Health 2.0

Why I Don’t Accept E-mail From Patients

Dr. Wes (a cardiology blogger who all should read) wrote a very compelling post about technology and the bondage it can create for doctors.:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) – we’re seeing a powerful force emerge – a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smart phones.

Doctors, you see, must be always present, always available, always giving

This sounds like dire words, but the degree to which it has resonated around the web among doctors is telling.  He continues:

Increasingly the question becomes – if we choose future doctors on their willingness to sacrifice for others without expectation of appropriate boundaries and compensation – will we be drawing from the same pool of people as the ones who will make the best technically-skilled clinicians? What type of person will enter medicine if they know that their personal life will always take second place to patient care?

Dr. Brian V (long last name, but another one who you all should read) adds his voice to this:

It started with the pager and it’s evolved to real-time social media.

I’ve seen it too many times:  Physicians excited to please open the door to unlimited patient email only to see themselves shutting their families out at night as they answer questions – all for free.  And those physicians who suggest that emails should carry a fee are indicted for greed.

We have been on EMR for 14 years, yet we don’t accept email from our patients.  We could do it, but we don’t – and both of these doctors hit on the head the reason why we don’t.  The goal of IT in our office can be summed up in one word: efficiency. The practice of medicine has become dominated with non-clinical tasks.

  • We have to gather information and organize it.
  • We have to serve as an “information central” for our patients, collecting from disparate sources to make informed choices.
  • We have to comply with the maze of government and insurance industry rules.
  • We have to give information to patients and to other medical providers.

So what actually happens in our office is less medicine and more information management.  IT allows us to do this in less time, leaving more time for our patients.

Accepting emails from patients at this point would mean more time spent doing un-reimbursed tasks.  Actually, it would potentially decrease our revenue, handling problems outside of the office (for free) instead of being paid for our services.  Doing so would give us three options:

  1. Working extra hours to make up for lost revenue.
  2. Giving free care via email and just accepting less pay, seeing less patients total.
  3. Spending less time with each patient to make up for the decreased revenue.

I am busy enough that I don’t want anyone to have to come in for things I could handle remotely.  Email communication with patients sounds ideal in many ways.  But unfortunately, the business case for this is so bad that we can’t open ourselves up to patient emails.  One answer would be to have a minimal charge for an e-visit ($20?), which would be credited toward an office visit if the e-visit warranted that the person come in to be seen.  The amount needs to be enough to ward off frivolous questions, and would have to be applicable to ALL insurances (including Medicare and Medicaid).

Email also works well with the idea of the “medical home,” which reimburses doctors for overall care of populations.  (I give my opinion on the medical home in this post.)

Until this happens – until we are somehow paid for giving care outside of the office – this useful technology will remain unused.  Is it greedy to not want to give things away for free?  Is it greedy for me to not want to spend less time with my family, make less money, or spend less time with patients?  Is it greedy to think I am worth $20?

If so, you can call me greedy.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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58 replies »

  1. ” And hire an intern to screen emails and respond accordingly.”

    At a minimum it would have to be the office nurse as is done with phone calls now. The problem is it takes a well trained person to get all the history points just to make a good judgment about disposition. So, the costs remain since a staff member must get paid and then there is no revenue against that. Insurance contracts and public plans prohibit payment for anything but a face to face visit, reinforced by the arcane coding system which requires an exam component. I expect telemedicine will occur over the internet. It will just come from outside the country where the regulators can’t reach. The answer is cash only.

  2. Go ahead. Charge – I believe good things in lide needs to be paid for. And hire an intern to screen emails and respond accordingly.
    because heal is an issue that does not follow a clock. i would prefer to write to my family doctor, who knows my history, to respond with a suggestion or referrral instead of standing in ER and being checked by an unknown doctor.

  3. I would have no problem paying the 20 dollar fee out of pocket for being able to report symptoms and rationales and getting a test ordered before my visit thus avoiding the second visit to review the test resulting from reporting this information and saving trips and time and delay in treatment. . .it’s what a co-pay costs anyway!

  4. Didn’t take long for the validation, re: how the government is planning to make emailing a forced practice: “And what many believe to be an outdated reimbursement system–one that drives doctors to schedule office visits when a phone call or email might do–doesn’t help”
    Ok, but based on who’s judgment? Isn’t that the doctors’, pardon the pun, call?
    http://www.usatoday.com front page story today, I can only wait to read the health deform advocates’ take on this. Oh, go to page two if you read a paper (you know, that material you line your bird cage with, to wipe your windows with, oh, and get some information from when your computer crashes), “A Portland Ore practice where doctors provide more care via the phone or email than face-to-face”.
    One more pearl from the article: “Greenfield Health [probably the group in Oregon as noted above, founded in Portland in 2001] doctors answer questions and resolve problems, such as interpreting test results or adjusting medications, without seeing patients.” Hmmm, I wonder how many follow calls they take after the patients did not write down all the critical facts/points from that first call?
    Yes, there is probably a sizeable percentage of situations that a phone call or email would suffice, but does the government understand the greys of health care? Nope. One size fits all. And oh how tight around the collar it feels for a good many of you in these situations from government regulated matters, eh?
    Enjoy the article. Health care deform does fit for me!!!

