Monday, January 21, 2013

Fee for advice

This is a topic I wrote about several years ago on Mothers in Medicine, but I've decided to revisit it here. (Because it's my blog and I'll do what I want to!)

When my older daughter was two, she woke up one Sunday morning and one of her eyes was really swollen. This had never happened to her before and I was concerned, so I called our pediatrician's office (it was a large, university-affiliated practice). I was met with the following message:

Due to the high cost of after hours phone calls, all calls to the advice nurse after regular business hours will be charged a $20 fee.

At the time, I was a resident and my husband was a student. I thought about the $20 and decided her eye didn't look that bad and decided not to pay the $20.

In retrospect, I'm still pissed off. I think this is a terrible practice. I can understand charging parents who call excessively a copay, but I don't feel like it's fair to put a parent in the position of deciding if their kid's swollen eye is worth the $20. And what if my kid had a health problem that required more monitoring? Would I just be screwed and have to keep paying $20 every time my kid got sick and I wasn't sure whether to go to the ER? What if it's the middle of the night and I need to give my kid some Tylenol??

I've used two different pediatrics practices since then and neither charged a fee for after-hours advice. (My current practice actually has an amazing email line that I use frequently for rashes and appointment scheduling.)

When I initially posted this, several people vehemently disagreed with me and said I was wrong. And this bothered me because I'm never wrong. (Just kidding! (Or am I? (Yes, I am.)))

The biggest argument against me was that other people aren't expected to give advice for free, so why should doctors? Also, that if there's no $20 charge for calls, that cost will be otherwise worked into your bill anyway. Also, I was told I just "didn't get it" because I never ran a private practice.

I'd say that, yes, I'd rather the charge for all services go up than have to make a decision about whether my child's health problem is bad enough to call the pediatrician. And I say this as a doctor, who is probably better at making these decisions than the average person. If I were a pediatrician, I'd be a little frightened about discouraging parents from calling when there might be something serious going on. On my Tylenol post, a resident commented she didn't even trust parents to correctly give their kids Tylenol!

And there are tons of professionals who will talk to you on the phone or on off-hours for free. If I have a problem with my cable and call the company at 9PM, they don't tell me that I'm going to have to pay $20 to talk to someone about it. When I have an after-hours plumbing emergency, I don't have to pay $20 to talk to the super. Part of what is generally expected is for people to be able to call their medical practice if they need advice.

Do people abuse it? Yes, of course. But I'd say to deal with the abusers individually rather than punish everyone.

51 comments:

  1. I can see why some practices charge a $20 fee, but I completely agree that it would discourage people from calling when they probably should. I'd also rather have them charge me more overall than pay the fee separately. I'm not sure all the details of whether that is legal though, particularly if you serve public aid patients.

    ReplyDelete
  2. This is a tough one and I really don't know the answer---I think the real answer would involve thinking outside of the box of our current medical payment model. On the one hand, yes, we want to provide emergency care for our patients and for them not to have to worry about a fee. On the other hand, its not just "a few patients" that abuse this...pretty much all of them do. And this isn't just after hours, it is patients calling for someone to go over their lab results or to rehash whatever was said in a clinic visit (sometimes going over literally everything again because a family member wasn't able to come)...I spend hours upon hours of time on the phone with patients, all of which is unpaid work. There isn't really a way to "charge more overall"---insurance companies have negotiated a rate, and medicare payments are set nationally. Where will the money come from? Nowhere. This unpaid work was definitely a cause of burnout from clinical work for me---not being reimbursed for my time and expertise made me feel undervalued. Yes, you can call Comcast at 9pm and speak to someone, but not the manager or even the technical specialist. You talk to the admin or some call center employee. And the plumber is happy to talk to you because he can then add that cost into what he charges when he comes over, as no external forces are setting plumbers' hourly rates. Also the plumber has absolutely no liability if he is tired and gives you crappy advice on the phone at 11pm or even if he decides not to call you back.
    Our division has talked about how we can charge for phone/email advice but haven't come up with a suitable method yet. In reality, insurance should reimburse it, often times a phone call can prevent an ER visit or even an office visit and overall save them money, but insurance has not been known to be reasonable.

