Dealing With That Problem Patient

Joyce Sauvager has it easy when it comes to dealing with patients. “If I have a difficult patient, I just put them under. No more difficulty,” says the veteran nurse anesthetist. “People can be nasty. They get violent with me, I step away. But then the drugs go in, the patient goes out. End of trouble.”

OK, that’s an unfair advantage. And certainly, Sauvager has had her share of presedation scuffles. Still, positively interacting with patients, along with getting them to honor your practice policies, challenges all who work in the medical field. What can you do to foster a mutually beneficial relationship with those your serve?

Let’s look at each of the major types of difficult patients for answers.

The bill shirker

Insurance contracts require you to collect a copayment for every patient visit. So why is it so hard to collect them? “Part of the time the person just doesn’t want to pay, even if they have insurance,” says JoAnn Johnston, director of operations for the 170-employee Heart Center Medical Group in Fort Wayne, Ind.

To be sure, some people really do struggle to produce a $25 copay, and insurance companies are piling more and more out-of-pocket expenses onto the consumer. “There’s no more $10 copays,” says registered nurse Denise Kleber, who is the team leader for the Heart Center’s gastroenterologist. But with overhead costs absorbing half of your gross receipts and reimbursements shrinking like the polar ice caps, you need to be on top of collecting every dime you’re due from reluctant patients.

Luckily, there are some specific strategies to help you ramp up your collections at the time of service:

• Offer varied payment methods. Nearly four out of five physician practices accept credit cards, reports the 2005 Medical Practice Monitor by American Express’s OPEN division, which focuses solely on small-business development. If you’re one of the 20 percent that still doesn’t, then get on board. Increasingly, people pay with plastic. Yes, there are fees associated with processing credit cards, but you can find good deals through credit unions or bulk warehouse businesses such as Costco. You’ll get paid in just a couple of days, and without worrying whether the check will clear. Put your Web site to work, too, by getting set up for online payments. The easiest way is through PayPal, a popular and safe method of Internet payment. Anyone with an e-mail address can send you money electronically, using either a credit card or a bank account.

• Set and publicize a “same-day payment” office policy for copayments. Post it everywhere. Also, send a letter to your entire patient panel, announcing the policy. Explain how this same-day payment strategy will help to keep administrative costs down because you won’t have to spend hundreds of dollars and hours of time sending out paper reminder statements (which often go ignored). Emphasize that insurance contracts legally bind your practice to collecting copays from patients. Be nice, but also firm in your statements.

• Engage your staff. Make phrases like “Will you be making a payment today?” verboten in your office; instead, teach your staff to ask, “How will you be paying today?” Do not allow your team to offer a choice of paying or not. Also, personalize the issue of collecting payment by pointing out that the money in staff paychecks is connected to the money they collect. Set collection goals, and when they’re met, reward them with some sort of incentive, such as a catered lunch.

• Be flexible if the situation truly warrants it. Work with those who are truly struggling to pay you. Set up a payment plan. Consider offering a slight discount for paying the bill by an agreed-on deadline; some is better than none.

The appointment jilter

Your schedulers do their best to fill the appointment book in a way that keeps the patients flowing. Perhaps the schedulers also make reminder phone calls a day or two before patients are supposed to come in, and maybe your practice even levies a fee for those who never materialize at the appointed time. Still, certain patients just don’t show up.

Frustrating? Yes. Can you improve your stats? Depends. “You really have to look at each case individually,” says Kleber. When you have a patient who is chronically late or in absentia, start by probing for details. Can they drive themselves? Are they handicapped in any way? “We’ll be a lot more tolerant in those cases,” she says.

Johnston concurs, adding, “If it’s someone who’s institutionalized, it’s never their fault.” She also takes into account the fact that 60 percent of their patient population is on Medicare, which seems directly related to appointment time befuddlement. “They’re either 15 minutes late or a half-hour early.”

Regardless of where the fault lies, you still have a right to decide whether you want to continue a relationship with a patient who’s habitually AWOL. Decide on a policy that works for you: First-offense forgiveness, then $25 a pop?

If a patient contracts a case of terminal tardiness you may choose to discharge him, but make sure you’ve noted - literally - a pattern you can prove. “Grievously late” is fairly subjective; decide what’s right for your practice. If you use open access scheduling, you’ll have a varying ability on any given day to retrofit Johnnie-come-latelies into the daily docket. Those with traditional scheduling will have less wiggle room.

For Heart Center, says Kleber, “If it’s someone who no-shows three times, the doctors here will consider discharging that patient.” She says this is in deference to the rest of the patient panel, some of whom wait four weeks for an appointment. Also, decide when “late” becomes an official “no-show.” After 15 minutes? Twenty?

