Help me decide how I should feel about this

[DesertBlossom]

My dd with Type 1 diabetes sees an endocrinologist 4 times a year. In 2010 the office began charging a $100 "office fee" each year because endocrinologists spend a lot of time outside regular office hours fielding calls from parents, writing or phoning in prescriptions or prior authorizations, responding to emails, etc. This is not a "form fee" for filling out school or FMLA paperwork, which would be an additional cost. Let me say that I am very grateful that the doctor is available to talk to outside of office hours, and I understand that this type of doctor does a lot more of this than most. And I LOVE the doctor. I have no complaints about him at all. I wouldn't consider switching doctors.

 

When they first starting charging the office fee we were on state health care (ie: poor) and he just told us not to worry about it. We now have private insurance and have been paying the office fee (a bit begrudgingly) since then. While our income has increased since we were on state health care, we now pay premiums for our insurance and we have copays for prescriptions and deductibles and yadda yadda yadda. At every visit we pay $30 to get an a1c done because it's a finger poke in the office that takes a couple minutes instead of a blood draw at a lab (that our insurance would cover but is a pain to do). Diabetes is an expensive disease, even when you have insurance.  The $100 office fee is just more money on top of it all.  IMO, we are very low maintenance patients. (I say "we" like it's my disease too... but let's face it, I do all the work for it!) I've called the doctor outside of office hours maybe 2 or 3 times in 5 years.  When we need prescription refills the pharmacy or diabetes supplier probably has to call and get information from the office, but that is during office hours.

 

The letter from the doctor about the office fee is almost apologetic. He does not want it to be a hardship for families. For families that choose not to pay it, he promises they still receive excellent care and they've never discharged a patient who didn't pay it.  Sure, we have the money. I mean, if I have to pay it, I'll find the money. But we live on a very tight budget.  I would prefer not to have to pay it. I feel like our medical expenses are high enough as it is. But, I'd also feel like a shmuck if I didn't. In fact, if I didn't pay it, that would probably be the year I needed a lot of "outside of office hours" help as diabetes is just one of those things you can't always predict.

 

Help me here. This may just be the "spent too much money on homeschooling supplies this year and my budget is in a crunch" talking, but it's always kind of bothered me. Again, I adore the doctor.  I have absolutely no complaints about him at all. 

 

 

[Slartibartfast]

That sounds unreasonable to me. I wouldn't be willing to pay an additional fee.

[Jean in Newcastle]

I've never heard of an endocrinologist charging such a fee and we have a lot of diabetics in our family.  I'd talk to the insurance company to see if it aligns with their policies for providers.   All of my doctors handle questions, prescription refills, and e-mails for no additional fee.  If the question is not one they can answer simply, they just ask you to make an appointment to come in to discuss it.  

 

Your insurance won't cover the finger poke?  I guess I'd go to the lab but I'd never heard of a fingerstick for a1c.  Daily monitoring yes, but not the other.  You got me curious and I googled.  I guess you can buy your own A1C kit even.

[hornblower]

It's called concierge medicine and it's creating lots of controversy here in Canada.

 

Personally, I wouldn't pay for this. It feels like a cash grab.

 

http://en.m.wikipedia.org/wiki/Concierge_medicine

[StephanieZ]

I think it is lame. If the doctor chooses to accept an insurance plan, he should accept it without inventing new fees to skim more $$ directly from clients. I'd ignore the fee unless I felt I had no other choice medically. Insurance companies are awful, but the doctor doesn't HAVE to play it that way. 

[Kathryn]

I've never heard of such a thing and I'd be upset. I have heard of charging for after hours calls actually made, but not a yearly fee for everyone for the privilege of going to a doctor that year.

[Um_2_4]

Have you asked your insurance company if they are allowed to charge this? I mean they have a contract to be providers with your insurance, so I assume any allowed extra fees would be outlined in that??? (like filling out school forms, etc)

[Joanne]

$100 a year? It would not bother me and I don't think it is unreasonable.

 

ETA; I do have a child who sees a specialist for a chronic condition.

[Lolly]

I kind of thought the reason the office visit was so ridiculously high was to cover having to field calls and take time outside the appointment to do paperwork and stuff. 

[Lisbeth]

I think it's reasonable and would pay it. I actually would love a full-on concierge doctor.

[GinaPagnato]

I have never heard of a doctor spending time on the phone with a patient or answering emails. It's just not done around here. If i could get that kind of service for $100 per year, i would pay it in a heartbeat!

 

Whenever I've wanted to have a few minutes of phone conversation with a doc I've always had to make an appointment for an office visit, which is an additional charge. I'd gladly pay the fee if I knew the doc would be available via phone or email. And dont forget, your $100 may be helping to subsidize the lower income folks (like you used to be!) who cant pay the fee or their copays, but still want good care.

[stripe]

I take my child to a specialst and I once had a question, left a message, and he actually called me back. What a thrill! I otherwise end up having nurses at the PCP calling me to read what the doctor says, which is annoying.

