Doctor's Office Visits - Do You Get Your Money's Worth?
Your Healthcare Providers
Questions about your care
In a little departure from the usual topics and format for my "Spotlight On" hubs, this hub can be considered:
- a social experiment or
- a way to see how people in other parts of the world receive their health care services and how they feel about the way they receive them.
In the United States (because that's where I live), how we receive health care has changed a lot over the last ten years.
Whether or not you have been impacted in any way by Obama's Affordable Health Care Act, you may be seeing a change in your doctor of record, your points of service (private offices vs urgent care or clinics), and/or your level of care and services (actual visit duration and the offered treatment plan).
I hate to start out with a lot of questions, but please be patient (no pun intended) with my polls. Your answers will actually provide other readers with good information so they can evaluate how good (or bad) their medical care and health insurance really is. At the end, I'll post screenshots with the latest survey information (as of January 2014) pertaining to most of the poll questions.
Thank you in advance for your participation.
The size of the city or town (just guess)
Thinking about the doctor you see MOST often, does the city or town where he is located have
Considering where you live, do you think you have a good number of doctors available given the size of the population?
About your insurance
Do you think having medical insurance means you have better access to doctors and medical care?
Question about appointments
Thinking about the doctor you see MOST often, how long do you have to wait to get an appointment?
Question about primary vs specialist appointments
I have better luck getting an appointment within what I consider a reasonable amount of time with my
Question about waiting room time
Thinking about the doctor you see MOST often, how long do you wait in the waiting room to be called back to the exam rooms?
Question about face to face time with your physician (see next question for NP or PA visits)
Thinking about the doctor you see MOST often, after you are placed in an exam room, how much time does the doctor spend with you (i.e. your face to face time with him/her)?
Question about nurse practitioner or physician assistant visits
Thinking about the doctor's office you use MOST often, do you actually get to see the doctor for most visits, OR do you see the nurse practitioner or physician assistant?
Thinking about the doctor you see MOST often, when you are having one on one time with him, are there interruptions with phone calls or asking staff to locate reports that should be in your chart?
Pertaining to the last question, do interruptions make you worry that you are losing time with the doctor?
Question about attentiveness
Thinking about the doctor you see MOST often, do you feel your doctor takes time to listen to you during your office visits?
Electronic records and visits
Thinking about the doctor you see MOST often, has your visit gone electronic where computers are used during the majority of the visit time?
Meaningful use of electronic records
United States Health and Human Services Secretary Kathleen Sebelius asked for one thing to be a key part in President Obama's 2010 Affordable Health Care Law and it was a biggie.
It was written into law as such:
80 percent of physician practices or medical institutions (see chart below for qualifying entities) providing services or treatment in practices
- whose income comes from at least 30% of their patients on MEDICARE or
- whose income comes from at least 20% of their patients on MEDICAID
must convert over to all electronic charting by the end of 2013 and the remainder 20 percent to come into compliance by the end of 2014. While doing this, they must still maintain paper charting for up to ten years or until 2021.
The federal government gave these healthcare providers monetary grants to buy electronic technology for their practices. The money was paid to them out of funds from the Recovery Act of 2009 and the 2010 health care law budget.
Each year since 2009, to keep getting funds (see chart below for how much $$$!!!), these health care providers must show they know how to store the data, then track it, then show they are using it to electronically send prescriptions and referrals to the appropriate entities and obtain lab results and other reports. By actively using technology to show this, they were considered to have demonstrated "meaningful use."
By the end of 2013, more than 291,000 providers and 3,800 hospitals have received incentive payments because they are meaningfully using electronics in their practices.
Our tax dollars at work! Are you mad yet?
Source: USA Today
Click on the following two graphics to enlarge. It shows the percentage of cooperation and what each doctor felt were the benefits of using electronic charting.
Electronic Charting Efficiency & Financial Benefits
Thinking about the doctor you see MOST often, does he spend a large amount of time typing into his computer during your visit time?
