The Guilt Factor

I think I've touched on this before, about feeling bad when people have to leave here, but the guilt issue is really the worst part of this whole setup.
Most people, even if they have to change doctors ("have to" vs choose to is a different topic), are not bitter or angry, and send their verbal support and words of encouragement. There's a source of guilt right there, these people aren't mad or bad, and I'm "driving them away". Then, there are the angry ones, I am ok with them leaving, because I don't really like to deal with angry people anyway. But there are others who might as well have taken lessons from my Mom about how to make me feel guilty. One lady couldn't even call me herself, her daughter called to cancel her appointment because the patient had been in the hospital twice "because of all the stress I had caused her." Her appointment was scheduled before the Medicare end date, but she could not even bear to come in and see me. As unrealistic as that is, and as much as logically I want to say "if you're that upset about it, find a hundred dollars or fill out the financial hardship form!!", I know this lady, she matters to me, and while I think she needs to reevaluate her coping skills, I truly do not want to cause stress in her life. Part of my job is to help people through stresses, not to cause them (real or imagined). I have also heard from several people variations on "how can you do this to me?" and "I thought we were friends". And really, I do have a connection with these people. I don't just look at them as "customers" or "clients".
Then, there are the ones who stay. I know that it is hard for some of them to come up with $100, or the discounted fee schedule if they qualify. And it is near impossible for me to charge people the $175 for "extended" visit. That's a lot of money. And I just keep telling myself that the plumber, the electrician, the mechanic, the vet, the lawyer all charge high fees, and many of them do not have student loans the size of a small mortgage. But I still feel bad.
Then of course there's all the other things in this job I can feel bad about, making people wait (not usually too long), addressing lifestyle issues like weight and smoking without offending people, my own human error and (hopefully rare) mistakes, and delivering bad news. I'm mostly used to that stuff though, and that's part of why they pay me the big bucks...

What to charge?

Ever notice when you go to the doctor or a hospital, the bills seem outrageously high? That's why all doctors are rich, right? But then did you look at the EOB (or explanation of benefits)? They are very tough to read, and even when you do realize what the different columns are, it seems there a magic 8 ball somewhere determining percents, amounts, and denial codes.
So here's a brief overview. When a doctor contracts with an insurance company or agrees to a medicare contract, they agree to accept "fair and reasonable payment" for services rendered. In many cases, the standard contract does not list what that will be, the insurance company changes the reimbursement rates based, somewhat, on the current "market value". Except that they can really just pay whatever they decide is fair and reasonable. Often this is a percentage (usu from 70-150% ) of the medicare allowable amount. (not usually 150.)
So medicare decides what is "fair" to pay for an appendectomy, a pap test, a chest xray, a basic office visit, open heart surgery, etc. These all have codes, and a medicare committee determines the value of each code. (this committee, by the way, is made up of 17 surgeons and 9 non-surgeons, that's fair, right? not.)
So I could charge $10,000 for a 99213, (a standard office visit), but it doesn't matter because I am only going to get whatever medicare says is "fair and reasonable". (Unless you are one of the uninsured, in which case you're just paying the full amount, whatever it is.) But, medicare and the insurance companies won't pay you extra, so if I only charge $50 for a 99213, even if they "allow" $77 I will only get the $50. So I should really make sure I charge high for every visit to make sure I get the maximum amount back. But if you are in the category of "cash patient", that higher charge makes a big difference. It makes it tough to evaluate what people charge, because in this industry, very few people expect their charge amounts to have any relationship to their amount received.
But I think it makes us look bad to charge more than our service is really worth, just to make sure we get paid the bare minimum. Someone told me they had surgery for a knee replacement. The total bill was $50,000. The final amount paid out was $12,000. How does one financially analyse what was "lost" or not in this transaction. What was the surgery really worth?
So when revamping my business model to exclude the Magic 8 Ball Effect, it is really hard for me to figure out what to charge. I tried to factor in my expenses (ouch this year), my debt from school and the practice, how many patients I hope to see a day, how many patients I am able to see a day, what people might be able to afford, and what other docs get paid. I decided on $100 a visit, unless the visit is over 40 minutes, and shots would be based on market price (like when you order lobster at a fancy restaurant). Is $100 enough? If I can see about 50 people a week it will be fine. Is it too much? I almost hope it is, so that I will be able to lower my rates and make care more accessible to more patients.
I wonder how much the perception of the healthcare crisis would change if doctors really charged what they needed or deserved. I personally have a hard time being sympathetic for someone who is charging $50,000 for a surgery, even if I know they are only getting $12,000. How can people understand what is really going on with their healthcare dollar, if the numbers are so abstract? How can doctors really know what their write offs are if their charges are not really what they need to be? This is a fairly easy step that doctors could take to demystifying health care finances.

so that's what my kids look like!