I understand that $100 a year is not much money, but there is something troubling about it. Of course, I think almost everything is troubling about the American system.

I wonder about whether the insurance company allows such a thing. I think this is included in whatever else you pay. Otherwise charge for whatever actually happens. But honestly, it's normal for doctors or other staff to phone in prescriptions and paperwork. Since when did this require an extra charge?

[Pawz4me]

I have mixed feelings.  My first thought was that $100/year isn't much, most doctors (or their employees) do spend a lot of time on phone calls with patients and pharmacies, etc., etc..  Most people wouldn't miss $8.33/month.

 

On the other hand, I wonder if it's just the top of a slippery slope..  $100 year could quickly become $1,000/year.  Where would it end?  It could become a significant expense on top of our already expensive health care.  And does it mean we're headed for an even more "have and have not" health care system?  This to me seems different from what I've heard about concierge medical groups.  My understanding of those is that everyone who is a patient participates, which means everybody should get (reasonably) equal attention.  I wonder in this sort of voluntary situation could open up a whole can of worms.

 

I understand why you need help deciding how to feel about it!

[Alice]

It's not uncommon for doctors to charge these kind of extra fees. In some cases it's actually illegal as many insurance contracts don't allow it. It's hard for you as a patient to find that out, the insurance contract that matters is the one between the doctor and insurance company, not the one between you and the insurance company. He actually couldn't have charged you if you were on Medicaid or state insurance, that is definitely illegal and not allowed. It might not actually be illegal in this case as he's stated clearly that there will be no repercussions if the fee isn't paid (making it sort of optional). I'm a physician but nowhere near a legal expert in this kind of thing. My understanding is that we can charge extra fees but if not allowed by insurance contract we can't pursue collection of them if not paid. 

 

On the other hand, for many doctors the costs of practicing are rising. The increase patients see in their health care costs aren't being seen as increased income by most individual doctors. It sounds like he is seeing the rise in costs (malpractice, health care for his office staff, overhead, etc) and looking for ways to increase income. Solutions are: see more patients in the same amount of time, go to a concierge practice (something different than what he is doing), or add on extra fees. He can't charge more for what he is doing...insurance sets those charges. (Well, he can charge whatever he wants but insurance sets how much he actually gets paid.) Unlike another business, he can't say "well, my expenses are greater so I need to bring in more so I'll increase what I charge for an office visit" and then see if patients like him enough to stay or choose to go elsewhere with lower costs.  For things like the HgbAIC, it's likely that your insurance sets that you pay a $30 copay for any time you are seen. You may pay $30 for that quick visit but you probably also only pay $30 for a longer visit where the doctor spends a lot time managing your dd's diabetes (or if you don't need those visits, you would only have to pay that much if you did need them). 

 

I'm not trying to justify him charging fees but just explaining what might be behind it. Another thing to consider is that healthcare has gone to paying mostly for what we do and not for thinking. Endocrinologists think a lot and don't do a lot of procedures. Much of their time therefore is not considered valuable by insurance and can't be charged for, or is charged for much less than if there were a dermatologist who saw someone quickly in their office and did a quick wart removal. (As a pediatrician I can charge a lot more for wart removal than for a visit where I discuss complex behavioral issues.) 

 

Finally, a lot of doctors feel like charging for things like phone calls is similar to how most professionals charge for their time. Lawyers charge by the minute for anything they do for their client. My husband, an architect, has to keep track of all his time in increments of 15 minutes in order that they can charge their clients for their time. That includes phone calls, emails, drive time to locations, etc. Most people expect their doctors on the other hand to roll in anything extra they do as far as time into the cost of doing business. 

 

ETA: I think if you really like this doctor, I'd stick with him and just not pay the fee. If they question you about it just state that you don't think it's allowed under your insurance or that you're not able to pay it at this time. If it becomes a bit issue I might switch but if you've felt like you've otherwise gotten good care I wouldn't let this be a reason to leave. 

[readwithem]

Since you really like the doctor, I would go ahead and pay it eventually, maybe after you lose the sting of paying for homeschool materials.

 

My PCP moved to a concierge model about a year ago.  Her annual fee (on top of our insurance copays) is $1350.  I wouldn't blink at paying $100 to be one of her patients.  

[sassenach]

Since you really like the doctor, I would go ahead and pay it eventually, maybe after you lose the sting of paying for homeschool materials.

 

My PCP moved to a concierge model about a year ago. Her annual fee (on top of our insurance copays) is $1350. I wouldn't blink at paying $100 to be one of her patients.

Wow! $1350 is a large amount of money! I guess that pretty much guarantees that only the wealthy will be your patients.

 

All of our specialists and PCPs are available by email and phone at no charge. I'd be bummed to pay, but I probably would do it at $100.

[Mommyof4ks]

I would pay it and not give it another thought. It is so very hard to find docs you like and that work well with your child and their disease, so $100 a year is worth it for a great doc.

