Getting messy in the game of health care [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“Many patients, doctors, nurses, and health care administrators appear to have a seat on the blimp with little concept of how the game has evolved over the years and is being played now. They may have attended the game in the past, but they likely haven’t seen the action from 5,000 feet above the field—and seeing the health care picture from the big picture distance can create some impetus for adapting to the new rules. We need to not only explain the new rules of the game but also show how passion of the team can overcome adverse conditions and ultimately prevail. Everyone on the blimp needs to become engaged, including those who have been riding involuntarily. The health care game has changed. We will find season ticket holders. And those of us on the field will get messy, no doubt. But who knows? Our game might just become a national pastime.”

Paul Pender is an ophthalmologist and can be reached at his self-titled site, Dr. Paul Pender. He is the author of Rebuilding Trust in Healthcare: A Doctor’s Prescription for a Post-Pandemic America.

He shares his story and discusses his KevinMD article, “Getting messy in the game of health care.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we welcome back Paul Pender. He is an ophthalmologist, and he wrote the KevinMD article “Getting messy in the game of health care.” Paul, welcome back to the show.

Paul Pender: Well, thank you for having me, Kevin. It’s a pleasure to be here.

Kevin Pho: So we’ll get into the article in a little bit, but for those who didn’t get a chance to listen to our first episode together, can you just briefly share your story and journey to where you are today?

Paul Pender: Well, as we were going on set, I heard that you’ve been doing this for 20 years, and I’d been practicing ophthalmology for 38 years before I started to think about how I’d transition after retirement, and I took a writing course. You were kind enough to publish some of my essays, and the next thing I knew, I was contacted by the chief executive officer of a health care company who wanted me to advise his company. And I thought, well, that sounded pretty cool, but I really didn’t know a lot about what that entailed. And so the more I learned, the more I realized that I still had plenty to learn, because my own little world was fairly isolated.

I had to deal with insurance companies sort of through the layer of my own back-office people, and I did experience the frustrations that doctors experienced with regard to pre-authorization and a lot of the busywork and documentation that was required. So I hired a scribe, and she helped us to some degree, but it was like a Band-Aid for my own purposes, and it really didn’t address how I might be able to help others. So I decided to take on this role as director of digital health communications at this company, Vxtra Health, and I’m excited because it’s now gone to crowdfunding with StartEngine, and we’re doing pretty well after the first few weeks.

Kevin Pho: So I talk to a lot of doctors who are interested in making that transition outside of clinical medicine, whether it’s through retirement or whether they just want to transition mid-career. Now, during your own transition, what were some of the challenges that you faced, and is there anything that you would have done differently when making that transition?

Paul Pender: I think so. I would have informed myself a little bit more about the ins and outs of insurance, both commercial and federal programs. Certainly, as an ophthalmologist, I had to submit lots of claims to Medicare, but the commercial insurance side is something that I think I really wasn’t as aware of as I should have been. And I would have started preparing for this job earlier had I known that this is the job I was going to take on.

Kevin Pho: Now, we talk about preparing yourself and finding more about the commercial side of insurance. Where can physicians find that type of information and training?

Paul Pender: Well, I think certainly there are certain books that deal with the crisis that physicians have had to face and the lack of their influence on systems. Steven Brill’s book is one that comes to mind. But I think having this kind of personal friendship with the CEO of this company has given me kind of a road map of what I needed to learn, and speaking to the people that deal with claims administration, those who are also involved in essentially the stopgap, or stop-loss, insurance for certain programs, so that the employer is not really hit too hard by catastrophic claims such as organ transplantation. So there are plenty of things that I had to learn, and I’m starting to get a better feel for how the team really works together.

Kevin Pho: All right, so let’s transition now into the KevinMD article that you wrote. It’s titled “Getting messy in the game of health care.” Now, for those who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Paul Pender: So it’s kind of an analogy to a professional sport and a professional game in which observers are up in a blimp and trying to figure out what’s happening down on the field. And because the rules of health care have changed, I think it’s important that we inform those people, some of whom were involuntary riders on the blimp, to pay attention and to learn what these new rules are.

And what I found was that the physician has had such a weak voice lately in policy and in being able to deliver the care that the physician wants to deliver, because they have to go through all these additional steps. And one of the things that struck me, I think there was a TikTok video that showed this fellow going back and forth trying to explain pre-authorization, and what it came down to is that insurance companies are effectively practicing medicine without a license. And so it kind of struck me that these are the new rules of the game, but we need to actually do something about it. We can’t sit in the stands and be observers. We’ve got to get messy on the field. We have to commit our energy and our expertise to giving physicians a greater voice.

Kevin Pho: Now, when you say that insurance companies effectively are practicing medicine without a license, and you put that in the context of pre-authorization, give us a real-world example, perhaps, of something in your own clinical field.