  5. I don’t think you answered my question. Do you believe in a for profit model to drive health care, or not? And if you do, how do you really provide good care when you are simultaneously watching your wallet? Not that I think you personally do this. But, I think our colleagues have bought into this bs that we should be making a killing. Literally!

  6. Exhausted: The only way it can be a for-profit business model is if we can post our prices up-front and compete based on quality and cost. The hidden nature of the cost of HC is what makes it so damn complicated and frustrating. It’s what makes people not trust us. Why should hospitals charge $10 for 1 pill of Tylenol? Why should there be hemorrhoid cream that costs $100?? Why don’t doctors ever tell you what they will charge for a visit? The system prevents/enables this, and makes us targets of mistrust. Add to it docs who do gouge the system by seeing 50 patients per day, and we are obvious targets of suspicion. The problem is that people are lumping us all under the same mistrust. Why go after a PCP who wants $20 for an email the same as you go after cardiologists doing stents, ophthalmologists removing cataracts, or other specialists making 4-10 times our income doing less vital work?
    Joe: I don’t charge half for a 10-minte visit, but you have it backwards. If I spend 45 minutes with them, I get the same as if I spend 15 minutes (roughly), and if I spend 10-mintues or even 5, I get 75% of what I get for the highly complicated patient. The system has decided that I am better served to spend 5 minutes than I am to spend 30. I would that reimbursement was related to time spent! It’s not. That’s not my fault.

  7. My mistake for giving a damn. Just hope the people who visit this site find what they want. It won’t be enough from a computer though. When we stop getting enough satisfaction from genuine, supportive, sympathetic human contact, all will be lost.
    Good luck America. you need it, you just won’t be getting it from these people in DC.

  8. So let me see if I “get it”.
    You spent 12+ years in advanced schooling, endured rigorous and exhausting training, spend every waking minute with the specter of having someone’s life in your hands at a moments notice, carry a pager and a cell phone constantly which can go off at any time with anything from a nit to a traumatic situation, work 80 hours a week, plus weekends, etc.
    But it’s “just a job”. It’s just a way to make a living.
    And your patients are not customers; they are just people you interact with in order to get some payment from a “third party”. In fact, mostly these people frustrate you with their ignorance, selfish demands, lack of self-control, lack of personal accountability and compliance, and their general laziness regarding their own health and well-being. And all they want from you is to be “fixed” – who cares about the diagnosis. All of your skills and knowledge are seldom appreciated, and certainly you are not paid enough for what you do. Especially if you are a family practice physician watching your equally trained specialty peers making double or more what you make (and working half as hard). Even worse is your neighbor, the lawyer, who only went to school for 3 years, isn’t half as smart as you, and makes more money.
    And all that would be frustrating enough, lots of other people want you to prove that you provide “quality” care (which is just b.s because everyone knows you can’t be held accountable for outcomes of patients who won’t do what you tell them to), you are supposed to follow “evidence-based guidelines” (which are ridiculous because there’s really no such thing as a “standard of care”), and they want you to be “efficient” (which is just code for “spend less money” and “get paid less money”), and besides your patients are sicker than most. And now they are forcing you to use computers, which don’t do anything but cause more pain and frustration and more importantly take up time and resources that keep you from making money treating patients. You have to spend a lot of time doing everything but see patients, talking to insurance company peons trying to tell you what to do, and trying to keep you from making money. And there’s always a lawyer lurking somewhere behind a patient just waiting to sue you for something. I won’t even get into all the stupid government rules that dictate what you can and can’t do in order to bill Medicare for the pitiful amount they’ll end up paying you. And that was before the government took it over completely with this latest legislative monstrosity.
    But despite all of this, you are the best doctor you can be every day for the patients that come to see you.
    Do I “get it”?
    No wonder you are angry.

  9. Dr Lamberts:
    Do you believe that health care should accept this enforced belief it operates under a business model, that as a basic premise there should be a profit driven expectation to the services in the end?
    I honestly am interested in your opinion.
    Sincerely,
    ExhaustedMD

  10. Fee-for-service is clearly corrupting American medicine and bankrupting ordinary Americans to the financial benefit of medical professionals. Maybe Dr. Lamberts should get a salaried job working for the VA or one of the high quality, low cost “Clinics”. Then he would find out that us poor salaried workers never get paid extra for working extra hours.
    Dr. Lamberts, do you charge your patients half as much for a 10 minute visit as for a 20 minute one? I didn’t think so.

  11. Medicine in the U.S. is a business, as it should be. There is no reason why a practice should not be allowed to decide whether or not to “charge for email access to the practice” in the same manner that they are allowed to charge for other forms of access (office visit, phone call, etc…) to the practice. That is a business decision to be made by a practice on a case-by-case basis. Some practices may wish to include the ability to contact your physician via email in their business model, maybe it would be a good “selling point” or differentiator for the business. I wonder if some practices must provide email access to the practice as part of being a member in a larger provider network? Regardless, I don’t believe it would even be possible to mandate that a practice couldn’t charge for email access.