    ReplyDelete
    Replies
    1. Even though I don't do clinic now, when I was a resident, I used to take after-hours calls from clinic patients, and I thought the questions were mostly fairly reasonable. Maybe they had some sort of filter I wasn't aware of.

      Is it really true that "pretty much all" patients abuse this? My current pediatric practice has an after-hours line that's free, and in three years at the practice and two children, I literally only called once after hours.

      I just don't like the idea of patients having to decide if their question is important enough to talk to a nurse based on a pretty hefty fee. It's not about the money so much as the influence on decision-making and the chance that something potentially serious could get ignored. If the practice wanted to charge a yearly out-of-pocket fee to each patient in order to finance the call line, I would be less bothered by that.

      Delete
    2. On the other hand, I know a private practice doc who gives his patients his private cell number, and he has very few phone calls made after hours. It's a matter of the patient population, I think.

      Delete
    3. During my pediatric residency "mommy call" was torture. The calls started at 5:01 and went on all night for minor things (ie diaper rash). None of them ever followed up in clinic when asked to.

      Delete
  3. There is a CPT code for telephone calls. So far Medicare/Medicaid and almost all private insurers have chosen to value them at $0.

    If a doctor is contracted with your insurer or Medicare/Medicaid they are not allowed to increase the bill for your office visit.

    After hour phone calls are priced into the cost of your rent/cable bill so those analogies are irrelevent.

    Office visit bills are reimbursed to cover that visit and work directly related to that visit(including calls about results of testing) but do NOT cover other unrelated phone calls.

    Many(most?) practices do not charge for phone calls currently but as overhead continues to go up and reimbursements from insurance/Medicare/Medicaid continue to not go up, revenue will have to be made up somewhere.

    JustADoc

    ReplyDelete
    Replies
    1. Yeah -- Bottom line is that people keep expecting doctors to provide more services for less money. Yay.

      Delete
    2. I find it telling that even a doctor, likely personally aware of some of the financial challenges faced by doctors running a practice, expects doctors to provide more services for less money.

      And she expects this of pediatricians, one of the field's worst paid groups (and probably with one of the highest rates of after-hours calls given the nature of anxious/worried parents), at that!

      If a doctor isn't willing to pay another doctor for services rendered, then how can I expect laypeople to appropriately value our services?

      Delete
    3. It's true that most practices do NOT charge for this service, so that makes the price much harder to swallow. At this point, charging will probably cost a practice money, because many patient would likely leave the practice.

      First of all, I do not expect the pediatricians themselves to return calls. A nurse would be fine.

      Second, I think there's a difference between people who call doctors and people who utilize other services. When you're calling Verizon, you know how big an emergency you're having. But in medicine, many people *don't* know. In that Tylenol post I cited, a pediatrics resident said that lots of mothers can't even accurately assess if their kids are febrile and need Tylenol. If we start putting in this $20 pay for calls, the frivolous calls will be reduced, but a lot of really important calls will be missed. Are we, as physicians, really okay with that??

      Also, I spoke with Dr. Grumpy, the king of ridiculous pages, back when I first posted this, and he felt it was absolutely unethical to charge for these calls from patients. Hopefully, he'll weigh in here.

      Delete
    4. I think it depends on the payment model of each practice -- The salary of the nurse answering the calls has to be factored into the budget, and if you're working strictly fee-for-service and are not able to bill the insurance company for such calls, then that money has to come from somewhere. I don't think that its fair to say that it's the physicians' "ethical duty" to swallow that cost and essentially provide a medical service that has some cost associated with it for free. Do you provide after-hours services without any compensation? It's not as if lives are being lost due to this. If people are really concerned about their kids, they have the option of taking them to the ED. I think the main purpose of these after-hours lines are more for convenience of the parents -- and as a way of deterring unnecessary trips to the ED -- rather than the indispensable lifeline you're making them out to be.

      Also, as for the usefulness of a nurse-operated helpline, I can say that up here in Canada, many provinces have a free 24-hour health line operated by nurses and frankly, they just tend to tell everyone to go to the ED - particuarly for infants and young children. Its a bit irritating to have to see all these completely non-emergent patients in the ED who are only there because the health line told them to come in, but on the other hand, I understand it. There is probably only so much a nurse can do over the phone, partly for liability reasons and partly because sometimes you just have to eyeball the kid yourself. In your example, I can pretty much guaranty that the nurse would have told you to go the ED -- what if it's a periorbital cellulitis? -- even though I assume from your story it was not an emergent issue.

