An ongoing dialogue on HIV/AIDS, infectious diseases,
April 22nd, 2015
Seriously — How Much Would You Pay for a Curbside Consult?
Yes, seriously.
Let me start with an email exchange I had with a PCP recently:
Hi, Paul, quick question 😉 This lady, 49 YO woman from Haiti, asymptomatic, totally healthy. Got TSpot done for immigration purposes, it’s positive with negative chest Xray. Treated with INH 6 months in 2001. She travels to Haiti annually so could had been reexposed, though doesn’t report being with anyone with TB. Do I need to treat her again? THANKS!
Carla
To which I responded:
Hi Carla, unless there’s been a significant re-exposure and immunosuppression, no need to re-treat.
Paul
p.s. You know we could start getting paid for these “eConsults.” How much do you think they are worth?
So it’s now Carla’s turn to answer my question:
Priceless!!!! Seriously, not sure, since some questions are more complicated than others. Sometimes it’s straightforward like this, and sometimes you have to review more data so that should be compensated more no?
Carla helped me out here, especially with her first response — priceless indeed. But the second part — where she suggested that this “straightforward” question is worth less a more complex one — hints at why estimating the value of these consults is so difficult.
And it’s important that we figure it out, and soon. With the inevitable move to “value-based” insurance contracts, many ID doctors are getting the push to formalize these clinical relationships. That’s a good thing, as clearly getting advice from a colleague can be a more efficient way to provide quality care than referring everyone for a formal consultation, and it puts a value on what previously was almost always done gratis.
Back to the question in the email — is it so straightforward? Clearly not to Carla, who as a generalist has to manage all medical problems not just ID ones, but to us brilliant ID doctors, sure. An IGRA (the T-Spot) and tuberculin skin test are basically two different ways of looking at the same thing (evidence of immune response to TB), and I’ve already been asked this question (or one like it) several times. Plus, I can touch-type (as I’ve bragged elsewhere, I could crank out over 70 words/minute in my 8th grade typing class), and happened to be sitting at my desk daydreaming about puppies playing baseball when the email popped into my in box.
Even if you account for the distraction factor — it was hard to get that puppy image back — it still took only a few minutes.
And as I’ve calculated before, if paid on an hourly basis, this comes out at a whopping $6/consult, or almost enough for a couple of fancy coffees at Starbucks. If we believe the good news from this latest Medscape salary survey that ID doctors are no longer in the basement when it comes to annual salaries — sorry, pediatricians — we’re only up to $8/consult (add a bagel to your coffee order).
So when it comes to curbsides, if you pay by time/consult, we ID doctors could be in deep trouble — the faster we do it, the less time-value it has, and the less we make. It’s quite different with surgeons — they get paid more with greater experience and efficiency.
Furthermore, though the fee-for-service model is horribly broken for ID as a specialty — no way to win on either volume or procedures — our clinical productivity is still mostly measured by how many patients we actually see. Every curbside we do is potentially a patient visit that didn’t happen. Note again how we differ from surgeons and other procedural specialists — from a revenue perspective, they have an incentive to keep simple non-operative cases out of their clinics.
Finally, the consultant is taking on some non-zero medicolegal risk. Should that be somehow factored into the compensation? In this excellent review — which is very pro-curbside — the author states that courts have consistently concluded that there is no actual medicolegal risk to the person being curbsided provided there is no relationship between him/her and the patient. However, he also accurately states: “Of course, even in the absence of actual liability, there is always a possibility that the consulted physician will be sued for medical malpractice. Although such a physician should ultimately prevail as a matter of law, the entire process is best avoided [emphasis mine].” Hard to disagree!
Other payment models are out there for informal consults, such as getting a flat rate per consult regardless of complexity (how much?), or getting a percentage of your salary covered for being “on call” for this service (what percentage?). And of course many will still have to live with the status quo of getting nothing — gratitude counts for something.
Provided, of course, it doesn’t end with (pet-peeve alert) “Thanks in advance!” A simple “Thanks” is perfectly fine.
Now, how much would you pay?
12 Responses to “Seriously — How Much Would You Pay for a Curbside Consult?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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Wed. 22 April 2015
Dear Paul,
Don’t you think that Carla should follow her patient and repeat chest x rays and the sensitve igra test for TB? After all, she could have been exposed at the airports and on the planes to Haiti, and the tests could be negative at first, but after 6 months, the disease may be apparent.
Many years ago I received a letter from either Merle Legg, (Pathologist at the NE Deaconess) or Bob Scully (MGH PAthologist) who apologized for having to bill me for a consultation. Prior to that time, a consultation in Pathology was always considered an honor, and not a service. I never failed to have the bill paid, since the honor was mine to have received such good attention to the care of the patient. I think you deserve as much as possible for your advice.
Don Feldman
Curbsides are valuable and with increasing pressures to produce, our time is valuable as well. Bundling will likely lead to more “curbsides” and could lead to a significant intrusion on our schedules. Perhaps we should attach an hourly rate to it: time to discuss, consider and reply; similar to attorneys (sorry for the bad comparison!). Unfortunately we have no mechanism to perform and justify this approach nor do we have a way to get reimbursed from the patient who is the ultimate beneficiary. Our advice, of course, puts the requestor at risk for an outcome based on our advice. Until we can fromalize this process, I will continue to offer my advice as a gesture to assist my colleagues with the hopes it may lead to other formal consults.
