New twist to "fee-for-service"

[edinOH]

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During my ED shift today, I saw a guy with an abscess in his axilla. Everything about him said "piece of ****" from his attitude to his lifestyle. When I asked him about his social history he told me "off the record" that he used and sold meth. Fine, whatever.

I come back in a few minutes to I&D his abscess and he says to me, "I'll give you $100 if you make it not hurt any."

I look at him with a straight face and say, "OK"

He reaches into his pocket, pulls out a thick wad of bills and quickly snaps of five $20 bills and hands them towards me. I smile and tell him to keep his money.

It got me thinking though. Why the hell not? I guess it is unethical in the strictest sense but it isn't like this guy is really ever going to pay his bill. If I was in private practice or even a licensed EM doc not in residency why couldn't I just keep his money, write no charge on the billing sheet and be on my way?

Like I said, something about it just seemed wrong, but why?

Cash in hand payment is acceptable in any other field of business/commerce and even in the private medical office. Why not in the ED?

 

[docB]

In theory I'm with you. But, I imagine that by taking cash in hand and underbilling on the chart you could run into problems with medicaid or medicare. You also (I admit I'm being picky but it's just for discussion) shouldn't carge more for it to not hurt. In terms of the M&M stuff my group has a strict policy against writing scripts under the table for nurses, techs, medics and so forth. The reason for this is not billing or even liability (since my liability would be personal they couldn't care less). It's because it's possible that the M&Ms could find out and then say "Well DocB, you treated this persons sore throat for free and then you billed our medicaid pt $X. Therefore you are charging medicaid more than your regular pts which is fraud. You are now out of the M&M program and you have to say that you've been investigated by us. Nayhh, nayhh, nayhh you're career's over."

BTW when I was a tech I saw a pt (drunken jackass) try to tip his EP $5 as he left.

 

[Sessamoid]

In theory I'm with you. But, I imagine that by taking cash in hand and underbilling on the chart you could run into problems with medicaid or medicare. You also (I admit I'm being picky but it's just for discussion) shouldn't carge more for it to not hurt. In terms of the M&M stuff my group has a strict policy against writing scripts under the table for nurses, techs, medics and so forth. The reason for this is not billing or even liability (since my liability would be personal they couldn't care less). It's because it's possible that the M&Ms could find out and then say "Well DocB, you treated this persons sore throat for free and then you billed our medicaid pt $X. Therefore you are charging medicaid more than your regular pts which is fraud. You are now out of the M&M program and you have to say that you've been investigated by us. Nayhh, nayhh, nayhh you're career's over."

BTW when I was a tech I saw a pt (drunken jackass) try to tip his EP $5 as he left.

You're assuming he was covered by a government program. I'm guessing from the OPs comment, that the patient wasn't likely insured at all. In my view, he was offering to pay for services rendered, and I have no problem taking money for that. For most uninsured patients, $100 bucks and I'll accept that as payment and write off the rest of the bill. Sure beats what Medicaid would pay for a similar procedure, and we'd end up writing off most of the bill anyway. There's a difference between adequate treatment that meets the standard of care and "extra special" treatment. I'll do the extra special for patients I sympathize especially with, or who are clearly going to reimburse well, and I don't think there's anything unethical about it. I doubt anybody truly treats every single patient equally regardless of ability to pay. You can't tell me you're going to treat the drunk assh*le the same as if one of your own colleagues came in needing trauma care. Both will get treatment that meets the standard of care, but one will get (and deserve) better attention.

I've often wondered why we don't collectively (the whole ED staff) have a tip jar that patients can drop money into. Every other personal service worker that I know of expects and receives tips for the work they do. Why shouldn't we? It's not just low paying service workers who get tips either. The Maitre Ds at expensive restaurants easily pull in 6 figures, and they get tips out the wazoo. The movers who did my last move got a pretty significant tip for manual laborers. Masseurs, high-class hair dressers all get hefty tips.

 

[Sessamoid]

BTW, for large abscess I&Ds I've generally gone to using etomidate for sedation, espeically if it looks like it will have a lot of loculations that need to be manually broken down. Lidocaine is close to useless in infected soft tissue.

