Latest / Get Savvy...Demystifying Healthcare / Episode 135: Who Really Controls Your Care—Your Doctor or Your Insurance Company?

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Episode 135: Who Really Controls Your Care—Your Doctor or Your Insurance Company? · Get Savvy...Demystifying Healthcare

• 0:00
  SPEAKER_00: We're seeing that insurers are deciding for us whether or not we'll be on their network.
• 0:10
  SPEAKER_00: And we may have been on a network with an insurer, been listed as an A plus provider for 15 years or longer.
• 0:20
  SPEAKER_00: And then all of a sudden we'll get a letter in the mail saying, you didn't do something.
• 0:25
  SPEAKER_00: We sent a letter, we sent some communication, you didn't respond, so you're no longer in our network.
• 0:30
  SPEAKER_00: And we know we never received that letter.
• 0:33
  SPEAKER_00: And we're seeing on Instagram and social media that other doctors are getting the same correspondence and they never receive that letter.
• 0:45
  SPEAKER_01: If healthcare has ever left you feeling frustrated, overwhelmed, or stuck, this show is for you.
• 0:51
  SPEAKER_01: Welcome to Get Stabby, the Mystify Healthcare weekly podcast, where we take complicated healthcare topics and make them simple.
• 0:58
  SPEAKER_01: We bring you experts in real-world strategies, from using health insurance to lowering prescription costs, to patient advocacy and the latest healthcare trends.
• 1:08
  SPEAKER_01: So you give more options on your turn.
• 1:11
  SPEAKER_01: Get Stabby with your host, Debbie Kibling, changing how healthcare knowledge is shared.
• 1:20
  SPEAKER_02: Hello everyone, before we get into the show, just a quick 90-second update.
• 1:25
  SPEAKER_02: What could you accomplish if you could gain five or even 10 hours every week?
• 1:30
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• 1:33
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• 1:38
  SPEAKER_02: Yes, it's that AI topic.
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• 1:41
  SPEAKER_02: I believe that AI should make your life easier, not leave you buried in confusing tools, technical jargon, and endless tutorials.
• 1:50
  SPEAKER_02: As always, I am doing what I do best, and that is demystifying those confusing topics and making them simple.
• 1:58
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• 2:12
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• 2:29
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• 2:33
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• 2:35
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• 2:37
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• 2:43
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• 2:46
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• 2:52
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• 2:59
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• 3:01
  SPEAKER_02: Let's demystify AI together.
• 3:04
  SPEAKER_02: And now on with the show.
• 3:10
  SPEAKER_02: Who's really making the healthcare decisions?
• 3:13
  SPEAKER_02: Healthcare insurance is expensive and complicated, but what if it limits your care, your prescriptions, and impacting your overall health outcomes?
• 3:21
  SPEAKER_02: Does the traditional healthcare system and insurance really have this much of an impact?
• 3:25
  SPEAKER_02: To help us get into this topic, I have Dr.
• 3:27
  SPEAKER_02: Erica Roe Urkhard on the show.
• 3:30
  SPEAKER_02: Dr.
• 3:30
  SPEAKER_02: Urquhart holds degrees from Harvard and Johns Hopkins, and she's also earned an executive MBA from Oxford, giving her a unique perspective on both the clinical and business sides of healthcare.
• 3:42
  SPEAKER_02: She is an accomplished orthopedic surgeon, author, and healthcare advocate.
• 3:47
  SPEAKER_02: With over a decade in private practice, she has seen firsthand how insurance systems influence the care patients receive and the toll it takes on medical professionals.
• 3:57
  SPEAKER_02: She is the author of the Amazon number one best-selling book, The Invisible Hand Wielding the Scalpel, where she breaks down the hidden drivers behind today's healthcare challenges.
• 4:07
  SPEAKER_02: Welcome to the show, Erica.
• 4:10
  SPEAKER_02: Thank you so much.
• 4:10
  SPEAKER_02: It's a pleasure to be here.
• 4:12
  SPEAKER_02: Well, Erica, I was hoping that you could tell us your story and really how it's led you on the journey you're on today.
• 4:18
  SPEAKER_00: Well, thank you so much for asking.
• 4:20
  SPEAKER_00: It's a pleasure to be here on this podcast to talk about such an important issue.
• 4:26
  SPEAKER_00: My story begins in the hospital and the clinic with my orthopedic surgery training.
• 4:33
  SPEAKER_00: When I was a chief resident, I um had our first child, my husband and I are both orthopedic surgeons.
• 4:41
  SPEAKER_00: And that put me on the trajectory of private practice.
• 4:45
  SPEAKER_00: After I completed my residency training, I joined my husband and we formed ERCART Orthopedic Associates.
• 4:53
  SPEAKER_00: And that's really how my practice journey began.
• 4:57
  SPEAKER_00: One thing that I am discovering, especially as I talk to alumni and students at uh the hospital where I train, Johns Hopkins, is that we don't learn very much about the business of healthcare as we're being trained in medicine.
• 5:18
  SPEAKER_00: And so it was a journey of learning, exploration, discovery, as I began this private practice saga.
