About every 6 weeks or so I go through the onerous task of posting the Explanation of Benefits from the insurance companies, sorting through what patients owe, and packaging up and sending off the invoices. This process is painful to accomplish and therefore serves as a great force for my creative juices--should I rant about poor reimbursement, administrative trivia which results in rejection of claims (discussed so nicely in Megan's post), or perhaps the stupidity of a process which is so complex, three different entities have to be billed in order to collect one office visit charge? Those are valid and important topics, but during this round of billing, I became more aware of the constant struggle I have between being a healing professional and getting paid for being a healing professional.
When I first opened my office nearly 6 years ago, the average copay was $15 with the top end being $25. Now, even though the insurance allowable has not appreciably increased, the average copay is $25 with many people having high deductible plans and therefore having to pay 100% of the allowable. This trend not only represents a shift of cost from the employer (who pays the premium) to the patient (who pays the office visit) but also a shift in collections from the insurance company (who collects the premium) to the doctor's office (who collects the office charge).
Some people hail this trend as a good thing. After all, if patients know how expensive medical care is, they will be more apt to choose wisely when they need that care. Others feel in a capatalistic free market society, people speak with their money, and so the good docs will get paid because patients feel they are worth it. I disagree with both these theories. Shifting costs to the patient causes many of my patients to avoid coming in for routine (but important) follow up care, and I have plenty of patients who are truly grateful for the care I give but cannot afford to pay me--especially during the recent economic downturn.
The difficulty for me is that there are different forces at play. The first is the value placed on family physicians by our society. We incurred the cost (both in money and time) of medical school and residency. We take on the responsibility of the health of our patients and collectively the health of the nation. And yet, the end of primary care looms as medical students shun primary care for more lucrative specialties. Certainly, as a nation we have to come to grips with how and how much our primary care docs are compensated. But, we are also healing professionals and we know intrinsically that our patients' health are in many ways directly related to their financial situation. Should I send those going through difficult times to collections for not paying me the $50 they owe? Although it may be the correct business decision, it does not seem to jive with being a healing professional and it certainly does not augment the doctor-patient relationship (upon which everything in medicine should be based).
Some docs realize early on they do not have the stomach for the nasty job of collections and hire a collections agency or business manager to do it for them, but this does not solve these underlying conflicts, it just removes the doctor from the front lines. So I wonder, am I a healing professional or a bill collector? Can I wear both hats at the same time or does wearing one exclude me from the other? Will there finally come a day when I can focus only on healing? If so, that would be a glorious day for me and my patients.