Paul Pender: I’ll give you an example. A gentleman comes in to me for a LASIK consult. He wants to correct his vision, but he was not a good candidate because of dry eye, and because he couldn’t really pass some of our preliminary tests, including putting a speculum between his eyelids. He did not want a foreign body in his eye. So I tried to get the insurance company to OK an expensive dry eye condition, and they were giving me all kinds of grief because I didn’t start with plugs in the patient’s tear ducts first. I’m thinking this guy is not a good candidate for plugs, because he’s rejected everything I put near his eye. So, you know, you go through the song and dance with people who are not medically trained, or are doctors in a separate specialty entirely that are passing judgment on my judgment. And I think that’s really inappropriate.

Kevin Pho: Now, I’ve talked to a lot of insurance company executives and physicians who work for insurance companies. So tell me, in general, who are these clinicians who are reviewing cases? And specifically, give an example of a physician who may not be in the specialty of the claim.

Paul Pender: I mean, as you know, I practiced ophthalmology in New Hampshire, and I’m on the phone with a dermatologist in Chicago trying to evaluate my clinical judgment, and I think that that just doesn’t connect. So I think what you really need is a peer, someone in your own specialty, to actually look at what you’re doing. But let’s take it one step further. Let’s say you practice at the best level of your clinical care. You shouldn’t be second-guessed by these plans. You should be able to offer your best work for the patient and be accountable.

Kevin Pho: So what do you see as the path forward in terms of resolving this pre-authorization? Because I think one of the reasons people do pre-authorization is, of course, to control the ballooning costs of health care, and this is kind of a draconian way of doing so. So with that in mind, what would you suggest?

Paul Pender: I think, you know, speaking as a fellow physician, I think you realize that there are outliers, where there are certain behaviors or procedures that are probably beyond what’s considered acceptable, and that’s unfortunately the bad apple that’s spoiling it for the whole barrel of all the rest of the doctors. So if you actually concentrate on those doctors who are the best in terms of their own status within the academic or clinical community and incorporate those people into your own network, then you can forgo the whole business about pre-authorization. And that’s part of what Vxtra Health is stressing in their own plans.

Kevin Pho: So in your article “Getting messy in the game of health care,” I think one of the things that you talked about is that clinicians are just too busy seeing patients, and we just don’t have the time to educate ourselves on various policy issues and things that really do affect our lives. We talked about pre-authorization and how that affects clinicians every day. What are some other areas physicians need to be better versed on?

Paul Pender: I think it’s a very good question. And in my mind, it’s like, OK, if you are a busy clinician, you are kind of delegating a lot to your staff, right? They’re handling all the insurance claims. Your technicians often take a history before you walk in the room. You try to be as efficient as you can. But we’re talking now about the future. We’re talking about the future of clinical practice, what’s going to allow physicians to become more influential again in the care that their patients get. And I think that that’s an important part. That’s what getting messy all really means. It means, you know, contributing your energy and your expertise to this kind of work.

And I realized that the important aspect for me to go forward is that I was going to commit to do this because of three reasons. One, I want to improve the trust in health care. And two, I wanted to actually focus on what was doable, and if we concentrate on employer-based health plans, we don’t run into all the difficulties that come with the federal programs. So this is a more focused approach. And finally, if you take the attitude that you’re going to listen carefully and adjust accordingly, then you can actually modify your plan as you go.

And this is going to be sort of the entire range of patient navigation, using our nurses that provide a personal touch instead of just a tech solution. So it’s going to allow for an earlier look at the health data on the patients to be able to make interventions sooner. And hopefully, as one of my fellow advisors says, if you get that diabetic to be managed properly, not only have you saved their limb that was going to be amputated, but you saved the health plan, you know, hundreds of thousands of dollars. So I think there’s a benefit to early intervention when you can.

Kevin Pho: We’re talking to Paul Pender. He’s an ophthalmologist, and he wrote the KevinMD article “Getting messy in the game of health care.” Paul, I want to talk about your experience during your transition outside of clinical medicine. I’ve always thought that it’s important for physicians to be involved in new health care startups, because I think you obviously share that experience that you had from your decades of clinical practice. How often is your voice listened to when you’re talking to a group of people in a health care startup?

Paul Pender: I think they pay attention, and that’s part of the reason why I feel I have a role, because this is really created with professionals, and many on the executive board, if you will, are physicians. So this is kind of by physicians, for physicians, and with physicians. And that is probably the first element of the crowd that we’re hoping to attract, that these are people who see that an investment in an idea like this could be carried forward, that could actually have some influence nationally. So we’re starting in Atlanta and in Charlotte, and we hope to move to other cities. As I said, listen carefully and adjust accordingly, and then you’ll be able to modify your plans as needed.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Paul Pender: I think that what’s important is that I started out taking care of individual patients, I became a physician and patient advocate, and now I’m advising a company, because I think it goes beyond just my own personal needs and desires and accomplishments, and I’d love to see this carry forward to other physicians.

Kevin Pho: Paul, thank you so much for coming back on the show and sharing your time and insight.

Paul Pender: Kevin, thank you so much for having me again.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes