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Physicians ask patients: What is this visit worth?

Doctors held pay-what-you-can days to help uninsured patients and to get an idea of how much patients value medical care.

By — Posted May 24, 2010

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How much do patients think primary care is worth? A handful of physicians decided to find out by asking patients, for one day, to pay only as much as they could.

"We were talking on a [practice management] listserv about how underappreciated primary care is and how underreimbursed we are," said Gary Seto, MD, a family physician in South Pasadena, Calif. "And someone posed the question that it would be interesting to experiment and see how people really value primary care. What would happen if patients paid whatever they thought it was worth? And I thought I would give it a try."

Physicians chose their own dates for a pay-what-you-can day and got the word out. Often they issued news releases, getting local media interested.

On the day of the events, no insurance was accepted. Care was provided only to the uninsured, who were asked to pay what they could afford. Laboratory tests were provided at cost, and patients who needed additional services were referred to various public resources. Practices also handed out lists of generic medications available for reduced prices at large, discount pharmacies.

Physicians who accept Medicare are not allowed to include Medicare beneficiaries in any pay-what-you-can program.

Overall, participating physicians said they learned that although patients valued the physician visit, they didn't always put the value of care at its actual cost. Still, most valued it enough to pay something. Some patients paid nothing; some paid $100. Visits were as short as 10 minutes or as long as an hour.

None of the participating physicians collected enough money to make the concept financially viable over the long term, mainly because payments didn't match a typical day's collections from insurance and co-pays. Yet most say they want to do it again and enjoyed having one day free from insurance paperwork.

"I couldn't afford to do it every day and feed my family, but I will probably try and do it once a year," said Jean Antonucci, MD, a family physician in Farmington, Maine. She held her pay-what-you-can day March 25. "It was a lot of fun to be nice to people."

Many patients who participated in the pay-what-you-can days arrived for routine physicals. Others had pain complaints or upper-respiratory infections, or needed care for chronic conditions. Most practices were willing to take cash, checks or credit cards.

"I was very interested in what people paid. Some scraped up $20, some paid $60 to $80," Dr. Antonucci said. One patient, a waitress and college student, paid $80, mostly in singles. "I gave her $20 back. She couldn't afford it."

Lessons learned

Physicians found hosting pay-what-you-can days was a good opportunity to provide care to the uninsured from their own practices.

"It was satisfying to be of service to people who have a need, even just for one day," Dr. Seto said. "I have volunteered at free clinics, and that experience was less satisfying, because I had to see a patient every 15 minutes. I could not really do a decent job. For me to do this in my office, I had total control."

Another advantage of pay-what-you-can days: Discussions about money, always an awkward topic, became shorter and simpler. There was no need for physicians or other office staff to explain why services cost what they did. Rather, the burden was on patients to pick a price they thought was fair.

"I made it clear that paying was totally optional. They didn't have to pay a cent," Dr. Seto said. "They only had to pay what they thought the visit was worth."

Most physicians said asking for some amount was important, because people tend not to value something for which they have paid nothing. "I would rather patients place their own value on the service than come right out and say it's free," Dr. Seto said.

Physicians also said that these types of events make patients more aware of how common special financial arrangements are for those having trouble paying for medical care. For example, Dr. Antonucci discovered that many patients already had primary care physicians but were too ashamed to admit they had lost their health insurance.

"They think it's bad and shameful to not have insurance. They don't understand that doctors despise insurance, and doctors will see people who don't have it," she said. "I told some people to call their own doctors and work something out."

Physicians discovered an unanticipated and unintended benefit: Pay-what-you-can days can help build a practice. Local media coverage may increase a practice's profile, and patients from pay-what-you-can days might return when they do have insurance.

Pay-what-you-can days also brought an unexpected amount of goodwill to medical practices and produced public recognition within their communities, physicians said. Participating physicians say they have been stopped on the streets and in grocery stores by people thanking them for their efforts.

When a local newspaper ran a story about Will Conner, MD, a family physician in Matthews, N.C., holding a pay-what-you-can day at his Conner Family Health Clinic, one of his patients who was a nurse volunteered to help.

Someone else dropped off a flower with a card that said Dr. Conner was "receiving this because you have done something nice."

The pay-what-you-can day "definitely got recognized. We know we did the right thing," Dr. Conner said. "It's not very practical to do every day, but it is good for the community, and good for patient care."

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