Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep148: The real problem with health care, with Melissa Lucarelli, M.D., FAAFP, and Erica Rowe Urquhart, M.D., Ph.D., MBA
Transcript
- 0:00 When you choose Copic, you're not just getting industry leading medical liability insurance, you're getting a true partner, one that's here for you every step of the way. Need quick answers. Our physicians are just a phone call away on our 24/7 hotline, you'll get specialty specific support and proven resources built on decades of experience, C, o, p, i, c.com, we're Copic here for the humans of healthcare, here for you, 0:24 what we're seeing now in the 21st Century is that the undivided focus on profit and profit margins does not necessarily benefit society and culture as a whole. 0:42 You business of 0:50 medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economic medical economics, and I'd like to thank you for joining us today in today's episode medical economics, editorial advisor and family physician. Dr Melissa Lucarelli sits down with Dr Erica row Urquhart, an orthopedic surgeon, independent practice owner and the author of the invisible hand building the scalpel, the hidden cause of America's health care crisis, for a conversation about what's really working against physicians and their patients. Dr Urquhart, thank you for joining us and Dr Lucarelli, take it away. 1:27 Every physician makes an educational journey through medical school to learn the best ways to diagnose conditions and ideally to help patients heal. Doctors in independent practice also need to learn about the best ways to operate their business. At times, working in medicine feels like a series of lessons about the economic factors working against physicians and their patients. I'm Dr Melissa Lucarelli, a family physician, clinic owner and editorial advisor to medical Economics. Today we'll discuss these issues with Dr Erica Rowe Urquhart, a 20 year orthopedic surgeon and independent practitioner with degrees from Johns Hopkins School of Medicine and Oxford University said business school. She's the author of the new book The invisible hand wielding the scalpel, the hidden cause of America's health care crisis. She's also the creator of the podcast up Med, the Journal of Health Care's race to the bottom. Dr Urquhart, welcome and thank you for being here. Thank you so much. Dr Lucarelli, it's a pleasure. So let's start with your titles. You borrow the invisible hand metaphor from the 18th century economist Adam Smith, and you describe Healthcare's race to the bottom. Why did you choose those descriptions, and what does this mean for physicians and patients right now? Yes, so these particular metaphors phrases were historical, and I think, particularly relevant to me during my formative years growing up, establishing, you know, my educational foundation as a member of society, not as a physician or any particular professional. And what I found so profound about both of them was that we are now seeing a reinterpretation of the meaning as you mentioned. Adam Smith coined this phrase in the 18th century, and it really was a positive phrase. It was meant to provide, I think, a foundation for those in general society to understand that economic development, economic advancement, the creation of markets, would benefit culture, society as a whole. But what we're seeing now in the 21st Century is that 3:48 economic development and the focus more so than economic development, the focus, the undivided focus, on profit and profit margins, does not necessarily benefit society and culture as a whole, and so I am taking this phrase and using it to amplify the concept that the focus on profit, the focus on the market side of healthcare, is actually deterring its progress and shaping 4:25 its I would say malformation a form, a term we use quite a bit in medicine. Then with the race to the bottom. 4:34 You know, we always think about ourselves as Americans, taking American centric focus. We always think about ourselves as 4:44 a culture, a country that welcomes people, welcomes people groups, so that we can create something new, so that we could advance, so that we can pursue. 5:00 To knowledge lend ourselves to the curious exploration of the world. That's sort of the American dream come here, work, hard, learn, grow, and that's a race to the top. But what we're seeing in healthcare is the exact opposite. We have all of this knowledge in one sphere, but then we're not really using it to leverage the growth of healthcare, to leverage the progression of healthcare, to make the delivery of care symmetric with our knowledge base. So two real big, heavy handed terms that may actually deter listeners or readers from grasping the sentiment, but I feel anchor us in who we are and give us a framework through which to operate. Yeah, it's disheartening, but but true, and I'd like to get back to your book. We'll be sure to do that. But first I could we take a step back. You've lived, lived in different parts of the country. I read in your bio urban San Diego, when you were growing up, New England, when you were at Harvard, Mid Atlantic, when at Johns Hopkins, what made you decide to practice and what you described as an under resourced community in New Jersey? Yes, two separate things, I think, fully, as you mentioned, urban San Diego, which San Diego of the 1970s 80s, is not the same San Diego today. It was much smaller, and very much, I think, a small, 6:38 welcoming city. And then I went to New England, which has its tradition, San Diego is very much a flip flop shorts kind of culture. And then going to New England, which has all of its tradition and history, that was quite the culture shock, to be honest. And but those experiences that