Saturday, July 07, 2007

Customer or Patient? (part deux)


As many of you know from reading here I have a big problem with hospital administrators. It used to be that doctors, as they progressed in their careers, became hospital CEOs or Presidents or whatever. Doctors ran hospitals usually for the better in my opinion. Doctors in charge of doctors is really the only way it should be. Asking me to respect the judgements of a business guy regarding how best to run a hospital and therefore how to best practice medicine is simply foolish.

Medicine is unique, and applying a business model to our current 'system' is just insane. Now we have business folks who have trained in 'medical administration' as the captains of our ships. Most of them say they "would have gone to medical school but... (fill in blank here)". They have brought with them, the "customer" model from business and are flummoxed at how poorly it applies to medicine.

Now it's not rocket science why this hasn't worked out so well, or, as David Lee Roth said recently, it's not "rocket surgery". Medicine is not a business. Patients are not customers. Encouraging repeat "customers" in the ED LOSES us money as patients with insurance would normally go and see their own physicians. We collect 30% of what we bill so again, operatin' on rockets this is not.

Also, being mandated by a federal law to treat all-comers with an "emergency condition" (still waiting for the definition) without any money to back pay for it makes us more like speculators than businessmen. We hope that by mining a certain percentage of patients that we will strike enough hidden money to make it all worthwhile for us.

I have comprised the following list to help those having difficulty with the above concepts.

A Customer...

1. Seeks you out to purchase a good or service.

2. Knows the reasonable price of said good or service and agrees on a final price for said good or service prior to purchase.

3. Has, many times, special knowledge obtained about said good or service thereby becoming an 'informed customer'.

4. Can walk out the door at any time without paying prior to the sale.

5. Must pay for good or service or repossession of goods, arrest, or imprisonment for thievery after the sale.

6. Can rightly complain for poor service as, with a competitive business, making your customers happy, and making them repeat customers, helps your business to succeed.

7. The business owner can refuse to serve customers if they are disruptive or, as is often seen posted in businesses, "we reserve the right to refuse service to anyone".

8. The business owner expects a certain number of complaints. Certainly complaints should be a very small percentage of customers served, but let's face it, you can't please everyone and some people are just assholes.

9. A customer pays with his or her money or through an intermediary in the form of a bank card or a loan.

Patients (medical "customers")...

1. Never seek me out personally, they are either delivered to me by an ambulance that could just as well have driven twenty miles the other way to a different hospital, or end up on my doorstep as a 'last resort'.

2. Have no clue, ever, how much the goods and services I will deliver will cost, and, for that matter, NEITHER DO I!

3. Have, generally, no special knowledge about his or her particular medical condition (with some rare exceptions). Reading about something on the internet does not count and is the equivalent to learning where to place your fingers to play a "C" chord on the guitar as opposed to learning to play a classical repertoire like Andres Segovia. Let's face it, unless you know a whole lot about EKGs I could hand one to you and tell you that you were having a heart attack and you would have to believe me. You would not snatch it from my hand and argue that what I am seeing in the anterior leads is "early repolarization" and not "ST segment elevation".

4. Can walk out the door without paying at any time, even after delivery of goods and services (providing they actually can walk) and, even without paying, can complain about my service. This complaint will be dutifully typed onto an official hospital form and deposited into my box to punch me in the gut before the start of a shift. The burden is then on me to explain my poor "customer service".

5. Will get a bill for the goods and services provided. After sending a few of these and turning the bill over for collections the "customer" skates and maybe pays a little or pays nothing. The worst place to be here is to have a job. Then the collections agency will get something from you. If you are illegal or unemployed however, it's not worth it... blood from a turnip you know.

6. Can complain, rightly or wrongly, about the perception of bad care. I have had patients complain that I was "rude" or "brusque" or "didn't seem to care" only to review the chart and find that I have either saved them from imminent death, or had not had time to fully explain why the spider bite that they thought might be from a "brown recluse" was (a) not visible and (b) not a spider bite. Doesn't matter. Letter in my box.

