AHLA's Speaking of Health Law

The Physician Perspective on Changes in Health Care

April 20, 2021 AHLA Podcasts
AHLA's Speaking of Health Law
The Physician Perspective on Changes in Health Care
Show Notes Transcript

Sarah Swank, Counsel, Nixon Peabody LLP, speaks with Dr. Mark Stephan, Chief Medical Officer, Equality Health, and Dr. Tripti Kataria, an anesthesiologist practicing in Chicago, IL, about how the health care system has changed over the past decade and the effects of health care laws and regulations on physician practices. They discuss value-based care, patient care coordination, patient quality and safety, and the pandemic’s impact on medicine. They also offer advice to policymakers and attorneys and talk about the issue of physician burnout.

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Speaker 1:

Hello everyone, and welcome. Today's a H L A podcast, a physician perspective on changes in healthcare. Today I have two physicians with me. Um, we're gonna walk through this journey of, of healthcare and the changes that have happened. Um, mark, do you wanna introduce yourself?

Speaker 2:

Hi, mark Stephan. I'm the Chief Medical Officer for, uh, equality Health, uh, family doctor by trade.

Speaker 1:

Great. And Tripti.

Speaker 3:

Hi, my name is, uh, Tripti Aria. I am an anesthesiologist, and I practice in Chicago, Illinois.

Speaker 1:

Thank you both. I'm Sarah Swank from the law firm of Nixon Peabody in Washington DC and we're gonna get started. So first, let's, I was, you know, we've been reflecting back on this year and, and even the fact that it's 2021, if you can believe it, and it's been 10 years since, you know, we saw some of the first implications of the Affordable Care Act, and I remember at the time thinking, okay, we're on a journey with, with, we're on this journey and we're gonna see where we're headed. Um, are we where we thought we would be 10 years later? I'll start with you, mark.

Speaker 2:

It's, uh, it's interesting. I, I think in some ways yes, and in some ways, no. Uh, I, I would, I would call out two examples of where I think we really have moved on from a physician community, um, from the initial skepticism, mistrust, um, uh, just not understanding the model, being a little bit suspicious. And, um, and I think we've moved a along, that's been my experience, um, from my perch, is that physicians now have sort of learned lexicon and, um, get it a little bit and, uh, understand the playing field, if you will, of, uh, the beginning of value-based care. But on the flip side, I think that we are not where I was hoping we would be in terms of the progression, um, in, in value-based care, um, contracting sophistication and an engagement of all parties really in the system.

Speaker 1:

How about you? Trip D? Are we where you thought you would we would be, uh, 10 years later?

Speaker 3:

No, I think I, I agree with Mark. I thought that by this time we would be further along where it came, when it came to value-based care. Um, but I think what we're learning is that value-based care is really nuanced and it's, it's something that was not part of the psyche 10 years ago, and definitely not 20 or 30 years ago. And I don't think that we have evolved as, um, in healthcare as a whole yet to be able to, um, to embrace it fully. The pr one of the major issues is, is that the way that the ACA and they started looking at quality, it was, the metrics were very operational. Did you give an antibiotic? Did you check this, this test? And they don't necessarily, they don't necessarily, um, you know, point to a better outcome. And part of that is that we don't have the data yet. And some of that, those out, that outcome data and those outcome studies haven't come yet. I think that, you know, as we go forward and as we continue to evolve with better, better studies, better data, larger data sets, we're going to start seeing bigger leaps and, um, really moving to what the a c a wanted to do in, in the first place.

Speaker 1:

So I remember reading the A c O regulations, and yes, the preamble, I did read it, and there was a note in the comment in the preamble about, this isn't gonna be realtime data, this is gonna be claims data. And that obviously we would get some, at some point, maybe the realtime data, but it wasn't gonna be through the traditional mechanisms of claim data, right? From C M s, for example, or a payer. So have we evolved past that trip trip D

Speaker 3:

You know, I, I think that this gets into the whole EHR issue and, um, a lot of the EHRs were set up for billing and they weren't really set up for value-based care for looking at, for physicians and documentation. It was really created in a way to, to bill. Um, it's even hard to pull information, you know, from some of these EHRs to do, to do research. Um, I don't think we're there yet. I think that, you know, there needs to be a further evolution in all of this.

Speaker 1:

What do you think, mark?

Speaker 2:

Well, it's a, it's a really good point. Um, and the cuz claims tell an old story, and that's assuming that you get, um, everybody gets timely, uh, claims data that's complete and accurate and, um, uh, I won't tell you all the data war, war stories, but, um, the, the EMR is, is, uh, only goes so far if you think about population health 1 0 1, right? The, the first thing you have to do is identify the patient. Are they attributed as an identified member of this, uh, population in the contract? And the EMR only tells me about the patients that I see or have seen. And so, if you think about just the very fundamental of panel management, I first need to understand that if I'm the shepherd, I need to, I need to know my entire flock. And that includes patients that don't come to see me, um, maybe have never come to see me or used to see me and, and don't anymore. And, and so, um, the need for, um, up to date and complete, and as you said, real time is, um, is critical.

