Unveiling Doctors' Struggles: Pioneering a New Era of Empathy and Reform in Medicine with Dr. Scott Ellner

Transcript

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Hey everyone, welcome to Exploring Health Macro to Micro.

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I'm your host, parker Condit.

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In the show.

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I interview experts from all areas of health, and this can be in areas you might expect, like exercise, nutrition and mental health, while other topics may be in areas that you're less familiar with, like understanding how exactly our healthcare system works and the toll it takes on our doctors, and that's something we go over in today's conversation.

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My guest is Dr Scott Ellner, who's a general surgeon and healthcare executive.

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Dr Ellner is a doctor of osteopathic medicine and holds a master's degree in healthcare management from Harvard University, among a long list of credentials which can be found in full in the description, and I think this will be an interesting perspective for a lot of people to hear, because it's easy to rail against the healthcare system here in the US, and a lot of times doctors sort of get lumped into that negative light, probably unfairly, and I'd say more often than not they're just as unhappy as their patients being stuck in a system that is less than optimal, to put it lightly.

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So today you're going to get an insider's perspective and hear what it's like from the doctor side, and we start off with a very under discusseddiscussed topic, which is physician impairment, and that's understanding what happens when senior and well-respected doctors start declining mentally and it starts putting patient care at risk.

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We later go into reimbursement models, which is how money moves in the system, and if you want to understand how decisions are made in the healthcare system, understanding how the money works is a crucial first step.

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And then, finally, we get into some current events in healthcare and we talk about where we see things going in the future.

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So by the end of today's episode, I think you'll walk away with a better understanding of how money flows through the healthcare system and you'll also be able to bring more empathy to the doctor-patient relationship, now having a deeper understanding of the physician side of that interaction.

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So, without further ado, I hope you enjoy my conversation with Dr Scott Ellner.

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Dr Scott Ellner thanks so much for being here.

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Great to be here, yeah.

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So today's conversation as kind of consistent listeners are probably going to understand or are going to have an understanding of, most of these are around the patient side or the consumer side, understanding the healthcare system and you know, I think, rightfully so I bring about a fair amount of criticism to the healthcare system and there are certain things that you know require to be called out.

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One of the things I don't think gets enough attention is understanding the medical side from the medical doctors, understanding the empathy and the compassion that's required on that side because they're also operating in a healthcare system that is obviously not ideal.

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You have a handful of stories and anecdotes that we're going to go through to get a better understanding of that side, and that's where I think we're going to go through to get a better understanding of that side and that's where I think you're going to offer a really unique perspective.

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So I'd love to start just getting an idea of how you describe physician impairment, because I think that story is going to encompass a lot of the relationships that are involved with the education within healthcare and then also understanding just kind of the frame of the rest of the conversation.

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So I think starting with understanding physician impairment will be a great place for us to start.

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Sure, and I appreciate you bringing up this topic.

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It's an important one.

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We've seen the issue of physician impairment become ever more so present, actually because of the pandemic, and I want to just remind the listeners that physician impairment doesn't mean you can't perform your duties well if you have a chronic disease like diabetes, or you have some sort of physical type of disability.

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Impairment occurs when you cannot perform your duties in accordance with the ethical obligations of the Hippocratic Oath do no harm.

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And the challenges that we're seeing with healthcare not just with physicians but also with other healthcare professionals is that the stress, the administrative burden, the challenges with something such as workplace violence are actually creating an environment where healthcare professionals are feeling more stressed out than ever.

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They're suffering from mental health issues, behavioral health issues, sometimes they resort to illicit drug use, such as opioids, and becoming addicted to painkillers and alcohol abuse.

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And then there's this loss of the idealism of why many of us went into healthcare, and that was to really serve people, to serve vulnerable populations, care for others, to improve their health.

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And when the stress gets so intense and, by the way, on average most people do experience some form of stress 10 times a day, whether it's traffic, whether it's finding a parking place, whether it's having an argument In healthcare, particularly working in a hospital, it's 10 times an hour.

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So the level, the intensity of that stress caring for people and then forgetting to care for yourself leads to impairment and we've seen this with, unfortunately, with physicians went into their professions to serve a calling.

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But with all the challenges that we're facing today and we'll go into more detail about those challenges there are sometimes issues that arise which you know we need to help.

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We need to care for our healthcare workforce, essentially, show compassion.

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Yeah, exactly, I think that's a great point and it's just so often.

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I've talked to so many doctors and it is exactly that they they're just as frustrated that they can't practice medicine in the way that they want to that best serves patients.

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But again, it's just we're operating in the system that doesn't necessarily facilitate that as well as they like or at all.

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Can you give an example of physician impairment, just to kind of bring this kind of bring this concept down to earth for a lot of people impairment, just to kind of bring this concept down to earth.

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For a lot of people, yeah, this is, and again I want to stress, you know, physicians can perform with having disabilities or other chronic diseases.

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Impairment is when your emotional balance, your well-being, gets to a point where actually there's a risk of creating harm harm toward the patient, harm toward the healthcare professional themselves or to the people around them.

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And so let's talk about anxiety and depression.

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We saw mental health became an important issue and continues to be a very important topic to discuss in relation to supporting our healthcare workforce because of all the demands put on them.

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Supporting our healthcare workforce because of all the demands put on them.

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When depression starts to set in and I'll be honest, you know, as a physician myself, I've experienced episodes of depression you start to lose that drive, you start to lose that ability to stay focused on doing what's right for the patient.

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You're just trying to survive and get through the day, and it may be because you're overwhelmed, it may be because you're having stress at home, it may be because you're not feeling fulfilled in the work that you're doing.

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In the work that you're doing and you're actually at risk of people suffering harm and what we talked about a lot, particularly with situations that occurred during the pandemic, was moral injury, feeling like we just could not perform to our absolute best level or potential to serve our patients, and it creates this perpetual cycle of not feeling good about yourself, not feeling good about what you're accomplishing and then losing your desire to actually do what's best for the patient.

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Your desire to actually do what's best for the patient.

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Mental health is one issue.

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When you resort to substance abuse we saw in my experience.

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There was a colleague who was addicted to opioids.