[lovinmyboys]

I don't know in your particular case, but I do think in general doctors aren't compensated fairly for things like being on the phone, answering emails, consulting with specialists, doing referrels, being on call, etc. I'm not sure we should expect them to do them for free.

 

I don't feel like I am a high maintainence patient/parent in general, but when my first baby had jaundice the ped. told me it was a borderline number for hospitilization but he would let me just keep an eye on him and call if I was worried. Of course I called and he spent a good deal of time on the phone with me (it was a holiday weekend and the office was closed). The other time I called my sons ear was bleeding and it freaked me out. It was Iike 10pm and our urgent care was closed, so if the ped wouldn't have called me back I would have been in the ER with him and it wasn't an emergency. AFAIK, those are the only two times I called after hours, but I don't think the dr was paid for it at all and I definitely received a valuable service.

[kroe1]

Concierge doctors around here are $2000/yr. They do not take insurance and do not charge for office visits. Your insurance would be needed for labs, supplies, and hospitalizations. For the $2000, one gets unlimited office visits and the doc's cell phone number. While it seems expensive, these concierge docs are getting plenty of business. It is a good alternative for many people.

[Word Nerd]

I don't think it sounds out of line and wish I had the option to email our doctors. I would pay the fee, and if I didn't feel it was reasonable I would find a new doctor. I don't think it would be right to simply opt out of paying the fee, especially if they had waived it for me before. I'm sure all of his patients would prefer not to be charged the fee, so not wanting to pay it isn't relevant in my opinion.

[Lawana]

If you think it is truly a hardship for your family, don't pay and don't feel guilty. I would look at what I would have to give up in order to come up with $100. If it were anything close to necessities, I would consider it a hardship.

 

If the $100 s a hardship, I would consider skipping the fingerstick A1c and getting a blood draw. That would save you $120 a year. Not as convenient, true, but what we had to do in the old days;)

[goldberry]

I think it is lame. If the doctor chooses to accept an insurance plan, he should accept it without inventing new fees to skim more $$ directly from clients. I'd ignore the fee unless I felt I had no other choice medically. Insurance companies are awful, but the doctor doesn't HAVE to play it that way. 

 

Off Topic..Stephanie, when I first looked at your avatar, I thought it was a toilet seat!  It's really an egg though...right???

[plansrme]

I would pay. The doctor only has his time to sell, and if you are taking it up outside of an event for which he is paid, he deserves compensation for that. He is not a charity. Doctors have not charged for such things traditionally, but their reimbursement rates have gone down while their costs of doing business have skyrocketed. It sounds completely fair to me, and I would make paying it a priority.

[Harriet Vane]

I would pay. The doctor only has his time to sell, and if you are taking it up outside of an event for which he is paid, he deserves compensation for that. He is not a charity. Doctors have not charged for such things traditionally, but their reimbursement rates have gone down while their costs of doing business have skyrocketed. It sounds completely fair to me, and I would make paying it a priority.

 

:iagree:

 

I have several friends who are doctors. They live on a tight budget too. The cost of med school plus the cost of doing business means that their living wage is often lower than one might think. I am not saying the doctor is poor; rather, I am saying that he is not rich either. He deserves to be compensated for the hours he is working.

[Catherine]

I don't know in your particular case, but I do think in general doctors aren't compensated fairly for things like being on the phone, answering emails, consulting with specialists, doing referrels, being on call, etc. I'm not sure we should expect them to do them for free.

 

I don't feel like I am a high maintainence patient/parent in general, but when my first baby had jaundice the ped. told me it was a borderline number for hospitilization but he would let me just keep an eye on him and call if I was worried. Of course I called and he spent a good deal of time on the phone with me (it was a holiday weekend and the office was closed). The other time I called my sons ear was bleeding and it freaked me out. It was Iike 10pm and our urgent care was closed, so if the ped wouldn't have called me back I would have been in the ER with him and it wasn't an emergency. AFAIK, those are the only two times I called after hours, but I don't think the dr was paid for it at all and I definitely received a valuable service.

When I used to do primary care, I spent on average 90-120 minutes per day on uncompensated activities like answering phone calls, following up results by phone, and helping people navigate the system. I often gave my number out to patients and never once was it abused. However, I did not publish it in the office as I believed that I had a tiny subset of patients that might not be trustworthy with it.

 

I remember the office managers explaining to us (I was salaried and worked for a large group practice, so was shielded from the nitty gritty of billing and the costs of things) how much they billed for an EKG, and for a 30 minute office visit. Reading an EKG, which took me less than 5 minutes, is better compensated by insurers than an office visit. Alice is exactly right. Thinking is no longer worth much. And our system reflects that IMO.

[chepyl]

My friend's dad does concierge pediatrics. He charges $100-200 a month. Takes no insurance. But he will make house calls so you don't have to haul sick kids into the office.

