Home Forums Discussions General Discussion Patients leaving secondary to better copays

Hi everyone,

I would love to get everyone's opinion here. We have always had basic policies on whether or not to take someone back. If someone leaves the practice due to moving, I'm OK. About the only other reason is the patient that has the guts to look me in the eye and tell me I suck. Most just leave and we find out by a release.

Another policy we have always had is when someone leaves due to another practice's (usually a hospital or FQHC) insurance deal is better. Basically, the thought is, hey, we are fine with your leaving, but if you think we are the best practice, then we are worth the cost. We don't have a big hospital or the Federal Government behind us.

So, if these find out the $20.00 copay was worth the better service and want to come back, do you let them? We generally don't.

What about the patient who leaves because the other practice can bypass the deductible for signifcant savings but want to come back? I am in the boat right now. I am leaning toward saying no. Obviously, they are willing to pay it now. Or maybe there is something we don't know, e.g. the insurance benefit changed.

Any help?

I take them back as long as they didn't disrespect me or the staff when leaving. In my area, there are a lot of School Districts and employers that jerk their employees in and out of our participating plans every year. I take that into account.

But if they disrespect me, they get pinstuck.

Hi Bert,

I usually decide based on the specific patient. If I liked them, they get back in. If not, they don't.

"It's not personal, it's just business"

Gene

Thanks John and Gene,

Gene, thanks for the info, but you just contradicted yourself. According to your strategy, it should be, "It's not business, it's personal." lol But, I get your message either way.

The doc that I'm helping with implementing AC... patients that have left, did so respectfully. If the patients come back, they take them back. No other experience with patients leaving otherwise...

Thanks Les,

How long have you been helping. I once told the amount who left here, and I was told by another on here I was a bad doctor. This town is cut throat for pediatrics. FP, maybe two a year. Pediatrics maybe two a month or more for ALL of the peds practices. It is doctor shopper city here. Makes one get jaded. We once got 11 patients in one month from another practice. Thanks again.

I think life is too short to waste it taking care of people who don't make me glad to see them. You are right; it's not just business; it's personal.

Bert... I've been helping the doc (my wife works for him) with his computers/network for 6+ years... but my wife has been with the doc for 20+ years... so kinda long experience. Here in Hawaii... it's generally respectful overall. Very small community, so essentially everyone watches whose "toes" might be stepped on. Also, medical insurance in Hawaii is "mandatory" for employees with 20+ hours per week, so not really an issue.

Let me clarify- I meant this on the patient's part, not my part. Usually their decision to leave is business (financial) not personal.

Yes, agreed, my decision to take them back is personal.

Gene

Thanks Gene, that makes more sense.

I guess this is one of those times where I am looking to hear what I want to hear. But, it is still good to hear others and learn. And, it gives me a different perspective.

David and I have disagreed on a few things before, but here I think this is the smartest thing he has said. My staff says I'm crazy. They tell me they hated leaving, and they REALLY liked me. And, Gene is right, they probably should do the business decision.

But, I think part of that decision should not be, "We'll do the right thing business-wise and we will get less care, but we can always go back."

The decision should be, "We need to do the right thing for us financially, but we have to accept we are losing the best pediatrician in the area." (That is from their perspective when they left, but it is true nonetheless."

Thanks to everyone. I'm sure there will be more.

David, thanks.

I have to agree with Gene. If I and the staff like them, then we take them back. If we don't we won't. It's all personal.

The ones that tend to leave over money are more likely not to return, so you won't run into the situation as much as they were told Dr. X is a better doctor or has better hours. Oh well.

Are you filling your schedule, turning new patients away, or happy with your current mix of patients?
If not, from your previous description of your practice being heavily medicaid dependent you would be crazy not to take them back if they were good patients to begin with.
If you do the math, do these folks pay better than medicaid.
It has to be in part a business decision.
I just had a patient bemoaning that the local base will not allow her to see me any more but only a hospital employee provider. It saddened me a bit but tricare pays worse than medicaid or medicare so it is easier to get over.

Currently, Medicaid pays about 27% better than private. Faster turnarournd. No copays. Parents bring in a real ear infection, and two with, "hey maybe they do too." That's business.

Send me a letter. We'll work things out. Otherwise, I am with David. They made their choice, money over quality. Don't get me wrong, I understand their decision, but I am not going to be an acre of grass where they choose what is greener. So, what happens when Geisinger comes to town? Are they going to transfer again?

I realize if they have a $2500 deductible that is waived at, "We don't care pediatrics." But, hey, call my staff and get my email. Doesn't take much.

I am still with David. And, I still appreciate the input.