7. Can not be refused service at any time. The only way for me to "refuse service" for someone is to have them refuse to let me care for them by signing a form that says they are choosing to leave "against medical advice". People know this and take full advantage by being loud, demanding more pain medicine, more blankets, faster service, a second opinion, more XRays, food, and television to be delivered to their bedside.

8. Can complain about anything and generate a letter to me. Hospital CEOs expect zero complaints. Idiocy. Physicians are experts in a specialized field of knowledge. Often the right answer to a patient request is "no". Often, the best thing for a patient would be to refuse to treat them with narcotics for the fortieth time this year for their 'migraine' headache and 'herniated disc' pain. Since receiving narcotics is the only thing that will make this large group of customers happy the right answer is, "No, get out!" The business answer is, "We have more pain medicine than you have pain."

9. Pay some mystical amount determined by the three fates for their medical bills. I have no idea how the amount at the bottom of the bill is calculated and how much becomes the patient's responsibility and how much is paid for by the taxes of the Smith family in Podunk, Arkansas. Besides the fact that the way our "business" collects money is some weird morph between a Buckminster Fuller contraption and a slick three-card monty game, acting like pleasing the "customer" will ultimately lead to a robust medical system sends me into fits of apoplexy and makes my tongue cleave to the roof of my mouth (not my fingers though).


  1. I've gotten exactly two complaint letters and both were from drug seekers. If you're asking me to ask the doc for a Fentanyl patch for 3rd day post-op tonsillectomy pain (in addition to the 3 mg of IV dilaudid you've gotten in addition to the PO roxinol you have at home), I'm going to tell you "no". Apparently, I'll get a letter in the mailbox saying I "took over" and "refused to let the doctor treat her". She was also mad that after she was discharged, that she had to wait "30 minutes" to have her scripts filled and that walking in to my department and demanding an IM dilaudid "due to the wait at the pharmacy" also didn't impress me enough to bother the doctor.

    I have to waste my time filling out forms and explaining why I don't want to waste a doctor's time asking for a Fentanyl patch for a drug seeking post-op patient and why telling a discharged patient that she couldn't have more narcs was the right thing to do.

    The fact that that letter even arrived in my mailbox was insulting to me. Plus, my documentation was stupendous because I knew she'd probably complain.

  2. I had no idea those letters actually got noticed at all. I sort of thought they might just get tossed in the garbage. Since the complaint letters get noticed, do the letters I write (the nice ones that tell how wonderful everything was and how kind the doctors and nurses were) get noticed too?

  3. Often the right answer to a patient request is "no".


    Just recently we had a pt insist on having either a stress ECHO or MPI even though he had NO SYMPTOMS and works out at the gym for 1-2 hrs a day. He works in a satellite clinic within our organization and complained via the COS and patient rep.

    Of course the complaint trickled down and the cardiologist I work with capitulated and ordered the test.
    But he did tell the pt rep that he would not see the pt in clinic anymore and referred him to another cardiologist a significant distance away.

    Really wish that administration would stand behind us when we make decisions based on the clinical appropriateness.


  4. If hospital managers were truely competent managers they would find a way to run a private emergency room.

    In a nation that purports to believe in a free market, those without the cash should have their gurneys rolled out beside the dumpster and left.

    Yes yes, there is a place for charity hospitals, but when you simply legislate every hospital into being a charity hospital you have corrupted the system so that it will eventually collapse.

  5. I dunno. You do a pretty good job here demonstrating why doctors are such famously bad businessmen.

    Patients are not customers? Are you crazy? True, there are a lot of ED customers who are not customers by choice, and medical pricing is not exactly transparent. But what percent of your ED volume comes in by ambulance? 15%? 20%? That leaves 80%+ of your business coming in by choice. Unless your hospital is in the middle of the Gobi desert, that probably means that these patients have options. **The funded patients are the ones most likely to exercise that choice by bypassing your facility and going to one with better customer service.** If you are stuck with only the indigent and medicare crowd, the ED *will* be a money-loser.