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He was having a nurse practitioner in his office actually write prescriptions for him because he had low back pain which he developed from a weekend outing playing softball changed.

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He became incredibly short with his staff demeaning, belittling in some instances and then actually started having relationships that were inappropriate with patients.

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Of course you know when it gets to that point people need to call that out and people need to address it because it will not only perpetuate but it will or other people.

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It's unacceptable.

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But you have to realize there are factors that lead to this happening.

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So, generally speaking, I mean, I'm sure this can happen at any point in your career, but do you find it happening later in your career, with like cognitive decline and just sort of a compounding effect of this high stress situation constantly being kind of imparted on the physician?

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So that's a good question.

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So as we talk about the more senior physician, as they get toward the twilight of their career, so I want to separate that out a little bit because I think that's important.

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We in residency, as a surgical resident, I was the chief resident in a very difficult esophageal case on a 21-year-old young lady who unfortunately had problems with swallowing, and my attending surgeon at the time was 84 years old, Well regarded globally, known for his work, and I could see he was struggling.

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He was struggling.

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It was a difficult case and it was hard for me to watch and I also knew we had a young lady on the table here and every stitch that you place, every suture to repair that esophagus and this was a redo case, so it wasn't like it was, you know, new tissue.

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This was a difficult case because he was renowned for his work in this area.

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You had to be precise and I knew he was struggling and it wasn't because you know of anything more than just at that point.

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Your ability, your dexterity, your even your judgment isn't what it was in your 30s, 40s.

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So I made a very, very tough decision to ask the nurse quietly to call one of my other attending surgeons to come in to help.

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That's difficult to do.

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That's difficult when you know somebody who is incredibly well-respected within their field and has done great things, has published hundreds of articles, and then you have to surreptitiously go around and ask someone to step in for them.

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It's like an athlete.

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It happens in pro sports Same thing.

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They're just not on their game.

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They're not in the flow state like they used to be.

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Yeah, but it's hard to, as a rookie, tell the superstar athlete on the team that you know they're not, they're not the one carrying the team anymore or anything like that.

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Even even a coach can be in a tough position there.

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To bring it to the sports analogy, so that that's a case where you described, uh, where action was taken, and to be a resident, um, and to be able to do that I'm sure it takes a lot of courage.

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Can you describe the relationship between residents and attendings, because that dynamic can lead to what I want to get into next, which is going to be a situation where nobody says anything, which probably happens quite often.

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But I think if you can start with describing sort of the power dynamic within the medical education system, I think that'd help frame the rest of the conversation.

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Yeah, at least when I went through medical school and residency, which was the late 90s 2000s, it was before there were work hour restrictions, fully work hour restrictions, which I think now, looking back, is a pretty good thing in some ways and maybe not so great in other ways.

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But the most important aspect of training in different medical specialties is this authority gradient.

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As a medical student, you are essentially on the low end of the totem pole and you're there to learn, you're there to listen and the ability to speak up.

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It can be scary because you don't want to look bad.

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You're also being graded on your performance and sometimes you're being asked a lot of questions.

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The term we use is pimping, which is you get pimped on questions and it's weird, but yeah, that's what they use as a term as a resident, as an intern.

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An intern is a first year resident.

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Again, you go right back to the bottom and then, as you ascend throughout your residency and eventually become a chief resident, you still have to defer to your attending.

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Now the attendings also have their hierarchy where you have junior attendings and you have more senior, and then you have the luminaries, you know, who are well regarded in different societies and who have published and there's a term I want to use that I think is really important, that that needs to be emphasized, and it's called psychological safety.

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I want to make sure I'm correct here.

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I believe it may have come from Amy Edmondson out of Harvard, who really studied behavior around how people interact in group settings when there is a need to speak up, and many times there are situations where somebody is about to maybe operate on the wrong body part and nobody speaks up because there's a fear of actually speaking up.

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Can you imagine that happening on an airplane?

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Can you imagine that happening in any other industry?

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Are you familiar with the checklist manifesto by Atul Gawande?

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I very much am yes Okay.

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Yeah, so I think it's examples in that book that they ended up taking in the medical field A lot of the protocols from the aviation field for that exact reason, like I think now it's like you you mark appendages with a Sharpie prior to surgery to to avoid things like this.

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Well, and actually Atul Gawande was somebody that I highly respect and did a lot of my research after using the surgical safety checklist in the operating room, because I think that checklist saves lives, and the whole approach of going through a pre-briefing and talking about the case beforehand and then doing what's called a timeout before you do anything on a patient to ensure that you're doing something in the right location is incredibly important.

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And then afterward you talk about it what went right, what could we have done better and then afterward you talk about it what went right.

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What could we have done better?

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But it's important to have the comfort where anyone in that room, regardless of their status on that authority grading, can speak up, particularly if they see something that's not right.

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So it's a tough dynamic.

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Right Because obviously the medical field has evolved so well, because knowledge has been passed down in a very deliberate way, and one of those ways is through this sort of gradient of the more senior leaders within an organization passing that information down in this particular way.

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But at the same time, how do you maintain that authority and that structure for the education and sort of the order of the operation but still have people feeling safe enough to speak up in these situations when you know it's very easy to be in that room, especially with a very esteemed senior leader, and you see them doing something wrong, but you're like everything else in your mind is like, it's like the halo effect, right, where you're like they can't possibly be doing something wrong.

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Right, they know so much, they know so well I must be mistaken on which leg we're supposed to be operating on.

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So it's a very tricky problem.

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Have you seen progress in, I guess, since then?

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Because you've worked as a healthcare executive so you've kind of seen different sides of this and how administering policy can help improve.

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Have you seen improvements in this case, since you were a resident?

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Yeah, it's a great question.

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Absolutely, and I think so just to let the listeners know it's much safer today to go into the hospital and have your interaction with your physician, whatever it is because of people like Atul Gawande and others who have promoted what's called high reliability principles or high reliability organizing principles, and these were tools that were adapted from the aviation industry, the nuclear power industry in order to ensure that in high-risk environments like healthcare, we implement programs where, if you see something, the approach we teach people.

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In my last few health systems that I ran, we taught people how do you speak up.

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The best way to do that is to ask a question or say I have a concern, and it's a way that doesn't escalate to the point of creating tension.

