Customer Service

[docB]

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I was at an unnamed electronics store the other day, let's call it Best Buy, and I paid by credit card. I was asked to swipe my card which I did. The clerk then asked to see my card and my ID. She took them, acted as though she looked at them and gave them back. I thought the point of those customer operated card swipers was to eliminate the step where they handle the cards. I asked "If they make you take the card anyway why do they make me swipe it?" The reply was "That's just how it is." accompanied by a look designed to let me know I was being a jerk by even asking.

So clearly customer service is not a high priority over there. I have found that to be the case in most electronics retailers. Yet they depend on repeat business just as much as we do.

So why is our industry literally reinventing itself and abandoning actual quality of service just to enhance the perception of quality of service? If Best Buy can stay in business with a "take it, leave it, up yours" philosophy why can't we? Don't people need emergency care as much as they need TVs?

 

[gman33]

My guess is they have managers telling them this is not appropriate behavior.
Doesn't mean they listen.

Plus, people value their TV more than their doctor.

 

[ERDude]

Plus, the average late teen/early 20-something working retail during the holidays for chump change/hr and no benefits probably doesn't care *that* much about their customer satisfaction. And in most cases (pure speculation here) even the threat of losing the job won't be enough be to change that.

 

[bad virus]

Plus, the average late teen/early 20-something working retail during the holidays for chump change/hr and no benefits probably doesn't care *that* much about their customer satisfaction. And in most cases (pure speculation here) even the threat of losing the job won't be enough be to change that.

lol, I'm just going to say that I used to work at best buy for 3 years back in high school/college.

 

[glorfindel]

So why is our industry literally reinventing itself and abandoning actual quality of service just to enhance the perception of quality of service?

I think it's because we have competing interest groups arguing about what the emergency department is for.

Some ED docs think it's for assessing for and treating emergent/acute illness.

Some patients think it's for quick medical care of any type, especially when their own PMD is so busy they can't get an appointment for another 3 weeks.

Some hospitals think it's for revenue generation -- the ED is the hospital's "front door." It's where the admissions are generated.

Some PMDs think it's for getting around insurance company limitations on payments for procedures like CTs and MRIs.

Some public health authorities think it's for screening the population for suicidal ideation, STDs, and domestic abuse.

An ED can have multiple missions, but of course I worry that some of the purposes currently attributed to the ED by various stakeholders are mutually exclusive.

 

[Birdstrike]

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[Deuce Doc]

Holy crap. Of all the sagely Birdstrikisms that I have read, this may now top the list--a clear nominee when the Greatest Hits is finally assembled. In fact, I like it so much I'm gonna quote it so it can be found later.

People value things that are worth something. They value something that they must pay for. People will clamor to get the TV with the $3,000 price tag, even more so than one that's half as expensive, even if in reality it's just as good. They respect something that demands something in return for its value. No one is impressed with stuff that's "cheap" or given away for free. Would they be impressed by a TV with a price tag that says,

"Very expensive and extremely valuable! Well, payment is optional, actually. I'm really great, and I'm really worth a lot, and you really should pay something for me. But when it really comes down to it, I'm free, if you want me to be. In fact you can walk right out of here with out having to pay a dime for me. Just pay what you can afford, please. Please?Actually, if you just quietly take me for free and don't complain to the manager about being unhappy with me, I'll call us even, okay?"

One of the unforeseen consequences of EMTALA is that it has completely devalued Emergency Physicians and their services. Who the hell respects someone whose services they don't have to pay for if they don't want?

 

[Birdstrike]

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[deleted109597]

Eventually the margins will decrease to the point where a savvy CEO will realize that appeasing the poor won't be worth it anymore. This used to happen in the pre-COBRA days. If you weren't insured, prepare to wait, etc. Then suddenly the government decided that people who weren't paying were worth just as much.
Now we've got hospital systems where 75% of the hospitals don't have docs on call anymore. They might have a hospitalist, but no ortho, neuro, etc. So everything is getting transferred to the tertiary centers. Similarly, the tertiary centers already are typically located in the geographic areas with lots of poor people. So now the wait outside is compounded by all the people from other hospitals taking the beds upstairs. Insured people are going to the stand alone EDs, because they can transfer people to hospitals where they have consultants who aren't on call, but are happy to see insured patients.
Once the first couple of charity hospitals in a state fall due to not having any money, the rest of the dominoes will fall and medicare/medicaid patients will be left out again. Nobody will listen to the over-entitled poor who are complaining because their doctor won't prescribe Tylenol.