  12. By the way, my Animal House comment was related to the John Belushi character saying “8 years of college down the drain”, making the reference he was a career student. I was not inferring that graduate students are the bums of that fraternity house. But, I do take issue with the rationalizing that it is no big deal for people to finish graduate training in more than 10 years including their college years.
    When you make that kind of committment to that educational demand, it takes true exceptional situations to put post graduate training on hold. I read the above commentor using this a valid rebuttal to my original comment to be, well, lame.

  13. you truly do not “get” it, Paolo. Carrying a pager to come to the lab, call a colleague, even for a vet to come to treat a sick animal, is not the same as getting paged to potentially try to problem solve a life crisis for a human on the phone.
    I have learned that until you carry a pager or be on call to handle life emergencies, or at the very least be called for alleged emergencies to only have to tell the patient or family to follow up in the office within the next 24 hours, you have no idea what that responsibility entails.
    Would another colleague reading here perhaps try to explain this responsibility to this commentor so he will “get it”?
    And, I will not look the other way while you try to propagate the lie that patients are customers. Really? Explain to the other readers here how health care interactions are soundly based in the business model.
    I will be waiting eagerly to read this!!!

  14. Dr. E., I don’t know where you get your stereotypes from, but I can assure you that the typical assistant professor at Harvard or MIT does not get there by living the “animal house” life or having little commitment to finishing what they start. These are people who have worked 80 hour weeks to get through an average of six years of grad school and several years of post-doc. And they typically make less than 100k salaries.
    And yes, patients are customers. If they don’t like what they see, they can go elsewhere, and they often do. I have used email in the past with clinicians and found it to be very useful. In the future, if I ever have to make a choice between a practice accepting email and another one not accepting it, all other things being equal, I will probably choose the one giving me better access. It’s a free country. We are all free to decide what we supply and what we demand.
    As to pagers and working hours, a large segment of the work force is already married to their company cell phones, with almost no boundary between work and private life. Fortunately or unfortunately, in much of corporate America today it’s not unusual at all to have work meetings at night when necessary. Welcome to globalization and the always-on economy.

  15. Dr. E, very few people work 40 hours weeks nowadays. Sure some PhD folks may be slacking, but those in sciences and engineering are working their proverbial butts off and it still can take 8 years. No, they do not have responsibility for people’s lives, but that’s no reason to dismiss their efforts.
    I don’t know what it is that you are protesting exactly, but I have a feeling it is the, so called, health care reform.
    Let me ask you a very simple question: in view of all the upheavals in health care right now and in view of the poor economy and in view of everything you state (and I strongly believe) the profession represents, don’t you find it a bit petty to be complaining about a handful of lousy emails?
    (Not even phone calls or pages, just emails and the quotes in the original post did not mention e-visits, just e-mail)

  16. Hey Paolo, why don’t you wear a pager for a week, but that is probably about 6 days longer than you and your examples of equivalent PhD programs would agree to handle, programs that do not have responsibilities for peoples’ lives like doctors do.
    So, when you think you are finding a peer equivalent example, do your homework first! Otherwise, you look dumb!
    And I do mingle with people who have varied interests, some who never spent a day in a graduate program ,but know more about what is right and wrong than what some people here just echo over and over.
    Fortunately, most of the people I have met who became doctors and other competent and committed clinicians understand and respect the expectations of providing care. Because I finish what I commit to doing, and do not try to rationalize that lack of committment is ok. Think about what you wrote above. And why those people are not in med school, do not become doctors. It is a committment you are expected to finish in the timely fashion that programs expect of you when you matriculate into them. And those top notch people, I doubt they took more than 8 years to finish their programs. Top notch people do not drop out to finish up later. And, uh, you think we make the salaries we do working just a 40 hour a week job? Hence the pager comment at the beginning here.
    Doctors are expected to finish the job! Not take a year or more off to live the “Animal House” life!
    Oh, and care to explain more this “…[patients] have the right to try to get as much service as possible.” Again, this absurd and outlandish application that patients are customers. Do you call your attorney at 11Pm and expect him to review documents, or your accountant to clarify your tax returns? Can I see this contract you have magically created that expects doctors to be 24 hour a day attendants?
    I hope responsible readers see through these comments!!!!

  17. “Why shouldn’t doctors be like any other person who doesn’t like to get pay cuts and wants to get pay raises.”
    Rob, of course physicians are people and have the right to try to get paid as much as possible. However, patients are also people and also have the right to try to get as much service as possible.
    Similarly, physicians (like any other professional) have the right to not accept emails, just like their customers have the right to move to a different practice where email is accepted.

  18. “Finally, I want to meet someone who spends 12 years or more of their life after high school spending the time, money, and energy it takes to complete the training that is the discipline of earning an MD degree and becoming board eligible in a field, and then offering your services for want amounts to an impovershed lifestyle.”
    Easy. Simply visit any good PhD program in the country. Only half the people who start a PhD program complete it within 10 years. There are numerous cases of people taking more than 8 years to complete the degree. And after completing their degrees, many can only work as a post-doc for a number of years. And once they get a real job, they don’t make anywhere close to a physician’s salary.
    Go hang out with some top notch and dedicated astronomers, archeologists, physicists, or marine biologists. It might open your mind a little.