• 5:29
  SPEAKER_00: And I wanted to create a legacy for private practices like ours that might not exist 25 years from now.
• 5:38
  SPEAKER_02: What I want to say to that, um just to kind of help, because that's a that's a staggering statement.
• 5:42
  SPEAKER_02: There might not exist.
• 5:44
  SPEAKER_02: And I think in the I think what what listeners may not always know is that it's so hard, and congratulations for you to have that independent practice.
• 5:53
  SPEAKER_02: But I think what we're finding today is it's so hard to maintain an independent practice because of the reimbursement many factors, but the reimbursement often um as practices have a contract, I know you know this, but just helping my listeners a bit with the health insurance companies.
• 6:10
  SPEAKER_02: And if increases aren't given annually, I mean, we all know prices go up annually, then it makes it hard to maintain an independent practice.
• 6:18
  SPEAKER_02: So we see practices being absorbed by large private equity groups or um large healthcare systems.
• 6:25
  SPEAKER_02: And as someone described it to me, it becomes this vice grip, if you will, of you're being um, I hate to use the word dictated, but maybe that's appropriate of how to manage your practice versus having the independent practice that you do today.
• 6:40
  SPEAKER_02: It's staggering to hear you say that, that independent practices may not exist in the next 25 years.
• 6:47
  SPEAKER_02: Are you seeing some of the same causes as what I mentioned and others in in terms of being able to provide the care that you really desire to for your patients?
• 6:56
  SPEAKER_00: Yes, absolutely.
• 6:58
  SPEAKER_00: You have hit the nail on the head very precisely.
• 7:03
  SPEAKER_00: One thing that we experienced, my husband had started practice when I started residency, and I joined him when I completed my residency.
• 7:11
  SPEAKER_00: So he was already five years in to practice, although it didn't look the way that it did when I joined him.
• 7:18
  SPEAKER_00: And one of the things that I saw when I initially joined the practice was that we did have relationships with the major insurers.
• 7:27
  SPEAKER_00: They had representatives that would come to our office or that would respond when we had problem cases, or that would provide, as you mentioned, the fee schedule, which is everything we do, taking a step back, everything we do in medicine has a code.
• 7:47
  SPEAKER_00: Many patients wouldn't even believe that.
• 7:50
  SPEAKER_00: But believe it or not, although medicine is very um subjective and uh very much an art as much as a science, at the end of the day, what happens with the patient has to be distilled down to a code.
• 8:05
  SPEAKER_00: And those codes and what we're compensated for for each of those codes comprises the fee schedule.
• 8:12
  SPEAKER_00: And what we found, I hate to say right around 2009, was that we weren't seeing our customer service representatives or those representatives that were assigned to our practice.
• 8:24
  SPEAKER_00: And we had a devil of a time trying to get the updated uh fee schedules.
• 8:30
  SPEAKER_00: And as you say, they should be updated annually because the cost of living increases annually.
• 8:36
  SPEAKER_00: And why should your doctor be paid the same amount of money in 2026 that they were paid in 2015?
• 8:44
  SPEAKER_00: It just doesn't make any sense.
• 8:46
  SPEAKER_00: So that is, I think, the environment that we were practicing in.
• 8:51
  SPEAKER_00: And that was one of the first signs that things were beginning to change.
• 8:55
  SPEAKER_00: And as you say, the pressures of having to do more with less, of having to try to find a way to communicate with the major insurers as a very small player, as, as you say, an independent practitioner, then we're not going to get the same attention that a major health system would get because we don't have the same number of patients.
• 9:19
  SPEAKER_00: Um, so all of those dynamics definitely push many practices.
• 9:24
  SPEAKER_00: And I would say in our area in northern New Jersey, we began to see these changes in practice composition around 2012, 2013.
• 9:35
  SPEAKER_00: And it just continued to escalate over time.
• 9:39
  SPEAKER_00: Um, but that pushed a lot of independent practitioners to look for the security of a larger network of providers.
• 9:48
  SPEAKER_02: It's interesting two things that actually happen.
• 9:50
  SPEAKER_02: I just want to help uh the listeners better also understand the impact of that.
• 9:53
  SPEAKER_02: I know that I mentioned to you I'd had a knee surgery done, and uh my surgeon here in Colorado is part of a big group that was uh taken over by private equity.
• 10:04
  SPEAKER_02: And I think he was so frustrated, it was he in this case, was so frustrated with the mandates that he was required to work under.
• 10:11
  SPEAKER_02: He kind of created his own business entity within so he could somehow manage that because when private equity takes over, he's now tied to their contract and he couldn't leave.
• 10:22
  SPEAKER_02: And the second impact, my ophthalmologist that I'd known for years left the practice and tried to go to another practice and then was banned, banned from practicing um for I think five years.
• 10:35
  SPEAKER_02: So I lost my ophthalmologist.
• 10:37
  SPEAKER_02: So it's just crazy what ends up happening, you know, and I'm so sorry to hear that for providers because it is, it's it's scary.