 

This $100 fee is different and unusual. My best friend is an internal medicine specialist. She get calls and texts even when she is on vacation and it is just a part of her job. She even fields questions from panicked best friends- "do I go to the ER, or can I wait until morning for the doctor to open?" And much, much more.

 

I would not pay the $100 every year. But if I had an extra sick year with lots of after hours calls, I might offer to pay then.

[Um_2_4]

When I used to do primary care, I spent on average 90-120 minutes per day on uncompensated activities like answering phone calls, following up results by phone, and helping people navigate the system. 

 

But you weren't uncompensated, you were paid a salary. This is like teachers who prep and grade outside of regular school hours. It is part of the job.  (ETA: thinking about it I wish I had ONLY spent 90-120 minutes a day while teaching doing prep work/talking to parents, mine averaged 8-10 hours a week at least plus time over the summer that was TOTALLY unpaid).

 

Many offices have moved to an email based system to save time I think. Patient care (calling about results, etc) is just part of the trade, always has been (used to include home visits, ahhhh those were the days). If the compensation per visit is not covering the overhead (staff hours needed, # of staff needed to handle calls, etc) then they need to look at renegotiating with insurance as a whole or streamlining the process in office to save time. I had one dr office that instructed all prescription refills to be faxed (no calls, maybe nowadays it would be email) as that took less time for the staff. Or can they start billing insurance for virtual office visits (via skype or facetime or phone)? Is there such a thing yet? If not,I am sure there will be soon. Maybe that is the solution to covering all those phone calls, etc.

 

Either be concierge or take insurance. I don't think the 2 can mix well. I mean next it will be $200, then maybe in 3-5 years it will be $1000. And if you think the staff doesn't know who pays and who doesn't... wellllll.....and I am pretty sure that those who pay will start getting preferential treatment at some point (ETA: even if it is not written office policy to give those patients priority).

 

Don't get me wrong, I am not anti-concierge doctoring. My MIL actually uses a concierge practice where she lives. She pays $x per year and it includes all office visits and some in office labs/tests. She only has to pay extra for anything that would require a trip to the hospital (xray or inpatient or the like), meds or an outside lab. It works well for her (she has diabetes and asthma, so lots of visits).

[Caroline]

I would either pay or find another doctor. I don't think it is unreasonable.

[TranquilMind]

Concierge doctors around here are $2000/yr. They do not take insurance and do not charge for office visits. Your insurance would be needed for labs, supplies, and hospitalizations. For the $2000, one gets unlimited office visits and the doc's cell phone number. While it seems expensive, these concierge docs are getting plenty of business. It is a good alternative for many people.

It is actually cheaper than insurance use, if you have to go a whole lot for regular conditions (we don't, thank God, but I did see a surgeon I paid directly). 

[StephanieZ]

Off Topic..Stephanie, when I first looked at your avatar, I thought it was a toilet seat!  It's really an egg though...right???

 

LOL, yes, it is a green egg from one of our Ameraucana hens. I needed to replace my internet-skimmed avatar, and figured that one was safe since we took the photo, and I preferred to avoid an actual photo of family. :) That is really funny that it looks like a toilet seat! I guess I shouldn't have done the fancy photo-cropping in iPhoto. :) I was trying to dress it up with the halo effect . . . unintended consequences!

[Lisbeth]

Concierge doctors around here are $2000/yr. They do not take insurance and do not charge for office visits. Your insurance would be needed for labs, supplies, and hospitalizations. For the $2000, one gets unlimited office visits and the doc's cell phone number. While it seems expensive, these concierge docs are getting plenty of business. It is a good alternative for many people.

oo, I want a concierge doc. I'm going to look into it.

[StephanieZ]

But you weren't uncompensated, you were paid a salary. This is like teachers who prep and grade outside of regular school hours. It is part of the job. 

 

Many office have moved to email based system to save time I think. Patient care (calling about results, etc) is just part of the trade, always has been (used to include home visits, ahhhh those were the days). If the compensation per visit is not covering the overhead (staff hours needed, # of staff needed to handle calls, etc) then they need to look at renegotiating with insurance as a whole or streamlining the process in office to save time. I had one dr office that instructed all prescription refills to be faxed (no calls, maybe nowadays it would be email) as that took less time for the staff. Or can they start a billing insurance for virtual office visits (via skype or facetime or phone)? Is there such a thing yet? If not I am sure there will be soon. Maybe that is the solution to covering all those phone calls, etc.

 

Either be concierge or take insurance. I don't think the 2 can mix well. I mean next it will be $200, then maybe in 5 years it will be $1000. And if you think the staff doesn't know who pays and who doesn't... welll.....and I am pretty sure that those who pay will start getting preferential treatment at some point.

 

Don't get me wrong, I am not anti-concierge doctoring. My MIL actually uses a concierge practice where she lives. She pays $x per year and it includes all office visits and some in office labs/tests. She only has to pay extra for anything that would require a trip to the hospital (xray or inpatient or the like), meds or an outside lab. It works well for her (she has diabetes and asthma, so lots of visits).

