Wednesday, November 17, 2010

Fee for advice

I used to love my daughter's first pediatrics practice. Then they went and totally BETRAYED us. (Sort of.)

Some background:

I'm not one of those mothers who calls the pediatrician for nothing. I would say that in Melly's first year of life, I called a total of twice, one of which was for simultaneous fever of 102, diarrhea, vomiting, and bilateral ear infections. (For the record, I had to beg for an appointment that time, which the nurse only grudgingly gave me. Should have been a warning.)

When Melly was about two, she woke up one Sunday morning and one of her eyes was swollen. This had never happened to her before and I was concerned, so I called the pediatrician's office. 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.

I can understand why they might do this. Even if you're not a physician, if you've ever read Dr. Grumpy's blog, you'd see the ridiculous, trivial, non-urgent things people call about in the middle of the night. I bet parents are even worse than neurology patients.

But I also think it was horribly unfair. 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?

I've used two different pediatrics practices since then and neither charged a fee for after-hours advice.

What do you think? As physicians or mother or patients, do you think it's wrong to charge for after-hours nursing advice?

88 comments:

  1. As a mom, a $20 fee seems outragous. As a physician who got an absurd number of calls from parents when I was in general pediatrics (think _hours_ on Saturday mornings sitting at a desk unable to do anything else because of multiple back-to-back calls), I understand that there is a cost to having 24hr access to health advice -- there is a person on the other end who needs to get paid for their time and expertise. However, also as a physician, I'd far rather have to answer a phone call than to let a patient ignore a potentially serious health problem. Especially if the phone call leads to an office visit or an ED visit, charging an additional fee seems unfair, since you'd then also have to pay for the visit for the same problem, and essentially the call did you no good. On the other hand, if it doesn't lead to a visit, and the problem can be dealt with over the phone, then charging some kind of (maybe lower than $20) fee seems more reasonable, since it likely spares the patient other charges or copays. It would also cut down on the number of people who call for routine med refills and other things that shouldn't happen after hours. I guess that would be a compromise that I could live with from both perspectives.

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  2. Hmmmm..... I do see your perspective. However I am also imagining lots of phone calls for truly asinine things. Maybe the $20 is too steep? Maybe they need a scale that goes first call in a month = free, 2nd call = $10, 3rd call = $20. What do you think?

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  3. Yeah, I think $20 is too steep. There should be some number of free calls you get, like five per year. I don't think that's unreasonable, to call five times the whole year. And after that, you can charge.

    And there should be a waver for kids with serious health problems. Like if your kid has cystic fibrosis or something, you should be allowed to call all you want.

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  4. I think that we, as physicians, provide far too many services "for free." I can think of no other profession that gives away more of their very valuable expertise than ours. By and large I believe it is because of the kind of people that we are, generally compassionate, caring, and interested in helping others. However, sometimes, we also have to protect ourselves. I cannot tell you how incensed it made me, as an essentially solo practice physician, when a patient would call me at midnight from Wally World to ask what type of cold medicine they should buy, or to tell me that their period had started (!)

    Perhaps your pediatric practice has a patient population that has completely abused the physician on-call system, and the message is meant only as a deterrent for those who may be calling for a trivial reason. The reality may be something more benign or akin to Old MD Girl's "sliding pay scale" or no charge at all for "real emergencies." Truly, though, if your child is experiencing a real emergency, you wouldn't be calling for phone advice, you'd be going somewhere (be it office or ER) to be evaluated immediately.

    Bottom line, your physician is a professional and is entitled to charge for professional advice. I don't think I have called a physician after hours for anything. I've either made an appointment for myself or my child, or figured it out for myself. Obligating a physician to essentially work for free because you happen to have a chronically ill child hardly seems fair or logical.

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  5. I'm a fan of our old office's policy which said that a $25 fee MAY be charged. Basically, it's there in case they have to use it when someone starts driving them crazy at 2 am for no reason, but it doesn't sound so definite to deter a first call.

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  6. As an RN who works for an entirely pediatric advice line I think $20 is high, even for the more economically sound areas of our coverage, cost wise for a small practice, thats about what the break even rate probably is when you factor in time spent reviewing and returning overnight triage.
    Antidotally however the calls from the practices that do charge are much less likely to be "she's been coughing for a month, she's sound asleep, but she keeps waking me up," and much more likely to be absolutely incensed when I refuse them antibiotics over the phone for ear pain.
    Also,the calls that I get from parents of chronically ill kids in a month, I can count them on my fingers. Perhaps they call the specialists not the PCP, or perhaps they know that most times a visit to the ER is going to be recommended.

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  7. Boy am I glad I have enough friends that I have met in training that I can call - I have never called the pediatrician's office for advice (ahem - Dad is a trained pediatrician too - and neonatologist which really came in handy since Jack was 6 weeks premature). Also rarely needed friends, but I did use my best friend ophthalmologist a time or two for free. She's had path questions too, so we're even there.

    So I had no idea that this was an issue, and don't even know my own pediatrician's office policy. I can see all sides, in the comments. That's a toughie. I kind of like the sliding scale idea.

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  8. My goodness. Not a mother in medicine here, just a mother, a bit surprised at the reticence to offer help to parents who might really need it. There probably are crazy patients. Still, our ped office always says to call anytime - that's what they are there for. We don't call much at all, maybe 1-2 times in a year. But I can think of at least three times that they have kept us out of the ER with advice over the phone on the weekend, twice with tricks to help kids who were getting dehydrated and once with ideas to get a 105 degree fever down in a big hurry.

    If I know we're heading into a long night, I try to call before 9pm if I need help and I don't call until after 7am unless things are truly awful. I'm not sure I've ever called between 9pm and 7am actually. But it means an awful lot to me that my doctors (my kids' OWN docs, not some state-wide nursing service) are there, 24 hours a day, if I need them. I do not have physicians as friends and I have no medical training so if we couldn't call for help, we would be clogging up the ER at least occasionally.

    I realize we are getting advice for free when we call after hours. However, most after hours calls are connected to at least one office visit. Furthermore, the fantastic availability is one of the reasons I recommend our practice to new parents.

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  9. I cannot tell you how incensed it made me, as an essentially solo practice physician, when a patient would call me at midnight from Wally World to ask what type of cold medicine they should buy, or to tell me that their period had started.I can see all sides, in the comments.

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  10. Just an RN here, not a mother or a physician... Interesting post and I tend to agree that $20 is a bit much seeing how it's almost a co-pay for an office visit in an average private insurance.

    I am also a bit disappointed with the person who showed reluctance to give advice for "free." I see your point, the know-how and years of school should pay off, but it's YOUR patient. My own father is an internist and my father-in-law has his own peds practice and I definitely hear enough complaints about erroneous phone calls. Does my father-in-law LOVE phone calls? No. Would he rather take it than some nurse across the country at 1 am? Definitely. There is no heart-wrenching I-love-my-patients story behind it, it is just something he does because medicine is his profession not an 8-5 business.

    So, then these patients with these "superfluous" problems like runny noses and mild fevers clog up the ERs, and the ER docs complain about how these people should "go to their doctor" or "urgent care." And then of course you get the million dollar what's-wrong-with-our-heathcare-system question... but I won't go into that one...

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  11. i think the sliding scale/judgement call is really the best idea i've heard. charge people the $10-20 for the ridiculous phone calls, but "real" calls are free of charge. it really is infuriating that patients think that we belong to them completely and call for every little thing that is usually treatable at home. i actually plan on making a "users guide God never gave you" type book with symptoms that are dangerous and require an ER visit asap, ones that require a call to me, and how to deal with the everyday symptoms that parents sometimes just don't know about. lofty goals from a med student :)

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  12. A few months ago, I called my pediatrician at around 8PM (who now doesn't charge) because my daughter had a high fever and was sobbing that her head hurt. If I hadn't been able to reach the advice line, I definitely would have packed her off to the ER, but the nurse gave us some advice and a next morning appointment, and saved me both a lot of trouble and anxiety. If I had to pay for the call, I might have considered going to the ER anyway, because I'd figure that was what was going to be the eventual outcome so why make two copays?