Click on the next two graphics to enlarge and see exactly how much money each healthcare provider got. I hope you will be as amazed as I was when I read these amounts.
So how much money did the grants pay each healthcare provider from 2011 to 2016? Wait until you see these two charts!
Aren't the annual payments on those charts absolutely astonishing?
I don't know about you, but with all that money being paid to these doctors, I don't see very elaborate electronics or technology in use at any of MY doctor's offices. What do you see at your doctor's office?
I see each nurse practitioner, physician assistant and doctor partner with a laptop and I see the expected office equipment that I've always seen in my doctor's offices.
But I don't see any state of the art equipment or services in use that utilized between $44,000 and $63,000 of tax free "incentive payments" since 2011 for Medicare (continues to 2016) and since 2011 for Medicaid (continues to 2021).
Our tax dollars at work again! Are you mad yet?
This is who gets the money
Your doctor's employer
Do you know if your doctor works for himself or if he is employed by another entity (hospital, HMO's, part of a physicians group)?
Question about payment for office visits
Thinking about the doctor you see MOST often ...
I often feel my doctor has one eye on me and the other eye on the clock.
Question about point of care
Thinking about your medical needs, which of the following 24 hour facilities do you use when you need medical care before you can get an appointment with your doctor?
Do you feel that a doctor has to give you a prescription for something to remedy the reason for your visit?
By the way
Do you add on to the reason for your appointment with a "By the way, what do you think this is, Doctor?..." OR "Can I get your opinion on this...." after your original reason has been addressed?
Your level of satisfaction
Overall, I am very satisfied with the health care I receive
Hopefully the poll results have given you a little peek into how other readers view the quality of their medical care and the way they receive it.
And oh my gosh, I hope you weren't the first person to answer the polls, so that there's no other results for you to see yet! If you were the first person, please share this hub with your followers so more readers will have participated. The next time you come to this article, the results will have been updated. Click "follow" on this hub so you get email notifications.
Now, why did I ask all those questions? Because I wanted you to voice your opinions but I also wanted to show you various pieces of information I found so you would get as mad as I am!
The electronics grants above is only one case in point. Read on for results of:
- how medical insurance pays your doctor for visits and services,
- how much your doctor respects your time (or not!)
- how you are supposed to be respectful of your doctor's time (or not!)
- how your doctor treats you and for how long at each visit
Merritt Hawkins is a national physician search and consulting firm. They conducted a survey of 1399 medical offices and tracked how long the average patient needed to schedule a NEW patient appointment in 15 of the largest metropolitan cities in the US.
Here are the results of average wait times to get an appointment in cardiology, dermatology, OB/GYN, orthopedics and family practice.
Boston was the longest average wait time overall: 72 days to see a dermatologist, 66 days to get an appointment with a family doctor, 46 days to see OB/GYN, 27days to see a cardiologist, and 16 days to see an orthopedic surgeon. See graphics for more detailed information.
Results of January 2014 Survey
Click to enlarge, it is easier to read
Wait Time vs Visit Time
Have you noticed that your wait in your doctor's office waiting room has changed over the last few years? Is the actual time spent with your doctor in the exam room much shorter now?
If you answered yes, it is not surprising, given the number of patients a doctor has scheduled each day at his office.
If you are like most people, you expect your doctor to take at least a passing interest in your health issues, especially when you want to discuss new symptoms, medication reactions, long term care/treatment of newly diagnosed conditions or possible alternative medications or treatment plans.
With the new medical insurance plans offered through the health law's exchange website, doctors are finding that insurance companies want to pay them less money but want to send them large numbers of patients.
Doctors who are concerned with payments generally provide less actual patient services in person, but are able to charge for using the time and services of other professional (billable) personnel, like EKG technicians, phlebotomists, physician assistants and nurse practitioners.
In a typical fee for service office practice, the doctor is rewarded for seeing patients in bulk. He has to decide how many patients to see in a typical day of office hours, decide how much time he has to spend with each patient so that patients get enough "face" time and the doctor gets enough "billable" time, and then balance this patient load with his out of office commitments (surgeries, procedures, clinic or hospital time, family time) and still be able to run a profitable practice.
