“Take it or leave it” is not negotiation but coercion [PODCAST]

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“Physicians can exert their influence in a health care environment to put the patient-physician relationship at the center of the enterprise. Working with middle-market employers (between 200-2,000 employees), some companies pair bold doctors with innovative employers to bring exceptional value to employee health benefits. There are no pre-authorizations for medical decisions, but doctors are held accountable for best practices. Customized health benefits offered within the ERISA framework allow employers to tailor programs and coverage to their employee population. A purpose-built tech solution allows all the players to see more, see it sooner, and maximize health. Nurses serve as the point of contact for employees and as trusted guides for any health concerns, facilitating appointments with doctors and other healthcare professionals. In this model, doctors are equal partners with employers, reducing avoidable costs while delivering higher quality care. Instead of a fragmented journey, patients are supported through three phases of care—navigation, facilitation, and resolution.”

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, “‘Take it or leave it’ is not negotiation but coercion.”

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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 we welcome back on the show Paul Pender. He is an ophthalmologist, and he’s the author of the book Rebuilding Trust in Health Care: A Doctor’s Prescription for a Post-Pandemic America, and he wrote the KevinMD article “‘Take it or leave it’ is not negotiation but coercion.” Paul, great to see you again.

Paul Pender: Kevin, thanks again for having me on your show.

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

Paul Pender: I was very fortunate that you published one of my essays, and a CEO of a health care company contacted me afterward and asked me to advise his company. So I’ve been involved in some of the communications, not only among the principals in the company but outside as well, and being able to talk to you is a great honor, so thank you.

Kevin Pho: Wonderful. And I guess the last time I talked to you was either a few weeks or a few months ago, and we’ve been chronicling your journey. So now that we’re talking toward the end of November, is your journey outside of clinical medicine what you expected it to be?

Paul Pender: It’s actually better than I expected it to be. I was looking for something that was going to give some meaning to my time after retirement, and in advocating for patients and for physicians, this just gave me a better platform to do that. So the fact that I can work toward improving physicians’ voices in health care, that’s my mission, and I’m excited about being able to play that part.

Kevin Pho: Whenever I talk to physicians who step outside of the exam room, I always like to have them articulate how they’re helping patients even though there’s no direct patient contact. So let me ask you: Tell me how you’re helping patients in this nonclinical role that you have right now.

Paul Pender: I think it’s going to be an indirect influence. Hopefully, when you improve the relationship between physicians and patients in general, you’ll be able to allow patients a greater experience. And as we’ll get into later with the article, I think that it’s an adversarial relationship now within health care for a lot of patients and physicians. So to be able to restore trust in that relationship is one of our primary goals.

Kevin Pho: Now give us an example of what you mean by the patient-physician relationship being more adversarial now than it was before.

Paul Pender: I think patients are feeling vulnerable. They’re feeling like they’re not being heard, and physicians are being pressed for time. They’re often having to take work home with them. It’s been called “pajama time,” but I think that’s not a very favorable term for having to complete your medical records when you’re outside the office. So instead of having what I think is a meaningful and productive two-way relationship, oftentimes it becomes a sort of perfunctory episode, and I think that can be changed. I think we can do something to improve that situation.

Kevin Pho: All right, let’s talk about your latest KevinMD article, and it’s titled “‘Take it or leave it’ is not negotiation but coercion.” Now, for those who didn’t 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: Well, as I’ve been a regular follower on your platform, I came across an essay written by one of your contributors that said when he asked for more time from the health insurance company to review his proposed contract, he was told that he was no longer in the network, and that a patient who he had for many, many years and had established a close relationship with had been sent to a different physician in the network, essentially without him having any recourse. So that whole idea about the power play that insurance companies and health systems are exerting on the doctor-patient relationship really offended me.

And so I wrote my article because I have also experienced some of the same heavy-handed tactics. One of which was: The medical director of a large health insurance company sat down with myself and our partners in our ophthalmology practice a few years ago and wanted us to hire the people, buy the inventory, and run an optical shop in his multispecialty clinic, and declining the offer would risk losing patient referrals for eye care. And we sort of felt like this is not the way to conduct business. After doing all the work to create this entity within his multispecialty clinic, he was going to command such a healthy percentage of the revenue that we said it’s not a deal that we wanted to take. So yes, at the risk of losing referrals, we declined his offer.

But this is typical of what’s being done between large health insurance companies or hospital systems, where they have the size and reach to exert terms that they feel are in their best interest, and I feel are at the expense of the doctors.

Kevin Pho: This story certainly happens a lot, just like you mentioned, about how these large systems can gang up and sometimes even bully doctors to take unfavorable terms. Now, what are some things doctors can do about that? Because a lot of physicians, we’re not trained in negotiation, we’re not trained in business, and a lot of us are too busy seeing patients or going to the hospital and to the operating room to do procedures, and we just don’t have the time. And a lot of them just sign on a dotted line without really negotiating. What are some things that physicians can do to fight back?

