Penny for Your Thoughts? Or Are You Worth More?

Rebecca Bechhold, MD

I find it difficult to put a price tag on what I do. It is mainly a thinking profession we are in, though in recent years it has become more like data entry! My head used to hurt after working on calculus homework. I feel the same way after seeing a number of difficult cases in the office. It really does burn up a lot of calories, which leads to hypoglycemia and hence the headache. A piece of chocolate is in order, right? A beer, if you are one of my brewery-owning partners.

On those days I think I can’t possibly be paid enough. Mentally and emotionally it is exhausting, extremely challenging, and the wrong decision is oh-so-costly. So I check the charge box without hesitation.

So, what about the follow-up cases that seem routine after so many years of practice? Many of my patients are more like friends who have dropped by for a chat. Breast cancer follow-up, taking hormone therapy or not, doing well, 10-point review is unremarkable. They spend more time showing pictures of family and vacations than answering my health queries. After 30 years in practice, it doesn’t feel that taxing to see them. I really enjoy it! And yet … I have to bill them to show my productivity. I already am at the bottom of the heap because I don’t charge high enough levels for visits. It isn’t that I do not value myself, I just don’t see an uncomplicated visit as being worthy of a level 4. I almost never get to a level 5. Mind you, there is nothing wrong with those who do charge that level. One colleague said I need to think about all the things I am ruling out in my head, all the complications I run through and exclude. Oncology patients are complicated and can have a life-threatening complication at any point. They rely on us to be aware and on alert for signs of recurrence, progression, or treatment toxicity. I always worry they will think I am not worthy of the charges they see on the explanation of benefits, though no one has ever made that remark.

I am also sensitive about co-pays. Many are up to $50 a pop. So I try to be über-efficient about the number of visits. I make a lot of phone calls with results to 1) get the information to the patient quickly, and 2) avoid a trip to the office that entails time off work, travel time, and a co-pay to hear that all the results were normal. That behavior is great for a medical home, but not so smart for fee-for-service. Plus, even though I have a reputation for being obsessively on time, my patients are always saying, “Do I have to come back in 3 months? Can’t we make it 6?” My nurse navigator thinks it is hilarious that the patients who wait the longest for their doctor are always the ones willing to make frequent appointments, while mine practically want walk-in service. I have convinced myself that they are all so confident I will see them on a moment’s notice that they are comfortable with longer follow-up times.

On the other hand, I get insanely frustrated with the phone calls from a friend or friend-of-a-friend or some remote connection just wanting a second opinion on their cancer issue. Excuse me-I make my living this way, meaning I generally get paid to tell you my learned opinion. One volunteer at the hospital came and sat down and asked me all about her breast cancer and what I thought for a good 20 minutes. Then ended by saying, “I am seeing Dr. Whozy Whatsy. They are the best in the city.” Did she really not realize what a slap in the face that was? I always try to be gracious when that scenario occurs. No snappy remark. They have cancer, I don’t. How do you handle the situation? Because I know it happens to all of us.

Hospital census is down across the country, but oncologists still see a lot of inpatients. The ratio of time spent to fee paid is not favorable. So, why do so many patients have half dozen doctors seeing them each day, each one focused on one tiny detail? Do you really need a hem/onc to come by each day to check the INR? Or, if the cancer patient is in for something unrelated, do they need an oncology “consult?” And can you even bill for that? Does copying forward your EMR note with a full review of systems, physical exam, review of lab and x-rays, and one new sentence at the bottom qualify for a level 3 hospital visit? I am asking the question. I don’t know. Maybe it is better to have more eyes on the patient. One doctor tells me the reason they call so many consults is to share the liability. I think he is cynical. Many times, I just make a “social visit” and stop in but do not make a note or charge. Is that risky or naive on my part?

Does the 90-year-old with pneumonia and chronic anemia from the extended care facility need a heme consult, and after you do the initial consult, do you need to go by each day after that to make note of the hematocrit?

Help me out here, readers. Physicians-give me some billing advice. Patients-weigh in. How does it feel on the receiving end of those bills? Do you even care? Am I being way too sensitive?