 

I agree with the argument against the "uncompensated time" perspective! Dh is a vet and owns his practice. Some practices have gone to "production pay" models for their employed vets, paying straight percentages of various fees billed. I know many MDs work on similar models.

 

The upside for the owner and employed docs are obvious, but the downside is an attitude that can appear of "I'm not compensated to do that." -- whether it is staff meetings, safety training/meetings, continuing ed, paperwork, staff supervision, free/discounted care for staff or needy pets or marketing/coupons/etc. . . and of course those time consuming calls to clients that aren't being billed. It really opens an entire can of worms as the employed docs may or may not have the right attitude to still perform all those "uncompensated time" activities cheerfully if they consider it "uncompensated time". The truth is that ALL those things are part of the job. If you do them well, your practice will thrive and grow and those "billable" events will thrive.

 

We have retained a salary/hourly wage structure to avoid that issue with our employed vets, but if we ever went to a production model for vets, we'd be sure to VERY clearly outline ALL those activities that are considered part of the job. The reality is that at the end of the day, you just need to be making whatever salary/wage is fair/acceptable to you and doing acceptable amounts of the various work required. IME, it is not ideal to charge extra fees for those minor "unbillable" events. Charge enough for the routine billable events so that you don't feel compelled to tack on extra charges. THAT is why a doctor exam is $200 (or whatever it is) or a blood draw $60 . . . and lab tests $400 . . . The charges must have built in enough cushion to cover the interpretation/record keeping/etc. I never would question a $300 exam fee at a specialist or a required $200 consult to review labs. . . because I understand the multitude of costs that must be covered by those fees . . . but tacking on extra fees that insurance doesn't cover isn't Kosher in my book. It can get out of hand if clients/patients abuse calling in or the doc's staff is ineffective at controlling those calls . . . and that is something we watch for in our practice. Dh and his employed vets do take calls and spend time on the phone with clients, but they are aware of the bottom lines and have the control to cut off the conversation (or not accept the call, having staff handle it or redirect it to a billed appointment) . . . if the client is abusing their time . . . In the end, it is a balance, but the balance isn't fairly remedied by this kind of fee IMHO.

[Reefgazer]

I sort of get it  - you are paying for excellent service, which is how the market for anything works.  Is it possible to negotiate a slightly lower fee ($50-$75), by explaining to the doctor that it is a financial burden for you and that you try not to call unless it's critical.  At the same time, can you request the lab test rather than the finger stick, so that insurance will cover it?  Perhaps you can save a bit with these 2 modifications. What I would *not* do is just not pay.  Assuming it is not against his insurance contract, your doc has the right to set his office fees as he wishes, and by accepting his care, you agree to pay them (or something negotiated with him in lieu of the full amount).

[Cera]

I would probably talk to the doctor about paying a reduced office fee...maybe half.  

[zoobie]

My old OB/GYN had an $85/yr fee for paperwork and insurance form filing. If you didn't pay it, you had to come in for an office visit to get anything completed, and if the first insurance filing didn't go through, they would not help and would bill you directly.

 

Our ped charges $15-25 per after hours phone call.

 

I'm guessing he and his office manager have wrestled with whether to charge per call (which is inefficient) or do an annual fee. There are pros and cons to each.

 

I think the advent of email and cell phones has made immediacy of response a much bigger issue than ever before. People get really ticked if they can't get an answer RIGHT DANG NOW even if it's not an emergency. It's changed greatly in just a few years. So I bet the doctor is getting a bunch more after hours calls in general, and he doesn't want to discourage the real emergencies from calling. Anyway, it sounds like you would benefit from a per call model rather than an annual fee. As it's not mandatory, maybe pay $25 for each call instead?

[Um_2_4]

I was talking to someone about this and it reminded me of a dental plan we had YEARS ago. I wonder if medical insurance might switch to something like this one day.

Basically we choose a dental office for each person (kind of like a primary care doc) and that office received $x per month, from the insurance, that we were registered with that office. That covered any office visits/cleaning(2x per year)/ xrays( as needed)/basic fillings. We had co pays for crowns, root canals and other more expensive items. 

But basically that dr made $x per month whether he saw us 1x a year or 1x per week. I know on the average that worked well for them and they were motivated to accommodate us and provide good care as we could switch to another office if we were not happy (if we called before the end of a month it became effective on the 1st of the next month).

If an HMO switched to that, then the dr office would make more off some patients and less off others, but they would have a guaranteed monthly $X coming in and it would not be ALL about the billable events. They could still bill insurance for extras, like wart removal, in office blood work, etc.

[Mona100]

Since you go four times a year, I would ask to pay the fee in 4 increments so you can put the fee into the budget. Since I have been budgeting, I always ask if I can split it in half or thirds or what have you so some huge fee won't hurt my budget as badly. 

[DesertBlossom]

Thank you for all your responses. And the wide variety of responses indicates to me that this issue isn't as black and white as I'd hoped, and perhaps my conflicting feelings about it are normal. 

