Thursday, September 20, 2007

Money Makes The World Go Round

Back when my father was in his last months of life, a young, enthusiastic doctor wanted to run all kinds of tests on him. The physician’s eagerness to get lots of laboratory results (perhaps a self-induced billing frenzy?) was palpable. He was dumbfounded when my mother refused to give her consent for any more tests.

"But he needs them!!" exclaimed the young internist. “He needs those lab results!”

My mother -- who has never failed in her talent to nail someone to the floor with sarcasm -- calmly replied "Listen to me. I know he's dying. He knows he's dying. We all know he's dying. So if the decision hinges on whether he gets to die in comfort or whether we put him through the misery of having all these tests performed because your wife wants a new Mercedes, then tell her she can wait a little longer for the car."

Physician greed is a popular topic among medical transcriptionists. Needless to say, horror stories abound. There are plenty of hospitals that claim they shouldn’t have to pay for spaces between words and/or paragraphs. There are doctors who scream “Why should I pay for that line? There are only three words on that line!” There are physicians like the one who billed a patient for an office visit dated two weeks after the patient had died. And I’ll never forget the plastic surgeon who called me one December morning asking if I had any fat friends who wanted to squeeze in a liposuction before the holidays!

The most common phenomenon encountered by medical transcriptionists is people who want everything from a medical transcription service but don’t want to pay for it. In second place is the concept that a transcription service is the same thing as a secretarial service. It is not.

  • A transcription service is not responsible for parsing the addresses from all of a doctor’s consultation letters and producing labels for his Christmas card mailing list.

  • A transcription service is not responsible for finding the address of “Dr. Smith in Pennsylvania.”

  • Most importantly, a transcription service is not required to alter its procedures every time one doctor wants something on his reports done differently from the way it is done on everyone else’s reports.

Some medical transcription service owners try to accommodate such nonsensical demands with no understanding of the hidden costs that may be incurred by their business. This may be due to a severe co-dependent streak in their personalities which prevents them from establishing boundaries, communicating limits and sticking to them -- or failing to understand that, in the long run, they will incur the extra costs of having to train each new transcriptionist to adjust to the formatting quirks of each physician’s dictation. Like it or not, standardization of document formats is the way to succeed in building a modular business where new dictators can easily be added to the mix.

While some people believe that outsourcing is a way to save money, that’s not necessarily the case. Outsourcing becomes more cost efficient if it saves a company the burden of having to manage more people. By eliminating an entire human resources segment of a company’s business model, it allows other parts of the operation to function more smoothly.

Although clients who are shopping around for a new transcription service may have done a thorough job of researching which rate each MTSO charges, they may not understand the grotesque variations in the definition of a line -- or how pricing is determined using a different unit of measurement (such as the minute of recorded dictation time).

In any event, price should never be what a potential client tells an MTSO he has determined it should be as a result of his own calculations – or what he’s heard on the grapevine. The rate that service providers charge should be calculated to cover their real costs of bringing a new client on-line, the standard costs of doing business and should earn sufficient profit margins to fund future growth.

The law of supply and demand applies to every kind of business. The healthcare market is currently suffering from a glut of physicians and a shortage of medical transcriptionists. The fact that physician incomes are getting squeezed by managed care does not mean that medical transcriptionists should devalue their professional services by lowering their rates. If anything, MTSOs should be taking advantage of today’s shortage of qualified professionals by raising their rates if the level of service merits such compensation.

In recent months my company has received some bizarre inquiries. One man told me that his hospital was desperately backlogged and needed a transcription service that could get it through the next four weeks before all of the hospital’s dictation got sent overseas to India. He could only pay 12 cents per line and needed us to start immediately. Perhaps he assumed that because his need was so time-sensitive, MTSOs would immediately drop everything and come running to save him.


Why should any transcription service go through the stress of bringing a large group of dictators on line just to see that account waltz out the door as soon as an Indian vendor can take over the work? Who needs the aggravation (especially if they’re not going to make any money on the deal)? Why bother!

Another call came from a small hospital that could not find medical transcriptionists to work in-house but assumed that, since they were located in a rural area, they should not have to pay “big city transcription prices.” Does Microsoft lower its prices if someone lives in the boonies but still want to buy its software? I think not.

The piece de resistance, however, came from a doctor who had determined that because his facility’s hardware was not Y2K compatible, it would be wise to outsource transcription by the end of the year. He explained in detail every bell and whistle that he desired from a transcription service – including free dial-in 800 service for his doctors – and boasted that his figures demonstrated he was currently paying 10 cents a line to have the work done in-house. According to his calculations, he was convinced that an MTSO should be willing and eager to take on a 70-doctor clinic -- with all kinds of specialized demands -- for only 9 cents a line! When he asked me what I thought, I told him in no uncertain terms.

I informed the good doctor that his expectations were totally ridiculous and that the mere fact that he was a physician did not qualify him to understand the costs of running a medical transcription service. To get the ball rolling, I explained that there is no such thing as a free dial-in 800 service. Someone still has to pay the phone company and, whether or not he wanted to believe it, the cost of maintaining toll-free dial-in service gets built into the rate the client is charged. After a polite but highly educational discussion, he sighed “I still can’t understand why transcription is so expensive!”

My reply was simple. “That’s really interesting, because a lot of people who go to an emergency room can’t understand why they get charged $8 for an aspirin!”