exposure 7:03 allowed me to appreciate that through our diversity, we have still certain commonalities, and even as an undergraduate, I volunteered at one of the Boston hospitals, Boston City Hospital, and I did a public service project where I basically would just come into the NICU, the neonatal intensive care unit, gown up. And at this time it was the AIDS crisis and also an IV drug use crisis, and I would just hold newborn babies, and that gave me, I think, a grounding, just to appreciate that 7:50 we don't have any control over how we enter this world. We don't have any control over the things that we're born with, what our family's legacy is, and so that means that we really have to appreciate one another where we are and try to level the playing field, if possible. And I thought that there was a way for my husband and I to do that through medicine. So I would say, yes, technically, our practice is in an under resourced community, community, but we're adjacent to New York City. We're adjacent to cities that are more affluent, suburbs that are more affluent. And I would say that our mission was really to create a sleeper practice, a practice where anyone could walk in a CEO or, you know, a single parent, and find that the care was personal to them, and cutting edge, that's in our motto, 8:55 you know, cutting edge, timely and and accessible. So it was really about modeling all of the things I learned during my educational journey. And I think you know, the time that I spent in the hospital holding those babies in Boston, and then also the 9:17 opportunity that I had as a Johns Hopkins Medical Student shaped that mission. For me, that's that makes a lot of sense, and that's interesting. I read a data analysis article in a surgical Journal recently which stated that New Jersey leads the nation with the highest number of physician offices per 1000 households at 2.3 9:38 Wisconsin, where I practice, was like less than one and North North Dakota had the lowest in the country, country with 0.5 medical offices per 1000 households. Does it feel that way to you? Absolutely. It's a very 9:55 dense population of health care providers. It's also a very dense population. 10:00 Motivation of patients, where I am, in northern New Jersey, and so, yes, the competition is fears for, as you mentioned, those independent practitioners. Although one of the motivations for writing the book, and I know we'll get to that later, but one of the motivations was that this was a Legacy product project, because I do feel that independent healthcare practitioners are a dying breed. We're probably dinosaurs, and one day, a medical student is going to want to research why that happened, when that happened, and I wanted this to be a firsthand report of that for them, say, 30 years from now, 50 years from now, 10:44 another thing in that same article, and I may be recalling, recalling it not quite right, but another thing that that they had mentioned was that they they were looking to see how many independent practices really did kind of close, and it was hard to find, because there's venture capital money out there too, and so are those independent practices. They're not hospital owned, but they're not physician owned. So it's a little murky. I hope that we're not I hope we're not dinosaurs. I hope we're not a dying breed. And there is some, some evidence that there is a little bit of a resurgence of interest in going into independent practice. So my my hope and my motivation is to try to get students and young folks to want to be open minded to joining a small physician group or an independent practice. So we'll we'll see. Yes, yes, we shall see. I had the benefit of having a conversation just yesterday evening with a group of medical students at my alma mater, and there was interest absolutely in private practice. They're They're certainly curious. And there is an argument to be made from the decision standpoint, I think the biggest challenge is the livelihood, right, well being, 12:05 job advancement, those are the big, iffy 12:10 intangibles that could impact their decision. You actually segued right into my next question. You and your husband are both accomplished surgeons practicing your major hospital systems in New Jersey, where hospital employment would clearly have been an option. What made you want to pursue independent practice instead of a hospital based practice? Yeah, so I think I'll have to speak for my husband, because just as a little bit of background, my husband started his practice when I started residency. So we ended up in New Jersey, by virtue of the fact that I matched for orthopedic surgery residency in New York City, and then he decided to become a hospital employed physician when he first started. So that's how this journey began for us, which is quite fascinating. I think there are pros and cons to either dynamic. I like autonomy and just understanding the through line of how patient care is administered, and sometimes in hospital systems, administrators and physicians can be at odds, and it is challenging, I think, because as someone who's working within a hospital system, there are just the usual things that can happen. Medical records can be there one day they're not there the next, depending on the technology that's adopted, 13:45 there can be additional requirements for immunization and documentation and other things that just constantly come up that make it challenging, I think, on a day to day basis, to be employed in a hospital system or in a large health network. But on the positive side, when you are an employed physician, you don't necessarily have to carry the burden of focusing on overhead, of focusing on the financial aspects, the billing may be something that you're working