The Health Insurance Illusion

I don't know. do a little research and see who's going to go first in the draft. >> I know draft order is like the most important thing. >> Yeah, if that you find out the draft order the day before your draft, there's no way you're going to like plan for it. You know, how do you plan for a fantasy football draft if you don't know uh when the draft order is or what the draft order is? >> There's a big difference in picking sixth or like first. >> Oh, dude. Total game changer for sure.

Um I honestly though I'm more I'm more interested in what the uh what the punishment is going to be for last place this year. >> Yeah, I've seen some interesting punishment throughout the years. You know, some people there's one the one we talked about was interesting where the the loser takes the SAT for the you know on a Saturday for six hours and just post their sports show how they did. >> I think I think that's a great one.

I mean just the humiliation alone, the nuisance of signing up for the test, dedicating a Saturday to go take with a bunch of high school kids. Um, just funny. >> Imagine walking in like there's a bunch of 18y olds, 16 year olds, 17 year olds, and you're walking in a 35year-old man that's uh >> here to take the SAT. >> Yeah. It's like, why are you here? I uh lost my fantasy football league. >> Yeah, just taking the SAT for fun.

Yeah, >> that I mean my suggestion was the you know the the the loser has to have a mustache only look but some people thought that was just a nice look to have >> stash only. Hey the stash is coming back man. More and more people are keeping just a stash. >> I don't know man. I think it's still creepy though. >> It's very super trooper vibe. >> I think it is. Yeah.

But yeah, but you know the fantasy football things like that, you know, keep you distracted from all the all the daily uh hustle and bustle of uh practice, you know, dealing with those uh prior authorizations. >> Oh gosh. No problem. >> You did you did a pretty big uh pretty big surgery this week. Did Did you have trouble with insuranceances with that one or >> you know that the insurance uh gosh the insurance game, the insurance nightmare, however you want to call it.

Um it's very annoying to navigate because like I I practice in a lot of different settings, right? I I'm in academic medicine, but we have a private hospital setting. Um I work sometime at the VA, sometime with the county hospital, uh the level one trauma center. And so, you know, each of those has its own unique insurance environment or a lot of times at the county hospital, lack thereof, a lot of those patients are uninsured.

I mean I think something at at the Houston hospitals like Ben Tob it's something like 90% of the patients are uninsured um which means the onus is in that setting on the taxpayers in the institution you know so like a big surgery like you're talking about you know we had a really large um shoulder surgery um and we need a very big graft a cadaavver an alligraph to reconstruct part of the shoulder and you know those grafts are expensive and there's a time constraint on them and getting them And it was a fight with the institution to, you know, buy it, pay for it, and have it ready um because it was needed for the patient's case.

And same things like that happen on the insured side that, you know, there's a special type of case or special surgery um that needs a custom implant or something like that. A lot of those can become fights with the insurance companies to really justify them paying for the care that the patient needs. The patient is paying into their premiums every month and paying for their insurance for a setting like this. Yeah. deal with it all the time. >> I mean, isn't it amazing though?

Uh, you know, just because I wish that was more prevalent where an institution like, uh, you know, where you practice and a county hospital which is tax fair taxpayer funded was able to pay for such big and lifechanging life-saving surgery. uh kind of like makes me feel like maybe that's where I want my taxpayer money to go rather than you know unnecessary things out there uh that you know we're engaging in currently.

But uh you know >> no for sure >> saving someone's life uh providing them with a chance and livelihood uh you know the um being able to be with their kids and if if my taxpayer money is going towards something like that where someone can get a new arm or new shoulder or a new heart because uh you know and they can live a better life because of that that's much more return on investment than anything out there right >> yeah I think you know when you see tangible benefits of where a taxpayer money goes.

I mean, it always helps rather than it's just it's kind of nebulous. Okay, I paid my taxes. What actually happened? What materialized from that? I mean, often you don't know. Often nothing. >> Yeah. Often nothing. Often useless projects or worse even wars. I mean, money is being used to kill people. That that is much more devastating and, you know, morale lowering for someone who's working hard paying taxes.

But when you hear stories that you told me uh you know someone's uh shoulder and scapula being saved after big cancer removal uh and then them having a chance to spend time with their baby. uh you know that's that's a huge that's the that's kind of like rewarding uh and you know that's the thing with uh the insurance is where a surgery like that would not be possible at a private uh practice institution where a physician was in private practice and was planning that kind of surgery.

It would not it would be possible but not uh too much incentive to do something like that on someone who's not insured. >> Yeah, totally. I mean, you know, that's the unfortunate reality that there's almost like in some cases a disconnect in the ability of a patient with a really complex or challenging problem.

Um, and the team that's able to handle it and do it because not all hospitals have the same resources and the same training level of providers, surgeons, nurses, the whole hospital setting. It's not just a one-man show. I mean, it's a whole team to to do a lot of the these complex reconstructive procedures.

And unfortunately, when the resources are limited, like a patient who doesn't have insurance, as an example, and if there's a very high-profile group or someone who can take care of them, and there's no one to pay, it becomes now a question of is this a charity case or not, or do you just not do the surgery? And then if it becomes a charity case, how many of those can you feasibly do in your practice?