    It's not fair to make people work "for free," but we also all realize that medicine isn't like other fields. You can see a doctor at 2AM but you can't see a lawyer at that time. I think the nature of illness obligates a practice to provide 24 hour coverage, and I think a hefty fee encourages people to ignore problems that are potentially serious... or overreact with an ER visit.

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  13. As a veterinarian who does not charge for phone questions, I've worked out a simple formula over the years:

    Less than ten minutes on the phone? Basic advice given; check in with me again.

    More than ten minutes on the phone? No advice given other than: animal needs to be seen. Repeat as necessary.

    Professionals should be paid for their knowledge, within reason.

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  14. "Free" is never truly free Fizzy.

    The office makes up for that cost of time and personnel in other ways ie higher base visit charges or cutting their nursing staffing or ending offerings of flu shots and so on.

    I have a high deductible insurance plan this year and pay for everything out of pocket up to some huge amount of money and I am the one who pays the higher out of pocket visit fee that makes up for the "free" phone calls services.

    We all pay for health care.

    Add the free phone call to your next tax bill.

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  15. Another data point, my own practice is out of network. I take no insurance and patients pay me with cash or check.

    Sort of a boutique practice.

    I do not charge patients for phone calls. If an issue is complex and/or is better suited to an in office evaluation, I offer an appointment.

    As many of you have pointed out, a quick check in can alleviate time and aggravation for patient and doctor in the long run.

    But many times there is more to the story and a full in person evaluation is essential to get to the bottom of things.

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  16. I would not participate in a practice that routinely charged for calls. I might consider the "optional" plan, but only if the mechanism for deciding what to charge was spelled out to all patients ahead of time.

    I have no problem charging for copies or for filling out forms and I have no problem refusing to refill routine meds off-hours, but I draw the line at anything that would discourage people from seeking help when the need it. Medicine is not like any other field, and it shouldn't be. We have an obligation to our patients, and if we're not interested in fulfilling that obligation, we should get out.

    And yes, I was in primary care practice for 20 years and yes, I received my fair share of inappropriate middle-of-the-night phone calls - all of which pale in comparison to the patient who showed up in the ED in florid pulmonary edema, requiring intubation, two days after she'd called on a Friday night and been told by the answering service, in error, to wait until Monday.

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  17. I have to agree with dr. whoo. I'm sad to see that so many people think their health professionals' time and expertise are worth so little.

    Why are health professionals, particularly doctors, expected to be completely self-sacrificing? Is it reasonable to expect the nurse on the other end of the after hours line at 3 AM to be on call and work for free? Of course not. So how do you think that nurse gets paid if the patient is not charged a fee? Tigermom is absolutely right that if you're not being charged overtly, it's likely built into the visit costs.

    Is $20 really outrageous? First of all, the correct comparison should be the copay for the ER, not the copay for a regular office visit because the office is not open and that's not an option. So $20 could save you the ER copay (what is that typically, $100?) and maybe 4 or 5 hours of waiting. I don't know if people are imagining the pediatrician rolling around in the piles of bounty he's reaping from the after hours line, but I highly doubt it. Did you know that your average primary care doctor is in the red by $9600/year for years after residency? Did you know that on average, family practice overhead costs are higher than any other specialty... around 60% of their net revenue? Did you also know that a recent survey of pcps suggested that a third were burnt out to the point that they were planning to leave medicine? I agree with dr. whoo again that doctors do tend to be compassionate and giving, obviously to the point that a lot of us just end up burning ourselves out.

    I do agree though that finances should never be a barrier to receiving medical care. So I think the real issue here is that it's obvious that both doctors and patients agree that after hours phone advice is an important part of medical care, so why don't insurance companies cover a fee for after hours phone advice? For that matter, why is there a copay at all for office and ER visits? Doesn't that deter people from seeking medical care for potentially serious issues?

    In Alberta, we have a telephone line called Health Link which is staffed by nurses 24/7. You can call in with any health problem, they will do a detailed assessment and then they follow an alogrithm to give the patient a recommendation. It's "free", meaning there are no user fees and it's funded by the government. Then again, it's also "free" to go to the emergency room here, and "free" to go to the doctor's office.

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  18. Liana and Tigermom I think said it best -- We are paying for the service regardless. What's interesting is how transparency of costs to the patient influences his/her behavior.

    Fizzy, I'll bet you didn't realize that you were a subject in a fascinating experiment on incentives and human behavior.

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  19. As a physician in private practice, who has to work many weekends (see fizzy's prior blog) and take night calls, and can rarely leave the office before 7PM, I admit to being annoyed with the current blog. Not the reasonable question of whether patients should pay for calls - I think that is a question for rational debate. But the use of the word "betray", or the phrase "horribly unfair". .There seems to be a large chip on shoulder problem.
    What you are asking is that I pay megabucks for malpractice, and then give "free" advice over the phone. It's the sense of entitlement that is so grating.
    I do not personally charge for after hours calls, but I do expect that most will follow-up with an office visit. Too many nuisance calls and no office visit = no more free medical advice.

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  20. I'm w/ Dr. Nana--the question of whether to pay for phone advice is a reasonable one worth debating (and it may have a different answer in different practices/for different physicians) but to say that the practice betrayed you for charging for their time and expertise? It's a little over the top.

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  21. Well not to bring back another high volume blog, but for the same reason you Fizzy were driven to tears at the need for weekend work, your pediatricians feel they should be able to pay for the coverage they provide. I cover my own calls M-F 24 hours and am sometimes amazed at the complete lack of respect some patients have for my time. While I will not charge, I do direct to an office visit or the ER because I cannot always trust that my non medical patients will provide the needed information over the phone. Sunni

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  22. It is possible to bill for telephone calls, although insurance may not pay for it. There is more and more of a push to have insurances reimburse for telephone based care. The rules are such that if the telephone call is related to a recent office visit, or leads to an office visit, that you cannot bill for the call. If otherwise it was a stand-alone call and the issue was resolved with the telephone advice, then it is billed according to the time spent on the phone.

    I think this addresses Fizzy's ideas about no charge if the call is followed up by an office visit.

    Some pediatricians do routinely bill for telephone calls, and it is in recognition that pediatricians get a lot of calls after hours. I can tell you having done 50%-50% internal medicine and peds that I had a LOT more calls from parents about their kids than from adults.

    I don't think it's unreasonable to charge for calls. The exact cost is of course up for debate. And doctors will have to make a decision about charging for the time they spend giving medical advice over the phone versus losing patients like yourself, Fizzy, who may opt to change pediatricians based on being charged for phone calls. It's really no different than doctors charging for no shows or doctors charging for filling out paperwork and/or med refills outside of regular office visits. At the end of the day, it's a tradeoff between time/money vs. patient satisfaction.

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  23. If I'm paying $20 for medical advice, I'd better hear it from my child's physician or partner, not the nurse line.

    Doesn't the nurse get paid for working the nurse line, whether s/he gets called or not? Why not have him/her field all calls since they're being paid to do it anyway? Like the other posters said, the alternative could have enormous consequences.

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  24. >>Doesn't the nurse get paid for working the nurse line, whether s/he gets called or not?>>

    Say the average nurse working the "nurse line" works an 8 hour shift on-call and takes 2-3 calls per hour (about 20 calls/shift). That's a gross of $400 if each caller is billed $20.