• 10:44
  SPEAKER_02: But help us understand, you know, not only are you losing a provider, you're having to work under different circumstances, what are you seeing how it impacts the care that you're trying to give to patients?
• 10:55
  SPEAKER_00: Yeah, so I would say because we're still independent, we don't have the dynamics that you mentioned that your orthopedist and your ophthalmologist are dealing with.
• 11:05
  SPEAKER_00: We still have that autonomy, which in my mind is worth its weight in gold, although it does come with uh certain challenges.
• 11:15
  SPEAKER_00: But from the patient standpoint, what we are experiencing impacts them in regard to, I think, primarily the utilization management strategies that are employed.
• 11:28
  SPEAKER_00: So what I mean by that is that again, as everything we do in medicine has a code, when we submit those codes or the request for care to an insurance company, most of our patients have insurance, when we submit that information, they then get to make the decision as to whether or not they will pay.
• 11:49
  SPEAKER_00: And we may get the authorization right away or we may not.
• 11:54
  SPEAKER_00: Um I think the challenges that we experience that directly impact the patient is again those delays in care because we do have to go through that process so that the patient doesn't have to pay out of pocket for the care that the insurer would pay for.
• 12:12
  SPEAKER_00: Um so those utilization management strategies, I think.
• 12:16
  SPEAKER_00: And then the lack of clarity in terms of from year to year, will my doctor be in my plan?
• 12:25
  SPEAKER_00: Uh, we're seeing that insurers are deciding for us whether or not we'll be um on their um network.
• 12:37
  SPEAKER_00: And we may have been on a network with an insurer, been listed as an A plus provider for 15 years or longer, and then all of a sudden we'll get a letter in the mail saying, um you didn't do something.
• 12:54
  SPEAKER_00: We sent a letter, we sent some communication, you didn't respond, so you're no longer in our network.
• 12:59
  SPEAKER_00: And we know we never receive that letter.
• 13:02
  SPEAKER_00: And we're seeing on Instagram and social media that other doctors are getting the same correspondence and they never receive that letter.
• 13:09
  SPEAKER_00: So essentially, doctors are being dropped from the network.
• 13:12
  SPEAKER_00: And those are the two ways I think that directly impact patients and their care.
• 13:19
  SPEAKER_00: Because one of the reasons that patients choose independent clinicians is because they want to be known.
• 13:26
  SPEAKER_00: They want to have that personal relationship with their doctor.
• 13:30
  SPEAKER_00: They don't want to show up at the office and all of a sudden they're seeing a new provider without any notice.
• 13:38
  SPEAKER_00: Um, and there's just, I think, a security in that.
• 13:42
  SPEAKER_00: And so patients are having to cope with these uh vacillations in terms of what are the hurdles that we'll have to clear in order for me to get care?
• 13:53
  SPEAKER_00: And will I be able to see my doctor within my network come January?
• 14:00
  SPEAKER_02: Oh my.
• 14:01
  SPEAKER_02: So let's break this down because this is a little hard to believe, and I want to make sure uh everybody understands this.
• 14:06
  SPEAKER_02: I'm sure they do, but kind of walk me through that.
• 14:09
  SPEAKER_02: I mean, you're the orthopedic surgeon.
• 14:10
  SPEAKER_02: You you you're you have a consult with a patient, you're saying, look, I looked at the x-rays, patient Susie needs a knee replacement, all of the factors that go into making that decision.
• 14:21
  SPEAKER_02: So you go in and you go to the insurance company to get that authorization, you utilization management, the whole thing, and you're told no.
• 14:29
  SPEAKER_02: I mean, they're gonna override your decision.
• 14:31
  SPEAKER_02: Help me understand that.
• 14:33
  SPEAKER_00: Oh, yeah.
• 14:34
  SPEAKER_00: So let's back up.
• 14:35
  SPEAKER_00: Yeah.
• 14:36
  SPEAKER_00: First and foremost, as a clinician, I'm the provider of health care.
• 14:41
  SPEAKER_00: I'm the person that's trained, that studied the specialty, that has the experience and the expertise.
• 14:49
  SPEAKER_00: That's number one.
• 14:50
  SPEAKER_00: The insurer is, or the the name of the company on your insurance card is an economic vehicle for payment for that care.
• 15:01
  SPEAKER_00: It's very important to understand the distinction.
• 15:04
  SPEAKER_00: Your provider, your clinician is the trained medical professional, and the entity on your insurance card is a financial entity.
• 15:15
  SPEAKER_00: They pay for the care.
• 15:17
  SPEAKER_00: So let's be clear on that.
• 15:19
  SPEAKER_00: As such, a financial entity has responsibility to whom, first and foremost.
• 15:26
  SPEAKER_00: Ask ourselves that question.
• 15:28
  SPEAKER_00: You're a corporation.
• 15:30
  SPEAKER_00: Who are we responsible to as a corporation?
• 15:33
  SPEAKER_00: Corporations are responsible to their shareholders.
• 15:39
  SPEAKER_00: Patients are customers, but they are they're accountable to their shareholders.
• 15:45
  SPEAKER_00: So there are many mechanisms by which these companies, these financial vehicles, have sought to return value to their shareholders.
