Why doctors shouldn’t bill for time

As health care rightly moves towards a model of rewarding quality over quantity, the issue of how best to reimburse physicians is also taking a front seat. If not fee-for-service, then how best to judge and reward quality?

In this new value-based system of the future, some members of the medical community have been increasingly advocating for billing purely for time. In fact, over the years I’ve heard many doctors (usually on bad days) remark that they have just spent a long time on a specific non-reimbursable task — like as an extended meeting or phone call — and how they wish that they could have “just billed directly for time exactly like lawyers do.”

The argument behind this model is that it will adequately reward doctors for actually spending time on patient care tasks (for obvious reasons, this applies mainly to medical specialties rather than surgical ones). More time equals a higher reimbursement, and that sounds fair, right? I can understand sentiments such as these in the midst of a frustrating day, but I could not disagree more with the suggested solution. In fact, I must confess that even the idea makes me balk. The way the legal profession operates shouldn’t be our role model in an industry like ours. It would be a disaster if doctors start to expect to be rewarded directly according to time spent with patients.

Let me say why, by drawing on a personal experience from the above-cited legal profession. A couple of years ago, I met with a local attorney at their office regarding a minor matter. The attorney seemed personable and friendly, and the advice was excellent. A week or so later, a follow-up question came to mind. I called and left a message for an answer. The attorney soon got back to me and the question was answered in about 5 minutes. A few days later I was somewhat shocked to receive a letter in the mail that was billing me directly for this “time,” also including the “research needed” which equated to about 15 minutes (and, looking back, it was the most basic of questions).

I dutifully paid my dues, but was quite surprised to be charged for what I thought was a quick follow up phone call. But this makes me think, what if doctors acted in the same way? A similar method of billing our patients may sound extreme, but would be exactly what happens in a purely time based system where we accounted for all our conversation time.

We should never become like the legal profession in this respect. The current inpatient billing system with broad blocks of time, such as 30 minutes, is one thing — but the extreme of this would be unthinkable. Even an employed physician model that may involve an hourly pay rate (which I don’t necessarily agree with either, as a salary is more befitting of a professional) would still be better than billing for exact increments of time.

What if we decided to spend a few extra minutes trying to educate our patient about their illness? What if we decided to drop by a patient room to check up on them out of a sense of duty? Or what if we bump into a family member in the corridor and stop to discuss their loved ones’ progress? I certainly don’t want to work in a profession where the person we are talking to is worried about some type of “dollar stopwatch” that’s ticking for their physicians’ precious time. Could the doctor be talking to me with dollar signs in their eyes?

In such an environment, patients may even become suspicious of doctors who are spending extra time with them. No patient should ever get a bill that quotes “10 minutes of doctor time equals a certain dollar amount.” It would be to the great detriment of the whole medical profession, eroding trust between doctor and patient. We could also experience a kickback from patients, who may well themselves start trying to rush us through our time with them!

I recently read an article in a major medical publication that was debating whether email consults should be billed. I understood the logic behind it, but the next natural question is should we start billing for email advice to patients as well? To draw another comparison from a service based industry, think of how your realtor or mortgage broker works with you when you buy a house. They get paid a certain fee, and at least in my experience, are always available with questions. I’ve appreciated how they’ve guided me through what is often a complex and emotional experience (sound familiar to all of us in health care?).

I think it would be awful if every time I emailed them a question, I was sent a bill! It takes the whole meaning away from the relationship, and isn’t the way professionals should work. At a time of tumultuous change in health care, doctors mustn’t go down this route. We should keep our respect as a noble profession and do everything possible to retain the special bond between doctor and patient.

Collectively, a red line should be drawn to say that there’s no way we will become focused on billing for exact minute values of time. While we may not yet have all the answers on how best to reimburse physicians in the health care system of the future, that isn’t one of them. With doctors, duty to the cause of healing comes first. That’s what makes us different.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

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  • southerndoc1

    I have absolutely no idea how a “value-based” payment system would work. Can anyone help me out?

    • Dr. Drake Ramoray

      Value based. The insurance company pays you what they think you are worth, which aint much.

      • southerndoc1

        Oh , , , business as usual.

  • Dr. Drake Ramoray

    I find it very interesting that you use e-mail as an example but then use realtors as your service industry. Whereas my attorney bills me for phone calls, e-mails, and when he thinks about my case at the beach. My acountant isn’t terribly different either. But hey being a doctor is like selling a house, sure…

    And who is going to take care of all the complicated diabetics with diabetic shoe forms to fill out, a DMV waiver, and in the case of my type I’s who want a waiver from the government for a commercial driver’s license that is several pages long, filled out?