on as an employed physician, that you're continually trying to quote, unquote, optimize, which could be a good word or a bad word, but the collections dealing with those claims that take an extremely long time to process or following up on. 14:45 We have in healthcare these things called EOB. So when we submit a claim to the insurer, they're then supposed to give us an explanation of benefits that will allow us to understand the decision that they've made. But sometimes we don't. 15:00 Get that EOB, and we have to go tracking that down. So as an independent practitioner, you have to manage that, but as an employed physician, you don't there. There are mechanisms, administrators, other individuals who who share that burden with you. So it's you know, 5056, of one and half dozen of the other when one is making that kind of decision. Well, on the flip side, it seems that independent doctors statistically have a higher overall compensation compared to their employed Doctor peers. Maybe not at first, but in the long run over the career, I found a couple sources that back that up. 15:42 There's some research showing that independent physicians also have lower rates of burnout. There was a Family Medicine Journal article that attributed this to adaptive reserve scores, and I had to figure out what that was. That's defined as a practice's internal capacity for organizational learning and development. The authors of that study concluded that at least in primary care practices, efforts to reduce burnout should focus on strengthening factors that support organizational capacity for change, like strong communication leadership supports innovation. And that really resonated with me, and as a small practice, especially going through the covid pandemic, I really felt like we were positioned for rapid change and agility versus some of our larger systems. What do you think about that? Yes, and I think the covid pandemic is a phenomenal example of the agility of an independent practice. We were able to develop our protocols very quickly and implement them. We were able to get patients back into the office, obviously on an emergency basis, but we were able to devise safe ways to make sure that patients were seen. We were able to communicate directly with our patients. You know, when you're employed sometimes 17:02 for purposes of practice management and efficiency, the telephones are managed off site or even offshore, and so it's extremely challenging for a patient to communicate with your office directly, but as an independent practitioner, you have the option of answering the telephone, and you also have the option of communicating directly with the patients you know, to make those outgoing calls as well, or to use the electronic health record as a means of communicating with patients. So we had patients wait in their vehicles, and we would communicate with them to say, Okay, we're ready to see you now you can enter the building. So yes, the dynamism and the agility of an independent practice does benefit, especially in those circumstances where all rules are gone and you really have to just operate based on public health standards, where you might have to bring that to committee in a large health system, and if you're one hospital in a group of hospitals, then it's not just your hospital committee, it's the committee for the whole region that then is going to be 18:17 a sticking point and will create opportunities for 18:22 waste and and also just slow things down. 18:27 Agreed, which? Which brings me to your podcast. You've addressed concerns about American health care through both your book and your up med podcast, which is where I first became familiar with your work. Season Two of your podcasts seem to me, to end on a cliffhanger in 2024 18:44 and then your book came out. And are there plans to resume the podcast? Yes, absolutely. So we are resuming. And Fingers crossed. I just need to, you know, it's all about my bandwidth. I just need to record the audiobook for the invisible hand. When that is done, then we will finalize the podcast. So hopefully we'll be seeing that by no later than June of 2026 19:10 you know what I mean by cliffhanger, dude, 19:13 I get the sense that you do have some insights, and maybe I don't have 19:20 it ended where you said, in next season, we'll have some of the solutions to all of these problems that we very clearly described. And I'm like, Okay, what are the solution? Yeah, so I can just give you the teaser that many of the solutions that I will be discussing are possibilities that have opened up because of the development of large language models and AI, a lot of the waste that we're seeing in healthcare is centered on how we process our information and AI has sort of changed the goal post in a lot of ways we have. 20:00 An opportunity now on the clinician side to use AI, and I think also the payers have an opportunity, if they choose to use AI, to create some standards for us in terms of the way that we are submitting our information and prior authorization requirements are 20:21 transparently revealed to everyone involved in the process. There are so many opportunities for us to use technology. So the teaser is, technology is one of the solutions right on I actually attended a technology school up the road from your undergraduate, so I'm on board with 20:39 technology 20:42 down the road from the liberal arts school insider groups. 