Pediatricians and other physicians are seldom compensated for telephone calls with patients. Yet telephone encounters play an important role in medical care, especially when the office is closed. They constitute ~20% of all encounters between patients (or their caregivers) and physicians.¹ They provide patients and caregivers with important reassurance and advice,^11,12 prevent visits to the office or emergency room,^8,13 and enable cost-effective follow-up of acute and chronic illnesses.¹⁶ Accordingly, it has recently been argued^19,20 that paying physicians for telephone encounters, or counting them when measuring physicians' productivity, would have multiple beneficial effects. It would give physicians fair compensation for the time, inconvenience, expertise, and liability risk involved in talking with patients by telephone. It could be expected to increase the efficiency of providing medical care and to improve the documentation of telephone discussions.

The health care system is, of course, rapidly evolving toward managed care, although payment of physicians by capitation is still far from the norm, especially for specialists.²¹ As such risk-sharing arrangements with physicians become more common, however, physicians' incomes and the measures of their productivity will no longer be a function of the numbers of face-to-face encounters with patients, and they will lose the incentive to maximize such encounters. The telephone and eventually other modes of telecommunication are likely to be increasingly attractive ways to care for patients. Yet it will be many years, if at all, before most American physicians are paid by pure capitation. In the meantime, they will continue to work within a variety of fee-for-service arrangements in which telephone consultations, although a very common part of continuing medical care, are largely uncompensated.

What pediatricians and other physicians think and feel about telephone calls, whether they want to be compensated, and how well they claim they are documenting calls have been little studied. The purpose of this investigation was, therefore, to describe more fully the physicians' point of view.

MATERIALS AND METHODS

Subjects

Research Methods

Statistical Analysis

Descriptive statistics were calculated for the entire sample, for each specialty, and for the subgroups of generalists and subspecialists within pediatrics, internal medicine, obstetrics-gynecology,and surgery. The proportions of physicians who favored compensation for phone calls as well as of responses to the other variables (representing physicians' experiences with and attitudes about telephone consultations) were compared across specialties and subgroups.

Differences among physicians in their sentiments about after-hours calls were treated in two different ways. They were summarized by aggregating the five individual scores. In addition, however, because these aggregate scores were artificial constructs and because the individual scores were ordinal, rather than interval, and were variably linked to each other, the individual scores too were used in the comparative analyses.

Power calculations were performed by Instat software to examine the limitations resulting from the relatively small sizes of some of the specialties and subgroups.

Two multivariate models were then developed: a dichotomous choice (logistic) model to predict the probability of favoring compensation for telephone consultations and an ordinary least-squares model to predict the suggested dollar charges among those who wanted compensation. The models were used to infer what variables were independent predictors of physicians' responses. The models were then examined to determine whether they adequately accounted for the observed between-specialty differences in the proportions favoring compensation and in the amount of compensation desired.

Tests of goodness of fit²² and of predictive accuracy (using the Receiver Operating Characteristic [ROC] curve²³) were performed on the estimated logistic model to determine how well it described individual physicians' opinions about compensation. The measure of goodness of fit compared the observed and expected proportions of "successes" (responses in favor of compensation) at each decile of estimated probability of favoring it. The ROC curve for the model was constructed by plotting the rates of true-positives and false-positives at different cutoff probabilities of favoring compensation. Because only 335 of the respondents answered all the relevant questions, this sample was used for the regression analyses; it did not differ significantly in demographic characteristics from the whole group of respondents.

RESULTS

Sample Characteristics

Table 1. Characteristics of Population and Sample [View Table]

The medical school faculty were represented equally among the surveyed population and respondents (29% of both). Both the population and the respondents were largely male, 84% and 82%, respectively. The mean age of respondents was 47.3 years (SD, 10.5); the median, 46; and the range, 31 to 81.

Opinions on Compensation

Table 2 shows the responses to the general question about compensation according to specialty and groups of specialties. Internists and neurologists were significantly more likely than the combined sample of physicians to favor compensation, and surgeons were less likely. The lower than average percentages of pediatricians and general and family practitioners favoring compensation were not statistically significant because of the limited sample sizes. Gender, age, and faculty status had no significant effect.