• 15:55
  SPEAKER_00: And that does not align 100% with the Hippocratic oath of your clinician.
• 16:01
  SPEAKER_00: So that being said, now we go back to that surgery.
• 16:07
  SPEAKER_00: What are some of the ways that I can slow, I'm speaking in the from the positive position or the hypothetical position of the insurer.
• 16:15
  SPEAKER_00: What are some of the ways that I can slow my patient population, my subscriber population down so that they're not all having surgery right now because I need to, again, return value to my shareholders.
• 16:28
  SPEAKER_00: One of the ways is to look for different specifications within that request for surgery.
• 16:37
  SPEAKER_00: One of those might be um radiographic evidence, as you mentioned, of the disease in mention for an orthopedic surgeon of osteoarthritis.
• 16:49
  SPEAKER_00: And one insurer, insurance company A, may require a list one through four of the different criteria that have to be mentioned in the radiographic review.
• 17:02
  SPEAKER_00: They're not looking at the actual x-rays, they're looking at the read of the radiographs, the patient history, all of that.
• 17:09
  SPEAKER_00: They may have a certain set of requirements, one through four, and then another insurance company may have another set of requirements, four through eight.
• 17:16
  SPEAKER_00: And those may have applied in 2025, but then in 2026, it's a different set of requirements.
• 17:22
  SPEAKER_00: That's one way to slow things down, to keep patients from having a surgery.
• 17:28
  SPEAKER_00: We in our practice have even had instances where patients have severe arthritis, they're using assistive devices.
• 17:36
  SPEAKER_00: It's clinically, there's no question that a total joint replace replacement would be the best treatment for them.
• 17:44
  SPEAKER_00: However, their body mass index was requested by the insurer.
• 17:49
  SPEAKER_00: And when we provide that information, they would say, Well, this BMI or body mass index is too high.
• 17:56
  SPEAKER_00: And we recommend that you send the patient for weight loss surgery or treatment to, you know, the patient must lose X number of pounds, have a certain BMI in order to be a candidate for surgery in our plan.
• 18:12
  SPEAKER_00: And that's just amazing.
• 18:14
  SPEAKER_00: But there's really nothing we can do.
• 18:16
  SPEAKER_00: So we're sending patients off for surgery for weight loss before we can do their joint replacement.
• 18:23
  SPEAKER_00: When if they had the joint replacement and they were able to exercise, they could lose the weight naturally.
• 18:29
  SPEAKER_00: But this is the dynamic that we have experienced in our practice.
• 18:34
  SPEAKER_00: And this is the absurdity that we are experiencing as people who are clinicians who are genuinely wanting to help our patients get better, but we're just constantly running into these hurdles, these roadblocks that are preventing us from providing the care that we know our patients need.
• 18:51
  SPEAKER_02: Well, no, that is so counterintuitive.
• 18:53
  SPEAKER_02: I was thinking the same thing about, well, if I can walk, I could exercise, right?
• 18:57
  SPEAKER_02: But I remember I we talked about my having knee surgery, and I remember I was at a an insurance company and they said, Well, you have to go through step therapy.
• 19:05
  SPEAKER_02: And the first was my favorite to use Volterin, to use the numbing jointment or ointment on my my knee, which I broke out from, right?
• 19:13
  SPEAKER_02: I couldn't couldn't do it.
• 19:14
  SPEAKER_02: I had a garage and I scratched my blood, it was awful.
• 19:18
  SPEAKER_02: And um, and then the second was to do physical therapy, and then only after a year, year and a half of that could I go and get get surgery.
• 19:25
  SPEAKER_02: And I don't mention that to say that, and anyone who struggles with knee pain, I mean, it was horrific.
• 19:31
  SPEAKER_02: I mean, it was just debilitating.
• 19:34
  SPEAKER_02: And I thought, okay, I'm look- I and I didn't go to med school.
• 19:37
  SPEAKER_02: I'm certainly not as smart as you are, but I can look at an x-ray and see bone on bone.
• 19:41
  SPEAKER_02: And no vulgarin or no physical therapy was going to change arthritis or the fact that I had bone on bone rubbing in my knee.
• 19:49
  SPEAKER_02: And I just, I'm listening to what you say.
• 19:51
  SPEAKER_02: I'm thinking, I almost feel like it's a a bit of a dictatorship because you're the provider, you're the one that I trust, you're the one that went to med school for this, but I'm having to live in pain because of line BR549 of some contract or or a you know financial goal.
• 20:10
  SPEAKER_02: I mean, that is just mind-blowing.
• 20:12
  SPEAKER_00: Yes, but again, getting back to the agenda, and I don't necessarily feel it's incumbent upon you, the subscriber or me, the clinician, to justify.
• 20:23
  SPEAKER_00: But the agenda is to slow things down, and which was successfully happened in your case, in that there was a year and a half between the time that you presented to the time that the surgery occurred.
• 20:36
  SPEAKER_00: And so that is the objective, just to slow things down, to create enough friction so that maybe you'll decide not to have the surgery or life could happen.