    Out of that $400, pay the nurse, the phone bill, buy supplies, etc. Also I don't think it's unreasonable to make a small profit for the practice vs. simply breaking even.

    Does anyone know what the average nurse working the "nurse line" is paid per hour to be on-call after hours? (I don't; it's an honest question.)

    As several have pointed out, service costs money - someone, somewhere is paying for service, maybe even you, buried deep in a bill somewhere.

    Finally, physicians - those who do NOT currently take phone calls of this nature: if an average phone call from a parent lasts 10 minutes, how do you feel about being paid $120/hour ($20/10 minutes) for your professional time after hours? Dr. Nana and Sunni have already alluded to the malpractice risk of giving advice over the phone, so don't forget to take that into account.

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  25. You know, I think what bothered me most about it was not getting charged extra money, but having to make a decision about my kid's health based on money. If they simply charged everyone a little more overall the whole year, that would have been much more acceptable than having to decide whether to pay a $20 fee per call.

    To compare it to something similar, what if we had to pay $20 every time we called the police? Or called the fire department? Isn't their time worth as much as ours? But I think we can all agree that something like that would be ridiculous.

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  26. I called a doctor and it was the same message. I also decided I did not want to pay the fee so I waited until the morning. Luckily, it was not an emergency.

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  27. As a physician, I think the real issue is that you should be paid for call. Call is call and your life is affected whether you are actually "called" or not.

    The actual amount you are reimbursed can depend on what you are on call for (ie. home phone call vs. in hospital obstetrics, or whatever), but I believe there should always be some kind of stipend for call, no matter who is doing it.

    Whether you then get to bill on top of that stipend depends on your local situation: what the call is for, who shares that call with you, what exactly you are responsible for doing. eg. anesthesia on call from home gets a stipend, and then bills if he is called in. OB on call gets a stipend, but splits billing with all the docs in the call group (so that patients are handed over appropriately and decisions aren't made based on whether she'll get paid for it or not).

    Call is call. Call is work. You should be paid for work.

    As a Canadian it is extremely hard for me to imagine taking cash directly from a patient. The ethics of that just seem crazy. But I know it's totally a reality for most of you, and had I grown up in that system, I would be OK with it too I'm sure.

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  28. I do have to pay a $50 fee when I call the police. When the alarm system goes off, and I tell them to call the police, that's how much it costs.

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  29. "To compare it to something similar, what if we had to pay $20 every time we called the police? Or called the fire department? Isn't their time worth as much as ours?"

    --It's not the same or even similar because in this country our medical care is not paid for through taxes. Physicians in private practice run a business--they do not have any incentive nor responsibility to provide free public services.

    I hate that that's the way it is and if I had my way, we'd be more like Canada or Europe, but that's the reality and people deserve to be paid for their services.

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  30. PS. You ARE charged for calling the police or fire department. It's called paying taxes.

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  31. Dr. Katie, I said that I would be OK with paying an overall fee, but I just didn't think it was right to be charged for individual calls. So paying taxes is the equivalent of that. People who call the police more often don't pay more. You don't have to make a decision whether you're emergency is worth $20.

    And yes, I do think the US system of health care makes no sense. Obviously, health care is different than other private services. I don't think there are ANY private practitioners in medicine who have no on-call system, so obviously we are different than, say, someone setting up a business selling tires. You can't refuse emergency health care, but you can refuse to sell someone tires. Medicine being private makes no sense to me, so perhaps that explains the tone of my post. Especially recently, since my new health care plan has a high deductible and I have to make decisions about whether my health is worth the money... but this is a highly political debate that probably isn't worth getting into here.

    OMDG: But are you paying the police or the private company that sold you the alarm system? Can't you cut out the middle man?

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  32. I think that $20 is pretty steep for a phone call. Obviously the goal is to discourage after-hours calls.

    I would hesitate to phone my doctor in the middle of the night. Our local hospitals offer a "free" 24-hour nurse line for people to ask questions. So does my insurance company. I would prefer to phone one of those services, where the person is already awake and working.

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  33. In the state I live in, a family recently lost their house and property due to a fire. The fire department came but wasn't allowed to do anything because the family hadn't paid their fire tax. The place I work recently received a bill from the police department for responding to a false alarm.

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  34. >>my new health care plan has a high deductible and I have to make decisions about whether my health is worth the money>>

    As you know, had your employer chosen a lower-deductible plan, the premiums would have been much higher... probably much higher than an extra $20/month. Your salary would have been lower, too.

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  35. Fizzy- I think you are agreat writer. Perhaps what gets me most bothered by your posts is the effulgence of your tone: BETRAYED, TEARS, the anger. Yes $20 is high but that probably cuts down on the refill calls etc that should get done during the day. I have a few patients who wait until 5:05 to call in so they page me directly instead of going through my triage nurse. Why? They wanted to hear from me instead of relayed through the nurse or they did not want to leave a message.If there was a fee for after hours calls, I bet they would have left a message an hour prior.

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  36. Anon: It's truly a challenge figuring out which word to BOLD in order to piss people off most each time. I think I've been right on the money.

    The $20 fee wasn't why I switched practices... that was because of moving. But it really upset me and was a source of stress in my life. And it caused me to call more during the day, about things I probably never would have called about, because I felt if I didn't call right away, I'd have to pay for it later.

    Also something that perplexes me (I know everyone really hates that word) is that if there has to be a nurse on call all night for the help line anyway, what's the difference in cost for how much the volume of calls is? Do they have to pay HER per call? I doubt it. It's not like they could ever eliminate calls entirely, so in that sense, it's not clear to me how high volume of calls drove them to this.

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  37. >>if there has to be a nurse on call all night for the help line anyway, what's the difference in cost for how much the volume of calls is?>>

    Your former pediatrician decided to pay the nurse's salary transparently, by billing parents who use the help line rather than burying the costs of maintaining a help line elsewhere.

    Some parents never call the help line. Some, like you, call occasionally. Some no doubt abused the help line. Should the parents who never use the help line subsidize those who do?

    People are generally willing to pay for a valued service. A help line is a service. Why not ask those who use it to pay for it?

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  38. For peds, this concept makes less sense since kids are always getting sick.

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  39. >>For peds, this concept makes less sense since kids are always getting sick.>>

    That may be true, but not all parents call the help line. Some parents need more support.

    Some kids never have problems their parents don't feel they can handle. Those parents never call the help line.

    As someone pointed out earlier, the parents of chronically ill kids also seldom call a help line (for whatever reason).

    Some parents undoubtedly don't remember there is a help line and either tough it out or go to urgent care.

    Some parents are fortunate enough to have friends, siblings, parents or grandparents who have substantial experience with minor childhood illnesses. Many people probably choose to call Mom before using a pediatrician's help line. It's human nature.

    Why should those who don't use the help line subsidize those who do?

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  40. "If they simply charged everyone a little more overall the whole year, that would have been much more acceptable than having to decide whether to pay a $20 fee per call." There are such practices in adult medicine, they are called "boutique", and you are entitled to call your physician 24/7 for just about anything and the fee is around $1500 annually. Your pediatrician was probably stuck however, signing up to take your insurance, where his/her general fees for service are dictated to the penny by the insurance company. These fees are usually so low that a pediatrician has difficulty meeting expenses (Note - I sympathize with them - but I am not a pediatrician). So, with high overhead, low fees, and patients trying to avoid office visits and copays, they are forced to charge for filling in forms, getting pre-authorizations, and answering after hours.

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  41. Fizzy -- I pay the private alarm system AND I pay the police. You get a bill from the city of Philadelphia sometime after they respond to the call. Oh, and I also pay city taxes.