You know, it's it's almost taboo and um kind of shun to talk about finances and money, but these things are real. That a lot of people I mean, I mean, I'm an academic, so I don't want to speak for anyone, but a lot of people in private practice, they don't do the same volume of highly complex surgeries because a lot of them for your unit investment of time don't always reimburse as well. And a big reason for that is the insurance game is skewed.

um the compensation models, whether you are RVU based in an employed model, whether you are collectionsbased in a private practice type model or some mix, they're very skewed to doing a high volume of relatively straightforward primary surgery. It's almost biased away from complex cases, revision cases, and things like that. I mean, what do you think? Do do you see that in the way you practice? >> That's exactly how it is in cardiology.

In cardiology there there are procedures that can take a long time. For example, you know, when someone has a chronic total occlusion of a coronary artery, you know, when your arteries are completely blocked, 100% blocked, those procedures can sometimes take hours and hours, you know, and um sometimes doing that case is equivalent to maybe just doing a couple of cats, but it would take 10 times as long.

Sometimes a hard cat can uh can be done in maybe 15, 20 minutes, sometimes less with someone faster. and uh opening a completely oluded artery uh which can be very helpful for some certain population uh uh can take a very very long time. So someone in private practice I mean they're not incentivized to do a 4 hour 5 hour long procedure 3-hour long procedure when they're going to get paid for doing two you know much more for doing maybe 15 simple procedures during that time.

So uh it's it is un the unfortunate reality of it and I think being uninsured in this country uh can be devastating you know especially if you develop a chronic illness. Um you know we both trained at uh county hospital. I you did your training part of your training at and and you practice at uh Benab and I uh did training at LBJ and University Hospital in San Antonio where uh we took care of a lot of patients that are uninsured and we provide the lifesaving treatments to them.

You know we there's patients that had no insurance but came in with you know uh complex conditions. They were able to get new valves. they were able to get new um uh stances in their heart, bypass surgeries. Um that gave them another 10, 15, 20 years to live with their family. Uh and if they were uninsured, that would be a lifelong debt as well. They'll keep getting bills from the hospital of a $100,000, $90,000 procedure they just went.

So, um being being uninsured can be very devastating, but insurance is also so confusing, right? A lot of people don't really understand what insurance they're signing up for. Uh and you know these these key words and jargon related to insurance like what is what is a premium and what is your co- insurance and what is a deductible and what is your out-of- pocket expense. So those are the things uh I think uh might we might be able to explain here a little bit right? >> Yeah for sure.

I mean you know the the landscape and the jargon is what makes anything complicated. It's kind of like when you read which no one reads. you go on a new website and you read like the end user license agreement. Everyone just scrolls and clicks it. But um you just hit I agree. It's like a knee-jerk reaction. I got to use this thing. I'm just going to click it. But the devil's in the details. I mean, you don't even really know what you're signing or agreeing to.

And a lot of times, I mean, I myself included when I got health insurance for myself and my family, I mean, I don't know every single aspect of it, every detail, every contingency. Like, god forbid if this happens, what is the reality? what is the maximum amount they'll pay? What what is my annual deductible and what is my co-pay expected for a PCP visit, a primary care versus a specialist visit? Is it different for me and my son who's a child? You know what I mean?

So all those all those things are very complex and I think in some cases, you know, not everything is with bad intentions, but in some cases things are purposely opaque because it allows people to pay more money for stuff that they don't know whether they need or not.

And so like the co-pay is a very common thing that almost everyone with insurance is going to do that basically you go into a visit whether with your primary care doctor or specialist in a portion of the bill you pay often upfront and a lot of insurance cards will say that like co-ay for visit $25 or and it'll sometimes have a distinction primary versus a specialist like 50 bucks for primary 100 bucks for specialist that number varies obviously depending on how good your insurance is.

Um so you know that that's a very common thing that basically everyone who goes and sees a doctor is going to have to do. >> Yeah. Yeah.

You know I truly didn't understand what insurance is and what each of these things meant until I started my own practice and then I had to kind of explain it to the patients you know and even maybe for the first 6 months man I didn't I don't think I truly understand insuranceances 7 months 6 months I was like okay let's just build to the insurance like what does that even mean? >> Yeah.

So, you know, like what do you mean like you the patient's going to pay or uh it's going to be I'm not going to get any money for this procedure I just did because I didn't collect money from the insurance like what or from the patient. What do you mean? So, the way it works is you know there uh first when you get insurance you see an amount a premium right? Premium is the monthly or the yearly amount that you pay to just get that insurance.

I mean that's for example they say your premium for the year is $6,000. That's what you're paying monthly or yearly to get that insurance plan, right? Then the next next big thing is um you know uh your deductible. Deductible is an amount set by the insurance and some of these cheaper plans, the ones that cost less have a very high deductible. Now the plans are very cheap because the deductible is very high. And what is a deductible?

Deductible is a amount set by insurance that the patient will have to pay everything out of pocket until they meet that amount. So for example, you you buy an insurance and it's $7,000 a year that you have to pay for that insurance, health insurance, right? Now on top of that, your deductible is $7,000. So for every expense you're making, uh uh you know, you're having to pay out of pocket. So, a physician visit, a cardiologist visit, your new patient visit is $189.

So, the cardiologist will bill to the insurance uh a certain amount of money and the insurance will say this is what the patient owes you $189. And the patient will have to pay out of their pocket. And those multiple payments of $189, $450 for procedure, 650 for imaging study, and those add up. And once you reach that $7,000 amount, that's when you meet your deductible, right? Then comes a co- insurance. Uh and co- insurance is the amount you pay once you met your deductible.

