Doctors who give cash to patients for running late

When Dr. Timothy Malia of Fairport, New York, runs behind schedule, he passes out five-dollar bills to everyone in the waiting room. And when Dr. Cyrus Peikari of Dallas, Texas canceled his appointments for a family emergency, he gave each patient 50 bucks for the inconvenience.

Most doctors apologize. Few offer cash. Others get creative: Dr. Gwen Hanson of Bellevue, Washington gives out Starbucks cards; Dr. Sharon McCoy George of Irvine, California, doles out movie passes; and I award gifts from a giant wicker basket by the door.

As America inches toward patient-centered care, some doctors are leading the way.

I transitioned from assembly-line to patient-centered medicine in 2004 when I invited citizens in Lane County, Oregon, to design their own clinic. I led town hall meetings, collected 100 pages of testimony, adopted 90% of the community’s feedback, and opened one month later. Our community clinic is thriving. But I’m always looking for new ideas.

Who is accountable for wait time?

Then my friend Elaine disclosed, “If I’m kept waiting, I bill the doctor. At the 20-minute mark, I politely tell the receptionist that the doctor has missed my appointment and at the 30-minute mark I will start billing at $47.00 per hour.” More often than not, she gets paid.

I reported her story on my YouTube news channel where it was picked up by CNN and over 11,000 other media outlets. Ultimately, Elaine’s waiting room remedy became the lead segment for a “Patients’ Bill of Rights” series on ABC World News.

Why all the fuss? Patients, frustrated by excessive waiting, have had no immediate recourse. Until now.

Amid the media frenzy, I met up with a patient named Pam. She billed two chiropractors and a neurosurgeon. The neurosurgeon waived her balance; both chiropractors paid up. One offered a bottle of wine from his private collection and promised prompt service upon arrival for future appointments — ahead of scheduled patients — because, he said, “those people don’t mind waiting.”

Comments from news stories confirm Elaine and Pam aren’t unique. Jacob Raitt, a retired pharmacologist, writes:

“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 three 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 $75.00, ignored her bill, and compounded interest monthly. When my bill to her exceeded $100.00 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.[1]”

From anger to empathy

We’ve all waited for the doctor. But why so long? Here’s the not-so-simple answer:

Physicians cannot set, charge, or receive proper payment because government and insurance companies control reimbursement. In other words, there’s no free market for physicians who accept insurance. By boosting the volume of patients seen, they buffer the loss from low reimbursement, resulting in production-driven practices that pack up to five exam rooms per doctor to cover ever-increasing overhead.

When physicians enter the exam room, they have no idea what multitude or complexity of problems they’ll encounter, nor the insurance hassles, paperwork, and phone calls they must endure to adequately care for the patient.

Patients believe doctors are insulated from economic distress. Yet with high medical school debt, low reimbursement, and 24/7 call duty, some physicians earn less than minimum wage. I know doctors who can’t afford their own health insurance; fortunately, their kids meet federal poverty guidelines and are enrolled in Medicaid. Recently, a physician friend confided she’s defaulting on her student loans.

For the promise of loan repayment, some doctors take government jobs with no control over their schedules. Myria Emeny, MD wrote in an email (June 2011): “When I worked for the community health center it was mandatory that a patient be put in every 15 minutes — didn’t matter if they needed an interpreter or were elderly and very sick or disabled and needed extra explanations — didn’t matter. Patients waited for me two or more hours … I worked through lunch and continued past the time my nurse left.” After years of self-neglect from working inhumane schedules, doctors burn out.

Doctors taking responsibility: Victims no more

In our automated and alienated medical system, both patients and doctors feel dehumanized and commoditized. Will invoicing doctors solve the problem?

While it’s easy to blame doctors, patients bear some responsibility. One person writes: “Wait time too long? Leave. Can’t leave? Then stay. Your doctor is running late but can’t bend time. And frankly, if you show up for an appointment still fat, smoking, and not taking your meds, then you’re wasting their time, and everyone else’s time in the waiting room. Maybe they should send you a bill.”

In fact, the underlying issue is: We all must be responsible for our actions — and inactions. A patient named Colin challenges, “I have negative hope that lawyers and politicians in DC have the capacity to fix any one of the thousand problems with health care if physicians cannot come to a consensus on a ‘simple’ issue of should physicians bear responsibility for running late.”

One physician admits, “At my old job I was routinely scheduled to have three patients in the 8:30 am time slot. There’s no way I could finish seeing all those people before the next three scheduled in the 8:45 am time slot.” A patient contends, “The fact that you have to see [12] people an hour because the insurance companies are screwing you doesn’t change that fact that long waits waste our time.” The truth is: when both patient and physician sign contracts with insurers, both carry equal responsibility.