Speaker 1:

So Mark, one of the things you said was the lexicon. So when this all started, there wasn't really a lot of vocabulary around this. And I remember even write, trying to write operating agreements and participation agreements and trying to figure out like, what words are we using? Because this wasn't the traditional primary care gatekeeper model. It was something different. And words like navigate and care coordination came out of, out of those changes. And as an attorney, from my perspective, someone would say is like, is care coordination? That's okay, right? We can do it. And it's like, well, what do you mean by care coordination? It could mean a hundred different things to a hundred different people. What is care coordination? What are you, what, who's doing what, where or when? Why are you with the patient? Are you embedded in a physician office? Are you on the phone? Is it digital? Like what, what does that mean? Um, what, what is, what has happened to the vocabulary? Have we, have we advanced it? Are we still using the same words? And

Speaker 2:

Well, I

Speaker 1:

How does that change care?

Speaker 2:

You know, one of the, one of the, I think from a, from a, the physician's perspective, um, and I'm speaking on behalf of, you know, colleagues who are still practicing and, and out there that, um, I think part of the challenge has been what does care coordination mean? And who's the one who's wielding that word? And so if I am a, uh, hospital owned aco, for example, coordination of care, um, may mean that I want all the, all the procedures to be done in my facility. And that may not, um, have been what the physician ambulatory practice was thinking when they signed up, which, um, ideally would, uh, imply coordinating care for the best outcomes and, um, uh, and, and, and in a patient centered way. And so there's, um, there's still some, uh, uh, navigating, um, who's doing the talking. And, and what exactly do you mean when you say to me as a, as a physician care coordination,

Speaker 1:

How about you trip d What, what do you think about the language and these concepts of care coordination navigation?

Speaker 3:

You know, um, I think that first of all, that the concept of care coordination is something that was inherent to the old, the old school family physician, primary care doc, um, back in the day when there weren't, you know, when, when healthcare wasn't very complex because they had the, they knew their pa not only did they know their patient, but they knew their mother or their father and their kids, and they knew the community of physicians was small. And, um, so they had the favorite cardiologist that they were, that they were, um, consulting or endocrinologists, and they were friends. So frequently it would be, they would, you know, they had this relationship, this one-on-one relationship where, oh, they would talk about Mr. Jones and his, you know, his, his heart disease medicine has become so subspecialized and complex and large that care coordination is in and of itself is an industry. And I think it's incredibly difficult for mom, you know, individual physician offices to, to take on that role. Um, it's difficult. It's almost impossible for an individual physician to do it. I know, um, in an, in the surgical world, we are looking as anesthesiologists. We're looking at like what we call the perioperative surgical home, and how do we make sure that the patient is set up and ready and tuned up, you know, for surgery for that elective hip or knee replacement. Um, is there, is there diabetes under control? Do we have them at an, hopefully a better weight? Um, what are, is there, are they on a statin to decrease their risk for a heart attack during surgery? Is their blood pressure under good control? These procedures are now outpatient. So then it's like, not only are we looking at what are they doing before surgery, are they well tuned up, let's make sure that they do well during surgery and then they're going home either the day of or the next day. And so what happens when they go home? So there's the whole aspect of what are we going to do about physical therapy? Are, is there somebody at home that's going to be able to take care of them? And so this has become an evolution throughout healthcare, even in the surgical field where we're seeing anesthesiologists who were the people behind the screen for so many years that we're now looking at this globally. And I think that it's to the benefit of the patient, but I would have to say that it's really challenging, um, because you're taking into account things that you don't think of and things that you don't necessarily learn in medical school. I mean, I learned the pre-op stuff during med school and residency, but all of the coordination of the physical therapy, et cetera, well, I didn't learn that. I'm, you know, we're continuing to learn that now.

Speaker 2:

It's, it's a great example of, of the opportunity and the challenge of coordination that communication, that physician to physician, physician to surgeon communication, for example, um, around, uh, let's just further the example of an uncontrolled, uh, a person with uncontrolled diabetes who's, um, preparing for an elective procedure. Uh, it's not right or wrong, but it is best practice to control the diabetes before the procedure. And if the patient is not hearing the same message from all parties, um, it, it not only isn't ideal coordination, but it, it can be confusing.

Speaker 1:

So, and

Speaker 3:

The outcomes can be worse.