 

[Annette]

The reason you can't accept the money is because if you do, the insurance companies who do pay will claim most favored nation status, and only pay you $100 for "their" I&D's.

 

[DrQuinn]

I wouldn't have taken the money.

I woulda gone for some free meth though!

Q, DO

 

[Sessamoid]

The reason you can't accept the money is because if you do, the insurance companies who do pay will claim most favored nation status, and only pay you $100 for "their" I&D's.

You do realize that $100 dollars is far more than what Medicaid (the most favored nation by far) is paying currently for this procedure? The alternative is you could accept the money and report it as a tip on your income taxes, keeping the bill for services rendered (and written off) the same.

 

[roja]

I wouldn't have taken the money.

I woulda gone for some free meth though!

Q, DO

I'm with Quinn. Take the meth. You don't have to pay taxes it on it and you avoid this whole conundrum of billing etc.

And you'll stay up more.

 

[drboris]

I don't think medical professionals should be tipped (especially doctors). Physicians should maintain a certain level of prestige and professionalism that separated finances from patient care. These two cannot be one and the same. Patients need to focus on their care and not on how much they have to pay their doc. I encountered a situation like this when I was shadowing a heme/onc doc. He immediately avoided talking about money during the patient visit.

However, docs should be properly reimbursed. If there is no way to get into legal trouble by taking the money from the patient, then what the hell...let's do it.

 

[Sessamoid]

I don't think medical professionals should be tipped (especially doctors). Physicians should maintain a certain level of prestige and professionalism that separated finances from patient care. These two cannot be one and the same. Patients need to focus on their care and not on how much they have to pay their doc. I encountered a situation like this when I was shadowing a heme/onc doc. He immediately avoided talking about money during the patient visit.

However, docs should be properly reimbursed. If there is no way to get into legal trouble by taking the money from the patient, then what the hell...let's do it.

I disagree. Part of the problems we have in the exploding costs of medical care in this country are precisely because patients are too insulated from the actual costs of their care. When the insurance company is paying for it all, then by all means let's go for the most expensive drug/treatment available. If you're not insured and not planning on paying for it anyway, then the same applies.

We'll see how you feel about separating your pay from the work you do when you actually start working and are faced with the problem of doing a significant amount of work for negative income. Otherwise, how do you propose we ensure that we are "properly reimbursed?" In the old days, money was paid for in cash at the time of service. I don't know why somehow people think doing so again is somehow "evil."

 

[kinetic]

You ED guys confuse me. On the one hand, half of you are running around posting that you average $300K/yr working <40 hr/wk. On the other hand, you're talking about how you're getting soaked by uninsured/underinsured bums. You have to get together and decide which story you're gonna stick to. (And it's not that I don't agree that the health care system is majorly f-ed up or am so naive that I think people don't take advantage of the third-party payer system that insulates them from costs.)

 

[Sessamoid]

You ED guys confuse me. On the one hand, half of you are running around posting that you average $300K/yr working <40 hr/wk. On the other hand, you're talking about how you're getting soaked by uninsured/underinsured bums. You have to get together and decide which story you're gonna stick to. (And it's not that I don't agree that the health care system is majorly f-ed up or am so naive that I think people don't take advantage of the third-party payer system that insulates them from costs.)

You white guys are confusing me. Some of you say we should invade Iraq, some of you say we shouldn't. Why don't you all get together and get your story straight?

And you Christians? You're confusing me too. Half of you say the world is coming to an end, and that all us non-believers are going to hell. The other half say that Jesus forgives all. You should really get together and figure out which story you're going to stick to.

In case you haven't figured it out, "emergency medicine" isn't some monolithic entity where everybody toes the party line, despite what you may think or wish.

BTW, I don't remember anybody saying that we average 300K for <40 hrs/wk, but if it makes you happy to put words in other people's mouths, knock yourself out.

 

[kinetic]

You white guys are confusing me. Some of you say we should invade Iraq, some of you say we shouldn't. Why don't you all get together and get your story straight?