Bert,
I do not want to offend anyone on the board, but I was watching a PBS special the other day and there was this artist named Wright from Tennessee that made it big in the art world. He worked his way up from poor means, moved to LA after working for Pee Wee Herman's set in NY and then on to bigger and better things. But during this documentary he said something I found interesting. He said early on in his career he had to play the games and laugh at the producers jokes, etc. to procure work. Now he has made enough FU money not to play the games anymore.
So I guess everyone has to analyze where they are in their career, but I am not quite there yet.

Thanks but I think:

Wright is wrong.

Bert,

I just assumed it would be the other way around. I would absolutely not take them back if I had a full schedule and medicaid pays 27% more. Even if they were nice.

I do agree that it depends on how busy you are. I too am 2/3 medicaid but in IL it pays 40% LESS. Still, I would rather take a gracious medicaid patient than an ingratious private pay who will jump ship at a moments notice.

I've actually been looking to cut the size of my practice down, so I welcome the patients who want to switch out without me having to cut them. If they try to come back, I tell them simply that I already closed my panel to new patients and can't take anyone back in now.

I'm still waiting to see if the Medicaid Expansion plans to bring the rates up to Medicare rates in NJ actually happens. Although I'm already looking to add in a part time doc on board, if the expansion opens I'll re-open the practice to new patients and may let back in the respectful patients who want to come back to the practice.


Shankar
Family Med
Lawrenceville, NJ

What does everyone mean by the "respectful patient?" We have had a handful of patients who call and tell us why they are leaving. I do find that very nice. Patients that leave because they are unhappy are rarely if ever respectful, again whatever the definition for that is.

But, most patients who move to another practice due to financial reasons, leave nicely but I don't usually hear from them or get a dozen roses.

We treat patients who are leaving, for whatever reason, with respect. We transmit their records without charge to the next practice at their request promptly. Most patients act similarly. But a good sized minority threaten or abuse us, thinking they need to do so to get their records sent, or to maybe get out of paying a balance they owe. That we never forget. I had to explain that to a father once, when I refused to take his daughter back, in excruciating detail. He was almost in tears. But he understood.

I have to hand it to you. I could never do that.

I guess I am a bit confused with the respect stuff. The patient goes to another practice and we get a records release form. We have no opportunity to respect them or disrespect them. But, we do charge them for their records.

And, as far as for the daughter, I would have just asked them to leave without saying a word to them.

For me there is only one respect. Coming in or mailing me a letter explaining why they are leaving.

I canned the daughter for getting controlled meds from another doc & me. I didn't tell the dad that. I did tell him I can't take his daughter back (he & his wife are still solid patients) and I wouldn't reconsider because his daughter and I disagree on what's good medical care.

I agree with you, people owe their doc an explanation for leaving. But those who give the explanation with attitude, that's disrespect.

I'm not necessarily really taking about the patients who leave in a huff.

Rather, I am talking about the (parents) who come in with a chip on their shoulder, look and act like they are sucking on lemons, and treat the staff as if they are slaves. It's not quite bad enough to discharge them from the practice, but it IS enough that I would not consider taking them back. That would include the parents who let their children run wild in the office.

I would agree that most patients don't tell you why they leave, you just get a release. We always release - once. If we receive a second request from a different provider, we send a letter back stating the records were previously released and we do not send a second copy without payment. The only exception is those who are out of town.

I wish I could remove ALL these folks from my practice. There would be few patients left if I did. A sad commentary on the maturity level of the average person in our fractionated, over-lawyered, handout-loaded, me-first society.

There are times where I know why the patient left. Something my staff did (who are always forthcoming in telling me what they did, right, lol) or something I do. I send a letter, apologizing and letting them know I understand. I let them know we will always be here if they want to come back.

The others are are let back are those who actually take the time to either call, write or talk to me in the office.

I have had two patients who, after I rounded on three of their babies, but not the fourth because I simply cannot continue to keep my privileges as a solo practitioner. I will say if they let me know and let me know their frustration, I would visit. But, how can a patient not understand the need for you to no longer go to the hospital each time. They left. Please try to come back.

So, I guess it comes down to:

1. Leaving the area (a no brainer)
2 Leaving due to my mistake (they don't tend to come back)
3. Someone with the guts to talk to me or send a letter.

We take a broad range of insurances, so usually if they leave it is not because of insurance.

I will usually ask my staff on any record release in the area if they know why the family is leaving. The staff usually knows, they often check to make sure it's a valid release. I review every fax so I know what releases come in.

Occasionally, the patient doesn't realize we accept the insurance. The others are leaving because they did not like the staff, the hours or want another opinion.

If they think the grass is greener elsewhere, I'm not in a hurry to take them back. If I like them, I might, but then again... If I don't (or the staff doesn't) then NO Deposit, NO return. They burned the bridges behind them.

