By Joseph Sameh
Nationally, medical telemessaging service has a problem. Typically, when a person purchases a service, there is a perceived notion of value gained through that purchase. Housekeeping, snow removal, tow truck services, and office janitorial services are just a few examples. Physicians’ point of view towards answering service once fell into that category as well. But that was then and this is now.
The Problem: Each evening for more than 60 years, answering services have been providing overnight backup telephone support for physicians. Many of our readers are descendants of these pioneers. Today, messaging services for doctors are considered a necessary evil. When patients call after hours, the physician may be contacted by the answering or messaging service. If so, the physician and the patient discuss the crisis at hand and map out a strategy. For all the commitment, hard work, and effort of the call center staff, the only thing the physician perceives today is an invoice from the call center at the end of the month — that is with the exception of the middle of the night wake up call to treat the patient. How would you feel if you were a purchaser of this service?
Early on, and before, managed care, most patients and their physicians had a one-to-one relationship that lasted throughout their lives. Most physicians were sole proprietors in private practice. When a patient called the doctor after office hours, the doctor naturally had great insight into the patient’s history and medical needs. The two grew old together. The invoice amount paid by the physician to the message service was viewed as part of the overall cost of maintaining good relations with the patient in an era of increasing economic advantage for healthcare providers. A fee for service insurance reimbursement model characterized the era. As such, the patient and the provider were both beneficiaries of the after hours call. The patient received the round the clock care that was expected and the physician knew the patient would be a loyal customer in return.
With the advent of managed care, certain concurrent events changed the landscape of medical practice management. One change that exerted great influence on the patient-provider relationship was managed care itself and the impact of its lists of network providers. No longer was the relationship between patient and provider under the control of the patient and the physician. It was suddenly under the influence and control of the insurers and employers.
Managed Care Organizations (MCOs) began to apply downward financial pressure for reimbursements to physicians. As a result, the patient/provider relationship hit a low point. Patients began to complain that not enough time was spent with them in the office. Sometimes physicians were no longer readily available after hours. Doctors began to complain that they couldn’t treat the individual appropriately due to managed care oversight. Doctors also began to experience income stagnation and even contraction. Consequently, doctors no longer perceived themselves as the beneficiaries of the after-hours transaction. The new beneficiaries became the patient, the answering service, and on occasion the pharmacy.
Your physician however still has to retain 24-hour coverage, and therein lies the problem. Physicians still must pay for messaging services. Along with the emergence of MCOs and due to some of the same pressures, solo practices began to disappear as ever increasing group size became an unpleasant fact. This trend benefited the physician in some quality of life measures. Permitting and supporting a nightly call coverage scenario, one in which physicians began to experience evenings off on a regular basis, is one such benefit. The era of sole proprietorship was largely over. Now we have the day of the physician-employee. This further inflamed the breach in the patient/provider covenant as patients lost control over who would manage both their daytime and after-hours needs.
Development of large, multi-disciplinary groups led to another tension: the successful management of on-call coverage schema by the message center. Due to human error or lack of understanding, often the wrong physician is paged or no one at all is contacted for urgent matters. Indeed, industry experts agree that incorrect message dispatch is the most daunting issue for doctors in medical messaging today.
Adding to this challenge, outside market forces have inevitably affected every provider to the health care field. Answering service is no exception to this reality. In terms of inflation-adjusted dollars, the rates for answering services are significantly lower today than they were 20 years ago. Labor costs are higher as a percentage of overall costs than ever. An abundance of high-tech equipment and a search for lower paid, entry-level employees answering phones for doctors is the result. When one adds the cost to adequately train and retain quality employees there is scant room for error on the employer’s part.
To add insult to injury, regulatory pressures on the health care delivery system have created more paperwork for every medical practice. Consequently office staff has a greater burden than ever before. According to Howard Wolinsky, co-author of Healthcare Online For Dummies and a veteran medical and technology reporter for the Chicago Sun-Times, “If we could get physicians and their patients to communicate via email and avoid voice mail jail, we could save loads of time and even squeeze out more time for docs to spend with their patients face to face. Now that would be a breakthrough.” According to Wolinsky, “with the availability of broadband and new technologies, the pieces already are in place.”
Other sources, including Harris Interactive, according to the results of a survey conducted in April 2002 indicate that 95 percent of patients want to exchange email with their doctors. However, a much smaller percentage of doctors do so. This suggests that many patients hope doctors will take advantage of Internet technology to improve patient outreach efforts, but that doctors themselves may still be ambivalent. We’ll explore doctors’ current attitudes towards technological change in our next article, Technology: Threat and Opportunity, to be published in the next issue.
Joseph Sameh is the founder of Mediconnect, Phone Screen, and NeedMyDoctor.
See part two, The Trouble with Medical Messaging Service,
[From Connection Magazine – Jan/Feb 2003]