is in order. Most of us have cell phones these days. How about, “the doctor is running 45 minutes behind, would you like to wait, or reschedule for a different day?.” Or maybe give us a call or text 15 minutes before an opening, so we can spend our wait time running errands instead of siting in the waiting room or – worse yet – abandoned in the exam room. Minor emergency clinics can do on-line wait lists – why not other practices?

Penny
Doctors can’t be running to telephones or giving nurses orders between patients to be calling everyone. If they did, they would be even further behind. I don’t know why patients just don’t ask when coming in, how many are ahead of them, and then rebook if necessary. If it happens too often, simply switch doctors.
Today more signs are appearing at receptionist desks stating,
“We try our best to accommodate patients within a reasonable time period, so please be understanding. Abusiveness will not be tolerated.”
I don’t know why doctors don’t get together to design a standard “rejection form” stating that patient services had been terminated due to:
___ Abusiveness
___ Inability to handle delays with understanding,
___ too many late or missed appointments,
___ unreasonable demands, etc.
Patients are free to design their “own” bills and forms too, of course, although they shouldn’t be surprised if they receive one in the mail in return versus payment.
If it’s not (yet) legal to design such forms, surely it would be easy to aggravate intolerant patients by “purposely” delaying them until they finally “learn” to develop patience or are literally driven out.
Doctors who continue to accept intolerant patients will never be rewarded. Instead they will find themselves inundated with those already rejected by wiser colleagues.

Vox Rusticus
Sending me a bill would be an invitation to dismissal, which I would issue, without payment.

Elaine F
That smacks of paternalism. “bad patient; shame on you. here is your punishment”

stitch
What an arrogant comment.
You don’t like how the doc practices, find another doc. There is nothing that says the doc has to put up with getting a bill from you. Period. It is absolutely within his/her right to dismiss you as a patient.

http://www.drmartinyoung.com Martin Young
Hell, I work in a country where some people have to walk for 20 miles or more to even see a doctor. They don’t mind waiting when they get there. Even those that don’t have to travel far wait for hours for public health care.
But private healthcare is different. Doctors are selling both a service and their time.
I wonder what a medical minute is worth, looking at all the investments made by a doctor to graduate, the opportunity costs, and everything else that goes towards the real cost of being in practice.
And then I’d like to see what the average reimbursement per minute is, and see if it adds up to being a profitable exercise. I suspect it’s not particularly lucrative.
And then one could set rules for payment that take the waiting patient into consideration.
I think this would leave more patients unhappy, out of pocket and poorly treated than with the present situation.
Finn
Generally when one of my doctors is late, it’s because of an emergency or I assume because another patient needed more time, not because my doctor was socializing or dilly-dallying. The only time I get ticked off is when my doctor keeps me waiting for an hour or more because she can’t run her own damned life–husband took her car keys, she booked her own kid’s doctor’s appointment same time as mine, etc. First time’s free with a simple “I’m sorry”; second time ticks me off and I expect a fairly florid apology; third time, I’m taking my copayment back and looking for another specialist. I’m self-employed, and she doesn’t get to ding my income because she’s disorganized.

stitch
This is why, frankly, I work part time – so that I can organize the rest of my life around the times that I am not working. Yet there are those who feel that I am not giving my patients their due by doing so, or not fulfilling my “social obligations” (see NYT guest op-ed a couple of weeks back.)
Oh, and yes, I’m female. Your gender comments are noted.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Great Stitch ~ Ya gotta take care of yourself first so you can care for your patients. Beautiful. Your patients must adore you.

stitch
Whether or not my patients adore me is not my goal, frankly.
stitch
but let me add this: my colleague runs chronically late, sometimes by as much as an hour or more. And her patients do, indeed, adore her. Not even kidding, she has the largest volume in our practice, by far.
Which just goes to show that different patients have different needs from their physicians. It’s not a one-size-fits-all kind of world.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Agreed. Medicine should not be one-size-fits-all. They say there is someone for everyone. And our happiness is in our own hands.
Amy
If doctors don’t take time to take care of themselves then they won’t be functioning for us very well. Doctors are people too.

Penny
Finn, why would you stay with the doctor after the second time? Don’t you think that would be making an “enabler” of yourself? Two such excuses would’ve sent me packing.

Alice
Can doctors dump a patient who bills them? What if we demand our rights and cut off our nose to spite our face?

Janet
Doctors are not required to see you. But… once they have established a relationship with you, they are required to give you 30 days notice that they will be terminating that relationship. During that 30 days, they will only be avaliable for emergency situations. So claim your right to bill for waiting, but don’t forget that doctors have rights, too.

http://Www.twitter.com/alicearobertson Alice
I have read that once they start treatment they cannot dump you…only before or after?

ninguem
No, physicians can dismiss a patient for any reason or no reason. Certain commonsense notions of providing adequate notice (30 days is typical). You don’t walk away from the patient in the middle of some acute event……like you just operated on the person yesterday. But a stable hypertensive, to use one example, you don’t have to wait until the patient no longer has hypertension or some nonsense, you can dismiss.
You don’t dismiss for certain discriminatory reasons, race, creed, etc. You don’t dismiss for disability, age, sex, unless related to your scope of practice. The gynecologist not seeing men, the pediatrician not seeing the elderly.
And, I suppose, if you have signed some sort of agreement with an employer or an insurance plan that limits your ability to terminate a physician-patient relationship.
That’s the general idea. But just as the patient can say “I don’t want you as my doctor anymore”, the doctor can say “I don’t want you as my patient anymore”.

http://Www.twitter.com/alicearobertson Alice
That is interesting. I was fearful at one time because I complained about a specialist harming my daughter…I was fearful the doctor we loved would dump us. He was in agreement with us…but then shared some scenarios that do get patients harmed. Really…it was so revealing it rocked my world a bit…he shared that if doctors do not like you they can play games with you and some will even brag about it. Sharing that arrogance towards a doctor could mean lesser treatment (translation…less dosages of meds…or no meds…delaying returning phone calls….a type of control freak personified). I brought up Roger Ebert’s thyroid cancer…this doctor said he followed the case and felt Mr. Ebert was a victim of extravagance. Huh? Then he shared that some doctors do not treat rich patients well….sharing tales of ways a segment of doctors teach patients a silent, but loud lesson about who is really in control. It was a bit of shock reality for me….another one of those dark side of medicine reality checks. I considered learning how to bake gourmet cookies and brownies to keep the narcissists happy:). Thankfully, the doctors we finally found were able to see beyond the tip of their nose and I believe because of the strong bond we formed we were treated better than some of the rich patients (I love the nurses and befriend them…one shared she had not seen residents jump so quickly….the doctor said they were warned that he would hear from the mom via emails from me [highly entertaining emails he enjoyed...felt they were incredibly fun amidst the mundane]).
All this to share that bullying the wrong doctor, on the wrong day may mean lesser care….because doctors are not robots…yet.
http://www.womeninpainawareness.ning.com carol
(I was dumped by a doc. Strangely we had a fine relationship until he was not needed to testify in a med. mal case where he would have made $1250 for a few hours time,
This occurred shortly after a tech in the office was unmitegatedly cruel to me: she tried to force me to do a test that they never make me do because it is extremely painful, for me, and of no worth to the doc. I insisted on an apology. Instead I received a letter stating I was too “unpleasant” a patient and they no longer would accept me in the practice. Strange though for the preceding 10 + years i was a fine patient and they had no complaint about me. (This was also about 3 months after another doc in the practice wrote me a letter apologizing for something he had done and writing that I should come in whenever I needed to, and what happened with him would not happen again. (I have a ‘chronic emergency’. I call and they always make space for me – that practice for years until the letter and the other practice I have been with for over 30 years. Of course this is also one reason why you may have to wait sometimes. They fit me in as best they can but I am always an ‘extra’.. And very greatful for my docs willing to accommodate my situation.)

http://willowelephant.wordpress.com Peggikaye
15 years ago, one of my doctors started enforcing the ‘arrive 10 min early’ policy, if you’re not checked in, you dont’ see the doctor .. you’re late and he doesn’t see late patients.
In that first year I can say I saw no changes. (I’m never late anywhere so all it did was provide me with a reason to be there 20 min early because something in my DNA has me arriving 10 min before the time asked for). After that I noticed a trend … I started being called back within minutes of arrival .. if scheduled for a 15 min slot, I was being checked out at the end of that 15 min slot.
Now, I get there 20 min early and in the last 3 years, every single appt I’ve been checking out at the time of my appointment.
My husband insists that the appointment time is the ARRIVAL time (as in arriving in the parking lot) and I find it funny that he always has to wait longer than i do … it appears if patients would show up on time, know what they need to cover … barring an emergency in another exam room … docs could stick to their schedule better. But if patient A B and C show up on time, then D shows up a few minutes late, E shows up 5 min late, F shows up 10 min late .. the doctor is now late … for everyone following up

Jo
Thank you for getting it.

MDtoBe
This is just one of the reasons why there is a huge shortage of primary care physicians. I’m a medical student and when I hear people talk like this, I share it with all my med school friends in an effort to sway anyone thinking about going into primary care.
Are you mad that your doctor is overbooked? Start paying them more.
I really hope people start charging their doctors for being late and treating them like the plumber or cable guy. It will just make more medical students flee primary care. Then the NP’s can have it.

Family Medicine Doctor
You are so right. Oh, how I wish I knew now, what you already know in med school.
If I did, I wouldn’t be in primary care.
Keep spreading the good news, buddy. It’s important.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Avoiding the problem and running away solves nothing. Gandhi says, “be the change you want to see in the world.”
Elaine’s actions confront a double-standard in medicine: Do doctors deserve more respect than patients? Should doctors charge for no shows/cancellations when the same agreement does not apply to doctors when they are in the wrong?
The answer to our problems often requires us to take a look inside ourselves, re-evaluate our own behavior. Ultimately there is no escape from our own life’s lessons–even in a well paid specialty.

http://Www.twitter.com/alicearobertson Alice
Pam…that is a wonderful quote…in context, intent, and reciprocation. Really….I am thinking next time someone is in the intersection and turns left in front of me I may as well hit him…I am in the right to do so….but I am also called to prevent an accident if at all possible. Sometimes we can stomp our foot, proclaim our right to this or that, justice our own bad behavior….but we are placing some doctors in a …damned if you do…damned if you don’t scenario. Doctors fluster me on several levels…and waiting is one of them…but….some patients are bullies. I cannot encourage that type of behavior fon a professional or personal level.
The last year of my life has been nightmarish….details are not important…but we were one day from losing medical insurance on the eve of a neck dissection for my daughter’s cancer..my husband was going to be fired…a relative stole our income tax..on and on….I held up well…until…sigh…I called the doctor’s office and talked to a nurse….she started to cry when she heard my soft sobs. She went and got the doctor…who, obviously, left a patient waiting. She kept asking me if she could help…was I alright…I felt bad…said there are patients waiting…she said they would understand. But did they? Did her kindness to me cause a bill to arrive? A rebuke for being late?
All that can really be learned from this thread is if you are irrate with your doctor…and do not trust them…move on. If the doctor is irresponsible why stay? Unless they are a specialist who cannot be replaced and they are unchangeable….you may have to suck it up. Otherwise….dump ‘em…in time they will reap what they sowed.

K
Long-time reader, first-time commenter here. I’m both a patient with several chronic illnesses and a soon-to-be first year medical student. I’ve seen your comments on here quite a bit, Alice, and I was so moved by what you said here, especially your 2nd paragraph, that I had to reply. You are someone who really seems to understand every side of many issues, and I hope that my future patients share your understanding. I wish you and your family all the best.

MDtoBe
Pamela, I don’t think anyone who “left assembly-line medicine” has the right to talk about running away.
Besides, your platitudes are not enough to make me want to choose primary care. Sorry… The bottom line is that no matter how much you talk about change, respect, or double-standards, at the end of the day I get to choose what specialty I go into.
If I don’t want to go into primary care, start a clinic, and put up with patients who feel so entitled that they will “charge” me for doing my job, then I do not have to. And you know what the kicker is? Patients get the losing end of that deal.
Hopefully me forwarding this to my medical school class will dissuade others from choosing primary care. All the dissatisfied patients like Elaine can rest easy at night knowing that they are promoting the shortage of a specialty in desperate need of more doctors.

ninguem
Pamela Wible MD – “……Avoiding the problem and running away solves nothing. Gandhi says, ‘be the change you want to see in the world’……”
Sorry Pam, I’m with MDtoBe on this one.
I think your practice is great, and I’m heading in that direction. Nevertheless, you ran away from plenty. You ran away for very good reasons, and I’m right behind you.
Contrary to the party line from the primary care organizations, you can get specialty training and still do primary care if you want to. And I’m in primary care. I have multiple family members getting their primary care from oncologists and cardiologists and no, they don’t have cancer or heart disease, beyond hypertension.
Don’t worry MDtoBe, your attitude is healthy. Now hey, at the end of all this, you might be a cardiologist with a hospital practice and still run a micropractice next door to Dr. Wible.
I might be across the hall.
You want to control your own destiny. So does Pam. So do I. Approach it in your own way. That you’re NOT swallowing the propaganda from Family Medicine is the healthiest thing of all.
Elaine F
Wow, you sound really frustrated and angry MDtobe.
ninguem
Elaine F – “…..Wow, you sound really frustrated and angry MDtobe……”
Sounds to me like he’s grabbed the bull by the tail and has a clear view of the situation.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
MDtoBe ~ Choosing a specialty does not resolve the issue at hand. Transparency in scheduling and mutual respect does.
http://www.womeninpainawareness.ning.com carol
How sad, MDtobe, you already have the attitude of some of the jaded MD’s here.

http://www.drmintz.com Matthew Mintz, MD
@Pamela Wibble MD
“Matthew, it is the doctor that signed the contract with the third party who is destabilizing his or her practice so isn’t the doctor partially at fault?”
True, but the alternative is not to accept that insurance, which will mean that either the patient with that insurance will either not be able to be seen by the doctor, or will have to pay out of pocket.
Your ideal medical practice principles are all sound and what doctors and patients should strive for. However, 3rd party payors make this almost impossible. Patients deserve respect, but they should also understand that you get what you pay for. As the health care system moves to larger and larger systems (ACO’s), personal relationships between doctor and patients are only likely to get worse. Many (if not most) of the doctors on your Ideal Medical Practice site have removed themselves from the insurance system. This allows them to give the care and attention patients deserve. Patients need to realize that if they continue to rely exclusively on their insurance for their primary care, unless the systems radically changes, they should expect to wait a long time to see the doctor.

pcp
“Your ideal medical practice principles are all sound and what doctors and patients should strive for. However, 3rd party payors make this almost impossible”
Both in her posts here and elsewhere, Dr. Wible is very good at pointing out what docs do wrong. However, correcting these problems is often truly impossible when working with insurers. She seems to be promoting concierge care without being willing to come out and say that; consequently, I (and others) find her message fairly confusing.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@pcp & Matthew: I have a low overhead model so I don’t charge patients extra fees. I take most insurance like most ideal practices. It’s “VIP without the fee.” Simple.
We each define our own ideal. I invited my community to collaborate in the creation of our “ideal clinic.” Now, my job description has been written by patients, not administrators. Liberating to say the least.
Instructions on my website: IdealMedicalCare.org
Call me if you need help. . .
I’m here . . .
Pamela
Family Medicine Doctor
Dear PCP,
It is more than confusing. It’s a thinly veiled play at putting anti-doctor, commercial like messages for her concierge practice on the internet that will be picked up by search engines when people google her. I’ve read many of her messages before on this website, all very similar.
Dr Wimble,
I agree with you that to some extent some physicians need to be more aware of problems & anger they cause when they overbook, etc. I am not one of those docs. I never double book. When I get even 15 min, which is unusual, I’m nervous. Most causes of doctors being late are due to patients, not doctors. And given the very nature of what we do, always maintaining complete punctuality is impossible, and could easily be argued as not desirable. These are human beings we are providing care to. They need respect, as you wrote in your post, but they need compassion maybe even more. We have a cruel world. If doctors slavishly adhere to time table, we are contributing to that cruelty. Sometimes a patient needs a bit more time than was scheduled, and asking them to make another appointment right after you find a lump in their breast would not be right. Or compassionate. You wrote ” Functional clinics attract functional patients. Patients fall to the level of dysfunction within a clinic. A chaotic, disorganized clinic attracts chaotic, disorganized patients.”. So, Dr Wimble, you only provide care to those in your community who…have it all together? I would love to do that too, except in my community, we have a few citizens who are anything but. To them, the world is a chaotic & scary place & I provide, I would like to think, a nurturing place where I as a doctor can help a few of these lost souls. Yes, they are late sometimes, but I squeeze them in somewhere else if possible. And if they miss an apt without calling, I still charge them.
Part of flying on a plane means arriving early to the gate, waiting, then finally taking off. But the plane may depart a bit late due to factors completely out of the airlines control- specific factors such as SAFETY, or weather. I accept that as part of the journey.
Doctors also can be late due to safety- chest pain as the last complaint comes to my mind. Patients must accept that if the apt says 1000, it might be 1015 before they see the doc, and that could be routine for that office due to no fault to the physician.
That you are promoting to the general public will, I am certain, aide you in you internet commercial, but I suspect has not endeared you to your colleagues. Believe me, I know all too well the response to you the medical community I practice in would have with this post: anger. At you. They would be incensed you would promote such an idea. And they might distance themselves from you. I’m not saying I agree with that, just being honest. I just don’t think you fully contemplate the gravity of your article & how obvious your ulterior motives are.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I have a thriving practice. I’m not advertising for more patients. There is only one motive here. I have a request that we respect each other and heal our sacred profession. Don’t shoot the messenger (me). Don’t vilify Elaine.
Complete punctuality is impossible and that’s why apologizing and offering an explanation is so important. Patients know docs run late at times. They do not want to bill their doctors. But in some cases docs are clearly in the wrong. Maybe an invoice from a patient is a wake-up call?

http://briarcroft.wordpress.com Emily Gibson
I really try not to be late (see my post at http://www.kevinmd.com/blog/2011/06/reasons-doctor-running-late.html ) nor do I overbook for any reason other than the demand for care from a population that has difficulty accessing affordable care elsewhere in our community. The vast majority of doctors are not lazy, wasting time or “socializing”. We take our jobs very seriously and that is to provide the best care we can with each and every patient, no matter how long it takes.
I do like the idea of posting wait times for different providers on our website home page with regular updates.
The logical outcome from billing the late doctor would be to put that clinic out of business, something that no community can withstand.
This will only get worse as hundreds of thousands of uninsured people get benefits under health care reform and there are simply not enough of us primary care doctors on the front lines to take care of them. I already see patients on a ten minute schedule some days. I don’t think I can do five minute visits nor would anyone want me to. We can try to stamp out illness and injury so people don’t need to be seen urgently, but I don’t think that has worked too well either.
Muddy Waters
Pamela Wible,
I hope you realize your “physician-caused” excuses are normal components to ANY person’s day. You should also probably add to the list: parental emergencies, bathroom breaks, snacks, paperwork, etc. Your article has further illustrated the point that most lamens have no clue how HARD doctors work. Many patients have their “life blinders” on, and think their life is most important, and greedy doctors are overpaid. If you observed most of the workforce in America, you would find that roughly 3-4 hours of an 8-hour workday is spent doing actual work. Many physicians, including myself, are working EVERY MINUTE of 8+ hour workdays while in clinic, excluding 30 min for lunch if we’re lucky. I seriously doubt Miss Elaine holds herself to such standards, but expects the same in return. And, to cal it off, most people complain about paying for the visit. This is why doctors burnout.