      ER MD

      Delete
    5. oops -- i mean 'orbital cellulitis'

      ER MD

      Delete
    6. During my one after-hours call to a nurse, I got excellent advice. My daughter had a high fever and headache, the nurse gave me a dosage and schedule for Tylenol, and an appointment first thing in the morning. I'm sorry the helplines where you are aren't as helpful.

      I think saving people from ER trips is a very valuable service, and recommending them even more valuable. While lives may not be saved by the vast majority of after-hour calls, it probably happens sometimes. If you have ever read AnonDoc's blog, he seems to frequently get late calls from patients who have underestimated the seriousness of their condition and needed to be told by a professional to go to the ER ASAP. If there were a $20 copay for calls... well, who knows?

      Delete
    7. I think after-hours services -- when staffed by doctors, as opposed to nurses, like the blog you mentioned -- are a valuable service, and deterring unnecessary trips to the ED is also important. In fact, many practices in Canada are starting to encourage physician-staffed after-hours lines (with compensation of course). It just has not been my experience that a nurse-staffed health line would accomplish the goal of deterring unnecessary ED trips. But again, if the clinic's fee model allows for that service to be provided, like the one in your current pediatric clinic, then yes, of course it's more convenient for patients.

      What I disagree with is what you were implying by stating things like:

      "If we start putting in this $20 pay for calls, the frivolous calls will be reduced, but a lot of really important calls will be missed. Are we, as physicians, really okay with that??"

      "It's not about the money so much as the influence on decision-making and the chance that something potentially serious could get ignored."

      is that somehow physicians are shirking their ethical duty and putting these childrens' lives at risk but not offering an after-hours service (when their fee schedule likely does not make this possible). I would say if there was a $20 copay, then parents would likely use their own judgement and decide to either 1) watch and wait or 2) go to the ED (which as your example illustrates, is exactly what the nurse would tell them to do). My impression of what brings parents to the ED is that they tend to OVERestimate by a great deal the seriousness of their kid's illness. Again, it would be great to avoid unnecessary trips to the ED and make things more convenient for parents, but I disagree that physicians have a moral obligation to provide such a service at their own cost.

      And I'm from Canada. The thought of charging anyone for anything is a bit foreign to me, but this -- without getting into it -- is a particular feature of the U.S. multi-tiered healthcare system, and I don't think it's fair to pass the costs on to the physicians themselves by stating that it's part of their "duty".

      ER MD

      Delete
    8. What's interesting to me are the behavioral economics issues. If you charge $20 for a phone call, how many people decide not to call? Which people are these? Which calls don't get made? What if you charge $5? What if you could come up with a dollar amount that incentivised each patient to make more thoughtful decisions about what they called about.

      Not to mention, since doctors often can't charge for these services (because they serve public aid patients), what is the role of "waiting time" as an incentive to the patient. Having to wait on hold, or having to page a nurse and wait for him/her to call you back certainly isn't free.

      I know some people who study this in the ED... but I can't think of a study that has looked at this for a help line. Ergo, I don't think any of these issues are settled -- i.e. nobody has actually measured these effects in a controlled experiment. As a researcher (who loves these sorts of questions) I find it completely fascinating.

      Delete
    9. That's a really good point, OMDG. I wish someone would study it and find out how likely it is that a serious condition gets missed, or how much a $20 charge discriminates against lower income patients.

      Delete
    10. To OMDG:

      They actually have done studies on the subject of "co-pays" -- what in Canada would be roughly equivalent to user fees or extra-billing (i.e. charging patients in addition to getting a fee for a specfic service that is already deemed "essential" and therefore covered by the provincial health plan), and have found that these do not really save costs or deter unnecessary usage of the system, and tend to dissuade the poorest (and sometime sickest) people from accessing help. I don't know the details of the specific studies (I suspect they are more likely to be economic analyses rather than RCTs), but that's the basic upshot of these studies. Again, without getting into it, there are many many differences between the multi-tiered and single tiered systems.

