Some physicians also feeling the pain of dropping incomes

[+ Pensant]

Yesterday, I had my annual physical. I was only one of two people in the waiting area. I usually have a nice conversation with my young internist, and yesterday was no exception. I was wearing my N95 mask, as was he. Everything checked out fine. I asked him if this was the new normal. He said yes. Patient visits have dropped precipitously, although he, like many others, was using telemedicine. Pediatricians, surgeons, and, especially, orthopedists are all feeling the pain as elective procedures are postponed. I imagine plastic surgeons, in particular, are hurting. I doubt if many Botox and filler procedures are being performed.

 

I wonder how many of these doctors will be drafted into the front lines?

 

BTW, my temp was 96.8.

[+ Charlie]

I am sure dentists are also seeing a fall-off in income, since so much of their practice is routine procedures like cleaning and filling, which can't be done with the patient wearing a mask or through telemedicine.

[+ Pensant]

I am sure dentists are also seeing a fall-off in income, since so much of their practice is routine procedures like cleaning and filling, which can't be done with the patient wearing a mask or through telemedicine.

For sure. My neighbor is a dentist and that’s what she’s seeing. I’ll get an update tonight at our weekly social distancing cocktail hour.

[LookingAround]

Did you have an annual physical by going into a doctors office? I wouldn’t go near a doctors office right now for fear sick people would be there some of whom have Covid-19.

[maninsoma]

Did you have an annual physical by going into a doctors office? I wouldn’t go near a doctors office right now for fear sick people would be there some of whom have Covid-19.

 

Same here. I have Kaiser insurance and they are basically trying to get everyone to stay away from their facilities except for people who work there and patients who absolutely must be seen in person for diagnosis or treatment right away. Otherwise everything is being done online or via telephone and prescriptions are being mailed. I, too, would not want to go to a medical facility right now unless absolutely necessary in order to prevent infection either direction (me getting exposed or me, potentially being a carrier without any symptoms, exposing others).

[jjkrkwood]

Same here. I have Kaiser insurance and they are basically trying to get everyone to stay away from their facilities except for people who work there and patients who absolutely must be seen in person for diagnosis or treatment right away. Otherwise everything is being done online or via telephone and prescriptions are being mailed. I, too, would not want to go to a medical facility right now unless absolutely necessary in order to prevent infection either direction (me getting exposed or me, potentially being a carrier without any symptoms, exposing others).

 

I don't really understand this concept of "virtual visits".... UNLESS you simply have questions that need to be answered, an office visit

allows the doc to check your vitals as well as "physical" issues you might be having which cannot be done online... If its a followup appt to one you've already had simply for check-in, I get it..... Otherwise I have cancelled ALL my appts that required "touch"...

 

I just keep praying I dont get a toothache or cracked tooth. not sure how dental offices are handling this ?

[Guest]

We're certainly not doing routine physicals in my office. The only routine exams are those who really have to be seen, including prenatal visits, and baby exams. Most visits are done by phone, although some things have to be seen, of course, including injuries, earaches, and so on. Even some things one would normally have to see the patient for, we try to avoid. A colleague of mine treated a vaginal discharge over the phone. The patient had a benign sexual history, so she went by the symptoms (no itching, discharge with a fishy smell), and treated based on the history, advising the patient that if her guess as to the correct treatment didn't work, the patient would need to be seen.

[+ Charlie]

I had my first telemedicine appointment last week on Facetime, which worked pretty well. It was a follow-up with an allergist to go over results of tests done in the office on March 2nd, so there really was no need to actually be "seen" by the doctor (though I don't mind "seeing" him, because he is so cute).

[jjkrkwood]

I had my first telemedicine appointment last week on Facetime, which worked pretty well. It was a follow-up with an allergist to go over results of tests done in the office on March 2nd, so there really was no need to actually be "seen" by the doctor (though I don't mind "seeing" him, because he is so cute).

 

Wouldnt a PHONE CALL be more efficient ?

[+ Charlie]

Wouldnt a PHONE CALL be more efficient ?