• 20:48
  SPEAKER_00: But if there's any way for the entity that's paying to slow things down so that one might not have to do as many or pay for as many surgeries a year from now or two years from now that they would if they just authorized them as they came along, then then that's what they would do.
• 21:07
  SPEAKER_00: So I completely agree with you.
• 21:09
  SPEAKER_00: It's it's just uh standard of care at this point that every patient has tried and conservative treatment is the category.
• 21:17
  SPEAKER_00: And it has been this way since I started practicing.
• 21:20
  SPEAKER_00: Conservative treatment comprises, as you mentioned, activity modification, it comprises anti-inflammatory medications, it comprises physical therapy.
• 21:30
  SPEAKER_00: Um and if we don't check those boxes, we can't even submit the request for authorization.
• 21:38
  SPEAKER_00: And then we do check those boxes and we're still getting the denials.
• 21:43
  SPEAKER_02: Unfortunately.
• 21:44
  SPEAKER_02: Oh my gosh.
• 21:45
  SPEAKER_02: The other trap that people have is even if you say, okay, I'll go around my insurance, most people can't do that.
• 21:50
  SPEAKER_02: And I'm in Colorado, so of course it's different.
• 21:53
  SPEAKER_02: But a knee surgery, at least recently in the within a year,$67,000 out of pocket.
• 21:58
  SPEAKER_02: That's I mean, if you were to pay.
• 22:00
  SPEAKER_02: That cost.
• 22:00
  SPEAKER_02: Maybe you get a small discount for cash paid.
• 22:02
  SPEAKER_02: But who has that kind of money to pay out of pocket and then pay your premiums on top of your insurance?
• 22:08
  SPEAKER_00: It's an insult to the person paying the premiums to have to pay out of pocket.
• 22:13
  SPEAKER_00: But as you mentioned, the cost of hospital stays, the cost of the implants, the cost of the operating room time, all those things make it an astronomical figure that one really would not be able to pay out of pocket without giving it significant consideration and making significant lifestyle changes.
• 22:38
  SPEAKER_00: So, yes, that's that's um college education.
• 22:42
  SPEAKER_00: That's one year of tuition in a private university.
• 22:46
  SPEAKER_02: My goodness.
• 22:47
  SPEAKER_02: So now that we've gotten through this depressing but yet factual topic, certainly something that needs to be talked about.
• 22:53
  SPEAKER_02: But what do you do as a provider?
• 22:55
  SPEAKER_02: I mean, you're trying to provide care, and I'm sure you deal with those patients in front of you who just look at you with a pain and they're kind of stuck.
• 23:02
  SPEAKER_02: I mean, how do you it really is a two-part question?
• 23:05
  SPEAKER_02: How do you deal with it as a provider, wanting to provide the care you know that patient deserves?
• 23:10
  SPEAKER_02: And how does a patient who's on the other end somehow get the care they deserve?
• 23:16
  SPEAKER_00: Yes, yes.
• 23:17
  SPEAKER_00: And it's interesting, I just had a conversation with a college student who had an interesting experience with her urgent care ankle fracture as an undergraduate.
• 23:30
  SPEAKER_00: And one thing that I think we have to recognize is that the clinician or the provider is the bearer of the bad news.
• 23:39
  SPEAKER_00: We're always the one that has to tell the patient, oh, the insurance company didn't approve this.
• 23:44
  SPEAKER_00: Uh, but we're not the ones that are making these decisions.
• 23:49
  SPEAKER_00: And we in our practice, we have these fat, you know, three-ring binders, the biggest three-ring binder you can imagine, with all of the details of what insurers are requesting and what um information we need to supply to prevent that first denial.
• 24:09
  SPEAKER_00: And so I would say for the patient, please be patient with your clinicians because they're doing everything they can to try to make sure that you get the care that you're expecting and certainly that you deserve.
• 24:25
  SPEAKER_00: But again, we've got this middleman who's got a lot of power, both legislatively and financially, to um make rules, change rules, decide who gets treated, who doesn't.
• 24:38
  SPEAKER_00: And so both the clinician and the patient are dealing with that.
• 24:42
  SPEAKER_00: On our side, uh, the coping mechanisms are certainly strategic because this could be numbing for us.
• 24:50
  SPEAKER_00: We could become callous.
• 24:52
  SPEAKER_00: That's the risk of constantly dealing with these denials and knowing that the insurers aren't paying us on the back end, and then they're also trying to prevent patients from getting care.
• 25:03
  SPEAKER_00: So we have to constantly try to stay in alignment with our mission, why we chose to be uh physicians in the first place.
• 25:13
  SPEAKER_00: Um, but at the same time, we do have to recognize and accept, give a word, a vocabulary to this particular environment in order to survive.
• 25:24
  SPEAKER_00: Because if we became outraged every time this happened, um, we would be burned out.
• 25:31
  SPEAKER_00: Um, it's just not uh sustainable.
• 25:35
  SPEAKER_00: And so it's it's a double, you know, two-sided kind of coin where we're trying to be empathetic, be uh systematic, pragmatic.