  19. > maybe it is time for the majority of us MDs to
    > realize, it is time to fight for what is right
    I sincerely hope you do, and I hope it is not too late already. Policy is a very, very blunt instrument but it is the only instrument available if The Guild behaves like a fraternity and not a Guild.
    t

  20. First of all, Rob is right on the mark, the inconsistency of this society is more than annoying when you deal with those who expect us to act like the initials after our names are G.O.D., and then are so outraged when we perform because the initials are really M.D.
    Personally, I get the sense we are reading a lot of projection by these commentors who are so quick to demean and diminish our positions, especially about money. I again offer my daily pay for a day to read just one of these attackers who call us greedy pigs to admit to their financial policies they live by that is so illustrative of their expectations of us. The ones who call this profession greedy are in fact, until responsibly proven otherwise, the ones who look to cash in on this pending change.
    Second, to Tom Leith, yes, doctors contributed mightily to the problems we now have in our laps, and we suck at disciplining ourselves, mostly because of the lame “fraternity” attitude that still persists to this day among colleagues. I speak personally in noting how difficult, if not impossible it is, trying to rein in maladaptive behaviors of others that gets twisted into basically whistleblowing; and when you get ostracized for doing what is right, and your alleged “peers” reply by attacking you and forcing you out, it really makes you wonder who is promoting advocacy and concern for the public, and who is just acting like an immature college student on frat row!
    That said, I believe the majority of doctors, even if it is just 50.1%, practice medicine because they care and sincerely want to help people help themselves. Sorry it is not 95%, but, from the writings of those of you who want to condemn the whole field, well, just hope you are never lumped into the lynch mob mentality against you for the dumbass behaviors of the minority you unfortunately are guilty of innocent inclusion.
    Third, to twa, sorry to say, but the writings that pervade by certain “usual suspects” is fair to interpret as doctor hating/bashing fairly much solely over income matters first and foremost. To those who are so quick to promote the example of one guy who is a materialistic jerk, you seem to easily push aside the OTHERS who are just earning a paycheck like the majority of middle class earners, but hey, you need your poster boys to sell your falsehoods, eh? Unbiased and objective readers can go back to other threads that degenerate into income debates and can read who is raising legitimate concerns, and who is just basically saying someone else should be profiting.
    Hey, you’ll read in more than one place my passionate disgust for the FOR profit model in health care. But, health care has degraded into a profit driven model. And yet, it is NOT a business. Well, until those who want to profit from it will argue otherwise. You can’t make large amounts of money and provide good care, they are mutual incongruent agendas. Don’t believe me, just see the history of examples that show this to be a truism.
    Finally, I want to meet someone who spends 12 years or more of their life after high school spending the time, money, and energy it takes to complete the training that is the discipline of earning an MD degree and becoming board eligible in a field, and then offering your services for want amounts to an impovershed lifestyle. Yes, I am sure there are Mother Teresa’s in medicine out there, and if these individuals are happy and find full reward in their choices, I sincerely applaud and admire them. But, that is not the reality that most people embrace when making those sacrifices in accepting this discipline. And it is not first about the money, but hey, hard work has rewards, and part of it is income.
    Honestly, if I was told I would be paid 1/3 less money a year but I would be respected and have the autonomy to practice the way I was trained, certainly accountable to my State Board and Specialty Board to maintain the standards of my training, I’d accept it in a second! But, too many non clinicians have found ways to intrude into the patient-physician relationship and too many people have bought into the agenda of this intrusion that is “hear the lie enough and it becomes the truth”, and we certainly have those supporters of that adage here in these comment threads!!!
    So, the Dr Lamberts will continue to be respectful and polite in trying to redirect for the better. I’m done trying that route. My sacrifices to be the doctor I have been for the past several decades will not be lost for the greed and poor choices of the few. Sorry, the other cheek ain’t going to be shown. And maybe it is time for the majority of us MDs to realize, it is time to fight for what is right, or just lay down and be pummeled into submission or death. That is how I interpret the agenda of this legislative attack on what little freedoms and abilities to practice responsibly and efficaciously we have left as of 2010.
    Hey, believe me, or just listen to all these non clinicians tell you they know better than me. It is your choice.
    At least for now!!!

  21. Dr. L,
    There is a fine line here. Doctors are people and they should not be expected to sacrifice everything “for the sake of our patients”, but we are not really talking about sacrificing it all, are we? We are talking about “sacrificing” some, and maybe sacrifice is not even the right word when medicine is one of the best paid professions in this country, by far.
    Maybe we are just expecting the best and the brightest and the most educated and those with the highest ethical standards, to not confine their outrage to minor financial concerns (by comparison to their income), particularly during hard times when most Americans are doing very poorly.
    You are supposed to be, you chose to be, the patient advocate, not the prosecutor and judge rolled into one.

  22. It’s a job. Jobs pay money. That’s not less noble. Why shouldn’t doctors be like any other person who doesn’t like to get pay cuts and wants to get pay raises. It’s silly to think docs should do otherwise.
    It’s funny how people get mad when docs have “god complexes” and yet they want us to act in a non-human way by not caring at all about our own needs but sacrificing all for the sake of our patients. Uh…can doctors be humans? Can we not be expected to be saints? We severely disappoint people like twa who think we should be more noble than other people. Nope. We are just people. Sorry.