Uh an extra money that you owe. For example, they tell you in these high deductible plan, the patient owes 50% of the cost once the deductible is met. So not only they had a deductible which they had to pay out of their pocket $7,000. Now, their their imaging studies are only covered 60% or 70% or 80%. So, if it's a if it's a $2,000 study, 1,600 might get paid by insurance, but the patient will still have to pay $400 out of pocket even though they met their deductible, right?

So, all that out-of- pocket amount is co- insurance that they have to pay along as a percentage of what they owed. And the last thing is uh your out-ofpocket maximum. So once you paid all these extra costs that goes towards your treatment, then once you meet your out of pocket maximum, which could be another $10,000, that's when everything is covered. So a very cheap plan that you're maybe paying like, you know, uh $200 a month or $150 a month or even less.

A cheap plan is cheap for a reason because all the cost that you're going to pay towards is going to come out of your pocket. Insurance will not cover anything unless a huge expense happens. So what they're banking on is you're a healthy person. You won't have to go to doctors. You won't have an emergency. You won't end up having needing a surgery. So you have a high deductible. You'll pay these small piece primary care visits, uh maybe a specialist visit out of your own pocket.

Uh but it does save you against those devastating things where if you get into a huge car accident, have to go to a trauma center, get multiple surgeries, and your expense is $9,000. Now you only have to pay $7,000 deductible or out of pocket. and then you know and the rest is covered. So that's that. But there are some plans that are pretty good. They're they're expensive plans, but they're only plans where all you have to do is pay your copay.

So you show up to doctor's office, you pay $25 copay, and you get all the studies and everything else is covered. But then the premium was very high and and cost. >> There's a there's you know, and that's just like a brief overview of it. But it's stuff like this that makes insurance so annoying. And especially, you know, when you when you put it in context of real life, like I'll give you an example that happened to me earlier this week.

I have a patient, a 70 72 73 year old lady, and she fell about a week and a half ago just walking in her house. You know, she's active. She's older, but she's pretty active lady, not majorly sick or anything. Does all of her own stuff. Goes to the grocery store. Her and her husband walk the neighborhood. They take vacations now and then. normal normal pretty healthy 70some year old lady who fell and she had a really bad fracture dislocation of her shoulder.

She broke the humorris the proximal humorous and it dislocated. It's pretty bad injury. Obviously she she's in remarkable pain. She went to the ER. They tried to align it. They took the X-rays, gave her a sling and had her follow up with me. And so, you know, I see her in clinic and I talked to her and her husband that the this is a really bad injury based on your age, the amount of fragments of the fracture, all this stuff. The best treatment for you is actually a shoulder replacement, okay?

Which is not an uncommon treatment, especially for older people, to do a shoulder replacement for a bad fracture in the shoulder. It's stable. It helps with the pain. They get their motion back. Uh it's pretty reliable treatment. And so, obviously, we go through insurance and all this stuff like we do anytime we book a patient for insurance, for a for surgery, and the insurance company um denies the claim. The insurance company says that because all they're looking at is these checklist items.

They have the procedure code. In this case, the procedure code is just a shoulder replacement. There is not a distinction between I'm doing a shoulder replacement for just arthritis versus a fracture, which is a more urgent matter. All they see is shoulder replacement. And they say this patient has not done 12 weeks of formal physical therapy. This patient has not had a steroid injection. And so they deny it.

They say this is unindicated because the patient has not yet failed physical therapy and steroid injection. And I get the claim back and I was like, "What are you talking about? This patient's hummeral head is literally dislocated. The humorus is in four different fragments. This lady is miserable." And now we have to do this back and forth nonsense when the insurance company because they just have a default knee-jerk checklist. There's not really a human reviewing it.

And if there's a human reviewing, they're just looking at this itemized list that doesn't give them any information. So I had to do a peerto-peer. We wrote an appeal letter, but it's just again instant rejection. It was almost as if they hadn't even read the appeal letter, which very clearly said, "This is not a routine case. This isn't just someone with arthritis that I'm money hungry trying to sign up for a shoulder replacement. This person has a problem that can only be fixed by this.

It's a trauma." So, I had to get on the phone and I did a peer-to-peer with this person from the insurance company who was an employee of the insurance company. And I just asked him, I was like, "Are you still practicing?" And it turns out that they're a retired family medicine doctor who hasn't practiced in over 15 years. And I I wasn't even being rude. I was just being genuine with the person on the phone that to be frank with you, you're not my peer in this setting.

This is called a peer-to-peer, but you're not practicing and you haven't for 15 years. You're not a surgeon. You've never done a shoulder replacement. You've never treated a proximal humorous fra dislocation. How are you the designated peer from the insurance company who literally has the decision to dictate whether this patient's care is going to be approved or not into a payment plan? She has been putting in money month after month for year after year just for a situation like this.

And the person on the phone was just like, well, you know, we have these protocols. And I was like I was like, dude, forget the protocols. I'm telling you, this patient has a horrible fracture. Did you even look at the X-rays? Do you have the context for that? And and that's the issue with this insurance game and at homeu I'm sure you have examples so many examples of your own. I have numerous like this.

Eventually, thankfully, the patient's care got approved and, you know, I I was able to get her on track for the surgery and but this stuff happens so often and the amount of time and extra wasted energy to do this and this kind of lobbying back and forth, volleying back and forth of these issues and this discussion just to get our patients the right care they need because the payer in this setting, the insurance company just doesn't want to do it. >> Yeah.