Speaker 1:

Yeah. Yeah. And so one of the things I wanted to talk about, which is when you, is the idea that you could get, have good quality in some way, or meet some certain metrics in some way, but then the patient's not necessarily safe, or there's a safety issue. And I'll give you a couple examples that I've been thinking about. Um, one would be the idea that we're now looking at race, for example, as a social determinant of health, but also a, a patient safety issue. Like there are, there's data out there that shows that, that there are, like, for example, maternal deaths are wildly different for white mothers and black mothers. So there's a patient safety issue there. Um, also we look at, uh, not only like race, but you could, um, look at other social determinants of health where, okay, you met all the metrics and then you, somebody like leaves your hospital and they're, you know, they still have the other conditions that are gonna end up ultimately bringing them back into the ed d to use it as a, as a primary care physician. Uh, so so when you think about like patient safety and, and quality, how do you, how do we put those together?

Speaker 2:

Well, one of the, I think one of the keys there is to, is to not forget the patient as a, as a, you know, ideally, uh, we all want the patient to drive their own bus, um, to make healthcare decisions, um, in a, in a educated and informed way. Um, we need the system, uh, often doesn't take into account cultural preferences, beliefs. Um, who's your support system? Who else needs to be, be involved in, in the decision making, uh, uh, regarding in for, uh, a healthcare event or, or procedure or treatment for you? Um, in general, I think that there's, um, uh, we need to move towards a more personalized, I'm not sure I like the term, you know, consumer, but, um, but really, you know, uh, every patient is unique, uh, even though we often view'em in terms of population swaths.

Speaker 1:

So one other way thing I was thinking about with quality is the fact that there's gonna be, we're gonna find out about delayed care pro, probably, right? I mean, and, and when you're doing population health or care coordination, navigation, whatever it is, you're just trying to make sure that you're trying to be patient-centered. How do we, how are we gonna deal as a system with the, the idea that there work, there's, there was care that was delayed that might have impacts down the road, and how are we gonna identify and work on those?

Speaker 3:

So I think that there's some, there's some really interesting things that are being developed around the country, and, um, mark is probably even better to handle this than I am, but I know of some of Duke, um, their healthcare system, they have created a homegrown AI system. It's a closed AI system where they are identifying people that, um, that they take care of, um, that are at increased risk for kidney failure. And what they've done is they've been been able to create an algorithm where they see patients who are, you know, who have diabetes and high blood pressure and their metrics, you know, their, you know, hemoglobin, which the hemoglobin A1C is, is high. So meaning that their diabetes isn't under great control and their blood pressure is in undergrade control. And then they've looked back over time at what their kidney function is. And what they've been able to find is, you know, through, through looking at large data sets, is they've been able to identify patients that they think should be in a specialized program where they can address these issues early with the hope that they will never get to the di, they will never get to become a dialysis patient. And I think that's where we all wanna go. If there is a way, if there is a way that we can look at their data and see that while this person is at risk because they have these, these, you know, um, comorbidities, how can we shunt them to a place where we can preventatively, you know, help to, you know, foster their health so that they will never get to that endpoint of dialysis or need or having the heart attack or, you know, or other, or having other issues.

Speaker 1:

So that goes back to data, right mark, right? Or are we back with data<laugh>, or are we back with something else?

Speaker 2:

It's, it's, um, part of its data and part of it's the, the patient population. So from the data perspective, I, I think most, it'd be fair to say that the vast majority of clinicians do a good job most of the time with the patients who are A, in front of them, B, have all their tests done and up to date c know all their medications and, um, and medication, reconcili hap reconciliation happens, and d follow up with all the appointments with any specialty care. Um, the cha one of the, I think, greatest challenges is, again, looking at it from a, a population or a panel perspective to, to be able, so the clinician is again, turning into a shepherd here on the primary care side, where, who are the lost sheep? Who's not getting the test done, who's not getting, I don't even know their diabetes as I'm controlled or not because I haven't seen them, uh, for all the barriers to care that you mentioned earlier. And, uh, the test isn't done or they're unable to follow up and transportation's an issue. And so there is, you know, the greatest first hurdle is just to understand my panel as a, as a primary care clinician with an attributed population, understand my panel. And then within that, say for chronic kidney disease, um, who's doing pretty well, who's got some issues and who's, uh, really looks unstable, and we need to have a, a plan of care that involves probably more than just me as the pcp. It's the greatest first challenge is really just understanding and risk stratifying, um, my population.