 

As far as the fingerstick a1c vs a blood draw-- it has only been in the last year that DD didn't get completely hysterical over her endo appointments. (which is so weird, but anyway) There's no way I was also going to put her through a blood draw 4x a year.  She has annual bloodwork done as it is, and we include her a1c in that when it comes around. But the other 3 times during the year the fingerstick is worth the $30. I assume the endocrinologist's office makes some money on those as well. When I remember to buy them, the endo also lets me bring in a1c kits that I can by at Costco for 2 for $30 and do those in his office, which saves me a little bit of money.  Also, it is really nice to have immediate a1c results in the dr's office because the endo makes adjustments to her insulin dosage and a current a1c is helpful in determining that.

 

I find myself spacing out endocrinologist appointments to about 3 times a year in order to avoid some of those costs, which I probably shouldn't do. I do feel really confident in my "diabetes management skills."  I make insulin dosage adjustments throughout the year on my own. I haven't called the office outside of a regular visit in probably 2 years. And It's probably been 3 years since I called "after hours." I am a very low maintenance patient. ;)

 

The office does break down the payments. In fact, at each visit they phrase it "would you like to put anything towards the office fee right now?"  

 

Anyway, you all have given me a lot to think about. I appreciate all of your responses! Thank you!

[stripe]

But basically that dr made $x per month whether he saw us 1x a year or 1x per week. I know on the average that worked well for them and they were motivated to accommodate us and provide good care as we could switch to another office if we were not happy (if we called before the end of a month it became effective on the 1st of the next month).

If an HMO switched to that, then the dr office would make more off some patients and less off others, but they would have a guaranteed monthly $X coming in and it would not be ALL about the billable events. They could still bill insurance for extras, like wart removal, in office blood work, etc.

I sort of thought that was how it works in an HMO and why you have a primary care doctor at all, and that the office does get something monthly, and that's why some of them send a letter saying your kid is due for a checkup or whatever. Sort of as described here

https://www.miller-miller.com/content/health/ppo

And therefore they are getting paid to do things like take your phone questions and call/email prescriptions in, and so forth.

[Goldilocks]

Our situation sounds similar to yours. My oldest is type 1. We hardly call for anything as I feel comfortable adjusting his dose myself.

I would be very upset if I had to pay that extra money. We could afford it, but $100 is a lot for us. If that is what it takes to keep this Dr. in business though, you may just need to pay it.

I do feel like now that my son is a teen, we do have more issues. I have called this year more times than the previous 5 years combined!

[maize]

I think I might pay $50 as a compromise, along with a note explaining that we appreciate all the Dr. does for our family but money is tight.

[elegantlion]

But you weren't uncompensated, you were paid a salary. This is like teachers who prep and grade outside of regular school hours. It is part of the job.  (ETA: thinking about it I wish I had ONLY spent 90-120 minutes a day while teaching doing prep work/talking to parents, mine averaged 8-10 hours a week at least plus time over the summer that was TOTALLY unpaid).

 

 

 

This is my thinking, many jobs require hours of effort behind the scenes. Ex was a self-employed carpenter for many years. There were periods of time when all he did was work and field calls from clients in the evenings and weekends. I'm sure most people would cry fowl if your home improvement guy started charging extra for phone calls and questions outside of regular office hours. 

 

The concierge model sounds intriguing though, and would appeal to me in the right situation.  

[LMV]

I agree with the argument against the "uncompensated time" perspective! Dh is a vet and owns his practice. Some practices have gone to "production pay" models for their employed vets, paying straight percentages of various fees billed. I know many MDs work on similar models.

 

The upside for the owner and employed docs are obvious, but the downside is an attitude that can appear of "I'm not compensated to do that." -- whether it is staff meetings, safety training/meetings, continuing ed, paperwork, staff supervision, free/discounted care for staff or needy pets or marketing/coupons/etc. . . and of course those time consuming calls to clients that aren't being billed. It really opens an entire can of worms as the employed docs may or may not have the right attitude to still perform all those "uncompensated time" activities cheerfully if they consider it "uncompensated time". The truth is that ALL those things are part of the job. If you do them well, your practice will thrive and grow and those "billable" events will thrive.

 

We have retained a salary/hourly wage structure to avoid that issue with our employed vets, but if we ever went to a production model for vets, we'd be sure to VERY clearly outline ALL those activities that are considered part of the job. The reality is that at the end of the day, you just need to be making whatever salary/wage is fair/acceptable to you and doing acceptable amounts of the various work required. IME, it is not ideal to charge extra fees for those minor "unbillable" events. Charge enough for the routine billable events so that you don't feel compelled to tack on extra charges. THAT is why a doctor exam is $200 (or whatever it is) or a blood draw $60 . . . and lab tests $400 . . . The charges must have built in enough cushion to cover the interpretation/record keeping/etc. I never would question a $300 exam fee at a specialist or a required $200 consult to review labs. . . because I understand the multitude of costs that must be covered by those fees . . . but tacking on extra fees that insurance doesn't cover isn't Kosher in my book. It can get out of hand if clients/patients abuse calling in or the doc's staff is ineffective at controlling those calls . . . and that is something we watch for in our practice. Dh and his employed vets do take calls and spend time on the phone with clients, but they are aware of the bottom lines and have the control to cut off the conversation (or not accept the call, having staff handle it or redirect it to a billed appointment) . . . if the client is abusing their time . . . In the end, it is a balance, but the balance isn't fairly remedied by this kind of fee IMHO.