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It's a way of escalating to the point of creating inquiry and allowing people to have a conversation.

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So, looking back today with the older surgeon that I was in that case around the esophagus, I probably would have said, instead of behind the scenes asking the nurse to call my attending, I probably would have said to the senior surgeon Dr So-and-so, I have a question.

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Is there something that I can do to help you?

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Is there something we can do to address this situation I'm seeing a lot of blood, a lot of blood and do it in a non-threatening way that maintains dignity, respect and the authority.

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It's almost like searching for clarity versus conflict.

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Absolutely, and I think that's where we get into trouble many times is, instead of approaching that in an effort to define clarity, we create conflict and then that creates tension and that leads to sometimes bad behavior.

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So going again.

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I want to go back to the situation where something doesn't get said and there there doesn't, it being like a very adverse event for anyone who's in medical school or residency.

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Is there adequate training?

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Maybe you can speak to when you went through it and maybe where we are now for dealing with like the emotional toll of possibly losing a patient in a situation where it wasn't it was just a tough case, it was more of a case of I didn't say something when I could have, um, because, yeah, having all the school, uh, the tools and the skills required for whatever specialty you're going into as a medical doctor obviously required, but this seems like one of those things that happens and probably I mean I've just seen like the lack of nutrition training going through medical school.

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So is there adequate skill training around emotional resiliency and emotional tools to deal with loss as a medical doctor?

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You know, parker, that's such a great question how do we teach the younger generation of healthcare professionals physicians, nurses, those who are going into the allied health professions to deal with loss and to develop resilience or hardiness?

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I would say there's so much information that we're trying to learn today, and then, on top of that, add how to document appropriately in the electronic health record, which has only added more of an administrative burden.

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I think the skills to teach people how to be resilient during tough times is sort of overlooked.

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There are some organizations and training programs and schools who are now thinking about emphasizing I don't want to call them soft skills, because they're they're not.

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These are important skills that that uh are that's fine.

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That's a term that people can latch on to.

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Right, but the but, the reality is um.

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First time you see someone die and they're under your care.

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It's heartbreaking.

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And I remember, I vividly remember, a patient, a 47-year-old man, who I was caring for.

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He was actually seeing me because he was interested in weight loss surgery, but he was having pain in his right side and we did a CT scan after a few weeks and it turns out he had a metastatic colon cancer.

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So colon cancer had spread to his liver and he died not even six months later.

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And I remember talking to his wife and his 12 year old daughter just before he was passing, explaining to them that there was really nothing more we could do.

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It takes a toll on the clinician and you know it's okay to cry, it's okay to to show emotion, it's okay to be sensitive in those instances because you care and, uh, we, we don't have to always be desensitized, because I think what that does is it hardens us to the point where we become cynical.

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We lose our our purpose or sense of purpose at times have you found that there's ever environments that don't necessarily facilitate the, the compassion and the ability to feel your emotions, and then people do end up getting desensitized and cynical and then you end up seeing people exit the industry.

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I'm thinking more examples in nursing than physicians, more so around like the pandemic and also issues around like safe staffing ratios.

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The example that kind of comes to mind is not in directly, where there's somebody under your care but a nurse couldn't do everything that he or she would have wanted to because the staffing ratio wasn't adequate in a particular facility.

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So are there issues like that as well?

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Of the epidemic is the ability to create the appropriate levels of staffing so people aren't so overwhelmed that they feel like they're not doing their best.

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And even before the pandemic I think that was starting to happen.

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And what the health systems are facing today is workforce dislocation.

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We're losing really strong nurses who love what they do, but the financial dynamics don't make it easy to continue to support the labor force, because it is the number one cost for health systems is labor, and to strike that balance and have the right ratio so that people don't feel overwhelmed and are working to their highest potential.

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It's difficult to navigate that fine line and I think that we saw the requirement of bringing in a lot of outside contracted labor into the workforce because a lot of people left.

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Some of them are coming back, but still it's incredibly difficult to recruit people into the healthcare profession because they know how difficult it is.

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So we're now parlaying into the financial side of things, which I think is required for people to understand the dynamics of the healthcare system.

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So physician burnout or healthcare professional burnout, physician impairment, do you think any of that's related to I mean, it has to be related to the financial model that we're operating in.

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I think it'd just be easiest if you first describe the predominant payment model of fee for service within the healthcare system and then we can kind of talk about how that influences decisions, kind of up and down the board.

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Talk about how that influences decisions up and down the board.

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Yeah, so to make this, just try to a service whether it was a primary care visit, whether it was performing an operation, you got paid.

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You got paid a certain amount.

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That's called fee for service.

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So you provided a service and then you were reimbursed.

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Reimbursed is not the correct term either, because reimbursed means that if you take everybody out to lunch and it's on the company, the company will reimburse you for the full amount.

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That doesn't happen.

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Instead you get a payment which could be maybe 60% of what you charged.

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So again, there's some nuances there.

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So fee for service is you charge a fee and you get paid a certain amount from a third party.

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Typically it doesn't come directly from the patient.

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Now the patients do have to now pay co-pays.

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They have a deductible, have to now pay co-pays.

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They have a deductible, which is incredibly expensive now.

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But the reason why fee-for-service and the mechanism of how healthcare has evolved into this payment structure really stems from the early part of the 20th century, back in the early 1900s, with the development of insurance, employer-sponsored insurance programs.

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So essentially the medical care that people were receiving over time was other people's money, and so today we're trying to combat healthcare expenditures and the costs.

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By 2030, the healthcare expenditures will be over $7 trillion 20% of the US GDP.

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Despite challenges in those rising costs and trying to provide value in healthcare, we continue to outspend other countries.

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So the fee-for-service model while I think it can work, what it does lead to also is sometimes something called unnecessary medical services.

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So doing things that quite aren't really necessary.

00:32:49.244 --> 00:33:11.789
I think there's nuance there as well, because a lot of it can be done defensively, because we also live in a very litigious country where there can be procedures done because there's a potential risk a few years down the line that you as a physician is going to be on the hook for missing something on a CT scan, right when somebody comes in with what you think is dehydration and you you miss an aneurysm or something like that.