I suggested it, but I suspect that financial reimbursement for telemedicine is better; he probably doesn't get paid for a phone call.

[Guest]

...I was only one of two people in the waiting area. I usually have a nice conversation with my young internist, and yesterday was no exception. I was wearing my N95 mask, as was he. Everything checked out fine. I asked him if this was the new normal. He said yes. Patient visits have dropped precipitously, although he, like many others, was using telemedicine. Pediatricians, surgeons, and, especially, orthopedists are all feeling the pain as elective procedures are postponed. I imagine plastic surgeons, in particular, are hurting. I doubt if many Botox and filler procedures are being performed....

 

No reason to lose income and sit around in an empty office. Any physician without enough work can probably call the state or local hospital and chip in. In this emergency, hospitals are taking all the help they can get. At least in NY and California, I know that the governors have said that even physicians who are retired and without a license, as well as those finishing medical school can work in the hospitals, and formal privileging procedures will not be needed. I suspect other states have followed suit.

[jjkrkwood]

I suggested it, but I suspect that financial reimbursement for telemedicine is better; he probably doesn't get paid for a phone call.

 

Makes a lot of sense...., but would that be considered price gouging in a sense ? I suppose it doesn't matter, we have way bigger problems to address..

[+ Charlie]

I believe I read somewhere that a doctor gets a much smaller payment for a telemedicine appointment than an office visit that covers the same subject, but gets even less or nothing for a phone call.

[LookingAround]

No reason to lose income and sit around in an empty office. Any physician without enough work can probably call the state or local hospital and chip in. In this emergency, hospitals are taking all the help they can get. At least in NY and California, I know that the governors have said that even physicians who are retired and without a license, as well as those finishing medical school can work in the hospitals, and formal privileging procedures will not be needed. I suspect other states have followed suit.

That’s not true. To practice medicine they need a valid license at least somewhere.

[LookingAround]

I believe I read somewhere that a doctor gets a much smaller payment for a telemedicine appointment than an office visit that covers the same subject, but gets even less or nothing for a phone call.

True traditionally but exceptions are made during Covid.

[Guest]

I believe I read somewhere that a doctor gets a much smaller payment for a telemedicine appointment than an office visit that covers the same subject, but gets even less or nothing for a phone call.

Our office is doing telemedicine knowing that as of this time it may not be reimbursable. Management is hoping they'll change the rules for this crisis. In the meantime, we're just making sure everyone gets taken care of in the safest way possible. Just crossing our fingers hoping we'll get paid for it later.

[Guest]

My temp is 96.7... folks like plastic surgeons will suffer a permanent loss of elective procedures. But the backlog of people needing that regular cancer screening or colonoscopy will only grow and certain specialities and ambulatory surgery centers will be operating at full capacity for some time once it’s safe to do so.

[Guest]

Our office is doing telemedicine knowing that as of this time it may not be reimbursable. Management is hoping they'll change the rules for this crisis. In the meantime, we're just making sure everyone gets taken care of in the safest way possible. Just crossing our fingers hoping we'll get paid for it later.

I believe telemed will get fully reimbursed. If not voluntarily, I believe congress will act to assure that it will. The alternative, is that you can claim some reimbursement for rent under the CARES Act.

 

The long term implication of telemed will be to reduce the office rent component of the reimbursement since, like an anesthesiologist, telemed docs don’t need an office.

[mike carey]

I believe I read somewhere that a doctor gets a much smaller payment for a telemedicine appointment than an office visit that covers the same subject, but gets even less or nothing for a phone call.

Here, the government has authorised a wide range of telemedicine consultations, and as I understand it they apply equally to telephone and video. I don't know if they are the same as an in-person consultation. Since payment is from the public health system, not an insurance company, the approval of the use of technology came with the approval of the payment and the amount paid. For a lot of things, providers can set their own fee and Medicare pays the 'scheduled fee' either to them or as a refund to the patient but these services apparently have to be 'bulk billed', that is the provider receives the scheduled fee direct from Medicare.