20:47 Okay, so regarding the podcast, what advice would you give to other physicians who may be interested in addressing a wider audience through a podcast, whether it's on a clinical topic or something unrelated to medicine? And do you have advice about the writing process for physicians who are interested in a book. Yeah, so it's all really about your talent and your your level of interest on on both sides, but with the podcast, you just need a good team, 21:21 and it could be you, you know, team of one, there's so many resources now that are available. Just like zoom where you record your podcast, it gives you the audio track, the video track, 21:34 and the 21:36 similar to publishing, the platforms are wide open as well Apple store as well as Spotify YouTube, everything is very much egalitarian now. So if you have an idea, you can even now, as we talked about, use AI to help you refine that idea and then download a podcast recording software, and go from there. I was very fortunate to have a friend of mine who doesn't live very far from me, who had a podcast, and so she introduced me to her producer. And you know, your producer could be anywhere. They don't have to be close to you, but the producer is my team, so it's just me and the producer, and then, you know, thinking about the topic and who you might want to have for your guests is the next step, but it's certainly a lot of fun. I think it's therapeutic, because it gives you the opportunity to 22:40 have a sounding board that's broader than your immediate community that you know, and I'm so grateful that we made this connection through the podcast. That's phenomenal. With regard to the book, it's a similar environment. You have so many options now in terms of publication, the traditional publishers or the big five have steep requirements for the number of followers that you have in social media and your demonstrated marketability. So you don't necessarily have to waste time working on that before you get your book out there. You just have to then say, Okay, I'm going to hybrid publish, or self publish, and that's what I decided to do. I hybrid published, and that provided me with resources that helped me create the book cover that I wanted. It also gave me the opportunity to keep my title. One thing that came out of 23:43 my investigations and taking courses, you know, as I was thinking about writing a book, was that with traditional publishing, there's no guarantee that you would be able to keep your title and not to say that they would necessarily take the title, but it's not a guarantee, and I was very much wedded to my title. So I was able to keep the title with the hybrid publisher. I was able to design my own book cover. I had essentially 100% autonomy, but editorial support, and there are within the industry, there are so many resources for new writers. Now, if you just start Googling, if one is interested, just start Googling, you will find those resources, and there are a few that stand out, but what they offer quite often is developmental editing. So as you're thinking through what it is exactly that you want to write. They will help you, as those have who have worked for the big five or still work for the Big Five, they can help you come up with the flow your table of contents. Give you strategies. For example, my developmental editor was the one who. 25:00 Strongly advocated having a glossary at the end of my book. 25:04 The developmental editor helped me to identify the best story for the opening of the book. 25:12 They also showed me the blind spot of, you know, the medical ease that we all tend to use, and encouraged me to try to make sure that I was inclusive to all audiences in terms of the tone and the language that I was using, and then at the end, you can also engage an editor to go through and help you with the proofreading. So it's quite a fascinating process. It is nice to go the hybrid editing route, as opposed to the 100% self published route, just because then, by virtue of having that team, you have accountability, and it's an incentive to see the project through to completion with the podcast, it's nice because you have the episodes, and so there's gratification with every episode you see a finished product. But with the book, yes, you write a chapter, and you might be happy with the chapter one month, and then you come back to it two or three months later, and you're not as happy. And so you have to go through the editorial process again, or, you know, give it to someone who you trust to reread with you. So the book is a little bit I felt stickier but, but I think both are worthy endeavors. I encourage everyone who even has an inkling to give it a shot. And I do think that, like I said, it's wide open in terms of you're not having to have all of 26:47 the followers, the social media engagement, the the all of the things that would say you are marketable. You can put your ideas out there and then work on those things as you go along. Fantastic. So in your writing, I'm going to kind of kind of dive into the book a little bit. You use the metaphor of a consumer buying a cup of coffee, and you talk about paying an advertised amount for a product that you receive when you go and buy your cup of coffee. But in health care, when patients purchase services from a doctor, the amount the doctor charges isn't what the patient pays, and the doctors often receive much less than the middlemen in the transaction. Would you expound on this idea, and how can we make this process easier and more equitable, especially for the doctors and the patients? Yes, there are two sides to the story, and it's much more complicated than I'm going to make it. But for one side, let's just talk about, if you look at the front of your insurance card, you can present to different types of conditions. You can present to a clinician that's a specialist. You can present to a clinician that's primary care. You can present to an urgent care. You can present to an emergency room. And at the front of your insurance card, it will give you $1 amount that you're responsible