Monday, January 27, 2014

The doctor will see you NOW!

Here in Maryland, we have the best laws.  And Delegate Robert Costa, a Republican from Anne Arundel County (District 33B), has another Bill proposed:

Okay, so if the doctor runs more than 30 minutes late,
 the appointment is free.  I love it! Didn't Pizza Hut 
once have a similar policy at lunch time?  Your order
 gets filled in a specified period of timeor your pizza is free?
  You're worried about Emergencies? Del. Costa has 
you covered, all the doctor has to do is present the
 patient left waiting with an "emergency verification
 services number" if he was held up by an emergency, 
and he can charge.  What's an "emergency 
verification services number?"  I have no idea, but I'm wondering 
if this means the patient who had to wait
gets all the clinical details on the patient with the 
emergency.  How does it get challenged?
 I hate waiting, so I'm Lovin' It (oops, wrong fast food franchise)...
But I'm kind of wondering: Why did Del. Costa 
choose doctors as his target to legislate promptness?
Why doesn't my hair stylist have to give me a free 
blow dry if she's running late?  How
come the furniture delivery guys make me wait for a
 4 hour window and then still come late?
Shouldn't my couch be free?  I wait at the mechanic, 
I wait (often way too long) at restaurants, 
I wait for the plumber and the guy who fixes the 
furnace.  I wait on line at the grocery store, 
I wait for patients who are late, no one is prompt 
anymore.  Why is it only doctors who should 
not be paid if they run late?  If they get stuck in traffic?
If a patient has an unexpected problem
and needs extra time?  If they have to call other
 docs, pharmacies,
 family members, labs, and insurance companies 
 to coordinate care?  If someone's late 
and their schedule gets thrown off?

"I'm sorry Mrs. Smith, I know you came from 50 miles away after hiring a babysitter to watch your handicapped son, and  I'm truly sorry to hear about that accident closing down the Beltway this morning, but you're late, and if I see you now, I'll be late for the rest of my appointments today, and I won't be able to bill for them, and there is the matter of my mortgage, the kids' tuitions, and my student loans, not to mention dinner at the steakhouse and my BMW lease.  Please do schedule another appointment to see me. I imagine you guessed that I asked you to come in to discuss your biopsy results, and indeed they did show a particularly aggressive form of cancer with a poor prognosis, but we'll go over that when your appointment is rescheduled".


Anonymous said...

This should be called "Christie's Law." Republicans protecting us against bridge tie ups...

Simple Citizen said...

Doctor's are always held to an impossible standard. We also have to see patients who either can't pay what we charge, or simply can't pay at all.

If I have to see people for free, why doesn't everybody else?

Are home builders obligated to sell me a house for less than it cost to build it?
After all, my family needs shelter - it's the home builder's social duty to provide it! Yeah, it's their duty to operate at a loss and go out of business!

Does the car mechanic have a social obligation to fix my car though I can't afford it?

Is the grocery store obligated to give me food when I can't afford it?

Forget the necessities - Does the movie theater have to let my family in for free because my kids deserve entertainment?

It's the same with being late for an appointment. It's about entitlement. Americans are entitled to medical care, right now, for free.

Good luck turning this freight train around, it's been gaining speed for decades and the track is never ending.

Anonymous said...

Simple Citizen, with all due respect, you are missing the point. Of course the law that Dinah mentioned is absurd.

But so many doctors and their staffs don't seem to understand that the time of their patients is just as valuable even if they don't have an MD by their name. A simple acknowledgement of that (which is not an entitlement) would be nice instead of acting like we are space aliens when we ask after waiting for an hour how much longer it is going to be.


Dinah said...