And you Christians? You're confusing me too. Half of you say the world is coming to an end, and that all us non-believers are going to hell. The other half say that Jesus forgives all. You should really get together and figure out which story you're going to stick to.

Yes, that's quite the same as a discussion on average salaries, which apparently consists entirely of opinion rather than numbers. Thanks for proving your intellectual superiority. The analogy you draw, though quite compelling in Bizarro Land, isn't quite as strong here on Earth.

BTW, I don't remember anybody saying that we average 300K for <40 hrs/wk, but if it makes you happy to put words in other people's mouths, knock yourself out.

You can talk about me putting words in your mouth all you want, but I never said, "Sessamoid claimed ...!!!!" If you want to claim that ED physicians aren't talking about how much they make, and in comparatively short working weeks, then you're just being argumentative to argue. Which wouldn't surprise me. Why don't you poke around the forum? The lowest -- LOWEST -- figure I've heard quoted for an EM salary is $250K/yr. The highest one is someone who claimed that a few rural EM docs they know make $400K/yr; however, I am not using that as the norm because, unlike you, I'm being rational.

P.S. Note, if I had jumped on here and started goofing on "the destitute EM docs," I would have gotten, "hey, I made 600K just taking a dump this morning!"

 

[roja]

Hmmm, I find just taking crack works well for me. Its not reportable to the IRS.


kinetic Salaries in academia are way below 250K/year. So it really depends on what type of environment you are in. Starting in some cities in academia is around 150,000K for 35 clinical hours (and this in no way encompasses meetings, lectures etc.)

 

[drboris]

I disagree. Part of the problems we have in the exploding costs of medical care in this country are precisely because patients are too insulated from the actual costs of their care. When the insurance company is paying for it all, then by all means let's go for the most expensive drug/treatment available. If you're not insured and not planning on paying for it anyway, then the same applies.

We'll see how you feel about separating your pay from the work you do when you actually start working and are faced with the problem of doing a significant amount of work for negative income. Otherwise, how do you propose we ensure that we are "properly reimbursed?" In the old days, money was paid for in cash at the time of service. I don't know why somehow people think doing so again is somehow "evil."

I actually have encountered something like this already. I used to have a job where sometimes the clients would avoid payment. So I do know how it feels to work for negative income. Granted when I finish residency, this will be on a much higher level.

Medicine and Money should not mix. We do, however, need to reconfigure the system and find a way to satisfy both demands. I know I am being idealistic since I am not proposing any practical solutions. Maybe cash payments are acceptable, I am just saying that docs should not outwardly discuss this with their patients. Secretaries and billing people can do this job. A physician should strictly practice medicine and not bill collecting.

 

[spyderdoc]

The lowest -- LOWEST -- figure I've heard quoted for an EM salary is $250K/yr.

Geez, I'm barely at the $200 mark with min 36hrs/wk and a lot of extra shifts...I'm 2 years out of residency...How sad is that....I am lower than the lowest. Damn Los Angeles! Maybe Oklahoma isn't sounding so bad afterall!

 

[paramed2premed]

At the risk of seeming like a naive med-student:

It seems like the real issue is not reimbursement, but rather that a patient thought that getting adequate procedural analgesia requires a bribe.

 

[docB]

You ED guys confuse me. On the one hand, half of you are running around posting that you average $300K/yr working <40 hr/wk. On the other hand, you're talking about how you're getting soaked by uninsured/underinsured bums. You have to get together and decide which story you're gonna stick to. (And it's not that I don't agree that the health care system is majorly f-ed up or am so naive that I think people don't take advantage of the third-party payer system that insulates them from costs.)

I don't make $300k/yr. I work right around 40 hrs/wk. I could work more and make more or work less and make less. That's one cool thing about ER. There are guys in my group who make a load of money but they work all nights (with a differential) and work ~200 hrs/ month. No matter what we are getting soaked by the bums because it costs us money in malpractice and lost billing to see them. If your point is that we shouldn't care about getting soaked because we're doing well overall I'd say that I'm not running a charity.