I mean the pair uh insurance company is a is a corporation and their goal is to maximize their profit and their goal their um you know their loyalties lies lies towards their shareholders right in the end uh they need to see on S&P and NASDAQ what their next earnings are and you know uh and report to report to their board and the shareholders of why the earnings were less.

So their goal is to maximize their profits and not pay for things and maximize the profit by collecting as much money as possible from patients and paying for least amount of things possible. So is that's how that that is the nature of the the system we practice in. It is very frustrating um you know just uh basic things like getting a stress test.

I mean, you know, you I have to do tons of these peer-to-p peers with uh uh for stress testing and it's it's mostly a non-cardiologist on the other hand. And you can tell from right away from the first like sentence they say uh if your peer-to-peer will be approved or uh disapproved and a lot of times these these physicians on the other end they agreed they said yeah I mean you know it makes sense but this is what our protocol says and uh the protocol is in front of them.

And they said, "Oh, you have to do a basic exercise treadmill test first before you do a nuclear exercise treadmill test." But a nuclear stress test much more information about the heart's condition and the lack of blood flow than a just basic exercise treadmill test with an EKG only. Uh, and they always want you to do that first. And you know, it's like, okay, no, but that's not what I'm looking for. I'm looking for u, you know, I'm looking for eskeeia or lack of blood flow to the heart.

I mean, that's what more information I need.

this never they they're like yeah we get it we know but this is what our guidelines say so this is what you have to follow and it's a lot of times frustrating and I know a lot of doctors out there that have even stopped ordering certain tests because they're like it's not worth the hassle of waiting for the phone call getting on the phone it's not like you can just pick up the call and be like hey I want this approved you have to you know call them wait on the on the line someone from the staff has to stay on the hold for a long time give them all the information director they have to review it >> it's the worst they give you like a window as if it's like a repair for like someone's coming to repair your toilet at your house.

It's like, "Okay, we'll be there from 8 to 12, so just be available." >> It's not even that. It's not even that. Yesterday, I I had a peer-to-peer schedule at 12:15. My my clinic ran longer and I had two more patients seat. So, I was going over time and I was some patients needed a little bit more information about their procedure that I'm about to do on them. So, it's just longer. And at 12:15, my phone rang and I missed it because I was talking to a patient in the middle of the chat.

And that was my only opportunity to do the peerto-peer. And now my staff had to get on the phone again, stay on hold, tell them again, set up a new time. And luckily at 4:45 p.m. I was able to get on the phone and do the peerto-peer for a stress test the next day. So the patient was waiting, I was waiting, the staff was waiting, and uh at at the end of the day, we finally got it done. But it's just a hassle. And you know, it takes away from your clinic and patient care time.

It takes away from writing notes. It takes away from uh talking to the patients and and running your practice and it's it's just a pain. But and that's why Medicare sometimes it's it's easy, right? Medicare for me is a Medicare patient comes in, I order a test, it will get done because Medicare does not right now currently I mean I think in the future there are plans uh to implement prior authorization in Medicare but right now Medicare procedures and and tests do not require prior authorization.

So if I order a test on a Medicare patient, it will get done. Yeah, I'll get paid a lot less, but it'll be easy. It's easier to take care of those patients and requires less staff, less resources uh if you take care of Medicare patients, but just because because every year Medicare payments keep going down. So a lot of pat a lot of physicians stop taking Medicare because sometimes it's not worth uh uh taking those patients. I still enjoy seeing Medicare patients and I think for me they're easy.

Um but that's that's that's that's the key. You know, Medicare is government run. So they are not focused on profits versus versus um you know private insurancees or corporations and their their their focus is maximizing profits, right? >> Yeah. And that that's something that you know it's it's very frustrating for a lot of my friends who are in private practice. Uh I mean there's a lot of them that just straight up do not take Medicare.

Like Medicare patients are not seen in their clinics in their practices. they don't operate on Medicare patients. Um, and it's it's not that they dislike people above the age of 65. I mean, it's it's purely because of the finances that running a practice is running a business. And if you can't exceed your expenses with your revenue, you're not going to survive and you're not going to then take care of anybody.

And so, it's not just, you know, the the incorrect cliche that, oh, these doctors are just looking to make more money. They don't want to take Medicare because it doesn't pay as well. their practice and their overhead and their business model may simply not allow that. It may not be feasible to keep seeing those patients. It doesn't mean that they're cherry-picking just to be greedy. A lot of that is basically the finance like Hayo you're talking about, right?

That the Medicare payments, the reimbursement has historically been cut again and again and again. And obviously private insurance, these commercial insurance plans, they pay higher, right? They pay some multiples of Medicare. Um and so that that incentivizes people a lot. That's that's just the reality. >> Yeah. Yeah.

Uh like you know if you have 40 patient slots in a day and that's all you can see in one day and and out of those 40 patients if you're 10 of those patients are Medicare and but on the wait list there's 20 other private insurance p patients waiting to be get on your schedule. uh then as a business it's much more prudent to schedule only private insurance patients because the returns will be higher.

You'll be able to pay your staff salary, run, take care of your expenses and some practices depend on that because their overheads are very high. Uh they're paying, you know, the the cost of uh running a practice keeps going up. The regulatory agencies have put in so many requirements where you need to hire more staff to make sure you're meeting all the regulatory requirements.