• 25:46
  SPEAKER_00: We try to reverse engineer, figure out, okay, this didn't work last time, we're going to try something else.
• 25:52
  SPEAKER_00: Um, even in terms of recognizing the changes that occur annually.
• 25:56
  SPEAKER_00: So, again, as I mentioned, the month January is really important in healthcare.
• 26:01
  SPEAKER_00: Uh, we try to reverse engineer, okay.
• 26:04
  SPEAKER_00: Well, we didn't get a notification officially that these were the changes, but if we work backwards from what happened this time relative to what happened just a month ago in December, we can try to figure out what we need to do in order to be successful.
• 26:19
  SPEAKER_00: So we try to channel the frustration into a strategic approach that is calm, pragmatic, and also accepting of the realities that at the end of the day, we're not the financial instrument for this healthcare.
• 26:35
  SPEAKER_00: Although we are advocating for our patients, um, we do not have the final say.
• 26:42
  SPEAKER_00: But the insurer who usually does have the final say on the financial side will always say, they will always cover themselves by saying, we're not denying care.
• 26:54
  SPEAKER_00: It's just that we're not going to pay.
• 26:58
  SPEAKER_02: I want, I do want to say on the provider side, every contract, every insurance company is different.
• 27:04
  SPEAKER_02: Sometimes every product within a contract is different.
• 27:07
  SPEAKER_02: That's the the product name on the front of the card, whether it says gold, silver, platinum, bluebird, whatever it says, it can be very different.
• 27:16
  SPEAKER_02: What you guys do in terms of authorizations, peer-to-peer, all that kind of stuff is so powerful.
• 27:22
  SPEAKER_02: Agree that you know providers are you guys are working hard on behalf of the patients against a very at times bureaucratic system.
• 27:30
  SPEAKER_02: But I'm thinking about what consumers can do.
• 27:32
  SPEAKER_02: It's so interesting as a health insurance broker.
• 27:35
  SPEAKER_02: Again, this is where you can say I don't feel comfortable answering the question or not, but as a health insurance broker, I ask them at the very beginning, you know, what are some upcoming surgeries?
• 27:43
  SPEAKER_02: What are the medications?
• 27:45
  SPEAKER_02: What doctors are you want to make sure you can continue to see?
• 27:48
  SPEAKER_02: And then I give them a choice and they're like, well, which insurance is better?
• 27:51
  SPEAKER_02: I think in my mind, what can consumers really, really do?
• 27:55
  SPEAKER_02: And I think about someone who says, okay, I have an upcoming hip surgery that I know I'm gonna have to have done this year.
• 28:01
  SPEAKER_02: And so, you know, and they're trying to choose, can they call an office and just say, hey, I'm deciding between insurance company A, B, or C.
• 28:10
  SPEAKER_02: Um, I hate to put it this way, but which do you have better luck with?
• 28:14
  SPEAKER_02: Or I I can change, but I just I don't want my surgery to be denied.
• 28:18
  SPEAKER_02: Right.
• 28:19
  SPEAKER_02: So I'm you know what I'm saying?
• 28:20
  SPEAKER_02: I'm just trying to figure out what can patients do?
• 28:22
  SPEAKER_00: No, we can't, because um, as I mentioned, the reverse engineering, we could have great success with one patient.
• 28:30
  SPEAKER_00: And as you mentioned, just a nuance of maybe one letter change in the plan.
• 28:33
  SPEAKER_00: So the prefix is say YHZ, and then on another plan, same insurance company, it's YHK.
• 28:41
  SPEAKER_00: That could make all the difference.
• 28:43
  SPEAKER_00: But at the end of the day, I would say that patients need to get what's called a summary of plan benefits.
• 28:50
  SPEAKER_00: And I actually did a little spot on a morning uh news program talking about this.
• 28:55
  SPEAKER_00: Take your insurance card out of your wallet and first know what's on it.
• 29:00
  SPEAKER_00: Know that if you're seeing a specialist, you're going to pay$100 out of pocket.
• 29:04
  SPEAKER_00: Or if you're going to the emergency room, it's$200.
• 29:07
  SPEAKER_00: If you're going to the urgent care, it's$150.
• 29:09
  SPEAKER_00: All of that should be on the front of your card if you're lucky.
• 29:12
  SPEAKER_00: But on the back of the card is an$800 number or an$888 number.
• 29:17
  SPEAKER_00: Call that number and say, I'm a subscriber and this is my plan information, my my uh plan number, um, my account number.
• 29:28
  SPEAKER_00: May I please have either in writing or by email.
• 29:32
  SPEAKER_00: Um, so snail mail, email, my complete summary of plan benefits.
• 29:37
  SPEAKER_00: Because quite often patients have access to either just the information on the front of their card or a partial summary of plan benefits, just a brief taster.
• 29:49
  SPEAKER_00: But as you mentioned, patients need to know how much am I going to be responsible for if I'm going to have this hip replacement surgery.
• 29:57
  SPEAKER_00: Or more importantly, it may not be on the front of your card, but if you have physical therapy after your hip surgery, how much are you going to have to pay as a copay every time you see the therapist?