 

[kinetic]

I don't make $300k/yr. I work right around 40 hrs/wk. I could work more and make more or work less and make less. That's one cool thing about ER. There are guys in my group who make a load of money but they work all nights (with a differential) and work ~200 hrs/ month. No matter what we are getting soaked by the bums because it costs us money in malpractice and lost billing to see them. If your point is that we shouldn't care about getting soaked because we're doing well overall I'd say that I'm not running a charity.

Nah. Bums should get bum-level treatment.

 

[DeLaughterDO]

And if you don't mind me asking, kinetic, what exactly is "bum-level" treatment? Just enough to keep them from bringing charges?

I personally believe that every patient deserves the best the system can provide. Problem is, right now the system is broken and it leaves a lot of people out in the cold. If we work on the system (meaning population control, medical funding, education, etc), maybe we can all get back to what we are going/went to school for - to practice medicine.

I hate having to look at a patient's insurance status to determine which scripts I can send them home with or how hard I'll have to work with social services to get the patient help with their hospital bills/medications. It really disgusts me. But that's the reality of medicine now. We have to put in extra time to try to get ourselves paid and our patients medications taken care of. And the government doesn't seem to care.

So, again - what is "bum-level" treatment?

jd

 

[kinetic]

And if you don't mind me asking, kinetic, what exactly is "bum-level" treatment? Just enough to keep them from bringing charges?

Yes.

 

[Homunculus]

Whoa. This cat is so cold he poops ice cubes.

maybe so, but i doubt he's the only person that feels that way. i would have done ER if it weren't for the freeloaders that eat up all the resources for everyone else, lol.

i think they should have two lines at the ED-- one where you sign a waiver saying you agree not to sue in exchange for being seen "quckie-style" with no labs no rads and a script for lortab or a hot meal or a rectal exam or a drink of water or whatever you *really* came in for, and another line for people with real medical problems who actually need the ED. docs can treat and street the bums, and have more time for the regular folks. win-win for everyone involved 😎

 

[Febrifuge]

I don't disagree. I'm just thinking that it's the classic dilemma. The person or people who can figure out how to balance the need for industrial-strength BS detection with a level of care the public would be happy with will be rich enough to buy a solid gold pony of their very own.

 

[LaurieB]

I've spent a good deal of time observing and learning about the Cambodian medical system. One of the big problems they have in all professional fields, and especially medicine, is that the level of service is often contingent on tipping in advance. This includes judges and government paid physicians in adition to bureacrats and private physicians. Many people have no chance of getting services without paying additional unofficial "fees." This makes the process of getting medical care in particular very intimidating because the patient is at the mercy of the physician's fee demands.

Taking $100 from a drug dealer for reducing the pain of a procedure may seem very different from the situation in Cambodia, but it is a step on the slippery slope to institutional corruption. While I'd like to think that American physicians are too noble to go down the same path as their Cambodian counterparts, I also at one time thought that the American military were too noble to use torture. Without extending the argument further, my point is that institutional ethics codes, regulations, and billing procedures all keep us honest.

My answer to the guy offering to give me $100 would be to escort him or have someone escort him to the cashier after the procedure and put the $100 as a credit towards his bill.

My 2 cents.

 

[Sessamoid]

Taking $100 from a drug dealer for reducing the pain of a procedure may seem very different from the situation in Cambodia, but it is a step on the slippery slope to institutional corruption.

I fail to see how accepting payment for services is falling towards corruption. Conscious or deep sedation is not currently the standard of care for I&D of cutaneous abscesses, but I do it at times depending on the size and location of the abscess. I'd be more inclined to do it if somebody wanted it badly enough to give me $100. I don't believe that everybody deserves the "best" our healthcare system has to offer, and anybody who does probably doesn't understand the costs that would require. If somebody wants to pay more for extra service, I don't have a problem with that.

I also at one time thought that the American military were too noble to use torture.

I haven't believed that since... well, I don't think I've ever believed that. At least not since elementary school. I've never had any illusions about the character of my fellow man, and have almost no belief in the nobility of nation-states.

My answer to the guy offering to give me $100 would be to escort him or have someone escort him to the cashier after the procedure and put the $100 as a credit towards his bill.