We've become a society where everyone is late. I have friend friends who will run an hour late to meeting me for lunch with barely a nod to apology, and when you hear their schedule, you know they should never have planned to meet me. Patients routinely run late (and yes, sometimes I run over if there's not a 'next patient' and rarely, if someone is in dire straits and was very late because of traffic, I'll stick my head out and tell the next patient I'm running 10 minutes late.
In clinic settings, I've been much less rigid about my time, people show up two hours early, two hours late, on days they don't have an appointment, and everyone of the clinics I've worked at has been set up such that the doctor has to look for the patient, the staff don't inform you, so if I look for someone and they are not there, I may not come out and look again for a little bit. Once I went to lunch and when I got back the staff told me someone had been waiting for well over an hour, but I had no idea they were there. (Just a bad miscommunication, it happens). I apologized and saw them. In fact, unless someone showed up minutes before I was scheduled to leave, I saw everyone-- yes they sometimes had long waits but if they came the wrong day, or late, or early and someone else was late I'd see them early -- because it was a population that life was hard for, often multiple buses and general life chaos. So the choice is rigidity (which I personally prefer), or seeing people on their terms to best offer them help, but that does mean that some people wait. Oh, and did I mention the 30% no show rate, so that if someone wasn't in the waiting room on time, I didn't know if they were coming 5 minutes late or not at all, so I just took who was there, even if they were early or there on the wrong day, rather than sit for half an hour waiting for the person who's slot it was. But people don't like it if they are 5 minutes late and someone else was taken and the next person is here, so they get moved back to whenever they can be fit in. I have no perfect answer to that. Sometimes I ended up apologizing profusely. The hairstylist, the plumber, the furniture delivery guys, they don't apologize.

Taz said...

I don't know if I'm reading it right, but it does seem that billing the doctor is optional. It's just an option for patients to pursue. I don't know how many would actually bill their doctors for being 30 minutes late. I wait something like 45 minutes to see my doc.

Also, you need to remember that docs have the option to bill patients for being 30 minutes late or forgetting their copay. They don't always do that. But they have that option. You forget your copay, the office refuses to let you in to see the doc, you get a giant bill in the mail. I think, if they take insurance, they only have to give you somewhere between ten and fifteen minutes to show before they cancel your appointment and just charge you for it.

I think this evens the playing field. And frankly, Im starting to get very turned off by doctors and their horrific billing habits. I'm seeing more and more front desks sending me nonsensical bills, claiming my copay is higher than it actually is, etc.

Taz said...

Actually, now that I think on this some more, I wonder if this is to discourage doctors from charging patients who choose to leave after a certain amount of time has passed by claiming they were a "no show" because they left.

What is an appropriate amount of time to pass before a patient can walk out without repercussion? five minutes? ten? an hour? an hour and a half? What if the patient waits an hour, needs to get to work, and asks for their copay back. The front desk could refuse to give it back. And what if they send the patient a bill charging for the full cost of the visit because insurance won't pay for "no shows." You could always tell them no. But what if they send it to collections? That makes everything much more messy.

There should be a certain amount of time, agreed upon, that a patient can say, "The doctor has missed my appointment" and be allowed to take back their copay and exit without fear of being billed or having it sent to collections.

I think it was on The Doctors where a woman said her credit took a hit after not paying a ten dollar copay cuz the doc sent it to collections.

I'm agreeing with this law more and more.

Joel Hassman, MD said...

Keep letting politicians set the tone for health care policy and boundaries. You will get the care you deserve! Based on what uncaring and unsympathetic incumbents do in alleging to be your "representatives".

But, the antiphysician lobby that trolls blogs like this, they just love this political interference to no end!

Taz said...

I don't even think what I wrote was anti-physician. If I had an appointment with a hairdresser, and I walked out after waiting half an hour for my appointment, and she sent me a bill...well I don't think I should have to pay that.

Personally, I have been offered things on the house. Wait was a million years at Starbucks, so guess who got a free coffee.

And even if the physician DOESN'T want to give a free service, they can always give you back your copay and reschedule for next time.

Though I don't know how many patients will demand their copays back and get a free service because the doctor was 35 minutes late.

If the patient is really that aggressive, the doc is probably the kind of person who deserves to be billed for being late. No one is going to charge a kind doc who does everything to fit them in and is generous with them when they miss the bus to their appointment. DInah's not going to start getting a legion of community health patients demanding refunds unless they all hate her, and then that's a separate issue

Taz said...

