Time is money… for doctors & patients;

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More often, canceling an appointment at the last minute or failing to show up will cost you

Delaware News Journal

When a last-minute business meeting summoned Lisa Pertzoff to Washington, D.C., a couple years back, she went.

It was only after she arrived in Washington that Friday evening that she realized the meeting was going to force her to miss a Monday morning appointment with her neurologist.

Her doctor required 24-hour notice of cancellation, but only business hours counted. So, the following week she paid a $30 fine.

“I had missed a couple other appointments before there, so it was like they had put a star over my head,” said Pertzoff, executive director of the Delaware Council on Gambling Problems, in Wilmington. “I paid it without protest.”

No-shows at the doctor’s office have long been a problem, but now many health specialists are cracking down. You may have seen a no-show warning sign in the waiting room at your doctor’s office. Or perhaps you were mailed a reminder postcard with a similar warning days before your dentist visit.

Though there’s little research on the issue, patients, doctors associations and consumer rights groups say more health-care professionals are administering fees of $25 or higher on patients who miss appointments. Some are even dropping patients who cancel or miss too often.

For health-care professionals, the charges are a way to recoup the administrative costs of running a business. After all, they point out, assistants and receptionists need to be paid whether or not a patient shows up. And doctors typically aren’t salaried, they’re paid only for patients they treat. Some patients understand that. But for them, the fees still are one more health expense to shoulder, atop rising insurance premiums and co-pays.

Arthur Caplan, a professor of bioethics at the University of Pennsylvania, said the fines are justified, but the system isn’t fair since patients often have to wait for their appointments. Doctors would have a stronger argument for fining, he said, if they charged less for people who had to wait for them.

“If it takes them more than a half-hour to see me, maybe I should get a discount,” he said. “If you’re there on time and you have to wait, you could pick your time, maybe a half-hour or an hour, where if you have to wait that long you get some money back.”

Wilmington dentist James Tigani III said no-shows are “kind of like your boss saying for the next hour you’re working, but you’re off the clock.” Why? Because he’s working, but not making money.

In 1979, when he was building a practice, he worked every other Saturday. He had 16 appointments lined up one rainy Saturday. Not one person showed and only one called to cancel. He ended up sitting in the office with two of his assistants and watching the rain.

“It was probably my worst day in my 31 years of practice,” he said.

Tigani, who has 2,100 patients, said the ones who often miss appointments don’t realize he still has to pay the dental hygienist, dental assistant and receptionists for the time. He can’t just shut the lights off.

“I have CEOs here who miss appointments, and I have people who make 1/100 of a CEO who also miss,” he said. “I can’t categorize it.”

Tigani charges $50 for no-shows. But, like many other health professionals, he doesn’t charge the first time it happens because he realizes life issues can get in the way.

“There are legitimate reasons, that’s why you don’t routinely charge in every case,” he said. “I’ll tell them I’ll knock it off this time but not next time.”

But chronic offenders are another story. He has dropped patients who “miss six out of eight appointments.”

On any given workday, two of his 12 scheduled patients miss their appointments, said Adrianne Vespe, Tigani’s patient coordinator.

“A lot of people will pay the fine right away,” she said. “They know they’re in the wrong.”

Doctors cite lower reimbursements

The American Medical Association says doctors may charge patients for missed appointments and ones that are canceled less than 24 hours in advance. It says this is a reasonable policy as long as patients are fully advised that a doctor will make such a charge.

In Delaware, these charges have ranged from $25 to $85, depending on the specific practice and the time allotted for the appointment.

Doctors, dentists and others say fines are needed because of rising expenses and lower reimbursements. Over the next nine years, for instance, Medicare payments in Delaware will be reduced by $710 million, according to the 2006 Medicare Trustees report. That averages out to a cut of about $35,000 a year per doctor. Plus, missed appointments mean a doctor isn’t making money.

At the same time, however, health care costs for patients are rising. According to the annual employer health benefits report by the Kaiser Family Foundation, about 27 percent of workers covered by health maintenance organizations were charged a $20 co-pay by their doctor in 2005. In 1996, only 5 percent of patients were charged that much. Deductibles for employees with single coverage also have risen, from $414 in 2004 to $602 last year.

Fines on top of rising health insurance costs are unfair, said Jerry Flanagan, health care policy director at the Foundation for Taxpayer and Consumer Rights.

