Need a lawyer? Chances are that if you do you will need to pay for a retainer. The retainer is a set amount of money you pay the lawyer that s/he holds and bills against. Every action the lawyer does takes away from that retainer. Do you need her to send a letter? The time to draft and mail the letter is deducted from the retainer. Do you need to speak to him on the phone about your case? Every minute you spend talking to him is billed against that retainer. Once the retainer is gone you either have to add funds to it or find yourself another lawyer.
As the husband of a newly minted family physician – and someone who seriously considered law school at several points over the years – I am often amazed at how different being a doctor is from being a lawyer. The biggest difference is that my wife can only bill for office visits. Everything else she does outside of meeting a patient face-to-face is free.
Dr. Richard J. Baron, a physician in private practice in Philadelphia tracked his and his associates time and reported the results in the April 2010 issue of the New England Journal of Medicine. On average each physician responded to 24 phone calls each day, as well as answered 17 emails (majority being lab results), refilled 12 prescription, evaluated 20 lab results, reviewed 11 imaging (CT and MRI) reports, and handled 14 consultation reports that often required adjustments to a patient’s medications. All this work cannot be billed for and is done for free.
On top of the unpaid busywork, each physician saw 18 patients daily. If each patient visit was 15 minutes long, the physician spent 4 1/2 hours of her day in front of her patients and billable. But the visits themselves require more unpaid busy work. The doctor had to exam each patient’s medical record before the visit, and then make notes and annotations of the results of the visit to the medical record and add appropriate billing codes after each visit.
According to Dr. Byron, doctors at his practice worked an average of 50-60 hours a week. I would estimate that is less than my wife works, but she is still developing her administrative and time managements skills so I hope that eventually her hours will decrease.
Because doctors cannot bill for the time they spend doing busywork, there is no constraint on it and it will grow. In order to attempt to handle it, the physicians at Dr. Byron’s office hired more staff. But this is unsustainable since a bigger staff adds costs to the practice without increasing revenue. Electronic medical records (EMR’s) help but these systems only store information that must be entered, accessed, and interpreted – and the physician himself is the only person qualified (and legally responsible) to interpret the information. EMR’s are an integral part of improving the efficiency of a medical practice, but as Dr. Byron points out, the implementation of the EMR did not reduce staffing, it only changed the skillset of the staff. His office laid off a registered nurse but later brought on another to perform “information triage.”
The only way to stop the growth in unpaid work is to charge for it. That will not sit well with doctors, insurance companies, or patients. But unless doctors bill for this unpaid work and insurance providers and patients pay, the unpaid busywork will only grow until physicians are forced into more lucrative specialties, boutique medicine, or leave the field entirely.
UPDATE: The Texas Medical Association reports that in 2001, a $1000 Medicare payment netted a physician a $410 profit after expenses. In 2010 that same payment only provides a $290 profit. If planned Medicare cuts go through, it will net just $72. PCP’s are opting out of Medicare at an alarming rate in the Lone Star State. The majority of the patients the Wife sees are Medicaid/Medicare. If she stopped seeing them, she would not have patients and worse, her patients would not have a doctor. She has options: boutique medicine, treating suburban patients with private insurance. Her patients in the mountains do not.