    Never mind the fact that doctors have a hazy concept of professional billing (at best) and almost *no* understanding of facility billing, no experience with personnel management, physical plant management, etc etc etc. Yeah, you need doctors intimately involved in the leadership, of course, but let's not get *too* into the "MDeity" fiction, shall we?

    BTW, I manage a $15 million practice and am on our facility's board, so I speak with some experience. But I am also smart enough to know my core competencies, and more importantly, to know where they end. Our hospital CEO is an MBA/MHA and a sharp guy. I've never known a doctor who can manage as well as he does. He holds our feet to the fire to meet impossibly high standards (and we hold his feet to the fire to ensure that the facility prospers).

  6. "That leaves 80%+ of your business coming in by choice."

    I'm not sure they come in by choice; they come in because it's one of the "many" hospital stops they will make along the way to get what they want or more of what they want. Many times I've seen a patient who has been seen by all three of the local hospitals that day.

    Now, about those CEO's. Don't even get me started! Our CEO is an EMT with a business degree; but he looks great (wink) doing whatever it is that he does.

  7. shadowfax,

    i *bow* to your obviously *superior* knowledge and ability to us the **asterisk** key to help *emphasize* your points.

    i was kind enought to make a point by point argument about the differences between a *patient* and a **customer** and i see that what you have done here is to throw out the old saw that doctors are *famously bad businissmen* and then imply that you aren't one of them because you run a **15 million dollar practice**. then you throw in the old *ad hominem* attack by calling me an *idiot* which is a debating tactic of a democrat or fourth-grader or both.

    and obtw, if the standards your super-duper business guy sets are **impossibly high** then you can not, in fact, meet them. kinda like having **twelve out of ten** pain or believing that having the government take over health care would be a **good thing**.


  8. i *bow* to your obviously *superior* knowledge and ability to us the **asterisk** key to help *emphasize* your points.


    As far as choice goes, most insurance plans that I've heard of have hospitals/doctors that are "in-network" and not in-network. In my area, there are a few hospitals, but...only the one I work at is in-network.

    So, if I have a major vag bleed sometime in my life, my co-workers will have to be looking at my crotch whether I like it or not. If I had "choice", I'd go anywhere but. Yeah, I could pay 20% of my ER bill and go to an out-of-network ER to save my dignity, but I'd rather everyone look down there then have to fork over that kind of money.

    Generally speaking, at least around here, you choose your hospital when you choose your clinic since family doctors' groups don't usually have privileges at numerous hospitals, and most people prefer to be seen by their regular doctor when given a choice.

  9. I wish the editor of Newsweek magazine would run this as his cover story.
    Succinct and accurate, 9-1-1- Doc.

  10. 911,

    I'll avoid non-standard punctuation to avoid confusing you.

    You say that doctors are better than MHAs at running hospitals, yet you admit that you have no idea how the bill is calculated, and how much is paid by whom? You might want to hold off making sweeping public health policy arguments till you master the basic elements of your own business first. It's not that hard to learn what a fee schedule is, how it's generated, and which payors pay what.

    Your "point by point argument" seems to revolve mostly around the unrelated ideas that a) medical economics is not transparent and b) you get a lot of complaints. Great. Also irrelevant. Truth is, in the average American ER, 85% of patients are funded. Each patient has financial value to you and your paycheck. If you don't get that, I'm not sure I can explain anything else to you. If you want your business to grow, and if you want to attract and retain commercially insured patients, if you want to make more money, you damn well better take a customer service attitude into the ED. Otherwise, the insured patients will go down the road to the ER that's offering the 30-minute guarantee and you will be left with the unisured and Medicaid customers.