 

The insurance saturation for veterinary medicine and human medicine is very different.  Physicians who have contractual relationships with insurance companies have an agreement on what fees will be paid for the service and often that fee is far below the market value of the service.  So your point that they should just charge more for the "billable" service is often not applicable.  The insurance contract likely has already eroded a significant chunk of the profit margin.  

 

Of course, physicians do not have to contract with various insurance companies, and I think we're going to see more of that in the future.  The pediatrician our children see does not accept or bill any commercial private insurance.  She does accept Medicaid because she feels that children who qualify for Medicaid are not usually in a position to pay out of pocket and then get reimbursed.  She expects payment in full at the time of service and provides an itemized receipt with the applicable service codes.  We then submit that paperwork to my husband's insurance and get reimbursed at their out of network rate.  This allows her to set a fee for the service that she feels is reasonable and requires the patient to pay her fee because she is dealing with them directly and has no contractual agreement with their insurance. It also reduces a big chunk of her overhead because she no longer has to submit claims to the insurance, resubmit claims to the insurance, or wait six months or more for a valid claim to be paid.  We do pay more out of pocket than we would if we used an in-network pediatrician but the quality of care is far superior and worth it.

[zoobie]

This is my thinking, many jobs require hours of effort behind the scenes. Ex was a self-employed carpenter for many years. There were periods of time when all he did was work and field calls from clients in the evenings and weekends. I'm sure most people would cry fowl if your home improvement guy started charging extra for phone calls and questions outside of regular office hours.

 

The concierge model sounds intriguing though, and would appeal to me in the right situation.

The home improvement guy doesn't have to respond within a certain time frame. He can turn off his phone and sleep like a baby all night. And he can bid higher on the jobs for high maintenance people who will take up more of his time. BIL certainly does! The doctor has neither of those luxuries with an established patient. If he misses an emergency or gives the wrong advice at 3am, he is legally/ethically/morally culpable for the result. Any other professional who would incur liability for his advice would be charging you by the minute for every call, no matter what time. And their advice generally can't kill you.

[LMV]

My dd with Type 1 diabetes sees an endocrinologist 4 times a year. In 2010 the office began charging a $100 "office fee" each year because endocrinologists spend a lot of time outside regular office hours fielding calls from parents, writing or phoning in prescriptions or prior authorizations, responding to emails, etc. This is not a "form fee" for filling out school or FMLA paperwork, which would be an additional cost. Let me say that I am very grateful that the doctor is available to talk to outside of office hours, and I understand that this type of doctor does a lot more of this than most. And I LOVE the doctor. I have no complaints about him at all. I wouldn't consider switching doctors.

 

When they first starting charging the office fee we were on state health care (ie: poor) and he just told us not to worry about it. We now have private insurance and have been paying the office fee (a bit begrudgingly) since then. While our income has increased since we were on state health care, we now pay premiums for our insurance and we have copays for prescriptions and deductibles and yadda yadda yadda. At every visit we pay $30 to get an a1c done because it's a finger poke in the office that takes a couple minutes instead of a blood draw at a lab (that our insurance would cover but is a pain to do). Diabetes is an expensive disease, even when you have insurance.  The $100 office fee is just more money on top of it all.  IMO, we are very low maintenance patients. (I say "we" like it's my disease too... but let's face it, I do all the work for it!) I've called the doctor outside of office hours maybe 2 or 3 times in 5 years.  When we need prescription refills the pharmacy or diabetes supplier probably has to call and get information from the office, but that is during office hours.

 

The letter from the doctor about the office fee is almost apologetic. He does not want it to be a hardship for families. For families that choose not to pay it, he promises they still receive excellent care and they've never discharged a patient who didn't pay it.  Sure, we have the money. I mean, if I have to pay it, I'll find the money. But we live on a very tight budget.  I would prefer not to have to pay it. I feel like our medical expenses are high enough as it is. But, I'd also feel like a shmuck if I didn't. In fact, if I didn't pay it, that would probably be the year I needed a lot of "outside of office hours" help as diabetes is just one of those things you can't always predict.

 

Help me here. This may just be the "spent too much money on homeschooling supplies this year and my budget is in a crunch" talking, but it's always kind of bothered me. Again, I adore the doctor.  I have absolutely no complaints about him at all. 