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  42. Fizzy - Your health care decisions are ALREADY made based on money. You resent having to make the decision to call or not to call based on money. However, doesn't money also affect your decision on whether to bring your child to the doctor or urgent care or the ED? Unless you have Medicaid (which only has very limited copays), there is a copay for any private insurance for a doctor's visit. That copay is higher for urgent care, and the copay is higher still for the ED. I know that absolutely makes a difference to me in terms of what I do. I avoid the ED unless I truly believe it's an emergency. I also avoid urgent care unless I or a family member has to be seen that day and we have no PCP or the PCP isn't available. And if this is something that I feel I/my child can tough out (i.e. viral infection, etc), I/we don't go to the doctor at all. It's the same reason why I always request a generic, and if possible, a med on the $4 list, rather than a brand name med. All these decisions are made in consideration of cost. For some physicians who choose to charge for calls, the patients/parents will have to factor that into the decision as well.

    In terms of a nurse triage line, keep in mind that not every physician has a nurse to do triages. I didn't have that in my prior practice and don't now either. All calls come to me. So that means I have to answer everything from "What's this rash my child has that started 5 days ago" to "My child is having a fever. What do I do?" Answering calls from parents takes time, and it is NOT unreasonable to charge for it. Since you disagree with that, absolutely vote with your feet, and find a practice that doesn't charge for calls, and you have already done that!

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  43. From CardioMom:
    I agree with Liana. I do not believe that doctors should provide free services anymore than lawyers should (if the government doesn't agree then they should pay for it). We as a profession are highly undervalued, underpaid for services, underappreciated, overworked and then oversued. The phonecalls are a huge source of liabilty (anecdotal evidence of this: patient claims to have called about stopping plavix prior to a dental proceudure, claims to have been told to stop, stops it , has his teeth fixed and thrombosis his stent 5 days later, sues for $1.5M , gets paid, comes back to hospital every month throwing it in our faces - his settlement terms state we have to keep seeing him in our practice). I think that $20 dollars is a fair price for a call, let me tell you a LOT of calls get screened by the cost issue alone. I would charge for all calls, and then convert it to a copay credit if the patients come in to the office to get seen about the problem. The alternative is to allow patients to call into a voicemail service with the disclaimer that if they do not hear back from the office within a certain time (eg 30 minutes or one hour) and they feel its urgent then they should come in for an unscheduled appointment or go to ER, otherwise 'their call will be answered in the order of which it was received'- ever heard that one? They absolute no no's will be refills on meds after hours (you can imagine how many 3 am calls i have received for zocor and and crestor refills). Since all patients will be insured very soon, then doctors will definitely get even more work for less pay, our time will therefore cost more. No one is sentimental with doctors when we get sued, justified or not but once we demand a fair price for services, everyone starts talking about compassion, professional satisfaction, sefless giving , blah blah blah.

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  44. Someone brought up the cost per hour of a phone call.

    I noticed that the discussion only references time spent on the phone with the patient.

    Please add in, documenting the phone call and filing the paperwork in the patient's chart.

    So, any phone call takes a minimum of 15 minutes, assuming easy chart access PLUS the time spent on the phone.

    Answering services also cost a monthly fee plus a per call fee in and out. In other word, services charge for each call: the patient calls into the service (1st call). The service calls the doc or nurse (2nd call).

    These things add up quickly.

    That's not even counting any payment to the on call RN or MD for their time spent.

    To the Canadian and others, yes, it is a bummer to talk about dirty money and health care. But things cost money.

    I think it is a bummer to talk about the cost of food. Why can't everyone in the world have access to fresh food?

    But it costs money.

    And so on.

    I think a lot of us think it is worth it to provide health care to those who need it. And that is a great investment for a society to make. Yes, it costs more to have healthy people who live longer, but it is often worth it.

    But it costs money.

    Not dirty money. Just money.

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  45. >>So, any phone call takes a minimum of 15 minutes, assuming easy chart access PLUS the time spent on the phone.>>

    Agreed.

    If an average parent consults the nurse line twice a year (on a per-child basis), and the average pediatrician has, say, 3500 active patients, the nurse would be answering about 19 after hours calls a day, every day, per pediatrician. Busy, busy...

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  46. If a practice has 3500 active patients (I have no idea how accurate this is) and each person paid a $50 per year fee to be part of the practice, that would leave $500 per night for calls. I don't think that's a bad sum of money for an advice nurse to make in one night.

    Do I think people who use the advice line should be charged more than people who don't? No. I think people who *abuse* the line such as by asking for med refills should be charged. But if my kid ends up getting sick a lot, why should I be penalized for that? Why should I be afraid to call my pediatrician because of money?

    Yeah, everything in the world comes down to money. But I do feel like health care ought to be different. That's not to say people who work at night shouldn't be compensated for their time because they should. Just that I think decisions we make for our own health shouldn't be influenced by money.

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  47. >>I don't think that's a bad sum of money for an advice nurse to make in one night.>>

    As TigerMom explained, that would not be the nurse's salary. There are other expenses associated with maintaining a help line in addition to salary.

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  48. So could charge each patient $60 per year. Or give the nurse $400 per night. Or cut out the answering service. Still not a bad salary for a job that could theoretically be done at home and you never have to leave your house. Imagine making 62K per year to just take phone calls three nights per week.

    I think this all comes down to the question of whether or not medicine is a private business. I think both doctors and patients would be happier if it wasn't. But I guess the fact of the matter is that it IS a private business, so we should really expect things that feel morally wrong.

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  49. >>So could charge each patient $60 per year.>>

    Would participation be mandatory? Some parents may resent paying an annual fee for a service they do not value or utilize.

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  50. >>But if my kid ends up getting sick a lot, why should I be penalized for that? Why should I be afraid to call my pediatrician because of money?<<

    It's not a question of PENALIZING you, no one is saying, "Oh, that horrible woman, her child is always sick, how dare she!" But it IS a question of whether you're entitled to receive a service for free. Someone is spending time answering those calls, and if you think their opinion is worth enough to call them, then it's worth enough to pay them for it.

    If I need to call Poison Control about a dog, there's a $50 fee. But their advice is valuable (and someone is spending time and effort taking my call), so if I need it, I don't feel entitled to it for free.

    And isn't this is partly what emergency rooms are for? If something is SO serious that it can't wait until morning, it's an emergency. If it's NOT that serious, then it can wait until morning! Of course it's not always immediately obvious if something is an emergency, but then you have the option of spending an hour of your own time observing the situation and seeing if it's progressing (in either direction) or paying a (small) fee for someone else's expert advice.

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  51. Dr Fizzy! Aren't you quite the Miss Controversy of late?

    Another here who just can't imagine needing to take money for advice like this.

    In Australia there is a private sector but any after hours care happens for the most part for free in the public sector and if people wish they transfer to the private sector.

    We also have no direct access to specialists in general. We would need to see a General Practitioner or an Emergency doctor before seeing a paediatrician which has its advantages and disadvantages. But I am a public sector Doctor through and through and believe whole heartedly in free access to health care for all, especially children! I would rather see 10 mildly ill children and give sound advice and reassurance than see one flat child who didn't come earlier becasue their parents prioritised food shopping or the like.

    General practitioners in Australia have an out of pocket fee but almost all of them will waive that for anyone under 20 and just receive the government rebate.

    Whatever will you blog about next Fizzy?

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  52. Bekkles: Believe it or not, I actually thought this was a less controversial topic!

    I have an HMO plan (which I had no choice about), so I don't have direct access to specialists either. But certain specialties, such as pediatricians and OBs are considered generalists, so we don't need referrals for those.