It's possible the staff might have been rude, but it would have been in reaction to worse behavior on the other side. Usually I can tell, even though the parent/patient is sweet in the exam room, I can usually tell those that are saccharin vs the truly sweet people. Saccharin parents are usually not nice to staff.

I have never received a letter detailing why they are leaving. I have never sent a letter to let them know they are welcome back. I have talked to parents who are moving out the area, they are usually welcome back.

Very well put. And, it is so true how they treat the staff poorly and then treat me like sugar. I generally get the heads' up and will usually ask the parent if they had an issue with the staff.

It's ironic, because I am often right next to a staff when a parent is giving them hell on the phone. I have always told them they have carte blanche when it comes to holding their ground. But it is tough for them as they are employees where I am not.

I have found two things when it comes to staff. They seem to remember well why the patient is leaving when it is clearly not their fault. I have yet in 18 years to hear an employee say, "Oh, I know why. They called for a school physical in two days, and I absolutely wouldn't let them."

One thing for sure that I know Wendell can attest to. It is simply a fact that parents in pediatrics are a much higher risk than a 32 year old patient responsible for themself. I have really learned a lot over the years. I never tell a parent that 99.9 is not a fever. I just base my diagnosis and treatment on the very low grade temp. And, I won't quote it back as a fever, but I will say their child has a cough and a low grade temp.

But as pediatricians there are many scenarios you have to handle. For instance if a two year old and a three year old are running all over, and the parent doesn't seem to care, I really have to watch my eye roll. And, how much do I discipline them? Another scenario is what words can I use. I may not think shut up or stupid are bad words but for this particular parent they are. I have been caught on that a hundred times. They are just words I am used to using, although I see their point. The parent will tell me, we don't use those words at our house. It takes every ounce of courage to not say, "Yeah, well this isn't your house and we use them here." But, obviously, I don't. I just apologize. Parents tend to get angrier when we are running behind. I remember a patient the other day who actually asked at the window how much longer it would be while we were giving epinephrine, oxygen and a neb. I was so proud of my receptionist when she said without changing her expression, "You're next in line. He should be able to get to you after the ambulance arrives."

When patients leave the practice for another practice in town, and then want to come back, I charge a reentry fee of $25. This causes them to engage and value their decision. Sometimes I might waive the fee, after they agree to pay the fee - if this fee would be a hardship for them.

if there was any ill will, rude and all that, then I would not take them back.

Why would you not take back a patient who paid their bills and left quietly?

Because we provide a service, obviously there are people we would prefer not to serve again. But when have you seen a waitress refuse to seat someone at a restaurant? Would a plumber come back to your home? Would an accountant want your business? Would an attorney take your case again?

My point is not meant to be rude, but I believe that we depend too much on our patients trusting us to know how to help them. This is because we know so little about what really works well in health care, and that medicine is much more art than science. A patient leaving violates that trust.

If medicine was all science, it would be like H&R Block doing your taxes again.

Dan,

Too bad the rheumatologists in my area don't have at least some of your attitude. We can't get them to take the patient in the first place without the doctor reviewing my note and the demographics, deciding whether they think it is worth their time to see a patient I want to refer to them, and then telling the patient they have to bring cash up front before they will be seen. And, yes, there are a number of plumbers and others that refused to do repeat jobs for my husband. I went for months not telling my knows-how-to-do-anything repair guy that I was a doctor because he had said in passing early on he will not work for doctors because they tend to be PITAs. I am the daughter of a fifth generation haberdasher and was raised in a home where it was drilled into us "The customer is always right" but I watched my abused father drag down to the store on a Saturday night or Sunday afternoon so a customer could pick up the suit the tailor had finished the week before because he now needed it for a party that night.
Sorry, Dan, but to me providing a service does not equate with being made to service idiots and ingrates. And, my restaurant experiences would be better if waitresses did refuse to seat miscreants and loud-mouths. Our society has become so afraid of offending those who offend us, of not being politically correct. JMO

Dan,

I read your post and found it interesting. I am embarrassed to say I didn't understand it completely. I couldn't tell if you were for taking patients back that were nice or against it.

Do you mind explaining in more detail. Thanks.

Leslie,

The following link discusses how the state wants to deal with the worsening shortage of doctors just as everyone in California is about to get insurance.

http://www.latimes.com/health/la-me-doctors-20130210,0,1509396.story

Two years ago my long time RN graduated from her Masters as a NP, and I had to decide on letting my PA go or try to keep both busy.

I can only say that you appreciate every patient when you are trying to keep two mid-levels busy as a rheumatologist in this economy. At least I can say I'm ready for ObamaCare.