“Patients often have to miss doctor appointments for things that aren’t their fault,” he said, “like the baby sitter not showing up, the car breaking down or the boss saying you’ve gotta come in early.”

For Wilmington resident Susan Edgar, it was the car breaking down on Kirkwood Highway while she was en route to an appointment with a counselor several years ago. She got a free pass that time. But the next time, when she simply forgot, she wrote a check for $50.

She thinks it’s fair to charge patients for missing appointments as long as there’s an established policy.

“If there’s never been a policy, then you don’t know that there’s a fine,” she said. “So then you’d have an argument.”

Office decides to end fines

Caplan, the ethicist, generally doesn’t think fines disrupt the doctor-patient relationship.

“There’s a business side of medicine,” he said. “People know about it and they position around it.”

But Halpern Eye Associates, which has eight locations in Delaware, recently rescinded its policy of charging $85 for patients who missed appointments because it was creating animosity. Still, warning signs — which read “A charge will be made for broken appointments without 24 hour notice” — remain posted in the waiting rooms. Halpern hopes the signs will encourage patients to cancel in advance.

“Even if another patient can be seen, it’s a time slot that hasn’t been filled,” said Dr. Priti Patel, a Halpern optometrist.

Some patients fail to show because the visit no longer seems necessary. For example, a patient awakes with a sore throat and calls the doctor, only to find she’s booked solid till three days later. By that time, the sore throat has subsided and the patient decides it’s not worth the hassle to take off work for the appointment.

In an effort to solve this problem, the Medical Group of Christiana Care, made up of 20 practices, has changed its scheduling system. The group now offers same-day scheduling on Mondays, Tuesdays and Fridays. Forty percent of calls for care come in on Mondays, said Dr. Alan Greenglass, medical director of the group.

“We were thinking we should provide more access to care on Monday since that better matches the availability of the patient’s time,” he said.

A few years back, the group also started sending automatic telephone reminders to patients a few days before their appointments, letting them know they should cancel right away if they couldn’t keep the appointments. That strategy, started in 2003, has helped drop the no-show rate from 12 percent to less than 3 percent.

The group still charges for missed appointments — $25 for 15-minute sessions and $50 for 30 minutes or longer — and it posts signs in patient treatment rooms. But like Tigani’s office, it fines only chronic no-shows, Greenglass said. The purpose of the fines, Wilson said, is to remind patients how important it is to keep their appointments.

“If a patient has a family emergency we’re not going to assess the charge,” she said. “It’s for people who miss continually.”

Patient says my time is valuable, too

Pertzoff stores all of her health appointments on her PDA. Since she routinely has a schedule chockful of meetings, she prefers the earliest appointments possible. She doesn’t want to worry about waiting for a doctor who’s running late because of delays with other patients.

Two weeks ago she had to be at a business meeting at 9 a.m. She scheduled a doctor’s appointment for 8:15 a.m.

“I was hoping to get in and out and to the meeting before 9,” she said.

The doctor, who had just returned to the office after hospital rounds, wasn’t able to see her until 8:45 a.m. She didn’t have a problem with his reason, but she still was late for her meeting.

“If I miss a couple appointments, then I’ve acted like a dufus and I’ve gotten exactly what I deserved if I get fined,” she said. “But on the other hand, there’s very little appreciation for my time as a patient.”

Patel, the optometrist, said only on rare occasions do patients wait at Halpern for more than 10 minutes. If patients become aggravated because of their wait, they can get a 10 percent discount on eyewear.

“We’ll do our best to try and appease them,” she said. “[But] it’s not a good idea to make that the policy. This is a business deal and they should be handled case by case.”

Tigani said it’s reasonable for waiting patients to get a discount — but only if the health professionals have an established policy that charges patients for being late.

“I don’t charge for being late, just for no-shows,” he said. “If I didn’t show up for work, they’d be entitled to a big discount.”

For some though, discounts aren’t enough. After waiting more than three hours, a Las Vegas man in 2003 sued his doctor.

Aristotelis Belavilas got so fed up waiting for a steroid injection to help his back pain that he left his doctor’s office and headed for his lawyer. He sued for $5,000. A Las Vegas court awarded him $250.

Belavilas said at the time: “I decided to sue him because my time is worth something just like his is.”

Consumer Watchdog
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