for depending on the type of clinician that you present to. So that's defined. But on the other side of the interaction, the costs are not well defined, depending on the zip code where you present 28:23 the and also the facility or the institution that you present to the amount that you're actually charged again, your insurance company helps to pay for health care, but the bill has our name on it. The bill has your name on it as the patient, so the amount that you're actually charged could vary significantly. It could vary, as you mentioned, based on the state that you're in. 28:50 Be it like North Dakota, where there are very few clinicians per patient. It could vary based on the 29:01 index, meaning, because of the location of the facility, the types of patients that are seen, if they are, you know, very complicated patients, then the institutions can charge more. So, you know, it gets really, really complicated on that end, and that is an opportunity for 29:26 transparency, improvement, 29:30 elucidation of the standards that affect that aspect of things. So we see very prominent people going to Capitol Hill, maybe almost annually to 29:43 talk to legislators about this, this variability in terms of charge for patients when they present for care. 29:53 Then I think on the other side, we have the clinician angst. Ha. 30:00 So and these two are not completely separate and distinct, but the clinician angst is that cert, everything we do in medicine has a code, 30:12 be it the diagnosis of the patient, be it the care that we provide, everything is coded. Nothing, nothing happens in medicine without a code, and what we find in that context is that 30:32 if the payer is, say number one or a insurance company 30:39 versus B insurance company for the same code, the reimbursement amount could vary. Or if it's doctor number one versus doctor number two, with those same insurance companies for the same code, the amount that is paid could vary. And then you add the variability of the patient's plan, some employer funded plans pay one amount versus corporate plans that pay another amount. And so it's just it's not like Starbucks, where, you know, it's very clear that the 31:17 Carmel macchiato is going to cost a certain dollar amount, we could offer our caramel macchiato and healthcare, and depending on all the variables that I just mentioned as a clinician, we could get paid very different amounts from receiving a check for like which we do, sometimes $1.50 because the patient paid Almost all of the amount in their their co pay to, you know, $30 for an office visit. So, yes, it's murky. It's complicated. And if you didn't understand what I just said, I don't really understand it either. I don't think it's designed. The system is designed for anyone to understand. Do you mind talking a little bit about the middlemen and insurance? Because it was interesting. Yes, and this is fascinating, and this is something that I discovered personally, but then also through investigative journalism that I saw in the New York Times around 2023 2024 32:17 so what is a trend in on the payer side is to engage, 32:26 as you say, a middleman or another company to 32:30 negotiate the payment that would be given to the clinician who's providing care. So let's just say, as a clinician, I saw a patient and the level of care that I provided for the service amongst you know how I've devised my payment strategy. It's about $100 worth of care that I provided to a patient. So I send my bill to the insurer, and we'll just talk about the middle man here. I send my bill to the insurer, and the insurer receives that $100 charge. And rather than saying, Okay, for this code, 33:09 our average, and again, everything's based on zip code, our average in this zip code is this amount we're going to pay, let's say, $50 off of that $100 rather than just being fully transparent for this code, in this zip code, we're going to pay $50 they send the bill to this second company, and this second company they may have shareholder interest in. It's not 33:35 guaranteed that the middle company is separate from the parent company or the the insurance company 33:41 and that second company then goes through this process of repricing. So they will look at what insurance networks you are in nationally, they will look at all kinds of information, and then they will try to reduce what the insurer will pay. So rather than paying, I threw out that number. Rather than paying $50 this middle company says, You know what? We think you can get away with paying $23 34:13 and they benefit because the percentage that they reduced, let's just say half the percentage that they reduced that payment, they get compensation for so if the parent company owns the insurance company and the middleman company, they essentially get paid twice, if you think about it figuratively, because they didn't pay the $50 right off the top, they didn't pay the $50 then they sent it to this other company that they owned. They paid the $23 34:48 and then the middle company made a profit, and so they're recouping profit from the middle company as well. It's a contrived system, but with the advantage. 35:00 Advancement of technology, we are seeing more of these middle companies. And when the middle companies get into trouble, it's almost like a paper company. They just shut it down and they open another one. 35:13 Continuing in that vein, are you aware that Medicare Advantage Plans add yet another layer of middleman, the insurance brokers that are paid incentives to steer patients towards specific products. 