[maninsoma]

I don't really understand this concept of "virtual visits".... UNLESS you simply have questions that need to be answered, an office visit

allows the doc to check your vitals as well as "physical" issues you might be having which cannot be done online... If its a followup appt to one you've already had simply for check-in, I get it..... Otherwise I have cancelled ALL my appts that required "touch"...

 

I just keep praying I dont get a toothache or cracked tooth. not sure how dental offices are handling this ?

 

I doubt a doctor would do a virtual visit for someone they have not already examined. However, I can tell you how valuable they have been for me since I got Kaiser -- and not just since this pandemic started. When I had Blue Shield insurance, every little thing required a trip to the doctor's office (where I always had to wait way past my appointment time for the doctor and where, of course, I had to pay a copay). Need to review the results of labs and potentially start treatment with something? Go to the office just to get a prescription. Have an ongoing issue like asthma and need another inhaler? Go to the office to get a new prescription. Have a concern that you might have an STD? Go to the office just to express that concern in person, and then get referred to a lab for screening. With Kaiser, my lab results are posted on their website. My doctor will message me if something is of concern, and I can order a prescription to be delivered via mail if I need something. If I need a refill of something, I can request it on the website and it either gets filled (if there are refills available) or a message is sent to the doctor requesting him to authorize refills. For something like STD screening, I assume that if the patient's report is murky a provider might want that patient to come in first for screening, but most STDs require lab work and not just visual inspection anyway. Why not just have the person go to the lab?

 

I have saved a lot of time and money by switching to Kaiser and feel like I get better care. My doctor is responsive. I can see him (or someone else) if I want, usually the same or the next day -- I'm talking pre-pandemic here; I think right now they are trying to keep everyone away who doesn't absolutely need to be seen right now -- but if the delivery of care can be done via message, phone call, or video call then I can do that as well to save everyone time and money. I think the difference is that Kaiser doctors are employees of Kaiser and get paid the same whether they see you in person or provide care in some other way. There is no financial incentive for a doctor to insist that someone come into the office for something as simple as getting lab results. For providers, I can see this has a downside -- if you have a busy independent practice, I assume you can make much more money than you would as a Kaiser doctor. For a patient, however, I see no downside. I always had difficulty finding a doctor I liked who was accepting new patients when I had other coverage, and once I was an established patient it was frequently difficult to get an appointment without waiting at least a few days if not a week.

[+ Pensant]

I am involved with a telemedicine company which is booming right now. A bright spot in a otherwise gloomy market. They’re being reimbursed.

[JayCeeKy]

My nephew has been doing telemedicine (psychiatry) for four years in two different states and is fully reimbursed by insurance. I have two nieces who are dentists and one doesn't leave her home as she is pregnant and the other only sees patients on an emergency basis - so, obviously, their incomes have plummeted (luckily, one is married to a diagnostic radiologist and he is being kept very busy). I have a niece and nephew who are ER docs, and they are working extra hours - though they are having to perform extraordinary safety rituals before entering their homes at the end of their shifts.

[nycbystander]

I doubt a doctor would do a virtual visit for someone they have not already examined. However, I can tell you how valuable they have been for me since I got Kaiser -- and not just since this pandemic started. When I had Blue Shield insurance, every little thing required a trip to the doctor's office (where I always had to wait way past my appointment time for the doctor and where, of course, I had to pay a copay). Need to review the results of labs and potentially start treatment with something? Go to the office just to get a prescription. Have an ongoing issue like asthma and need another inhaler? Go to the office to get a new prescription. Have a concern that you might have an STD? Go to the office just to express that concern in person, and then get referred to a lab for screening. With Kaiser, my lab results are posted on their website. My doctor will message me if something is of concern, and I can order a prescription to be delivered via mail if I need something. If I need a refill of something, I can request it on the website and it either gets filled (if there are refills available) or a message is sent to the doctor requesting him to authorize refills. For something like STD screening, I assume that if the patient's report is murky a provider might want that patient to come in first for screening, but most STDs require lab work and not just visual inspection anyway. Why not just have the person go to the lab?