    For all those arguing with me, I have one final (probably not) word on the topic: Imagine you were a pediatrician and one of your four year old patients had obvious signs of appendicitis at 7PM. The parents call the help line but they're not wealthy and because of the $20 fee and the fact that they can't recognize the signs themselves, they decide to wait till morning to call. The child ruptures his appendix overnight and ends up dead. A call to the nurse helpline would have probably led the child to the ER and probably saved his life. Are you comfortable with this theoretical situation? You can blame the parents, but really, you are partially responsible. Personally, I couldn't live with that.

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  53. >>A call to the nurse helpline would have probably led the child to the ER and probably saved his life. Are you comfortable with this theoretical situation? You can blame the parents, but really, you are partially responsible.>>

    Keep in mind I do NOT charge for after hours calls.

    The fact is, I have had clients not recognize life-threatening emergencies (surgical abdomen), and their horses have indeed died as a result.

    Though it is difficult to absolve myself of the guilt, this is NOT my fault, and I don't think a pediatrician would be at fault, either. Just my opinion.

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  54. My little brother was in a similar situation and god knows what would have happened if he hadn't called me and I told him to go straight to the ER.

    You can talk about fault and legally you wouldn't be responsible... yet, I would have trouble with guilt if it were MY patient, a four year old child, who would have lived if I hadn't instituted that charge. Can we really say we don't care? Aren't *some* of the things we said when we applied to med school true?

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  55. Tigermom hit it on the head with her comment, "Not dirty money. Just money."

    I understand that the Canadians, Australians, and British are inured to a different system. Everyone, however, needs to understand that in NO country is there such a thing as "free" medical care. It's either paid for in "fee for service," insurance premiums, or TAXES. If, as in those nationalized systems, it's PAID for by taxes, the costs just are less visible to the individual.

    Well, there is some "free" care, I suppose, given to people who don't pay taxes or, in our system, can't afford insurance and can't afford to pay out of pocket. But even this "free" care is subsidized by other members of society.

    In the end, economics can't be separated from health care, just as it can't be separated from food and clothing (again, nod to Tigermom). Economics is about goods and services. Health care is a service, and it is an industry. So spare me the moans about the ethics of taking money for a service provided. How about the ethics of forcing a person to provide a service without fair compensation? We know a little about that here in the Deep South...

    And spare me the holier-than-thou "our system is better than yours" and "our doctors are nicer than yours because we see anyone for 'just the government rebate'". We are all colleagues here, and we all do our share of charity work. We all care about patients' welfare and outcomes.

    Having vented all that, I think there are several different ways to address the cost of after hours calls. The sliding scale approach discussed earlier is a good idea. I think annual fee "concierge" or "boutique" primary care practices are a great way to provide 24-7 high quality primary care without running yourself to death. (I enrolled my dad in such a practice, and it's been great for him, well worth the $1500 annual fee.) Unlimited phone calls are included in the fee. Also, call stipends are a very fair idea. My partners and I receive a stipend for trauma call which helps offset the costs of providing high intensity care to the uninsured.

    So, I do think there should be a visible price for after hours calls. It is a professional service. Personally, I think $20 per call is a little high, and I agree that Fizzy (and anyone else) has the right to shop around for a better deal.

    And I also agree that the cost of such an after hours call is worth it, especially if it prevents a more expensive visit to the ER. It's the parents' responsibility to seek advice when their child is sick. There are many costs involved in child-rearing, and this is one of them. I would feel terrible, yes, if a child died because of a delay in coming to the ER, but I would not feel personally guilty. (I would if I had given incorrect advice over the phone that led to that situation.)

    Our society needs to get over its sense of whiny entitlement. But that's a discussion for a different forum/different day.

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  56. GCS15: I definitely understand that the Australian people pay for their health care in taxes. It is simply a different approach to have to find the out of pocket expense at the time that a person is sick.

    There is much talk about health funding in Australian politics and media and it is by no means hidden and there are those in Australia, though I would say it is a minority, who would advocate going down the road of user-pays privatisation.

    I am not one of them. I believe we need to look after needy members of our society just as well as we would the wealthy.

    This is my philosophy. I don't think our doctors are nicer than your doctors I just think it is nice to have the option of not worrying about such issues as these. In fact, a government funded system means that often things such as after hours access to primary care is well thought out, as it is in the interest of the government to ease pressure on emergency departments. I definitely didn't mean to offend. Simply offer a point of view from down under.

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  57. It actually surprises me how many people support charging per call. Whenever I mentioned this to friends, they were all horrified. When I mentioned it to Dr. Grumpy, who is the king of stupid calls, he was horrified and thought it was immoral. And I've used two other pediatrics practices since then (due to moving) and neither of them charged for after-hours calls. My OB/GYN doesn't charge for after-hours calls. My PCP doesn't charge for after-hours calls. This was the first time I'd ever come across a practice that did that. So it's not like I was upset about something that's really common... I truly believe it's sort of cruel and a potential danger to patients.

    Also, my first practice was a very large university-based practice. It wasn't one guy in the boondocks trying to make ends meet, in which case I might have understood.

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  58. >>I do think there should be a visible price for after hours calls. It is a professional service...

    >>...It's the parents' responsibility to seek advice when their child is sick. There are many costs involved in child-rearing, and this is one of them. I would feel terrible, yes, if a child died because of a delay in coming to the ER, but I would not feel personally guilty...

    >>Our society needs to get over its sense of whiny entitlement.>>

    Agreed, agreed, and agreed.

    Many years of listening to a similar litany of arguments from veterinary clients who don't want to pay for essential, sometimes life-saving services, has caused me to realize the sense of whiny entitlement is an American character flaw, not specific to either horse owners or veterinary clients in general. This attitude can eventually contribute to compassion fatigue amongst primary care physicians, pediatricians and, yes, veterinarians.

    Because this attitude is frequently accompanied by a stunning lack of insight, the only answer for practices trying to cope with staff burnout is to set limits. Charging a fee for an advice line is an attempt to set limits.

    Consider that one hundred years ago, it was common for physicians to make housecalls (even after hours) and patients frequently knew where the physician lived. I suspect the change to office-based practice with set hours resulted in complaints by a subset of entitled patients, too.

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  59. I don't want to come off as an animal-hater, but I do think there's a big difference between having a sick pet and a sick child, which society does recognize.

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  60. >>I do think there's a big difference between having a sick pet and a sick child, which society does recognize.>>

    I recognize this, too. But many owners of animals - some of whom are my clients - do not.

    Just try saying "it's only a horse" to an entitled owner who doesn't understand why my coming out to examine a horse with, say, a swollen eye on an emergency basis will cost $XX vs. a scheduled appointment during regular hours.

    Even better, try saying "it's only a horse" when the client is a deadbeat who owes the practice money and calls with a truly life-threatening emergency.

    Best case scenario, the indignant client will fire back: "Don't you love horses?" and proceed to trash your name around town. Worst scenario, the client reports the veterinarian to the board of registration, or consults an attorney.

    Not too different from your complaints of "betrayal", "horribly unfair", "having to make a decision about my kid's (horse's) health based on money", "morally wrong", "you can blame the parents (owners) but you are partially responsible", and "cruel and dangerous".

    You, unlike me, are a physician, but you obviously haven't internalized the challenges of providing primary care, which I provide and you do not. I guess I don't understand the seeming lack of empathy for your pediatrician colleagues.

    At least some of my clients are professionals, but there's no such thing as a professional parent. I can't imagine a practice full of entitled parents. The minority of entitled horse owners I see are quite enough, thanks.

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  61. >>I don't want to come off as an animal-hater, but I do think there's a big difference between having a sick pet and a sick child, which society does recognize.<<

    I don't think anyone is saying they're the SAME, although I don't see how that's relevant. Your child has value TO YOU. My clients' dogs have value TO THEM. You don't give a hoot about their dog, and I'm sure they don't give a hoot about your kid.