35:24 In my area, lately, there have been some local insurance brokers that have been switching or encouraging patients to switch to medical Advantage plans. And I looked into this, and they actually, in the state of Wisconsin, a broker can get $626 35:43 per patient that they switch from regular Medicare to an advantage plan as a bonus from that insurance company. And each one who renews like if they come back and renew next year, that same broker gets like half of that 103 35:59 113 patients per $313 per patient for them to renew. And the thing that was so frustrating when I figured this out is they're being told, the patients are being told that they can see any doctor that they want to, that that it's there's no there's no fees for this, and they can see any doctor. But what it really is is a PPO, so they used to be able to see any Medicare doctor because they had regular red, white and blue Medicare, but now I'm out of network for this plan. And so these patients, when they come for what they thought was a free annual wellness visit, all of a sudden they've got a significant coinsurance. Because, yeah, sure, they can see whoever they want, but we're not in network with this HMO. So now their care that they're entitled to, that they thought that was free, is no longer free, and all of their physical therapy, all of their specialists, because nobody in our area is in this network. They're all out of network. Now it's super, super frustrating. Absolutely we've seen the same thing, and I would say it started to peak around a decade ago, and we, 37:06 at first, were caught off guard, and we were seeing patients. The patients were upset because their insurance had changed and we were no longer in the network. And the first thing we told patients was, you know, as you're making this consideration, do the due diligence and call the doctors that you are currently seeing to see if they are in that network. Don't take the brokers word for it. But as you say, the transparency on what's in it for the broker is not there. And then patients, when they're signing up, they get all of these benefits, these perks, like a monthly budget at CBS or tickets to the movies or free memberships at the gym, so many things, the guarantee that they don't have to pay out of pocket, where Medicare is 8020 unless you have an additional health insurance. So you're guaranteed to pay 20% of your care unless you have a health insurance that will cover that 20% so there's the fear of the 20% 38:12 versus the all of these promises that are made. And it's a huge challenge. 38:18 And as you say, 38:20 the cost to maintain that continuity of care is is a challenge, and if we as the provider, let's just continue this down the line, because this is what we've experienced in our practice. If we as a provider, say, You know what, we're going to petition this insurer, this managed Medicare insurer, on a case by case basis, and use the argument of continuity of care to try to do what we can for our patients who we know, and we get that approval, so this plan that we're not in will approve on a case by case basis, our ability to see our patients, to continue to see our patients because they have a condition that we're treating them for. So again, under this auspices of continuity care, we do that, be it a surgery or whatever the treatment might be. Then when we come back and submit our bill, they'll say, oh well, yes, we did kind of say, you know you could continue under continuity of care, but actually we don't want to pay you, and the reason is because you're not in our plan. 39:29 Yep. 39:32 Well, I'm going to circle back to coffee because I'm a coffee fanatic. Back to your I love, I loved the coffee analogy. So back to your coffee analogy, paraphrasing your podcast at certain National Coffee retailers, when you buy your mocha macchiato latte, it's a nearly identical product, whether you're in California or Wisconsin or New Jersey. But how should that expectation of consistency be applied in healthcare, given the very real problems with access and equity? You. 40:00 Mentioned AI standardizing protocols and guidelines. Maybe tell me a little bit more about your ideas on that topic. Yes, I think you know one thing we have to accept 40:12 is that medicine is an art as much as it is a science, and we are continuing to grow and develop as clinicians, and we see a lot in the media these days about clinical trials and expanding the populations that are included in these trials so that we can better understand how the therapies that we provide, be it pharmacologic, medications or other therapies, how they impact different people and different conditions on different circumstances. So first, I think first, we just have to accept that medicine is an art, meaning, if someone were to treat Erica versus someone treating Melissa, it's not going to be 100% identical 41:00 that we have to accept, but in terms of what happens when you present to facility and the way that the care is delivered, there are opportunities for standardization. There are opportunities. And 41:18 one thing that I've been exploring more recently is the concept of administrative waste within healthcare. How every dollar that we spend, a certain percentage of that dollar is attributed to wasteful activities, be that repeating an activity like calling the insurance company to follow up on the status of a claim, 41:43 or, you know, any repetitious activity, administrative time 41:51 that's spent to get the patient the authorization for the surgery or the treatment plan that they need. So there's a significant percentage of that dollar that's spent on wasteful, quote, unquote, wasteful activities. I think the challenge is, for example, if I'm ordering an MRI for a patient and I want to get authorization, if I'm applying for authorization for that MRI with one insurer, insurer 42:25 A, the criteria that I need to supply to insure 42:31 a is not going to be the same as the criteria that I need to supply to insure B, but in terms of standardization, and again, that karma, macchiato, the MRI of the knee is the same, right? The code that I'm using to diagnose the patient is the same. So can we have the same criteria amongst insurer a and insurer B and ensure C for that MRI so that everybody knows if you're ordering an MRI of the right knee. These are the criteria that you need to substantiate that request. 