• 30:09
  SPEAKER_00: Some patients don't realize until after the surgery that every time they go to see the physical therapist, they have to pay$25,$50.
• 30:17
  SPEAKER_00: Well, if you're going to therapy three times a week to get the optimal recovery from your surgery, that's a significant sum if you need therapy for six weeks.
• 30:26
  SPEAKER_00: That's not a small amount of money.
• 30:28
  SPEAKER_00: And you're recovering from surgery, so your ability to make money may be limited by the fact that you're recovering from the operative procedure.
• 30:36
  SPEAKER_00: So having that summary of plan benefits then gives you the leverage to compare.
• 30:41
  SPEAKER_00: Now, obviously, if you don't have the plan, you can't necessarily get the complete summary of plan benefits, but certainly that would be the question to ask someone like yourself, Sandy.
• 30:51
  SPEAKER_00: Can you give me, you know, this information about this plan so I can compare to my current plan and make a more informed decision?
• 30:59
  SPEAKER_00: But quite honestly, the best barometer of the quality of a health insurance plan is that summary of plan benefits.
• 31:07
  SPEAKER_02: I appreciate that.
• 31:08
  SPEAKER_02: I often say it, it's why I started this podcast is people rather have a root canal, no painkiller, than talk about health insurance.
• 31:16
  SPEAKER_02: All right.
• 31:16
  SPEAKER_02: I did it.
• 31:17
  SPEAKER_02: I think it is complicated.
• 31:19
  SPEAKER_02: It is, oh my God, we could talk on and on and on.
• 31:21
  SPEAKER_02: But I appreciate those tidbits and that support of that because um there are workarounds, and and I know sometimes patients can ask for an appeal and go through processes as well.
• 31:32
  SPEAKER_02: And they're all different by carrier and um that that you choose.
• 31:36
  SPEAKER_02: And so they all, to your point, it could be one-letter difference between one versus another.
• 31:40
  SPEAKER_02: And so um that that's so important.
• 31:43
  SPEAKER_02: Like I when I mentioned my situation, I was with a completely different insurance carrier.
• 31:46
  SPEAKER_02: But when I went to the other one, I was on a PPO plan, went right in, made the decision, got my knee surgery.
• 31:52
  SPEAKER_02: So you do have to look at that.
• 31:54
  SPEAKER_02: But all of that said, somehow along this this journey, you were inspired to write The Invisible Hand, Wilding the Scalpel, your book.
• 32:03
  SPEAKER_02: So tell us what inspired you to write it and what's it's what's it all about?
• 32:07
  SPEAKER_00: Well, thank you so much for mentioning the book.
• 32:09
  SPEAKER_00: You know, this was a labor of love, uh, Sandy, that I started at the beginning of 2025.
• 32:15
  SPEAKER_00: I just felt exactly what you described that pressure, that angst on our practice of um not knowing um what we could do to help our patients.
• 32:28
  SPEAKER_00: And I decided to just use the opportunity to write as a vehicle to express everything that was going on.
• 32:37
  SPEAKER_00: And then as I mentioned at the top of the podcast, this was also a legacy project because I was hoping that some medical student or researcher, historian, say 25 years from now, when they're looking for independent practices and wondering where they went and wanted a primary resource to doc that documented what happened, that they would know that in 2025, 2026, this was the environment, this is what happened.
• 33:05
  SPEAKER_00: So it was also, I think, for historical purposes, but I I could never decide.
• 33:10
  SPEAKER_00: I have a dual audience for the project in that it's both for patients and for clinicians.
• 33:17
  SPEAKER_00: It's not for one group or the other.
• 33:19
  SPEAKER_00: And I try to give clinicians the support that they might be able to point to certain paragraphs and say, yes, that happened to me.
• 33:27
  SPEAKER_00: Yes, that happened to me.
• 33:28
  SPEAKER_00: And even just having the glossary at the end of the book to be able to talk to their patients about some of the uh definitions around uh the conversation of the economics of healthcare.
• 33:40
  SPEAKER_00: And then for patients, so that they could really get that behind the scenes um perspective on what's happening.
• 33:49
  SPEAKER_00: Because this conversation that we've had, although it's gone on for almost 40 minutes, it's a very deep conversation that one cannot have in the midst of a busy office hour day with every patient.
• 34:02
  SPEAKER_00: So, how do patients find out why this is happening, why there are the delays?
• 34:08
  SPEAKER_00: Well, this book is a resource that allows patients to understand uh with I hope full transparency why we are where we are right now in healthcare.
• 34:21
  SPEAKER_02: Well, I want to we'll make sure and link to that.
• 34:23
  SPEAKER_02: And I know I always said in the beginning, I I do keep my podcast, but I at a certain time, but I don't mind going over this.
• 34:28
  SPEAKER_02: It is such a powerful conversation and one that I think that everybody needs to hear about.
• 34:33
  SPEAKER_02: So I appreciate your grace and going over a bit with your busy schedule.
• 34:37
  SPEAKER_02: Well, with that said, as we draw to a close, again, we'll link to your your book.
