Discussing money is the price of doing business

5 minute read

We’re not trained to talk about fees, but we should see it as part of obtaining informed financial consent.

I was talking to a colleague-patient this week about the fees that patients pay and how we discuss them, if at all.

This colleague expressed the familiar sentiment: “It’s better if the doctor isn’t the one handling the money.”

I see on the forums doctors getting upset, especially in general practice, if patients are not billed appropriately at the front desk, or question the fees post-consult, or are advised by reception staff to “check with the doctor” if they request to be bulk billed.

It was an interesting conversation for me to have, on two levels.

When I was in general practice “proper”, I decided, on the strength of my average consultation time, to tweak the patient fees. I approached the practice manager, who was initially reluctant to implement my gap fee schedule that was different from the other doctors’. We negotiated and eventually put up separate signage for me, including in my room within view of the patient.

If a patient had booked a standard appointment and was about to go into a longer appointment I’d point it out so they had a choice of continuing or ending and rebooking another appointment. If there was more than one issue they presented with that was eligible for two item numbers, I’d warn them ahead of time so they had a choice about the fees they’d pay.

When I transitioned to skin cancer work, I’d warn them ahead of time of additional fees for a biopsy, as well as fees for further excision. I documented this verbal agreement and cost quoted, and this all happened in the room.

That way, when they went out to pay, they knew what to expect.

So it is interesting to see the regular anxiety and unhappiness peers feel about discussing money, both as providers and especially as patients. 

Some shy away from it as it makes them uncomfortable. Others report feeling “greedy” and money focused. Others have some notion that money and medicine are two entirely separate entities with no overlap – they’ll handle the medicine if someone else handles the money.  

Because I’ve always worked in areas where there are many item numbers in terms of billing, I see it as an opportunity to ensure the patient and I are on the same page when undertaking consultations as well as any additional treatments and procedures.

Unlike many non-GP specialists, who are largely limited to two item numbers – initial consultation fee and review consultation fee – which reception staff can easily relay when booking, most areas I work in have numerous numbers that can be legitimately stacked. Unless I choose to no-gap any of them, it is imperative to me to advise the patient of all potential appropriate fees. 

Does this mean that I’ve no fear around talking money? Or that I somehow actively enjoy talking about fees for service?

Not at all. What helps me overcome this fear every time is my belief that discussing money is a key part of informed (financial) consent, without which consent is incomplete. By this logic, if it is not discussed, the patient may have grounds to complain, which is stressful at the best of times.

I am not prepared to discount my services by 50% or more due to poor communication or an expectation that it is someone else’s job to obtain financial consent.

As healthcare workers we are never taught the business of medicine, nor to talk about money. But in ANY business, it is an unavoidable part of the job unless we are salaried employees. Even so, most retail workers need to learn to talk about money and handle customer complaints, so we are in a uniquely protected position to think we can practise without ever getting our hands dirty and talking about money.

Someone who is afraid to talk about money will inevitably struggle to implement all the other areas of the job required: setting expectations of scope for the time and fee, and setting boundaries that work for both parties. Failing to do these things can lead to frustration, resentment and even burnout.

So while I’m not suggesting that everyone should get comfortable charging patients themselves at the front desk, or similar, I am suggesting that it may be in our best interests to examine why talking about money makes us so uncomfortable and whether it is a deeply held belief that needs to be dislodged.

Reasons commonly cited for burnout among healthcare workers are unrealistic patient expectations, ongoing pressure to do more, long working hours, organisational issues and poor communication.

How many of these are directly linked to our aversion to discussing money, and sometimes pushback from management, who may feel we ought to let matters around money slide, especially when it comes to patient complaints around fees after the fact?

This aversion is something we can learn to master, improving our quality of life and allowing us to find the joy in our work again.

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.

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