00:33:11.789 --> 00:33:16.757
Um is also on the financial side.

00:33:16.757 --> 00:33:23.335
There is a responsibility on the population of loving to take people to court and taking doctors to court.

00:33:23.335 --> 00:33:25.185
So there's that side of it as well.

00:33:25.185 --> 00:33:28.653
So that's fee for service.

00:33:28.653 --> 00:33:33.108
There's a shift towards something called value-based care or value.

00:33:33.108 --> 00:33:42.526
Can you describe that, and maybe I'd love to actually just hear your thoughts on value and what do you think that's a viable solution, kind of moving forward?

00:33:44.309 --> 00:33:44.490
Right.

00:33:44.490 --> 00:33:58.967
So value-based care really came out of work that was done through the Affordable Care Act and, by the way, the Affordable Care Act wasn't really about affordability, it was about improving access.

00:33:58.967 --> 00:34:15.858
So value-based care is now you get paid for the value you provide to the patient and the value equation is the outcome divided by the cost.

00:34:15.858 --> 00:34:24.199
So if you have high quality, a great outcome and low cost, that increases value.

00:34:24.199 --> 00:34:28.355
And so the payment models.

00:34:28.474 --> 00:34:49.949
Now today and we'll talk a little bit about Medicare, because I think that's important to discuss Medicare is moving from a traditional approach, where it's fee-for-service, to now Medicare Advantage, which is a value-based product that is run by commercial health plans.

00:34:49.949 --> 00:34:56.056
That incentivizes physicians to provide value.

00:34:56.056 --> 00:35:17.637
So the physicians are paid based on their performance, on managing chronic diseases or keeping people healthy, keeping people actually out of the hospital and potentially performing less and thus by lowering costs.

00:35:17.637 --> 00:35:28.110
So Medicare fee for service or the traditional Medicare, which was passed in 1965 in the Social Security Act was you do something, you get paid for it.

00:35:28.110 --> 00:35:40.878
Medicare Advantage, or value-based care, is today we do things that will bring value, hopefully will bring value at a lower cost and will provide high quality.

00:35:42.945 --> 00:35:44.789
So it sounds like on the surface.

00:35:44.789 --> 00:35:48.597
When I first started learning about this, value-based care seems like a great proposition.

00:35:48.597 --> 00:35:51.114
I also really enjoyed the idea of Medicare Advantage.

00:35:51.114 --> 00:35:52.851
It also seemed like a great proposition.

00:35:52.851 --> 00:36:09.315
I have concerns about Medicare being shifted towards private companies or in the form of Medicare Advantage and the control kind of going away from the government to these private entities for our aging population.

00:36:09.315 --> 00:36:15.097
I also have concerns about the financial incentives in that model as well.

00:36:15.097 --> 00:36:26.945
I guess at a very surface level, fee for service encourages more procedures, more things to be done, because that's where the revenue is tied.

00:36:26.945 --> 00:36:39.130
On the other side, value-based care sort of incentivizes less things to be done and you can kind of keep more money, as long as they don't end up having a really adverse event like ending up in the hospital.

00:36:39.130 --> 00:36:53.695
So maybe if you can just speak to a little bit more depth about the good and the bad of value-based care, Well, I think you described it pretty well.

00:36:53.885 --> 00:37:18.583
So, as we transition, or try to transition, into value-based care delivery, the idea is to minimize the amount of care services medical care services, expensive care services in order to keep populations of people healthy.

00:37:18.583 --> 00:37:28.340
The challenge is that when you're dealing with populations, there are always going to be a few outliers.

00:37:28.340 --> 00:38:11.916
And so, for example, let's say you have a managed care plan that is responsible for Medicare Advantage and they have an algorithm that says, if a woman under the age of 65 has an abnormal pap smear, has an abnormal pap smear, instead of referring them to an OBGYN for potential workup in a biopsy, they have to have four abnormal pap smears, which is a lot cheaper than a biopsy, before they can get a referral to a specialist.

00:38:11.916 --> 00:38:16.132
The problem is you're going to miss some aggressive cancers.

00:38:16.534 --> 00:38:16.914
Sure Sure.

00:38:20.902 --> 00:38:25.244
Now it's a numbers game if you think about it right.

00:38:25.244 --> 00:38:42.458
So one person may not benefit from being part of this value-based delivery system, but as a whole, it does, in an effort, decrease costs and keep people relatively healthy relatively healthy.

00:38:42.458 --> 00:39:01.632
So the downside is that some people are going to miss being diagnosed or have a delay in diagnosis, misdiagnosis or delay in diagnosis, and then that gets into the legal ramifications that you talked about and the duty of care and breaching that duty.

00:39:03.880 --> 00:39:12.554
What about from I'm not sure how to phrase this the Medicare population 65 and older?

00:39:12.554 --> 00:39:24.132
Obviously it's a big population right now and the shift has been drastic from Medicare to Medicare Advantage over the past decade and it's continuing to ramp up.

00:39:24.132 --> 00:39:29.632
It's 50% of Medicare patients or Medicare beneficiaries are on Medicare Advantage.

00:39:29.632 --> 00:39:35.692
Now Is there a danger of the continued shift towards Medicare Advantage?

00:39:35.692 --> 00:39:41.873
I don't necessarily know that there is because I don't understand macroeconomics that well.

00:39:41.873 --> 00:39:51.891
I do have concerns about maybe some of the big players right, because it's not evenly distributed, this Medicare Advantage population either.

00:39:52.300 --> 00:39:58.500
It's like United has a huge stranglehold on that industry and they're already a monster of a company.

00:39:58.500 --> 00:40:10.998
I just don't know if it's great for one company to have so much control over what is our biggest industry in this country, as you described, going to be $7 trillion, t trillion with the T by 2030.

00:40:10.998 --> 00:40:23.880
And for reference, like when a lot of people are saying, oh, I wish we had more money for insert your favorite thing in this country, they usually say, oh, if we spent less money on defense, we could do this other thing, but we spend less money on defense.

00:40:23.880 --> 00:40:26.565
We could do this other thing, but we spend way more on healthcare than we do on defense.

00:40:26.565 --> 00:40:32.632
So just I want to call that out for people who maybe don't appreciate how much money we spend on healthcare here.