Uh and uh you know and that makes a private practice very tough to do uh because uh just you know of something um you know maybe 10 years ago a medical assistant would get maybe paid 11 hours 12 $12 an hour $13 an hour and now it's hard to find a medical assistant for less than $20 an hour. Um so it can be it can be challenging and as as the overhead uh cost have gone up or running a practice the payments from Medicare have gone down.

So it's a inverse relationship and you don't ever see that something that uh you know I I remember 3 years ago when I started my practice an echo for through a Medicare uh patient and echo would pay maybe $210 or $212 and uh this year it's $195. So in what industry do cost of doing a service that the quality hasn't changed, the need hasn't changed but the price that you get reimbursed goes down uh and the cost of doing that service goes up.

Uh and because of that I mean um a lot of people are moving away from um you know these Medicare plans and you know these Medicare advantages are taking adv care of these taking advantage of this as well. Medicare advantage is pretty much private insurance is getting money from the government to provide health care for patients. So what they do is you know they say that you know for example uh uh blue cross blue shields Medicare advantage plan.

Now they say that we will you know take that Medicare signed money and use that to provide care for a patient but then they bring in all the private uh healthc care jargon in that where you do need prior authorization. there is a certain co-pay, there's a higher deductible sometimes, sometimes procedures do not get covered with these Medicare advantage plans.

So, it is government subsidizing these big corporations, but they're also running that insurance just like a Medicare uh just like a private insurance plan. Um so that's uh another complicated thing the Medicare advantage and they they keep growing and growing and I think there's a push from the current administration about making Medicare advantage more more uh prevalent. >> Yeah. I mean the you know in most things in a lot of things private privatization of stuff can lead to innovation.

It can make things more efficient um rather than nationalizing industries.

I mean we've seen that that's a lot of that is capitalism but you know it begs the question right and this is maybe like a bit of a philosophical and ethical question in addition to just logical but is privatization like this with health insurance in medicine really like the best way the right way and does it actually increase efficiency of care I mean I I find that in a lot of ways it decreases efficiency because there's so many extra checkpoints to hit for even what would seemingly be simple stuff comes in with an injury, they have a broken bone, they need to get it fixed.

Um, and like in the example I gave for the patient's shoulder placement, there's these roadblocks because the prior authorization, knee-jerk reaction of denial or just looking at a few um hot button items and keywords and buzzwords, you know, it also um adds work in the clinic and a lot of doctors, a lot of providers will purposely put information in the note for insurance companies.

It's almost as if the note is now like a ledger to justify what you're doing rather than actually just detailing the true purpose, the history and the physical of the patient. You you're putting all this stuff like like for example for interpretation of imaging like an X-ray for example, I can't just say patient had wrist X-rays that demonstrate blank a fracture the disadius or arthritis in the DRUJ joint.

I have to mention that three view radioraphs of the wrist were taken on blank date and they because there is just specific criteria that have been put in that will make the insurance company either accept this now as an added portion. You've reviewed the imaging or you didn't. And so it's almost like adding extra stuff every so often. Extra stuff every so often because some people won't catch on. Some people won't find out until later.

It's not like we get a list every week that here here's the new stuff that blank blue cross Blue Cross Blue Shield said or United said or Sigma said that you got to do. You just got to find out as you go and you find out when something is denied after the fact retroactively. Uh it's a it's a huge nuisance and it creates more paperwork, more time, more effort. Um it it delays you from seeing additional patients. Um it adds a big inefficiency I think in your clinical practice.

Yeah, it keeps it keeps getting harder to see patients and then you know there there's the other complication are different types of plans, right? So there's multiple types of insurance plans. So there there are HMO uh plans, there's PO plans, there's EPO plans. So you know patients should also be kind of educated about what kind of plan they're signing up for.

um you know HMOs are uh plans where there's a limited set of uh providers, physicians, primary care specialists that are part of a group uh a large connected group where they can only refer to p refer physi patients within that group.

So uh for a lot of the HMO plans, you need a referral and if you don't have a referral and you're not in the network, you cannot see that patient and if the patients want to come to you, they cannot because you're not part of that that that HMO network or the primary care does not want to refer to you. So that that is the HMO plan.

they tend to be a little cheaper, but because they're limited, >> you know, I I'll just tell you as a quick aside, like we see that nuisance so often because um I mean everything is so hyper specialized. Like for me in orthopedic surgery, we're so subspecialized in our thing. Like I do upper extremity stuff from finger to the scapula. And every now and then in the clinic, you know, like our goal is to get patients in if someone has something wrong.

So, I'll see someone like there's a patient with low back pain or sciatica or like a toe injury or something in the clinic and rather than wasting that patient's time and my time because it's not what I do and if they have like a surgical problem, I'm not going to operate on someone's toe or their lower back. Um, I have partners that do that and they're experts in that.

They went to fellowship for that rather than just switching them to my partner's clinic who a lot of them have clinic on the same day. The patients are already there. It would be immediately easy for the patient. No extra time, no need to reschedule their life, their work, their child care to come in and see someone on a different day. But then we find out, ah shoot, this guy's got an HMO plan. He's got a direct referral to me. We can't switch them.

We have to now contact the patient's primary care doc. They've got to send a new referral for the different provider and then they can see them. And often that doesn't happen that same day. And so because of the restrictions like Homaya you're talking about in a lot of these HMO plans that mandate a direct referral to that provider rather than a more generic referral to the orthopedic group or for this specialty care. A lot of times the care gets delayed.