      As for help lines, I haven't seen any evidence that access to Telehealth services improves appropriateness of ED visits, improves morbidity/mortality, or is any better than the parent's own gestalt (in terms of recommending ED visits) for the really sick children.

      ER MD

      ER MD

      Delete
  4. I know this post was serious, but it made me laugh because I worked for a long time for a large law firm...and they are probably the only professionals who charge for EVERYTHING at exorbitant rates. Oftentimes I would add up the total hours billed by a single lawyer and find that he had "worked" a 30-hour day. A physical impossibility you would think, but apparently not. (One lawyer regularly charged clients for "thinking" about their case while going to the bathroom.) Clients gripe about this tendency to charge for everything, but are not surprised by it. There should be a way to give the people taking calls some autonomy, so that if you don't abuse the system and your question is a simple one, they could waive the fee or substantially reduce it so they don't have to put a person in the position of deciding they can't afford it...and perhaps jeopardizing their child's health because they should have asked. But the system doesn't permit flexibility. And the point the other posters make about unreimbursed time is a valid one. The answer is apparently for everyone to go into law I suppose, where there is no such thing as unreimbursed time.

    ReplyDelete
    Replies
    1. I don't think every lawyer works this way... what about the ones who just take a cut of the settlement?

      Delete
    2. You're right. I was talking about lawyers who bill at an hourly rate, not those that do contingency work. We did very little contingency work (probably because it wasn't relevant to our practice areas rather than because it wasn't remunerative enough).

      Delete
    3. A lot of lawyers don't bill for everything they do, even those who bill by the hour. Many write off a portion of their time each month.

      Delete
  5. I'm torn also by this. Especially for after hour calls. Am I calling a nurse? Typically a nurse is not the owner/partner of the practice so compensation would be required. My insurance has a 24-hr nurse hot-line. Called it once about 5 yrs ago (hubby thinks 5 hrs of fever requires ED visit...such a sap concerning his little girls)and didn't find it very helpful so never bothered again. Now my girl-friend has called peds during office hours and gotten follow-up instructions based on changes since visit earlier in the week. Yes, that took time from the nurse & doc but it's continutity of care. So I guess (taking me long enough) if it's follow-up no charge but if it's after hours, no issue...send me a bill.

    ReplyDelete
  6. I disagree, I think having to pay for advice is something that should happen. Maybe not $20 but perhaps $5. As it should be just enough to make people think about why they are calling and discourage people calling for frivolous things, but not enough that someone concerned about something would balk at it.

    Fizzy - for your idea of only making those that abuse it pay for it. How do you decide; without getting sued for discrimination?

    ReplyDelete
    Replies
    1. You can leave a message on the line that says: "If you are calling for any of the following reasons (med refills, fever less than whatever, etc), you will be charged for your call."

      Also, this service brings in money, but considering you likely pay an on-call nurse by the hour, not by the call, the amount of money it brings in probably does not correspond with the cost. No matter how many people call, you have to pay the nurse the same, right? I mean, if it was a slow night and the nurse got paid $20 for being on call the entire night, that would not be acceptable.

      Delete
    2. But then if you say "fever less than --" you might still be missing a lot of very sick children who just happen to not have a high fever. Babies and young children (and anyone, really) can have a meningitis or severe sepsis and have just a low-grade fever, or be hypothermic, so that wouldn't work either as a way of filtering out the "abusers"

      ER MD

      Delete
    3. ER MD: I'm baffled. You just named a situation in which a parent might be fooled into thinking their child is not that sick and a good helpline could save a life. Yet according to you, that's not possible. Which is it?

      Delete
    4. Did your pediatrician never give you any guidance on when to bring a young infant to the ER? I find it is routine among my colleagues to give young mothers guidance concerning what symptoms (including what levels of temperature) are concerning enough to warrant a visit.

      Delete
    5. No, they didn't, Anon. Or maybe it was in the stack of paperwork they handed me, that I'm sure every parent reads through in great detail.

      That practice actually made me call three times (all daytime calls, no charge) about my one year old daughter's high fever. After two days, the nurse finally growled at me, "If you're so concerned, we'll see her!" Brought her in and she had a double ear infection. The pediatrician was concerned enough that he made us come back the next day for a follow-up. In retrospect, not my favorite practice.

