If a doctor isn’t face to face with a patient, is he still a doctor?

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a federally qualified health center, the payment we actually receive is the same.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose x-ray results suggest he needs more testing.

As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.

A specialist will write “I recommend an angiogram,” and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.

An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer. Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.

Most people are aware these days that procedures are reimbursed at a higher rate than cognitive work but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.

Just lately, there is a new trickle of money flowing into medical offices for the type of between-visit oversight that goes with the new patient-centered medical home model of care, but it is not enough money to substantially change how doctors’ time is scheduled.

Taking a primary care physician away from direct patient care for just an hour can cost the employer somewhere around $400 in lost revenue. In today’s economic climate, few health care organizations can afford to fully embrace the notion of all the different indirect care activities others think physicians should engage in besides seeing patients one by one for a fee.

Of the three professions, physicians probably have the most confusing payment arrangement: Members of the clergy tend to make a straight salary regardless of how busy they are, lawyers bill for their time whether spent with the client or without, but we only get paid if someone is watching us.

If a tree falls in the forest, does it still make a noise?

If a doctor isn’t face to face with a patient, is he still a doctor? Is he still doctoring?

I say yes, but, then, how should we get paid?

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • NPPCP

    Hi Country,
    Serious question. Wanted to clarify because it may sound a little sarcastic. Do not want it to be – just sincerely curious. “If a physician hires 3 NPs that see the patients and the physician sits in the office and reaps the incredible rewards from this legislative arrangement, but never sees the patients…are they still a physician?”

    • PCPMD

      What scenario are you referring to?

      1) The physician may really just be a businessperson. I.e., built the office, reputation, overhead, organized the work flow, hired the PA’s, MA’s, Nurses, front-desk, negotiated the insurer contracts, does all of the paperwork, licensing, etc. for the office.

      The PA’s (and possibly other physicians) are employed in this arrangement, and the revenue they generate goes towards the business. Depending on the state, no physician oversight may be required, and there is nothing morally or legally wrong with this arrangement

      2) The physician does supervise the PA’s, reviews their charts, takes legal and medical liability for their errors, and takes most of the proceeds from the visits to pay their salaries, benefits, office overhead, etc., and keeps a bit for himself for his efforts. Again, nothing morally or legally wrong with that – that’s how its supposed to work in states that require a supervising physician.

      Wondering if you had any issues with these scenarios, or were specifically envisioning something overtly illegal, and then asking if its wrong?

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

      I would assume you are referring to arrangements I’ve seen in some States where physicians that may not even practice medicine at all are signing up as the “supervising MD” for a bunch of what are practically standalone NP practices, and get a piece of the billing in return for doing absolutely nothing at all.
      Nope, these are not doctors anymore….. business persons, maybe?

      • NPPCP

        Well….yes…that’s it. They still practice medicine, so they are a doctor; just not with the NP. They aren’t required to. It is more like a tribute from the NP because of selective state legislation. So they call themselves a doctor with their patients, but given the “country doctor scenario” they are no longer a doctor really. They have left the patient for legislatively mandated financial gain. Again, just the irony of it all. No offense – at all. I think you guys are incredible – especially you Margalit. And I would work with you any day PCPMD. Just another honest assessment and perspective.

      • buzzkillerjsmith

        Is that so wrong? Business people need love too.

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

          Sure thing…. most people are not doctors, and we all need love… :-)

    • Acountrydoctorwrites

      In my state NPs practice independently, and can even own their own practice. I was referring to what in Federally Qualified Health Centers is referred to as “incident to” services, where a medical assistant, nurse or other non-provider staff member provides a service, supervised by the physician and billed by the physician as long as there is a “face-to-face” component of the encounter.