Primary Care Internist
i think 3-4 hours is generous. i’d say 1 hour tops for many, is their total time actually spent working. A friend of a friend is an MTA conductor in suburban NY and works twice a week, going back and forth to NYC once on each of those, a 50 minute trip each way. he brags that he sleeps for most of his trip!
and my practice pays a unique “MTA tax” to support the perpetually underfunded MTA that i don’t even use!
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
As doctors we are role models for our patients. They look to us for how to stay healthy. Overbooking and inhumane/unrealistic scheduling undermines our ability to be human, care for ourselves, or extend that care to our patients.

Primary Care Internist
i agree we are role models on one hand, but on the other everyone keeps trying to point out that we are not above our patients, or anyone for that matter. Our opinion is just that, and no more valuable than our patients’ or the NPs or the physical therapists or our patient’s cousin’s friend who just started xray tech school. So are all of them OUR role models?
If we are indeed looked at as role models, maybe we should portray SELF-RESPECT rather than self-deprecation. Waiting is part of any service industry, and billing the doctor who has spent years training to help you is ludicrous. If it’s that much of a problem, go to someone else!

Elaine F
I respectfully disagree.
“Waiting is part of any service industry”
The point is that many of us want to maximize the doctor’s office model in terms over overall human time, rather than doctor time. A 2-sided rather than 1-sided model.
” and billing the doctor who has spent years training to help you is ludicrous.”
I will happily pay you handsomely for your services. And I Will Not wait in your waiting room excessively for free. Help me understand how this is disrepectful and ludicrous.

http://Www.twitter.com/alicearobertson Alice
I am the curious type. Do you pay cash or employer paid insurance? Just trying to figure this whole scenario out because cash from our own checkbook makes a difference. My daughter was denied a service that is costing me a whole lot of money…it sure makes going to the doctors different when you are required to pay hundreds upfront. Makes me grateful for the $25 copay I usually pay for an office visit.
I just wonder though…I do not wait much more than a half an hour…but in truth…I cannot say I gladly pay for even the best service…it is killing me to pay…I do not like it one little bit…but I do it fir my daughter.
Primary Care Internist
you need your doctor, NOT the other way around. Isn’t that true with your dentist, financial planner, landscaper, haircutter, etc? Are any of those people paying for your self-declared hourly wage for waiting?
And if so, do you declare this as income to the IRS? Not doing so is tax evasion.

Sheila Mullen
I think the revolution Dr. Wible is starting is amazing. She is lightening rod of change in a system that needs it. Bravo. And yes, Dr. should pay for our time when late.

Jo
How much do you actually pay out of your own pocket to see your doctor?
You may say that you are paying the insurance premium, did you know that most of that premium goes to pay for the insurance upper management salaries?
The next time you go see your primary care physician, read the Explanation of Benefits when it come in the mail and see what your insurance actually paid your physician for that visit then add up the time spent on your whole visit (not just the time the Dr was in the room) and see if in any other profession the amount that was paid for, including your co-pay would be acceptable.
Remeber the training/time for a physician is worth more than what it would take to get your toilet fixed, but they do not get paid as much to see you as the plumber gets when fixing a leak.

X
Fortunately, I would feel no obligation to pay as patients aren’t actually paying me, their insurance companies are (I would make an exception for a patient who legitimately paid cash). If you want guaranteed promptness, pay for it by going to boutique/concierge. If you want a place your insurance is accepted, accept the hassles, including delays.
It’s rare, but patients have had to wait an hour to see me. When I see my personal physicians, I’ve also had to wait up to an hour. It sucks. Get over it.
Elaine F
I get it that the patient queue is a stochastic rather than
deterministic model. That is, your industry has clients whose care require differing amounts of time, and exactly how much time each person needs can only be estimated.
And of course, as a business model you want to care for as many patients as you can in a given day.
Do you guys know if some doctors take probability into account when scheduling patients? That is, are there doctors that schedule differing amounts of time to patients based on factors (multiple diagnosis, past experience w/ patient, health risk level, etc.) that give a greater probability of needing a longer appointment?

stitch
Yes, some do. Not all docs have that ability. Like others who have commented, I have worked in a clinic setting where all appointments were set at a pre-determined time, regardless of whether they were new or known to the practice, multiple medical problems or simple issues, or whether or not they spoke English and required a translator. I constantly ran late, and the stress it caused me almost made me lose my mind. I finally had to leave that job, despite the fact that I did want to serve that population.
Now I work in a more affluent and, frankly, healthier area and have had more flexibility in setting appointment times. That flexibility, however, is being taken away, and I find myself in the position of “should I stay or should I go.”
In this day and age, many primary care docs are not masters of their own domain; they are employed. I have always been so. And increasingly I am seeing the value of the practice of retainer medicine.
In short, you get what you pay for. And if you don’t like the way your doc practices, then go somewhere else. You have other options; you just may have to pay more for them.
Dear patients: you cannot have it both ways.

YokelRidesAgain
Sigh. It’s a tired cliche, but true: you can’t have healthcare that is fast, cheap, and high quality. Pick two.
Look, if I was a PCP charging patients a $5000 retainer yearly for the opportunity to see me same day whenever they liked, it would be entirely appropriate for them to charge me for wasting their time if I double booked my office.
On the other hand, if I was the only whatever-ologist in a 75 mile radius and I was thirty minutes late for an appointment because I was taking care of someone who was actively dying–any “bill” for lateness in that circumstance would be ludicrous.
Most health care in the United States is far more analogous to scenario B than scenario A.
“Solutions” to the US health care muddle that are based upon “concierge care” concepts are perfectly fine for patients with the financial resources and physicians with the emotional resources to engage in those types of relationships. They are also clearly impractical for the vast majority of patients and providers.

joe
The selfishness of americans never ceases to amaze me.
Honestly, if the doctor is late due to screwing around then find another…..I would. The simple fact is most doctor’s are late not due to messing around, rather because they are dealing with acute patient issues. Dear Elaine to be blunt a doctor’s day is not just about you, sick people are not IT. If I am late it is because somebody is sick and needs my attention…period. Your average doc takes no lunch and runs from patient patient .When Wible talks about socializing or personal calls I want to laugh. I don’t have time to pee. Frankly, if Elaine pulled a stunt like that when I am dealing with an acutely ill patient I would do what another doc suggest and give her a 30 day notice to find another doc.
PS: Who decided Dr Wible is: “America’s leading voice for ideal medical care”? All I see is a mouthpiece for concierge care. That might be good for 10% of the population. In a nutshell those who can’t “do” teach/consult/lecture to those who do.

Ralph
Elaine if I was to receive a bill I’d not pay it and tell you to find a new Dr.
http://Www.twitter.com/alicearobertson Alice
I try to be open minded…I am very transparent…and in fairness…well….maybe this is playing devil’s advocate…but as much as I support patient’s rights we could be shooting ourselves in the foot. The doctor at Cleveland Clinic who harmed my daughter proclaimed he was overworked…they say he wasn’t spending enough time with his patients. Sigh…the misery his wrong action has caused often leaves me speechless. Yet, if I were a doctor doing my best a bill would really bug me…I would probably prefer to pay the patient off just to leave me alone?
Yet, because they are salaried and care… two physicians either stay late unpaid, or come in early without pay. I waited an hour on one recently. He was saying his good-byes to patients. He was known not as careless, or arrogant…but empathetic and did leave patients waiting at times to care for another. He answered emails at home at night on his own time…just like the other doctor…telling you not to apologize..it is their job…what they dedicated themselves to.
Just a type of compare and contrast. The doctor that misdiagnosed twice has a high turn over of patients because he is burned out…can’t be bothered…roams around talking to female employees eating snack food.
And short changes patients for goof off time. Other doctors hate the way he handles patients. I would not wait for him..nor bill him…he should not be practicing on live people. The other two doctors…I would wait…and never consider billing because I know they are not negligent.
That said one of the doctors I trust said patients who exhibit the kind of reactions many patients do are asked if they would like a referral to another doctor. It is just best to move on if you feel animosity towards the doctor. Billing may feel empowering…but if that doctor is really good at what they do I would extend them grace until it proves to be the rule of their practice…email or discuss with them. We beg for honesty, empathy, transparency…..we need to give it to….then…maybe bill:). Billing should be a last ditch effort, not your first choice.

Elaine F
Hi Alice,
Thanks for posting. I agree — billing should be a last-ditch effort. In my life (I’m 46) I’ve only billed doctors six times and was at a frustration point when I did it. Frankly I avoid doctors who are habitually late — like most people I try to limit the amount of irritation and drama in my life.
Of course, the doctor is free to laugh at my invoice and tear it up, refuse to see me, etc. It’s an open market.
- Elaine

Family Medicine Doctor
To Elaine: I know I will treat you while you & I are alone in my office w respect & take time to listen & hear your words. I won’t rush you out when you need me. I may be a bit late at times (never more than 30 min, & usually less than 15 min), but your health & safety are of paramount importance to me. Treating you with compassion is also important. But feel free to bill me or any other doc who is late. Most won’t pay, I will NOT, & most doctors don’t want you as a patient if that is your attitude towards them. I know I don’t.
Penny
In Canada so many doctors have left the profession or have decided to not entered the profession to start with, that there is an extremely critical shortage. Patients who switch doctors may be unable to find another for up to three years unless they want one with less than a couple of years of experience.
Most new doctors are immigrants because Canadians themselves aren’t signing up in large numbers. Doctors have such a choice of who they want for patients that most patients are “very careful” about how they treat their premium prizes, including those who are late. “Better a late doctor than a new one” most feel (even though that’s not necessarily the truth).

solo fp
It is the patient who insisted on paying an average of $5,000 a year to the insurance company for a $60 office visit that lasts around 15 minutes.
If you do get a bill for $47 from a patient and want to pay it, try giving the patient $20 like the HMO would.
As a side note, the doctor starting the office 30 minutes late has poor planning. To start on time means get up early to see the hospitalized patients and don’t waste time gabbing in the lounge. If you start the day late, it is hard to catchup.
http://medicalcrises.blogspot.com Dr. Rick Lippin
In my opinion this issue goes way beyond just common courtesy and mutual respect. Rather It is one of the sure signs of the demise of paternalism in Organized Medicine which is predicated on secrecy of information and, more importantly, maintaining power over another person.
In the new world of modern medicine, driven in large part by more educated patients and the democratization of medical information through the power of the internet, rather doctors and patients will (should) interact as adult to adult. This will takes considerable adjustment by both patients and physicians and will probably take decades to fully become the norm.
Power is not easily ceded to others easily. But there is now no turning back.

Elaine F
yea Dr. Lippin!!

Elizabeth
I just love how you asked for your co-pay back. So you were wiling to pay what, $10-20 to see your doctor but you bill $47? You should try billing your insurance company. If they would pay fair rates, the doctor would not be overbooked and late to your appointment. I love how quickly people are to say that doctors need to take responsibility for their time when their time is clearly not their own.

Jo
Not to say that the insurance will not send in their payment for the visit for another month or two depending on denials of claims.

Mzmd
To respond to Elaine F’s comment-
The idea of variably booking based on the patient characteristics, complexity, etc is a very interesting one. Unfortunately, at least in my situation (multi specialty private practice group affiliated with an academic medical center) there is just no way to do this unless I booked all the appointments myself. When we all had variable schedules (for instance a new with pap could book a 45 minute appt during any opening of the day whereas a person with a sore throat could book a 15 minute) what ended up happening was that there were different unrolled gaps in the schedules. When people no showed these longer appointments (it happens more than you would think!!) I would then be left with blocks of time that I was sitting around with nothing to do or patient were not able to book a visit because even though I could have fit them in in that 15 minute slot, the phone room defaulted their appointment time to a longer timeframe and thus they could not use the unused time. Now we all have either 15 minute slots or 30, and these scheduling problems don’t happen anymore. That being said, I do find it difficult to accommodate “mega physicals” that everyone wants with pap plus several other items to be addressed on top of routine care. I always get to the office at least 30-45 mins before my first patient, never talk to drug reps, rarely eat lunch (I work straight through), however still do fall behind. Usually not more than 15 minutes but on a weekly basis someone shows up having booked a “check up” and oh by the way they are having unstable angina, or severe depression, or something else that they felt too embarrassed to tell the phone room about when booking. So, they wait. I always apologize. I have had a breast cancer diagnosis myself so I understand what it is like to be on the other side of the table, and I have waited my fair share as well. I have to say though, if I received a bill from a patient I would be also discharging that patient from my practice. After everything I have been through, I just feel that life is too short to try to accommodate someone who probably will never be satisfied.
It is really sad that this is what medicine is coming to… It is issues like this that have me on the verge of leaving clinical medicine altogether…
Christina Buck
I am amazed at some of the comments by doctors. I’m not the customer? I am your patient! You are supposed to care about my health and well being and not how much you are being paid or not paid by my HMO. You work for ME. I fire doctors who are assholes and find better doctors. I had one doctor who claims she is the only specialist in her field that does what she does. As I need her due to my specific medical needs when I found myself having to wait 2-3 hours when I had an appointment I wrote a complaint to the director of the hospital she works for explaining that the solution to my problem should not be “find a new doctor” but rather for her to better manage her time and her patients. I fully understand having to wait for 20-30 minutes. Beyond 40 with no explanation is ridiculous. Hours and hours without explanation is unacceptable. I have a serious progressive illness for which there is no treatment and no cure. I have to see doctors all the time and they basically get paid for doing nothing other than having a conversation with me. They are aren’t improving my health and they can’t do anything for me. But I have to see them because I collect SSD and I am on medications for my symptoms. People should fire their doctors if they aren’t caring for them properly. Remember half of the doctors practicing (and practicing is the word) graduated in the bottom half of their class and apparently too many have a nasty attitude about how subservient their patients should be. I’d love to to see each and every doctor who wrote a nasty comment on this board say the same things to the faces of their patients. Just goes to show it doesn’t matter what you do, you can still be a complete jerk who thinks he’s better than everyone else. It’s basic customer service and I’m sure all of you doctors who wrote nasty responses treat people in the service industries like crap. The hypocrisy stinks to high heaven. If you hate your patients and work only for the insurance companies, why don’t you find a new line of work?

Family Medicine Doctor
Dear Christina Buck,
I’m so sorry for your illness. I hope someday they find a cure for your illness.
You wrote, “If you hate your patients and work only for the insurance companies, why don’t you find a new line of work?”
We don’t hate our patients, I know I don’t. I actually really enjoy working with them- alot. I just hate being treated poorly for situations out of my control.
You also wrote,”I’d love to to see each and every doctor who wrote a nasty comment on this board say the same things to the faces of their patients.”
Gosh, what you wrote felt really nasty to me. I’d like to say the same thing to you: say what you wrote on this board to the faces of the doctors you seem to hate so much.
Actually, it sounds like you hate your doctors.
Primary Care Internist
“I have to see doctors all the time and they basically get paid for doing nothing other than having a conversation with me. ”
How do you know that’s all they’re doing? do they not review lab/radiology/historical info about your disease and your course with that disease? If it’s that worthless, why don’t you be dr.google and order your meds from mexico? If I was your dr. and knew how you felt i’d bluntly ask you to find another dr.
How completely disrespectful your post was.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@everyone. I know this seems simplistic, but honestly. . .
The Beatles said it best:
“All you need is love.”
As a result of posting Elaine’s case, I’ve been called nasty names in hostile emails from doctors. I’m happy to say one doctor wrote me back the next day to apologize for his emotions getting the best of him.
Elaine’s case unearths deep-seated frustration on both sides. Let’s take a deep breath and solve this together.

Family Medicine Doctor
Dear Dr Wimble,
“Let’s take a deep breath and solve this together”.
Agreed.
But your approach is unhelpful. And antagonistic towards your peers. I have read your comments for quite sometime, even your website months ago, but you still fail to see how you are coming across. This is not the first time I have read your writings & felt they were unrealistic, condescending to your profession, superficially bright, & self congratulatory in an unpleasing manner. Your manner comes across as lacking in humility that is impressive at times.
Clearly, the medical community will not tolerate, for the most part, being billed by a patient. Most seem quite hostile & resentful to the idea. Remember, YOU initiated this bitter debate summing a heated response by your colleagues.
I have concerns for you & your relationship with your peers.
Clearly you care. Clearly you want to help. And this laudable. Please do some soul searching & see if anything I am writing could be true & readdress your topic. Surely, alienating your peers must not be your goal.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Will do.

Jo
Sorry for your illness, also sorry for your misconception, Doctors are not your employee you do not pay their salary. They are employeed by groups or self-employed, you pay only a very small portion of the fee they charge, and they contract with your HMO insurance company and agree as part of the agreement to see you as a patient, only if the Doctor/Patient relationship stays intact. The insurance company pays only a small portion of the fee that is charged. If you add what you pay and what the insurance pays the doctor is not being paid what it is worth to see you.
Does that mean that you must put up with rudeness? No, but that also means the doctor does not have to put up with it either.
If in fact you did pay directly, full fee, for your primary care (which is proposed by some) then have insurance only for specialty and hosptial care then your insruance would be less per month. You would then appreciate what the care being given to you is truely worth.
Penny
That’s just the point. Patients can indeed “fire’ their doctors. They are free to leave ad find another any time they like, so I can’t understand why anyone would stick around if they felt they were treated badly the first time.

Roy B
While it is easy to take aim at those elitist, wealthy, intelligent, doctors who have it all and are driven around in a chauffeured limousine during their three hour lunch break….long term relationships, if they are to be long term, must be based on mutual, not unilateral, respect Nor should those long term relationships be based on unilateral disrespect. The principal of mutual respect is one such that if a patient is recurrently late for their appointment due to factors within their control- i.e. poor time management, etc.- then it is not unreasonable that a individual provider/clinic charge that patient for a no show fee if that patient cannot be seen on the day of and even after their scheduled appointment time. That specified appointment time was set aside for that specified patient and there is overhead required- staff, building, etc- required to support that specified space in time. For a patient to simply waltz in three hours late with no valid excuse for doing so….. on a fully, not double, not triple- booked day and say, “I’m here”… doesn’t work. Even Einstein could not make more time. However, if that patient is late due to factors beyond their control- for example, highway shutdown due to multiple car pile up- then that patient should not be held responsible for a process they do not control. Which brings up another point of reason- i.e. if one is in control of a process then one is responsible for that process. However, not all processes are in the control of an individual, institution or joint venture entity. Sometimes there are just random spontaneous scatological events. Furthermore, a corollary would be that those, whether they be doctor or patient, who hold an individual responsible for a process they do not control are essentially tyrants/bullies. If a patient is yelling at a doctor for being late because that doctor just had to deal with a unpredictable or previously unknown situation (which if not dealt with could lead not only to physical harm as well as significant liability exposure) …and if that same patient continues to yell at the doctor even after it is explained that an emergent situation had to be managed….then that patient is a tyrant. If a doctor yells at a patient who is late because they just had their car stolen (and the patient can even prove it) and…that same doctor continues to yell at that patient even after it is explained or even confirmed that the patient did indeed just have their car stolen ….then that doctor is a tyrant.
For counterpart, those clinics that often double book, etc.-.most often because they have a significant no show rate but are either contractually inhibited from charging a no show fee or just too timid to discourage such behavior (and therefore enable it) – do a disservice to the responsible patient who shows up on time but is not seen (because the clinic’s double/triple booking master plan routine did not go as precisely planned for that precise moment in time). That responsible patient and their time is being disrespected due to an office scheduling policy which fails to get at the root of the problem. Also, if a scheduling error is done by office staff, the patient shows up for their appointment but cannot be seen in a reasonable amount of time (say 15 minutes) due to that scheduling error, then that is an internal office process that is in control of the office staff and the patient should not be held accountable for that office staff error. It would be reasonable and consistent with the principle of mutual respect to pay that patient the same equal no show fee due to the no show of the doctor; however, one needs to check contracts to see if said payment is allowed and one needs to clearly specify why that fee is being paid to the patient in order to avoid any RICOH kickback accusations.
Jack
Elaine,
You need the good doctor not vice versa. Have to try billing the DMV or Uncle Sam?
If your doctor were to be late intentionally or for no good reason it’s best you find another who respects you.