But physicians are more capable of fixing long waits than patients. As the business owner (or employee agreeing to work for a group), physicians consent to the creation of this situation and should be challenged to take responsibility for it.

Dr. Timothy Malia took control of his medical practice by lowering volume and working a humane schedule. He says, “I do what I can in the part of the world I have some control over, most often just the 10 feet around me.” Imagine if we all did the same.

Informed scheduling

One solution: Offices must clearly inform patients what to expect before they arrive for an appointment. With open-hours scheduling, patients sign in and are treated on a first-come, first-served basis. With wave scheduling, patients are booked at the top of the hour and seen in order of arrival. Most common is stream scheduling — assigning one time slot per person, with overbooking for same-day appointments.

Uninformed patients are often in for unpleasant surprises. After a long wait, one patient confides, “I started asking people what time their appointment was for and it turned out there were four of us with the same appointment time. I switched doctors.”

While informed scheduling may seem to be a simple fix, it’s also a threat to standard operations, as many practices maximize efficiency and benefit financially by having people wait for free.

Just a little respect between doctors and patients

Most physicians are compassionate and caring. But one woman recalls waiting in the exam room for almost two hours while her doctor was “calling all his friends on the phone and telling them about his fabulous Florida deep-sea fishing trip”

It’s basic: mutual respect is a prerequisite for a healing relationship.

José, a physician, shares a personal anecdote. Pulled over by a police officer on the way to the doctor’s office, José’s uncle was five minutes late for his appointment. The administrator told him it didn’t matter why he was late and to expect a bill for not showing up on time or canceling within 24 hours. He rescheduled for the following day and waited two hours in the exam room for the doctor. No apologies were made. José summarizes, “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.”

Doctors have hundreds of reasons why they run behind and claim it’s never due to lack of respect for patients. Yet many offices charge patients late, no-show, or cancel fees, while physicians miss appointments with no reciprocal financial obligation to patients. The assumption: patients don’t have as legitimate a reason for tardiness or missing appointments as physicians.

From paternalism to partnership

Some believe waiting for doctors is a fact of life. Not so. Whether physician or patient, here are five ways to avoid delays at the doctor’s office:

  1. Schedule smartly. While physicians should select the scheduling method that works best for their workflow, patients should be offered informed consent when it comes to scheduling. Choose offices that allow reasonable time intervals for appointments.
  2. Communicate clearly. Whether by mouth, text, or tweet, clinics must inform patients of delays. And patients should state the real reason for their appointment at the beginning of the visit.
  3. Practice mutual respect. Patients: be on time, on task, and compliant with agreed upon treatment plans from previous visits to prevent schedule delays for other patients.
  4. End the double standard. If offices charge patients no-show, cancelation, or late fees, patients have a right to invoice doctors who miss their appointments.
  5. Vote with your feet. Physicians and patients have choices. Dislike how you are treated at a medical clinic? Find another clinic. Fed up with insurance? Bypass third parties with cash. All across America, doctors are using their energy, creativity, and love of medicine to create medical sanctuaries for patients. Celebrate what works.

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

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  • Anonymous

    If your doctor double or triple books an appointment slot you have a point.  Otherwise, billing your physician is ludicrous and will only serve to force more doctors out of medicine, many of which are the critical primary care doctors.  I rarely run more than 15-20 minutes late and generally get behind when one of my patients shows up late or one of my patients brings a list of 10+ problems to address in a 15 minute appoint.  I don’t double book or overbook and I can accomplish everything I need to in my 15 or 30 minute appointment slots if my patients have a reasonable number of issues to address.  And that is including the ER calls I take (some forced on me by my local hospital), the multitude of calls and complaints I address between patients via phone messages (for zero reimbursement), and the consultant notes I review and respond to in various ways.  And oh yeah, if I gave my email address out as many patients request, I would have tens if not hundreds of emails to address.  Really, the expectations for me as a doctor and primary care provider have become unreasonable…from the government, from my patients, from the ‘Elaines’ that are out there, from hospital administration, from my subspecialty colleagues.  It is out of control and primary care is dying before “patient centered medicine” can evolve.

    And I am happy to wait at my dentist’s office, barber, accountant’s office, etc. and never bill them for running behind.  I schedule waiting into the time I spend there. And I have never sent a bill to a local Midas muffler shop because I feel like they wasted my time…a la Elaine.  Bad stuff and unfortunate delays happen to us as people every day…I accept them as part of my life and Elaine views herself as a victim and seeks out someone to punish.  I have had this discussion with several colleagues and nonphysician friends…Elaine greatly overvalues her time.  I would question how many doctors she has had in her life b/c of her behaviors…probably too many to mention if she were honest about it.