How many times have you sat in a doctor's waiting room to hear someone complain about how long they are waiting to see the doctor? Probably more now than ever before.
How many times have you learned that your appointment which was scheduled for say 3PM has another patient scheduled at 3:10PM and yet another at 3:20PM?
With patients complaining of long waiting room times and short actual one on one face time with the doctor, many practices are using nurse practitioners (NP) and physician assistants (PA) to help them see more patients per day which cuts down on patient frustration regarding waiting room wait times, provides time addressing their complaints and allows for the ease of getting a "sooner rather than later" appointment to be seen. This is so prevalent now in the US, that every 3rd or 4th office visit actually results in seeing the doctor whose name is on the door, while all other visits utilize the billable professionals.
Some practices have also used nurse practitioners or physician assistants to creatively (and legally) bill insurance companies for a patient visit. They make a patient see the NP or PA first, who takes their history or reason for visit, and then they make the patient go through the whole thing again when the doctor comes into the exam room to see them.
One of the reasons doctors do this is because they have to document the actual use of the NP or PA in billable hours. Another reason is a doctor is able to charge an insurance company for a different type of visit if it goes over a certain amount of time and if it uses other professional (billable) personnel.
This speaks to time management skills, and the lack thereof, but it also speaks to struggling to meet their bottom line, which is to pay their overhead, pay their staff and still keep their office doors open with what they receive as payments, either from direct pay patients or from insurance stipends.
A stipend is a guaranteed amount which the health insurance company has agreed to pay the doctor (or health care provider) as per patient, per service and per length of visit.
Doctors had to give managed care networks discounts on their office visit rates and to reciprocate, the managed care networks sent more patients their way to make up the difference.
The doctor's regular rate may be $150 for a brief visit of up to 10 minutes but the insurance company will agree to pay the doctor $35 in insurance stipend. An extensive visit of over 10 minutes but up to 30 minutes may pay the doctor $75. An extended visit over 30 minutes but up to 60 minutes may pay the doctor as much as $125 for the visit.
It behooves him to see as many patients as he can for ten minutes each at $35 stipend, so he can reasonably see five to six patients per hour (@$175 to $210 per hour).
By scheduling as such, he can give every patient an appointment, so no patient can say they were denied an appointment date within a reasonable amount of time. The heck with whether they are getting actual care from him personally at the appointment, but they are getting an appointment with "a health care professional."
If he gets enough of these submitted to insurance companies per month, he can afford to take a few extra minutes to
- schedule more new patients who require longer "first visits" to take a history, do a workup and deal with their complaint reason for visit, and
- take more time with certain patients who have terminal diseases or are "handle with kid gloves" types of patients.
Myth vs Fact
Myth: If a doctor accepts a lot of medical insurance plans, he is making a truckload of money.
Fact: If a doctor accepts a lot of medical plans, if he does not have enough patients who are on each plan, he is not making a truckload of money.
Being a doctor used to be looked at as a profession.
Nowadays, it is viewed as a professional business.
If a doctor is not making money, his business will fail. If he doesn't see enough patients in the course of a day or a week, he is not going to make enough money to cover his employee and business expenses (rent, salaries, office equipment) and still have take home pay to support his family.
Add in how much managed care insurance actually pays a physician versus how much he would make with private paying patients and you have a doctor who is going to increase his patient load to accommodate the patients who use a medical insurance as their primary way to pay their doctor.
The only way he will make more money over and above the insurance stipend is if the patient has a copay (varies according to the plan) which he gets to keep. Usually even then, if the doctor has a practice with many patients who have one particular medical plan, he will receive even less of a stipend per patient because he has more participants paying the copay per visit.
This is why you will see each year around Medicare enrollment time (October to November) that your doctor's name is no longer on the provider list. You can get mad at the doctor assuming they are at fault for not taking your insurance any more, but it could very well be the other way around.