Table 2. Answers to Whether Physicians Should Be Compensated for Calls [View Table]

Experience With Calls

Table 3. Physicians' Experiences With Calls [View Table]

Sentiments About After-Hours Calls

Table 4. Physicians' Attitudes Toward Calls [View Table]

Most physicians, however, felt that receiving after-hours calls, no matter how unpleasant, was part of their job (median 1) and did not make them "want to quit" (median 2). Nonetheless, a substantial minority (13.1% of the total and 31.3% of the general pediatricians) did report that these calls made them want to quit (ie, gave ratings of 4 or 5 on this item). These included 5 of the 7 faculty general pediatricians (71%) and 5 of the 20 private general pediatricians (20%) (relative risk, 3.6; 95% CI, 1.4 to 8.9).

Concern About Liability

Regression Analysis of Favoring Compensation

Table 5. Regression Model for Favoring Compensation [View Table]

Both measures of statistical fit demonstrated that the estimated logistic model described quite well physicians' opinions on compensation. The Hosmer-Lemeshow ² statistic computed for the test of goodness of fit was 4.36, with a corresponding P value of .82. The calculated area under the ROC curve was .81. The actual percentages of pediatricians and surgeons who favored compensation, however, were too low to be explained by the model (ie, they lay below the 95% CI for the predicated values). It is very likely, therefore, that factors other than those evaluated in this survey are important in explaining the differences among specialties in their opinions about compensation for telephone encounters.

Suggested Charges

Table 6. Dollar Charges Suggested by Physicians Who Favor Compensation [View Table]

A regression analysis showed that among the factors surveyed, concern about liability had the largest impact on suggested charges. Every 1-point increase in the rating on concern about liability was associated with a suggested charge that was higher by $1.33 (95% CI, $.53 to $2.12) for 1- to 5-min calls, by $2.16 ($.94 to $3.35) for 6- to 10-min calls, and by $2.55 ($.58 to $4.51) for calls of >10 min. Sentiments about after-hours calls had, after adjustment for the other variables, no impact on suggested charges. In addition, no correlation was found between amount of charges and a respondent's age, sex, or faculty status.

Documentation of After-Hours Calls

A report of more complete documentation of after-hours calls was associated with a greater concern about liability for calls (P = .0005), holding other factors constant. Yet, even those who worried most about liability were likely to leave most calls undocumented; of those who rated their worry at 4 or 5, the mean reported rate of documentation was still only 45.5%. The percentage of documented calls was associated negatively with the number of calls received on weekdays (P = .03). Multivariate analysis revealed that after controlling for concern with liability and number of weekday calls, no significant between-specialty differences remained in the proportion of after-hours calls that pediatricians and other physicians said they documented in their patients' charts.

DISCUSSION

Most physicians in the Albany area stated that they should be compensated for at least some telephone calls with patients. The inverse may, however, be more surprising: 30% of all physicians and 42% of pediatricians did not think that they should be paid for telephone encounters, even though they know from experience that dealing with patients by telephone involves time, risk, and, often, inconvenience. Of those who did favor compensation, 89.6% affirmed this for patient calls after hours, 61.7% for patient calls during office hours, but only 26.3% for follow-up calls initiated by the physicians. They appear to see telephone access as part of the routine services offered to all patients who join a medical practice.²⁸ Accordingly, even most of the respondents who favored compensation for after-hours calls felt that such encounters were "an expected part of my job." Most pediatricians and other physicians may agree with the designers of Medicare's resource-based relative value scale²⁹ that follow-up calls are part of the service already charged for in the office visits.

Opinions about compensation differed among specialties. Internists and neurologists were more likely than physicians as a whole to want payment for telephone encounters (80.8% and 94.1%, respectively). Part of the variation can be accounted for by differences among specialties in those factors that were important independent predictors of whether individual physicians would favor compensation (such as worry about liability, sentiments about after-hours calls, and average duration of calls). In particular, neurologists were most upset by after-hours calls and reported the longest duration of calls. Yet, after adjusting for these factors, pediatricians and surgeons emerged as significantly less likely than physicians as a whole to want payment for telephone encounters.

This study provides no explanation of these residual differences among specialties. Nonetheless, it is easy to speculate about their sources. Surgeons may be accustomed to reimbursement for procedures rather than for talking. Moreover, many of the calls to them will concern these procedures (especially postoperatively), for which a single charge often includes the surrounding care; they are less likely than primary care physicians to be called by a patient about a new problem. Pediatricians, on the other hand, must give advice continually to parents on a multiplicity of important and unimportant topics and see this as part of their role. They may, in addition, be more sensitive than other physicians to the risks to their patients of any restrictions on access to care.