Dan

Bert,

I didn't see your note, hope my note to Leslie clarifies it. Without wanting to get judgemental, I was trying to question why a philandering patient causes a reaction.

As a specialist, about 15-20% of my practice is lost every year, and has to be replaced with new patients and returning old patients, so I don't see a need to reject them. It is common for me to see patients after long intervals. Some can't afford specialty care, some get better, some have bigger problems than their arthritis, some travel to a bigger city or the universities, etc..

I see chronic pain and fibromyalgia patients and much prefer the autoimmune disease patients, so I am not perfect by far. If I don't want a patient back, I send a letter to formally discharge them, and I have had my share of discharged patients.

Dan

But, your situation is completely different. A good portion of your patients leave because they get better. If they can't afford speciality care, then the specialist across the street likely isn't much better.

I think you hit on the head, actually, when you stated it violated a trust. The difference between a plumber and a doctor is that the plumber does a job for you, and you may not call him or her again for months. The plumber doesn't receive a release form asking him to send all of the information on your pipes to the next plumber.

Doctors are different (in my perspective). We are the patient's doctor every day whether they come in or not. I, hopefully, give the best I can to the patient. Which, I happen to think is the best around. If they are not happy or don't perceive that I am giving good care, then they should leave. And, it is unlikely they will ever return. But, when a patient basically says to me, "I like you as a doctor, in fact I find you to be outstanding and if I didn't have a better deal somewhere else, I would stay except I have a better deal somewhere else. I just think we provide the level of care that may cost more. We can't compete with the FQHCs and the hospital practices. So, for the most part, if they leave for a better deal, and then don't like it, there is that other practice in town.

In the very long ago, when I was single and dating, I had a number of relationships that didn't work out for one reason or another. When I got dumped I was hurt and miserable; when I was the one terminating the relationship I felt guilty and miserable. In the fog of that misery, it was easy to say "So and so is really a rotten person". However, there was nothing wrong with either me or any of these fine women; it just didn't work. Now, in my maturity and with a long, happy marriage under my belt I realize there is simply no way to gracefully end a significant relationship. It is going to be ugly no matter what. It is not unusual that when I acquire a new patient who has been in the community for some time and has been seen elsewhere that many express a deep concern to not hurt the feelings of the previous provider. Just as I feel that life is too short to stay in any relationship that is truly unpleasant, I do also feel that it is best to remember the part that neither party has to be guilty of anything. It just didn't work. Let us wish each other a long and happy life.

Bert,
I agree with David, but that is only part of the equation. Your original question dealt with office policy, and whether you take someone back, who has chosen to go elsewhere based on an economic decision.
So if your practice is not full, and your reimbursement is better with another type of patient, such as medicaid who reimburses 27% more, the decision can be quite easy to set policy as, "no we will not take these patients that chooose to leave back, but instead fill the openings with new medicaid".
This can be a decision based on both wisdom and economic foresight to keep your practice healthy and profitable long into the future.

I am with David. I did want to hear what others were saying. And, I learned a lot that I will keep in mind. But, like a gf who leaves even on good terms, when she says, "I love you and will never leave you," how do you trust her.

Now, sure this is different. And, it has NOTHING to do with money. It has to do with a trust built on a doctor-patient relationship where the patient decided saving money was more important than the care they were receiving. WHICH IS COMPLETELY FINE. But, I am not going to go down that road again.

My staff told me they were nice. They said they liked me, but they didn't tell me. They said they wanted to come back, but a letter would have gone a long way. A long way. This is just my feeling.

I'm with you Dave. Also, my biller wants to move to Alaska. Know any good practices up there?

Jimmy,
But it's not that simple. Why they leave is often more important. I have found that many of those who leave are unhappy in life and think the grass is greener on the other side. They are unhappy with themselves and are usually unhappy at the front desk, the MAs and in the exam room. I'm happy to be without these unhappy people. There are those who have other reasons for leaving either out of location or because they had insurance issues. If I like them, I want them back.

Wendell,

I think it has to be that simple. I don't have any ill will if someone chooses to go elsewhere. My ego may be bruised, but it is best to let them go their own way.
However, I am not going to kick out any of my existing patients, and replace them with higher reimbursing patients. As I try to stay in business with the mounting difficulties being posed each and everyday, I think of my bruised ego, and get over it rather quickly if I can put in a higher reimbursing patient that may meld with me better over time anyway. This patient (that chose to leave for economic reasons) just gave me more of an opportunity to stay in business a day longer. No hard feelings, just simple math, and a hope that the new replacement will be better for me and my practice in the long run, both on a personal and financial front.
However, if I had to choose between a good paying pain in the *$$ patient versus a self pay nice respectful patient---it would be the latter everytime.