When I had an attorney review my contract for a new job position he charged me per hour. I got a bill for 1 hour for reviewing the contract, 20 minute phone call with myself and 40 min drafting the follow up email.
Why shouldn’t doctor’s get paid for the time spent doing work? How many hours of study did it take to get the knowledge to answer all of these “straight forward” questions?
I think we work in a system that doesn’t value the time we spend “behind the curtain” caring for our patients. We may spend 15 with them in the exam room, but what about the 15 minutes spent on the phone speaking with a specialist, the 15 minutes spent reviewing the test done in another facility, the 30 minutes on the phone with the insurance company trying to get a medication or procedure approved….
We should start giving more value to our time, maybe the day will come when everyone else does too.
I liked the omnibowl video. It (like a curbside consult) is priceless.
Have you seen the video about the turbo entabulator?
https://www.youtube.com/watch?v=oIS5n9Oyzsc
Dear Paul,
You may or may not be aware that there is a movement to ‘formalize’ the curbside consult — multiple AMCs are rolling out eConsults through their EMR. At all five sites within the University of California system (UCSF, UCSD, UCLA, UC-Irvine and UC-Davis), PCPs can get similar questions asked and answered by their specialist colleagues. The specialist gets paid for their work, the PCP gets their question answered (and also gets credit towards their productivity goals), the patient is happy because it is one less physician visit (no need to take time from work, pay for parking/childcare etc), and the Medical Center saves money (the cost of the eConsult is far less than a first-time consultative visit). More hospitals need to consider formalizing the ‘curbside’ with electronic consults. Thanks —
Dr. Rosenblum, I am quite aware, and indeed there are many advantages to curbside consults. For obvious reasons, we ID doctors are obsessed with the topic!
http://www.ncbi.nlm.nih.gov/pubmed/9739975
Paul
It looks like there was a comment on the older post you linked to that made a good observation. If there was a fee associated with it, there would be more expected regarding this. Probably more liability too, as this would no longer fall into the same legal category.
That said, in the era of value-based care, I have noted a much greater willingness to reply to even difficult curbsides when the patient is in “the ACO.” It might lead to a future state of the curbside doc standing by the EMR/phone answering questions for most of the day, like an all day board certification exam. Not sure how I feel about that image, but it might be interesting for a while.
Dear Dr. Sax,
I am concerned about the efficiencies and accuracies of Curbside Consultation as they are frequently based on inaccurate or incomplete clinically important information.
Although the accuracy and safety of Curbside consultation is not extensively studied in the literature, Burden M et al. found that there were major differences, with potential patient care effects, when comparing Curbside Consultation and Formal Consultation advice on the same patients due to inaccurate or incomplete information. Perhaps, a Non-visit Consulation format with appropriate review of patient information dependent upont the complexity of the question and appropriate remuneration by time would work.
Separate from the remuneration issue, there clearly needs to be careful thought to the use of Curbside Consults to insure patient safety and care.
Burden M, Sarcone E, Keniston A et al. Prospective Comparison of Curbside Versus Formal Consultation. J. Hospital Medicine 8:31-35 (2013)
i am a pcp who often calls and emails the specialists who i know ( or at least hope will answer)… with increasing value attached to removing waste from the medical system , it seems to make sense to me. Sometimes i’m not sure who the appropriate specialist is to see a particular problem, often it is to help with whether an xray interpretation requires an official consult, and most commonly it is an id question. i think it is probably best as a system , if we have an expectation around the time it takes to generate a reply, and the value of the service . i think paying you a fixed part of your salary to do this makes the most sense, then there is av alue placed, that can be estimated, and you can portion your time as you see fit to answer, jplatt
You’re nicer than me. My answer is always along the lines of “sounds like an interesting situation. Probably a few caveats that might affect the recommendations. I’d be happy to see her if you would like.” My time is valuable and if I’m not getting paid, my family deserves my time for all they’ve given up for this job.
As a generalist I find the variety of prior responses interesting. I’d estimate I’ve elicited 10 times as many curbsides than I’ve provided. But I’m invariably flattered that a colleague asks for the benefit of my expertise. I also am strongly biased that generalists should be much more than mere gatekeepers.
If an issue has even moderate complexity, I offer a formal consult or referral.
If collegiality is not important to you, and your practice is overflowing with patients; or if you feel cheated, refuse- politely or not.
I also work routinely with 2 different ID docs. One signs off when a course of treatment has been identified. The other sees his referrals every day until discharge, often requiring a phone call to clearly state a course of treatment. I’d say the pay to value relationship is backwards there, but hear no complaints.
Dear Paul
Thank you for your excellent posts
In Canada, within our single payer provincial health insurance, many (?all) provinces have a billable service for “telephone consults”. Specialists can bill $60 for providing telephone advice to colleagues if the call is answered within 2hours (even for “straightforward” questions), $40 if within 7 days. It’s not yet able to accommodate email consults. The PCP may also bill $40 for initiating the call and designing a care plan based on the discussion.
http://www.sscbc.ca/fees/telephone-fees
http://www.gpscbc.ca/system/files/GPSC_Initiatives_Update_January%202011-no%20logos%20_2_.pdf
Jan