Paul Pender: What you have to do is make sure that you can speak up for your patient, and you have to be able to do that within your own circumstances. If you’re an employed physician, it’s not as easy. If you’re an independent physician and you have some other choices, or to go to a competing institution and say, “I’d rather work with you,” you may be able to pull that off.

I think that what you hope to create, I believe, is a sense of hope for physicians. You’ve been doing this now for over 20 years. You’ve heard time and again physicians complain about their situation and not feeling that they had any power to do something about it. Well, that’s why our company is addressing that issue in two test markets, in Atlanta and in Charlotte. And the reason why I think it’s important is that instead of feeling like you’re a victim of this coercion, we’d rather create what we consider a collaborative care organization.

So in preparation for this discussion, since I know you wanted to keep it in general terms and not so much what we have in mind, I’m just looking at some of the brainstorming sessions that we’ve had, where we’re looking through categories. On the one hand, you have traditional health insurance, and on the other hand, you have a collaborative care organization. In something as selecting a doctor, you know, in the traditional plan you’re doing it from a ZIP code list, whereas in a collaborative care organization it’s guided. Credentialing is economic, often, from the traditional health insurance, compared to an outcome-based setting in which outcomes and data are given back to the doctor to know what are appropriate practices.

There’s cost shifting in traditional health insurance. As you know, some of the big players are covering Medicare at a loss, but there’s cost shifting to commercial insurers, and we think that those costs can be reduced significantly for employers in this middle market that have between 200 and 2,000 employees working with them. If you’re looking at the contrast, they continue. You know, in traditional health insurance, it’s a self-service approach, whereas in a collaborative care organization, you’ve got local partners in health. The analytics are totally different. In the traditional, they’re based on historical, or things that have already happened, and in the collaborative care organization, they’re predictive, because the information is not siloed. It’s going to be shared by everybody.

So there are a number of different areas where we contrast with traditional health insurance plans. And I think if doctors can start to understand that we’re not trying to be better at what they do, we’re going to try to do something that’s kind of unique, and if we can convince the doctors that this is an appropriate way to go, then they will not be coerced. They will be equal partners with employers, because they’ll be combining forces to look at what are the best health offerings for these employees under ERISA guidelines.

Kevin Pho: So tell me, how does a physician go about finding a collaborative care organization?

Paul Pender: They’ll have to contact us, because I think it’s fairly unique, and because I think it’s important for doctors to know that this is an idea that is germinating and, I think, is going to work. Our company is Vxtra Health. So I said I wouldn’t be putting in plugs, but I have to say that I know of no other organization that’s actually doing this.

Kevin Pho: Short of contacting you, any other options they have when it comes to negotiating terms that could be more favorable to them?

Paul Pender: It’s a hard call, because in general these groups are either going to force your hand or hire people to replace you, and that’s been the technique that they’ve used. So a lot of doctors cave. And you know from what your readers say to you and what the contributors are writing that this is untenable. And we believe that the old ways of doing business are not going to be successful, because they’re going to have a workforce that just can’t put up with this.

Kevin Pho: We’re talking to Paul Pender. He’s an ophthalmologist, and he’s the author of the book Rebuilding Trust in Health Care: A Doctor’s Prescription for a Post-Pandemic America. Paul, you’re an author, and you’re part of Vxtra Health as a health care executive. So how did you prepare yourself for these roles that aren’t part of a traditional ophthalmology skill set?

Paul Pender: Right. I read a lot. I think Marty Makary’s book about transparency and costs for hospitals really came to fruition when hospitals were forced to actually show what some of their prices were. There’s been this obscuration of drug prices that has gone on for a long time, and pharmacy benefit managers are taking advantage of that, giving false discounts. It’s really mired in a black box, and being able to shine some light of disinfectant on that, I think, will go a long way to helping to improve the trust in health care. And I think a lot of these players that are middlemen and are just adding costs to the entire equation are going to see less influence. And I think it has to be, because the current system is not sustainable.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Paul Pender: Your audience is bright. They are idealistic. They are looking for solutions, and they want to represent their patients’ best interests, which they feel is part of their mission. And we believe in all that, and we also believe that there’s a better way to do this, in a collaborative way. And I hope people will give us some time. As you said earlier, you know, people don’t have time to do a lot of investigating for themselves, and I spent a lot of time learning about this through books, through journal articles, through your contributors, and also from a personal relationship with the CEO of this health care company that I advise now. So yeah, if people give us a chance to learn more about it, we think that that can be a compelling argument.

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

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

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