    The removal of billing for time (you can now if you know how to do it correctly at face to face visits) is one of the major issues I have with pay for performance and is at the top of the list of things that will have me go concierge or thyroid only.

  • NewMexicoRam

    I don’t understand your point.
    Currently, I am being paid less, or at best the same, and having to do more uncompensated work (ie, more paperwork or computer work) for documentation purposes.
    This causes me to go to the office earlier and earlier, and leave for home later and later.
    And I’m just supposed to suck it up because that’s what good caring doctors do.
    Don’t think so, pal.

    • Dub

      NMR, you should go ahead and become a membership Doc. Call me at 704/363-3395. (East Coast)

  • Gerdoc

    I make $110,000 a year working 60 hours a week. If i billed for time…maybe i wouldnt be retiring in 3 months

    • Deceased MD

      pretty sad. What part of the country do you work?

  • MS1

    You dislike the idea of billing by the hour, because you believe that this will lead patients to suspect the motives of doctors. Unfortunately, the practice of billing for procedures has led to the widespread belief that doctors order superfluous tests and procedures solely to inflate their incomes. Is this better? In my opinion billing by the hour is simpler (and hence cheaper because it requires fewer billing specialists), more transparent to the patients, more fair to the providers, less likely to encourage over- or under-treatment, and more likely to foster trust in the providers. Also, it should be added that studies of realtors have shown that on average they get less money for properties they sell for others than properties they sell for themselves, calling into question the whole idea that paying for a procedure is the superior way to go.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    There is nothing wrong with how attorneys bill for their services. It’s called time & materials. If the “job” has no precisely defined scope, as is true for doctors, time & materials is the only fair solution, where nobody gets cheated. Don’t psychiatrists work that way already?
    Realtors on the other hand work on a fixed price contract and usually get a percent of the transaction. For doctors,this is equivalent to capitation or bundled payments for specialists.

    As to “value-based”, payments, in some cases attorneys get extra cash if they win a nice settlement, so maybe a bonus for being successful.
    Realtors who are paid percentage points get more money if they can sell the house for you at a higher price, so maybe that’s a value-based bonus as well.

    How you apply this to medicine? I have no idea, unless you wait until the patient dies and see if he had a good life, all things considered, and then pay bonuses to his doctors out of his estate… :-)

  • Suzi Q 38

    I once had to hire two attorneys and 3 expert witnesses in a competency case regarding my father in law.
    The first month after I hired them, I had to call one of the attorneys several times with questions.
    I didn’t think much about it until I got the first bill.
    She had billed me for every phone call.
    Anyway, I learned and decided not to call her at all the following month.
    After about a week, she had questions to ask me, so she called me.
    I informed her that since our phone calls would be charged, that she would not be able to charge me if she called me, asking for advice as to how to win our case. If she did, I would not pay her.
    Since she wanted my opinion and advice, she did not charge me.

    Should a doctor charge for time spent?
    Why not?

  • guest

    I received a call from my colleague’s patient asking for a 2nd opinion after hours. This service is still free for patients. Why not give a call to the specialist. I can see it from a patient point of view. However, in a health care system where everything is becoming ridiculously expensive, it surprises me that these direct calls to physicians are still free. It is especially frustrating to have disrupted sleep repeatedly at 3 am for non urgent questions and have to function in the clinic the next day. Attorneys do not get called at 3 am especially if it is not an urgent issue.

  • guest

    On the other hand, you don’t hear nearly as many people complaining about their lawyers as you hear complaining about their doctors and the care they have provided…perhaps you do get what you pay for.

  • guest

    I find it slightly amusing that an MD who derives only part of his livelihood from patient care, and the rest of it from “writing and speaking about healthcare issues,” should be telling the rest of us that “duty to the cause of healing comes first.”

  • Dr. Drake Ramoray

    I generally speaking have positive thoughts on your comments as they are presented on paper. You pretty accurately discuss the pitfalls of each system.

    With regards to compensation based on overhead, what are your thoughts on the current use of facility fees and how hospitals use this to charge higher rates. Thyroid ultrasound in my office $125. Thyroid ultrasound a few blocks down the road at the hospital, patient’s responsibility after insurance $544, in large part due to facility fees. It is my understanding that hospitals use their “overhead” as justification for these fees.

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