  23. What a shame that the medical profession is reduced to thinking about what it does and doesn’t do based on payment. This may be a common practice among some professions – lawyers, some CPAs, and I guess prostitutes. But I think it’s sad that physicians would be so eager to lump themselves in with other professions whose sole value can be measured in specific allotments of time or in specific activities. A person’s illness (or health) is not so clearly served by such specifics, but over multiple providers, across settings, and over time. To the extent that physicians have let the discussion devolve to this level it is no wonder they are Exhausted to the point of losing civility. I think Tom hit the nail on the head. The guild has outlived its usefulness and new models of care are needed. These models exist and several posters have described how care has evolved where such a silly issue of whether to accept email are not discussed with regard to payment, but instead with regard to what kinds of tools and resources might be used to improve care for patients.
    Quit hiding behind this notion that some of us “hate doctors”. That is a convenient story you tell yourself to justify the response to your cynical and archaic view of the world. I would suggest that we are instead disappointed and a bit frustrated with physicians. So much potential, so much talent, so much dedication and yet the profession seems to be more interested in self-preservation than serving the interests of patients.

  24. Dear Exhausted,
    It seems to me the medical profession eradicated ITSELF about 90 years ago when it got the government to eliminate the competition and then failed to discipline its own members. They wanted the benefits of being a Guild without the responsibilities, and that’s finally beginning to hurt. Search for my name on THCB along with the phrase “The Guild” — you’ll find this has been a recurring topic.
    I’m not saying it was you personally, but it has been the trend for almost a century. To repair the damage, maybe docs will have to drop Medicare altogether and stop accepting assignment and refuse to join PPO networks. They must also begin to review each other’s work in earnest and address shortcomings one way or another. This is going to be very, very painful — you’ll be undoing a century in a decade. But if you and your colleagues don’t address the well-documented problems of clinical practice and finance from the bottom up, they will be addressed for you from the top down, howsoever clumsily, and you yourselves will have collectively deserved it by insisting so strongly on your individuality.
    Do you even know when the next meeting of your local medical society is? If not, why not? If you do, great! Go attend, but not to kvetch, rather to lead. Who knows, but you may find you are not powerless, and leave refreshed and energized.
    t

  25. Are you sure about that?
    Medicare does not pay for yearly physicals, but you can still offer them. Medicare patients will pay out of pocket and privately insured will pay according to their plan rules.
    There are private payers who do pay a pittance for e-visits (Cigna and Aetna come to mind, $25-$35 or so) but that’s more than just an email exchange. I believe the CPT is 99444.

  26. Here’s the rub: We CANNOT offer e-visits to our non Medicare/Medicaid patients while denying it to the public plans. That is considered discriminating against those patients. We also can’t require $x fee for it and expect the M/M patients to pay. You cannot balance bill in any way, and that is what it would be.

  27. Margalit – I’d say 80% of ALL patients have email. Most Medicaid do. Many have smartphones.
    This post was not in reference to e-communication as a whole. I prefer informing patients of labs, getting refill and appointment requests via email or online form. No charge for that (since it saves me time). I am ONLY talking about giving care via email (which is an incredibly good idea that would save the system money if implemented properly).

  28. Treat people who only take and do not give, do it for 15 years, and get back to me!
    They have become a thankless population by in large in my specialty, and from what I have heard from other colleagues in other specialties, basically the same.
    And for someone who is not liable like we are, it shows that you assume things that are not the same in this profession. And when in medicine is a question really quick and finite? It always has a follow up until proven otherwise.
    This is a thread I will be following until it is closed or people get bored!

  29. “…deeds not words truly reflect what this population is about.”
    “This” population is about poverty and lack of education. It is about vulnerability, misery and lack of recourse.
    Of all wealthy people, I would have expected doctors to have most compassion for the poor. I guess not.
    I think you should charge for e-visits just as much as you charge for an office visit and if the insurer will not pay, you should not engage in e-visits.
    I also think that refusing to answer a quick question over email, when you already do that over the phone, is a bit peculiar.

  30. It is a shame the comment I painstakingly wrote last night was lost, and I am beginning to wonder why there are glitches with regularity at this site. Oh, I forgot, it is the harbinger of things to come with all the gleeful support of health care deform many of you pine for!
    Ms G-A, you are out of touch with reality to say that Medicaid pts appreciate doctors as much if not more than the average regular insured pt does. With no show rates more than 25% and compliance with standard treatment recommendations hovering around 50-60%, deeds not words truly reflect what this population is about. Your comment is beyond hollow, it is truly clueless.
    And, can we have a moment of true honesty, candor, and frankness. As government gets its paws on running health care for all of us, you really do not see that doctors will be asked to treat people over the internet, even if it is by teleprompter contact?! What is cheaper folks, an office visit, or typing/talking into a mic?
    As I wrote last night and will repeat now: This insane dedication to a legislative act that was created by non clinicians, rabidly supported by mostly non clinicians, and has a covert following who are showing their true colors in trying to eradicate the medical profession, if not at least tie it down and make it a wimpering pet, all of you deserve what is coming.
    I just hope the Theater of the Health Care Absurd make this site it’s running commentary for 2015 and put the names in bold print of some of the most clueless and inconsiderate repeat commenters in demeaning the practice of medicine, so people know where to turn when they realize they were sold out by said charlatans.
    Dr L’s last comment was nice. I have given up being nice, because this is an environment that is expecting us as clinicians not just to turn the other cheek after the first slap, but turn around so we can be clocked with the 2×4 of “get the F— out of here, you bastard doctor!”
    Wait for it, it will be coming if you are foolish enough to turn your back!!!