I know I keep posting (last time!), but I had a flashback to a buddy of mine from a few years back. She was very annoyed at a doctor who kept her waiting for 3 hours (I think that was how long it was). The doc was way overbooked. I think she took a drive, walked around a park, and then came back. When she got in to see him he asked her why she looked so pissed off. She explained what happened. He said, "I didn't know the wait was that long!" He then refunded her copay and asked, "Are we even now?"

Honestly, if you run any business, doc or not, at some point you probably will have to give someone a refund for poor service. It's just the right thing to do.

Dinah said...
This comment has been removed by the author.
Taz said...

"I have never gotten a free coffee at Starbucks because the wait was long."

I'm a lucky one :) The barista thanked me for my patience and it was on the house. Also, I'm from a small town so maybe they can get away with that a little more. Small towns don't always have long waits for coffee.

What I was thinking is that everyone signs in and pays their copay right off the bat. So, if the doc takes 35 minutes then the patient would have to be really aggressive, demand a refund of the copay, and threaten to sue or whatever if they don't get it back. And I just don't know how many patients would do that. Yes, the law says it's free. But I think it would be on the patient to pursue reimbursement. It also protects them from any future bill if they decide to leave cuz of the wait time.

Also, I don't know if they mean billing patients or billing insurance. Because they talk about providing the patient with Emergency verification in order to collect from them, but there is no mention that they have any obligation to the insurance company to do that. It sounds like they get paid by insurance no matter what. It's only the patient that is getting off the hook and requires documentation of extenuating circumstances.

"It would mean patients who came late would be sent home"

That is already standard procedure for doctors. Maybe not for psychotherapists, but the longest I have ever heard is 15 minutes late. If you come later than that you are sent home and charged for the appointment. I called a doc's office recently when I had car trouble and didn't know if I could make my appointment within the 15 min time frame. They didn't bill me, but they cancelled the appointment and told me to come back in another MONTH.

I applaud your decision to not reschedule the guy who blew you off for no legitimate reason.

Joel Hassman, MD said...

Med Chi needs to put out a "political hit" on this moron who proposed this bill. Frankly, I would love to read that if this bill even comes to a vote before the end of this legislative session, EVERY physician in Maryland closes their offices until this anal sphincter politician either leaves office or is voted out of office, whichever comes first.

Could be a long Spring for Maryland patients if physicians finally see the writing on the walls by politicians across America, and decide to let the public know what are the consequences, much less in this pathetic state of Maryland.

Just keep sitting on your hands, colleagues. Makes it easier for people who want to crush medical care walk up and put a gun to your heads!

Anonymous said...

I take back what I said about doctors being late. From now on, I am going to be very disappointed if they aren't as it seems I get more time and don't feel like I am being pushed out the door. Perhaps out of guilt?

Yesterday, the doctor who was very late at the previous appointment was only a few minutes late. I felt like he would hardly wait to get me out of the door unlike the previous appointment.

All sarcasm aside, it really boils down to courtesy. As Dinah infers in her post, it is sadly lacking in this society and no one gives a darn.

Dinah said...

I think the sad thing for me about this bill is that by singling out physicians, it creates a public, adversarial position of the public vs. physicians. Shouldn't we all be on the same side? I, too, have been annoyed at being kept waiting, but by trying to legislate it, there assumes a purposefulness on the part of the physician. There is some unpredictability in medicine...some patients talk longer and some patients come in for a 'routine' visit, but have a long list of problems. Some doctors are disorganized, or trying to cope with their new EMRs, or get waylaid by "you need to call the insurance company to get this medicine approved now" (how do you predictably schedule that one?), or a patient needs to be hospitalized unexpectedly. If every patient showed up precisely on time, never wanted to have any small talk (business only please, you have 10 minutes and don't ask about the doc's new puppy -- my internist has a dog I always ask about, and I've been shown videos on the phone). If every patient was told in advance how long the doctor could spend with them (we do this in psychiatry and it works quite well, if you're late, you time gets truncated and you know this up front)and knew to ask for a longer appointment if there was a complicated issue, and if we could guarantee that the doc would never take a call from a school, a sick child, another physician, a hospital or pharmacist, and would never get stuck in traffic, and if we refused to pay other people for their work if it was not prompt, then I could see legislating this. I believe it was prompted by the legislator's personal frustration.