Elaine F
Hi Jack,
Yes, I do find another doctor when one of mine runs habitually late. Like most people I avoid irriation and drama in my life so frankly I avoid it.
In my life I have billed doctors six times, and it took quite a level of frustration for me to do it.
I have not billed the DMV as I could not make an appointment with them. I have, however, refused to set aside a 3 hour window for the cable guy without compensation. We came to a compromise, and the driver called me at work as he was getting ready to drive to my house.
For me, It’s about respecting others, self-respect, and honestly asking yourself what your time is worth.
- Elaine

pcp
As has every other doc who has posted here, I’ve waited for lawyers, accountants, other docs, cable guys, priests, and so on, and NEVER thought of sending a bill.
Maybe it’s because we have a little ability to walk a step or two in their shoes.

Amy
What about the patient after you? Does it matter if the Dr’s late for the next patient in the middle something that could be important to your health? I think doctors need a lot more credit than we are giving them. I think this is just selfish. This is why we are called patients. Ok that’s my 2 cents.

Family Medicine Doctor
Thank- you Amy for understanding.
Elaine F
Hi Amy,
As a patient, are you asking me to take responsibility for my doctor’s schedule?

http://willowelephant.wordpress.com Peggikaye
Well, if you’re demanding to be seen on time, then you also have the responsibility to end on time, regardless of unmet needs or questions. You can’t keep a doctor over then bill them because they went over with another patient.
stitch
Short answer: yes. Know how long it will take for the doctor to address your problem and stick to that question only. Do not happen to mention after that: “gee, another thing.” If you are depressed, do not spend time crying or going on and on about the stresses in your life. It takes up too much time and makes the doc stress about whether the next patient is going to send him a bill.

john
I don’t think it gets any more naive than #1 up there. Patients are no shows all the time, several a day. They don’t care because they aren’t paying anything for their care.
What typically happens is a couple of visits end up taking longer than necessary. This is very common. I spent a lot of time on two direct admits because someone’s blood pressure was 220/120 with neurological symptoms.
You have to wait an extra 30 minutes. Pardon me while I save someone’s life. I think that is part of my job description. The pathetic thing is YOU WOULD WANT ME TO DO THE SAME FOR YOU. As much as I’d like to have everything operate according to a set schedule, sometimes it is simply not possible.
There are obviously incompetently slow doctors and people who don’t care. The above situation is the majority of the cases for why you are waiting. We aren’t in the back watching you on CCTV and laughing.
Send me a bill, it’ll go straight to the trash. You respect my job, and I’ll respect you.
In addition, if you are on medicare this is particularly disingenuous. The average medicare recipient have only paid for 1/3 of their promised services. I’m in the top 10% of income earners and paying for your lavish benefits, while you sit and wait because I’m doing a good job.
Then you complain.
It’s obvious what is wrong with this country.

Nick McCallum
Kudos, John! Can anyone say “personal responsibility?”

Elaine F
Hi Nick,
I can say personal responsibility. From john:
“Patients are no shows all the time, several a day.”
>> I have never been a no show to a doctor appt.
“They don’t care because they aren’t paying anything for their care.”
>> wow – what is your number? I have been billed and paid for every doctor appointment I’ve had.

AA
As a patient, I understand that doctors will run late. But if I pleasantly ask how much longer it is going to be after waiting 30 minutes past my appointment, the office staff shouldn’t look at me like I am asking the dumbest question you have ever heard in your life.
Also, if I am kept waiting a long time for my appointment and then finally called, it is really galling when the staff person acts extremely impatient because I am not fast enough in putting away the PDA I was using to keep myself occupied. You kept me waiting past my appointment time but you can’t wait a few extra minutes for me when I need to put away a device?
That is the ultimate lack of respect.

Elaine F
Thank you AA. Hopefully, the “respectful” doctors here will not call you selfish, self-serving and naive as they have me.

Outrider
I’m a solo mobile veterinarian. Not only is my schedule completely packed, I am also on-call for emergencies. I cover a large territory, and I travel to my patients.
What do I do? I update my patients. They all have cell phones. Most of them text. There is no excuse for not keeping them informed.
Some clients tell me, I’ll be home all day. Don’t worry, doc.
Some clients like it when I call ahead (“I’ll be there in 30 minutes, traffic willing.”)
Sometimes I write notes in the schedule (“Must be done by noon. Client has appointment with physician (!!!).”)
I have a reputation for running on time, even though it’s undeserved. Maybe it’s because my clients feel respected? When I tell clients, I have a huge laceration repair and I’m now running two hours behind, most thank me and either re-schedule or tell me to call when I’m done.
I think retaining clients who feel respected has done far more for my business than cramming as many in as is humanly possible.

Vox Rusticus
Well, you are a veterinarian, and I’m guessing in large animal practice. Your patients are the property of their owners, and valuable to them as such. I am guessing you also expect cash payment at the time of service or if not, pretty quickly thereafter or no more service. Also, if your costs go up, so likely do your fees, and those fee increases are collected.
That model works in human medicine as well, in cash-pay practices and so-called “comcierge” practices. It can be pleasant and rewarding, as long as there are enough people around able and willing to pay you directly. I am guessing you aren’t waiting of a check from an agricultural livestock insurance company or the government for your fees, so you can create a schedule that is realistic enough that you can make your rounds without falling behind too often, emergencies aside. I don’t know whether you keep an office clinic as well, but I would think you could do most of your business from home and your vehicle with the right and probably minimal tech support.

Outrider
To recap: I schedule what I can reasonably accomplish in a given day. I keep my clients informed when I’m running late (or early – it goes both ways). My clients are generally understanding and rarely angry. Yes, most do pay me at the time of service, but I get stiffed like everyone else running a small business. It is generally a good life, with one major difference vs. concierge medical practice: I make less than half the salary of the average physician… the average primary care physician, that is. I also work much longer hours, and it’s physically strenuous and sometimes dangerous work.
I don’t blame patients for being angry at physicians running late, because though emergencies happen, the primary reason seems to be overbooking, the motivation for which seems to be money.

Vox Rusticus
I don’t think overbooking is to blame unless what you mean by that is patients demanding 30 minutes worth of professional time when they have been scheduled for half that and are paying accordingly. Then it isn’t really the doctor’s fault so much as other patients. But there is an answer: pay by the minute and pay cash. If you want the appointment time of another patient then prepare to pay for it, then I could do the right and fair thing and refund part of the lost time to others.
Elaine F
Thank you for sharing Outrider! I’m inspired by you.

http://www.BocaConciergeDoc.com Steven Reznick MD
There is no question that physicians should be respectful of a patients time. When I ran a busy traditional practice seeing 30 -40 patients a day we had protocals for running late. If the doctor was delayed beyond 15 minutes we announced it in the waiting room and offered the patients the opportunity to wait or to re-schedule. Our staff went into the filled exam rooms of patients waiting to be seen and informed the patients. They were given the opportunity to re-schedule or wait in the room or come back out to the reception area. We called everyone with later appointments and informed them that we were running late giving them the option of coming in a few minutes later or rescheduling. We did not charge a fee if a patient missed an appointment or came in late.
Physicians run late because patients do not come to the office with little problems you can package and dispose of in 15-20 minute sessions. Despite determining a reason for the visit in advance and trying to allocate appropriate time, once you closed the doors and were alone with the patient the problem changed and the time allotment required was different. Add to that phone calls from the ER, ICU, consultants who needed to speak to you about a mutual patient, and it was easy to fall behind. We tried to educate our patients that we were being respectful of their time and needs but if their problem was emergent or needed more time and resources we would give it to them. You could not satisfy everyone. Our state medical society did a study that showed that working people under age 50 would tolerate a 20 minute wait before becoming upset and were less likely to accept an explanation even if it was reasonable.
http://www.youtube.com/watch?v=ji_G0MqAqq8 AustrianSchool
After deciding between two furniture stores, I decided to by a set from Ashley Furniture. The salespeople were new and took over an hour to wrap up the paperwork and arrange delivery. Then they asked me to sign a form stating that if I was not home for delivery between 8am-12pm I would have to pay a $100 fee. I agreed to this, and asked the manager if the delivery was not done during the agreed time, would Ashley refund my delivery charge and he said no, that he had no control over the delivery company. So, after two hours in the store for a $2500 purchase, I walked away and bought elsewhere.
Likewise, if patients do not agree to the terms of their insurance or the policies of their doctor’s office, they have a choice to go elsewhere.
Hopefully, the doctor and patient can establish a rapport that transcends this business of firing off invoices. If they can’t then they should break-up and establish with a more compatible partner.
ElleCB
Wow. Some of you patients need to spend a day shadowing a physician and then see how you feel about all of this.
I’m not a physician but well versed in how hard they work and how much they give up to do it.
How can all of you bow at the feet of Dr. Wible when concierge practice caters to those who can afford it? Aren’t you the same people insulted that a physician wouldn’t just take care of anyone and everyone, regardless of whether they can pay?
So which is it, do you want free care or care on demand? Everyone is quick to point out that any other industry employs customer service techniques, but name any other industry that does it for free. Try going to a restaurant, demand world class customer service, no wait time, and oh yeah, I can only afford part of the bill (or none at all). You cannot compare healthcare to any other industry, it’s simply apples and oranges.
To physicians, I admire you for dealing with such extravagant expectations, but I swear it’s reaching the point for all of you to just quit and then see how people feel about it when there’s not anyone around to save their ass.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
. I’m not a concierge practice. I never turn anyone away for lack of money
This topic is not about concierge vs. traditional practice. There are all sort sorts of innovative models. Many of the most satisfying models are relationship-driven rather than production-driven.
61% of doctors say the single greatest professional satisfaction comes from patient relationships. Keep the relationship front and center and life’s good.

ninguem
Pamela Wible MD – “…..I never turn anyone away for lack of money……”
That’s an extreme statement, are you running a charity with outside support?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
No not a charity. No outside support. Received a $50 tip once from an uninsured couple.
There are models that care for the poor and are so inspiring to the community that they get unsolicited donations. My friend got an unsolicited check for 50K!
I did a 60 second news spot on him:
http://www.youtube.com/watch?v=dtEFIFqhw6I
Again, there are many inspiring and innovative models out there. And they’re much preferable to the alternative: A centralized one-size-fits-all system designed by “experts.”

http://deleted pcp
‘A centralized one-size-fits-all system designed by “experts.” ‘
Are you daring to say you’re not a fan of ACO/PCMH/assembly line medicine?
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Exactly!
ninguem
Nice little blurb on St. Luke’s Family Practice. Modesto California. Stlukesfp.org.
They’re a nonprofit in Modesto. As a nonprofit, their IRS Form 990 is a public document. It is available at guidestar.org.
For anyone so interested:
http://www.guidestar.org
It’s free, but requires registration.
A little over nine hundred grand goes through the place, annually. Two doctors.
“A doctor who leaves a lucrative job to serve migrant farmworkers”
Their pay is better than most family physicians. Better than mine. I’m telling no secrets. It’s a public document that’s available for anyone to look up.
Somebody pays me that, I’ll take care of the farmworkers too. It would be a raise in pay from my job taking care of suburbanites. From their website:
http://www.stlukesfp.org/faq.htm
Each physician is only able to accept 300 patients.
Doesn’t sound like there’s a terribly impressive (subsidized) volume for all that cash flow.
And hey, that’s fine. They’re doing a great fundraising job it appears. But don’t paint them like they’re Mother Teresa.
ninguem
Sacramento Bee article on the place:
http://www.sacbee.com/2011/02/21/3420088/healthy-change-benefactor-approach.html
“……Heck and Forester see just 575 benefactor patients between them. Even with the 1,200 or so uninsured patients they treat each year, they still see far fewer patients than many primary care doctors…….”
I’m even less impressed, Pam. Nine hundred grand gross revenue for that?
I’ll take the sacbee’s sentence a little further:
“……they still see far fewer patients than many primary care doctors AT FAR HIGHER COST…….”
A staggering amount of money to treat a fairly small number of patients.
It’s a solution worthy of government. And you know, it’s not the first time I’ve seen it. Clinics that pat themselves on the back about how they’re treating the poor, but when you look at the financials, there’s more money going through there than in a well-insured private practice. From coast to coast, I’ve seen this over and over, big cities, rural access clinics.
It’s harder to obfuscate this stuff now, thanks to Guidestar.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
ninguem ~ I demonstrate that there are many innovative ways to design a practice. I do not control the ethical standards of any particular physician. Just trying to stay in alignment with my own values is a 24/7 job.

ninguem
No, but you can control what you write.
There’s the story behind the story. And hey, maybe there’s more to it…..but I doubt it. And I say “I doubt it”, because this is not the first time I’ve seen charity or “public service” medical operations that paint themselves as some sort of “Mother Teresa” (compared to a private doc like me) or a better businessperson (compared to a private doc like me), when all they’ve done is find ways to extract higher payments from payers, and in this case talk california yuppies into giving them money, using a Washington DC law firm to craft it into a legal nonprofit entity that the local legal talent was unable to do. I’m going by their article.
And everyone goes gaga, doe-eyed articles in the press, your YouTube clip, and no one…..no one……has bothered to do the simple step I just did. Look at the financials.
The Family Practice Management article on the practice, mentioned they needed the help of “a
high-powered Washington law firm specializing
in charitable and philanthropic works……..we flew to
Washington for a meeting with the IRS attorneys,
addressed their concerns and hammered
out the final details….”
There are hundreds of thousands of charitable organizations all over the country. This one could not set up with local legal talent. Regional talent could not help them, they had to go to Washington DC to craft some entity that’s…….unique all right. I mean that’s straight from the article.
But I agree with you, this is an innovative way to design a practice all right.
Think of it……it could be your next innovation.
Call Phil Knight. See if he’ll give you, maybe a half-mil a year, you won’t have to bill any of your patients, and I bet you won’t have any difficulty convincing the Eugene press you’re running an innovative free clinic.
And I want to make it clear……I’m saying NOTHING about the ethical standards of the individuals involved. I’m sure their high-powered Washington DC law firm that probably dines with the President, has made sure that everything is 100% squeaky-clean legal.
And much as I admire your business model, I admire theirs.
Run nine hundred grand though my office and I’ll run a free clinic for the poor as well. Comparing my financials to theirs, it would be a raise in pay for me to be Mother Teresa.
All I need is a high-powered law firm and a few rich backers.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Points well taken. Hey, I may not admire everything they choose to do, but love the innovation. I think that Amma is the closest thing to the Mother Teresa in healthcare: http://www.aimshospital.org/
Had a patient who went to her hospital in India for arthroscopic knee surgery.
Pamela

http://dogpawz.com David
I am a technologist, there is no excuse for not making technology available to inform your patients in real time. You give us options and we can take them. If you’re running behind by 40 minutes maybe I DO want to move my appointment this afternoon to a different time *which will solve a portion of your behind problem*. Let the patients solve your scheduling problem by giving them the ability to free it up. You have more happy patients, you waste less of all of the patient’s time.
Saying this costs too much is merely speaking from a position of ignorance – you simply don’t understand how cheap this technology is compared to people time. The overhead of keeping your patients informed through automatic text messages, web sites, and even robot phone calls to their preference is trivial indeed. One system can inform thousands of patients for years for the cost of only a month of a real person behind the counter.
Part of showing respect for the patient is enabling them to help when they can, by not hiding information from them that they can use to make your life easier.

Jo
And are you offering to pay a fee for this “technology” to be available?

http://dogpawz.com David
I’ll happily pay exactly as much as it costs, because it costs so little its inconsequential. Here’s an extra dime for each appointment, don’t spend it all in one place, okay?
Now if you expect some kind of profiteering from the system and charge me a dollar, I’m going to get pissed. I know how much this stuff costs, profiteering on a service that costs only incrementally and benefits you as well as me is merely greed, which I will not condone or offer to fund.

Primary Care Internist
so i invite you to come to my office, install and maintain the equipment, and i’ll give you 11 cents each time my office collects the dime, allowing you a massive 10% profit on it. whatdya say?

http://dogpawz.com David
Sounds reasonable. You agree to collect a dime additional for every appointment and pay it to me. Allow continual integration with your scheduling system and provide me actual wait time information on an appointment by appointment basis in real time and yes – I will provide a web site with not only accurate timing statistics on your office, but also the text/web/email/robocall informational alerts to your patients with back-integration to reschedule their appointments on demand. Its actually entirely doable.
You might notice the need for more than the dime though. The information about how delayed you are has to be digitized, as does your schedule both reading and rescheduling. And for the patient’s sake, you need to pay attention to the changes made electronically. (a printed schedule is instantly out of date)
Its not a bad idea really, the rub is in the human part – how can I make it so that the office can deliver the real time information I need to make notifications reliably without adding hard to remember procedures to their day?
Justin
David, your last paragraph is why it is not easy or cheap to implement the cheap technology.
Primary Care Internist
let me recap:
you : “I’ll happily pay exactly as much as it costs, because it costs so little its inconsequential. Here’s an extra dime for each appointment, don’t spend it all in one place, okay?”
me: “come to my office, install and maintain the equipment, and i’ll give you 11 cents each time my office collects the dime, allowing you a massive 10% profit ”
you: “You might notice the need for more than the dime though…”
???
http://dogpawz.com David
The dime is the only monetary component. My point is that as a technologist, I see that technology has a solution for it. If you determine that you are unwilling to allow technology to collect the information required for the tool to assist you, well, a saw won’t cut if you don’t push and pull it. Tools only work when you use them.
Elaine F
Hello,
Why the dismissive and/or antagonist comments towards David? He’s a technologist that is offering a cheap and reasonable solution. Rather than putting him down perhaps you can welcome the change he proposes. (by the application of his speciality)

Vox Rusticus
So I’ll take that as a “no.”

http://dogpawz.com David
and I’ll take that as, you won’t deign to allow me to help unless I bribe you first.