00:40:34.822 --> 00:40:38.791
Well, the insurance companies are doing well, I will say.

00:40:38.791 --> 00:41:07.963
However, however, the Department of Justice is scrutinizing the big insurers, commercial insurers like UnitedHealthcare.

00:41:07.963 --> 00:41:07.775
Unitedhealthcare or UnitedHealth Group is having a bit of a Boeing moment.

00:41:07.775 --> 00:41:07.739
A Boeing moment, right.

00:41:07.739 --> 00:41:07.077
So Boeing, as you know, is having its struggles.

00:41:07.077 --> 00:41:07.230
We talked about the airline industry.

00:41:07.230 --> 00:41:15.001
Well, you know, a door flying off mid-flight from your airplane is not a good thing.

00:41:16.882 --> 00:41:46.054
Unitedhealthcare has been in the news recently because of a cybersecurity attack on their change healthcare division, which they purchased for a couple billion, I think and are using it for adjudicating claims, which means paying out claims to their providers who are under UnitedHealthcare contracts.

00:41:46.054 --> 00:41:54.407
It's not a good look, because UnitedHealthcare is really struggling for getting those claims out because of this breakdown.

00:41:54.407 --> 00:42:12.443
Department of Justice is also looking at UnitedHealthcare Division of OptumCare for antitrust because I believe it's now roughly one in 10 physicians is now an employee of OptumCare.

00:42:12.443 --> 00:42:30.865
So you're creating what's allegedly an anti-competitive environment where it could be said there might be attempted alleged, attempted monopolization of the industry.

00:42:30.865 --> 00:42:40.788
And then one other case that UnitedHealthcare is facing goes back to what we were just discussing with Medicare Advantage.

00:42:40.788 --> 00:42:58.195
So the idea with Medicare Advantage is the sicker the patients are based on a risk severity coding system, the more the plans will get reimbursed by the government.

00:42:58.195 --> 00:43:16.782
So if somebody has diabetes, with chronic renal failure or so their kidneys are failing from their diabetes, and you put that, you document that into your electronic health record, you will get paid more.

00:43:16.822 --> 00:43:20.090
Next, the following year, including UnitedHealthcare.

00:43:20.090 --> 00:43:43.927
What UnitedHealthcare did is they scrutinized millions of claims using an artificial intelligence model, machine learning, looking at if they were coded appropriately, and then those that were undercoded, they upcoded them.

00:43:43.927 --> 00:43:55.994
What they didn't do is look at the codes that were overcoded or upcoded and bring them down to what they should have been.

00:43:55.994 --> 00:44:07.235
So the Department of Justice is now looking at that case for an alleged false claims act violation.

00:44:07.235 --> 00:44:13.806
So again, the insurers are really positioning themselves to.

00:44:13.806 --> 00:44:24.456
I would say the insurers are positioning themselves to really have a stranglehold over the healthcare industry.

00:44:25.940 --> 00:44:27.762
I think that's a great example of.

00:44:27.762 --> 00:44:35.744
I think there is absolutely nefarious activity sometimes when there's this much money involved.

00:44:35.744 --> 00:44:54.471
It's a great industry to make money but like what you described makes sense, if a patient is sicker based on more conditions, severity of conditions through what's known as a RAF score, it's going to take a little bit more resources to keep them healthy in a given year.

00:44:54.471 --> 00:45:00.268
So they should the plan should be compensated higher for taking on the risk of that particular patient.

00:45:00.268 --> 00:45:03.806
If you take on a whole bunch of those riskier patients, you should get paid more.

00:45:03.806 --> 00:45:07.938
The problem is it's like first order thinking right.

00:45:07.938 --> 00:45:17.603
It's kind of like chess moves back and forth, so the compensation is available in an appropriate way and then the other side goes.

00:45:17.603 --> 00:45:19.128
Well, how can we take advantage of this?

00:45:19.128 --> 00:45:20.521
Maybe just a little bit more?

00:45:21.123 --> 00:45:25.101
So I think things are never really done in a really nefarious manner.

00:45:25.101 --> 00:45:33.306
It's just there's an incentive and then you get a bunch of really smart people because there's trillions of dollars at stake to go.

00:45:33.306 --> 00:45:34.929
How can we get more of that?

00:45:34.929 --> 00:45:55.552
And then there needs to be more regulation to close up some of the loopholes that were found over here, and you just keep going back and forth, which I think, is how we ended up with this wildly complicated kind of big, cumbersome boat of an industry that does not necessarily want to turn very quickly.

00:45:55.552 --> 00:45:59.664
Nothing seems to happen very fast in this industry.

00:45:59.664 --> 00:46:15.302
But I'm just curious so you mentioned this earlier that we as a nation spend more per person than most other countries I think any other country and it's, if you compare us to most other like economic peers.

00:46:15.302 --> 00:46:17.983
It's close to double per person.

00:46:17.983 --> 00:46:31.275
With that much money, with that much money just in a vacuum, could you come up with a better system than what we have Not understand?

00:46:31.275 --> 00:46:33.896
Is it possible from a political standpoint?

00:46:40.590 --> 00:46:43.340
With the amount of money we throw at this, we should have better health, right?

00:46:43.340 --> 00:46:57.135
Well, I love what you said better health not necessarily better health care and I think it starts way upstream, starts early in our childhood of creating healthy behaviors.

00:46:57.135 --> 00:47:32.471
My background is actually in public health and I believe that if I didn't have to ever operate again on someone because they cared for themselves by eating right, moderating what they eat, avoiding harmful substances, getting enough sleep, good sleep, creating social connections, minimizing risky illicit behavior, I think that would be the ideal health industry.

00:47:34.742 --> 00:47:36.327
Yeah, so that's actually how you and I first connected.

00:47:36.327 --> 00:47:43.929
I saw you speak at a conference in July of last year and you were speaking largely on these lifestyle factors.

00:47:43.929 --> 00:47:44.891
Right, it wasn't.

00:47:44.891 --> 00:47:48.746
It wasn't, uh, improving RAF scores.

00:47:48.746 --> 00:47:49.367
It wasn't.

