Warning! Make Sure You're Admitted!

This is strictly for American readers, but others will get a taste of the grotesqueries of our medical system.

Let’s say you’ve been vomiting for a few days and drag yourself to an emergency room. The doctor says you need IV fluids, so an aide wheels you to a room where you spend the night and most of the next day and then return home, feeling better.

Or you have chest pain. The ER doctor doubts that it’s a heart attack, but he wants to keep you for observation. After two days connected to a heart monitor and getting blood tests, you’re discharged, feeling better.

In both cases you’ll get a bill for at least $5,000, and YOUR HOSPITAL INSURANCE WON’T PAY!! 

Hospital insurance only pays if you’re admitted to the hospital, but remaining in a holding area for a few days or being kept “for observation” is not admission. You’re still an outpatient, so you’d better have good outpatient insurance.

If you’re over 65 and have Medicare Part A (which is free) but have decided to skip Part B (which costs $109 a month) you have no outpatient coverage. Part A only pays for the hospital. If you’re under 65 and have the usual Blue Cross or Blue Shield, you’re largely covered for hospital charges. Depending on the policy you’re willing to pay for, outpatient coverage varies. A lot. 

The solution, when the ER doctor announces that you need to stay for a while, is to ask: “am I admitted or not?”

Of course, you’re probably miserably sick or frightened (if not, maybe you shouldn’t be in an emergency room), so asking about insurance is not a priority. Woe unto you if you don’t.

Night of the Concierge Doctors

Hotel doctoring has always been a dog-eat-dog business, but after 2010 another tiresome phenomenon appeared: concierge doctors.

These provide a personal service for a large fee in cash, no insurance -- American insurance -- accepted. Google “concierge practice” for the creepy details. When asked, these doctors insist that they’re not in it for the money which means that they’re in it for the money.

Building an office concierge practice from scratch takes a long time, but hotels are low-hanging fruit. Ambitious concierge doctors visit the general manager, something I never do. Even more effective is telling the staff that every call is worth $50. It’s illegal for a doctor to pay for a referral, and all deny doing this, but bellmen and concierges have begun hinting that, maybe, I’d forgotten something when I walked by on my way out.

I charge $300 to $350 for a housecall. Concierge doctors charge between $600 and $3000…. $3000?! Who pays $3000? The answer is: foreign travel insurers. Everyone in the world knows about America’s rapacious medical system so when an insurance clerk in Spain or Japan gets a bill for $3000, he probably assumes that that’s the going rate. This is no small market; insured foreigners make up a third of a hotel doctor's business.

At the lower end, American hotel guests will usually pay $600 to $1000, although they grumble. There is no free market in hotel doctoring as in all other areas of medicine. If guests want a housecall at a hotel served by a concierge doctor, that’s what they pay.

Crushing My Hopes

I didn’t recognize the number on caller ID, and when I heard “This is Adele from L’Hermitage” I nearly dropped the phone in my excitement.

L’Hermitage never calls. I serve many luxury hotels (the Langham in Pasadena is the most luxurious of all), but the celebrity Beverly-Hills-area establishments (Bel Air, Four Seasons, Beverly Hills Hotel, W, Beverly Wilshire….) as well as L’Hermitage pay me no mind. I don’t market myself, and plenty of doctors are eager to serve them.

The Beverly Hills Hotel is a borderline exception. I’ve been its doctor four times since the 1980s, making about 150 visits. Each period lasted a few years before a more entrepreneurial physician snatched it away. It’s been ten years since the last call, but I remain hopeful.

The L’Hermitage guest needed to speak a doctor, Adele informed me. Was I available? I was.

“I need help,” said the guest.

I listened, and my heart sank as I realized that L’Hermitage had not seen the light.

You can guess what had happened. His request rejected by L’Hermitage’s regular doctor, the guest was demanding that the staff find someone else. 

Recovering from my dashed hopes, I explained that I could not accommodate him. Going beyond the call of duty, I discussed his options, emphasizing that harassing the staff would not solve the problem. This was stretching a point because there are always a few doctors who would not resist.

Trusting the Guest to Take Care of Things

A guest at the Crowne Plaza was feeling under the weather.

The guest spoke poor English but, through the bellman, asked if I took his insurance: April Assistance. I did, adding that, unless he wanted to pay me directly, he must call April and ask for a doctor. Then April calls me.

After giving April’s 800 number to the bellman who passed it on to the guest, I hung up and immediately regretted it. I should have asked for the guest’s insurance I.D. and then sent him to his room. Then I should have phoned April to tell them a client wanted a housecall. They would have phoned him and then approved. I’ve done this in the past; when I’m lazy and trust the guest to take care of things, I often never hear back.

I called an hour later, but the bellman didn’t remember the guest’s name.