Elaine F
thank you for sharing David.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Can we be solution-focused? Nobody claims to know everything, but we can all learn something from each other. Let’s be constructive. David, I’d be willing to fly you to Primary Care Internist’s office to implement the technology that would help him. No joke.

boundbyinsurance
Most patients understand that things can happen to keep doctors from running on time. I don’t have a problem with a doctor running up to 30 minutes late because I know, as in my own profession, that the people I work with sometimes run late or have more complex problems than I anticipated. I don’t think asking for an explanation and an opportunity to reschedule (with no fee) beyond that 30 minutes is an unreasonable request.
I’m coming at this from the perspective of having fired three specialists who routinely ran 2-3 hours late with no explanation from staff, no apology from the doctor, and the looming cancellation fee hanging over my head if I dared to leave the office. I do my best to arrive at least 10 minutes before my appointment time. If I know I can’t be on time, I will call my doctor’s office to tell the staff and find out if I need to reschedule. Sometimes the next patient will be early, so we can swap spots, but if I have to reschedule, I realize that’s my responsibility for being late.
It would be nice if a phone call or text message ahead of time would give me the same courtesy I give my doctors’ staff members. It’s the same courtesy I give my own “patients” if I am running late. Sometimes I also schedule extra time to make myself available if I know something complex is coming up for the people I work with. I work on salary, so I’m aware that I’m “working for nothing” when I do this, but it’s worth it to me to keep people satisfied and do my job well.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
boundbyinsurance. Oh, you will LOVE this newscast on this story: http://www.youtube.com/watch?v=JVgp44hQG_0
30 minutes was given as the reasonable cut off for wait time. This guy is funny.

specialist
I don’t think doctors purposely overbook patients like an assembly line to make more money. Most doctors I know are booking out 2-3 months and some as far a 6 months. Many doctors are overbooking to shorten their wait times for appointments. If patients start sending bills for waiting, several things will happen.
1. Forget about the urgent appt/same day/ or emergency appointment because doctors will not accommodate in the fear of getting off schedule. You will be told to go the ER, wait even longer and pay more money.
2. If you are late for your appointment, either it will be cut short or rescheduled.
3. Your doctor’s appointment will promptly end when the bells rings.
There already is a huge shortage of physicians. Good luck.
anonymous
I wait 30 minutes for my accountant at tax time. I waited 30 minutes at the veterinarian’s yesterday. Is this a lack of respect for my time? Or is it only lack of respect when a physician does it?

http://dogpawz.com David
What hurts about lack of physician respect is that we don’t have power in the relationship. They have a corner on the market for prescriptions. I simply cannot legally obtain these substances without them, I don’t have a choice! The inequity of power provided by the legislation for substance control and the mystical magical educational and experience power of the doctor puts us at a distinct disadvantage, and that makes us feel uncomfortable. Who wants to feel like they know nothing and don’t even rate having their time valued, if nothing else?
The idea of billing for the time puts the patient back in a power position, hence its appeal.
But we are not always in a power position in every relationship – and when consulting an expert on anything, we are by definition in a subservient position, be that in plumbing, accounting, or medical expertise, or whether or not we should be taking a particular prescription drug.
So when we are in an inequitable relationship, we bend over and take it because we want a particular result. This is how we show respect for their knack. Perhaps the trick is merely not becoming bitter over it.
After all, sometimes, the doctor comes to you for service. And then he has to respect your knack.

ninguem
There are various call-a-doc services that will do this sort of stuff over the phone, and labs that will run any test you want if you’re willing to pay.
The nurse-practitioners, natuopaths, and various other midlevel, limited-licensure, and alternative practitioners have broad prescribing rights in many states.
You ARE able to go it alone if you really want. Doctors don’t have as much of a “corner on the market” as you think.

http://dogpawz.com David
That is not ‘what you’re supposed to do’. People are good at doing what they perceive that they are supposed to do based on the ambient information in society. And what they are supposed to do for being sick or needing a prescription is ‘ask your doctor’. So what do we do? We call the doctor.
If a nurse practitioner can deliver appropriate care and authority, the case should be immediately delegated to them by the doctor’s office so the doctor can take care of the more important things. Doctors, do you agree? Would you benefit from a lower level licensure to handle what you’re not needed for?

Jack
Why does it bother you that the relationship is not equal here? Same applies to a doctor needing a lawyer, plumber, electrician or DMV.
This is not a equality relationship. You are asking for their help not vice versa. You can always go to another doctor.
Billing the doctor only damages the relationship further. Have you try to bill the DMV?

http://dogpawz.com David
emotions are not rational, Jack

ninguem
Pam, a few practicalities of your practice.
Are you participating in the entitlement programs, Medicaid, Medicare? Worker’s Comp? Hospital work, or hospital call?
Are you on staff anywhere? Insurance in my area requires us to be on staff somewhere. Privileges in my Oregon hospital requires seeing the “no-doc” ER follow-up patients.
Simplifying to an “ideal” practice like yours……..and I agree, it is ideal……causes some compromises elsewhere. Actually primary care docs are coming to do the Atlas Shrugged thing, and stop the hospital work, etc., but I see the rumblings on the medical staff and the community. I’ve had patients who became upset that I would no longer admit to the hospital or do nursing home work.
Others, of course, appreciate an office setting that approaches your ideal.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I do accept most insurance. Have opted out of Medicare, but still see my Medicare patients at discounted cash rates. I use a hospitalist now as I only have a few admits per year. I do still visit my patients in the hospital. Do housecalls and pretty much will see patients wherever they are. Did a visit at the DMV recently.
In short, I have allowed my community to design my practice according to their principles and needs so I feel I provide the services they value most. And I’m happy. At one town hall meeting I led I’ll never forget the man in the back of the room who raised his hand and asked, “Is it possible to find a doctor who’s happy?”
We all deserve to be happy. Yes, even doctors!

ninguem
You didn’t mention Medicaid. Oregon Health Plan.
I assume you’re out.
I don’t criticize a single thing you’re doing, don’t get me wrong. I’m heading in your direction. I have to imagine having no staff makes bigger procedures a problem.
Being of the XY persuasion I have to have a female assistant, so I’ll probably never bee 100% staff-free.
Marcus Welby had Consuelo.
Would your practice pass muster with ADA access, 24/7 response, a lot of things required if in Medicare/Medicaid, and NOT required if you’re out?
Have you received criticism for the things you’re NOT doing……accepting Medicare or Medicaid, seeing hospital patients, nursing homes (I’m making an assumption about nursing homes).
I know I’ve received criticism personally, and seen it about the many FP’s on staff who have limited their hospital exposure, and sometimes from the community.
How do you answer?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Hey ninguem ~ Both my parents are doctors and they marvel at what I am pioneering. My dad thinks I routinely get hate mail from the “powers that be”. . . but I have NEVER, EVER received any hate mail or attacks in six years. . . ummm. . .until this story riled up my colleagues.
But now even some of them are apologizing for lashing out at me.
Nobody has ever criticized me for not accepting a certain insurance or not being on staff at the hospital. One old-school male doc in town told me: Follow your bliss . . .
When I opened the community clinic I took every insurance and then slowly pruned off the abusive and unsustainable ones. Hey, I value my sanity!
I provide 24/7 access in an ADA approved office. It was probably one of the first ADA-approved building in town as it was an old Easter Seals facility that treated disabled kids. It has a wheelchair-accessible pool and hot tub too.
At the end of the day I have to be true to myself. I’m living the community vision of ideal care. And I sleep well.
Call me if you ever need help. Email me your contact info and I’ll mail you something to get you started. . .

http://Www.twitter.com/alicearobertson Alice
Pam….I am pretty ignorant about all the details…but from what I have read here your practice is only helping a small segment of people with cash. I want to iron this out because others will have questions they will never ask…I do not mind asking because clarity is far better than assumptions. I know what you have shared about not denying care…but that has to be the exception not the rule (as it was pointed out it is not a free clinic). Another extremely small segment of your community will be helped because you need to survive and that will not happen….well…unless you live in a commune.:)
The more this unravels it seems you have a good business model that helps a very small segment of society. Which is great for those who can partake of it.
I don’t know…it just seems the more this thread scratches below the surface the more it seems implausible?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
80% of my patients are on standard PPO (fee for service) insurance plans. It is not a cash practice.
The secret as mentioned above is practicing in a way that is congruent with what my community has asked me to do.
1) They want a small cozy office and not a big box clinic. Done for $322/month (including utilities).
2) They want integrative services. My 280 square foot office is part of a wellness center with massage, counseling, yoga, a solar-heated therapy pool featuring arthritis, fibromyalgia classes etc. . . Done.
3) They want humanized service so I have same-day scheduling and generally start on time (or they receive a gift). Available 24/7 by cell. Done.
People have made fun of me my entire life for being idealistic. I’ve been called the female Patch Adams by some. Call me what you want. Idealism works for me and my patients. Optimism is the only thing that will cure widespread cynicism.
How can anyone be against “ideal care” as designed by the patients themselves?
And yes, ninguem, Country Fair starts tomorrow – lots of naked hippies running through the woods covered in body paint. . .

ninguem
Where’d you find space for $322 in Eugene? I have a vision of the men’s tree and the lady’s tree…….
I have a strong feeling I’m cutting my space way back when my lease renews.
“….When I opened the community clinic I took every insurance and then slowly pruned off the abusive and unsustainable ones. Hey, I value my sanity!….”
Works for me. I’m saying adios mofo to United Healthcare as I prune my own payer mix.
But I gotta say….you DID get the hate mail. I’m sure your response was far more diplomatic than mine would have been. I’ve had some as I’ve cut back my exposure to various abuses as well.
My hospital requires seeing the no-doc patients from the ER as a condition of privileges. I didn’t elaborate. “See the no-doc patients without regard to ability to pay”. They walk in the door, they expect to be seen for free, and they mean it. I’ve insisted on my well-discounted cash fee, it turned into a fight with the hospital because of that clause in the bylaws. I mean I had words with the medical staff director over their attempt to dictate financial policies of my private practice.
I’ve insisted on removing the clause; I’ll see the no-doc patients but you have no business dictating my financial policies. Mexican standoff so far.
And hey, you’re not getting the hate mail anymore, but you do know there are people who in fact do have a problem with refusal to accept the abusive and unsustainable payers….OHP comes to mind.
Oregon has tried linking acceptance of a certain number of OHP patients in your practice, to the rural tax credits, and I think the malpractice subsidies, as far as I know, they’re in place. Massachusetts has tried linking MassHealth participation and actual acceptance of the patients, as a condition of licensure.
I think you’re in another Oregon sometimes. Isn’t the Country Fair this weekend?

http://Www.twitter.com/alicearobertson Alice
Ideal care is relative… as this thread has shown. It has shown dedication, vision, accountability comes in different packages. I like that patients have choices…for now.
And, ultimately, the changing landscape of medicine may make you switch gears. We await a Supreme Court decision that will clear our vision, and federalism coming back in vogue:)
I don’t know…I have spent a lot of time reading this highly interesting thread….and see little the average patient, or doctor, can take away from it and learn…even some inconsistencies….
It is nice to get news coverage….I would be stoked…yet…encouraging billing doctors seems to cause more harm than good. It feels like another nail in their coffin? If power corrupts…let us use it with wise hands to build…not tear down.
Now that said I am thrilled you are getting national exposure. Sincerely..I mean this….Good on you..Pam!

http://deleted pcp
“I have allowed my community to design my practice according to their principles and needs”
Did your community really say they wanted you to not accept Medicare?

ninguem
Or Medicaid?
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
One woman specifically wrote to accept Medicare. Others said accept no insurance. I reviewed every comment and tried to adopt as many as possible. I took Medicare for a while and then opted out, but continue to see my Medicare patients.

http://deleted pcp
Not criticizing you at all for doing so. More power to you to run your practice in a way that works for you.
I think we need to acknowledge, though, that what the public wants and what works for the doctor running the practice are often not the same.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
pcp. Exactly. What the public wants is often never taken into account on the front end which is why I held town hall meetings and asked them to design the ideal clinic. Why not allow citizens to design their own clinics & hospitals? So simple. It works.
Why hold patients (and physicians) hostage to a system that does not work?
ninguem
Pam: “………What the public wants is often never taken into account on the front end which is why I held town hall meetings and asked them to design the ideal clinic…..”
Group Health in Seattle did precisely that……held the meetings and design healthcare to suit the members………before you and I were born.
They do that do this day, within the constraints of being a big enterprise now.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Awesome. I have a friend at GroupHealth. I’d love to find out more of their history. Thanks.
ninguem
Ty this
http://www.amazon.com/Serve-Greatest-Number-History-Cooperative/dp/0295975873/
or this
http://www.ghc.org/about_gh/co-op_overview/history.jhtml
or this
http://www.ghc.org/features/feature.jhtml?reposid=/common/features/story/20070701-60th_anniversary.html
for a history of Group Health.
I doubt they’re the first, either, but one of the biggest, and most successful.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
ninguem ~ YOU are amazing! Thanks. I ordered the book. I also spoke to a colleague who works at GroupHealth who claims he can get me another little book on the history. Much appreciated!
Love any other examples of grassroots, community-designed clinics/hospitals. It’s the focus of a documentary I am starting this fall.

Brenda
Just out of curiosity, how much did Medicare pay for a 15-min visit? I did some research on the cms site (not in your area) and the fees seem comparable to what Aetna would pay.
Also, do you take self-paying patients, and if so do you list your prices?
Thanks.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Part of the problem” It’s illegal for physicians to discuss pay schedules. Something about “conspiring against insurance companies.” Another indication that something has gone terribly wrong in medicine.
Physicians who have pried themselves away from third parties are free to post their fee schedules to the world. I see self-pay patients and give them 30% off the “insurance rate.”
Also (weirdly and inexplicably) the same insurance company can pay one doctor in one region 1/3 less than another doctor in another region. Rural Ohio seems to suffer most from these low reimbursement. And some regions have such low reimbursement that some docs call certain places in the United States “primary care dead zones.”

Nick McCallum
I agree with specialist’s, Elle’s and Pamela’s comments above.
A physician’s lateness is not financially driven or due to a lack of respect for a patient’s time. Quite the contrary – the overwhelming majority get into the field because they want to serve people and make a difference.
Stephen Covey said, “Seek to understand before seeking to be understood.”
Most patients have no idea what a doctor’s life is like, and
they don’t understand that more often than not, their doctor is running late because they had to spend extra time with a prior patient, take an emergency call, or because a prior patient was late for his/her appointment.
I think there is a great opportunity for physicians and their staff to do a better job of communicating, informing and managing the expectations of patients when their physician is running late. I think most customers, regardless of the the business, would accept being inconvenienced if the reasons why were better communicated.
If it were up to the doctors, they would spend much more time with each patient. However, there are tremendous pressures for physicians to see a high volume of patients – both financial and due to a desire to accomodate patients’ needs in a timely manner.
Many hospitals, practices and systems have tried to apply lean principles to increase efficiency in the healthcare value chain, with mixed results. Humans are not widgets and a healthcare delivery process cannot be as uniform as a manufactuing process. Nonetheless, there are pleanty of opportunities for innovation.
Anyone who thinks doctors over book because of greed should spend a week shadowing a doctor, both in the office and at home. It’s a crappy lifestyle and believe me, there are much easier and far less risky ways of getting rich.
I would add that billing for lateness is a two-way street. Patient no-shows are a very common occurance. Should they be billed, too?
Everyone needs to understand that the problem lies in our healthcare model. Patients are satisfied, but neither are physicians.

http://www.womeninpainawareness.ning.com carol
I see notices in many docs offices, no cancellation within 24 (and sometimes 48) hours and you will be billed for the app’t.

Nick McCallum
I meant patients AREN’T satisfied.
Shay Hosseinion, MD
Pamela and Elaine make good points. It surely is important to have mutual respect and realize that our practices as physicians can adversely affect the health of our patients; but I would argue that embarrassingly long wait times are the least of the problems. Obviously many docs having responded so far have taken as many steps as they can imagine to provide as great a service as they can to their patients.
I must admit, I have a low overhead micropractice with about 1,000 patients that I think I provide excellent care to: without concierge, extra price tags, and I even do my part to see those underserved without discrimination. All of that being said, even with me having longer office visits than average, I feel like I still can run late at times for all the reasons the other docs have mentioned. I do feel like my ability to be more timely is much better than when I was seeing 20-30 patients per day.
I think Pamela’s point is not that doctors START respecting their patients because physicians are in a profession of service to start with – we do this out of our love to help our fellow brother, but rather that our current system of delivering care is dysfunctional, and patient wait times are one example of things bursting from the seams.
It’s certainly a flamboyant quote to get the conversation started!

http://Www.twitter.com/alicearobertson Alice
Hmmm….wow…has the romantic met the realist.
The gist of the conversation was doctors being called to task…it has, obviously, changed directions. Pam’s business model is not going to be easily duplicated, but her respect for patients can be. There are just too many peripherals to lay down any concrete way of handling the emotional topic of medicine.
Yet….one marvels that patient’s have a doctor’s ear….I do not long for what some consider the good old days….nostalgic…maybe….good….relative…having six kids over a time span of medicinal Future Shock type of progress means just the fact that this conversation is taking place is really quite pleasant on a few levels.
I read these posts and think once again how adamantly I am against the one size fits all single payer. Yet, others will read this diverse thread and long for it.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yes, Shay is correct. There is absolutely a bigger political drama: Obama says access to primary care is a top priority, but 36% of physicians lose money every time they see grandma. Now he’s considering cutting Medicare further while sending mystery shoppers out to see what’s going on with primary care in America. . .
We can wait for politician saviors, but in the meantime anyone out there want to host a town hall meeting and inspire citizens to design an ideal clinic?
Let me know. I’ll bring my production team. We’re filming a documentary this fall on how communities are solving health care on their own. A positive, solution-oriented version of Michael Moore’s Sicko.

ninguem
Notice that Pam’s solution to the problem of Grandma is to not work with Medicare.
If everyone did what Pam did……….I wouldn’t mind seeing that, heh, but a whole bunch of people praising her approach here, might not be happy to see the change.

ninguem
I’m feeling funny in that I really don’t mean this as a criticism. Just that this is not new. Marcus Welby had a micropractice, just him, Dr. Kiley, and Consuelo.
Well…..and a TV crew.
And building a practice in response to a community vote goes back to Group Health and before.
All credit to Pam for executing the plan.
There’s a bunch of messes in downtown Eugene that Pam’s model will not help.
To Pam’s credit, she realizes it’s not her job to solve all the ills of the world, personally.
When all the FP’s in my hospital came to that realization at the same time, there was an uproar when no one was available to take call.
Medicare and Medicaid recipients will not like her model.
Nevertheless, I’m looking in the same direction myself.
MD2Be might find himself doing this. I tend to find that the ones talking loudest about doing primary care end up in dermatology in San Francisco, and vice versa for those talking specialty. Who knows?

http://www.FiresidePediatrics.com Nanette Nuessle
Respect is NOT reciprocal. For years I ran so on time that clients (patients) didn’t have time to hang up their coats before being called to the exam room. Often, I was waiting outside the room as soon as my assistant finished taking their vitals. Yet, I had a 30% no show rate, and many families that were chronically more than 30 minutes late. These same families would yell, scream, curse and threaten the front desk staff if told that they had to reschedule because they were late.
My extensive efforts to stay on time in a system that worked against me helped no one. I eventually left that practice AND that community. I now have the ability to “fire” patients who are chronically late, something my big corporate clinic wouldn’t allow.
There are 2 sides to every story….