00:47:49.367 --> 00:47:51.451
We're at a healthcare, what is it?

00:47:51.451 --> 00:47:52.172
Hmfa?

00:47:52.172 --> 00:47:53.063
It was like a re.

00:47:53.063 --> 00:47:57.724
It was basically a bunch of people trying to figure out how to get reimbursed faster or more completely.

00:47:57.724 --> 00:47:59.409
Um, and you were.

00:47:59.409 --> 00:48:01.313
You were there talking about, like, lifestyle factors.

00:48:01.313 --> 00:48:02.543
I was like, okay, this is a.

00:48:02.543 --> 00:48:05.532
This is the most interesting talk I've seen at this conference.

00:48:07.101 --> 00:48:17.427
So, speaking of lifestyle factors, I'm not sure how to influence change in this space, right, because everything just rattled off.

00:48:17.427 --> 00:48:26.050
None of it's going to be a surprise to people Eating healthy, making sure you get enough sleep, managing your stress, have strong social connections and relationships.

00:48:26.050 --> 00:48:29.215
Um, exercise, move your body, get sunlight.

00:48:29.215 --> 00:48:33.449
How do we start influencing this at scale?

00:48:33.449 --> 00:48:40.909
Um, and I'm happy to just start in a very theoretical way and then we can kind of try to narrow down to how to actually implement that.

00:48:40.909 --> 00:48:43.949
But you have a background in public health.

00:48:43.949 --> 00:48:47.217
We've been trying to crack this for a while.

00:48:47.217 --> 00:48:49.485
Right, a lot of people are trying to figure this out.

00:48:49.485 --> 00:48:50.690
It's hard.

00:48:50.690 --> 00:49:02.112
We have such a big country, 330 million people it's hard to figure out solutions that work for everyone 330 million people, 67% are overweight or obese.

00:49:07.800 --> 00:49:13.800
Significant amount of the population is also pre-diabetic or diabetic.

00:49:13.800 --> 00:49:20.043
Yeah, I wish I had the magic answer.

00:49:20.043 --> 00:49:21.266
I wish I had the Ozempic for behavior change.

00:49:21.266 --> 00:49:37.431
You know people want a quick fix and unfortunately it starts with, um, really your mindset and the will, not just wanting to change, but the willingness and the understanding of how to change change behavior.

00:49:37.431 --> 00:49:44.682
Um, you know, I, I loved, I loved operating on people because it was a quick fix.

00:49:44.682 --> 00:50:04.038
But I also recognized that a lot of what I was operating for, whether it was injury or illness, could have been totally preventable or avoided by early recognition of disease and behavioral change.

00:50:04.038 --> 00:50:25.355
You know, maybe it's through gamification and incentivizing people in a way that will create some sort of external motivation for them to change their behavior.

00:50:25.355 --> 00:50:29.951
Maybe we can get to people through their own intrinsic motivators.

00:50:29.951 --> 00:50:35.050
Maybe it's creating more empathy and compassion.

00:50:35.050 --> 00:50:47.192
Or maybe we just are terrible at providing access to the right, healthy choices and people need support navigating a complex system.

00:50:50.579 --> 00:50:52.186
I'm sure it's some of all of that.

00:50:52.186 --> 00:51:01.427
The point you mentioned earlier which was psychological safety within a medical setting that's something I want to kind of circle back to.

00:51:01.427 --> 00:51:03.985
I'm 35.

00:51:03.985 --> 00:51:07.922
Setting that's something I want to kind of circle back to.

00:51:07.922 --> 00:51:08.242
I'm 35.

00:51:08.262 --> 00:51:14.753
Even just in my lifetime I've seen the sense of community and the strength of relationships sort of diminish.

00:51:16.481 --> 00:51:46.094
I don't know if it's with the ability to travel and move is just a lot easier, or it's technology, or it's a combination of all these things where you can stay connected for anyone listening I'm air quoting, connected um, through technology and you can sort of you can sort of outsource a lot of, a lot of part, many parts of connection where you would have to normally spend time with somebody, have a real conversation with somebody, go over to their house.

00:51:47.135 --> 00:51:55.480
Now you can post something on Instagram and get a few comments and likes and that will get a similar feeling of connection.

00:51:55.480 --> 00:52:01.840
But it's very short, it's not long lasting and it doesn't necessarily contribute to something positive.

00:52:01.840 --> 00:52:02.983
I don't think in the long run.

00:52:02.983 --> 00:52:08.733
But I'm curious if you think like, do you think the sense of community is also diminished?

00:52:08.733 --> 00:52:17.282
And I don't know, I feel like we're life is sort of cyclical right, so I'm hoping that we're going to get to a shift back.

00:52:17.282 --> 00:52:31.168
I feel like we've shifted away from community and I'm curious if you think we're going to shift back towards more community, almost out of necessity, like I don't know if we can get any more isolated from each other.

00:52:31.168 --> 00:52:32.371
At least I hope not.

00:52:35.021 --> 00:52:37.925
It's a bit of an oxymoron, right, or, or a paradox.

00:52:37.925 --> 00:52:47.753
We can be global, we can have colleagues who are global, that we communicate with every day, but are we really connected?

00:52:47.753 --> 00:53:39.869
Are we really creating those deep connections that impact how we feel toward one another?

00:53:39.869 --> 00:53:42.172
In fact, I've talked a lot about this.

00:53:42.172 --> 00:53:49.539
What you're bringing up, this safety and feeling appreciated, wanted.

00:53:49.539 --> 00:54:08.373
I think we need to spend more time showing gratitude, recognizing people for what they do and being open to diversity of thought, diversity of purpose.

00:54:12.092 --> 00:54:16.684
Things are very polarizing today and I think that's what you're alluding to is.

00:54:16.684 --> 00:54:20.257
It's creating these dynamics where there's a loss of civility and let's.

00:54:20.257 --> 00:54:51.527
I mean, I don't want to bring the politics into it, but we saw this in healthcare, where the violence against healthcare workers was staggering and there was a loss of trust toward physicians particularly, and even today I think it still continues and I think physicians also.

00:54:51.527 --> 00:54:57.606
We have a part in this, because we have to remember that the way we were trained was a paternalistic approach.