Advice

Note: I originally wrote this for hotel general managers, but any reader will learn a great deal.

Having a house doctor may be the best service you provide that doesn’t cost the hotel anything. Except… how do you know guests are getting good service? How much control can you exert over a doctor? The answer is: a great deal. You would never dream of setting your family doctor’s fees, choosing his office hours, or insisting he respond immediately when you call. Not only can you influence all these factors, you should. If you’re reluctant, here are some questions whose answers might unsettle you.

1. Is your doctor charging $600 a visit? It happens, and guests pay. But they don’t like it.

2. Is he liberal with phone advice, and how much does he charge? The answers may not be yes and zero, but they should.

3. How does he respond at 2 a.m.? Is he a bit testy? Does he send everyone to an ER or suggest they wait till morning? Does he tell your staff to summon paramedics even if there’s no emergency? You don’t want that.

4. Does the doctor, as he leaves, slip $20 to a bellman or concierge? That’s illegal but a tradition among hotel doctors. Your employees will never mention this, but you may not want them to choose your guests’ doctor according to the size of his kickback.

THE NATURE OF HOTEL DOCTORING

When I began during the 1980s, only luxury hotels had a “house doctor,” usually a local practitioner who did it as a sideline. Nowadays, in a large city even the lowliest motel receives blandishments from a dozen individuals plus several agencies that send moonlighting doctors if they can find one. “Hotel” doctors often acquire hotels by dropping by to extol their virtues to front desk personnel, perhaps with the promise of a tip. I got my start in Los Angeles writing letters to general managers, but this was 1983 when no doctor served chain hotels (Hiltons, Holiday Inns, Ramadas, Sheratons). Despite this, responses were slow; it was 1992 before I became a full-time hotel doctor, and there will never be another.

During the 1990s, half a dozen housecall services sprang up. Working from a central office with an 800 number, they accepted calls from around the US and then phoned a local doctor to make the visit. At that time, their base fee was about $200. The doctor received half but could keep whatever extra he charged for drugs and injections. Finding someone willing to make a housecall on the spur of the moment turned out to be difficult. Agencies quickly learned about me, so I made hundreds of visits for organizations with names like Hoteldocs, Expressdoc, Travel Med, and Medical Express. An agency that clears $100 per visit requires an immense volume to make a profit, so most have vanished. I once made visits for AMPM Housecalls which charged $350 per visit around 2001-2. AMPM Housecalls remains in business.

Since GMs hear about only the most disruptive problems, they underestimate how often guests want medical attention. A hotel generates one to three requests for a doctor per month for every hundred rooms. As an example, my records over recent years show that the Ritz-Carlton in Los Angeles (304 rooms) called me 77, 84, 83, 77, 100, and 66 times.

Guests who ask for a doctor want a doctor. They don’t want directions to the nearest emergency room or a list of clinics. In my long experience, about ten percent of Los Angeles hotels refuse to name a doctor because of liability fears. The hotel lawyer has explained that when a guest sues the doctor, he’ll also sue the hotel that recommended him. That’s right, but it doesn’t matter! Having a good hotel doctor doesn’t cause liability problems, it prevents them.

Here’s the scenario. A guest feels ill, consults the staff, receives a list of clinics, returns to his room to think matters over, and dies. Under this circumstance, lawyers will fall over themselves in their eagerness to sue the hotel. After all, the guest asked for help and didn’t get it. When I visit guests who need urgent care (it’s not always obvious), I take them to my car, drive (gratis) to a clinic or ER and usher them inside. This is not only good medicine, it’s self-defense. I’m responsible for that guest, but once he settles into another facility, I’m off the hook. Your staff could offer the same service, but they lack a doctor’s authority. When I decide a guest needs to go somewhere, I don’t take no for an answer.

THE RELATIONSHIP

In the old days, hotel staff summoned a doctor in the same way they summoned a prostitute. A bellman made a phone call, and the lady arrived. Departing, she stopped by the bell desk to leave a portion of her fee. This custom has not vanished. In my regular hotels, I was always aware of a few employees who called competitors because they wanted the tip.

Even in the old days, a European hotel’s doctor was not an employee, but these things were managed better overseas where general managers chose the doctor. This is clearly not the case in the US because I recall only half a dozen interviews in thirty years. Of course, hotels that chose me sight-unseen never had cause to regret it, but this was not invariably the case. Google Jules Lusman.

An encounter with a doctor sticks in a guest’s mind, so you should do your best to ensure it’s a positive experience. This means an interview and a check of credentials. To find candidates, phone other hotels to ask who they use. Any experienced concierge or bellman can provide names if approached tactfully. Asking your family doctor might help, but most doctors hate doing housecalls, and you wouldn’t want someone with a busy practice. Internet searches are skimpy (“housecall doctor” works better than “hotel doctor”). Your mail may turn up publicity from housecall agencies, but these are a crapshoot because they employ an ever-changing cast of moonlighters.