    • Anonymous

      Thanks OslerDsciple. Get your points and agree for the most part. This piece was written as an attempt to bridge the divide between patient and physician. I absolutely think the average patient has no idea what primary care doctors are up against. 

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        Starbucks cards is a nice idea, I might try that.

        Though I’d still prefer voodoo doughnuts.

        • Anonymous

          I’m still waiting for a date at Voodoo. Sometime in February?

  • http://www.facebook.com/stephen.rockower Stephen Rockower

    Many times patients arrive 2 minutes before their appointment, and spend 30 minutes filling out forms.  That means I’m waiting for the 8:30 patient AND the 8:45 patient when the 9:00 patient arrives and gets pissed that “I’m late”.  We can’t help it.  If the patients want me to take less time with all the other patients, I can do that, but I try to devote my full time and attention to the patient in front of me. 

  • Anonymous

    I’ve worked at two different clinics, neither one charged patients late fees, no-show fees, or late cancellation fees.  In both clinic,  some patients repeatedly showed up 10-20 minutes late, often near the end of their scheduled appointment times.  Often no explanation or apology is given. My colleagues who accommodated these entitled patients helped enable and reward their disrespectful behavior. Most doctors who run late are not chatting on the phone with their friends, but rather are doing their job of answering patients’ questions, documenting, placing orders, or calling a specialist office on behalf of a patient for an urgent issue, or dealing with an unexpected urgent issue.  It is demoralizing and dehumanizing for doctors to have to work through “lunch,” often a sandwich inhaled in 10 minutes while working on the computer. 

    To the powers that be in Washington:  in order to fix the primary care crisis, you have to foster an environment in which the doctors are treated humanely and respectfully.  Asking us to do more and more, in less and less, time is not the answer and will only frustrate primary care doctors and patients even more!

    • Anonymous

      Let’s not enable patients (or politicians) who disrespect us.

  • http://www.facebook.com/people/Frank-Lehman/100002241640186 Frank Lehman

    Wible says: “Most doctors apologize.”   Where does he get that information?  I am 68 years old and no doctor has ever apologized to me for being late.

    • Anonymous

      maybe “most docs I know” apologize.  . . .

  • Anonymous

    As a worker’s compensation nurse case manager, I have seen patients kept waiting hours for their appointments. Sometimes it is due to emergencies, but often do to over scheduling. Since in California  worker’s compensation patients are required to see their primary treating physician every 45 days, they have to wait to be seen.
    I agree that doctors need to be treated humanly and respectfully, but so do the patients.

    • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

      RNPatty :

      Take a step back and think about what you are saying. re:”
      Since in California  worker’s compensation patients are required to see their primary treating physician every 45 days, they have to wait to be seen.” Do these patient NEED to be seen every 45 days or are you saying your  bureaucracy wants them seen every 45 days to check a box? Seeing a typical patient every 45 days for most docs is typically a chronically ill patient with multiple comorbidities. Do you honestly think cluttering up a doctor’s schedule with patients that don’t need to be seen for medical reasons just so you can check a box is a good thing? Remember, I am NOT talking about a patient being seen by a doc on workman’s comp that needs to be seen for an ACTIVE MEDICAL ISSUE.  Thanks for reminding me again what is going to happen what government bean counters take over.  

      • Anonymous

        Agree. One-size-fits-all medical care doesn’t serve anyone. Clogged clinics. Bored doctors going through the motions. . . 

      • Anonymous

        My bureaucracy?  Cluttering up a doctor’s schedule? My goal has a Independent WC case manager is to be the liason between all involved parties and help the patient get the treatment he/she needs to get well, and get back to his/her highest level of independence.

         In California Worker’s Comp. law it states  the Primary Treating MD has to  submit a report every 45 days to the insurance company incorporating other providers recommendations  into one report. Chapter 4.5. Division of Workers’ Compensation  states the following:

        §9785. Reporting Duties of the Primary Treating Physician.
        8) When continuing medical treatment is provided, a progress
        report shall be made no later than forty-five days from the last report of any
        type under this section even if no event described in paragraphs (1) to (7) has
        occurred. If an examination has occurred, the report shall be signed and
        transmitted within 20 days of the examination.

        If a patient is still on WC, there has to be an active medical issue, or their primary treating physician should have released them, or declared them permanent and stationary.

    • Anonymous

      Yep! Reciprocal respect goes a long way!