  31. Inform (via waiting room sign)patients that e-mail review and reply will require a fee. If it is “illegal” to do so in someone’s view, pursue civil disobedience by implementing with your own attorney’s knowledge. Do not reply to patients only seen at hospital ( as admissions or in walk-in/ER).

  32. Dr. L,
    What percentage of your Medicaid patients have an email registered in your EHR?
    I don’t think anybody here was talking about e-visits. How about this scenario: a patient comes in, you decide to try prescribing some new meds and the patient starts taking them, but feels constantly nauseous. A couple of days later he sends you an email saying the new meds make him nauseous and asks if he should come in or maybe you can change the meds, as you discussed during the visit.
    Would that qualify as something you give away for free or as an e-visit? Or just save you and the patient a phone call and possibly a bit of phone tag?

  33. The real problem is this: once we start giving something away for free that we should charge for, it is unlikely we will ever get paid. I am not talking about appointment requests, refill requests, or about me sending lab results via email. We are already doing all of that. What I am talking about is actual care given via email. I am talking about e-visits. I won’t give significant care via email until it is reimbursed. It is a task that takes expertise, takes risk, and offers value. Why should it be free?
    Margalit, I hate to disagree about the Medicaid population, but since we cannot charge a copay or extra money, they do tend to overuse resources. The number of ER visits for small problems and the number of office visits for the same are markedly more than are privately insured patients (and Medicare, for that matter). It sounds very much like stereotyping, but I’ve not met a doc who wouldn’t agree with this generalization.

  34. A primary care doc could easily put up a wordpress blog and offer NON-URGENT medical information to the global patient base for a fee and make a good living so long as their finances are in order. This would eliminate the need to have to continue putting up with the ever increasing bureaucratic BS and the I WANT and I NEEDS of whining patients, disgruntled employees, and out of control management that is stressed out and pushed to their limits.

  35. rbar, first of all, I do agree with your previous comment regarding the screening of email. emails should go to the clinic, not your personal gmail account and rules regarding emergency situations and expected response times should be established. Most docs that use email do that already.
    The way I see it email is intended to replace phone calls. Phone calls are intrusive and waste a lot more time than email, for both sides.
    As to doctors being busy, most professional people and a large number of others are equally busy. It’s part of modernization. We all work more hours than previous generations and leisure time is shrinking for everybody.
    A good email policy should take care of the minority of patients who are inclined to sit there and email the clinic 6 times a day. The vast majority, those who rarely see doctors, will also rarely use email.

  36. I feel like a doctor should be available 24/7. They care about money and that’s why they don’t take emails. They feel they should be paid for everything. Just because you went to a little more school and had to pass tests doesn’t mean you should even get paid for emails.
    For help with your search for an assisted living facility check out silvercensus.com!

  37. Uhmmh, Margalit, I am the first to admit that many doctors have shortcomings … but it is hard to deny that docs are a highly selected group, meaning that they have to pass exams and also have to prove reliability and usually at least a sliver of social skills in order to get through residency. They also tend to be busy. Therefore, the fact that docs did only raraly abuse that private cell does not prove anything. We are talking about a possible option for ALL patients here.

  38. Maybe you should change your alias to “incoherent and inconsiderate”!
    But, thanks for the validation to my comment about the doctor bashers! People really do not want to hear, read, or basically be exposed to the truths of health care, do they!?
    You people really deserve the realities this bs legislation will force on this country if it plays out unchallenged. And I will bet a day’s income most of the hardened supporters of this legislative crap have an ulterior motive to support it.
    But, honesty behind eloquent aliases ain’t gonna happen, eh?!
    Just pay attention to this, unspoken readers.

  39. Is this really a problem in and of itself, or just another indictment of the reimbursement system not accounting for time spent on coordination and other tasks where the patient is not in the room?
    For many years I have been on the other side: providing services for doctors. Every single one had my email address and the vast majority had my cell phone number. This was not part of the “support” package. It was courtesy to the customer and completely uncompensated and never charged to the customer.
    Did doctors abuse these lines of communication? Nope. Once in a while, you would get one customer calling at night, on weekends, etc., but by and large they were respectful of my time and happy to have the option of direct contact in an emergency, and so was I.
    I think physicians have great difficulty in acknowledging that they are in the service business. Perhaps because they are so much better educated than those they provide service to and much wealthier too.
    And to that last point, Dr. E., I can assure you that the “Medicaid crowd” will not be abusing their email privileges because more than most other people they have great respect for doctors and because they don’t usually have computers.

  40. Dr. Handley wrote:

    if you start to design your care system around your patients, rather than around your doctors, this is a core competency.

    I believe Dr. Lambert sincerely feels he has his patients’ best interests at heart – but I also feel his conventional training has kept him from doing much of anything, practice-wise, that is designed around his patients, and what they need, vs what he needs.
    As for Dr Exhausted – what a fraud. If s/he were really exhausted, s/he would – being exhausted – leave off all the self-pitying typing in THCB threads. Please get lost, Dr. Exhaust.