      Delete
    6. Regarding my above comment -- I was illustrating that there is no way to "triage" a helpline so as to avoid abusers like you had suggested in your blog (much like how we can't turn people away at triage in the ED-- something might get missed). Once you open up a helpline, you have to take all comers ("abusers" and non-abusers), which -- depending on your fee model -- may take too many resources and become too costly, which was the case in your previous pediatric practice as they had stated in their message "Due to the high cost of after-hours calls...". Remember that a university-affiliated practice does not run under the same fee model as a private practice, and typically works under a(suprisingly) strict budget.

      ER MD

      Delete
    7. Clearly there is a way to triage though, maybe simply saying that you "may" be charged for non-serious calls such as simple rashes or low-grade fevers or just wanting someone to review the details of an earlier visit (as someone commented above). I don't know how things work where you are, but in the ED where I am, they DO triage patients in that not everyone who comes to the ED actually goes to the ED... some are instead given appointments with urgent care the next day. And when I call the nurse helpline at my current practice, they have never told me to go to the ER.

      As OMDG commented above, I would like to see a study on how many seriously ill children would go untreated in a model like that, and it definitely discriminates against lower income families.

      Delete
    8. Well, as I stated above, they wouldn't "go untreated". Their parents would simply take them to the ED. There is no evidence to suggest that the helpline is any better than a parent's own instinct when it comes to the really sick kids.

      ER MD

      Delete
  7. $20 or $500 - The call line is basically saving you a trip in your PJs to the ER. Pretty cheap. And honestly, the money rules out the people just calling because of some lame reason. I am a doc and I personally take these calls. People appreciate that they are getting me on my sunday and I am happy to help them. But frankly, that small a price really cut down on the abusive type calls. I can always wave the fee if I feel like it was my error or something really basic.

    ReplyDelete
  8. First, every time I call my lawyer, he bills me. I expect it. But although I wish I could do the same, I have never worked in a place where I could charge, not even in private practice. Insurance companies don't pay for it and some will actually stop working with you if you bill in this way. I would think only cash-only practices could get away with this. Also, the option to waive the fee as mentioned above would probably be what happens to you anyway if you called with something that resulted in a visit later and told them you are a doctor.

    ReplyDelete
  9. completely off topic - super awesome work closing all of your parentheses correctly. I was a little concerned for a moment when you opened the third without closing any of them ... but it worked out ok

    ReplyDelete
    Replies
    1. Thank you... I used to be totally into embedded parentheses :)

      Delete
  10. The best part of your post is that you compare doctors to plumbers and the cable company. I love that. But you probably just pissed off a bunch of your colleagues for "debasing" your profession.

    ReplyDelete
    Replies
    1. Yeah, doctors are so much better than every other profession that it's an insult to make any kind of comparison, except maybe to God.

      Delete
    2. I remember telling a dude who wanted to be a neurosurgery that being a doctor was a trade. He got totally offended. He said it was "art." He was really pompous.

      Delete
  11. My kids' pediatrician's office charges $12/call, which I find reasonable as they have to pay the nurses staffing the line. They have a set of guidelines to walk through, and by calling this number, you can even get a referral to the after-hours pediatrician's office that is staffed every night and weekend until 10 PM and REQUIRES prior authorization (in other words, it saves you an ER trip, it's a real pediatrician that works there, it's connected to the hospital for labs/x-ray, and since it requires authorization, it's hardly ever busy!). If the nurse isn't sure, she'll page the doctor to call me at home. It's an awesome service that I'm more than happy to pay for. Even though I'm a nurse, talking with a triage nurse makes me feel better!

    Melissa

    ReplyDelete
    Replies
    1. This is probably a stupid observation, but I can't see how getting more calls *costs* a practice money. Presumably, the help nurse is being paid hourly, not by call. So how does the practice save money if less people call? I see how it creates revenue to do this, but why does having more calls cost the practice more than having less calls?