 

I have saved a lot of time and money by switching to Kaiser and feel like I get better care. My doctor is responsive. I can see him (or someone else) if I want, usually the same or the next day -- I'm talking pre-pandemic here; I think right now they are trying to keep everyone away who doesn't absolutely need to be seen right now -- but if the delivery of care can be done via message, phone call, or video call then I can do that as well to save everyone time and money. I think the difference is that Kaiser doctors are employees of Kaiser and get paid the same whether they see you in person or provide care in some other way. There is no financial incentive for a doctor to insist that someone come into the office for something as simple as getting lab results. For providers, I can see this has a downside -- if you have a busy independent practice, I assume you can make much more money than you would as a Kaiser doctor. For a patient, however, I see no downside. I always had difficulty finding a doctor I liked who was accepting new patients when I had other coverage, and once I was an established patient it was frequently difficult to get an appointment without waiting at least a few days if not a week.

 

 

 

Assuming, of course, you live in a region covered by Kaiser.

[Guest]

... Need to review the results of labs and potentially start treatment with something? Go to the office just to get a prescription. Have an ongoing issue like asthma and need another inhaler? Go to the office to get a new prescription. Have a concern that you might have an STD? Go to the office just to express that concern in person, and then get referred to a lab for screening. With Kaiser, my lab results are posted on their website...

You correctly point out the distorted incentives in a fee-for-service system. Within the last 4 years or so, however, almost all offices now offer patient internet portals which allow the patient to view his lab results directly and e-mail his physician directly. There are massive financial incentives the government has provided to ensure that all medical offices provide such access. I don't know of any physician who doesn't provide his patients with internet access to labs and physician messaging. In fact, when I have labs drawn, I can access results both through the lab's internet portal and the internet portal of the physician(s) who ordered the labs.

Of course, the unfairness of this situation is for the fee-for-service physician who cannot bill for telephone consultations or responding to e-mails. It used to be, many years ago, that STD testing required the patient to come in, because testing for gonorrhea and chlamydia needed sampling to be taken directly from the urethra (men) or cervix (women). It's been a very long time (I can't remember exactly, but probably at least 10 years) that the technology has advanced to allow GC/Chlamydia testing with a first-void urine. I haven't asked patients to come in for STD testing since that time, although coming in does allow one to examine the genitals for evidence of HPV infection, lymph node enlargement, and so forth. And one still has to provide full counseling on prevention, contact treatment, and so on.

I find it pretty obnoxious to ask a patient to come in just to ask for a refill. You didn't mention which asthma inhaler you were referring to in your post. If it's albuterol or another rescue inhaler, needing a refill within a one-year time period is problematic. That's the one medication for which I don't OK any refills (with some exceptions). Rescue inhalers don't treat the underlying asthma. Controller medications do. By definition, using more than one 18 g canister per year means your asthma isn't controlled. This obligates the physician to investigate the reason. Either the controller medications he's prescribing aren't enough, or the patient isn't taking the controller medication as prescribed (or both, obviously).

An exception might be for someone who's taking the maximum doses of all classes of controller medications, although even in those cases, the asthma should be evaluated by an allergist for treatment with a biologic asthma therapy (Xolair, Nucala, Cinqair, Fasenra, or Duxipent). These treatments are extremely expensive (like $10,000 per year), but usually control the most stubborn cases of asthma. I can't imagine ever asking a patient to come in to refill a controller medication, unless he hasn't been in for over a year (even then, I'll OK a month's worth to give him time to come in).

[OneFinger]

I was diagnosed last August with cancer and I do not yet qualify for treatment. The standard care for my type of cancer is to take blood test every 3 months until I do qualify for treatment. I "should" have had blood drawn in March. But, I didn't go to the lab for blood draw due to the "shelter in place" order where I live.

 

Got a call on Friday from my oncologist. He set up an appointment for me to go to his office for the blood draw. He emphasized that only me and lab tech would be in his office (no other patients). He also said that all rooms used are thoroughly sanitized after each patient.

 

We then set up a phone visit (2 days after the blood draw) to review the results. I think this is a perfect way to deal with this cancer issue. Also have a telecon with my PCC the same day for Rx renewals.