They have to get shifted to another day or they end up being forced to see a provider that may not be able to meet their needs and now they've paid that co-pay plus they have to still go see somebody else. That that happens a lot. It's very frustrating. >> Yeah. And patients like wait I didn't even get care. Why do I have to pay the copay? >> Yeah. patient get pissed. They get pissed at us.

And even though it's the patient's insurance company who's making these rules for them and the patient doesn't even know it, we're often the first person to educate them about their own insurance plan even though we're not insurance individuals. >> Yeah, it's exactly their insurance and they they cannot even get in touch with the insurance agent who can explain to them what their plan means. Right. A PO plan for example, unlike HMO, you can choose any specialist you want.

You can go directly and bypass a primary care physician and go to a cardiologist, endocrinologist and orthopedic surgeon. And then the issue comes in where patients just completely bypass a primary care doctor and they only see specialists and then things like a basic uh flu vaccination or a colonoscopy referral uh gets missed because for them it was easy to just see specialists for the certain needs they had. Uh but and and the PO plans are expensive and you have to pay a ton, right?

There's a middle ground of EPO plan which is a limited network, cheaper plan and within the area where you you can go to any specialist but those can be very limited as well. So honestly there's no one good plan. Each plan has their own advantages and disadvantages. Um you know Medicare has its own advantages and disadvantages. Medicare advantages plans have their own advantages disadvantages.

But the the hard part is within this we as physicians are the ones who are having to deal with it and be on the front line and and feel the anger from the patients when they have a certain cost right I mean a lot of times for example we schedule imaging studies procedures uh nuclear stress test echo you know all these kind of tests in my office and u our staff has to be on the phone you literally there's there's to find out how much a patient will have to pay.

We have to stay on the phone, wait for an agent. The agent may or may not tell us the right information.

Sometime you talk to one agent, they tell you, "Oh yeah, the patient the allowable for this uh procedure is $150, but then you talk to another there's no collectible and there's, you know, a co-ay of $20." So you get sometimes uh deferring um information from the insurance agents about the plan the patient has and then you know that's that's when you have to tell the patient okay we're collecting $189 for this procedure but you have to warn them that this is just an estimate and once we send the bill to the insurance company they will send you an EOB with explanation of benefits that will tell you that this is how much was build this is how much the allowable was and allowable is something that the insurance says that that's all that the do this physician can bill.

So you know a lot of times what happens is a physician practices for example it's an echo cardiogram in my practice right and we build the insurance $650 and that's what they tell us that that's what you could build that's usually a negotiate amount right and then what the insurance says the allowable was $300.

So you you bill $600 and you get paid $300 and the other $300 is a contracted write off that you have to write off and you know but sometimes patients get a bill and they say oh you charge me $600 for this uh what do you mean that's very expensive and this is not what I got but you know this is that's no that's not what you got charged that's what the insurance was build the insurance paid $300 now you you know your portion is $20 and that's what you have to pay So just explaining that we get so many angry calls whenever statements go out from our practice uh from patients complaining but hey this is the insurance is telling us what to collect and what to what you have to pay.

This is not something we decide as physicians. We do not get to decide what we collect for a certain service we're providing. And we're probably the only industry where someone tells us how much money we can collect for a service we provide. >> Yeah. It's it's crazy, you know.

I mean, and you know, we were talking about this a little before we we started the episode about, you know, cash pay and essentially like getting out of this insurance strangle hold on the ability of a physician and a patient to enter a relationship and the doctor to provide the right care for the patient. Um, you know, more and more physicians are entering direct care models where it's basically transparent. The patient and the doctor know the price of services.

They discuss it and you know, you just decide, okay, I'm going in for my primary care visit. I want to get a battery of labs and this is the cost of this, this, and this. Okay. Oh man, money's a little tight right now. Maybe I won't get that one. You know, but it's just like an honest conversation rather than it for one being taboo to talk about money with your doctor and your patient. And two, the fact that someone else is paying and now it's kind of arbitrary.

I mean, like you're talking about Hamayu, like having to be on the phone and calling the insurance to figure out if a patient can get the service they need. I mean, patients come to my clinic with like a wrist sprain. We have wrist braces in clinic. I mean, how easy is that to just give it to them? Um, but now like in a lot of patients insurance plans, we have to like call the patient's insurance company and make sure that it'll be covered. And I mean, I like maybe it sounds bad.

I'll just tell patients like, "Look, if it's not covered, I mean, go to amazon.com or walk into a Walgreens and get one for like $12." I mean, it's just annoying that I can't give it to you here in clinic for that nominal fee because I'm your doctor and I have it. It's just so dumb. But I think that direct care model is a real interesting thing. And I I I'm happy to see it growing.

Even though that's not my practice model, I think it's awesome that some patients are able to do that and some doctors are able to practice like that because I think it it's very refreshing for the patient to one have the transparency and know I'm paying this much and this is what I'm getting. And for it to be immediate rather than now you wait and you delay and it's it's not necessarily a surprise bill. It's just a delayed bill. Everything in healthcare is a delayed bill.

Like you don't even know what it's going to be. It's like every time you go to a restaurant and every single menu has zero prices and it's like good luck and guess what it's going to be at the end. You know, some super fancy restaurants do that, but it's not the norm. That is the norm in our industry. That's a norm in healthcare. It's like you have a menu and you order a bunch of food and you just good luck whatever the price is going to be at the end. >> Yeah.