  41. As a specialist physician, I am torn on that issue.
    On the one hand, I do believe that most US physicians are well paid (and many specialists are relatively overpaid), and patients should have good options to adress questions to their physicians.
    OTOH, if you take physician time (which is in limited supply) as a resource, I don’t think that unfiltered Email is the best use of this resource. The option to communicate with physicians personally without cost considerations and little effort will result in poorly motivated/considered Emails. I would be happy to answer the questions that really require physician attention (not: clarification of the dosage of a correct prescription etc.) … and Emails could be screened/answered by CMAs and RNs.
    I noticed that there might be a tendency to consider a physician a paid provider who is at the patient’s disposal. I consider myself to be in service of each of my patients. But unproductive/abusive patterns do surface at times (for instance, parents calling me via the answering service about restlessness/insomnia in their adolescent son – no other complaints – going on for a few days already on a Sunday morning at 2 am).

  42. I am using a Thinkpad laptop where I get 24/7 telephone tech support (in Atlanta, GA, not Bangalore, India) with replacement parts overnighted by 10 AM next day (owned various Thinkpads since 1999). The cost of the support is part of the price I pay for the laptop.
    I believe Kaiser physicians do answer and are encourged to answer emails (without need to charge additional money since, like my Thinkpad, the cost is folded in with “membership”).
    I would hate it if I had to pay everytime I called IBM/Lenovo for support.
    The problem with many docs today is that their business model is the out of date, fee for service model. Please, seek to be a patient (customer) centered business model and emulate Kaiser. Thanks.

  43. For me, this posting by Dr L is right on the mark. Right now I am covering a practice that relies heavily on computer charting, and while it has some advantages, to me they are neutralized by the consequences.
    For instance, e scripting, which I will not do for the sheer lack of documentation in the end, does not make it easier if the process does not work, which I have seen occur nearly daily. And only those who are not accountable for the liability risks are the quickest to be the loudest proponents for it. And let’s be very frank and candid here, you really think the Medicaid crowd is going to use this communication source responsibly? If you think yes, you do not work with Medicaid patients!
    A good post, Dr L. And again, we read the doctor bashers who just want to pile on us.
    Some of these commenters must really hate physicians. And yet, where do you go WHEN you need health care?

  44. I find it interesting that those most opposed to Email access to doctors are clinicians who have not tried it – at least not tried it at scale. We allow patients access to the EHR through the web, and allow secure messaging (think Email with appropriate privacy capabilities). We do this with over 200K patients, and our entire clinical community (about 800 docs) participate. Over 30% of “touches” between doctors and patients in primary care are through secure messaging, and we meet next day turn around 97% of the time. We do it for several reasons – but mostly because if you start to design your care system around your patients, rather than around your doctors, this is a core competency. We let patients choose the channel – secure messaging, a scheduled phone visit or an in-person visit (but can of course “veto” that if the clinician believes that they need to sit down together). And we have found that life gets better for doctors, not worse.
    This post contains the most common myths about secure messaging – mostly focused around the premise that doctors have to insulate themselves from patients and design systems to block access, instead of create access. It is in many ways analogous to the tired arguments about same day access – that it is unreasonable to be expected to provide great service to patients because we haven’t yet figured out how. Advanced access was hard to get to, but makes life easier for both patients and doctors.
    I have had the opportunity of helping several large groups add this capability. The concerns are generally the same, and there is considerable approach anxiety. We all consider our own patients to be different than other doctors’, and believe that they will inundate us with messages. In fact, patients are incredibly respectful about their physician’s time. The very small percentage of patients who are most challenging to work with (e.g., personality disorders) in the non-electronic world are still challenging but are easier to support electronically than in the in-person world (e.g., frequent unnecessary visits and phone calls).
    It isn’t easy to add this capability, and there are growing pains as you do it (just as there are difficulties achieving advanced access). But electronic messaging decreases the need for in person visits, allows for asynchronous communication and deepens the trust relationship between doctors and patients – arguably our most important therapeutic asset.
    It is possible that the real concern – and a legitimate one – is that electronic messaging access to doctors threatens income. In a fee for service world, there is no incentive (or at best it is a mixed picture balancing altruism with income stability) to allow patients to get their needs met without an RVU generating visit . Where I practice (Group Health Cooperative) we have the luxury of integrated payment and care delivery and can organize care around our patients needs. If payment reform is the issue lets have that discussion, but lets not conflate the two issues.

  45. Yes, the CPT codes are there, but the devil is in the government plans. We cannot offer services to others that we don’t also give to Medicare/Medicaid patients, and these plans categorically do NOT pay for phone or emails. We cannot charge a yearly fee to cover this either (something other practices have done – ones that don’t accept M/M).
    I also like the prostitution comment.

  46. There are CPT codes for phone calls and emails: (99441-99443) for Phone evaluation and management by physician, with differing time units, as well as CPT 99444 On-line and management by physician. These are priced by many payers, except these are very often routinely denied for payment by most payers. So the mother of the pediatric patient must take off work, drive to pick up little Billy at school, drive to the pediatrician’s office and wait to be seen, often for a problem that could be handled over the phone of by email. So much for patient friendly health insurance. I wonder if this is the situation at Nate’s plan.
    You need to institute a payment process for patient phone calls and emails, using the cpt codes above, with your charges posted to patients, who should be told they will be billed for payments not made by their insurance if not a covered benefit.
    I agree with Andrew W’s comment above re: prostitutes.

