Bills for noninsured services remain
a wellspring for patients' complaints
Dorothy Grant
CMAJ 1997;157:1266-7
[ en bref ]
Dorothy Grant is coordinator of patientphysician relations with the Medical Society of Nova Scotia.
© Dorothy Grant
In brief
Why do many Canadians become angry when told they have to pay for noninsured medical services? Dorothy Grant hears many protests about this type of billing in her job with the Medical Society of Nova Scotia. Here she describes steps doctors can take to reduce the number of complaints.
En bref
Pourquoi tellement de Canadiens se mettent-ils en colère lorsqu'on leur dit qu'ils doivent payer des services médicaux non assurés? Dorothy Grant entend de nombreuses protestations au sujet de ce type de facturation dans le cadre de son travail auprès de la Société médicale de la Nouvelle-Écosse. Elle indique ici aux médecins des mesures qu'ils peuvent prendre pour réduire le nombre de plaintes.
Few issues anger patients as much as receiving a physician's bill for a noninsured service. Many of the calls the Medical Society of Nova Scotia receives from patients concern bills for services they think are covered by the provincial health plan. The focus of the complaints may vary but the level of anger never does.
Charges for copying medical records is one of the major sources of frustration. Many patients say they own the records and a physician has no right to charge them for a copy. Others have complained after being charged for a syringe used during an injection. Still others cannot believe their family doctor expects them to pay for the examination and completion of a form required by a nursery or summer school. Some "go ballistic" when told they will have to pay to have a prescription renewed by telephone.
This is happening simply because it is decades since Canadians have had to pay a medical bill. In Nova Scotia most complainants say they have never paid a dime to a doctor and don't want to start now. Invariably, they also say that they were not satisfied with the explanation given about a bill.
Why are patients so angry and what can physicians do about it? Many Canadians have experienced financial problems in the '90s and feel threatened because the health care system shows signs of becoming both weakened and overextended. As well, the public is decidedly sceptical when told that many physicians are having financial problems of their own.
Alberta tackles issue
The Alberta Medical Association was probably the first to tell the public why physicians need to bill for noninsured services, and its guidebook for members has been a prototype for other CMA divisions. Today most divisions have developed protocols for telling patients why doctors are no longer willing or able to write off services that cannot be billed to government health-insurance plans.
In Nova Scotia, a joint public statement issued by the medical society and Department of Health in 1993 let patients know that billing for noninsured services had become a fact of life. It featured a clearly defined and detailed description of the noninsured services doctors can bill for, such as prescription renewals made over the phone. Physicians received posters containing the information.
Despite this publicity and even though billing for the services is now commonplace, Canadians still have a hard time accepting it. At the same time, the situation is becoming more complicated as provincial health plans reduce the number of services they provide and society develops an insatiable demand for forms that must be completed by doctors. Physicians who once completed a few forms a week now find themselves facing piles of complex forms. They are fed up and want to be paid for their time, but patients often balk.
What's the solution? Patients must be educated about the harsh realities of health care in the '90s. This means that doctors should have office staff explain diplomatically why charges are being made. For instance, when patients leaving a practice complain about a copying charge for their chart, staff should note that a doctor is obliged to keep the original chart for several years for legal reasons and that photocopying is expensive.
Doctors who accept patients transferring from another practice should think twice before telling them to obtain a copy of the complete record. Most physicians agree that few of them have the time to read a huge chart stretching back 20 or 30 years, so why copy it all? I tell patients to create a brief medical history that will offer the new doctor insight into any health problems they have and what pertinent medical information will be needed. This usually reduces the cost substantially.
In situations where patients cannot afford to pay for a copy of their chart, doctors should be prepared to provide colleagues with a concise medical summary or, at the very least, copies of all significant medical information. The College of Physicians and Surgeons of Nova Scotia advocates that this be done to ensure that patients with serious problems are not put at risk.
Here are some other tips:
- All new patients should receive information about charges for uninsured services. A booklet should be made available simply because posters are often ignored. An inexpensive electronic bulletin board placed in an office waiting room can also serve as a useful communication tool.
- Doctors and their office staff should be aware of patients who cannot afford to pay for noninsured services. Manuals should tell them to speak up if a charge represents a true financial hardship.
- Always discuss charges before providing a noninsured service. Most guidelines advocate this but the recommendation is often overlooked. Remember, the angriest patients are those who receive a bill they didn't anticipate.
- Missed appointments frustrate all physicians. Doctors should consider ignoring the first missed appointment for which the patient doesn't have a legitimate reason, but the next time one is missed warn that a bill will be sent if future appointments are missed without an adequate excuse.
Doctors should make clear that it is impossible for them to know when a prescription needs to be refilled, particularly when the original one covers several months. The best advice is to develop a policy concerning prescriptions that will or will not be renewed over the phone.
Charge an annual fee?
Many doctors now offer patients the option of paying an annual fee to cover all noninsured services. Physicians who do this should ensure that patients have several months to think about the concept. More will be willing to consider the idea if given sufficient time to digest it. Physicians should note that it would be considered unethical to deny medical services to patients who choose not to participate.
Because complaints about noninsured services can become cause célèbres, medical associations would be wise to have a committee in place to help resolve them. It should meet regularly to address emerging issues.
One thing has become clear in Nova Scotia: it will be a long time before Canadians accept that the health care system is no longer fully funded by government. Until they do, fees for noninsured services will remain a bitter pill for many patients.
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