It's both from the physician side and the patient side, right? You the patient comes in and they don't know what their true cost will be for a procedure and they're maybe getting an estimated cost that the physician's office had to stay on hours on the phone with certain insurance company. Hey, tell us what will his echo cost? How much can we charge him? And then you get that cost and you put that on the patient's chart that this is what we need to collect.

And the patient comes in, they're paying the $180 that was told to their physician's office by their insurance company. And then two months later, they get a bill for another $50. Hey, this is what truly your cost was, you know, and and and even we don't know. We will get paid for a certain procedure we're doing or certain imaging study we're doing. We don't get we don't know. We can't plan for that.

I mean, they we we have a certain estimates and idea and it's all about the the rate you negotiate it, right? Right. I mean that's why small practices and smaller uh private practices that are on their own are having a harder time because uh in a lot of cities unlike Houston a lot of cities uh it's very hard for a private practice to get good insurance contracts where they can go in and negotiate with the insurance company. Hey, no, for this service, this is how much I want to get paid by you.

By you versus insurance telling them, no, for this hospital will make $5,000, but you will only make $500. And that's that's the unfair advantage a lot of these bigger corporate hospitals get because they can bill uh and charge and negotiate with insurance companies at a much higher rate compared to a private practice physician on a smaller level who cannot negotiate those rates.

It is very prevalent in a lot of east coast and west coast cities where physicians are completely priced out of private practice where in Texas and Houston is still possible because we have a lot of these physician networks and organizations where they where we can pull in our resources together negotiate together as a as a big group uh with insurance. >> Yeah. I mean it's basically it's collective bargaining you know just like the NBA did when the players got together.

Um it's the same idea and uh I mean it it's worked here in states like ours in Texas. I I think it's it's like a form of uh unionizing in a way and more and more states that are doing it. >> Yeah. Kind of. But you know the the it's moving away from that. I don't know what the future of medicine will be like because a lot of that will go away.

uh it will unfortunately get harder and harder for private physicians who are incentivized for providing good service because they want to retain patients and provide good care to patients. That will slowly go away and the corporate takeover of medicine will continue.

There will be some people that will you know try to be and not saying that big corporations cannot provide u good care but the incentives a lot of times different because the people who are making decisions are focused on bottom lines rather than the patient care and we're physicians it's our in our DNA to provide to focus on patient care. I mean there are bad apples out there. There's physicians that are completely uh profit focused and only care about money.

But most physicians, it's in their DNA to first focus on patient care and the the money comes with it, but patient care is more important to physicians that someone who went to got an MBA and all they learned is uh balance sheets and and and bottom lines. >> Yeah, for sure. I mean, even at the big corporate level, right?

Like I mean when we have our institutional meetings and and not just us I mean every every big institution you know we may not worry about like for instance when a patient comes and sees me in clinic being the fact that I'm an employee in an academic model a lot of times I don't even look I I have no idea what insurance the patient has.

I mean whether they're um Medicaid plan, Medicare, an HMO from United, PO from say I I have no idea because it makes zero difference to me in a meaningful way in terms of my practice because I don't get paid any different regardless of what insurance a patient has. I'm RVU based so I'm based on the unit of work that is assigned to each surgical code. Regardless of what insurance it is, that doesn't change.

Now my employer, my institution, the academic center or if someone's hospital employed for them it matters because the payer mix is a huge factor. The more commercial plans the more uh I guess you would say better plans right they have contracts with these companies and so the institution when they bill for the services and their facility fees they have negotiated much higher rates with some of these institutions.

So to them it's very advantageous to have a payer mix that is very high percentage commercial insurance rather than what's like government insurance Medicare or Medicaid because then the institution makes a lot more money even though the individual employee doctor like myself this model sees no meaningful difference has it has no bearing on my practice it definitely has a bearing on the institution and that that's really what dictates a lot of the advancement and growth of these institutions where they have these satellite clinics all over the place They often will have a lot of little clinics and access points in affluent suburbs because those affluent suburbs have a very high percentage of commercially insured patients and professionals that live there.

Therefore, those people have insurance. They're going to go and see doctors with their insurance plans. And now for that same care, that institution is going to make relatively more money for the same care provided compared to someone who might have had a Medicare plan or a Medicaid plan. That that's very relevant for the institution for sure. >> Yeah.

No, I so you know for me I I always whenever I'm seeing patients and about to order certain tests for them I always open up their insurance benefits and see how much will they have to end up to pay and every time I see oh $20 covers all their studies I'm like okay well great I mean you know you won't have to pay as much for this you know I always keep that in mind because uh you know I'm seeing a patient and if I just blindly order a stress test and echo and a halter monitor and a cardiac CTA and I just blindly order it the patient will end up having a huge cost and they won't know what to do, what not to do.

Uh sometimes not everyone has that affordability. So I always uh tend to have that discussion with patients especially those with a very high deductible. Hey, you know this is the test I think we should get because this is will give us the best answer but this these tests will end up probably costing you around this much money.

the second best option which is a little cheaper but will maybe give us some good answers is doing these two things instead where it's not as ideal but the cost will be lower. Now I let you decide what you think is the best based on your finances because in the end you will have to pay.