    There's DEFINITELY a difference in the amount of legal trouble a physician can incur, compared to a veterinarian, and it's possible (although I hope it wouldn't happen since it's preposterous) that a client could claim that a call charge was partly responsible for their child's death, when the client wasn't responsible enough to prioritize their child's welfare over money. This would not happen in veterinary medicine, so in that sense you're right (although hopefully it also wouldn't happen in human medicine!).

    If your argument is that it's okay to charge for veterinary advice but not pediatric advice, because dogs are just dogs but your children are sacred (and therefore your pediatrician should be happy to answer the phone at 3 AM every day), I disagree. I don't think you're entitled to receive a professional service for free, regardless of whether it's for a dog or a child.

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  62. >>it's possible (although I hope it wouldn't happen since it's preposterous) that a client could claim that a call charge was partly responsible for their child's death, when the client wasn't responsible enough to prioritize their child's welfare over money. This would not happen in veterinary medicine>>

    Oh, dear, if only this were so.

    One of my friends was sued over this very issue. She told a client who paged her that the client's horse exhibiting signs of abdominal pain (aka colic) needed to be seen. The client declined care and elected to observe the horse. Several hours later, the client called a second veterinarian because the horse collapsed. The second veterinarian euthanized the dying horse. A necropsy revealed gastric rupture. The client sued the first veterinarian, my friend, for medical expenses and value of the horse ($25,000, IIRC). (Why didn't the client call my friend when the horse collapsed? In her panic, she dialed multiple veterinarians and the second veterinarian called back first. Why did the client sue my friend? It was a poor outcome, and someone had to pay - a similar motive for lawsuits in human medicine.)

    The case went to court and my friend won. Her malpractice insurance paid for her attorney, but not her lost wages, stress, depression, loss of clients (all horse clients know one another) and lost innocence.

    Re: lawsuits - it must mega-suck to be a physician.

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  63. It's not a matter of dogs being less important than children (or people). It's just that the government has set a precedent of caring for its people, not so much its animals. People have services such as welfare, food stamps, medicaid, police protection, etc, provided to them. Dogs, horses, etc, are not provided with that service. I don't know what the legal ramifications of turning a dying animal with no money away from an animal hospital, but you absolutely cannot do that to a person. So in that sense, it's different. Society at least attempts to provide for the safety, welfare, and shelter of its citizens, so why not the health too? Shouldn't that fall into the same category?

    And to the person who said I wasn't compassionate to my colleagues, the pediatricians: this was a NURSE HELP LINE. Never once got to talk to a physician. Was never even once told by the nurse than she was consulting with a doctor. And I'm sure she was well compensated for her time.

    I work in a private hospital, not in private practice. And you know what? I don't think that every time the patient hits the call button for some stupid reason, they should be charged $20. But that would be a great way to earn some extra bucks, wouldn't it? Inpatients are way too entitled :) Care at night should be extra! You have chest pain at midnight? You sure? Because it'll be $20 if you want to tell us about it....

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  64. So just to clarify, Fizzy, you don't currently have any experience with what it's like to deal with overhead in private practice, and you don't currently have to deal with providing after hours telephone advice to clinic patients. Hopefully you realize though that the cost of the nurse help line if there are no fees is covered by the pediatrician's office? And again, even if there are fees, I seriously doubt that the pediatrician is turning a tidy profit on his after hours care line.

    Re: your comment about this practice not being out in the boondocks, it's actually been my experience that overheads in urban practices are higher than in rural areas. Higher rent, fewer incentives, etc. In my current group practice, they take 35% off my billings for overhead (I cover my own medicolegal insurance, licensing fees, etc.) and the margins are extremely narrow. When I worked in a rural area, my overhead was 20%.

    Again, to reiterate, I do think that after hours telephone advice is important and that finances should not be a barrier.

    I have a problem when it always falls on physicians to be heroic and self-sacrificing and prop up a system that is failing in some way (as is the case when most insurance companies don't cover after hours phone advice). In our area, one of the barriers to access is wait times. I have had patients leave the maternity triage area without being seen because they've been waiting for hours and get frustrated and leave. The response from the government is often: "Ok doctors, just work harder." Maybe in the short-term this helps, but all that accomplishes is a delay to finding a real solution.

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  65. >>I don't know what the legal ramifications of turning a dying animal with no money away from an animal hospital>>

    This is well off the original topic, but in the state in which I practice, by law, a veterinarian must stabilize an animal in imminent danger of dying if the animal arrives, unannounced, on the proverbial doorstep. Even if the owner is unable or unwilling to pay. Mobile veterinarians are required to respond to emergencies, but this is understandably more difficult to enforce; we can only be in one place at one time.

    This law is why some of my less scrupulous colleagues do not answer their pagers if a known deadbeat calls.

    >>And to the person who said I wasn't compassionate to my colleagues, the pediatricians: this was a NURSE HELP LINE.>>

    Yes. Your pediatrician hired a nurse to take calls no doubt in the interest of preserving her own sanity and quality of life. I suppose the pediatrician could have eaten the cost and settled for a smaller salary, eliminated the nurse line entirely, or just sucked it up and taken the calls herself. You probably know better than I that it's difficult to obtain insurance reimbursement for certain services, so raising office visit fees, etc. may not have been an option to recoup the cost of maintaining a nurse line. So the pediatrician chose to bill the parents. Sounds fair to me.

    Your pediatrician also could have chosen another specialty, which I understand is not an uncommon decision made by newly-minted physicians. Thank goodness for your kid that she didn't. It sounds like your pediatrician did a fine job, at least in the medical department.

    Why didn't you become a pediatrician? Proving medical care for children is obviously a subject about which you care passionately.

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  66. I have experience with taking night call for outpatient practice from residency, which was not very long ago. I don't do it currently, but I have some idea what it entails... and we didn't have any kind of triage whatsoever... all calls came to me. So I get that it can be annoying. But I still strongly believe that it's necessary. And I've never heard of a practice that doesn't have any sort of after hours emergency line, so obviously I'm right in this assessment. And in a time when the economy sucks, I'm sure loads of people would love to pick up extra money manning a helpline.

    I'm a physician and no, I don't want to be a martyr or think anyone else should be. I don't think we should work harder than a human should. Everyone is attacking me because I don't get that there is an overhead and the cost is so high, but I said clearly that I think it is reasonable to charge everyone in the practice a little extra out of pocket to financially support a helpline. What I took offense with specifically was being forced to make that decision of whether my kid's illness was worth $20. It was lose-lose: if I didn't pay the money, I felt guilty that I put money over her health... if I paid the money, then I'm out $20. So I really hated being forced to make that decision.

    And to Outrider: There were lots of reasons I didn't do peds... mainly, I just found it too haunting when there was a bad outcome. Also, parents are annoying :)

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  67. >>I think it is reasonable to charge everyone in the practice a little extra out of pocket to financially support a helpline.>>
    Do you think it's fair to charge everyone, even non-users? Sorry, I don't, and I'd resent paying a mandatory fee.

    >>It was lose-lose: if I didn't pay the money, I felt guilty that I put money over her health... if I paid the money, then I'm out $20.>>

    Actually, if you paid the $20, you'd be receiving a service. To some, the service would be triage and advice. To others, yourself included, apparently, the service would include making you feel less guilty. I guess.

    >>There were lots of reasons I didn't do peds... mainly, I just found it too haunting when there was a bad outcome.>>

    I get that answer all the time when people tell me "I could have been a veterinarian...". It's a poor, canned answer.

    >>parents are annoying

    That's probably closer to the truth, since I know there is a pediatric PM&R sub-specialty.