The charm school dropout

Illness has a way of turning even the cheeriest patient into a sourpuss. After all, he’s sick, or his offspring is sick, or he’s afraid he or his offspring has contracted some as-yet-undiagnosed disease, or he’s frustrated by his insurance company, or he’s anxious to hear some test results. All these and more can bring out his inner-crankiness.

Or, the belligerence might stem from past history - a former problem that was misdiagnosed, a physician with a curt bedside manner, a snippy nurse, you name it. Such experiences, especially if never resolved, can leave a patient with hair-trigger anxiety and a snappy, demanding tone. Does this mean they’re just “nasty people?” No, not necessarily. Likely, their wicked ways are fear-based. For whatever reason, this patient’s trust in you, your practice, and/or the entire medical system has been damaged. Without trust, protection instincts kick in - sometimes to rather rude effect.

Although it can be tempting to respond in kind to a provocative comment, step back instead, remind yourself the rudeness is not personal, and concentrate on resolving the problem. The instant gratification of shootin’ from the hip may not be worth the decline in your patient base. As Johnston points out, “one disgruntled patient will tell 50 others.”

First and foremost, listen to your angry patient, says Johnston. Really listen. “A lot of times it just takes listening to the patients to calm them down. Not all of them; some are just mean. But mostly, they’re scared,” says Johnston. Ask a few clarifying questions along the way if necessary, and sympathize with the patient’s perspective: Yes, insurance companies can indeed be hard to deal with, Mr. Crabbington. Oh, I know, Mrs. Tensionstein, waiting for more than a week for test results can be nervewracking.

Next, enlist the patient in mutually solving the problem, while retaining control. Simply asking, “What are your thoughts on solving this?” puts some responsibility on the patient who’s off on a rant about waiting 25 minutes over her appointment time; she may have some truly good ideas.

Retain control of the situation as a concerned but professional caregiver. At times, Sauvager goes head to head with her charges. “They say, ‘You can’t put the IV there,’” she says. “Well, why not? Is it because you’ve had surgery there? OK. But if it’s because you don’t ‘like’ it there, well, I’m going to put it where I think is best. I’m going to do it the way I think it’s the safest.”

Some patients seem ready to unload an arsenal of sarcasm just before interacting with your staff. They’re irked about fill-in-the-blank, and somebody’s gonna pay. Front-line office staff and nurses often get the brunt of this. Teach them that matter-of-fact deflection will go a long way to keeping the peace. Licensed vocational nurse Bertha Romano provided 57 years of care in this way; she claims to have loved every minute of it. Retired just two years, Romano, 83, says she “never had a lot of problems with patients. They would start something, and I would change the subject. I would start kidding and teasing, and they would come around.”

Romano says she consistently maintained her composure by imagining herself in her patient’s place. “Some people don’t do that, and they get mad and say things. They always have to eat their words.”

Important note here: You do not have to become the world’s punching bag to provide good care. Draw a very clear line in the sand with your patients; they will honor it. Sauvager says, “I’ve had patients be rude and cuss me out. I tell them, ‘You talk to me like that again, and you can find someone else to help you.’ I’ve never had anyone say, ‘Good, go get me someone else.’”

Johnston also takes issue with the increasing societal demand for instant gratification: She recalls one infamous, hypersensitive patient with irritable bowel syndrome who barreled into the practice, sobbing, demanding an on-the-spot appointment. When Johnston said the nurse practitioner had a tiny open spot, the patient’s husband punctuated his response - “She’s not seeing a nurse practitioner. We want to see the doctor now” - by jabbing his finger at Johnston’s face. “Some of our patients - the next generation - want it now. Unfortunately, healthcare doesn’t operate that way,” says Johnston. “We offer the emergency room, in that case.”

From Johnston’s observations, the biggest demands come from patients who are not critically ill. “I’ll second that,” says Kleber. “You’ll have a patient with a hemoglobin of seven, and it’s like pulling teeth getting them in. They’ll say, ‘Gee, I really don’t feel that bad.’ The chronic ones want no pain.”

Finally, follow through - probably the most critical action you can take to appease patient peevishness, says Kleber. “If you can calm them down and get them to see that you want to help them, you must follow up within 24 hours or you lose all credibility.”

Johnston says that Heart Center Medical Group takes follow-up very seriously, even if it sometimes means making a call after business hours. “I think [patients] deserve that. We’re caregivers. We nurture. That’s the best advertising a practice could have.”

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the September 2007 issue of Physicians Practice.