Now a lot of times you know I I do that because I personally when I'm seeing patients and I hear about how much they will owe for this procedure I and I hear they oh they cancelled that because they couldn't afford it. I just personally feel bad and I'm like, I wish it didn't cost that much. And a lot of time if it's in my control, I I tell my office that, hey, why don't we give them a little discount? Why don't we do maybe a 50% discount on their co insurance? Yeah.

If they they owe $800 for the cycle, why don't we cut it down to $400 just so they could get that study? Because I can make that decision being being in ownership in my practice. But then it can get a little dicey as well. I can't do that for everyone because that will that can get me in trouble with the insuranceances. It can get me in trouble with uh the government because it's anti-competitive.

I'm I if I do that on everyone, I'm undercutting uh other competitive cardiologists that will not be uh offering the same kind of cost cutings or discounts, right? So, you can't do that for everyone. You have to pick and choose if a patient truly needs it and they really can afford it.

knowing their situation, knowing their financial situation will help me decide, okay, this is maybe I can cut the cost for you, maybe give you a payment plan, maybe write off that Echo and give that to you for free just so right now let's get it done and maybe you can think about paying for that in the future. But I can't do that completely just, you know, cut down the cost for everyone.

So that >> which is which is so ridiculous if you think about it in like the context of all other small business in the United States. What other small business is there in America where the government and insurance companies can actually tell you that you're not allowed to charge your customer less? >> Yeah. >> Like you like the you have to charge them more otherwise you're in potential violation of antitrust and kickback statutes. It's ridiculous to even even think about it that way.

But that that's really what's happen. The insurance can take away your contract and they can kick you out of their insurance plan because you've been you've been doing that. And that's not fair to other doctors who have that contract as well and they signed that contract of collecting that much money from a patient. And and I want patients to know it's not that we're deciding the the high cost that they have to pay.

>> Uh it's pre-negotiated the the insurance contracts that every physician enters, every group, every practice, every hospital, every academic group, everyone enters into a set contract with a full list of stuff. It's predetermined. It's not arbitrary at all. Yeah, >> it's not. And and and getting that information because you may have a Blue Cross Blue Shield plan.

You might have a United Healthcare plan, but there's 10 different variations, 50 different variations of a United Healthcare plan or Blue Cross Blue Shield plan where a different employer agreed on different different uh numbers and different deductibles. So, there's no one plan and I might be in network with Blue Cross Blue Shield with 10 plans, but there could be one plan in Blue Cross Blue Shield that I'm not in network with.

And then the patient said, "Oh yeah, you told me you're in network with Blue Cross Blue Shield, but now your office is saying you're out of network. You wasted my time by telling me yes, you were in network. What does that mean?" You know, and it's hard to explain to patients, hey, no, this is not how it works. I mean, this is not as simple. It's not just, yeah, take my money and and treat me. I wish it worked that way.

And you know, honestly, >> you know, if it if it worked that way, then we would be like dentists. I I really think in this sense, I'm not even kidding. And I I am you know applauding the dentists in this that they they have really maintained control of their relationship with their patients far better than we as doctors have. Um like when I go to the dentist I mean I have dental coverage or a small element of dental coverage as part of my overall healthcare plan.

Um but if I want anything extra it's such an honest I just ask my dentist like hey how much is that going to cost? you know, they always ask you like, "Do you want this extra fancy super fluoride whatever on your teeth?" And I was like, "Uh, I don't know kind of what you just told me, Omayo, in your practice where, you know, here's the one study that's probably ideal, but it costs blank. Here's the next tier that costs blank." That's not at all as easy across the board in medicine.

But in dentistry, I mean, they'll just tell you, "Yeah, okay, this one's like 130 bucks. This one's 80 bucks. This one's this. We could do that." And dentists routinely will give discounts for people that don't have dental insurance. It's just a it's a very common thing. Um, and they're not restricted in any way. They're very open to provide this the care they want at the price they want and they can meet patients where they can get the care.

I I think that's a beautiful model and I I really wish more of health care um for doctors was like that. >> Well, you know, and physician plastic surgery works that way, right? I mean, >> yeah. And cosmetics and cash pay it does. Yeah. aesthetics and cosmetics.

You know, if someone wants a a breast implant or a BBL, like they will pay cash pay, but when they come to for cardiac clearance and I need a an EKG, an echo cardiogram, and their insurance will not cover that, paying that much money is it's a little hurtful because something that you cannot see uh your cholesterol, your hypertension that is not outwardly as appealing or aesthetic, uh maybe it's a little hard to pay that kind of money for.

And but if you're getting a you know something externally um um aesthetically beautiful uh like you know beautiful teeth or a beautiful nose or you know a nice butt like you know that's that's worth paying for sometimes. >> Oh for sure. I mean it's a sense of identity right like you know it's vanity which all of us have to some extent and it's your identity. It's your outward appearance is what people see. Yeah.

But yeah, I mean we can keep going on on this insurance because this is a daily frustration and it's a it's a major cause of burnout for a lot of patients. I mean we we previously talked about physician burnout and you know uh dealing with insuranceances, dealing with uh dealing with having the staff deal with insurance. Dealing with the patients who are angry about their cost is is a big part of burnout.

And you know the in in an ideal world a patient would come in, they won't have to pay a single penny to me. I would treat them the way I want them and then everyone goes home happy. But that's we don't live in utopia. >> Yeah. Amen to that. Amen to that. Well, all right guys, thanks for tuning in. We'll catch y'all later. Two >> dots, one mic.