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Join Ron M. Aryel, a pediatrician whose journey challenges conventional views on insurance companies and electronic medical records (EMRs). Ron shares his remarkable story of transforming his practice in Reno, Nevada, into a beacon of high-quality care, even for the most complex and acutely ill patients. Through strategic collaboration with insurers and leveraging EMRs as a vital tool, Ron achieved outstanding outcomes and earned accolades for his practice’s exceptional performance.

Ron M. Aryel is a pediatrician.

He discusses the KevinMD article, “EMRs and insurance: a pediatrician’s success story.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Ron M. Aryel. He is a pediatrician. Today’s KevinMD article is “EMRs and insurance: a pediatrician’s success story.” Ron, welcome to the show.

Ron M. Aryel: Thank you for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Ron M. Aryel: Well, medicine was a third career for me. I started out in banking, I went to aerospace, and then following a short career in aerospace, changed directions and ended up in medical school, and decided to do a residency in pediatrics, and from there a fellowship in medical informatics.

And after that I always worked part time as a pediatrician, part time in government and tech consulting. And then we ended up here in Reno, and that was my wife’s fault. We moved up and down the East Coast, and I spent some of that time, three years, in the National Disaster Medical System, so I did disaster medicine. Ended up here in Reno and opened two private practices, my wife and I. My wife is a retired pediatric neurologist. She and I shared office space. I did pediatrics and she did pediatric neurology, using the same office and staff. That’s where we ended up.

Kevin Pho: All right, so you are a pediatrician, but you also have a specialty in medical informatics. Talk about that intersection for a bit.

Ron M. Aryel: Well, I started out, I learned how to program computers at UCLA Extension. I programmed mainframes for Hughes Aircraft Company, which today is Boeing, and I learned all about total quality there. Kaoru Ishikawa, W. Edwards Deming, those were new ideas to increase quality in manufacturing.

And I decided that I wanted to make a change, because I wanted to end up more in the sciences and more with interacting with people. So medical school came up as an opportunity. I have cerebral palsy, so I had a lot of exposure as a child to a lot of surgeries to help me function a little better. My left side is paralyzed compared to the right side. So that’s how I kind of ended up with medicine as a third career.

But I took that computer knowledge with me. And so when I did my residency there was an opportunity there to start shaping how computers would help doctors practice medicine, and I decided to get into that. And my fellowship after residency at Mass General Hospital was quite informative, and I used that knowledge later on in the practice. We were very much into electronic medical records in the practice, as a tool to help me manage information.

Kevin Pho: All right, so let’s talk more about that. Your KevinMD article is titled “EMRs and insurance: a pediatrician’s success story.” For those of you who didn’t get a chance to read your story and article, tell us what it’s about.

Ron M. Aryel: Well, it’s like this. Insurance, most of medicine is paid for by insurance, whether it’s Medicaid or Medicare or commercial insurance. Somebody else is paying for care.

And so a lot of my colleagues like to complain, well, it should really be between a patient and the doctor, and insurance companies shouldn’t interfere with medical care. But in fact they have to interfere with medical care, because they’re paying for it. So the only time that medical care is only between a patient and a doctor is if the patient is paying the doctor directly for care. Anytime somebody else pays for it, you as a doctor are responsible to that other entity for what you do. And so this leads to a lot of conflict.

And my experience here in Reno, there was a surprise in it. I was always more open-minded about what insurance meant. And insurance is necessary. They do the risk adjusting, they have actuaries to figure out how money can be allocated to medical care, and doctors don’t have that background. I mean, most doctors aren’t actuaries. I’m not an actuary. I can’t put a model together on how to spend money effectively to take care of patients, and they do. And ultimately they’re responsible to the employers who pay for that health insurance.

So here I was in the practice, and an insurance company came in and said, look, you’re doing a great job, we want to help you do it better, we want you to tell your story to us through those codes. They can’t come in and read every single patient note that I write in order to understand what I’m doing. They have to go through those ICD-10 codes and CPT codes to figure out what I’m doing, and the more precisely I can do it, the better they understand what I’m doing. And so yes, that involved more coding, but at the same time, once I’m telling them the story, I’m telling them exactly what I’m doing, in return they’re letting me do what I do. So they let me practice the way I want to practice.

And they helped me. They pointed to things in the EMR that I wasn’t using. Despite my background, there were things I was still missing, and they showed me how to use that EMR more effectively. They showed me how to use WebIZ, which is Nevada’s state database for immunization, more effectively. They helped my staff do that, they helped me personally do that.

And the results speak for themselves. We were already a top 5 percent type of practice in terms of performance, and they made us better. And it didn’t really change my workload. I was already in the office 12 to 15 hours a day, but the EMR really had very little to do with that. That’s just, if you want to take care of patients, that’s what you have to do.

A lot of my colleagues, they send a lot of stuff out to specialists that doesn’t require more than a Tylenol or an aspirin. If it requires more than that, they send it out to a specialist. Well, when you do that, you lose your skills. So in my practice we used the computers, we used the internet for research, and I did a lot of stuff in my office so that the specialists wouldn’t have to work quite so hard dealing with routine issues that should never have been brought to them.