Joel, I assure you that Med Chi is on it and the MPS will be as well. Oh, but you won't join those organizations...Perhaps you'll write a letter on your own to your delegates, and perhaps to Del. Costa as well?

I just don't like the public statement of physician as adversary. I want my doctors on my side, and if they are running late because of an emergency, at least I know they will run late with my emergency.

I often schedule appointments first thing in the morning so the doctor doesn't have a chance to fall behind, I ask in advance if they run on time (I bring stuff to work on if not), and patients leave the clinic all the time if they are not seen on time...there's no copay, no charge generated. I think it's reasonable to say that if a patient has another obligation and isn't seen within a reasonable time, they should get their copay back and reschedule, but what's reasonable ==15 minutes/30?/90? and does this really need a LAW?

Anonymous said...


I tried that strategy of scheduling the 1st appointment with another physician and this person was over an hour late due to getting tied up at the hospital. Can't win. :)

But in all honesty, as much as I hate having to wait, in the scheme of things, it really is a low priority issue. What matters to me is were my concerns addressed during the visit in a satisfactory manner which is a whole other post.


Maggie said...

In offices where the doctor is routinely extremely late while the patient is required to show up on time or be considered a no-show, there's a pretty adversarial environment being set up by the doctor and/or office staff.

I know that there are plenty of patients who have unreasonable expectations of doctors, but does that make it unreasonable for anybody to have any expectation of basic courtesy? I have no problem with short waits. I have no problem with the occasional longer wait; things happen, and my psychiatrist was good about rescheduling when I stopped at the gas station near my house on my way to my appointment and discovered an antifreeze leak.
On the other hand, routinely running extremely late while still expecting me to show up on time is not reasonable. If I have to expect to sit in the waiting room for an hour or more at every appointment, then there is a problem, and it's not with me.

Simple Citizen, where are you that requires you to see patients who don't pay? I'm required to pay my psychiatrist up front before every appointment.

Joel Hassman, MD said...

Why would I want to join organizations that do not represent the interests of the majority of physicians 95% of the time? But, you are onto something that needs publicized, and that is this seems to be the one random chance moment that Med Chi and MPS might actually fight for a cause that benefits the profession, not just the usual select few. I would suggest ALL physicians in the state offer $100-200 each as an advance to support solely this issue by Med Chi to refute this assault.

By the way, Costa announced he is retiring after this legislative session, so, is this his figurative dump on the profession of medicine before he slinks off into the sunset?

I hope if he sees a doctor in the next year, he is kept waiting more than 30 minutes. Who knows, maybe a SWAT team may have to be involved at that office.

What stuns me still is this guy is a Republican. Well, not that either party raises much hope or faith in me anyway...

Don't forget the person running for a legislative seat in Virginia last year had as part of her platform that ALL physicians HAVE to accept Medicare and Medicaid if they want to practice in America. And that was a Democrat.

Just keep underestimating what the Democrats are planning with PPACA/Obamacare. Still many pages to read to find out what's in it....

L said...

Dinah's offended because she's a physician. If the law was written for hairdressers she wouldn't take issue. What benefits her?

Standard delay - should not be more then 15 minutes. If my doctor is running later then that I expect him to let me know. ABsolutely unacceptable to have it happen regularly.

I had a doctor once who ran about 10 minutes late. I didn't find it a big deal and said something in passing once; she's never been more then a minute late since. She said she just needed it brought to her attention.

If I am more then 5 minutes late, I don't expect my appointment to run over. I appreciate it if it does. This also keeps me inclined to run on time (i have only ever been late twice, due to traffic). My time is not more valuable then my doctors, but her time is not more valuable then mine. If I make time in my busy schedule to come to appointments, I expect that time to be mine.

Basic decency on both sides.

Taz said...

Maggie is right that a lot of us don't get free care. In fact, most of us don't get free care. If you're getting it free then you're supposed to be destitute or chronically severely disabled. If you are a doc and complaining about all the free care you have to give then don't work in settings that require you to give free services.