    And maybe it escaped you in your management academy, but setting stretch goals is kinda important in getting the best out of your staff. Our goal was 90th %ile Press-ganey score. It was completely unreasonable considering where we were starting from. We didn't hit it, didn't even come close -- but we improved more than I would have ever thought it was possible to given constraints of space, staff, etc.

    I never said you are an idiot and I don't think you are an idiot. But you make a silly and ill-thought argument: "Medicine is not a business." Crap. Medicine is a $1.2 Trillion business. I want my part of that money and am not apologetic about it.



  11. shadowfax,

    i appreciate your response. my apologies, you asked if i was 'crazy' and you did not call me an idiot.

    i don't beleive that doctors are better at running hospitals because of their business accumen, i believe they are better at emphasizing the medically important issues and would avoid the millions of dollars wasted each day on pointless QA initiatives and chasing after press-gainey scores.

    again, many times the right answer to a patient is "no" while that is, evidently, never the right answer to a "customer". get all the MBAs you want to help you, great, but when i am dying from my heart attack give me the biggest asshole cardiologist alive, as long as he stents me correctly.

    as far as "mastering the basic elements of my own business first" well that is kind of my WHOLE POINT. i have run businesses, small ones to be sure, and when i did i got paid for what i did by the person i served. different customers didn't get their pizza for different prices based on ethnicity, the type of money they had in their wallet, or the phase of the moon. i guess i'm a simpleton.

    i have no doubt that the numbers and metrics you talk about are important to the health of an emergency department and a hospital, but guess what, the only reason we have to do such calculations and shell-game economics is that medicine is no longer fee for service and certain "customers" never pay a dime for their care while others, through insurance or out of pocket, pay the whole thing, and the whole thing is inflated to make up the shortfall.

    yes, it's true that the more patients i see the more i get paid, but only after payors have forked-out for non-payors and taxpayers have been screwed. and in what other business are donated goods or services not allowed as a tax deduction?

    also, in my area of the country the payor mix does not nearly approach yours. all people of means in the area already bypass us to go to the large university center so our paying patients, or those with insurance, are about 40%.

    a "customer service attitude" is, unfortunately, definitely required in today's medicine, and it is deleterious to good medical care. we end up spending a lot of time hand-holding the not sick so that our press-gainey scores won't suffer and we can have a job while the patient waits increase and we miss the occasional MI or ICH who was mis-triaged.

    it's a helluva thing to train for as long as we do and attain an incredible level of expertise only to be made to fawn to all manner of "customers" regardless of what the correct medical decision would be by some schmuck organization like press-gainey. press-gainey can hire a statistician or even train one to do their job in snap, try replacing us once the exodous starts.

    no doubt you ARE competing for business in your payor rich environment but, being a small hospital without many specialty capabilities we CAN NOT comptete with the mecca, nor, according to our administration, can we afford to hire more specialists. besides that, no specialists want to come here because the minute they hit the door they will be crushed with their call responsibilities.

    so, because medicine has been perverted into a shell-game where money for the uninsured comes from multiple sources or not at all, and where the uninsured have only us to depend on, we most certainly have a disincentive to cater to people who do not pay us anyway. here i am speaking not so much for myself as for my consultants who duck and dodge their federally imposed mandate to give away their services and lose their paying patient's because of their ER duties. big shock, many are dropping their priveleges and going private.

    against this is my real and true desire to do the best medicine for anyone regardless on their ability to pay, that's what i signed on for, but when my professional livelihood is put at risk every day by the consequences of EMTALA (namely that my name is attached to every patient that dies upstairs who would not have died elsewhere and, even if i am not negligent, i will be in court defending myself) i must consider why, in a country built on free markets and competition, we are trying to pretend that medicine works like other "customer service" industries.

    also, how the hell would it help me to understand the billing process? it's byzantine and changes every month by government fiat attached to medicare and medicaid reimbursement schedules. even when i ask i can not get a straight answer about what a particular test costs the patient because the cost is different for every patient based on their coverage or lack thereof.

    i maintain that the death of medicine as we know it, and i do believe that we have the best doctors and hospitals and care in the world, will be as a direct result of the separation of fee for service combined with the unfunded mandate of EMTALA.

    now, you and i are obviously of different beliefs on this and that's fine, but to have you admit that you set "unreasonable" goals for your staff just to get them to jump a little higher is what will drive the best and brightest from medicine and tells me exactly the kind of person you are. i'm sure glad i don't work for you and you will get exactly what you want in the end, timid doctors who are perpetually looking over their shoulders at you and will, eventually, leave the profession or go where their bosses filter out the bullshit at the front end.