Kevin Pho: So your perspective on the importance of insurance companies stands in contrast to pretty much the majority of physicians I talk to. They take more of an adversarial approach when it comes to the involvement of insurers in patient care, and it sounds like you’re taking a more cooperative approach by acknowledging that the insurers have skills that a lot of physicians don’t have. Have you always viewed insurers that way?

Ron M. Aryel: Yeah. I’m not saying that they’re perfect, OK. The recent MultiPlan scandal shows that there are major holes in ethics in some of these organizations.

However, I had a conversation once with the chief medical officer of Chrysler Corporation, which is now Stellantis. And she explained to me that, at the time she was saying, well, $1,500 out of every car goes to pay the health insurance for their employees. And she has to sit there and figure out, the Chrysler Corporation was only going to give so much money to pay for the health care of their employees. They were self-insured at the time. The insurance carrier did not use its own money, it simply cut the checks for the corporation. So, well, how do we figure out how to take efficient care of our employees and not raise the prices of our cars so that people stop buying them?

And that kind of crystallized for me the problem. The insurer, as a definition, the insurer is not the adversary. The insurer is a necessary partner in this, unless all of us all of a sudden become multi-millionaires and can afford our own health care. So at that point the doctor and the insurer become partners, because the insurer has skills the doctor does not, and the doctor has skills that the insurer does not, and when they work together, patient care improves.

Look at the integrated models, Intermountain Healthcare, Kaiser Permanente. Models like that work pretty well, and those are examples where the insurer and the doctor are not adversaries.

Here in Reno we have a problem that doctors want to make as much money as possible. They will talk about taking care of poor patients, but they don’t. Our practice actually was kind of unique. No other pediatrician accepted Medicaid. We did. Why not? Because they want to be paid what they want to be paid, and I wasn’t as concerned about that.

Kevin Pho: Let’s talk about some of the specific things your practice did to be so successful. So when you said that you had to tell the story of a patient coding, what exactly does that mean, and what does that look like?

Ron M. Aryel: Well, the ICD-10 system, which took over from ICD-9, which took over from the previous systems, had a lot more codes that are very specific to diagnosis. An ear infection, throat infection, the codes became a lot more granular, a lot more specific as to what exactly this diagnosis is.

And the CPT codes tell the insurer what you’ve been doing. If I did a tilt test in my office, or I took a blood pressure, or I did an EKG, for example, all these were very specific. I was able to tell, through the codes, more specifically what I was doing, and the insurance company can then parse that and make a much more detailed story out of that when they’re putting the history together from the point of view of their deciding on paying claims.

So they’re not going to read my specific notes about each patient. They need to see those codes, because the computers on their side can then parse that and create a detailed history of what happened to the patient and what is being paid for. And that’s why they’re doing it, and even critics of insurers will concede that that’s what they’re doing. The doctors just don’t want to do it. They resent doing it because that keeps them, they claim that keeps them in the office longer. I say that’s part of the job. Unless the patient directly pays you for care, that’s part of the job, and you are responsible and accountable to the person who pays you to take care of the patient.

So we did that, but because of the level of work that I was doing, the quality of the work that we were doing required documentation anyway, to help me understand a patient better, to help me organize my thoughts and think of ways to help that patient. The notes actually helped me do that.

And since I was being more specific about what I was telling the insurer, the insurer understood what I was doing, which in turn allowed the insurer to basically give me a free hand to do it, because that established trust with the insurer. The medical director of that insurance company, it was actually Health Plan of Nevada, came to see me twice, and it was clear that we had established a relationship of trust. And I did often wonder, she must have been going to some other pediatrician offices, I mean, was I the only one she was visiting? But they treated us like we were the most important people in the room, and I was doing what I was doing.

And I just know that when I sent out a claim, payments were coming in promptly, within 30 days. I didn’t have to wait for payment 99 percent of the time. When I had to send somebody to a specialist, after I had completely done everything I could in the office to take care of the problem, I couldn’t do any more and I had to send it to a specialist, the referral flew through. Nobody said a word. And the specialists appreciated a lot of the prep work that we did here in the office.

For example, I’ll give you one specific example. ENT surgery for sleep apnea. The standard of care is doing a tonsillectomy, but the tonsils are part of the immune system, so some ENT docs don’t want to take them out right away. So one of the ENT docs here in Reno noticed that patients with chronic sleep apnea and snoring, when they got a six-week course of antibiotics, they often got a lot better and didn’t require surgery.

So I noticed that he was doing that when I sent him the patient, so I asked him, would you like me to take that over? And he said yes. So that’s what I did, and I used the EMR to keep track of who was getting what antibiotic. And a patient would come to me with repeated episodes of sleep apnea, I would put them on six weeks of antibiotics, and if that didn’t work, I sent the patient over to ENT, and ENT then immediately scheduled surgery.

It turns out that I saved probably 50 percent of those patients from having to have surgery. We reduced the number of patients that needed surgery, and the outcome was, people walked out of there, they weren’t snoring, the kids weren’t snoring anymore, they weren’t at risk for high blood pressure anymore, they weren’t at risk for a stroke anymore. And the insurer ended up spending less money on them and still got great outcomes for it.