    Do you think your classmates who chose peds are any less "haunted" by bad outcomes? Outpatient peds is generally an upbeat specialty, from what I understand.

    Why didn't you become a pediatrician? Really, this time?

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  68. I think it's reasonable to charge everyone for a helpline because it's like insurance. I pay the same premium whether I use it or not. How do I know in advance if my kid is going to be sick a lot that year? Also, as I've said, I generally don't think it's fair for people who are unlucky enough to be sick more to have to suffer financially for it. It's not like you "earned" being sick less. It's luck.

    Regarding why I'm not a pediatrician: Some people have thicker skin than others. Especially now that I'm a mom, I am really bothered by children who are seriously ill. Rehab kids especially are heartbreaking. Some of those patients still haunt me. I would just wait till the rotation was over so I wouldn't have to see any more kids with burns on half their body or severe brain injuries from falling out a window. And on the other side of the coin, the kids who weren't as sick weren't particularly interesting to me: ear infections, strep throat, etc. To be honest, the parents weren't that bad. (Now I deal with adult children, who are pretty annoying sometimes too.)

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  69. >>I think it's reasonable to charge everyone for a helpline because it's like insurance.>>

    No, it isn't like insurance. It's a service some people simply wouldn't use, and not necessarily because their kids aren't sick.

    What you're actually saying is you want people who use the service less than you do to subsidize your usage. Of course, this is the way of the entitled American: small investment, large return.

    >>I am really bothered by children who are seriously ill.>>

    Do you really think pediatricians who are mothers are less bothered by seriously ill kids?

    Sorry, that's akin to "I could never euthanize a horse because I love them so much." Baloney.

    It's a socially acceptable canned answer, nothing more.

    >>the kids who weren't as sick weren't particularly interesting to me: ear infections, strep throat, etc.>>

    Ah. That's better. A little closer to the truth.

    How about the lifestyle and salary of the average pediatrician? It's a family-friendly specialty; I've even heard of shared residencies.

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  70. So in an interesting (to me) and completely unrelated to the point of your post way, I'll mention that I am a pediatrician with over ten years experience and I call my mom when my daughter is sick. Mom always knows what to do and her advice is always better than the on-call docs because she knows me and my little girl! Thank g-d she doesn't charge me. I am completely incapable of figuring out what to do FOR MY GIRL at 3 am.

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  71. memememe I hear you.
    When I go to doctors for advice when my babies are sick, I tell them whats going on, often diagnosis and all but then turn into a worried mum instantly. Like when my 2 year old had heamatemesis with a Mallory Weiss tear when my son was 2 days old, or carrying her into ED postictal after a febrile convulsion and dissolving into tears much to the surprise of my colleagues..surely I knew it was okay, I knew about febrile convulsions....BUt at the moment I was my babies mum and couldn't be her doctor.

    Outrider, I think you need to give Fizzy a break. Some people really can't cope with sick kids in a professional role, Just like I don't cope professionally in aged care. It breaks my heart to see people at the end of a long life with no family around, I want to take them home. I think I'd rather be a volunteer reader for old people than be their doctor, Yet I can deal with a child with cancer professionally...I don't know why...it just is. Different strokes.... How come you can't accept that?

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  72. Outrider, I'm baffled as to why my reason for not being a pediatrician is unacceptable to you. I actually even once wrote about it:

    http://www.mothersinmedicine.com/2008/11/i-could-never-be-pediatrician.html

    I don't think women who are able to see sicker kids are horrible... I don't think I'm a monster because dying old people don't bother me as much. Different people are able to tolerate different things. Of note, I also could never have been an ophthalmologist, because for reasons I don't understand, eye stuff freaks me out.

    As for the helpline, I think if you don't like the idea of everyone paying a little for a service that some people will use more than others, then you'd have to eliminate insurance entirely. After all, have you ever used your disability insurance? No, and you probably never will. But it's there and that's comforting to me. I rarely use the nurse helpline, but I like knowing it's available to me. And since it's for emergencies only, I think having it available IS a form of insurance. How does anyone know in advance if they're going to have an emergency? I wouldn't pay for a line that was for something nonemergent that I wouldn't use.

    Someday you may be sick and in need of these services and you'll be glad to have them and of the fact that your illness hasn't bankrupted you. It's easy to poo poo these things when you're still young and healthy... but one guarantee in life is that we all get old.

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  73. >>I think if you don't like the idea of everyone paying a little for a service that some people will use more than others, then you'd have to eliminate insurance entirely.>>

    Actually, I have a choice of plans when it came to insurance. I chose a high-deductible plan with few bells and whistles. Why should I pay extra for something I don't value and won't use?

    Also, as memememe said, many people - even pediatricians - prefer to call Mom.

    >>After all, have you ever used your disability insurance? No, and you probably never will.>>

    Not a good example.

    The probability that I, an equine ambulatory veterinarian, will use my disability policy is actually extremely high. Consider: one of my colleagues recently sustained a serious head injury on the job. She may be permanently disabled. Every single one of my close friends who has been in practice for longer than 10 years has had surgery for a job-related injury, usually chronic overuse: shoulders, knees, backs, fingers. There are discussions on the equine veterinary listservs to which I belong re: use of IA HA in humans (you may be professionally interested to know equine veterinarians have been using IA HA in horses for at least a decade). Equine veterinarians: Joints R Us.

    Our disability insurance rates are probably much higher than yours, justifiably. So: do you want to be included in the same insurance pool with us?

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  74. Actually, disability insurance is a perfect example then. The chances that I or my husband will ever use disability insurance are fairly low, yet we both contribute a decent amount for it each month. If you became disabled (which you said there is a high risk of), then all the money I put in would be used to pay you. I am paying for a service that I am likely to never use. Does this bother me? Absolutely not! And I wouldn't have any problem with being in the same insurance pool with you, as long as people like you were in the same insurance pool as old women with osteoporotic hips. As long as everyone pays equal amounts, I think it's fair. Yes, you'll overpay when you're young and healthy. But it will even out when you're old and sick.

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  75. "Actually, disability insurance is a perfect example then. The chances that I or my husband will ever use disability insurance are fairly low, yet we both contribute a decent amount for it each month. If you became disabled (which you said there is a high risk of), then all the money I put in would be used to pay you. I am paying for a service that I am likely to never use." The problem is that disability insurance is NOT a perfect example. Some independent evaluator will decide whether or not you qualify. And from what I see with my patients, it's not all that easy to qualify. The night call, on the other hand, is at the whim of the patient. As someone who takes my own call, without charge, I can tell you that "whim" is what causes the problem. I have 80 year old cardiac patients with chest pain who wait (inappropriately) for morning to call, and I have "entitled" mentality healthy young people who call after hours because their birth control pills ran out and they were too self absorbed to notice this between 8am and 5pm.

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  76. I think you are upset about this, Fizzy, because after-hours calls had traditionally been provided free of charge. It's the norm, and in your perception, is now your expectation of what good medical care means. For the pediatrician's office to change the rules and now charge for telephone calls, they're not playing by the rules.

    Whatever your feelings on this topic, you should realize that charging for after hours calls is becoming more common. There are actually CPT codes now for how to bill for after hours calls, and more and more pediatricians are starting to do that. This is not something that is going away.

    Alright, enough said. We can all agree to disgree.

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  77. Holy cow, this turned out to be a hot topic, eh?? I'm late to it and haven't ready all the responses, but I'll give my 2 cents anyway.