And that's not even counting the bull**** 30 day readmission stuff that has been going on since October 1.

 

[GeneralVeers]

Eventually the margins will decrease to the point where a savvy CEO will realize that appeasing the poor won't be worth it anymore. This used to happen in the pre-COBRA days. If you weren't insured, prepare to wait, etc. Then suddenly the government decided that people who weren't paying were worth just as much.
Now we've got hospital systems where 75% of the hospitals don't have docs on call anymore. They might have a hospitalist, but no ortho, neuro, etc. So everything is getting transferred to the tertiary centers. Similarly, the tertiary centers already are typically located in the geographic areas with lots of poor people. So now the wait outside is compounded by all the people from other hospitals taking the beds upstairs. Insured people are going to the stand alone EDs, because they can transfer people to hospitals where they have consultants who aren't on call, but are happy to see insured patients.
Once the first couple of charity hospitals in a state fall due to not having any money, the rest of the dominoes will fall and medicare/medicaid patients will be left out again. Nobody will listen to the over-entitled poor who are complaining because their doctor won't prescribe Tylenol.

What has to happen is that a practical way to perform an MSE within EMTALA guidelines has to be developed, standardized and adopted by the hospitals. If we can designate an "EMTALA Nurse" to sit our front and screen patients, it would go a long way to helping the situation. No insurance? We're happy to screen you for emergencies, then give you a referral to the local free clinic.

Our shop does no medical screening exams, while every other hospital in our area does. The poor know it, and flock to our departments for their "free" care. They aren't hesitant at all to complain when their dreams of unlimited narcotics, free MRIs and soft admissions aren't realized.

 

[8654Marine]

Birdstrike nailed it again.

There is no value since it is "free" care.

 

[Birdstrike]

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[DreamingTheLive]

I heart Birdstrike.

The level of entitlement among patients is disheartening. But, I believe, at some point in the rather near future, that it will get better. Probably 3 -5 years from now, and I'm sure it'll get much worse before then, but I'm optomistic EM physicians will grow some collective balls.

 

[Farmer2DO]

................................you are assembling a greatest hits?

Someone should.

Words to live by.

 

[Arcan57]

The Chupacabra of Emergency Medicine​

Honestly, Veers, I'm a little disappointed. You, of all people, have totally failed to pick up on a subtle way for doctors to be screwed. 🙂

The devil is in the details of how they set this up. You envision the long-dreamed about utopian-loophole to get around EMTALA once and for all? Truly, you seek the "Chupacabra of Emergency Medicine". Well, not so fast, you'll never find him.

Yes, having a hospital employed and hospital insured RN or NP that is in no way connected to, or supervised by, your group's MDs do these screens would be great. But that's not how a smart CEO would ever set it up (him paying paying someone else, taking the liability himself. No way).

What can happen is that you agree to the idea in theory, and in reality you end up doing the screen, sending the patient away, void your ability to bill them, and accept much greater liability if and when inevitably you are wrong, and one of these patients returns with some benign presentation of a concealed emergency. How is the jury of your "peers" going to like it when it comes up in court that you might not have sent out the "chronic back pain" that came back room-temp with a triple-A, if he did have the 100 bucks?

If you are in a private group, you must make sure that you retain some credit/payment/RVUs/stipend, or something for seeing these patients. Not an RVU "credit" out of your group's internal collection pool (taking money out of your right pocket and putting it in your left), but truly extra money kicked in from the hospital.

Even if you currently only collect 5, 10, or 20% on your non-emergent self-pays, under the above setup you give that up while not only keeping the liability, but increasing it. Whereas in the past you treated them, billed a Level 2 or 3 and took what you could get, you might end up screening the patient and truly sending them out for free. Amazing.

Under that setup, you (and the patient) are much better off calling everyone an "emergency," treating-and-streeting as you always did and crossing your fingers that you get a few chips for your 99203.

I worked in a couple of different states trying to implement MSEs. In TN, I got nothing for screening a patient out and consequently screened no one out. I couldn't be convinced that doing the same amount of documenting and exam for medicolegal reasons and guaranteeing I wouldn't get paid by screening them out made sense to me.