Kevin Pho: Now, the goodwill that you had with your insurer, that may have played a role when it comes to maybe some bureaucratic obstacles, pre-authorization and getting paid in a timely manner and processing of referrals. Do you ever negotiate with insurers when it comes to things like payment, and do you feel that the goodwill that you built up with the insurance affected those negotiations?

Ron M. Aryel: No, not really. I mean, the amount of money was fixed. The Medicaid side, that’s the state, the state decides how much to pay, the insurer is just the entity that cuts the checks, so there is no negotiation there. We got a Medicaid raise, but that came through lobbying state government to create the Medicaid raise.

As far as commercial insurance, I don’t know that it got us more money, but what it did get us is a lot smoother process to get the money. No, I wasn’t going to be paid more money to see a patient with a particular condition, but that money came through a lot smoother, without a problem.

And I was sometimes seeing, I saw the train wreck. So for example, a patient comes in out of an ICU, and it takes me three hours to get through that patient’s initial visit. So I’m sitting there and I’m actually, I kid you not, there was basically two and a half, close to three hours on that patient. So I charged a very high level, like a level five visit, I charged overtime, I charged for several procedures, I charged for a double overtime, and I submitted all those claims into the insurer. No problem, everything got paid. They didn’t question any of it, they trusted me on that.

Now, do I wish I had gotten paid more? Yes, but that’s a different issue. We all, every doctor wants to make more money. Did I want to make more money? Sure. But I understand it on the other side, somebody’s cutting a check, so it’s not for me to dictate to the rest of the world how I get paid.

Kevin Pho: So talk about the role of electronic medical records. A lot of physicians have, again, an adversarial relationship with their health IT systems. In your case you lauded it in terms of giving you the tools to best care for your patients and contributing to the success of your practice. So talk about the role of the electronic medical record.

Ron M. Aryel: Well, first of all, you have to know how to use it properly. If you’re sitting there and you’re typing and you’re not talking to the patient, then you’re not using it correctly. I never sat and typed on a keyboard and looked at the screen and mumbled questions to the patient. When I’m in the exam room, I’m not on the keyboard talking back and forth to the patient. If I use the EMR with the patient, I bring the patient over to the computer screen, and I would sit the patient down at the computer screen and show them what I wanted to show them.

Otherwise I took some quick notes, we had a conversation, did a physical examination, and then afterwards I completed the note, organized my thinking, said, oh, all right, I need to do some additional things besides what we discussed in the office. And then I would integrate notes from a specialist, carefully read the specialist notes, and those would be integrated into the EMR as well.

The reason I think that other doctors have problems with EMRs is because they’re in a rush to get out of the office. If you’re in a rush to get out of the office, then you’re not going to use the EMR well, and that means you’re not doing your job.

The purpose of the doctor is not to walk in at 8:30 and walk out at 5:30 in time for dinner. This is not that kind of profession. If that’s what’s on your mind, then you’re going to skimp on your notes. And I’ve seen other doctors’ handwritten notes, and often they’re pretty skimpy, which means that when they have a problem with the medical board or with the insurer over payment, they get into trouble because they haven’t documented enough. And that’s what the EMR does for me. And the EMR spotted trends.

This is medicine, OK. This is not fast food. You have to spend the time necessary to do the job, and if you don’t know how to use the tool, that’s on you, not on the tool. I’m not saying that tools are perfect. There are limitations to some of these EMRs, there are things that they have to work on to improve, but you have to learn how to use the tool.

And the visit from that insurer, and that nurse from the insurance company, proved the point, because even though I’m savvy about this stuff, even I wasn’t using the EMR to its full capability, and she showed us how to do that, and that became more cost effective and time effective for us.

Yeah, I didn’t get home at 5:30 or 6 o’clock every day in time for dinner. That just didn’t happen. That’s not the job. But the EMR had very little to do with that.

So I don’t like it when doctors make excuses like that. It’s equivalent to, once upon a time doctors didn’t use stethoscopes. Why would I use a stethoscope? Oh my God, I can’t, that’s terrible, these new contraptions don’t work. There were doctors who had that attitude about the stethoscope, and there’s still doctors today who have that attitude about the EMR, and it comes from ignorance and arrogance, frankly.

Kevin Pho: We’re talking to Ron M. Aryel. He’s a pediatrician. Today’s KevinMD article is “EMRs and insurance: a pediatrician’s success story.” Ron, as always, we’ll end with your take-home messages to the KevinMD audience.

Ron M. Aryel: If you want to be a doctor, be a doctor. OK, do the job fully. Increase your knowledge every day. Study. When you go home every day, that’s not when your doctoring ends, OK, because you still have to learn, you still have to study, you still have to think about all the cases you had today so that you can do better tomorrow and stretch your capabilities tomorrow. Don’t dump everything off on the specialist. If you’re in primary care, learn to do your job, and keep doing it better every day.

Kevin Pho: Ron, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Ron M. Aryel: Thank you.