Doctors caught in the middle as more patients move to high-deductible plans

PITTSBURGH _ The four-physician family practice of Sauer & Leibensperger has served families in the McKees Rocks area outside Pittsburgh since 1993.

One of the key things that remains unchanged in that near-quarter century: A reliable cohort of patients, some now well into their Medicare eligibility, has sought the caring treatment offered by physicians Gary Sauer and Stephen Leibensperger and their colleagues.

What has changed is the health care finance world they and everyone else must now navigate.

A joint survey by the Kaiser Family Foundation and The New York Times published in January found that about one-quarter of adults ages 18-64 said someone in their household had trouble paying medical bills in the previous 12 months, and that a person's insurance status "has a strong association with medical bill difficulties."

With the emergence of low-premium, high-deductible health plans, Patty Kessler, practice manager for Sauer & Leibensperger, said she is seeing more patients caught off guard when the bill arrives.

"I think they chose a plan based on a monthly premium they can afford, not realizing they have a $6,500 deductible."

It's not just deductibles, either. Because the practice is not affiliated with any of the hospitals in the Allegheny Health Network, one of the region's major health care providers, Kessler said the physicians have seen patients with tiered plans who have a $140 co-payment for a doctor visit.

"Our (accounts receivable) is higher, absolutely, but we're managing," she said.

The more immediate worry is that patients may be forgoing treatment rather than bear the cost of a visit. "We have patients asking, 'Do I need to come in for this?' which puts the physician in a difficult situation."

Few, if any, physicians went to medical school to learn about billing and collections, but the matter of getting paid is requiring more and more of their attention, particularly for small, independent practices like Sauer & Leibensperger.

"As the patient's responsibility (for the costs) has increased, the front desk staff have had to become more vigilant about seeing if the patient has met their deductible, to see if there's going to be any cost," said Mary Ellen Corum, director of practice support for the Pennsylvania Medical Society, a professional association of physicians.

Patients may notice small changes, such as being asked for a co-payment before seeing the doctor rather that afterward. More practices accept credit or debit cards as payment. The receptionist may ask, "How would you like to pay for today's visit?"

These days, there's almost always a sign near the registration window that says, "Payment is expected at the time of service," although Corum offered, "I'm not sure I've ever heard anyone say, 'I'm sorry, you're going to have to leave.'"

And there's the rub: As a rule, physicians want to treat ill or injured patients, regardless of their ability to pay, but they still need to keep the office on stable financial footing.

They also don't want to lose patients in a dispute over the insurance coverage the patient chose. So Corum said more offices are checking online to let patients know ahead of time if they still have an unmet deductible in addition to their co-payment.

Practices may refer a patient to a collection agency for nonpayment, but "I don't think it happens very often," she said. "It behooves a practice to try to work with a patient, to preserve the relationship. And the rates for collection agencies are pretty high."

Kessler said about half of the practice's patients are Medicare eligible and, for now, only about 20 percent of them pay with a credit card, where a processing fee cuts into practice revenue.

"Our doctors have always been very generous with the payment policies. If the patient at least makes an effort, they will take what they can afford," she said. "Most people are not trying to get away with anything."

She doesn't keep credit card information on file _ "I wouldn't want that responsibility," she said _ and they still don't ask for payment until after a patient has seen the doctor. The doctors "would never abandon a patient they started treatment on because of nonpayment," Kessler said.

As for tightening the payment policy, though, she said, "It might be a discussion we're going to have to have with the physicians in the next six months. Right now, it still seems to be working."