The doctor went on to tell me how surprised he had been to discover that not one physician on staff formatted his reports the same way as another. After carefully explaining that an important key to reducing transcription costs is getting physicians to modify their behavior, I asked him how many patients he tells to lose weight and stop smoking. When I inquired how many actually follow his advice, he confessed the number was tiny. “That’s the same problem we have with physicians ,” I chuckled. “ It’s like running a daycare center for disobedient children.”

That kind of news is very difficult for physicians to hear. But they’re the ones who are in trouble. They’re the ones who are drowning in paperwork. What many MTSOs fail to realize is that in a booming economy -- where there aren’t enough medical transcriptionists to do all the work that is out there -- market pressures of supply and demand dictate that MTSOs they should never devalue their services to the point where MTs are working twice as hard as before to earn less money. That’s why, when a transcription service takes on a new client, an important role reversal needs to take place in which the transcription service becomes the doctor and the doctors become the patients.

As a professional transcriptionist, I am particularly offended by hospitals and clinics that assume they should have a clause in their contracts allowing them to penalize MTSOs for every mistake found in a transcribed document. First, let’s consider the raw material (quality of dictation) that MTs must deal with! Then let’s not forget that the client who negotiated a contract based on the lowest price chose to hire a less qualified labor pool and, by doing so, probably purchased a higher percentage of errors.

Once, when I insisted that we add a clause to a hospital’s RFP stating that the MTSO could penalize the hospital by charging a dollar for every physician’s mistake that was corrected by a medical transcriptionist, the purchasing manager almost had a heart attack. “Are you crazy?” he asked. “We would never agree to such a penalty! Besides, our doctors don’t make any mistakes in their dictation.”

The man obviously knew nothing about transcription and assumed that transcriptionists are not entitled to any ideas about what their work is worth. Some people think that just because healthcare providers need to get their dictation transcribed, MTs are obliged to commit financial suicide to make it happen. Nothing could be further from the truth.

Medical transcriptionists are the people who know what their work truly involves. That’s why, when taking on a new client, it is critical to have the client sign a contract which clearly outlines the tasks for which a transcription service will be held responsible. If a service item is not mentioned in the contract, it does not mean the client is entitled to receive such service for free. The client can either do without that particular service item or else negotiate an additional fee for special services.

When push comes to shove, a contract acts like a condom. A contract is used to protect both parties and clarify responsibilities in an effort to avoid painful disputes or misunderstandings. Physicians are fond of demanding service on a “stat” basis when, in truth, they’re merely trying to cover their asses for having procrastinated for too long. A basic rule of business is that “Lack of planning on your part does not constitute an emergency on mine.”

  • If a client keeps demanding stat service but is not willing to pay for it, he should be told to spend some time reading his contract.

  • If a client suddenly demands that, because his office is understaffed, a transcription service needs to chip in and do all kinds of secretarial chores which would normally be handled in-house, an MTSO has every right to stand his ground and say that because the client’s request is not covered by the terms of the contract it cannot -- and will not -- be accommodated.

  • If a client is consistently late with payment, the MTSO can give notice to terminate the contract – and even hold transcribed documents hostage until payment is made in full.

  • Any client’s refusal to sign a contract (much like someone’s refusal to wear a condom) signals the start of a selfish and one-sided business relationship which, no matter how alluring, is usually not worth the risk. Nor should a client’s lack of discipline ever become a financial or procedural burden for a medical transcription service owner.

During MTIA’s annual business meeting in April, one person running for a seat on the Board of Directors delivered an impassioned speech about how medical transcriptionists should be paid twice what they now earn because of the unique value of their work and their critical role in maintaining a high quality of patient care. Some of the MTSOs in the room were, no doubt, threatened by the thought of having to raise their rates to clients (as well as increasing their compensation to transcriptionists). How the man packaged his statements may have worked against his winning a seat on MTIA’s Board of Directors. But his message was clear, concise and long overdue.

In this business, you get what you pay for. And if you want quality work from professional transcriptionists, then you should be prepared to pay for it. If you refuse to pay the appropriate price for such service, then you’re simply not going to get it.

1 comment:

222teresa said...

I love the way you write and think! It clearly makes economic sense for transcription services to charge at least twice the amount they currently charge and to pay their transcriptionists much more than 6 or 7 cents per line.

I refuse to transcribe for those rates. I respect my physical body too much and want it to last me more than five to ten years. In order for me to make a decent wage transcribing at those low rates, my upper extremities start to develop overuse syndrome (even with appropriate breaks), and it is just not worth it (and people wonder why there are so few transcriptionists out there--we've been burned and are too smart to come near the stove again).

It seems the very gifted, "speed demon" typists or those with "good accounts" (aka authors who care about their patients and actually speak clearly) are the only ones able to make a professional-level wage, making it more profitable for the average transcriptionist to work for Wal-Mart than to stay in the business.

I truly hope things change not only for the sake of the transcriptionists but for the sake of the entire healthcare industry.

Maybe medical transcriptionists should take a look at the history of the nursing field and then seriously consider unionization. Attitudes towards nurses only started to change when they united, stood up, and declared they and their services were worth much more than doctors were giving them credit for. If transcriptionists don't stand up and declare themselves and their professional services worthy of appropriate respect and compensation, who will? Definitely not the postee over on the JAAMTonline.