The insurance company could have dropped your doctor because he doesn't have enough patients on his practice for that insurance plan to continue keeping him on.
They only make money when they deal in bulk.
So who is really making money here?
The insurance company.
They get it on both ends - from your monthly premium and by not paying high stipends to the doctors who accept their plans as part of their professional "business."
When a doctor removes a health plan from his list of providers, he is not thinking about how many people will be impacted by his decision, because it is "business."
He has to do whatever it takes to keep income flowing to be able to meet his overhead and support his family.
Unless you can afford to pay his going rate, your best bet is to ask for a list of insurance companies he does accept and get the number (not the names) of patients on that plan. Then choose the plan with the highest number of patients.
He is more likely to keep that plan on his list because it is making money for him with copays and by stipends paid by the insurance company.
Time is money
The actual amount of time your doctor spends with you in the exam room or his consultation office has a direct impact on his earnings.
You might be thinking you waited three months for the appointment and took the afternoon off from work, that you now wasted two hours in the waiting room and have a long list to refer to for your appointment.
But the doctor is thinking, "I've only got ten minutes with this patient because I have to see at least three more in this hour in order to keep my earnings in line to pay for my expenses.
If he spends 45 minutes with you and, between you and your insurance, the total for 45 minutes is only paying him between $15 and $30 for example, then in those 45 minutes he could have seen three more patients at ten minutes a piece who may have had insurance that paid more of a stipend than your insurance, with patient copays higher than your copay.
If he wants to make any headway, he will have to conduct shorter office visits, and many more of them.
Patient-centered care is when you are involved in your care.
- Does your doctor listen when you describe your symptoms or complaint?
- Does your doctor interrupt you often or cut you off when you are speaking?
- Does your doctor take the time to make sure you understand information he has given you about your illness?
- Do you leave your visit feeling good about the outcome or generally how the visit went?
- Does the doctor respect your wishes in accepting or rejecting a treatment plan or does he push the treatment at you as the only solution to your illness?
- Do you have enough opportunities to ask questions?
- Does your doctor hurriedly say “Any questions?" either at the end your visit or as a way to end your visit?
If so, do you answer “No” out of habit because you don’t know what to ask or because you see he doesn’t really have any more time to spend with you?
Patient Centered or Physician Directed?
Is the care you receive patient centered or physician directed?
Physician directed basically means the physician does most of the talking, asks the questions, interrupts the patient often and only gives the patient the information he thinks the patient needs and/or is capable of understanding. The doctor decides and/or tells you how it is going to be.
Patient centered means you have a team of health care professionals and you share in the decision making process for your treatment plan and ongoing care. Your doctor invites your questions and answers to participate in your visits and if he is not available, there is always someone who "knows you" whom you will have access to and will be able to provide for your needs. The relationship between a doctor and patient very much determines the outcome of any treatment plan.
The video below explains more indepth the team approach to patient centered health care.
Patient Centered Care Explained
Resource List and Further Reading
Huffington Post - Slideshow of all 52 states in order of longest wait times to shortest wait times.
One doctor blames patients for long wait times - lateness, emergency delays and Oh, by the way!
Overheard while waiting at the doctor's office
Health insurance 101 - how it all works
Blue Cross Blue Shield - what to consider when choosing a healthcare plan.
Your money's worth - what really matters
Making you feel that you have been heard is very important because if you don't get the chance to say what you want to say (with or without referring to notes or a list), you won't feel like you got your money's worth in the fifteen or less minutes it took to get through your long-awaited doctor's visit.
In the end, it is not really the amount of time the doctor spent with the patient, because a short visit can be just as productive as a long visit.
It is how the doctor made the patient feel by the end of the visit as he is walking out the door. That will determine if he will ever return for another visit, or if he will go in search of another physician.
Last opinion poll
Did you find this topic interesting? Thank you for your participation in this important issue.
Rachael O'Halloran. April 26, 2014
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© 2014 Rachael O'Halloran