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Nanette — a functional physician trapped in a dysfunctional clinic. A cultural mismatch and the clinic won. Been there. Glad you got out.

Jack
Perhaps all the doctors should bill in 5 min increments like the lawyers (that includes phone calls and reviewing your records). Let see how much people complain then.
Lawyers were very savvy to implement the time/bill system.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I see where you’re coming from Jack. I called about 5 attorneys to get a quote on something last month. Several charged me for the phone call. I mean I got bills in the mail from attorney just for asking, “How much would that be?”
Attorneys. Hard core.
Dr. Roy B
Ever try a “Oh, by the way” at the end of an appointment with a lawyer…or try calling the lawyer in the middle of the night.
Actually, most lawyers bill in 15 minute increments. So, a one minute “by the way” is usually billed as a 15 minute encounter.
Don’t even get me started on mechanics. They can do a five minute job, then go to their reference book which states 30 minutes labor, then bill for 30 minutes labor.
But of course in the United Socialistic States of America, the culture of entitlement, armed with legal plunder enabled by disregard for the Constitution, the rabble has not yet set its intense sights of entitlements on to the professions of the mechanics or the lawyers (while the latter are a majority of the political representatives who write the vague, ambiguous, contradictory rules which are legislatively passed prior to Judicial review which, in turn, helps with the job promotion program for the legal profession in the U.S.S.A.). But ….neither would I advocate or support or tolerate entitlement access to those professions either. For to do so, sets the fuse for legal plunder of other professions with no end in sight…and that crap was tried in Eastern Europe…and that crap failed….miserably.
Money, real money like we used to have before we were taken off of the gold standard by tricky-Dick-I’m-not- a-crook-Nixon, is a claim to one’s labor. To try to lay claim to another s’ labor without payment for that labor is looting. It is quite a puzzling contradiction in a country in which both many in public and political lives profess religious values of “Thou shall not steal” but speak out of the other side of their mouth by demanding entitlements or a progressive income tax.

Colin
I have negative hope that lawyers and politicians in DC have the capacity to fix any one of the thousand problems with healthcare if physicians cannot come to a consensus on a “simple” issue of “should physicians bear responsibility for running late.”

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I love you Colin. Yes.

Kristin
Wow, people feel really strongly about this. I’m not surprised–money is involved–but I think it bears pointing out:
there are doctors who are late despite their best attempts to run on time;
there are good doctors, who genuinely care about their patients as people;
there are good doctors who can diagnose and treat things with wonderful efficacy;
there are bad doctors who can’t diagnose and treat for love nor money;
there are doctors who run late because they’re trying to fit enough patients in to make ends meet;
there are doctors who run late because they don’t give a crap about their patients;
there are bad doctors who don’t give a crap about their patients.
And these categories can overlap a lot more than anyone wants to think. Good doctors who care about you and will do a good job may still need to overbook to make ends meet. And doctors are people. In all groups of people, there are jerkfaces. (See: a whole lot of blogs, this thread.)
If your doctor is a jerkface and they aren’t the Second Coming, don’t bill them. Boot them. If your doctor isn’t a jerkface, don’t bill them. Ask them why they’re running late. If the answer doesn’t work for you, consider switching.
Retributive strategies are rarely worth it. Billing your doctor can provide, at best, a pyrrhic victory: you get the money, but you’ve lost their good will and destroyed the trust and faith in the doctor-patient relationship. In contrast, moving on to another doctor gives you a chance to form a better relationship.
Jose
First of all, I am a physician, but the common denominator here is respect. Recently a family member of mine went to the doctors office and on the way was stopped by a Police Officer on the way from the Airport to the doctors office, making her and her husband literally 5 mins late to his appointment. The administrator told my uncle that it was too late and that it did not matter why they were late, but to expect a bill for not showing up on time or canceling with a 24 hour notice. He was in a hurry and needed a physical ASAP, he made an appointment for the very next day and to his surprise waited 2 hrs in the exam room before the doctor “got to him” no apologies were made and was just told that the doctor was running a LITTLE late. When he asked to speak to the administrator and told her that he had been waiting for 2 hours and without any explanation she said that he was just running a LITTLE behind, that he needed to be patient. This is what kind of sent him over the edge, being that he had not received that patience or understanding just the day before. When he said that he was going to bill the physicians office for his time and lack of medical attention, the administrator dismissed his comment and told him that he was free to go to another doctors office to be taken care of if he was not happy with the attention he was receiving (which is just what he did). This lack of respect is what gives many of us a bad name, making patients feel like we think we are superior to them and think that our time is more valuable than theirs, alienating us from our patients.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Jose, I’m sorry that this happened. Please contact me as CBS news would like to interview you and/or your uncle.
Pamela Wible MD
roxywible@comcast.net
541-345-2437

http://Www.twitter.com/alicearobertson Alice
Curiosity meter…..Is CBS interested in any of the really good posters here as counterpoints? Just wondering…I like debate..when it encourages true journalism that educates from all angles.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Alice ~ Goal is a balanced story with patient lead. Yes, all sides represented. Important discussion that unearths lots of deep-setaed frustrations on both sides.

ninguem
Works for me Jose. I know this practice, with great docs but a crappy office. Had three patients in a row tell me they wanted new docs. These are consultants of some medical fame in Dr. Wible’s town. I mentioned it to the doc in question, as I was not happy having to write three new referrals, and the doc is good but the office sucks. I couldn’t believe it, the office was worse to my remaining referred patients, and I had three more transfer requests after that.
OK fine, he’s good but not irreplaceable.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
ninguem ~ where are you in Oregon. Let’s have lunch. . .

ninguem
I’ll be painted blue and dancing around at the country fair…….
I’ll wear a carnation so you’ll recognize me.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD

Christine Halvorson
I once had a doctor who made me wait 45 minutes in the OUTER waiting room. When I inquired with the receptionist, who had been sitting within 8 feet of me, when I might be seen, she obiged to tell me he had been called to an emergency. I suggested she might have told me that and rescheduled. She suggested *I* should have called ahead to see if the doctor was running late. I waited to be seen, not because I was having a major health issue, but because that doctor needed a piece of my mind. I give him one, never went to him again, and spent the next three years telling EVERYONE I knew not to see this doctor. I THOUGHT about billing him. I should have.

Penny
Surely that would be upsetting but I don’t understand why patients don’t ask that question, if not earlier, the moment they arrive. Every single time I go to a doctor I ask how many patients are in front of me. That allows me to calculate if I possibly have time to run a 15-minute errand or whatever beforehand. Reduces unnecessary frustration, that’s for sure. What’s stopping others from doing that?

Geoff
My goodness! I’m glad folks from both sides of the stethoscope are entering into this discussion. I’m seeing a couple “big-picture” threads happening here. First, is “responsibility.” – The MDs take responsibility for caring for themselves properly as people and for keeping their promises as much as humanly possible. The patients take responsibility to care for themselves as much as they can and not expect the MDs to be their personal slaves, (e.g., the 6-month med supply with no call-in refills) The second thread is “empathy”. We’re all humans here and metaphorical bedpans flip from time to time and it doesn’t matter whose former lunch it was. We all win when we pitch-in to try to clean up the messes, communicate with each other, and learn from the experiences to take steps toward dealing with the uglinesses and smellinesses. Dr. Wible’s solutions may not be the best fit in every context for everybody everywhere, but having been one of her patients from before she left Big Box Medicine until the present, I can say she’s become a far better doctor and I’ve become a far better patient and person because of what she’s doing. I think her process of rethinking the Med-biz is just what we all need to do to discover solutions in our respective realms.
Ernie G
Message for Elaine- It’s your health. If you don’t want to wait for a doctor then don’t. If you bill me, not only will I not pay your “bill”, but kick you out of my practice. I’m not sitting around eating BonBons. Good luck. Medicine is hard enough without dealing with BS.
Brenda
Elaine, well done! I thought about doing the same thing many times.
The truth is that quite often offices double, triple book patients for the same spot. There was one doc who booked 5 people for the exact same time. We waited 45 minutes because of it (there was no emmergency that the doc had to handle).
solo fp
Research the HMO/PPO/insurance contracts. Most plans to not allow you to bill patients for no show fees.
I have never heard of patients billing for late appointments.
There are cpt codes for phone calls, emails, care prior to or after regular hours, and care during holidays. In my area Medicare and 100% of the insurance companies refuse to pay for these. The phone calls during and after hours take up a lot of extra time – easiliy an 1-2 hours a day of free care that throws off the schedule.
If you opt out of nursing homes and inpatient care, you can cut almost an hour of calls from your schedule. The pharmacy refills, patient questions, and other calls knock out at least an hour a day in my practice.
As a final note, I allocate 30-45 minutes for lunch. If the schedule gets busy or behind, my lunch gets cut. If I am on time, I add on 1-2 same days during lunch. I run on time most days and reward myself with an extra $120 a day during lunch. Most patients appreciate the same day care.
paul
sheesh, 191 comments. guess this really pushed everyone’s buttons.
irrelevant to me, as i take no appointments (ed doc).. though when people with nonemergencies start squawking about wait times when i’m managing other, sicker people i often feel like asking them what time their appointment was for. of course, i never actually ask. y’know, press-ganey and all.
Elaine F
I’ve been reading this thread and want to make a few general comments:
It’s been pointed out doctors running late is caused by many factors. From reading this thread I’ve had my eyes opened to how much goes into seeing a patient that the patient doesn’t know about. Or need to know/care about. An anology in my field (data architecture) is explaining to a customer the details of the database paritions and indexes I chose to maximize query run-time. They don’t care or need to care. What is relevant are the screens they interact with and how quickly data is retrieved to the screen. In your world, the interface is the office staff, the doctor appointment, and the care I receive. That’s all I need to care about.
2. For me, a courtesy call when you are running late would go a long, long, way. As David pointed out the technology to do this is damn simple and cheap. And by the way, why did non-technologists dismiss/nay say him so quickly? He knows how cheap it is — this is His speciality folks.
3. I already knew and read more how stressed so many doctors are. Patients being willing to wait for hours is one of the pressure valves that can currently be used to release pressure in the system. I’m standing up and saying that the pressure valve will cost you to use, and that can be seen as a threat to the present system. To some, it adds more pressure. I’ll agree that the system is broken and I am thrilled that there are doctors out there willing to think creatively about how to fix and even heal healthcare.

Jack
Implementing the technology in medicine is not cheap.
You need to train ALL your staff to use it. You need to maintain it (IT cost). The system may crash your EMR causing a much bigger problem. Your staff needs to find out constantly how “on time” their doctors are (maybe simple for 1-2 doc practice but not when you have 15 docs in 3 offices and 3 hospitals). Oh…government may have something to say about it now or later. You’ll be surprised how many regulations they have……bottom line is it’s not cheap!

http://dogpawz.com David
EMR crash? No change is without risk, not even an external interface to the EMR. I can only do comprehensive testing to reduce the risk.
The matter of creating a tool that fits with the current workflow as smoothly as possible while still getting the appropriate information into the system is an engineering challenge both technical and social that has not been completed. I do not believe it to be insurmountable. I do believe it needs to be as automatic as possible, reducing the training requirements.
The technology is cheap. The social and regulatory costs of implementation can be high. Fortunately, the social costs are controllable with perspective and leadership, and the regulations can be handled with sensitivity to privacy and permission.
These aren’t insurmountable problems, or necessarily expensive issues. Bottom line question is, does the benefit of such information systems outweigh the cost?

Jack
NOTHING in healthcare is cheap.
Walk around and ask any doctor or hospital how “cheap” it is to install EMR.
If we can pass the cost on to the consumer then you’ll be the one complaining about the cost.
Yes, as of now cost outweigh the benefits of the system.

ErnieG
“I’m standing up and saying that the pressure valve will cost you to use, and that can be seen as a threat to the present system”
Actually, it will cost you– no doctor will see you unless you are willing to pay cash up front. Its your health. SO..you wanna be a pain in the butt?

Elaine F
Hi ErnieG,
The reality is different that what you state. Yes, doctors are willing to see me.

A
how many doctors have been willing to see you without paying cash AFTER you have billed them for making you wait? how many doctors have been willing to see you without paying cash after you make them sign a contract saying you will bill them for making you wait and they must pay? that is the only meaningful way to respond to ErnieG’s claim. if you have found such a physician, great. if you have not, your bills are just making you feel empowered.

elmo
Dr Wible.
You don’t medicare.
You don’t take medicaid.
You don’t see inpatients.
I am not surprised you run on time since you cherry pick your patients and don’t see your own sickest patients in the hospital.
You really think you should be lecturing those of us who do? Now you clearly have a good business model that your chosen patients will benefit from, but lets be honest this isn’t exactly “pioneering” healthcare. I wish you all the success to your likely lucrative enterprise.
Elaine:
Respect is not informing someone you will be billing for your time. Anymore, than it is a doctor wandering in from home 30 minutes late. Doctors DO have emergencies that can’t wait. These emergencies can be life threatening. To steal another’s line, It’s not just about you. Respect is when a doctor is running late to ask if another appointment can be made and obviously not get charged, or at least get an ETA. Respect is also expecting an office staff of keeping you in the loop timewise. Frankly, that is something I have insisted of my staff. Because I DO respect my patients, even if I run late with an emergency. I would do the same for you. Given that you already have billed 6 doctors at your relatively young age…….

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@elmo ~ I don’t cherry pick. I see a subset of patients who refuse to be seen by any other MD because they have lost trust in allopathic medicine. But they trust me. So when someone walks in after not seeing a physician in 20-30 years I get to diagnose/treat some amazing things.
1) My first patient walks in after meeting me at a town hall meeting with a BP of 220/120 and I diagnose him with renal artery stenosis and accompany him to angioplasty.
2) A hermit who lives in the woods hitch hikes 3 hours each way to see me for years. I diagnose metastatic lung cancer when I excise a large nodule from his back. I help him die at home comfortably in his cabin in the woods.
#1 gives me $90 and a hat he made for me. #2 dies with unpaid debt.
I’m not talking about his unpaid bills while he’s dying either.
Elmo, were it my goal to rake in the bucks with my practice I could easily do so. I choose to earn less because I Iive a simple life in a 900 square foot house and I do not want for anything.
Elaine’s story simply points out a double standard, We can do better.

joe
I can take your anecdotes and match them for compassionate free care and as I am sure any doc reading this website can….that is not the point. The point is you do not accept the most complicated and sickest patients out of hand. I am sorry but in today’s medical environment your model will be akin to the concierge docs until medicare/medicaid disappear, good luck with that happening.
PS: I had an emergency today and at times was over 30 minutes late, no bills. In fact, my patients did “get it”. I don’t see a double standard (I don’t bill for missed appts). I see a rather intolerant fellow human being.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@joe & elmo ~ agree. most docs are doing their share of charity work. My response was to elmo’s comment about my “likely lucrative” practice.

joe
Sorry Pamela but elmo happens to be right. If you remove yourself from medicare, medicaid, and all inpatients, you will be seeing only the privately insured and in general the least sick (not always). You will run on time more often and you will likely make more money (ie. more lucrative). That may offend you, it also happens to be the truth from my vantage point. Your model will also only function in the small minority of practices unless medicare and medicaid are dismantled.
Something elaine will never get is that she is not “just” a client. We are not selling widgets or IT (by the way my experience with healthcare IT people have in general been nightmares of incompetence). She is a patient. We have a professional duty (remember that quaint hippocratic oath) to our patients, when there are sick patients in your office you manage them and transfer as needed. That can cause delays, as it did to me yesterday. Honestly, Pamela if this is such a foreign concept to you then I agree with elmo, you are cherry-picking your patients for the worried well with an occasional “free care” patient which you extoll to the rest of us about…as if we don’t.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Joe ~ not a foreign concept. I have 20% uninsured (approximately) and see some pretty wild stuff. I try to give 110% to my patients as most docs so. Medicine is a calling for us.
While I do not turn anyone away for lack of money and I do still see Medicare and Medicaid patients I obviously attract less of them than other busier practices.
More and more docs are eliminating third parties that destabilize their practices; the government is dismantling Medicare and Medicaid slowly and painfully over time it seems. . .
I have incredible respect for my colleagues and this entire thread is meant to wake us up and help bridge the divide with our patients.

ninguem
My woods hermit had a glioblastoma multiforme.
The hemineglect and hemianopsia got my attention on the first visit.
Oregon Health Plan sucks, but they are good at finding ways to get people retroactively covered when the shit hits the fan. Person got operated the next day.
Maybe I should say WERE good at that stuff, budget cuts and all that.
You don’t have to be a small operation for that sort of thing, but it sure helps. Also allows you to give the middle-finger salute to a bunch of rules we complain about every day.

Family Medicine Doctor
Dr Wimble,
Where do your patients go to get their blood draws & how far is this lab from your office? Unless you draw your own blood.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Lab draws – next to my office – like a block away.

Family Medicine Doctor
Much thanks for the reply.
One more question: you said you have a 280 square foot office that is part of a wellness center. You said you worked without staff? Does that mean you don’t even have a receptionist to answer phone calls in your clinic during M-F 900 – 500? Does the wellness center where your office resides answer the phones for you during the day? Or are you saying that everyone just calls you on your cell for appointments etc?
Over numerous threads you have described your practice & I really wanna understand it.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I have a home business office where i do my admin work. Patients leave non-urgent messages there on the landline. They can also email me. Cell is for emergencies and folks who need to be seen within a few hours. The office I rent is 2 miles from my home. I have no services there other than office space and utilities.
I love separating the admin stuff from the patient stuff as I mostly never have interruptions to pt. visits. No beeping of phone or faxes. No nurses coming to pull me out of a room. Creates a nice buffer.
Incidentally I do all my billing myself through a free online clearinghouse (OfficeAlly – there are others) and it takes me just a minute or two after each encounter.
This office flow and structure works well for me. I think there are many ways to design a medical practice to relieve suffering of patient AND physician.
I am happy to talk to you any time. Call me. 541-345-2437
Pamela

Family Medicine Doctor
Dear Dr Wimble,
Much thanks again on your explanations. I’m learning alot. You have a phenomenal low overhead execution.
But I still have the question about receptionists/who answers the phones when you are doing clinical work in your office/seeing patients.
You said you worked without staff? Does that mean you don’t even have a receptionist to answer phone calls in your clinic during M-F 900 – 500? Does the wellness center where your office resides answer the phones for you during the day? Or are you saying that everyone just calls you on your cell for appointments etc?
Primary Care Internist
Just curious – does this allow you to write off part of your home as a business expense? No disrespect meant, but as ninguem points out above with the “mother theresa clinic”, usually money is at least a partial motivator to any new business model.
And i don’t think there’s anything wrong with that, but we should be open & honest about it, unlike the many many bogus “charitable” non-profit and not-for-profit outfits that basically exist only to rip off naive contributors and taxpayers at the same time.
joe
I am sorry Dr Wible but maybe it’s me but something is not adding up. I get pulled out of the room multiple times each day by docs with emergent issues on my patients. These are not things I can “blow off”. I also get paged multiple times each day. Some I can ignore until the visit is over, some I can’t. I also have an excellent staff dealing with the multitude of calls. I suspect this is the life for the vast majority of doctors on this site. Just how DOES a doctor who has an ememrgent issue on your patient get a hold of you if nobody is picking up the phone and you don’t have a pager anyways? Again, by not accepting medicare, medicaid, seeing inpatients, you have chosen a path which minimizes the most sick and the multiple interruptions. I certainly don’t fault you for it. But this is not a model but for the minority of more well and well off patients in this country.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Agree with Primary Care Internist. Yes, allows partial write off of my small house. I’ve never been motivated much by money. My dad (at 87) is still lecturing me on how to be a “good capitalist.”
Read more here: http://www.idealmedicalcare.org/docs/GS_Wible_2%20copy.pdf
I don’t claim to be Mother Teresa, but I’m trying my darndest to maintain my values. It’s been a wild ride, for sure . . .
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Joe ~ I have a cell and patients call with emergencies and can interrupt me. It is rare that I am interrupted with a patient.
I am not suggested everyone follow my example. I am suggesting that we all deserve to be happy. Hey, I’ve got an internist colleague I see in the hospital parking garage at 2:00 am and he is ALWAYS SMILING. The guy LOVES work! Just loves hanging in the ICU. Wonderful. . .Hey – there is something for everyone.
And there is absolutely nothing wrong with interruptions, just run a practice with some transparency in scheduling so patients know it is
first come-first served or that appointments “generally run 2 hours behind.” Just some kind of communication so patients have basic informed consent before agreeing to appointment.

