Posted by: notdeaddinosaur | March 21, 2008

Thoughts on Appointment Deposits

Following up on my previous post, I’d like to review some of the thoughts other folks had about charging a deposit to make an appointment with a specialist, and my final formulation for myself.

I completely understand the point about the value of a physician’s time and patient responsibilities. I feel your pain; I lose money when patients don’t show too. But although the concept seems valid, I have some real problems with it; at least with its execution in this particular case.

First of all, the comparison to placing a deposit for a hotel room doesn’t quite hold up. Although deposits are accepted practice in certain industries, they are hardly universal. You don’t need a deposit to make a restaurant reservation (last I checked, although precisely the same arguments hold.) Hairstylists don’t routinely require payment at the time the appointment is scheduled; neither do car repair shops that accept appointments. Does your lawyer charge you if you don’t show for an appointment? (I know, I know; he doesn’t have to; he can still charge for phone calls.) At this point in time, I believe it is still generally accepted that the risk of no-shows is considered a business expense for professionals in service industries.

Certain patients will fail to keep appointments, and certain other patients wouldn’t dream of it. Reminder calls are an accepted strategy to minimize no-shows. So is charging fees (albeit nearly impossible to collect) after the fact for missed appointments. The problem with charging everyone upfront is that you’re assuming the worst; guilty until proven innocent, if you will. Even if you give the check back, what I find insulting is the implication that you don’t trust the patient to show up.

What about patients who don’t have checking accounts? I suppose it wouldn’t rub the wrong way quite so much if it were a credit card number requested instead of a check, but I have some patients who don’t have credit cards either. In this case, the free-market argument is that those patients “can’t afford” to see those specialists; they’re just out of luck, even if they have insurance that would otherwise cover the visit.

Here’s the other piece of this that I think slipped past most of my commenters, some of whom said they’d be happy to pay if it guaranteed them face-to-face time with the doctor: the issue of choice. It’s one thing if a self-referred patient wants a second (or third, or fourth, or however many it takes to find one that says what they want to hear) opinion. In this case, my patient didn’t feel like she had any other option but to comply: I was the one who referred her, therefore she “needed” to see him. In a strange way, I felt guilty. If I were a better doctor — smarter, better read, more on top of her condition — then she wouldn’t have to see the specialist or pony up the $75 check. Somehow this felt like my fault.

I had actually spoken to the doc about this patient, and we had agreed on a trial of treatment for a month, after which he would see her. At no point in that conversation did he mention anything about this new office policy of his. If nothing else, I could have warned the patient. It sounds weird, but I felt betrayed. Perhaps the policy should be modified for patients when I speak directly to the specialist; perhaps they should have requested a credit card; actually, what they should have done was be more polite about it. My patient felt the appointment scheduler was rude; but again, she didn’t feel she had the option not to go.

After much introspection (and appreciation for all the thoughtful comments) here is what I have decided:

I completely support this physician’s right to run his practice however he pleases. However as long as this is his office policy, I shall no longer refer patients to him. I just can’t do it in good conscience. I haven’t decided if I’ll call and tell him so (I don’t really refer to him all that much as is, so it’s not like he’ll miss much) but that’s how I’ve decided to handle the situation.

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