43:11 I almost feel like it's by design. Sorry to interrupt you absolutely when we ask for the rules like there what are the guidelines that they're using for to get this particular test approved for this patient who needs it based on my clinical judgment, they won't tell you. They won't tell you, and they don't have to tell you. They have some internal rules. Yeah, 100% I was hoping you were going to go there, because this is, this is one of my frustrations, is that we should have standard like an MRI of the knee is indicated in these conditions, blah, blah, blah. And if there's an exception, sure you can, you know, try to get explain why this is an exceptional case. But we don't even know what the rules is. So we're playing, playing a game without having the full rule book, which is, which is unfair and frustrating as a as a physician, yes, and it changes from year to year. So the rule book you may have figured it out, say, for 2025 44:06 you may have figured out the rule book by, say, the end of February, and then you're okay for 2025 but then 2026 comes, and it's completely different. 44:17 So you're wasting again the first two months of the year to try to do that reverse engineering, to figure out what exactly is it that I need to do? 44:27 And yes, it's completely unfair to both the clinician and the patient, and it contributes to that, again, percentage of the healthcare dollar that's being wasted. That's a waste of my time. I wasn't trained to do this. I wasn't trained to reverse engineer what insurance companies want so that my patient can get an MRI. 44:47 It's making me feel exhausted to think about this. So going back to your book, I was impressed by your resilience as a physician after you experienced what you described as a personal health crisis, you pursued, pursued both an MBA. 45:00 A and A degree in theology, yeah, how did you balance the business of medicine and your focus on spirituality? Well, you know, that's a lifelong journey, lifelong process. I started as a person of faith and then entered into this wild, wild west of healthcare as an independent provider, and then was forced to sort of pause because of what happened to me from the health side, and as I was sort of making my way back, figuring out what the new normal was going to be, my true north was my faith, and it just gave me the opportunity. The catastrophe opened up the space for me to reflect on what was most important to me as Erica Urquhart, not as Dr Urquhart. And when I did that, I was able to pursue something that was completely different from what I had trained for, and it allowed me, I think, to recover in a gradual way, in a healthy way. Rather than being in a therapist chair, I was on Zoom, you know, writing papers, reviewing and learning, reviewing some scriptures, but then learning the historical background and going into, you know, the minutia, the details of my faith from an active academic standpoint. And I think that's what characterizes me. I'm a lifelong learner, but being able to do that was nourishing to me. You know, it really was like the cliche, the Chicken Soup for my soul and and then it helps me to then be ready to pursue the MBA and to come back and try to tackle some of these problems that we were experiencing. So it sounds like these educational pursuits were helpful to you to navigate this difficult time. And I wonder if it you you would recommend this for other physicians who are maybe looking for a little change or trying to avoid burnout. Do you think this, something, something along these lines, might be, might be your recommendation to that college? Absolutely, and I was fortunate, because 47:17 the program that I pursued on the theology side did not require for me to be there geographically. So I wasn't having to make my way into the classroom, but rather make my way to my computer. I had the flexibility to view some of the lectures on demand online. So those are, I think, characteristics that one might look for if you're practicing having that flexibility to do it on your own time, in your own way, but still getting that education, that quality exposure, 47:52 I would say, with the MBA as a physician, you are the ideal student for an Executive MBA Program, and they're designed for executives that have careers. So you are not expected to be in school full time. You're not expected to to quit your job, your day job, but rather, you're bringing the experience of your day job to a very interactive classroom setting. And the program that I pursued was one full week every six weeks we were interrupted by covid. So it didn't end up being exactly that way. But some programs are weekend programs where it's like a Thursday afternoon, Friday, Saturday, or strictly weekend, Friday evening, Saturday, day. But I do feel, and I was talking to the students, the medical students, about this yesterday, I do feel that having that business school training gives you language for skill sets that you were working on, but maybe you didn't necessarily, necessarily master, or you're not necessarily agile with so it gave me the language to understand why psychological safety is so important for your staff when you're communicating, and how your leadership qualities, your leadership personality, impacts your effectiveness and your