It’s Actually Quite Hard to be a Doctor in America These Days.
It used to be the case that if you were a doctor, you could work for yourself and make a decent living. As healthcare policy has shifted in America and as insurance companies gain more and more control of the industry, however, this is no longer a guarantee.
The percentage of American doctors in private practice has dwindled over the last 20 years.
Not too long ago, more than half of all practicing doctors in America were self employed. But as more rules have been imposed on us – needing a HIPAA-compliance officer, having the clinic be wheelchair accessible, mandating that paper charts be converted to electronic records, etc. – and as insurance billing has gotten exponentially more confusing – essentially requiring at least one full-time, in-house employee just to handle insurance billing – most doctors can’t keep up. Discouraged, they grow sick of spending more time on administrative management and less on patient care. They go looking for the highest-bidding hospital job.
But “selling out” doesn’t cure all ailments. Doctors trade in one set of headaches for another when they go work for somebody else. Sure, they don’t have to worry about insurance billing anymore. But suddenly their daily patient load is doubled, and their face-to-face time with patients is cut in half.
Whether it’s a private practice physician “playing the game,” or a doc-in-a-box with a quota to reach, your care suffers when your doctor has to hustle to get paid.
And here’s why your doctor has to hustle, every day:
Insurance Payment for Care is Inconsistent.
Some insurance companies pay your doctor relatively well, and others pay abysmally. (Medicare and Medicaid fall in the beyond abysmal category.) For this reason, your doctor has to stay incredibly busy, seeing a high volume of patients daily to sustain revenue. This means packing more patient visits into the workday. Which means – you guessed it – shorter visits. It also means double-booking visits, which is why your doctor is running around crazily and always running late for something.
Insurance Doesn’t Pay for No-Shows.
Medical offices are a bit like airline companies. Every day a certain number of “seats,” or visit slots, are available, and every day a certain percentage of customers don’t show up for their reservations. Airlines capitalize on this is by over-selling their flights, assuming that after some travelers don’t show up, every seat will be filled. The airline therefore gets paid for every single seat on the plane occupied, plus an extra 10% “bonus” for those over-sold and never-claimed seats. (Nice business model for them!)
But unlike an airline, your doctor doesn’t get paid when you no-show to your appointment. Insurance does not cover no-show or late cancellation fees. So this further justifies the practice of over-scheduling the doctor. But what happens when all of the patients acutally show up for their scheduled appointments? Longer wait times for you. And a crazy afternoon for your doctor, where she ignores the urge to urinate for two hours because there are too many people waiting. So bring a book and cancel your afternoon meeting, because it’s going to be a while. And forgive the doctor’s snippy tone; she didn’t get to have lunch today.
Insurance Doesn’t Pay for Phone Calls.
Some clinics have an advice nurse on staff who fields phone calls and answers questions like, “Should I take my toddler to the emergency room if she ate a little dirt on the playground?” Although that advice nurse is a full time employee and a health care provider, the practice cannot bill the patient’s insurance for those phone calls. Even if your doctor speaks with you directly by phone, he still doesn’t get paid. Insurance companies do not reimburse for any care that isn’t face-to-face. (This is slowly changing with some companies, but inconsistently, and at a snail’s pace.) This means the revenue generated from office visits needs to cover the expense of additional patient care.
Other Things Your Insurance Refuses to Pay Your Doctor For:
The 20 minutes your doctor (or her nurse) spends on the phone getting the pre-authorization from your insurance company to cover the MRI or other special study you need.
Your doctor’s time (or her nurse’s time) in appealing your insurance’s decision to not cover that medication you so desperately need.
Your doctor’s time in researching new treatments for your condition.
Your doctor’s time in chatting with your other specialists and coordinating your care.
Your doctor’s time (or his nurse’s time) in writing up referrals for you to see specialists, get blood tests, or have a procedure done at a hospital.
Your doctor’s time in reading your lab and imaging results when they arrive and signing off on them. (This takes hours, by the way.)
The office staff’s time and energy in printing out the 200+ pages in your medical record when another provider, your insurance, or you yourself request a copy of your records.
Your doctor staying up at night praying for your recovery and hoping that you’re feeling better. (Yes, we really do care very much about our patients.)
This is all work your doctor does essentially for free. Which further justifies her policy of over-booking her visit schedule. She needs to earn extra income to defray the money lost on all of these unpaid services.
…Plus there are other people who need to get paid – and no, your insurance company doesn’t take care of them either:
The front desk staff
The person in charge of ordering of medical supplies
The insurance biller (big practices usually have at least two, if not a whole team)
The office manager
The HIPAA-compliance officer
The person in charge of medical records
The nurses, MAs, and other assistants
The on-call advise nurse
The after-hours answering service
Of course the expense list goes on and on. Malpractice insurance, business insurance, liability insurance. Rent and utilities. Biohazard disposal. The security and alarm company. The cleaners. The guy who delivers the water. The special sensor that sounds an alarm bell and rings the doctor’s cell phone when the temp in the fridge storing medications drops below the acceptable range. That entire box of rapid strep tests that expired and now needs to be thrown away. And so forth.
…And Your Explanation of Benefits (EOB) is Outrageous
Sometimes patients come to me and show me the EOBs (explanation of benefits) they get in the mail after visits at their other doctor’s offices. $200 for the visit? But she spoke to me for all of five minutes and told me to get an x-ray! Another $10 for “educational materials?” That refers to the cheesy, generic print out on why you should quit smoking. And $10 for an ice pack? I didn’t even keep it, I left it in the room! Are you kidding me?
Your insurance just paid $220 for you to talk to a doctor for a few minutes after you slammed your finger in a car door. And yes, you do need to come in for a visit, your doctor can’t just send that x-ray referral over to the imaging center. Because she can’t get paid for her time unless you come in. And your insurance might not even cover the x-ray without that referral anyhow.
..But it’s Not Your Doctor’s Fault.
Looking at those numbers, you’d think your doctor was a crook. He is anything but. What’s actually happening is that he’s busting his gluteus maximi trying to get money wherever he can to cover all the other outrageous expenses that come with running a medical practice in America these days.
He knows that your condition deserves more attention, and that you deserve more time. He wants to give it you. But he can’t.
Spending an hour waiting for a 15-minute visit is a necessary evil of the system. Your time is disrespected, your concerns cut short, your care sub-par. But it isn’t the doctor’s fault. There’s a bigger corruption at play. Your doctor is just as victimized by it as you are.
So dear patient, the next time you come to my office and tirade on the injustice of it all, pointing out how nice it is that I give you 45 minute visits and personally return your phone calls, wishing other medical offices could be more like mine, I will be right there with you. I will agree that there is something very wrong with our system. I will rejoice that I set up my practice such that I don’t rely on having to “play the game.”
But when you call your other doctor an idiot or a jerk? I can’t agree. She isn’t an idiot. He isn’t a jerk. Your other doctors are victims of a system that just isn’t working. They are in so deep they can’t even fathom how to get out of its powerful undertow. They are hundreds of thousands of dollars in debt, striving to be of service to others, and just like you, they’re trying to make ends meet.