This isn't about free care. This is about doctors running ridiculously late and costing patients time and often money from all the work they have to miss while waiting. So what if you lost a copay after making a patient wait over an hour for a visit. The patient probably lost that much or more in wages because they couldn't get to work on time because of the wait.

Dinah said...

The word is that this law is going nowhere, it will not pass.

As written, the doctor can't bill the patient or file the claim if the appointment begins more than 30 minutes after scheduled unless there is something called an Emergency verifications services ticket. That is not an existing document. As written, it's not just about the co-pay, it's about filing claims or collecting ANY fee for services begun more 30 minutes after the designated time, even if the service are begun late because the Patient was late.

I am all for common courtesy. This bill has no bearing on my life in private practice (and I left the clinic during my EPIC meltdown) as in over over 20 years, I have never been 30 minutes late. I am rarely more than 2 minutes late.
On one occasion, my phone ate my schedule and someone showed up at my office when I was not there. I apologized profusely, rescheduled the appointment, and did not charge (or bill, fee = 0) for the appointment. I told the patient his time was valuable, it was my fault, and that I would render the service for free because I would bill if he just stood me up. He was very appreciative. However, when he cancelled an appointment at the last minute and I sent a bill, he did not pay it. And, yes, I still treat him, I don't have it in me to quibble. And I have never been more than 5 minutes late to the hairstylist, since I am so sensitive about having my time wasted, I assume everyone else is.

The bill is so ridiculous that it's obviously a joke, not well-thought out, perhaps jotted in anger by an out-going delegate.

But what it does do is make an adversarial statement by the Assembly of us vs. them, and I don't think this is to anyone's good. Perhaps L's way of gently mentioning the wait is a better way to deal with a late physician then crafting a law that says if someone runs late (perhaps with very good reason), that they should get no pay for the service. We don't do that in any other field.

And many people have no copay in public clinics. 58 million people in the US rely on medicaid.

I like my doctors. I don't want them to see me as their adversary, and if I have a crisis, I'd want them to squeeze my emergency in, or spend the necessary time with me, even if it means that I have to wait for someone else's crisis.

Anonymous said...

The wait never bothers me. I grew up waiting on the pediatrician, so I guess it's just something I'm accustomed to. I assume if I'm waiting, it's because they're busy. Last year my PCP was running about 45 min - 1 hour late, and he came out into the waiting room and apologized to those of us who were waiting. He apologized again when he saw me in the exam room. I told him not to worry about it, and that I knew shit happens. I tend to get worked up about a whole lot of issues, but this is one that doesn't bother me in the least. If I'm pressed for time, then I try and schedule one of the first appointments of the day, otherwise I wait along with everyone else.


Tigermom said...

Hi Dinah,

I wanted to point out that many of the things that make doctors run late are, in fact, free care.

The phone calls to get medications pre-authorized and phone calls to call in refills of medications are just two examples. Another is calling someone's other doctors to get collateral information.

All these things get the patient better care, but are not reimbursed and all happen outside the exam room. I know I am leaving out many other examples.

Phone calls to get prior authorization for medications are a favor we do for our patients who have the financial relationship with the pharmacy benefits company. We are not the one who have that relationship. We are doing the patients a favor that the pharmacy benefits companies prevent the patients from doing themselves. No charge.

Calling in refills are doing the patients a favor. They take the same amount of doctor/office time as a conventional appointment. I have to take the message, pull the chart, review whether or not they need the medication - pharmacies routinely ask for refills even when not needed as do patients who forget they have a script in their other purse, call the patient to clarify information, call the pharmacy or even ePrescribe, make notes about all of the above, then refile the chart. Easily 30 minutes. No charge.

Calling another provider requires calling the other doc, playing phone tag, and inevitably, catching up with that doctor after hours on my cell while at a kid's game, or excusing myself from dinner, etc. No charge.

I do not overbook. I see people in much the same way as you do Dinah.

The gyn in my building, on the other hand, triple books. No kidding. I heard his staff discussing it in the elevators. They have a significant no show and random show rate and this prevents them form twiddling their thumbs all day or firing staff.