In the past week, I've put my kids to bed every night (that didn't mean they went to sleep though), made lunches the night before they were needed, known where the shoes were most of the time, and thourougly decluttered my kitchen. I still have not been home for dinner much, but I see progress. I've also played scrabble and watched a movie with my husband, and taken the guest dog for a walk. And gone to the gym twice.
It's not that things have changed so much here at the office, but I feel like the burden has been lifted, that I will someday get through the charting backlog, and that I can go back to worrying about people first and money later. I still get panicky when 2 or 3 people cancel in a day, but so far, when that happens, the spots have filled back up.
There is another strange phenomenon too, yesterday I received 2 gifts from patients that are transferring. It seems funny to me that people who are changing doctors would be sending a thank you gift to the current doctor, but not staying. I understand that a little angel statue is a much more affordable token of appreciation than $100 a visit, but if my care is worthy of a hallmark card or even better, gourmet German chocolate, wouldn't it be worth it to get fewer manicures and get the top notch medical care.
Then, when I say that, I feel like I'm being snobby, and I don't want to be. I know that there are many Family Docs out there that are doing a wonderful job, but I know too many that seem like they are pressured to to more and more in less and less time. Every patient satisfaction survey I've looked at notes that amount of time is one of the biggest complaints.
So that's where we are a week into this adventure. So far so good.

government cheese

"Why should I pay you for a visit, when I can go to the doctor up the road with my medicare and get the visit for free?" asked the cute little lady whom I've grown to love despite her arguments and noncompliance. I asked her if she remembered government cheese. I tried to tell her that she's welcome to go to the doc up the road, and might very well do fine there, and I in fact like the doc up the road. But if she's looking for something else in healthcare, something different in her visits, she could pay to come here. Maybe, with healthcare, we are getting to a point where the government subsidized plan isn't the best one for everyone (I said carefully without trying to offend those still participating the government program). So I tried to parallel government healthcare with government cheese.
Turns out she loved "ronnie's cheese" as she called it, gave me a good recipe for veggies with melted government cheese, and wished me luck. I'll miss her, truly, but maybe she'll be back...
or maybe she'll make the best of the change.
Today is my last day as a medicare participating provider, and boy am I glad september is over. I'm still bogged down in charts to copy, issues to follow up on, and getting Connor to do his work, but I feel, at least, like I can move forward.

"are you crazy?"

So I've been thinking about trying to capture all my thoughts and ideas about what's going on with the practice, how it effects (affects?) my life and the life of those around me, thoughts on medical economics and "healthcare", maybe if it all makes sense I can avoid reliving some of the mistakes I've made in the past, and repeat some of the more positive stuff. I also want to track my hours worked, patients seen, and overall satisfaction, to see if all this effort is worthwhile. So this is the start.
Here's the baseline: graduated residency 2000 West Jersey Family Practice Resiency (Virtua), joined a group in Cape May County, decided I wasn't a team player, so bought out the "satellite" office down here in Cape May Courthouse. Was going along fine until I realized that I needed to be spending a bit more time with my patients in order to make sure I was doing a thourough job, so I spaced out my schedule to allow it. Then I realized that I didn't really get paid enough per visit to see less patients so in 05 I started dropping insurance plans, and up till now have been down to 3 plans, medicare, and 2 others. Starting october 1, I will be "opting-out" of medicare, and the other two plans will terminate in early november. I'll be all cash. People keep saying "are you crazy?" It is a little scary, and very hard to hear people say "I just cant afford to pay you" (and lots of other stuff). But scarier to think about how much I work for so little money.
So now it's 10:09 pm, I've got about 40 more minutes of paperwork, in addition to trying to process the charts of people who are transferring.

Future topics may include: what to charge, patient reactions, reactions of other docs, scanning charts, my dream practice