  47. Jason: I am sure your attorney and accountant charge for any time they spend on your stuff. They are allowed to do that. I am 100% in favor of email – in fact, I am a big proponent of e-visits taking the place of many face-to-face visits. But why should I be penalized for doing so? Why should payors reward docs who force patients to come in for anything and everything? If we want the system to get better, we have to stop paying people more for making it worse.

  48. Regardless of how much you can collect per email, if the patient emails to you at 2:00 am that they are having chest pain and by the time you respond at 6 am, the patient has died, you may be enjoying lunch downtown at the court house.

  49. How about allow only one email per year or more if they register to clinic website?
    Anyway this is what I call ‘time shifting’ which occurs in addition to cost shifting. The biggest advantage of insurance to me is them taking care of haggling with doctor’s billing office. I can easily foresee spending an hour per claim if doctor’s office were to directly me. Fidel Castro government might be more transparent then doctor billing office.

  50. Dr. Lamberts,
    While I can’t say I’m a physician who understands the demands of the job, my day job is in IT and I’m a volunteer EMT aside from that. Whether it’s the cell phone or the pager, there’s always something demanding my attention, and I have yet to get paid for it when I’m not in the office. So that’s a bit of background on where my comments are coming from.
    Five years ago, my grandfather’s cardiologist gave the whole family his cell and home numbers. Did we call him? Twice… once was a MI, the other turned out to be benign. But in five years, he got two calls, and one was reasonably important. Why so few? Simple. “If this man was so nice to give us his phone numbers, we CAN’T call unless it’s extremely urgent.” It can’t be explained how much it put the family at ease to know that if (when) a true emergency did arise, no matter what hour of day or day of week, we’d be able to get through to the man who had treated my grandfather for going on two decades.
    However, I think the bigger issue is social expectation. I have my lawyer’s cell phone number and email address, my accountant’s, my chiropractor’s, even the service manager at my car dealership. Given the relative urgency of calls I would place, wouldn’t I want the same access to my doctor?
    Yes, being a humble EMT, I still understand very well the pressures that hypochondriacs and the constantly-minorly-ill put on the medical system. But that has to be balanced against 1) the feeling of personal attention that simply having an email address will give to a patient, and 2) a firmly set email policy (along the lines of, but worded in a more compassionate way, “the doctor will spend 20 minutes each week day answering emails, and will spend no more than 2 minutes on each email. Urgent or more involved questions should be discussed at an office visit.”)

  51. Let me say clearly that I would love to allow email communication, and I think it would save the system money. I just don’t like shouldering the cost of that by giving it away for free. The 24/7 in our society is a bad thing, and just because others are being forced to forfeit their personal lives doesn’t mean I should.
    This is just another example of how our system discourages innovation and efficiency. The payment system must reflect the changes the Internet allows with communication.

  52. I wouldn’t allow e-mails from patients because they would constantly be e-mailing you and you don’t get paid to answer their questions. That is why you have to come into the doctors office and ask for your advice there.

  53. It’s interesting to read this post a few days after the post on the success of Minute Clinics and other walk-in clinics. The WSJ article on Minute Clinics noted “[patients] are shifting their demand for health care away from expensive, conventional physician offices with limited hours to affordable and convenient retail clinics. ”
    I can see why e-mail doesn’t work for a traditional physician’s office, reimbursed in a traditional way. However, e-mail IS a popular way for people who are patients to communicate, and it will be interesting to see how other types of providers of primary care fit e-mail into their services offered.

  54. Why should physicians be immune from the pressures that MANY of us feel to be available 24/7, anchored to our smart phones for no additional compensation? We all have to carve out time that we don’t respond to messages because we need to focus on our families.
    Most of us don’t get to bill our employer or customers for each email that we respond to and we see this progression as both a blessing and a curse. It helps us to manage more and often more efficient communication (if we are intelligent about selecting the proper medium for each communication) but subjects us to more risk of having our free time encroached upon.
    Answer your emails. Say “Please schedule an appointment” if that is what is appropriate. If you have the means hire someone or assign an existing resource to triage patient emails and create a dedicated email account for patients. With the proper management of communications this could become a competitive differentiation between you and other practitioners. In other words, look at this as an opportunity space and go exploit it.

  55. Dr. Lamberts:
    A very interesting and well-reasoned post. I agree with the central tenants of your commentary. As healthcare becomes more decentralized and patient-centric (or consumer oriented), the trends to which you refer will only accelerate. I do not see these trends abating, nor do I think that they necessarily represent a bad thing. What does need to evolve with these trends is the ability for physicians to charge for their time in different ways, whether e-visits or secure email communication. I fully support this and do not view for a moment the need to be compensated as “greedy”. The problem stems from healthcare patients not readily viewing the delivery of primary care services, or many types of healthcare services where time is what is being valued, as a business. Where something lacks tangibility in our society, there is a trend toward devaluing it. Unfortunately, the skilled and very valuable work physicians like yourself provide has been caught in this trend.

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