Determining a doctor’s competence is essentially impossible (fortunately most are OK), but you want to make sure there are no skeletons in his closet. Don’t spend money on internet companies that claim to uncover a doctor’s background. Simply do a search for “(your state) medical board complaints” to find a site where you can enter the doctor’s name and learn if he has come to the board’s attention. In California, this turns up http://www.medbd.ca.gov/Lookup.htm where you can check me out.

Then you or a trusted colleague should ask him to drop in. The interview shouldn’t take long; your guests will form an opinion based on a quick first impression, so why shouldn’t you? It’s a good idea to keep in mind the following.

WHAT GUESTS WANT WHEN THEY WANT A DOCTOR

1. When guests call the doctor, they should reach the doctor.

I’m amazed that physicians still use numbers that reach answering services, beepers, and receptionists. Mine reaches my cell phone. Guests love that I answer in person. Other doctors express horror that anyone can call my “home number.” I point out that hotel doctoring is a luxury service and expensive. Guests should get what they pay for. Since it’s also highly competitive, a GM should have no trouble persuading a doctor to respond quickly. It’s something you can check on by dialing the number now and then.

3. Phone advice should be free.

Lawyers agree unanimously that doctors should never, never give advice over the phone. Some obey, but you don’t want one to serve your hotel. More than half of guests who call me don’t require a visit, so this is no minor matter. Here you’re out of luck if you use a commercial housecall service, because the guest will speak to a dispatcher whose sole duty is scheduling a visit.

Every few months a guest will unpack and realize his or her heart medication or birth control pills are at home. They will be in despair, because they assume getting a replacement will be a tiresome, expensive process. They love hearing that the house doctor will simply phone a local pharmacy. I do that regularly, and I don’t charge.

4. When the doctor agrees to come, he should come.

Since competition moved in, my greatest source of new clients is doctors who take hours to show up. Patients will fume quietly in a waiting room, but hotel guests are quick to complain. Staff then call the doctor’s number, reaching the answering service who promises to page him. After a while they call me. In thirty years, no one has called to wonder where I am because I always tell a guest when I’ll arrive and call again to apologize if I’m delayed. This is such common courtesy that you should be deeply suspicious of any doctor who gets complaints. If asked about housecalls during the wee hours, all candidates will proclaim their eagerness, but your staff should keep a record of guests who ask for help late at night. You’ll soon learn if the doctor doesn’t like to get out of bed.

5. He should not charge an arm and a leg.

I charge $200-$250 during most of the day plus $50 for calls that get me out of bed. Guests at cheap hotels pay less. My only extra is for distant hotels which varies according to the distance and how reluctant I am to make the drive. I don’t charge for supplies or medication, and that includes injections. These turn out to be surprisingly cheap; I rarely give out anything that costs me over $10, and most guests get everything they need. My housecall fee is less than the going rate which is probably around $300 plus medication. Don’t assume this is because of my deep humanitarian instincts; it’s a rate that I feel comfortable quoting, and I’ll certainly raise it as time goes by. But it does cause resentment even among rival hotel doctors with whom I’m on speaking terms. They probably think I’m trying to steal hotels, but, if pressed, they’ll admit that hotel management doesn’t care what the doctor charges and most probably don’t know his fee. As long as patients aren’t complaining, management doesn’t don’t care. I’ve never acquired a hotel because my fee is lower.

Don’t be reluctant to tell the doctor how to run his business. An office practice may have several thousand patients. At my busiest I had forty regular clients and twice that many who called irregularly, so a single hotel represented a major source of income. No sensible doctor will ignore your suggestions. Here’s one that worked. Long ago, I charged $100 for a visit, but expenses were rising, so I decided it was time for an increase. Shortly after, I visited the JW Marriott in Century City, a regular. All upscale hotels and many chains will pay my fee, adding it to the guest’s bill (a good idea; guests like it, and it enables you to keep track). When I handed my invoice to the concierge, she examined it, hesitated, then said: “I see you’ve gone up to $120… Doctor Lusman stopped by a few weeks ago. He said he’d see guests for $100.” What could I do? Thereafter, guests at the JW Marriott continued to pay $100. Guests everywhere else paid more. Wasn’t that easy?

At midnight in the hotel restaurant, a guest asked the waiter to light her cigarette. When he complied, her finger burst into flame. She had recently applied acrylic nails, and the cement is flammable. The guest was drunk and abusive, and she refused to go to an emergency room… I’ll save that story for an essay in which I recount times I’ve saved a hotel’s bacon. This won’t happen often, but you’ll thank your lucky stars when it does.

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