      Delete
    2. I don't know where you're seeing this in my post, but I believe that the calls average out over time. Some nights might be really slow and only receive a few calls (like in the summer), whereas at other times (like the present), the after-hours phone is probably ringing off the hook. The nurse and registration specialist are paid the same, regardless of whether or not someone calls. (At least, I assume it would be that way. I'd rather stick a sharp object in my eye than do phone triage!)

      Melissa

      Delete
  12. If you are trying to run your practice efficiently, you might have paperwork that needs to be done sometime to keep the nurse productive between calls. You should also consider the possibility that the fees charged for the calls actually make it possible for some practices to provide after hours advice. The question you should ask is not "is it better to have this service for $ 20 or to have it free", it is "is it better to have this service or not." If the answer is "better not to have the service", just go to the ER instead of calling.
    Phillip Bailey

    ReplyDelete
    Replies
    1. But what if, say, there were only three or four calls per night? Charging $20 for those calls would never come close to reimbursing the nurse for her time. So does that mean there should be no helpline? Or that people who call should get charged $100? Or that there should be another way to pay for the helpline?

      Delete
  13. When my kids were little and I had to make a total of two after hour calls to peds practice in their entire preschool years. One of the calls was followed by Saturday office visit when pediatrician (thank her profusely) came to her office prior to hospital rounds to see us. So, no minor panic on my side. I still was take aback by the cost of the call (20$ like in your case) at the time. But in retrosepct I agree with that practice. They utilize out of town nurse practinioner service to asnwer calls, so they have to pay them. And nurse practinionr would reach a doctor on call if she could not field the situation. so, there is still access to your doctor. Pediatricians are some of the lower paid doctors. Our pediatrician one year we were their patients made total of 60,000$ after cost of running the practice.

    ReplyDelete
  14. The pharmacy after business hours receives many of these calls and it can be quite frustrating when they describe symptoms that clearly need to be evaluated, but the parents refuse to call the pediatrician.

    ReplyDelete
    Replies
    1. Yeah, and now you know one reason why.

      Delete
  15. I know some of the bigger insurance companies have (or perhaps had, it's been a few years) triage nurses you could call to ask, "is this serious enough sounding to call a doctor?"

    I've seen something similar in my field (computers). Way back before cellphones, a bunch of computer administrators stopped answering off-hours pages because they were getting too many stupid calls from the people in charge of monitoring the computers.

    The solution was to train a bunch of the people who were charged with teaching liaisons from the computer-monitoring people, so that the liaisons would understand the difference between "Hey, this keyboard doesn't work" (then go get a new keyboard, dipshit) and "Hey, the magic smoke came out of this computer!"

    The liaisons *were* paid overtime for the off-hour calls. The liaisons then determined which were serious and passed those on to the admins, who stopped ignoring their pagers.

    And lest you tell me that the difference between the fields is life and death, I'll tell you of the time the computers ate the University payroll.

    ReplyDelete
  16. At the end, you're comparing two completely different services. The cable and you're apartment, I'm guessing, require an ongoing monthly fee. The doctor doesn't.

    ReplyDelete
    Replies
    1. I only made the comparison because people commented on my original post that "no other profession" provides after-hours help for no additional charge.

      Delete
  17. Canadian perspective:
    1. We have a "health link", a publicly funded provincial phone line for questions, free to use, part of your tax. Call whenever. I've used them. And it's obviously cheaper to have a provincial group of, say, ten people, then each office have one.

    2. Any time a parent is put into the position of "is my child's problem worth this much money" is horrible. I don't think people in the US realize how horrible. This is not a problem in Canada (except dental, which is private). For me, as an outside, that sounds horrible. See point 1 on how to address this issue without debates as to who should get paid what for what and when. Did I mention that putting a parent into this position is horrible? I think I might have.

    ReplyDelete
    Replies
    1. Yeah, I feel the same way. I am quite surprised that the Canadian "ER MD" was arguing so vehemently that people should be charged for the helpline. I notice though that she seems to like to disagree with whatever I write.

      Delete
  18. The pediatric clinic where I did my 3rd year med school rotation contracted out their after hours calls to a nurse-staffed hotline, and that hotline charged the office on a per-call basis. They served a very low income population at this clinic and were concerned that the volume of calls was becoming too expensive to cover. Not sure if that was the situation with your Peds office, but maybe that is why they started charging.

    ReplyDelete