  12. Oh, I suspect we're not so far apart after all. We both agree that the system is fundamentally broken, with the shell game of cost shifting and with consumers having no vested interest in the cost of their care. we both rage at the frustration over the perversities of the system. My approach is this:
    1. Learn to thrive in the system as it is
    2. Work to fix it (I do my damndest to get invited to every fundraiser my congresscritters hold).

    I've had more success with #1 than #2! Having said that, our payor mix sucks -- 60% of our patients are Medicare/Medicaid/uninsured, which is why we focus so much on attracting patients with insurance. But you ask why learn the billing process -- well, MD compensation is up 50% since I took over administration of our practice. It can pay off for sure. I didn't do anything magic, either, and don't claim special talent -- just worked the system.

    Customer service -- maybe you and I are talking past one another on this point. I mean things like no waiting time between hitting the bed and seeing the doc, *not* giving narcs to every character with a sob story (there I go again with the asterisks!). In fact, I probably lead our group in "patients escorted out by security." I mean things like taking time to explain to the parents of the febrile toddler why, despite their expectations, an IV and antibiotics are not necessary -- ten extra minutes with the doctor is worth more than two hours in an empty room with an IV. In fact that's good business, too, since it shortens the turnaround time and you can see more patients in the emtpy bed.

    And by the way, I neglected to mention that the super-CEO we have is closely partnered with an exceptional CMO, a surgeon. It's a good leadership team, and physician leadership is instrumental in setting the direction.



  13. shadowfax,
    i thought, after reading your penultimate post, that we might end up, basically, agreeing. the only point of contention i have with you now is that i AM a fighter and i see the current system as a sinking ship. i'm anxious to bail but my bucket is not working so well. i appreciate that you have 'worked the sytem' and that makes good sense to me. my attitude now, unfortunately, is to go for as long as i can and do the best i can until i can leave or am forced to because i finally snap. sorry we had harsh words.

  14. The trick is to please the *paying* customers and not kill too many of the "other" ones.

  15. "Since the complaint letters get noticed, do the letters I write (the nice ones that tell how wonderful everything was and how kind the doctors and nurses were) get noticed too?"

    radioactive girl: your praise absolutely gets noticed. At my ED, the thank you letters are all up on a bulletin board in the break room.


  16. raven,
    we are informed of patient compliments. we get a copy of them in our box too. as far as i know, however, there is no system or plan whereby they are weighted against or 'cancel out' complaints. it seems to me that if my compliment to complaint ratio is 10:1 or so that i should probably be okay but it doesn't work out this way.

  17. As one who sits on the other side of the gurney, I think it's despicable that docs have to even think about anything that detracts from their patients. A happy doc is a superior doc, and I really wish the ball-busting insurance companies and fat cat CEOs who wouldn't know the ED from my car muffler would leave my docs alone. Damn, I feel a new chapter coming up for book 3.

  18. 911doc,
    I know the nurses get copies of any compliments in their personnel file to be reviewed at evaluation. Our docs aren't actually employees, though, so I don't know about them. I'll have to ask tonight, because now I'm curious. Do you contract with your hospital? I'm not sure how it works, other than our docs have to bill patients themselves, so they don't always get paid for their services.