  • NPPCP

    Hi Doctor! I completely understand your explanation and assessment. My point is the irony, I suppose. Not being able to spend more time with a patient as a physician because of paperwork, government mandates, and insurance company forms is not acceptable to the country doctor – they would like to be able to avoid all of these things and spend more personal time with each of their patients to reinforce and maintain the doctor/patient relationship. However, many physicians do the same thing on a daily basis WILLINGLY by bypassing the doctor/patient relationship in order to benefit financially from other professions (NPs) seeing patients. In some “supervisory” states, they aren’t even mandated to review any charts. They need only to sign a piece of paper for the NP to be able to practice and see “their” patients. By signing that piece of paper and having NO INTERACTION with any patient, it begs the question, “Are they still a doctor?” In more and more states, NPs are able to establish their own relationship with a patient without a legislatively mandated piece of paper standing between them and the patient. No sir – nothing illegal was implied at all! I am sorry for that. The legislative comment was just referring to the mandate for that “piece of supervisory paper” that allows a doctor to potentially (as country doctor mentions) not be a doctor – just under different circumstances and for personal financial gain. My thoughts and comments are just different takes on a similar scenario – just food for thought and an alternate view over which to mull. Thank you for being so kind.

    • buzzkillerjsmith

      You’re describing my dream clinic. I would sit with my feet up eating pork rinds and drinking Mountain Dew whilst my minions (aka NPs and PAs and nurses and MAs and anyone else I could trick into working for me) had to do every little of the work that some Luddites think of as practicing medicine.

      From time to time they might have the temerity to come into my office and ask a few annoying questions about someone vomiting blood or without a blood pressure of what have you, but I would discourage this kind of “disruptive” behavior and might even write up an incident report.

      I state for the record the corporal punishment would be mostly out of the question, at least in my dream clinic.

      • Katyb

        A much enjoyed & appreciated post! “Luddites”…lol.

    • Acountrydoctorwrites

      I was not primarily lamenting not spending enough time with the patient, although I would like to do that. My point is that if I do work on behalf of the patient I (read “my employer”) cannot bill for it unless the patient is watching me do it. That is a bit antiquated.

  • PoliticallyIncorrectMD

    Similar to the tax code, there is no logic behind how physians are compensated, EXCEPT the system makes it extremely easy to minimize or deny the compensation. As long as there is a third party payment system (which is not the case with other professions) this insenity will persist.

  • http://www.chandreshshah.com/ Chandresh Shah

    I am not a doctor, but I am troubled with this honest, open and frank discussion. What has happened to our great country? You, doctors, us patients, have absolutely no say in how our money gets transacted. I am paying the premiums – lots of it, you are getting paid – just a little bit. Something gets filtered along the way. How, where, when – no one knows. This fantastic complicated infrastructure was build to protect us – under the guise of consumer protection by lawyers.

    Greed.

    I don’t need protection. I know majority of you are honest and care about us. For just a few rotten apples, someone decided to create such a huge mess that there is no turning back.

    It would be so nice to have that old family physician structure and payment structure without anyone worrying about ‘liability’.

    As we say in our capitalist society – ‘markets take care of themselves’. Why can we allow the market of society to take care of bad providers? Why do we need such a regulated system?

    • Acountrydoctorwrites

      The problem with the market taking care of this is that some would go without health care then. Health insurance of some sort is necessary, single-payer or something else, but when people have insurance they aren’t as likely to be involved in making wise choices from a cost-benefit point of view.

      • PoliticallyIncorrectMD

        Medical insurance can be limited to cover catastrophic events (like most insurances do). The rest should be direct pay.

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

    I don’t know why this is such a big problem. They could leave the CPT system as is and use it for what it was intended – Procedures.
    Retire the office visit codes and replace them with pay-for-time. They can build a whole administrative nightmare around it if they wish, or just say $300 an hour, in 15 minutes increments, PRN, and get it over with….

  • JR

    Well, we have faculty fees to make hospitals profitable.

    How about “Primary Care Physician Fee” to cover those who are coordinating care for someone beyond the regular cold/wellness visit. In some ways, that’s what the concierge type doctors fees are anyways right?