In TX, our docs get somewhere between a Level I&II for screening a patient out. Our CMG has actually started sending the patients that have been screened out a bill that prices us (combined with the facility charge the hospital has started billing) right at where an urgent care visit costs. It's made the process more contentious but has also allowed us to screen out patient that got an x-ray or a urine at triage because of nursing protocols (excuse me, "standing delegated orders") instead of having to deal with the PG fallout etc from the fact that their URI doesn't require a week off work.

 

[Rendar5]

I worked in a couple of different states trying to implement MSEs. In TN, I got nothing for screening a patient out and consequently screened no one out. I couldn't be convinced that doing the same amount of documenting and exam for medicolegal reasons and guaranteeing I wouldn't get paid by screening them out made sense to me.

In TX, our docs get somewhere between a Level I&II for screening a patient out. Our CMG has actually started sending the patients that have been screened out a bill that prices us (combined with the facility charge the hospital has started billing) right at where an urgent care visit costs. It's made the process more contentious but has also allowed us to screen out patient that got an x-ray or a urine at triage because of nursing protocols (excuse me, "standing delegated orders") instead of having to deal with the PG fallout etc from the fact that their URI doesn't require a week off work.

speaking of URI's requiring a week off work, I had a pretty nice mom make the weirdest request on a saturday or sunday (forget which). she wanted her daughter to have a school note for her asthma attack not for tha tmonday since she had an extracurricular actity, but for that coming tuesdaay and wednesday for a test...i was like, no, you'll have to go to your pediatrician if you're still that sick.

 

[GeneralVeers]

Birdstrike,

I understand your disappointment. The entire problem comes down to EMTALA and a high-risk malpractice environment.

EMTALA isn't going away. It's a convenient ploy for politicians to push the problem (and costs) onto us and the hospitals. Unfortunately it's going to kill us, as average per patient reimbursement goes down. We need to turn away non-insured, medicaid, and a portion of Medicare patients if they don't have real emergencies. That is the only way we can keep our pay viable to keep attracting doctors.

I agree that the "medical screening" so far has been a failure. I've talked to the doctors at the other shops in town, and they also don't screen out anyone, as the paperwork to do so is the same as to actually see them, except you don't get paid. At some point the hospitals are going to be forced to turn people away just so they can keep their doors open. They are not going to be able to keep seeing Medicaid and Medicare patients at a loss. What's your solution, since you don't like mine?

 

[The White Coat Investor]

I don't think you guys are getting it. We're not going bankrupt because we spend a few minutes on self-pay/no-pay patients with non-emergent issues. We're going bankrupt for two other reasons:

1) Medicaid patients with non-emergent issues

2) Self-pay patients with emergent issues

I hardly spend any time at all on self-pay patients without insurance. Almost all my self-pays have real emergencies. The medicaid folks with the optional $5 co-pay on the other hand....Have you ever noticed that all your two-fers, three-fers, and four-fers are Medicaid?

I don't get much more money, but there are a whole lot more of them.

Sick patients take up a lot more time, and we definitely use a fair amount of time taking care of sick self-pays. But non-sick ones? That isn't the issue IMHO. They're rare and quick.

 

[DreamingTheLive]

EMTALA needs to go. Soon.

 

[Birdstrike]

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[keeping-it-real]

I've heard second-hand that in Europe they frequently turn people away if they are felt non-emergent. Any comment on this?

 

[GeneralVeers]

At our one shop we have about 50% self-pay. Our average reimbursement from them is $18. Billing, coding and malpractice cost $27 per patient. I lose $10 per self-pay patient.

 

[RustedFox]

EMTALA needs to go. Soon.

Not gonna happen. The politicians would rather drive us all over the cliff (not the fiscal cliff, but maybe, yeah, the same one) than take the unpopular position of taking away access to care.

 

[RustedFox]

I've talked to the doctors at the other shops in town, and they also don't screen out anyone, as the paperwork to do so is the same as to actually see them, except you don't get paid. At some point the hospitals are going to be forced to turn people away just so they can keep their doors open. They are not going to be able to keep seeing Medicaid and Medicare patients at a loss. What's your solution, since you don't like mine?

We have the MSE "screen-out" option. Makes no sense to do so at all. Paperwork is all still the same. Liability is still there, and if so you much as give them a tylenol - then you can't "screen them out" by definition. I screen out nobody.