  19. Here's an interesting read discussing this very topic:,0,3122856,full.story?coll=la-home-local


  20. Shadowfax

    The comment about patients going down the road to the hospital with "30 minute guarantee" made me laugh so hard I shit my pants. But that is a good thing because I was backed up like a 90 year old in a nursing home. I worked part time at a hospital that tried that crap and also tried to instill other untenable "customer service" goals, without making the appropriate staffing and coverage changes to acheive these goals. (You can only work a mule so hard, and It will eventually just sit down in the field and not plow another row) I suppose some CEO/CFO/Hospital manager etc. thought it looked good on paper. Of course, when numbers didn't come up to the level they hoped, they got rid of the hard working independent group, brought in a national group, and the Press-Ganey numbers went DOWN and the complaints from patients and staff docs went up. I guess you get what you deserve in the end.

  21. Warning to all patients out there: Any doctor who sets as a primary goal to "improve press-ganey scores" is a bad human being. Press-Ganey is the manifestation of all that is wrong and evil in health care.

    The dipshit CEO-types who bring in these bozos are looking for a way to *look* good and not necessarily *be* good. What a fucking waste.

    BTW, I'm digging *this* new punctuation thing.

  22. I'm a retired Psych Nurse in med school. Any complaints I got from a patient were rapidly treated. Some with restraints and typical antipsychotics. I've volunteered to serve the hordes of homeless in summer months in Vegas, and I treated them the same way.

    But, the odds are stacked in my favor. After all, if you're in my department you're either having a bad year or a bad life. Either way, the burden is on the patient. And the only time we ever get blamed -these days- is if we let them go too soon.

  23. From a responsible patient.
    You have omitted the fact that it is nearly impossible to find out the cost of any medical procedure.
    I was told by my PCP to have a test done. Well I'm not completely convinced that this is useful but if it did not cost too much I'd do it.
    I call the facility. In a difficult to understand accent, the response is "no they have no idea call the insurance company". I call BCBS, they have no idea I must have the CPT code and ICD9 plus the physicians ID number. Call the facility back and ask for the numbers. No they don't have them. Through research on the web I find the probably procedure I am supposed to have. AH but CPT codes are licensed by the AMA. I can not look them up. ICD9 code really should have no meaning in this case since I must have the test to have a diagnosis.
    More web browsing "Google is your friend" I find the CPT code from a web site that obviously the AMA has not sued yet. I discpover the ICD code from another web site.

    Call facility back, get another person of course, a little social engineering and I get the normal charge they will bill for the procedure. No, they have no idea what the allowable amount is.

    Use web site to find names of principals at facility. Call hospital to get physician ID based on name of big boss.

    Back to BCBS. Different person. I give the CPT code, the name and location of the facility. I am given the usual they pay 80% of the allowable charge. So What's the allowably charge amount. Get nowhere. Hang up and call again different clerk, with only a little persuasion, I finally get the allowable charge and what they pay.

    Call facility back just to confirm previous numbers now I am told oh there is a initial consult before the procedure $130 then a follow-up consult $300 after the procedure. Of course who know what I will be charged.

    The Medical system is designed for those who go to a medical establishment, open their wallets and say "Here keep taking until you're through. Oh there's not enough in here ? Use your credit card..

    I'll be damned if I do that unless I feel I am in severe pain or think I'm dying.

    My wife's PCP Knows how much drugs and medical procedures cost. She tells my wife in advance ball park figures. She know how much she costs. We can plan for the expenses.

    I understand there is no point in knowing for a big ER serving sumdude but for those of us who I think you're complaining about

    What's the matter with you that you don't find out a ballpark figure.

  24. dear mr hawkins.
    i'm on your side. i do complain about patients but that is not the point of this post. the point is that under our current ''system'', as you point out, it is nearly impossible to find out how much anything costs and you can not comparison shop. i point this out in the post that i myself have no idea how much my bill will be for my services. therefore my point, currently medicine is not a business as Americans understand business.

  25. Dear doc911, thanks for posting one of the sanest pieces I have ever read on this subject, from someone who has been working as a registered nurse in the acute care setting for over 36 years.