How Should Doctors Get Paid? – Part 1

It’s a strange business we are in.

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can see a Medicaid or Medicare patient for five minutes or forty-five, and up until now, because I work for a Federally Qualified Health Center, the payment we actually receive is the same.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.

As a primary care physician I get dozens of reports every day, from specialists, emergency rooms, the local Veterans’ clinic and so on, and everybody expects me to go over all these reports with a fine-toothed comb.

A specialist will write “I recommend an angiogram”, and we have to call his office to make sure if that means he ordered it, or that he wants us to order it.

An emergency room doctor orders a CT scan to rule out a blood clot in someone’s lung and gets a verbal reading by the radiologist that there is no clot. But the final CT report, dictated after the emergency room doctor’s shift has ended, suggests a possible small lung cancer. Did anyone at the ER deal with this, or is it up to me to contact the patient and arrange for followup testing? All of this takes time, but we cannot bill for it.

Most people are aware these days that procedures are reimbursed at a higher rate than “cognitive work”, but many patients are shocked to hear that doctors essentially cannot bill for any work that isn’t done face to face with a patient. This fact, not technophobia, is probably the biggest reason why doctors and patients aren’t emailing, for example.

Just lately, there is a new trickle of money flowing into medical offices for the type of between-visit oversight that goes with the new Patient-Centered Medical Home model of care, but it is not enough money to substantially change how doctors’ time is scheduled.

Taking a primary care physician away from direct patient care for just an hour can cost the employer somewhere around $400 in lost revenue. In today’s economic climate, few health care organizations can afford to fully embrace the notion of all the different indirect care activities others think physicians should engage in besides seeing patients one by one for a fee.

Of the three professions, physicians probably have the most confusing payment arrangement: Members of the clergy tend to make a straight salary regardless of how busy they are, lawyers bill for their time whether spent with the client or without, but we only get paid if someone is watching us.

If a tree falls in the forest, does it still make a noise?

If a doctor isn’t face to face with a patient, is he still a doctor? Is he still doctoring?

I say yes, but, then, how should we get paid?

(To be continued…)

3 Responses to “How Should Doctors Get Paid? – Part 1”


  1. 1 Bettercareelsewhere April 2, 2014 at 12:48 am

    I believe doctors should be paid for email & phone conversations. Document it and get paid for it. This would be for PCP types: PCP internist, GP, FP, ob/gyn and peds. The rest, ok that’s a little different but the primary care should get that.

  2. 2 Christina April 2, 2014 at 3:08 am

    I think a doctor should get paid like a lawyer. $X per [time-segment] for all work done on a case. And I am not an MD, just FYI. I further believe that all patients should be in charge of submitting their own bills to the insurance companies. As it stands now, people don’t know how much their medical care costs (BTW, it is my experience that most MDs don’t know what their fees are for different procedures either.) If patients had to submit their own billing, medical care would cost less, and insurance companies would be held more accountable by their insureds. I know my stance is unpopular, but I am just so tired of hearing from people that their medical care is “free” because they are insured.

  3. 3 Mj April 8, 2014 at 1:24 am

    Probably explains why so few U.S medical students choose primary care…hard to pay tuition bills practicing primary care


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