So he can pay the hospital for services that he offered to pay me for? That's clearly not what the patient intended or wanted.

 

[juddson]

I'm with Quinn. Take the meth. You don't have to pay taxes it on it and you avoid this whole conundrum of billing etc.

And you'll stay up more.

You DO technically have to pay taxes on the value of the meth. The tax code says than tax is due on income "from whatever source derived". The courts have been very clear on this point. For instance, if I agree to paint your house in exchange for you lancing a boil on my ass, both of us should report income on our 1040's for the fair market value of the services received (or rendered, which is theoretically the same thing).

Finally, it matters not a hoot to the IRS that meth is an illicit substance. Again, the courts have been clear about your obligation to pay taxes on the value of any "income" even if you could otherwise be arrested for accepting it (for instance, prostitutes have an obligation to pay income tax on their earnings even though they are clearly illegal).

As to whether accepting the $100 is ethical, I see nothing wrong with it. Fee for service. The more interesting question is whether you have a legal right to accept the payment outside the auspices of the ED itself. Much of that will depend, of course, on the financial relationship you have with the department and the hospital. Obviously if the hospital collects the money and then pays over a percentage (or fixed salary) to you, you have no legal right to accept the payment directly from the patient. In that case the hospital or department has a right to "participate" in the payment to the full extent of is contractual agreement with you. Pocketing that money would represent, at a minimum, a breach of that contractual agreement, and, at worst, perhaps a violation of your fiduciary "duty" to the hospital.

On the other hand, if you have no financial agreement with the hospital (you do all your own billing and collections) then the hospital has no right to any part of the money. Again, however, you need to be cognizant of your obligations to the hospital via the contractual agreement between you. For instance, I imagine even though it provides for your own billing and collection, it also might require you to submit an accurate bill for services through he hospital so it can generate its own bill for use of the ED, pharmacueticals, etc.

I have no idea how your atcual relationship with the hospital is characterized - just stuff to theoretically think about.

Judd

 

[juddson]

You ED guys confuse me. On the one hand, half of you are running around posting that you average $300K/yr working <40 hr/wk. On the other hand, you're talking about how you're getting soaked by uninsured/underinsured bums. You have to get together and decide which story you're gonna stick to. (And it's not that I don't agree that the health care system is majorly f-ed up or am so naive that I think people don't take advantage of the third-party payer system that insulates them from costs.)

What have you done with kinetic?

judd

 

[Sessamoid]

Much of that will depend, of course, on the financial relationship you have with the department and the hospital.

The vast majority of us are contractors who forms professional groups to provide physician services to the hospital. In general, we do all our own billing and collections. There are exceptions and complications of course (as always). Those who work for HMOs are direct employees, so any cash they accept they probably have to turn over to the HMO unless it's recognized by all parties ahead of time that a particular payment is only a "tip", and that the patient is still obligated by whatever agreement he has with the HMO. In addition, some hospitals that are difficult to staff for various reasons (usually poor payer mix in the patient population) also provide a subsidy in addition to whatever the physician collects from the patient. That type of agreement probably doesn't affect cash at the time of service, though. I mention it only as another possible complexity.

 

[Sessamoid]

What have you done with kinetic?

judd

I haven't noticed any particular change in posting habits.

 

[kinetic]

I haven't noticed any particular change in posting habits.

Me, neither. I'm still kicking ass and taking names.

 

[iliacus]

I've spent a good deal of time observing and learning about the Cambodian medical system. One of the big problems they have in all professional fields, and especially medicine, is that the level of service is often contingent on tipping in advance.

Wait, let's not dismiss the Cambodian medical system so quickly. I can imagine a scenario..

Pt: "Ahhh DocB I have no tip."

DocB: "What, no tip...no cat scan for you and I use extra big dirty needle!"

Pt: "Oh wait...I give you chicken."

DocB: "Chicken! Chicken!, that make 3 chicken in one day. Back out to waiting room! Bring in drug dealer with sprain ankle."

What a beautiful country we live in. It's cheaper to get a chest X-ray and broad spectrum antibiotics than a Krispy Kreme donut. God bless America!