00:54:57.606 --> 00:55:02.947
I say what you need, I say what you should do, so why aren't you doing it?

00:55:02.947 --> 00:55:05.163
Why aren't you adhering to the regimen?

00:55:05.163 --> 00:55:09.920
And maybe there's a different approach on how we get people to buy into healthy behavior.

00:55:12.925 --> 00:55:23.228
Yeah, yeah, it seems like the younger and younger generations I don't even want to say want, but need things to be more collaborative.

00:55:23.228 --> 00:55:38.833
The, the, the paternal approach as you described it is, I think, being readily rejected by sort of the generation behind me, and they're they're much more in the, the collaborative camp.

00:55:38.833 --> 00:55:44.851
I also want to circle back to the point you made about access.

00:55:44.851 --> 00:55:53.422
I always go back and forth to this right, because I have spent a fair amount of time on social media and especially in the health space.

00:55:53.422 --> 00:55:54.666
I kind of go back and forth.

00:55:54.666 --> 00:56:01.467
I'm like is it worth putting a video up just informing people that eating lots of fruits and vegetables is important?

00:56:01.467 --> 00:56:04.786
And like that's important part of your diet.

00:56:04.786 --> 00:56:05.931
I'm like it's so simple.

00:56:05.931 --> 00:56:07.556
And then I ended up do I?

00:56:07.818 --> 00:56:13.659
I post something about that, and a lot of the comments are coming like oh, why, why do we even need to say this?

00:56:13.659 --> 00:56:14.561
Doesn't everyone know it?

00:56:14.561 --> 00:56:18.150
Um, but I think there is still that piece of education.

00:56:18.150 --> 00:56:26.003
There's a study that came out looking at the snap program, where they looked at just uh, snap program, which is like food stamps or snap plus education.

00:56:26.003 --> 00:56:36.972
Um, so people are on food stamps but also some very basic nutrition education and the results on the snap plus education was like 66 better outcomes.

00:56:36.972 --> 00:56:42.666
So it's like clearly this, this basic education, is still a requirement.

00:56:42.666 --> 00:56:46.454
Um, so it it's hard to know where to even begin.

00:56:49.161 --> 00:56:54.432
I love that you brought this up, because I'm guilty of being one of those people.

00:56:54.432 --> 00:57:15.688
So I'm 54 years old, I grew up surfing, I was really mobile, I could surf big waves and then, a couple of years ago probably right around when I turned 50, I was in Hawaii teaching my 10-year-old daughter how to surf, and I couldn't jump up on the board like I used to.

00:57:15.688 --> 00:57:19.539
I'm like, wait a minute, what happened?

00:57:19.539 --> 00:57:24.722
My mobility completely changed my flexibility.

00:57:24.722 --> 00:57:32.505
My hips felt like they were stuck in the mud Over the last couple of years.

00:57:32.505 --> 00:57:55.094
I look at YouTube shorts and there are some incredible YouTube shorts that demonstrate hip mobility exercises that I just picked up from some random woman who is knowledgeable in physical therapy or in training athletes and I do it.

00:57:55.094 --> 00:58:03.291
So you know a guy like me who's a Gen Xer actually.

00:58:03.291 --> 00:58:10.887
Um, it appeals to me to watch something for about 10 seconds and then learn how to do a new hip mobility exercise.

00:58:10.887 --> 00:58:17.652
And and, by the way, yeah, I can get back on my board and surf again because of these YouTube shorts.

00:58:20.521 --> 00:58:35.510
So I I've categorized things into access, education and then action, where some people, some people don't have access to like they, they know what they need to do and they might even have the financial resources to do it, but they don't have.

00:58:35.510 --> 00:58:37.862
Like, there's lots of ways you can parse out access.

00:58:37.862 --> 00:58:45.153
Um, some people have access and the willingness but they don't.

00:58:45.153 --> 00:58:46.635
They just don't know what they should be doing.

00:58:46.635 --> 00:58:58.009
And then some people know what they should be doing, they have access, but they're they don't have the drive, the intrinsic or external motivation to take the action they want to do.

00:58:58.009 --> 00:59:06.909
So, I guess, from like a social determinants of health standpoint, there's, there's right, there's, there's no shortage of work that needs to be done in this space.

00:59:06.909 --> 00:59:34.108
Anytime somebody is knowledgeable in this space, I'm always curious to ask about social determinants of health and you've also operated in healthcare much longer than I have have you seen progress in social determinant, I guess, like programs or initiatives, and where do you see our big opportunities that we still need to kind of make strides towards for make more progress there?

00:59:38.932 --> 00:59:46.561
The first time I heard social and behavioral determinants of disease was in 2013.

00:59:46.561 --> 01:00:07.233
I was getting my master's at Harvard School of Public Health about social activities that would help promote health and prevent disease, like housing and food deserts.

01:00:07.233 --> 01:00:12.643
So that was about 10 years ago the first time I heard it, and I've seen progress.

01:00:12.643 --> 01:00:36.836
I think there's legislation that's been passed requiring the insurers to incorporate health and equity metrics to ensure that people of underserved communities are getting access to care, but I still think there's a long way to go.

01:00:36.836 --> 01:00:42.733
There's a tremendously, and I'll tell you where we're going to face.

01:00:42.733 --> 01:01:01.387
The largest challenge right now is with generative AI and the algorithmic bias in machine learning, not picking up the disparities in different racial, ethnic, religious and other sexual orientation and gender identity.

01:01:01.387 --> 01:01:05.460
That's going to be a problem which has to be addressed.

01:01:05.460 --> 01:01:12.523
So I guess a long-winded answer to address your question is we made some progress.

01:01:12.523 --> 01:01:31.684
I think there's attempts at being better, but again, it doesn't bring in the revenue into the healthcare industrial complex like a new drug does or a procedure from a device.

01:01:31.704 --> 01:01:46.764
Yeah, that's where it's hard, right we all know the answer, we all know the answer, but is there enough money in place to get enough people on that side?

01:01:48.989 --> 01:01:54.449
And currently, the answer is no.

01:01:54.449 --> 01:02:04.494
I have a couple of colleagues that work for venture capital firms and they don't want to hear it from me.