Penny
I’m puzzled too. Dr. Wible says she manages well operating most of her thriving business from home and handling patients in a clinic, all with great courtesy and generally on time. But to some doctors a thriving practice may mean seeing 10 patients a day and to others 20. The doctor who sees 20 would naturally be further “behind” in his appointments than the doctor with 10.
There’s no argument that courtesy should be shown both ways, but what’s so interesting about this entire thread is that there are close to 300 replies and it appears that the whole thing was started based on only an “assumption” that the doctor involved was late only because he was a jerk.
Sometimes, Dr. Wible, I got the feeling (rightly or wrongly) that the article was created mainly for the purposes of entertaining CBS to prove what a wonderfully courteous and organized doctor you were compared to so many of your horrid colleagues. Surely this comment will anger you and invite a flame, but the whole thread sounded odd at times, especially since neither you nor Elaine ever mentioned how you were able to “prove” (even when asked) that the doctor was running behind only because he was a jerk and not because he had difficult patients that day.
As far as billing doctors goes, that’s amusing too. It’s a doctor’s market, not a patient’s. If a doctor loses a patient he considers intolerant or impatient, he will probably be delighted because he will have so many other wonderful patients to replace the bad one with. Patients, on the other hand, don’t have a huge “pool” to choose from, especially when they have already billed 6 doctors, as Elaine has. That alone suggests she may have quite a serious problem.
The idea of billing doctors seems crazy as well. Somehow it reminds me of a rabbit looking a lion in the eye and telling him he will bill him if he chases him again. What lion would be foolish enough to pay instead of making dinner out of the rabbit?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Penny ~ the entire point was to share my friend Elaine’s story. I had never heard of a patient doing such a thing.
As far as proving that it happened. I was not there in the exam room with her. She mentioned this to me in passing. Elaine is a very private person and has no interest in the limelight. It took me like 10 emails to even get a photo of her to run in the video. She did it to humor me. She did send me her invoice, but I removed the docs name and Elaine’s address.
Elaine Thinks everyone stands up for themselves. She never believed this was a story. Her story IS a story or it would not have been picked up by major networks. (which surprised me!)
It even ran in the Czech Republic:
http://www.tyden.cz/rubriky/zdravi/prulom-za-cekani-u-doktora-budou-lekari-pacientum-platit_206053.html
__________________________________
Did my friend lie to me? Absurd.
Were the physicians at fault? Yes.
1) One doc (a therapist) scheduled another person in a one-hour slot for Elaine and when she showed up he told her to go home. Diagnosis: not a jerk, but the doc was at fault.
2) Obgyn shows up for work 40 minutes late with no good excuse. Diagnosis: not a jerk, but the doctor was at fault.
Your diagnosis?
____________________________________
My goal in running this was to make physicians think about this double standard.
And to empower patients who feel mistreated to speak up.
And to bridge a divide, to open up an honest conversation about why things are the way they are. With 350 comments I’ve done all three.
Pamela

http://www.kassydaggett.com Kassy Daggett
Integrity. Accountability. Honesty. Doing what you say you’re going to do, and not doing what you say you’re not going to do. These are attributes I value in ALL people–even doctors. Gratitude to Dr. Pamela Wible for raising the bar. You rock doc!

http://Www.twitter.com/alicearobertson Alice
Kassy says: “These are attributes I vslue in ALL people-even doctors”?
Alice asks: Are doctors a different species? Just wondering……

http://www.kassydaggett.com Kassy Daggett
Not a different species per se. It would have been more accurate if I had written, “ESPECIALLY doctors!”
This issue is asking physicians to be HUMAN and HUMANE. Rather than ascribing to the cultural stereotype of a white coat arrogantly sitting on a pedestal, sniffing the air of entitlement, celebrating an elevated status, and marinating in self importance, doctors of integrity, honesty, and accountability are actively shifting the face of healthcare–one office, one clinic, one hospital at a time!
I say BRAVO to all of you! Your courage and tenacity to provide patient centered care and to engage in what’s right and just instead of what’s common and familiar could provide new guidelines for the AMA’s 2012 Code of Medical Ethics.
When ANY humans (me, you–EVEN doctors) operate from an internal hierarchy of ego above respect, it becomes easier to act in hurtful and disrespectful ways. At core this is a values issue. If ANY person values knowledge, accomplishment, and tenacious pursuit of a professional career above basic humanity, kindness, and respect, it becomes easy to believe, “It’s OK to let them wait–I’ve earned it!” And, since beliefs drive behavior, anyone–including doctors–will leave people waiting. Well, you’re not alone, I too struggle with time agreements! I’m human. And so are doctors!
This issue is only one small part of the problem with health care. The whole system is broken. This issue is merely a symptom. Limiting the discussion to only this part is like working with an incomplete chart. Proper treatment requires a full understanding of the WHOLE PERSON. The same is true of the profession. This conversation is a great start.
Penny
They are in Canada, Alice — a most endangered and threatened species.

Elaine F
Thanks Kassy! It’s one of the ‘things you learn in kindergarten’ , yes?

http://www.kassydaggett.com Kassy Daggett
Yes! Along with looking both ways before crossing the street and other salient life skills like using scissors safely and taking naps when tired The buzz generated here is a small indicator of how HUGE and complex this issue is. Thanks to you and Doctor Wible for initiating such an important dialog. Brava!

jill
I suffer from a chronic condition that causes chronic pain and while living in a suburb of Boston became a patient of an elite group of doctors specializing in my condition. I showed up a half hour before my appt. and waited for 3 hours while they herded people in and out like cattle. After voicing my complaint at the long wait I was told not to come back as they did not need patient who complained. I worked in health care admin for many years and believe the whole “sick” system needs a revamp. Well care not sick care is what we need. Dr. Wible is totally shaking things up in a good way and we need more docs to be part of the revolution. Thank you Dr. Wible!!!
http://www.facebook.com/pages/North-Texas-Dallas-Ft-Worth-Sarcoidosis-Support-Network/191799090831123 Tejas
I’ve been left in exam rooms waiting over an hour for my physician and driven to the doctor’s practice and found out that he was called away. I can forgive that an emergency takes priority, but this happened multiple times and resulted in me being put on the short list for a layoff. Time is money, and having a physician who disrespected my time contributed to me losing income. An interesting concept for those left waiting…
http://drmaliareckons.posterous.com/ Timothy Malia, MD
Wish I had a chance to read all the comments, but there simply are too many. Obviously, it’s an issue that is relevant for both doctors and patients.
I was actually on the docs in the CNN.com story, and was the face behind the $5 bill, so for me this is an issue I’ve actually thought of a lot and tried to address in my practice. The other day, I did take a few minutes and blogged a few thoughts. Feel free to check it out, then let’s all realize that BOTH patients and doctors are in a toxic health care environment where various other parties are making huge profits while we are trying to do the best we can… our only option is to try to control what we can and strengthen/mend the doctor/patient relationship within which we sit.
http://drmaliareckons.posterous.com/waiting-in-doctors-offices-supporting-relatio
–Timothy Malia, MD
my practice
Running on time is easy *sarcasm*
7:00AM: Get to hospital. Admit patient I was called about in the middle of the night. Round on 2-3 patients. Patient in room 315 is short of breath. Why? They were supposed to go home today. Workup commences. Drive across town to other hospital I admit to. Same scenario.
8:30AM: Rush to office for first appt at 8:45.
8:45AM: Nurse has already received 3 calls from patients needing to be seen. My schedule is booked. Offer double booking and will see them when I have time or go to ER or urgent care Fit in all 3.
11:30AM: Have already seen 10-12 patients in the clinic this morning. Two patients didn’t show up for appointment. Eat quick lunch and drive back to hospitals to check on patient short of breath and finish rounding. Repeat at second hospital if necessary.
1:00pm: Return to clinic. See 12-14 patients in the afternoon. 2-3 people call to be seen. Send one to ER and see the other two. One patient doesn’t show up for appointment.
5:00pm: finish seeing last patient.
5:00pm -6:00: finish notes, paperwork, callbacks., review labs, review tomorrows schedule.
6:30pm: get home.
6:30-11:00pm: Get 1 more admission. patient is stable and will see tomorrow.
11:00pm – 6:30am: Paged at 2:30AM with new admission. Admitted by ER physician. Will see in the morning. Paged 5:00AM, Patient in 315 now has a fever. Leave orders.
7:00am: Get to hospital
*this is a typical day. I left out the multiple calls during the day for medication refills, interruptions from pharmaceutical representatives, “Urgent” paperwork, Hospital compliance calls, ER Calls during office hours, hospital nursing calls, patient family calls, office emergencies, work excuses, patient on cell phone, hospitalized patient in bathroom or outside smoking, Can’t find chart in hospital, Waiting on hold for other physician, Calling pharmacy because patient didn’t bring medications in today…………………………………………………….
I have completely left out the complexity of evaluating medical conditions especially in chronically ill people.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
@my practice:
Thank you for sharing. The general public has no idea how hard most physicians work. This conversation has been enlightening to say the least.
How many years have you been working this schedule and when was your last vacation?
stitch
Thank you very much for pointing out that double booking is often a way of accomodating patients, not just a way to boost/maintain income.
We have patients who call every day for same day appointments. I will look at my schedule and see if there is any way to accomodate the patients, and then may double book. It may mean I run late, which I hate; more often it means I am cramming in my lunch, if there is one at all.
But the point is, we’re still trying to work for the patients. Extremely hard to balance at times. Much of the time.

Tracey
My Doctor is always on time and I never feel rushed when I’m in with him.
The day I was early he didn’t have a patient so he took me in early.
Valerie brown
I couldn’t agree more with you, Dr. Wible. If we are to takenour clothes off, share our intimate concerns or poop for someone, then least they can do is be on time (I mean, just ask a husband or wife!). My doctor, WHO IS AMAZING, has never rushed me through an appointment, which encourages me to speak candidly with her and–in turn–allows for better medicine, trust and a delightful experience well worth the copay. With that, I have never waited for long in her office (a concept that was totally new to me, who usually packs a book or iPad to any other appointment. Were I not ensured, I’d stilling to her, because I feelnworthwhile to her!

Family Medicine Physician
But it seems that you miss the point of “my practice”, several comments above you. His/her point is that the practice of providing care for peoples lives is not something you can completely schedule for. Things happen. Terrible things happen. Sometimes it can make a doctor late.
Could you read that comment above & incorporate that into a response?
Vox Rusticus
“. . .well worth the co-pay.”
If that doesn’t say it all.

Primary Care Internist
ha-ha, almost missed that but your astute observation validated the skepticism that i read that post with. thanks

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
From MedPage today:
Dr. Jacob R. Raitt – Jul 08, 2011
Hurrah: I began to do that in 1968 when I had to take my infant daughter to a dermatologist. I called early, told the person who answered that my daughter had diaper rash and how I was treating her. We arrived at the office 15 minutes early, waited more than 3 hours, and when the doctor finally made her presence known she told me that my daughter had diaper rash, and wrote a prescription for the medication I had told them I was using. When I went home, I immediately invoiced the doctor for $75, ignored her bill and compounded interest monthly. When my bill to her exceeded $100 I started action in small claims court. She paid me, and ever since I have always told doctors what I would do if kept waiting more than 15 minutes. Other than in cases of emergency, I have never been kept waiting.

Family Medicine Doctor
Dear Esteemed Colleague Dr Raitt,
Yes, 3 hrs is unacceptable. I wouldn’t tolerate it, either.
But I wouldn’t tolerate a patient (even if it was a fellow colleague) telling me they will bill me & take me to small claims court (if I didnt at first pay) if I’m more than 15 min late. If you said this to me, I would, respectfully but just as honestly with you as you were with me, tell you this was our LAST appointment together.
Yes, waiting 3 hours, even 1 hr is too much. 15 min is reasonable, although not ideal, or even good (wait times in my office are generally 5-10 min, for real, although I’m generally 100% on time), but your response is even more unacceptable.

Vox Rusticus
If I heard of a “colleague” behaving this way, he would never, ever get an appointment with me, i wouldn’t care what his problems were, I wouldn’t give him the time of day.

Elaine F
I would like to ask Dr. Raitt how many doctors have refused to see him. Per posts from doctors on this site, their opinion is that most would refuse to see him. I have a feeling reality would prove otherwise for him — it has for me. To date, one doctor has refused to see me.

Vox Rusticus
Elaine, that is most likely because they don’t already know about you. You seem extremely inflexible, and I for one would not want you as my patient (and you should hope, really hope, that you never would need me anyway.)

Vox Rusticus
I would have responded to Dr. Raitt’s suit by demanding a hearing and replying to the court that I planned to defend. Then I would have demanded before the judge the evidence of work having been done for me in the time over which Dr. Raitt claims he waited and for which he billed me(and Dr Raitt had a remedy available to mitigate his “loss”, he could have gone to do real work and asked the dermatologist to call him when he was available–apparently he did not do that). If he couldn’t produce any work or evidence of work for which he was billing, I would counterclaim fraud and complain to the state medical board.
Primary Care Internist
it’s quite misleading and deceptive – Dr.Raitt is a pharmacist, not a practicing physician, and the post seems to want to validate this approach because dr. raitt is a doctor. i find that dishonest, to say the least.

S Shames
It will be worse when 30 million more patients are insured under the healthcare bill and the healthcare infrastructure has not been increased.
Can we bill the state when we wait at the registry of motor vehicles? How about we bill the airline if the flight is delayed?
Elaine F
It a new business model: keeping clients (i.e. customers i.e. patients) waiting costs money. I welcome you to figure out how to respond to it in ways other than anger and belittling the messengers and early adopters.

Elaine F
Let me change that last sentence, based on what I’ve learned from reading these posts:
I welcome you to figure out how to respond to it in ways other than intolerance and belittling the messengers and early adopters.
Vox Rusticus
Cherry-picking patients, with a few charity cases thrown back into the practice for community goodwill’s sake is not exactly a “new” business model. Requiring cash payment isn’t either. Low-overhead, cash-only practices may be new to you and your patients, buy those aren’t new ideas at all.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Vox Rusticus ~ None of these three statements describe my practice.

ninguem
I grew up in an old town that had lots of big old mansions. They were white elephants, hard to maintain. Most of them were owned by doctors, as the square footage allowed the doctor to raise a family in one part of the building, and the doc can run an office under the same roof.
Made for a short commute.
I knew one doc who started out living out of his office. Talk about low overhead. I didn’t believe him. I was in his exam room. He reached over to what I thought was a supply closet………he pulled down a Murphy bed.
He lived out of the office until he could afford his own place.
Some people walk the talk.
As does Pam………no none of these ideas are new. She still gets credit for executing the plan IMHO.

ninguem
And actually, nowadays, the mansions are now owned by investment bankers. Doctors can no longer afford them.
ninguem
And actually, nowadays, the mansions are owned by investment bankers and lawyers.
Doctors can no longer afford them.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Incidentally, I always tell people the low-overhead model has been around forever. My mom’s a retired psychiatrist and she had a pretty streamlined little office. Massage therapists and counselors do the low overhead thing well. Nothing new on that front.
What is new (to me) is citizens at town hall across the country tell me they actually want small and cozy, not some big box parking garage outfit:
http://www.youtube.com/watch?v=RQEx_xcWrEg
Big take-home message: If doctors need help (and most do) ask patients NOT politicians.
Pamela

http://Www.twitter.com/alicearobertson Alice
I noticed the doctor blog Medical Justice blogged on this topic today. So did CBS contact any posters here?
http://blog.medicaljustice.com/patient-bills-doctor/
Michael Rack, MD
I don’t charge patients for missed appointments and probably never will. In the unlikely case I do so in the future, I would consult with my attorney and provide written notice to my patients of the policy.
———
If a patient in advance presented me with such a policy for payment for wait time I would seriously consider keeping the patient and honoring the policy. However, I probably wouldn’t do so for a patient with mediare/gov insurance. Any payment from the doc to the patient could be considered an illegal inducement (If I pay a medicare patient $20 for waiting, the gov could say that I am paying that $20 in order to get $50 from the government for the office visit, and fine me heavily)
—————-
In my opinion, any policy/fines for missed appts/waits need to be in writing and agreed to by both parties (the doc and pt) in advance.
Michael Rack, MD

Vox Rusticus
When you can’t control every last possible event that would guarantee your being able to always be on time, why would you ever be so foolish to sign something like that? Do you really think agreeing to that kind of one-way deal is a smart thing? If you are late and you think it is your fault and you should have done better, you can always waive a fee. But there are cases when lateness is not your fault, when you are held by the pincers of the ED or the hospital or some colleague who feels he has to talk to you right that very minute.
I would take a request from a patient of that nature as just as it was–unreasonable. If they want to be guaranteed to be seen at exactly a certain time, they can reserve and pay for, in advance, the 30 minutes before and after the set time of their appointment. Cash retainer, please, as consideration for their agreement with me. Anything else can go to the door.
If patients like me and are willing to understand that I make an effort to be on time, they will stay; if they don’t like me or can’t live with the rare event of a delay, they can go.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Many Emergency Departments now promise (on billboards all across my town at least) less than 30 minute waits. If it can be done in the ER then. . .

http://Www.twitter.com/alicearobertson Alice
We have those commercials to. They do not pan out, only take minor cases, some do take you back…but not immediate care…and definitely no billing them for not being on time.
I guess everything that glitters is not gold.
http://www.womeninpainawareness.ning.com carol
My local ER had that ad. (I havent seen it in some time). I had to go there when they were still making that promise. As with most ads it was deceptive. What they meant was you would be seen by triage nurse within that time. I still waited quite some time before being taken back, and then longer before being examined.
Carol

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Sucks. Deceptive marketing.

stitch
If you have time to look up the wait time at the local ED, then it is not an emergency. Period. End of story.
And if this is not the ultimate sign of a broken healthcare system, I don’t know what is.

http://www.womeninpainawareness.ning.com carol
Stitch these were ads on the Tv and in other media, no looking up.

stitch
I understand. In some areas the ads post a website to look up the waiting time. And you are right, they are often deceptive.

http://www.MedicalManiacs.com PatricParamedic
It’s refreshing to see some common sense injected to the status quo.
Now while you’re on a roll, help save your own life – and that of your family members – by refusing to accept any prescription you cannot read.
It is up to all of us to be smarter patients.