Making after-hours telephone care available to their patients does not necessarily mean that physicians must provide it themselves. Solo or small-group practitioners routinely share call with others. Furthermore, in Denver,²⁶ 82% of the pediatricians in private practice have subscribed, for at least some of their after-hours time periods, to an after-hours telephone service that manages their patients' calls. The 18% who did not subscribe said that their patients' parents "expected and needed" them to be available to provide advice after hours. Such a telephone service has been set up recently in Albany as well. Physicians who want their patients to have after-hours access but who also find answering after-hours calls a burden would be expected both to desire compensation for such calls and to be willing to pay to avoid the burden.

Almost all respondents indicated that no matter how unpleasant it was to receive after-hours calls, it was a part of their job. Nonetheless, some were, of course, more annoyed than others; 13% of the total and 31% of the general pediatricians reported that these calls made them want to cease practicing. Similarly, other investigators have reported that ~25% of after-hours calls provoke hostile feelings.^11,24 Although it is alarming that after-hours calls make so many general pediatricians think about quitting, this reaction was less prevalent among the community pediatricians (20%) than among the full-time faculty (71%). It is unknown how many pediatricians and other physicians actually retire from or change their practices to avoid after-hours calls.

Pediatricians as well as other physicians, especially those who receive a large volume of calls, admit that they do a poor job of documenting after-hours calls in patients' charts. Similarly in Denver, 71% of pediatricians reported documenting "selected" calls in patients' charts, but only 43% did "most" calls.²⁶ This deficiency is understandable because of the inconvenience and expense involved in such documentation. Physicians are, however, constantly reminded and are surely well aware of the benefits of good documentation, namely to improve continuity of care and to decrease liability risks.^30,31 Indeed, those who are highly concerned about their liability for phone calls do claim to document these calls more frequently than other physicians; nonetheless, even they report documenting less than half their calls.

Shortcomings

Third, with a brief, written, anonymous questionnaire, it is impossible to ensure that the respondents understood the questions and intended their answers in the same ways. It is also impossible to do more than infer and speculate about why they answered in the ways they did. A more detailed and probing questionnaire would, however, have had a lower rate of response.

Implications

Third, compensating telephone encounters is likely to have a favorable impact on the nature, cost, and outcome of medical care. The low level of documentation of after-hours calls could be expected to rise if physicians had a financial incentive to do this. When physicians charge for encounters with patients, however they take place, they must be able to provide third-party payers with documentation to support their claims. Moreover, telephone encounters are efficient and inexpensive and, therefore, can save time and money for the patients and third-party payers whenever they are as effective as office or emergency room visits.^17,18 Patients and their caregivers realize that telephone access to physicians benefits them, and, as physicians and their staffs are well aware, frequently want to substitute telephone for office care. In the context of a questionnaire about otitis media, $25 was the median amount that 148 parents bringing their children to a suburban office reported they would be willing to pay to avoid an office visit (Sorum PC, unpublished data, 1995). Furthermore, the policy might well be extended to physicians' telephone consultations with other doctors. Even without the availability of full telemedicine capabilities, it is frequently more cost-effective for a primary care physician to talk with a specialist by telephone than to send the patient.

Like office visits, telephone encounters with patients could be compensated according to their complexity, not their duration. It would be simpler, however, to start with a payment schedule based on contact time. The physicians' proposals of dollar amounts (Table 6) can serve as a basis for establishing a suitable schedule, with an extra charge to cover the administrative costs associated with billing for and keeping records of telephone calls. A payment schedule of $15 for 1 to 5 min, $25 for 6 to 10 min, and $35 for >10 min would seem not only fair but also acceptable to physicians. The expense should be borne largely or fully by third-party payers so that parents are not dissuaded from calling when they should.²⁰

It appears that pediatricians, parents, and third-party payers should all welcome incentives to physicians to provide more acute and follow-up care over the telephone. Until capitation transforms how physicians' income and productivity are determined, such incentives will be in the form of monetary and nonmonetary compensation for telephone encounters. Payments to physicians will be cost-effective, as long as any actual charges to patients and families do not limit telephone access unduly and as long as physicians and patients use the telephone judiciously.