• 34:41
  SPEAKER_02: But what are any final thoughts that you would like to leave consumers with um before we close?
• 34:47
  SPEAKER_00: Oh, I love that.
• 34:49
  SPEAKER_00: I first want patients to believe that there is hope.
• 34:53
  SPEAKER_00: That there is hope that clinicians, uh, doctors want to care for you, that they want to make you better.
• 35:02
  SPEAKER_00: That's why we went into medicine and that's our primary goal.
• 35:06
  SPEAKER_00: Um, I think when there's trust between a healthcare provider and a patient, it's one of the most beautiful relationships that one can experience.
• 35:16
  SPEAKER_00: And so that's something that, you know, we're always, I think, looking for as people who have dedicated a significant part of our lives to training to be able to do what we do.
• 35:26
  SPEAKER_00: But then beyond that, I also want patients to again understand that healthcare is not pure anymore because we do have these corporate interests that are involved in the financing of it.
• 35:43
  SPEAKER_00: And so we have to be able to identify this is my doctor, and the doctor's making the medical decision, and this is my insurance company, and my insurance company is making the financial decision.
• 35:54
  SPEAKER_00: And my doctor is not responsible for the insurance company's decision, and the insurance company should have no role in my doctor's decision, but ultimately my ability to withstand the financial pressure may impact what my doctor does, even though in theory it should not.
• 36:13
  SPEAKER_00: And I think coming in with just those two suppositions that, you know, I want to trust my doctor, that I want to go for that relationship where I can actually entrust my health to someone who's been trained in the profession, and then that I want to be a great consumer and again look at the card, know what my responsibilities are, and hold my insurance company to task for what I paid for as a consumer.
• 36:38
  SPEAKER_00: I think coming in with those two suppositions changes the whole dynamic in terms of how things will proceed.
• 36:45
  SPEAKER_00: Um, when you're looking at surgery or just an uh annual physical, uh, a mammogram, it changes everything.
• 36:53
  SPEAKER_02: That's great advice.
• 36:54
  SPEAKER_02: Um, and and thank you for taking the time.
• 36:57
  SPEAKER_02: I mean, it's not like you you have so much time on your hands as a busy surgeon.
• 37:01
  SPEAKER_02: So thank you so much for writing the book.
• 37:03
  SPEAKER_02: Again, we'll link to that and for your expertise today.
• 37:06
  SPEAKER_02: You really put it in terms that we can understand.
• 37:08
  SPEAKER_02: And um, and really the message, I mean, I would end with this.
• 37:11
  SPEAKER_02: I think it is a partnership and care.
• 37:13
  SPEAKER_02: It's between a patient and a provider.
• 37:16
  SPEAKER_02: And with the circumstances, I think that exist today, it it takes a village of us to work together to get to the optimal outcome.
• 37:25
  SPEAKER_02: So um, so thank you so much for your time and all the great words of wisdom.
• 37:30
  SPEAKER_02: I appreciate you.
• 37:31
  SPEAKER_02: Thank you so much for having me.
• 37:33
  SPEAKER_02: It's been a pleasure and a joy.
• 37:34
  SPEAKER_02: I enjoyed having Dr.
• 37:36
  SPEAKER_02: Urkhard on the show.
• 37:37
  SPEAKER_02: I always enjoy hearing the perspectives of the provider from the patient and the business side.
• 37:44
  SPEAKER_02: Make sure and check out Dr.
• 37:45
  SPEAKER_02: Urkard's number one best-selling book, The Invisible Hand Wielding the Scalpel.
• 37:50
  SPEAKER_02: The link is in the show notes.
• 37:52
  SPEAKER_02: In our next episode, cancer is a word no one wants to hear.
• 37:56
  SPEAKER_02: And once it enters the conversation, the questions can feel overwhelming.
• 38:00
  SPEAKER_02: Understanding the diagnosis treatment options and what to ask next can feel unfamiliar, scary, and uncertain.
• 38:07
  SPEAKER_02: To help us get more into this topic, I am bringing on Dr.
• 38:10
  SPEAKER_02: Camille Williams.
• 38:11
  SPEAKER_02: Dr.
• 38:12
  SPEAKER_02: Williams is a board-certified radiation oncologist, a retired Army Lieutenant Colonel, and founder of Questions for Cancer Doctor.
• 38:20
  SPEAKER_02: She helps patients, veterans, and families better understand cancer diagnosis, treatment options, and the questions they need to ask when the road ahead feels uncertain.
• 38:29
  SPEAKER_02: Make sure and join us for that episode with Dr.
• 38:31
  SPEAKER_02: Camille Williams.
• 38:33
  SPEAKER_02: And one last request.
• 38:34
  SPEAKER_02: I hope you find the content in this podcast valuable.
• 38:38
  SPEAKER_02: To help others find out about the podcast so the conversations can help them, would you be so kind as to leave a quick review on Apple or Spotify to help support the show so that others may find it?
• 38:51
  SPEAKER_02: I would really appreciate it.
• 38:52
  SPEAKER_02: Until next time, get savvy.