 

[GeneralVeers]

We have the MSE "screen-out" option. Makes no sense to do so at all. Paperwork is all still the same. Liability is still there, and if so you much as give them a tylenol - then you can't "screen them out" by definition. I screen out nobody.

We've all identified the problem, but what is the solution? We can't keep losing money seeing these patients, yet we are forced to see them. Something has to give.

 

[docB]

If you are in a private group, you must make sure that you retain some credit/payment/RVUs/stipend, or something for seeing these patients. Not an RVU "credit" out of your group's internal collection pool (taking money out of your right pocket and putting it in your left), but truly extra money kicked in from the hospital.

Important point. We "pay" ourselves. This was not a choice. Consequently we are absorbing all of the cost and liability and moving our own money around to incentivize the process.

We're going bankrupt for two other reasons:

1) Medicaid patients with non-emergent issues

2) Self-pay patients with emergent issues

I agree with this.

1-Be aware of how your hospital funds this process. Are they paying you for these MSEs? Where's the money coming from? Are they allowing you to bill them for the MSEs (as in the above post) even when you've turned them away with a diagnosis but without treatment. If so, as the above poster says, you send them a bill between a level I and II, why not just punch the ball across the goal line, treat them and send out a bill for a level 3? Otherwise, the hospital just wants you to clear the bed for them for free, and put an insured patient in their place, so they can get them in for a CT, surgery, or other money maker.

Again this is a super important point. It exemplifies the inherent weakness of being a "contract doc."

We've all identified the problem, but what is the solution? We can't keep losing money seeing these patients, yet we are forced to see them. Something has to give.

It will. It will be painful. Once we are fully socialized the payer will start to ration. That will include emergency care. I foresee a future where you have to meet InterQual or Milliman criteria to get into the ER, not out of it.

 

[Arcan57]

We've all identified the problem, but what is the solution? We can't keep losing money seeing these patients, yet we are forced to see them. Something has to give.

Let's back up just a second. I understand you find it a moral issue that you're forced to see patients that aren't going to pay you what it costs you to see them. That's a debate that leads down the rabbit hole.

However, there are extraordinarily few businesses that have no customers/clients on which they lose money. Theft and fradulent returns, non-payment, lawyers taking cases on contigency, etc. all represent investments that didn't pan out. Yet businesses stay open despite these losses (usually) because the overall business is profitable. Even if you're at 50% self-pay and you're losing money on all of them, you're still making enough money that you haven't changed jobs. In areas where the self-pay rate is high and reimbursement is low, the hospital either needs to subsidize the EPs or risk losing them to more attractive offers elsewhere. Postulating some post-apocalyptic scenario where we (personally) are losing money each shift is vivid but also completely unrealistic.

Also, it is possible to make money on Medicaid patients (both in and out patient services) in a hospital setting. It's not easy, but it is possible.

 

[GeneralVeers]

However, there are extraordinarily few businesses that have no customers/clients on which they lose money. Theft and fradulent returns, non-payment, lawyers taking cases on contigency, etc. all represent investments that didn't pan out. Yet businesses stay open despite these losses (usually) because the overall business is profitable. Even if you're at 50% self-pay and you're losing money on all of them, you're still making enough money that you haven't changed jobs. In areas where the self-pay rate is high and reimbursement is low, the hospital either needs to subsidize the EPs or risk losing them to more attractive offers elsewhere. Postulating some post-apocalyptic scenario where we (personally) are losing money each shift is vivid but also completely unrealistic.

Unlike us, McDonald's doesn't encourage their customers to come in, pay nothing, get quick prompt service, and then have every right to complain/sue afterwards.

At McDonalds you don't pay or you steal, they have no further obligation towards you.

 

[Arcan57]

Unlike us, McDonald's doesn't encourage their customers to come in, pay nothing, get quick prompt service, and then have every right to complain/sue afterwards.

At McDonalds you don't pay or you steal, they have no further obligation towards you.

I can easily envision scenarios where McDonalds is sued by people that haven't paid. And nobody is encouraging just self-pays to come in, it's that there isn't a good (legal) way to increase paying business without creating a climate that is attractive to the non-resourced. But my main point is that we're not going broke seeing self-pays (or Medicaid). And I think billing for MSE'd patients is reasonable because the $500 bill is never going to get paid but the $40 has at least a chance.

 

[Birdstrike]

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