 

If the fee is truly a hardship then don't pay it.  If it isn't a true hardship but isn't a spending priority then you can also not pay it.  This isn't the decision I would make but it might be the right decision for you/your family and I am not in any position to judge.  I will say that I have a special place in my heart for pediatric generalists and sub specialists who accept medicaid because they believe it is the ethical and moral right thing even if the absolutely wrong thing for their practice's financial bottom line.  At the same time I realize that something has to give and they will have to cross subsidize somehow. 

[elegantlion]

The home improvement guy doesn't have to respond within a certain time frame. He can turn off his phone and sleep like a baby all night. And he can bid higher on the jobs for high maintenance people who will take up more of his time. BIL certainly does! The doctor has neither of those luxuries with an established patient. If he misses an emergency or gives the wrong advice at 3am, he is legally/ethically/morally culpable for the result. Any other professional who would incur liability for his advice would be charging you by the minute for every call, no matter what time. And their advice generally can't kill you.

 

Not if he wanted business, he didn't turn off the phone. Yeah, he's been out at 3 am in rainstorms putting tarps on roofs because of shoddy workmanship of the previous carpenter. Agreed that it's not life or death, but on many projects, emergencies did arise and his liability was on the line as well. And you never really know who the problem customer will be until you get into a job. 

 

I guess my point is that some people will give a doctor or medical professional a pass on extra fees, not questioning it simply because they're a professional. Yet, a professional of a different level is just assumed to have to suck it up and deal with "off the clock" work as part of the job. 

[Lolly]

The insurance saturation for veterinary medicine and human medicine is very different.  Physicians who have contractual relationships with insurance companies have an agreement on what fees will be paid for the service and often that fee is far below the market value of the service.  So your point that they should just charge more for the "billable" service is often not applicable.  The insurance contract likely has already eroded a significant chunk of the profit margin.  

 

Of course, physicians do not have to contract with various insurance companies, and I think we're going to see more of that in the future.  The pediatrician our children see does not accept or bill any commercial private insurance.  She does accept Medicaid because she feels that children who qualify for Medicaid are not usually in a position to pay out of pocket and then get reimbursed.  She expects payment in full at the time of service and provides an itemized receipt with the applicable service codes.  We then submit that paperwork to my husband's insurance and get reimbursed at their out of network rate.  This allows her to set a fee for the service that she feels is reasonable and requires the patient to pay her fee because she is dealing with them directly and has no contractual agreement with their insurance. It also reduces a big chunk of her overhead because she no longer has to submit claims to the insurance, resubmit claims to the insurance, or wait six months or more for a valid claim to be paid.  We do pay more out of pocket than we would if we used an in-network pediatrician but the quality of care is far superior and worth it.

 

Eh, the fees are still high enough to cover doing paperwork and phone calls. My dd's dr charges $350 for not even 15 minutes of his time at her office visit. The insurance agreement lowers that to about $250. That is plenty of padding. 

[maize]

Eh, the fees are still high enough to cover doing paperwork and phone calls. My dd's dr charges $350 for not even 15 minutes of his time at her office visit. The insurance agreement lowers that to about $250. That is plenty of padding.

It is true that most doctors are not in the poor house, but do remember that the fee for an office visit also needs to go towards office overhead--rent, reception and nursing staff, etc. The Dr. does not pocket $250.

[Lolly]

It is true that most doctors are not in the poor house, but do remember that the fee for an office visit also needs to go towards office overhead--rent, reception and nursing staff, etc. The Dr. does not pocket $250.

A thousand dollars an hour covers a whole lot. I realize it doesn't just go in the doctor's pocket. But, it does provide enough of an hourly wage to cover everyone in the office, plus the paperwork and phone time. The padding IS there despite insurance negotiated prices.

[Rockhopper]

As a type 1 mom myself, your post caught my eye and got me thinking.

 

We've moved 4 times since my son's diagnosis 6 years ago.

 

Our first ped endo was awesome. The next two? Enh. Overworked, overwhelmed. They were nice, but we had good control, ds was in good physical shape, decent A1Cs so it was kind of a pat on the head visit.

 

The third location? Only one ped endo, not taking new patients. Ds didn't get to see anyone for over 9 months. At that point I gladly would've paid $100 just to get him seen!

 

We're now in a new location and we have a "diabetes management center". On-site there's a psychologist, nutritionist, CDE and docs! I don't love, love, love the doc -- but what an increase in quality of care! I'm hoping for some actual education to happen again -- how to prepare to live on your own, psychological adjustment to young adulthood w/ type 1, that kind of thing. May be wishful thinking, but..

 

I think the point of my ramblings is this: the $100 may not be fair or even right, but it sounds like your dd has good quality of care. And that's a lot harder to come by than most folks outside our type 1 world probably realize, and might be worth the price. 

 

OTOH, if you can't afford it and he will make an exception, I'd say use it --that's why he has it! Let him know you can't afford it, and take him a plate of chocolate chip cookies instead. :-)