    I'm not a doc, just a premed, but I have a chronically ill child. Our pediatrician lets us email her when we need something. I rarely contact the office because the nurses honestly know less than I do about her particular issues, so if I need help making a call like "Do we go to the hospital this time?" the nurse wouldn't be able to help. Once I called for a "normal" kid issue, an allergic reaction (lip and tongue swelling with vomiting), and the nurse told me I could go to the hospital although it might end up being unnecessary or I could stay home and risk her going into anaphylactic shock. I would have been PISSED to pay $20 for that ambiguous advice which I already knew before making the call.

    I'm thankful that I have a good relationship with her doctor, because if we were being charged $20 to hear a nurse say, "I don't know what to tell you, you should go to the EC just to be safe." we'd be in the EC all the time! As for my other child who doesn't have any chronic issues, I think I've called the office after hours once in his whole life, when he was 8 months old and had a 105.something fever and I was a first time mom.

    Outside of my experience as a parent, I think co-pays for phone calls will just further increase unnecessary EC visits, because patients can be seen in the EC without paying upfront and dodge/ignore the bill later...which so many people do ALREADY to avoid paying for a visit at that PCPs office. This will just add more incentive to heading to the EC whenever parents are the slightest bit worried. A lot of primary care pediatrics is simply calming parents down and telling them they are doing the right thing and that their kid will be okay, but without that safety net a lot more parents will be hustling off to the EC.

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  78. Kyla: I do think being able to call the helpline has spared me at least one ER visit. Fortunately, we haven't had that many illnesses that have concerned me enough to call after hours (twice ever, I think). I would never abuse the line, but if your kid seems pretty sick, it's very reassuring to be able to call and have them tell you it's OK to wait till the next morning. If I knew I was going to have to pay $20 for the call, then the copay for an ER visit, I very well might have just gone to the ER.

    Kelly: I probably would have been far less angry if the charges were more mainstream. It seemed like i was the only one I knew who was paying. That said, I still feel like it's the wrong thing to do.

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  79. >>I wouldn't have any problem with being in the same insurance pool with you, as long as people like you were in the same insurance pool as old women with osteoporotic hips. As long as everyone pays equal amounts, I think it's fair.>>

    But we don't pay equal amounts, and most old women don't have disability insurance because they're retired.

    My disability premiums are higher than yours (pro-rated to income, of course). I receive my disability insurance through a company that insures veterinarians and is familiar with our needs. When I first opened my own practice, I discovered many insurance companies won't insure large animal veterinarians, or provide inadequate coverage.

    It's obvious you've never been involved in managing a practice. It's not easy and requires a fair bit of knowledge not taught in either medical or veterinary school.

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  80. Well, this is pretty far off from the original topic, but I wouldn't object to everyone paying the same premiums (or taxes, as the case may be) for disability or health insurance. I think it sucks that some vets can't get adequate disability coverage and is very unfair. And I'm a young, healthy person saying that. I think what's unfair is to say that since you are young and healthy or have lots of money, let everyone else go to the wolves. I don't believe in that. I don't believe in it because I think it's morally wrong and I don't believe in it because I know that someday I will be old and sick and in need of medical care.

    And you can accuse me of not understanding how to manage a practice, but a free afterhours line is the way most practices currently work and have for years. So obviously it's feasible.

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  81. >>I wouldn't object to everyone paying the same premiums (or taxes, as the case may be) for disability or health insurance>>

    I agree with you, in theory, regarding identical insurance premiums.

    I disagree with you re: taxes. Those who have higher incomes should be taxed at higher rates.

    You're right, though; this is far off-topic.

    >>I think it sucks that some vets can't get adequate disability coverage and is very unfair.>>

    No, it isn't unfair. You were a math major. Surely you have a general idea of what an actuary does?

    Veterinarians certainly can get adequate disability insurance coverage. The issue is insurance companies that do not specifically insure the veterinary industry tend to sell policies that are inadequate to our needs. That's why I chose a policy designed specifically for veterinarians.

    >>And you can accuse me of not understanding how to manage a practice>>

    Simply a statement of fact.

    >>a free afterhours line is the way most practices currently work and have for years. So obviously it's feasible.>>

    It may have been feasible in the past, and it may currently be feasible for some practices. Some practices, your former pediatrician included, obviously couldn't make it work, financially.

    Keep in mind physicians also used to make housecalls. This was great for patients, but also expensive and eventually unworkable for most physicians.

    "Free" nurse lines may also become a thing of the past, as others have mentioned. It's a business decision.

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  82. Was it not economically feasible or were they simply greedy and hoping to make more money? Why shouldn't restaurants start charging patrons $20 a pop to use their restrooms? (I'm sure cleaning and servicing bathrooms creates expense.) Or to give an example that I'm quite familiar with, why shouldn't inpt units charge patients every time they hit their call buttons? Hospitals, after all, are businesses too (at least, private ones). If you think people call nurse help lines for stupid stuff, you should see the kind of crap an inpt nurse has to put up with. After all, nobody calls the nurse helpline because they don't like their dinner. If patients got charged every time they called for the nurse, the hospitals would make more money and it would cut down on the work nurses had to do. Don't you think that's a brilliant idea? It seems like you ought to.

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  83. @Fizzy re 3:10 comment
    Or to give an example that I'm quite familiar with, why shouldn't inpt units charge patients every time they hit their call buttons? ... If patients got charged every time they called for the nurse, the hospitals would make more money and it would cut down on the work nurses had to do...

    Really? Must be different in your hospital, then. I recall never pressing the call button until I got extremely ill after my daughter was born. When I got sick and pressed the call button, over the intercom I was informed that they were busy so I'd have to wait. They were supposed to be doing routine checks on me and the baby to make sure we were okay, so I figured someone would be along eventually. They never came. They didn't come for routine checks, and they didn't come when I tried the call button again. A friend phoned me and learned how sick I was, so she called the nursing supervisor to see why there was a patient with a newborn that nobody was checking on. The nursing supervisor then phoned me, but still nobody came to help me. After a third try I gave up. It wasn't until someone brought a meal tray and found blood and vomit all over the floor, five hours later, that I was finally acknowledged. I'd cleaned up what I could, but there's a limit to how much cleaning a sick person can do without a mop, in between heaves.

    You want to cut down on the work nurses are doing? They couldn't be bothered to walk clear to the end of the floor where my room was. What work? They were standing around the nurses' station, having a party.

    You want to charge when a patient presses the call button? Call buttons are ignored. How about if nurses just take care of their patients in the first place.

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  84. Warm socks: I'm terribly sorry you had such a horrible experience. But I assure you it's not like that everywhere. The nurses were fantastic when I had my daughter. And where I work now, I know they come quickly, because I sometimes press the call button when I'm in the room with patients and they always come right away. And believe me, patients do press that call button for really dumb reasons. However, this is a little off topic.

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  85. Very off topic. Sorry. It's a sore point with me. It's good to hear there are places that are different.

    As for your original post. I can understand why a fee might be charged. From a business standpoint, it might have worked for that practice. As a patient, though, I wouldn't be willing to pay it.

    I mentioned previously that there are hospitals with free nurse lines. The idea is that if patients have a hospital they can call for advice, that's the hospital that will be selected when there's a need for medical care. Others also have free advice lines. My insurance carrier is one of those places. It costs the insurer less to pay someone to give out phone advice than it does to pay for ER visits every time someone has an iffy situation. I can't imagine paying for a service that can be obtained for free. I'm glad you now have a pediatrician that you like better.

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  86. If there were a hospital with a free advice line, that would be just as good. I mean, it's not like the random nurse answering my call knew anything about my daughter. Perhaps that's a good cost-effective solution.

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  87. It's obvious you've never been involved in managing a practice. It's not easy and requires a fair bit of knowledge not taught in either medical or veterinary school.

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  88. I've never managed a restaurant before... does that mean I'm not allowed to complain if I go to a restaurant and get bad service?

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