Elaine F

http://www.drjoe.net.au Dr Joe
I do my best to run on time and it is rare for people to wait more than 15 minutes to see me. I would be 100% on time if ALL patients stuck to their allotted time.
Maybe the bill should be presented to the previous patient who ran overtime?? Or the mother with the child who the doctor squeezed in?
Seriously though some doctors run consistently an hour or more late and there is no excuse for that -it is a mismatch of appointment scheduling to how the doctor actually works.
DrA
I have not read all the comments but I have read many of them. It seems to me that what everyone (or at least most) are missing is the main problem. The problem as I see it is the presence of a double standard. MDs want to charge patients for being late, no showing or canceling. Some patients are saying well if I have to pay for those things then so will you. MDs argue, well there are often reasons outside my control that force me to be late so it is not reasonable to ask me to pay that fee. By using this excuse and continuing to billing for missed or late appointments MDs are assuming that patients do not have a good (or as good) of a reason for being late or not making an appointment. This seems quite arrogant to me. The patient couldn’t possibly have a great reason (just as out of their control as the MDs reasons) for being late or missing.
So I think the problem goes back to one of a double standard. I understand that occasionally my MD may be running late for reasons he can not control. What I can’t understand is how my MD does not realize that the same may happen to me occasionally. It is about mutual respect.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Hallelujah Dr. A! Thank you. Some docs have gone straight into fight of flight mode and have missed the entire point of this conversation: Mutual respect.
WE need to end double standard: (2 choices)
1) If doctor has fees for no show/cancel < 24 then fees should apply to doctor too. (Exempting emergencies on both sides)
2) If doctor does NOT charge fees for no show/cancel then doctor should NOT be financially penalized by patient if doctor meets transparency in scheduling guidelines below.
Transparency in scheduling:
1) If an appointment is scheduled then most of the time
the patient should be seen +/- 15 minutes or so of appt time. (Barring rare emergencies or other good reason).
2) If appointments can not run on time then do NOT promise patient a specific appointment and run office as first come/first served DMV method.
If we are all honest, respectful, and clear in our communication and expectations of one another than
we can bridge the divide here.
Pamela
joe
I don’t charge for no shows. Never have. Of course, the vast majority of my patients show up. Certainly I can’t charge insurance, medicare, medicaid for no shows (the work wasn’t done). Where is the double standard? That’s the problems with lanket “assumptions”, you are as often as not WRONG. Where I DO DRAW THE LINE is I discharge patients who repeatedly miss appointments without an explanation. A couple without a call or explanation in follow up is it. Go find another doc to abuse.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Joe, I’m referring to docs who charge patients no show and cancellation fees. I’ve never heard of (nor is it possible as far as I know) to charge insurance companies these fees.
Certainly terminate patients for unexplained/repeated no shows. More power to ya. . .
DrA
Joe,
I do the same thing. I work my best to be on time and I almost always am. Sometimes things happen, and sometimes things happen in my patients’ lives that result in them being late or missing. I try to be understanding about their situation in hopes they are understanding about mine. However, if a patient gets into a habit of being late or no showing I have a conversation with them and then if it does not change they will be asked to go someplace else.

Family Medicine Doctor
“Maybe the bill should be presented to the previous patient who ran overtime?? Or the mother with the child who the doctor squeezed in?”
Dear Dr Joe AND ELAINE & everyone else:
Actually, that’s one of the best points I have heard yet. You put an idea in my head: why don’t I charge a fee when I squeeze pts into a schedule where I don’t truly have an appointment slot? The reason is that when I squeeze someone in, I invariably 1) will be late for other pts, 2) my day is going to be longer- it’s NO fun getting home at 800 when your day started at 800 am 3) if you add 20 min time to your 15 min appt (for a total of 35 min) I may not even get paid for the extra time by your insurance company.
Examples:
-you come in late at 1:15 to your 1:00 appt but I squeeze you in anyway cuz I truly care about you.
- you don’t have an appt today, im totally full, but you call in begging cuz you are sick so squeeze you in.
-you have some terrible new diagnosis & I have to spend an extra 20 min w you beyond the 15 min (for a total of 35 min) you scheduled for as I educate you, and emotionally support you as you cry thru your new diagnosis of HIV, Breast CA, suicidal thoughts etc. I’m not upset in offering more time- I really understand the need & love caring, but it disrupts the day & now Elaine is gonna bill me so I gotta come up with a plan.
All of these examples make me late. Put 3 of them in a day and if follows them, Elaine F is giving me an invoice. So should I charge a fee to those patients who do this to me & my patients on my schedule that day?
I’m going to consider the pros & cons about this idea. But does anyone have any comments about this? I’m open to hear. Especially you, ELAINE. Given that YOU, ELAINE WILL SOMEDAY be one of those examples I listed (you, just like I, like everyone else are human after all ), would you pay the fee? Would you be mad? Would you leave my practice if I did charge you?
Comments?

Elaine F
Hi,
Your comments (and all of them) have made me think about this much more than I ever did. I called myself an “accidental activist” to Pamela when the buzz hit: I just wrote a few invoices out of frustration, and Pamela was was fascinated regarding the ones I wrote to doctors.
Would I leave your practice if you charge me for last-minute services? No, assuming the bill was appropriate to the time slot. Would I bill you if I waited while you did it for others? I’d much rather know you were running late so that I could make the choice to wait or re-schedule. It’s about mutual respect and I’d rather work something out before I billed you. If you’re a good doctor I’m going to be seeing you again, so I’d rather build a relationship.

Elaine F
Sharing:
My most recent “opportunity” to bill came with Midas in June. I was on a road trip and my car wouldn’t start. I got a tow to a Sears auto center, since I knew they were open late and a local person told me there was one not too far away.
Sears diagnosed as a dead battery. I bought the battery from a Midas 5 states away and it was newish and still under warranty. I had the receipt with me so I called the original Midas shopped and explained, asking him how he wanted to handle it. He said “yes Ma’am, come right over to my shop. And I close in 20 minutes.” He wouldn’t pay for a Sears battery or tow me to the nearest Midas.
So I bought a Sears battery and, upon returning home from the trip, called corporate Midas customer service. . After 7 phone calls I had someone willing to honor the sales receipt. I addition to the battery and towing charges, I asked for compensation for my time stranded on the side of the road then waiting for car repair. He explained in a slow voice, as if talking to a child, that Midas was not legally obligated to pay me for my time.
I put the charges in writing. They were ignored and I was not reimbursed for my time. I wrote a negative online review of Midas, explaining what happened, then dropped it.
Everyone’s time has value, and how much your time is worth in dollars is an individual assessment. That many business models in our society scoff at reimbursement of time amazes me. How can we change that?

Andrew
You shouldn’t be proud of this behavior. It is void of humility and reeks of entitlement and self-importance. How do you know you didn’t accidentally leave your overhead light on three months ago and drain the battery? Any number of things could have caused your battery to die.

Jack
I agree. This type of behavior will drive this country to the ground.
Things happen. Sometimes it’s not within our control. You don’t just go run around and ask someone to “reimburse you” for everything.
Elaine, do you bill your attorney, Fed/State government as well?

stitch
I recently had an experience with a mechanic who neglected a critical aspect of a repair which could have led to a catastrophic event; fortunately it didn’t. It did, however, lead to serious inconvenience including having to wait for a tow truck, missing an important event, and requiring that we get a rental car.
Now, I could have gotten very confrontational and demanded that the mechanic reimburse me for everything, that I would hold them responsible, etc. etc. etc. However, I bided my time and the mechanic was extremely accomodating and has covered all expenses not only the damage resulting from the original mistake but also all the associated costs. Although I did not bill for the time. The event was missed, it could not be made up; there was no monetary gain to be had, so why push it?
And you know what? I’ll go back to that mechanic again, and I will still recommend them, because they stood behind their work, and even behind their mistakes. And I know they will take good care of me in the future.
So which approach do you think is better?
Primary Care Internist
i agree this behavior smacks of entitlement. I’m sure Midas said to themselves “who knows what happened with the battery, this lady’s kid probably left the lights on in the car and drained it 90%, but let’s just pay her and call it ‘nuisance cost’ so we can be done with it”.
All businesses have to deal with these unreasonable costs from people that assume there must be blame whenever anything doesn’t go exactly as planned, just like malpractice insurance, lawsuits etc. I think people to pull this kinda stuff don’t have kids, since anyone with kids knows that you can’t really plan for anything going 100% as expected.
The fact that midas paid you anything doesn’t mean they’re at fault to me, at all. If anything the story implicates you as entitled, rather than them as faulty – if you’re able to drive on that battery 5 states away, then the battery wasn’t the problem (alternator? user error?)

joe
Ok Elaine let’s turn the tables for a minute OK.
You are an IT consultant.
My practice added a new EMR about a year ago.
This has been a mess.
It has ADDED on average 5 minutes per patient, much more early on, to the end of my day. Certainly the EMR vendor has not offered to pay me for my time.
On top of that several times per week there is some type of bug in the system. I call EMR liason and inevitably deal with a clueless individual for 5-30 minutes. OFTEN WHILE THE PATIENT IS SITTING IN THE ROOM. God forbid this happens after 5:00 PM because you guys have gone home for the day.
In general I have found the “holy grail” of EMR and IT to be lacking, no matter what Obama says because of the simple fact that your field has little clue what my needs are.
Not sure what field of IT you are in, but why don’t go back and call your previous jobs and find out how much tiume they “wasted”. Then offer to repay them for their wasted time. You might get a very rude awakening.

Family Medicine Doctor
OMG PLEASE JOE, tell me what EMR did you buy cuz I’m shopping around.
I’ve been very impressed w amazing charts. If any doctor out there has bought amazing charts and has a story- good or bad- please tell me. I’m really afraid of drama.
Warmest regards to all my colleagues

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Have heard amazing things about amazing charts as well.

ninguem
Amazing charts works well, is affordable, and ideally suited for the micropractices discussed here.
If there’s one field that’s rife with unethical practices and ripoffs, it’s the EMR industry. Grossly overpriced software that makes physician fees look like charities. Nondisclosure agreements to try and gag the doctor from discussing what he paid for the software, or why he dumped it after six months.
Holding data hostage when you try to get out and go into something else.
I could go on, but this thread is getting long in the tooth.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yep, ninguem. I hear ya! (see my post below)

JustADoc
I do not use Amazing Charts but one of the doctors that we cover for in the hospital on occassion does and his notes are completely useless to me. Maybe that is just him though.

Family Medicine Doctor
Dear JustADoc,
Thanks for the input. But could you be more specific in why his notes are useless. Maybe it’s not him & it’s amazing charts after all.
I would love to know that before I buy it.
But amazing charts has a 90 day, use it for FREE & see if it works for you. If it doesn’t, you can return it without cost. I have not seen another EMR company that offers that. I actually spoke personlly to the owner of amazing charts, he’s a doctor actually. Really nice guy.
So please any comments would be most appreciated.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Incidentally I created my on EMR (no special bells or whistles) with off-the-shelf software that came free with my MAC. While looking around to purchase a system I created a temporary one on my own just to store patient information while shopping around and (what do you know) I liked mine better than anything out there (and there was not much for MAC) plus it was FREE!
Yep! never paid a cent for my EMR in 6 years.
Pamela
ninguem
If the chart notes are useless, I have to conclude the problem is the practitioner, not the software.
An Amazing Charts note, on computer or dropped to paper, is going to appear as a fairly standard SOAP note format.
Problem, history of problem, past medical history allergies, meds, exam, assessment, and plan. The format is as straightforward as you can get.
It’s far better than some of the EMR’s I see when they’re dropped to paper.
ninguem
Say Pam, do you know about this site?
The Lund Report
http://www.thelundreport.org
Diane Lund-Muzikant covers Oregon healthcare. A niche market to write a newsletter, but she’s pulling it off. I used to see her at the meetings back when I was a delegate to the OMA.
I bet she’d like to write about your practice.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
But ninguem. . . who are you? I want to contact this woman and tell her you sent me her way, but you are still unnamed. . . . call me. . .I don’t bite.
Pamela
541-345-2437
(just me and you. I won’t tell anyone else except the lady above)
http://www.facebook.com/profile.php?id=100000977601479 Melissa Gastorf
I don’t know if you have purchased your EMR yet, but amazing charts is a terrible system. It is not one we bought, but we took custodianship of a physician who left town, and that was the EMR she chose.
1. It is not user friendly. When I can figure out how to pull out the information she typed in, it is ok, but it is not in an easy to use manner.
2. They are not currently approved for any incentive bonuses if you are purchasing it for that reason. They are quite a bit a way at the last time I looked.
Basically the system is a mess from what I can tell. I am sorry to say that, but it is

Brenda
Dr. Wible
You wrote that ” It’s illegal for physicians to discuss pay schedules. Something about “conspiring against insurance companies.” You mean the insurance companies preclude doctors from disclosing their regular fees? I’m no talking about the rates docs negotiate with insurance companies. If it’s the first, isn’t that illegal? That would sound more like insurance companies conspire against the uninsured….

Vox Rusticus
You are actually allowed to tell others what you charge, you just aren’t allowed to collude with others to fix prices. Doctors avoid discussing fees with other doctors to avoid even the perception of colluding, for fear they be accused.

ninguem
You can discuss fees, just can’t collude to fix prices.
The practical problem is the regulatory agencies can use that discussion as evidence of collusion. You run the risk of having to defend yourself over a “guilty until proven innocent” mindset.
So as a practical matter, fees are not discussed.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yet with my own patients I am free to discuss fee just not with other doctors and on forum such as this due to the guilty-until-proven-innocent environment in which physicians work.
Insane, right?
Pamela

Family Medicine Doctor
Dr Wimble,
May I ask on average how many pts per month you see?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
I see no more than 11 patients per half day and work 3 afternoons/evenings per week.

Family Medicine Doctor
Ok, sorry, still confused. My fault. So you see around 33 pts/week? Maybe 130 pts/month?

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yep. I have a part-time practice. I quit medicine and had planned to return to waitressing (no kidding) because I could not personally deal with the inhumanity of overbooking and rushing through patents all day. I just wanted to be nice to people again:
http://www.youtube.com/watch?v=b4aWpjPtRwA
I spend my the rest of my time helping communities design their own hospitals and clinics. And helping burned out physicians from fleeing medicine into other professions!
Hope that helps. Feel free to contact me any time.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Yep Brenda ~ Antitrust laws prevent physicians from discussing fees with other physicians for fear of price-fixing, collusion.
Old old KevinMD articles discusses some of this:
http://www.kevinmd.com/blog/2009/09/price-transparency-affect-health-care-costs.html
Chip
John (#145) said:
“The average medicare recipient have only paid for 1/3 of their promised services. I’m in the top 10% of income earners and paying for your lavish benefits, while you sit and wait because I’m doing a good job.
Then you complain.
It’s obvious what is wrong with this country.”
Wrong. We have paid into the system all our lives. We worked very hard for these “lavish benefits”. We worked very hard to build the infrastructure, and the educational system, that allowed you to go to Med school in the first place. I recall guiding many a pre-Med student through fairly simple Chemistry labs that some were barely able to understand. I spent a lot of time tutoring some of those folks. I was one of the many who helped YOU get that “top 10%” salary.
Then you complain.
It is indeed obvious what is wrong with this country. It’s the overbearing sense of entitlement and the condescending elitism of those who disdain the hands that helped them climb the ladder in the first place.

http://www.womeninpainawareness.ning.com carol
Chip hits one issue right on the head. Some of the folks here, who say they are docs, are exhibit number one of the sense of ‘I above all else’ because I went to medical school. I see a lot here from others showing they understand we are all the same, the difference is what path we chose or life chose for us. You are lucky that you were born with the inate ability (ie intelligence) to go to medical school. That does not give you a free pass in life to show disdain for the people who give you your living; that allows you to be in the top 10% of income earners. (By the way I sit at home because I am disabled. Thankfully I worked long enough to pay into the system and get Medicare. )

ninguem
“….Wrong. We have paid into the system all our lives……”
So did the doctor. Your point?
Does this somehow give someone an unlimited claim to services? Do I have a claim to the services of my auto mechanic because he went to a community college and I paid my taxes?
How about the docs who financed their medical education through the military or public health service, probably 25-30% of my medical school class. Did their tour in Iraq or stint in Appalachia cover the bill, or is this a lifetime debt, unique to physicians?

http://www.consentcare.net Martin Young
Wow! Looks like doctors and patients are bridging the divide here!!
Good job, Elaine and Pamela!
http://RecipesForRecovery.com Leza Mesiah
I think it’s very individual. If the doctor is ALWAYS late then I might like the billing idea, but just don’t harp on me if I’m late…And sometimes I’m late, and sometimes the doctor may need to talk to a patient longer then expected. However, if they are always late and I’m alway waiting an hour, that is ridiculous. There are always exceptions to every rule, but late 100% of the time year after year, I’d look for a new doctor. Leza in Dallas
Patricia Randolph
This doctor privelege aspect of billing has been a one-way street for way too long. I do not go to a doctor very often because I have never had health insurance, but I do notice when I do go that one can be kept waiting for medical emergencies or just overbooking. I am sure if the billing cut both ways that there would be a lot more care in this aspect of doctor/patient relationships! Great idea.

Jack
Next time you or your love ones have a medical emergency remember what you posted. Your doctor probably can’t you because he needs to be on time or else his next patient will bill him.
Medicine isn’t fast, cheap and won’t solve all your problems.
Vox Rusticus
The doctor bills for work done and is prohibited from billing in most cases when work isn’t done, meaning that many times no-show patients cannot be fined for their wasting office appointments. You would presume to charge for waiting but otherwise not doing anything except warming a chair seat, reading magazines and using air conditioning.Sorry, I don’t think I would agree to hire you for those services. If you said “now I am going to start billing you for my time” I would tell you your so-called “services” were not needed and show you the door.

Jack
No one’s told me if they bill the DMV or IRS yet? How about their lawyers? Why not?
Family Medicine Doctor
Dear Elaine F,
From your comment dated July 7th you wrote:
“I will happily pay you handsomely for your services”
Primary care is a poorly paid specialty. It’s really bad. Unless you are paying me about $250 CASH for an office visit, please don’t think that your health insurance card you bring to my office pays “handsomely”. Not in any way shape or form. Don’t believe me? If health insurances paid primary care well, gosh or even fair, there would not be a primary care shortage.
Maybe that’s your problem? You want a concierge, VIP private practice-nothing wrong with that & they do exist- but you refuse to pay anything worth a darn.
See, I know you pay junk to your docs, through your health insurance, cuz if you paid “handsomely” you certainly wouldn’t be kept waiting.
Do you agree?
David
Wow.
The amount of anger and the attitude of disrespect toward doctors shown in these comments is a bit terrifying and disappointing.
And as an older non-traditional premed student giving up my other career and life to try to become a primary care doctor to serve others, it definitely does make me reconsider my current goals for medicine.

ninguem
Is it too late to go back to your old job?
I know a high school biology teacher who left his field to go to medical school. He graduated medical school, did an internal medicine residency, and practiced primary care.
For three years.
He realized primary care medicine sucked, and he’s back teaching.
I guess he can say, at long last, that he climbed that mountain, so to speak.