 

[docB]

Wait, let's not dismiss the Cambodian medical system so quickly. I can imagine a scenario..

Pt: "Ahhh DocB I have no tip."

DocB: "What, no tip...no cat scan for you and I use extra big dirty needle!"

Pt: "Oh wait...I give you chicken."

DocB: "Chicken! Chicken!, that make 3 chicken in one day. Back out to waiting room! Bring in drug dealer with sprain ankle."

What a beautiful country we live in. It's cheaper to get a chest X-ray and broad spectrum antibiotics than a Krispy Kreme donut. God bless America!

Nah, when I work shifts in Cambodia I demand at least a pig or a goat up front. A chicken gets you nothing but my scorn.

 

[kinetic]

Wait, let's not dismiss the Cambodian medical system so quickly. I can imagine a scenario..

Pt: "Ahhh DocB I have no tip."

DocB: "What, no tip...no cat scan for you and I use extra big dirty needle!"

Pt: "Oh wait...I give you chicken."

DocB: "Chicken! Chicken!, that make 3 chicken in one day. Back out to waiting room! Bring in drug dealer with sprain ankle."

What a beautiful country we live in. It's cheaper to get a chest X-ray and broad spectrum antibiotics than a Krispy Kreme donut. God bless America!

I like how DocB moves to Cambodia and loses his command of the English language.

 

[Sessamoid]

Nah, when I work shifts in Cambodia I demand at least a pig or a goat up front. A chicken gets you nothing but my scorn.

Some days, I'd settle for that Krispy Kreme donut. 🙂

 

[MoosePilot]

While I'd like to think that American physicians are too noble to go down the same path as their Cambodian counterparts, I also at one time thought that the American military were too noble to use torture.

We're as monolithic as the ED conspiracy.

I've never tortured anyone in my life. Except in church when I sing, but some of the time I just mouth the words to be kind to my neighbors.

 

[Sessamoid]

We're as monolithic as the ED conspiracy.

I've never tortured anyone in my life. Except in church when I sing, but some of the time I just mouth the words to be kind to my neighbors.

Of course, the vast majority of US servicemen and women are ordinary people placed in extraordinary circumstances. Only a small minority do really horrible things even in those circumstances. But we've been doing horrible things around the globe for a very long time, military and intelligence community especially.

I've also got no illusions about the nobility of some of my physician colleagues. There's a group of doctors undergoing investigation for allegedly recruiting patients for procedures they don't need so that they can bill Medicare/aid for the procedures. The story is that they'd hire people to find illiterate Mexicans in another state, have them coached on what to say when they got to the office, bus them to the clinic, perform endoscopies (or whatever on them) in exchange for some small gift, paltry amount of money, or just the free trip to California. If guilty, these people should go to jail for a REALLY LONG TIME. Taking advantage of the poor and illiterate in this manner is just despicable. They really make it hard for the rest of us honest physicians to ask for anything in the political arena. That kind of thing knocks physicians right off the moral high ground.

 

[edinOH]

I also at one time thought that the American military were too noble to use torture. .

Being forced to masturbate with a bag over your head is humiliating but I don't think it qualifies as torture. Just ask Quinn.

 

[docB]

...ED conspiracy...

ED conspiracy?

 

[MoosePilot]

ED conspiracy?

Just joking, kind of working back to the EPs not having their story straight about how much they make:

In case you haven't figured it out, "emergency medicine" isn't some monolithic entity where everybody toes the party line, despite what you may think or wish.

Now that soldiers and torture come up, I'm pointing out that we might be more monolithic than EPs, but we still don't get together and discuss what screwed up crimes we're going to committ with pyschos like in Abu G.

Not pertinent, off topic, my apologies.

 

[iliacus]

Being forced to masturbate with a bag over your head is humiliating but I don't think it qualifies as torture. Just ask Quinn.

I'm not so sure...I had a "friend" who was caught by his dad once (sans bag over head) and believe me sitting at the dinner table that night WAS torture.

"Son, did you wash your hands before coming to the dinner table?" 😳