01:02:04.494 --> 01:02:07.838
If I'm talking about wellness or, uh, health, don't bother me with that.

01:02:07.838 --> 01:02:12.612
If you're talking about specialty care, we'll listen.

01:02:13.393 --> 01:02:17.440
Yeah I was just out in uh, tampa, florida, for like a one day.

01:02:17.440 --> 01:02:26.014
It's like a one day conference, not even a conference, there's like a private invite thing, but they just get together and it's like 50 of us just talking about one particular topic.

01:02:26.014 --> 01:02:28.380
And the topic this year was private equity in healthcare.

01:02:28.380 --> 01:02:30.333
And it was fun.

01:02:30.333 --> 01:02:41.056
You know, in a group that small you can have really animated conversation to say, and there are people there from the private equity side, there are people there from the healthcare side side, there are people there from the healthcare side.

01:02:41.056 --> 01:02:47.119
And through eight, nine hours of conversation you kind of get to the end of the day and somebody asked the question like, does any of this help patients?

01:02:47.119 --> 01:02:49.737
And everyone's like, oh no, absolutely not.

01:02:51.170 --> 01:02:57.277
Just understanding the model of how physician practices get rolled up, how they private equity is always going to need to make a return.

01:02:57.277 --> 01:03:01.416
You know they're not looking to hold on to those group of practices forever.

01:03:01.416 --> 01:03:06.893
They're looking to have an exit event and then whoever they sell to, they need to make a return at some point.

01:03:06.893 --> 01:03:22.690
It's like somebody is going to be left holding the bag, but we as an industry just seem to be okay to continue down this route until I don't know it falls apart and we just have a bunch of independent physicians again route until I don't know it falls apart and we just have a bunch of independent physicians again.

01:03:22.711 --> 01:03:34.637
78% of the physician workforce is employed by either a health system or a hospital, by private equity or a payer.

01:03:34.637 --> 01:03:51.467
In Oregon, actually, there is a legislation that is um going through there, Um, I think it's now in their Senate to ban private equity from purchasing physician practices.

01:03:57.909 --> 01:03:58.192
I did see that.

01:03:58.192 --> 01:03:58.534
Yep, I brought up.

01:03:58.534 --> 01:04:01.992
I brought up that story because you'd mentioned how bringing up like wellness in those circles uh, just is not well accepted.

01:04:01.992 --> 01:04:05.480
And it was funny because one guy there brought up the fact.

01:04:05.480 --> 01:04:07.753
He brought up kind of what we talked about earlier.

01:04:07.793 --> 01:04:17.733
Like the younger generations, they're like they're looking to homestead and they don't trust the medical system, and this guy got like three sentences into what he was saying before somebody cut them off.

01:04:17.733 --> 01:04:20.376
They're like don't talk, don't you bring your health and wellness stuff in here?

01:04:20.376 --> 01:04:41.422
Um, but it's, yeah, that's just how that that side of the industry treats um, treats it Cause it's just, uh, it's just a commodity, right, patients are their units to drive revenue, um, unfortunately, but that's that's the reality of private equity, um, do you have any?

01:04:41.422 --> 01:04:43.945
I don't want to end on such a morbid note.

01:04:43.945 --> 01:04:48.358
Uh, do you have any encouragement towards like other models?

01:04:48.358 --> 01:04:48.561
Like I'm?

01:04:48.561 --> 01:04:52.778
I'm a big fan of direct primary care, um, cause they are largely independent.

01:04:52.778 --> 01:04:57.777
There's some bigger groups, like marathon health, and I think they're doing interesting stuff in the employer sponsored space.

01:04:57.777 --> 01:05:06.739
Um, but if you have any thoughts on direct primary care or any other models that you see as encouraging, I'd love to hear that.

01:05:07.623 --> 01:05:37.083
Yeah, well, I'd like to put a shout out to the American college of lifestyle medicine, because I think it's a it's an important society that is now creating a certification and actually a fellowship for physicians to encourage patients through lifestyle change or behavior change, and I believe that those models will be sustainable.

01:05:37.083 --> 01:05:41.429
I believe patients will appreciate those models much more.

01:05:41.429 --> 01:05:51.996
I believe the employers so direct-to-employer will appreciate those models because it'll lower their costs if they're self-funded with their insurance plans.

01:05:51.996 --> 01:05:57.184
I think they can work.

01:05:57.184 --> 01:06:15.824
An interesting model that I'm working on right now and I won't get too deep in this because it's probably for another day is I'm working with a company that's creating digital twins of a physician and health coaches.

01:06:17.391 --> 01:06:18.052
That's interesting.

01:06:18.092 --> 01:06:18.932
Talk about access.

01:06:18.932 --> 01:06:19.855
Talk about access.

01:06:19.855 --> 01:07:04.833
So patients will have 24-hour access, daily access, to the physician's digital twin for anything that relates to their personal or medical health history, health history and it will occur through a virtual marketplace, through a portal that's HIPAA protected, so all the protected health information that you worry about will be protected and to even take it one step further.

01:07:04.853 --> 01:07:07.918
There is a whole new digital currency.

01:07:07.938 --> 01:07:10.221
that will come out of this, that I'm sure of.

01:07:10.221 --> 01:07:12.985
So those innovative approaches are coming.

01:07:14.751 --> 01:07:25.177
So I think, with generative AI and sort of these digital twins that you're describing, there's a lot of things through technology that are going to help augment the workforce.

01:07:25.177 --> 01:07:36.706
But are we, are we going to be in a really bad place from a nurse, physician, basically just healthcare professional standpoint?

01:07:36.706 --> 01:07:41.971
Um, because, like, the problem with these jobs is, like you, you can't, you can't spin them up really quick.

01:07:41.971 --> 01:07:47.143
Um, like, it takes a lot of training and a lot of money to kind of get that training.

01:07:47.143 --> 01:07:50.438
Are we going to be okay from a workforce standpoint?

01:07:53.070 --> 01:07:54.713
Oh no, we're.

01:07:54.713 --> 01:07:55.894
We're facing.

01:07:55.894 --> 01:08:00.981

Unveiling Doctors' Struggles: Pioneering a New Era of Empathy and Reform in Medicine with Dr. Scott Ellner

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