influence. And those are things that as physicians and clinicians, we don't necessarily give as much attention to as business leaders and other spheres. But if you are an independent practitioner, you are a business leader, you are a CEO, you're a founder, you're a partner, all those labels apply to you, and you have to take that side of your practice, which is in itself a business, seriously, if you want your practice to be successful. I like that. I love that. I like thinking of myself as a CEO. That's nice. 49:55 On a personal note, your book dedication reads to mother with. 50:00 Respect and gratitude and your acknowledgements included. Dr Mary F Rowe, are they the same person and they are and was your mother an inspiration for you to pursue a career in medicine? Yes, thank you for that. So my mother is a doctor, but she's actually a Doctor of Ministry and theology, but she did inspire me to pursue a career in medicine. 50:24 I grew up in a time when as a child, if at any point you were presented to an adult figure, they would say hello, they would shake your hand, and then they would ask you, what do you want to be when you grow up? 50:38 Do that. I still do that. 50:41 I don't see that quite as much with my children, but that was the routine. Can you shake my hand? Can you look me in the eye, and can you articulate your dreams and aspirations? And I think because I had a certain level of quote, unquote, giftedness, is what they called it back in the day and an aptitude for science, I was steered in the direction of medicine, and, you know, it stuck with me. There's just so much about it that lent itself to 51:14 creating fulfillment, even along the process, even as I was in college, preparing for the MCAD and going through all of the hurdles that we have to overcome to get that MD, 51:29 there was still enough about what I was pursuing that fed me 51:36 and bullied me that, you know, I can appreciate being led to the trough by by my mother? Oh, well, considering that you and your husband are both surgeons, are your children interested in following in your footsteps? Great question. We have a 50% success rate there. I have two children, 51:59 one of whom is preparing for the MCAT as we speak. So, you know, I hope it is for him that he's not feeling, you know, the pressure of what his parents have done. But at the same time, it is exciting the possibility of, you know, sharing this experience with him. You know, just going through both of my children on college now, just going through the college experience with them. Now, it's like I'm reliving the college times, those college days, and I would be very excited to relive medical school, you know, with my son, 52:40 after our discussion today, I wonder, based on your experience, would you recommend medicine as a career today? Absolutely, absolutely, and I think it's our job as those who are in medicine to be guardians, to try to 52:59 preserve the ideal that we had the good fortune of walking into as people who care for other people, as clinicians. I do think that medicine provides one an opportunity to 53:16 foster a pureness of heart, because it is very altruistic. At its core, it's about sacrificing yourself, presenting your knowledge, presenting your assessment to a person, and hoping that you can find a synergy and bring that person, that that patient, to wellness. Fundamentally, that's what it is. But you know, as people who live in society, who by and large, are not independently wealthy Trust Fund babies, we do have to make a living, and we 53:54 as Americans generally give ourselves value based on our ability to be paid for the work that we do. And so that's, I think, the challenge for the next generation is maintaining that identity of, you know, the voluntary healer, the clinician who's trying to do their best for society and for their patient by caring for people, and then to maintain their self worth by feeling that they are being compensated for the sacrifice that they're making. And so, you know, that's the challenge that we have, is to contend for them for that, to try to make sure that at the end of the day, clinicians are going to be reimbursed for the work that they do 54:44 and to preserve health care and medicine as 54:51 a bastion of people who really do want the best for not only their patients, but for the communities they live in. Well put. 55:00 And that's probably a good place for us to end today. Unfortunately, 55:05 again for the listeners, I'm Dr Melissa Lucarelli, an editorial advisor for medical economics. My guest today has been Dr Erica Rowe Urquhart, MD, PhD and MBA, an orthopedic surgeon and author of the invisible hand wielding the scalpel, the hidden cause of America's health care crisis. She's the creator of up Med, the Journal of Health Care's race to the bottom, which you can find wherever you get podcasts. Dr Urquhart, this has been an illuminating conversation for our audience of physicians, and I think, for anyone who's ever been a patient, which is most of us. Thank you so much for your time and for your candor today. Thank you. Dr Lucarelli, it's been a pleasure once again. 55:50 That was Dr Erica Rowe Urquhart, an orthopedic surgeon and author of the invisible hand wound on the scalpel, speaking with medical economics editorial advisor, Dr Melissa Lucarelli, you can find Dr urquhart's podcast up Med, the Journal of Healthcare's race to the bottom wherever you get your podcasts. On behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts, and if you'd like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicianspractice.com off the chart a business of medicine. Podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Luttrell. Medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you.