How do family physicians work?

[Guest sparkle]

I went to my family physician yesterday with a bunch of unrelated issues (about 2 or 3) and a few questions (nothing extravagent or too time consuming). He told me that he could only address 1 or 2 today (because of time) and that I needed to make another few more appointments for the others.

 

I kind of understand that doctors are paid base on number of patients and that they are allocated a max time each day so I'm totally okay with where he was coming from. However, say I don't want to waste time coming back on so many separate occasions (because each appointment would only address a small issue), does it make sense if I made three back-to-back appointments? I tried to do this but the receptionist couldn't understand why and wouldn't let me do it. My single appointment felt so unproductive, especially considering I have to take time off from work and drive into the city. So what I am to supposed to do? Is this normal?

[Guest liz80]

You cannot see the same doctor more than one time a day. As far as I know, they can only bill one visit per day (i.e. get paid for it).

[Guest MMRU]

It is true that a doctor can only claim the 100% fee for a visit a day. However, let's say if a patient comes in for complete physical check-up and a routine pap-smear, then the doctor can bill 100% for the physical and 50% for the pap-smear. So it's not doing all the work for nothing.

 

In fact, there are different billing codes assigned for various kinds of appointment. For example...

 

1) Regular doctor office visit = 15 min (approx $27)

2) Counselling = 20-30 min (approx $35)

3) Complete Physical = 30 min (approx $60)

 

If you have a lot of questions, most GPs will take that as a counselling session with general concerns so they get a slightly higher pay.

[Guest jmh2005]

Unfortunately, it is about money (mainly) and time. Whether you come in with 4 things 'wrong' (ie. sore throat, chronic abdo pain, chronic headaches and a wart on your toe) or just 2 things 'wrong' (ie. chronic headaches and wart on your toe), here in Ontario, the doctor would get paid the same amount, but in the first scenario, it would take double the time, there are 4 issues to discuss/evaluate. In both cases, the most you could bill would be an 'intermediate assessment' as you would have to assess 2 body systems, about 27 or 28 bucks here in Ontario. There is a code that is more extensive but there are strict rules on using it (usually it needs to be a full 'physical')...

 

Its tough because some people rarely come to the doc, but when they do, they bring their laundry list...I always cringe when I see the list coming out...I too, now as a resident and even when I was a clerk, would politely tell patients that due to time and billing constraints we can address the two most serious issues today (and usually these are neither all that bothersome nor remotely life threatening...but more inconvenient than anything else, as it requires an additional appointment).

 

You can't bill for 2 intermediate assessments in the same day on the same person, so if he addressed your other 2 issues (say you had 4, as in the above scenario) the doc is essentially working for free and adding an additional 15, 20 or even 25 minutes to the schedule and getting behind...

 

The best thing to do is tell the secretary that you need some extra time and go in with a priority list of what you need addressed ASAP...if they are issues like the 4 above, you'll have no choice but to make another appointment. Those issues require a good history and an assessment of the head and neck, neurological, GI and integumentary systems at minimum.... But say you just need a refill on your asthma meds (you've been stable), some liquid nitrogen for a wart and a cold sore, well, those are easily assessed and treated, the doc would likely do all of these in 1 visit (but still bill for an intermediate and likely bill you for the nitrogen tx!).

 

I hope this helps...as I said above it's about money and time...if every patient came in with a 'list' of 4 things you'd be waiting an awfully long time for your appointments...It's by no means a perfect system unfortunately...

[Guest Ian Wong]

I'm going to move this out of the UBC forum and into the Primary Care residencies forum...

 

jmh hit the nail on the head. This issue essentially revolves around billing and compensation for services rendered. Under the current fee-for-service payment model, you get paid for each service you provide. Unfortunately, you can't get paid for each service you provide on the same day; otherwise, with the average elderly patient, you could try to bill stating that you helped manage that person's low back pain, diabetes, high blood pressure, high cholesterol, counselled them on dietary advice and preventative care, treated their earache, and refilled 4 prescriptions...

 

As a result, while it makes a lot of sense to do so (at least from the public's perspective), saving up a list of issues and hoping to get them all resolved during one physician visit is likely to be unproductive for both the patient and the physician.

 

The fee schedule is set up in such a way that each payment is hopefully reflective of the time and effort that went into that service. If you only provide one service, your fee should be commensurate with that workload (likely something that you can complete in 10-15 minutes for many typical problems you'd encounter in an outpatient FM appointment). On the other hand, if you have to provide multiple services (ie. by handling multiple problems), you still only really get to bill for one service that day, so you are spending more time with that patient for the same amount of money.

 

And since you've likely scheduled your office for 15 minute visits apiece, or something like that, it also serially delays each and every one of your next appointments.

 

If the reimbursements and fee schedules were set up in a different fashion, I think you'd see doctors much more willing to deal with all your issues in a single visit. It's more efficient that way for both the patient and the physician.

 

It's for these reasons that many physicians are unhappy about the proliferation of walk-in clinics. Those visits generally tend to be quick and for minor complaints (but you still get to bill for each visit), and therefore make you a lot of money with a relatively decreased time committment. They are also more likely to refer the complicated and more time-intensive things (ie. depression, counselling, etc) back to that patient's original family physician, which is kind of like creaming off the easy reimbursements and refusing to take the difficult cases.

[Guest MDWannabe]

Unfortunately, we have to bear some of the responsibility for the laundry list patients often come in with. In my experience, the number of issues a patient comes in with is directly proportional to the time that patient spends in the waiting room.

 

In general, most patients think their FP is the best FP in the world, and they are willing to wait as long as they have to wait to get service. The downside is that, knowing they have to wait, they are more likely to come in with large lists of issues, since they don't want to spend multiple hours in the waiting room. For the very simple issues (ie a cough, cold), they go to a walk in and avoid the wait. This compounds the waiting problem even more.

 

As you can tell, this is a bit of an issue for me, because I'm a bit anal about timeliness and the mutual respect that implies. I agree that it is incumbent upon the patient to tell the front office that there are a number of issues that need to be addressed so that other patients are not forced to wait. But in general, for the FPs I worked with who made it a point to be on time, the odd patient who came in with multiple issues did not significantly slow down the process.