Vox Rusticus
He has a doctorate, probably gets enhanced pay by having the advanced degree and teaching seniority, gets union benefits and a teacher’s pension, which in some states is nearly 100% of pay and gets all official holidays and summers off. My parents were teachers, I grew up around them; it isn’t high living, but it isn’t terrible either.

Mark
Go to medical school if you want, but RUN as far away from primary care as you can. The world is increasingly full of Elaines and there’s just no reason to prostrate yourself to serve her. Just do something else. You’ll never reap any reward for all the work and sacrifice you are about to endure. No reward–not money, not respect, not job satisfaction, not patient gratitude. It’s ALL GONE from primary care. People expect the world from you, absolute perfection, for peanuts, and then want to send you a bill because they had to wait.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
And to all doctors who are uninspired by their current work situation and would like to create something better for themselves and their patients I welcome you to attend a **FREE weekend workshop** with me this winter to learn how to recapture the dream that led you into medicine.
Contact me at roxywible@comcast.net if you or someone you know may be interested.
Amazing location with hot springs, ancient forest, and geothermally-heated cabins. The most beautiful place in the world.
Pamela
jm
My surgeon makes lots of money. He spent maybe 5 minutes with me to convince me to have a surgery I sure wish I’d never had. I paid $250 for those 5 minutes. “Consultation” fee. Only it really isn’t a consultation, it was a one sided pitch to convince me to have an ill advised surgery. Next problem, I don’t make that much money. In order to pay this person in cash, I have to work a lot of hours. So my time is actually really valuable to me. How dare he interfere with my ability to earn the ENORMOUS amount of money it takes to have him bless me with his presence for a few hurried moments by being chronically, habitually late? He cost me a horrendous amount of money by being over an hour late for the surgery that he INSISTED I needed to have! The hospital charged me by the minute for his tardiness. That isn’t cheap, especially when I only was making 12 dollars an hour. (a 70 minute out patient surgery cost more than I grossed that year) I cannot afford to spend an inordinate amount of time away from work, just so that I can wait for his eminance. My time is valuable. Maybe if *I* made 250 an hour and up I would have enough income so that I wouldn’t miss an hour or two here and there. I see both sides, but please don’t disrespect me by being late ALL the time. My surgeon actually got huffy with me when I left without seeing him because he was tardy. I was using my lunch break time to see him. I could get FIRED from my lousy little job by returning LATE! I am supposed to just be happy that he sees me at all, and graciously accepts my payment? I guess my money isn’t green enough for him? It’s not higher math folks, some of us “patients” need every dime we can earn, and we don’t take kindly to some “rich” doctor costing us time AND money.
Boundless
Charging doctors for being late is not a bad idea. I can’t see myself doing it personally. But what is important is that we GET THEIR ATTENTION.
Medstudent12
This whole thread is a terribly disappointing, discouraging thing to read as a med student. There are many problems with the way in which we deliver health care in this country (and, more importantly, problems with health care costs, which is a whole other topic), but the sense of entitlement and self-importance behind non-concierge patients charging primary care docs for being late ignores the most common reasons physicians are late: complex patients and busy baseline schedules to meet patient needs and practice overhead in an environment of declining reimbursements.
Are some physicians not on time with patients because they show up to work late, or are busy cavorting around with drug reps, as some posters claimed? As with any profession, I’m sure that explains the behavior of some outlier, bad apple physicians. But >95% of the primary care docs I’ve worked with are hard-working, dedicated physicians who want to give their patients the best care they can no matter what that means for their schedules. This includes rounding on hospitalized patients (unpaid), returning patient calls and refilling meds during a busy clinic (unpaid), discussing results/treatments with referring and consulting physicians (unpaid), not to mention the time many of them spent seeing homeless/uninsured/underinsured patients and volunteering at free clinics (unpaid, of course).
As many physician posters have detailed, it can take longer than expected to discuss a cancer diagnosis, review a recent hospitalization, or properly deal with suicidal ideation. My mother (an OB/GYN) recently shared with me a story of a patient who was enraged that she was 45 minutes late for an appointment. The patient ranted and raved about how important her time was and how the delay was simply disrespectful. My mother calmly explained that she intended to be on time, but that she also intended for the last patient to take her new diagnosis of cervical cancer better than she did.
On another note, I wonder what the 40+ million Americans without health insurance would have to say about charging their PCP for being late. Oh, that’s right, they don’t have one.
Imelda
If the patient who billed the doctor turned out to be having a complicated medical problem and took most of the doctor’s time to examine the patient, I hope that patient himself/herself would kindly explain to other patients -who are waiting for their turn to be examined- that the doctor was ‘late’ because the doctor had to examine him/her thoroughly, to avoid the doctor being billed by other patients and also proved that the doctor didn’t messing around.
And if the next-in line patients still want to bill the doctor, I think the one who must pay the bill is the patient who took the most of the doctor’s time.

MZMD
Well, considering how hard it is for patients to even bring themselves to discuss highly personal issues with their physician, I doubt most of my patients who are struggling with depression, or on their way to the ED for evaluation of unstable angina, or who have a breast lump or abnormal pap smear really want to share all that with the next patient in my waiting room.
Nor do I think that it is their responsibility to pay the next in line patient for me running late.
Not really a workable idea…

Sam D’Orazio
I like the idea! Perhaps we should extend this notion to other professions as well. Respect really IS a two-way street.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Billing late doctors has great media appeal, but the bottom line is people just want respect and empathy on both sides of the fence. If we all develop more empathy for each other through open and honest communication of our frustrations then we can start to heal–together.
Diane Sawyer reported this story I broke to CNN on ABC World News this evening:
http://abcnews.go.com/WNT/video/patients-bill-rights-14076222?tab=9482931&section=1206835&playlist=1363742
Pamela

DrB
Dr Wible,
It seems from your comments that you think you found the pot of gold and the rainbow just keeps going, but forgive me for pointing out that your “practice ideal” is not realistic for the general population. You see 33 patients per week. Typically, it’s safe to assume the average for PCP’s is to see about 125+ per week. If all of us PCP’s decided to go the route you are advocating, we would need FOUR times the number of PCP’s we currently have. Or, just four times as many hours in a day. Doesn’t matter which, they are both fantasy plans.
Can you understand why your master plan has a small hole in it? More pressing, can you please find it in your heart to quit stirring up entitlement amongst the average patient, so they will not expect ME and my FULL practice colleagues to provide the benefits you can so easily provide when you only see a fraction of the patients we see?
Thanks.
Dr B, PCP in Texas

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Dr. B; I am not advocating that any doctor follow my practice model. Everyone must discover their own joy in their respective careers. I quit medicine in despair to pursue waitressing in 2004 and thankfully discovered a way back–to find my joy in medicine. Since 2005, my story has inspired countless others not to abandon medicine.
There is no one-size-fits-all model, patient, or physician. My pot of gold IS serving my community. It is my hope that all physicians find their pot of gold at the end of their own rainbow.
Entitlement?
We are all entitled to basic respect. And it’s possible to be respectful to one another whether one works full time or part time. Whether one is a street sweeper or a doctor.
Patients don’t want money, gifts, and perks. They want respect and honesty.

Lola Lola
…and Dr. Wible I might add patients want quality healthcare. Since the doctor’s office is a place of healing I’m looking for tranquility, caring and compassion. I’m human and likely I’m not feeling real well so be gentle with me. If, as a professional medical practitioner you are unable to, “do no harm” consistently, be the healthcare provider patients need, then you really need to open an auto repair shop for cars, wait tables or become a carpenter…definitely get out of medicine!

Dr B
Not advocating that anyone follow your model? Can you say that with a straight face? From your website: “Welcome to the Ideal Medical Care Blog ~ where politics, health care, and humanity intersect ~ your home for intelligent, provocative commentary on the movement to achieve ideal care for all. Inspired? I welcome your comments.”
You call your Ideal medical care a “movement.” You state you want to “achieve ideal medical care for all.” Clearly, you are implying, if not outright stating, that your version of medical care is superior to the status quo. Clearly you are implying, if not outright stating, that my being late to an appointment is a lack of respect for my patients, and not simply a function of my trying to care for a standard-sized patient panel.
There are times when people are rude and condescending and disrespectful of others’ time, which I do not condone or tolerate. However, to imply that running “on-time” should be equated to respect for my patients, and running late is therefore disrespectful and I should be monetarily penalized…ludicrous.
My point is that you can comment all you like on how medical practices could be run and what patients could expect from their providers…IF you limit your comments to SMALL patient panels and PART time providers. At the very least, you could let your devoted patient followers know that apples are apples and oranges are oranges.
http://Www.twitter.com/alicearobertson Alice
First of all congratulations to Pam and Elaine! Your story was aired…that is exciting….not that the topic is new…it’s been around for as long as I can remember…but I watched Dr. Besser with Diane Sawyer and all I saw was PR to the viewers. He knows better than we do that few doctors are going to pay…he did not serve the public well by not warning them they may lose their doctor. But it certainly would rouse the naive patient to send a bill because he tapped into our insecurity with doctors. It seemed self-serving to me…not truly helpful to patients. I feel like I have just read a huge, PR, sugary-coated scenario that some patients will gobble up.
I guess I am dismayed…how is it mutual respect to bill? If I were a doctor, mechanic, nurse, waitress…I would find it offensive. Mutual respect would show a patient calmly having a conference or a warning letter before a bill. I know Elaine discussed this, but patients love empowering speeches….we love the emotional stoking this type of rah rah evokes.
I guess, logically, I am troubled why on earth one would stay with a doctor they find negligent in that manner. Respect yourself and move on. I do not understand how billing magically makes a patient a type of respect police.
Thinking…trying to explain…..a doctor allowed cancer to spread in my daughter’s body…I have not sued…I have not even rated him badly online….nor given the doctor’s name publicly. The Clinic contacted me…he was cited. I am hurt beyond measure…at times I honestly wanted to die. One day I will post his name…because he has not apologized. I have struggled through this thread and still do not understand it…yet…I read these posts because I needed to find redemption…I needed to like doctors…the doctors who I met here and write privately (Pam is one…thank you) have helped me more than they can know.
Maybe this is why, I, ultimately find these actions futile and harmful to patient/doctor relationships.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Alice ~ Billing each other for our frustrations is never the ultimate answer. It’s a wake-up call. We need to discuss deeper issues not yet reported by CNN and ABC. Maybe CBS will dive deeper. . .
Respect for each others’ time will create much goodwill.
Here’s a web-based program used to alert patients when physicians are running late: http://www.medwaittime.com/
I’m sure there are others.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
The movement for ideal care is a national movement led by citizens. I host town hall meetings nationwide and help citizens create ideal health systems that work for them. I am not attached to any particular model.
Dr B: we need mutual respect and both physicians and patients need to raise the bar on their behavior. It is not acceptable to have double standards in 2011.
Everyone’s time is valuable–to them.
I can say all of his with a straight face and with a great deal of love in my heart for humanity.
http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Dr. B: This was posted about 100 comments back and addresses clinics that chronically run late for scheduled visits.
Patients deserve transparency in scheduling:
1) If an appointment is scheduled then most of the time
the patient should be seen +/- 15 minutes or so of appt time. (Barring rare emergencies or other good reason).
2) If appointments can not run on time then do NOT promise patient a specific appointment and run office as first come/first served DMV method.
If we are all honest, respectful, and clear in our communication and expectations of one another than
we can bridge the divide here.
Patients suffer a great deal of “iatrogenic frustration” from our lack of transparency in scheduling: http://www.youtube.com/watch?v=JVgp44hQG_0
Pamela

joe
A recap for all as I leave this thread.
Dr Wible:
1: Does not take medicaid.
2: Does not take medicare.
3: Does not see inpatients.
4: Due to the above cherry-picks her patients.
5: Works part time and sees around 25% of a full practice.
I don’t begrudge her any of these decisions to keep her sanity. What I do begrudge is her idea that this model in which one would frankly have to be incompetent to run late is going to “sweep the country”. As Dr B correctly pointed out, only if we quadrupled the MD numbers. That aint going to happen. Sorry Pamela, but “mutual respect” is not handing your doc a bill when he/she is running late due to another patient no matter how you paint it. Frankly, I for one would not want Elaine in my practice.
PS: Funny how Elaine never replied my thoughts on her opinion if the roles were reversed and us docs were asking her field to repay us for all the time we “wasted” due EMR’s and IT services. I still suspect Elaine would get a nasty surprise if she went back and offered to repay her clients for there wasted time due to her “consultant services”.

http://www.idealmedicalcare.org/blog/ Pamela Wible MD
Oh Joe ~ please don’t leave. Elaine has just this sent me private emails supporting many of the doctors on this thread. A real 180 degree turn around in her perception of what goes on behind the scenes in primary care.
Awareness breed empathy and I see it developing among docs and patients on this thread. Beautiful.
Again, I see any patient who wants to see me. I never turn patients away for lack of money or because I do not accept their insurance. I see Medicare patients. I see Medicaid patients. I see my patients in the hospital.

joe
Sorry Pamela but you said here earlier a hospitalist manages your inpatients. Social visits at your leisure are NOT managing inpatients. You also said you don’t take medicare. Though you may take “some” medicaid, you clearly pick who you want to see. Every doc on this website knows what unrestricted medicaid does to a practice…which is why there are subsidized clinics all over this country that get paid significantly more than medicaid rates to see medicaid patients. By the way please tell me how this makes sense to an independant practitioner who tries to be socially conscious and takes medicaid? To repeat, I do NOT begrudge you for doing this except when you hold up a “look at me sign” for being on time when you work part-time, don’t take the sickest patients, don’t manage you own inpatients, and cherry pick who you want to see. Try being introspective and try to think how often you were late in your previous practice OK. I will have to take your word about elaine as she doesn’t reply here.

http://www.womeninpainawareness.ning.com carol
A clinic is certainly different but when I was a hospital clinic patient (this was in the 80′s) I had to sign in at 1:00 or I would not be seen. Each and every time the doc I would be seeing came out and told me “I won;t get to you til about 4 or later. Why don;t you go out shopping or something and then come back.” While I appreciated her decency in telling me there was no reason whatsoever that I needed to be there at 1 other than oure bureaucracy.

http://www.MedicalManiacs.com PatricParamedic
I’d have to wonder why there is any cause whatsoever to view this “bill” as either resentment; an insult or a knee-jerk reaction to a perceived slight.
I see it as a straight-forward business decision.
http://twitter.com/PamelaWibleMD PamelaWibleMD
More comprehensive coverage on this topic coming up on CBS The Early Show and NPR. Details forthcoming.
http://twitter.com/grilledcheez Grilledcheez
When I have a doctor’s appointment I NEVER get in at my scheduled time (I’ve been going there since 1994 long before the current secretaries have worked there). It’s usually an hour or more after.
Today I arrived 7 minutes late and was REPRIMANDED by TWO secretaries who stated to me that they want to leave exactly at the end of their shift and not stay over and me being late caused the whole day to run late. If I do it again, I will be asked to leave and schedule another appointment time on another day.
Why is it I ALWAYS have to wait 1 to 1.5 hours for the doctor any other time? I didn’t cause him to be late as he was running behind before I even got there. The reason: The Secretaries schedule 20 minute appointments when the doctor will take as much time as he needs with you (and it’s never less than 20 minutes).

http://twitter.com/PamelaWibleMD PamelaWibleMD
Grilledcheez ~ You point out the double standard well. Is this clinic owned by the physician? Or is the physician an employee? Many times docs may be unaware of what happens at the front desk. Do hope you will speak with the great doc and see if system can be improved. Important thing is to speak up.

http://www.facebook.com/profile.php?id=781809492 Linzee Ferguson
I didnt realise U were doing the Dr a service!!!!! this is the most unbelievable thing i have ever heard… u think they WANT to be late for u?? they are more than likely dealing with some other NEEDY patient! ffs.. grow a brain..
http://pulse.yahoo.com/_MOUJC6IADIXVREAMHIUI5WTMV4 Socrates
So, what would Elaine say?
She has an appointment with her doctor. He arrived on time, attended to her. Just as she is about to leave, she begins to experience a bad chest pain, which would probably require additional 30 minutes of unscheduled extra time that her doctor needs to spend with her. The problem, though, is that her doctor has another appointment with another patient. Should he spend the extra time with her, or shove her through the door, and go one to the next patient?
http://pulse.yahoo.com/_Q5XPNPGTCAGRLTLJPU7567XATA .com before the storm
I wholly agree with Elaine. My daughter’s former psychiatrist was notorious for “running late” (3:00 pm appointment? You’ll be early showing up at 4:30) due to the constant barrage of pharmaceutical sales reps. Granted, the majority of his practice is medication management and he needs to be informed (and sample-stocked), but I failed to see why he couldn’t set aside a half-day each week just for meeting with the reps rather than allowing them to disrupt patient appointments.
And then there are those who double and even triple book time slots. The reason, I was told, was due to patient cancellations. Translation: “I’m concerned about maximizing my revenue, not minimizing your inconvenience.”
Lola Lola
If I were you I’d speak to the doctor in private to tell him how upset I am by the tone used by the employees. I’d tell him what the employees at the front desk said and how I’m looking for another office because, although he’s great and the two of you are compatible, his office staff could use some courses from the local charm school. Tell the doctor you will not tolerate harsh treatment from them and he needs to make it clear ehw ill not have his patients treated with such verbal roughness. As long as you allow the doctor’s staff to abuse you they will continue to do so. The fees you pay the doctor fund their pay. If they persist on being rude they may never have to be concerned about staying late at that office again.
Anonymous
RE: “Elaine values herself and her time.”………I forgot, no one actually values physicians anymore.

There was a time when the term “thanks doc” resonated in medicine, now the term “i need more pain meds, i need more of this, how dare you are late, i read this online, etc.” is what medicine is about. I think respect is a two way street definitely, and that goes for any service industry, profession, business, etc. But the bottom line is that not ALL physicians are late. The last time I checked, physicians are human beings not automated robots engineered to serve society in a fixed fashion. They also get inundated with work, stressed out, and even delayed. Yes I agreed if a physician is chronically late, then something should be done about it. However in a day and age where there are simply way too many patients to see in any given day to maintain a positive profit margin, it comes with territory.

With regards to patients, there are always going to be some patients who are more needy than others that drain time. If you use common sense or common business terminology, if patient A, B, and C goes as scheduled, but patient D is a bottleneck and delays you by 15 minutes, then guess what, the rest of your day is delayed by 15 minutes. So then Patient E through Z are going to be disgruntled and according to the aforementioned article above, apparently be able to charge you money for taking time with Patient D who may or may not have a serious problem. Also, patients are more than free to pursue other means of receiving medical care if they feel their physician is being unprofessional by being late.

Another point I wanted to make is that the last time I checked, physicians don’t bill patients for every interaction they have. So if patients are going to bill physicians for being late, then I strongly feel that physicians should be able to charge for every single phone call/email/correspondence/answering service page that occurs between patients and the healthcare providers, because that’s fair isn’t it? Lawyers do it? Oh wait, how dare physicians discuss actually utilizing some sort of common business principle in other professions because then people will think doctors are greedy….oh wait….

highly disappointed with the spin on this article. it lacks the reality of what medicine is today. you can’t subsidize healthcare and show a small minority as a positive change towards progress.

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