  • http://www.facebook.com/people/Pedro-Nunez-Jr/1240575946 Pedro Nunez Jr

    From the article – “When I went home, I immediately invoiced the doctor for $75.00, ignored
    her bill, and compounded interest monthly. When my bill to her exceeded
    $100.00 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.”

    This is a great example of an abuse of the legal system to bully a doctor into paying. People like this make me sick. Do you think this case would stand a chance in court? No. But the doctor would waste far more money going to court to fight this, and it was more economical to just pay the outrageous bill.

  • Anonymous

    I have regularly scheduled appointments with my oncologist who is often late (1 hour or more) with his appointments.   He’s never ‘apologized’, but does at least acknowledge that he’s late giving understandable reasons which I accept.  I’ve never complained as I really like this doctor and credit him with my current well-being.  However, what I do resent is trying to make up for lost time by rushing my appointment.  Such as, the nurse arriving before the doctor and putting me in position on the exam table before he’s entered the room.  I don’t like greeting the doctor on my back half naked, and for the first time I made a complaint and said it was disrespectful.  There was silence in the room, but it never happened again.

    • Anonymous

      Good job. Speaking up is the first step. Some clinics really have no idea how it “feels” to be a patient there. Constructive feedback always helpful.

  • http://twitter.com/ExpatDoctorMom Rajka Milanovic

    My philosophy with patients as well: “Mutual respect!” Well said and well done with your Ideal Clinic!

    • Anonymous

      Aw. . Thanks Rajka. So simple. It works.

  • Anonymous

    I can’t ever remember a time when any doctor I saw was on time. Apology? Never! Not once!

    • Anonymous

      Good reminder. I have heard this three times today from patients, Not even an apology Sad.

  • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

    “End the double standard. If offices charge patients no-show, cancelation, or late fees, patients have a right to invoice doctors who miss their appointments.”  Agree 100%

    On the other hand, if doc doesn’t charge these fees, a patient shouldn’t expect to be able to invoice their doc.  Agree with “Vote with your feet”  and with “Practice mutual respect”.  Doctors, especially, owe respect to their patients. 

    Michael Rack, MD

  • Anonymous

    Good article!  One thing I have noticed about many doctors’ offices is that they don’t really understand how the patient flows through.  When the entire focus is on maximizing the doctor’s time the rest of the system will inevitably suffer a loss of efficiency, including long wait times by patients.  Intelligent scheduling and the smart placement of buffer time for the doctor to either catch up, rest, or knock out paperwork could go a long way to alleviating the issues.

    I suggest doctors go sit in their waiting rooms for 20-30 minutes to get a feel for what the patient experience is like.  I found all sorts of easy-to-fix issues in the hospital waiting rooms by doing this!

    • Anonymous

      As I understand, most solo doc offices are “organized chaos”. My PCP always says, “Solo docs can never give you 100 percent of their attention and devotion. It’s impossible! They have way too much other stuff to do. They are running patients through like cattle and hoping that they don’t ask too many questions”. I guess that’s why my PCP sold his practice to the local hospital group in preparation for the future advent of their ACO model. He will work there as a salaried employee with scheduled hours, scheduled vacation, a pension plan, a 401k plan, paid group mal-practice insurance, he will have medical and dental coverage for himself and his family and, most of all, he will be more relaxed and have much more time with his family! His patient base, the very same people he treated at his tiny little office that resembled practicing medicine in a garage, will have free parking, a cafeteria in premise, a gift shop on premise, regular health seminars and conferences on premise, spacious waiting areas and much more. He says he can’t wait until transition takes place!

      • Anonymous

        Wow, you touch on a really big issue here:  Are we seeing the end of solo practices and is this a good or bad thing?  I’m glad your PCP and patients will enjoy the transition.  I find myself nostalgic on doctor independence but maybe that’s not what is best for anyone sometimes.

  • Matthew Bowdish

    Our clinic will give a $25 American Express gift card to those that wait more than 15 minutes past their appointment time to be seen.  We don’t have to hand out many gift cards, but it is a helpful way to say that we respect our patients’ time.  We’ve also found that patients tell their friends & family about this practice.  And we’ve even had new patients come to our clinic specifically because they’ve heard that we do stress service aspects like this.

    • Anonymous

      Your clinic should be applauded! Sadly, with respect to your model of respect for the consumer’s time, you are alone. In actuality, consumers of health care are disrespected regularly and providers could not care less. Doctors do not even think about the people in their waiting rooms. The consumer has always been abused and, if providers have their way, nothing will change. Prima donna doctors treat dogs better than they do their patients.