Speaker 1:

So Mark, it seems like in healthcare, we like to talk about fruit a lot when we talk about laws and data. Cause we talk about low hanging fruit and cherry picking and everything seems to have a fruit condensation. I'm not, I haven't figured out why. Um, but, but ultimately, um, when we look at the sprint rules, which are the idea, we're supposed to be sprinting to care coordination. I don't know if you feel like we're sprinting, we're walking, crawling, running, whatever, but we're supposed to be sprinting to care coordination. And this January, um, the value-based entity exception to Stark and the value-based safe harbor of the and kickback statue came out. There was, it was interesting. So there's, there's a lot of that worrying about, you know, cherry picking and again, all our fruit. Um, also another concern that came out of the physician side was this idea of, of pushing forward con consolidation a concern that even though it, it, the rule was these rules were written to even have a one, two doctors get together in two different practices and do this, but that the, an unintended consequence would be consolidation in the market. So it, it does make me go back to the E H R discussion, which is that was an unintended consequence of maybe meaningful use that we saw consolidation in the market because they were expensive systems. And then we had to have connectivity and interoperability. And, and so when we think of these sprint rules, there's a lot of lawyers out there that think either one, boy, this is gonna be hard to do, or two, this is great, we can do this everywhere. But the, that wasn't necessarily fully the physician reaction to them. So what do you think about this, this idea that we've, you know, this is a little different than ACOs. You're not in waivers, but the idea that these laws that are, are like meaningful use or ACOs or these new value-based rules have unintended consequences for, for actual physician practices?

Speaker 2:

Well, I, I, you know, just, again, this is, this is biased from my, my practice and now my position is, is towards, uh, keeping independent practices independent. Um, so in, in, again, in my role we're, we're aggregating independence, um, to row together in a, in a population because a small practice, um, may not even have access to, to, you know, good value-based contracts, their po their ends too small to adjudicate them separately. So, um, uh, I think aggregation is still the, an ACO or, or whatever you call that, that network of, of independent clinicians, um, it's part of the key success to remain independent, um, the independent practice, I think, um, we can't let it be consumed. We can't let every, every, uh, primary care practice be an employed model. Um, I don't think that would be good for, for patient care or the system. But, um, uh, there, you know, that, I think that's part of what's changed a little bit in, you know, back to your first question. So 10 years ago, physicians, um, and in our ACO were, uh, sitting around the board table and saying, you know, I don't want you interfering with my patient. Um, you're the aco, but I'm, I'm the quarterback and I'm gonna, I'll be the one to communicate with my patient. Well, 10 years on, here we are. And you know, the, the, um, the governance council for us is sitting around and saying, I really need you to help me because my patient, um, I've told'em they shouldn't take this medication, or I've told'em they need to, um, I've referred'em to the specialty care, but I, I can't get'em there. Either it's social determinants or everyone's just googling their own diagnosis and coming up with their own treatment plan. But there actually is a, as a community now asking for more help, um, in engaging their patients and, and principally driving them into the right kind of care that the physician support. But, um, that's, that's, that's been an evolution is that acceptance of kind of, you might call direct to patient, direct to member, um, coordination, engagement and coordination of care.

Speaker 1:

So, Tripti, what do you think about this unintended consequence of consolidation? Some of these laws that US lawyers spend a long time reading and helping people advise on? Are there unintended consequences to, to physicians?

Speaker 3:

Uh, yeah. I do think that there are unintended consequences. Um, it really has led to almost a corporatization of medicine, and I am in lockstep with Mark in that I think that we need to, um, we need to preserve those independent physician practices. I think, you know, with independent physician practices, they're able to make their own, um, a lot more of their own decisions as to how they, how, you know, how they wanna work and what, um, how they, you know, how much time they wanna be able to spend with their patients. Um, whereas frequently in with these consolidations and with the large practices, you are, you, you know, you have these productivity numbers that you have to hit. Um, you know, and what's hard is sometimes those contracts are not, uh, and the, and the, um, and what the, what the business of medicine is not in alignment with taking care of patients. And I think that that's really challenging in this. They're, um, and I think that the, as a result of the business of medicine, you're also seeing at times physicians being sidelined where they are. Um, they are being sidelined for mid-level practitioners. And I, and, and at times you're seeing physicians being completely replaced by mid-level practitioners. And I think mid-level practitioners are great. I think that they have a incredible role in healthcare, but I also think that every patient should have a physician involved in their care. I think that's incredibly important. Um, and, but I think that there are consequences as a result of all of this consolidation, because they're frequently looking at the dollar and not looking as much downstream as a result at that individual patient.

Speaker 1:

So how do you think Covid changed medicine then? Do you, do you think it has Mark?

Speaker 2:

Uh, yes. Um, there's, there's plenty that remains to be seen, but you know, some, some notes from the field, if you will, um, that, that, um, uh, I, I check in as frequently as I can with my colleagues who are still practicing. But, um, you know, the telemedicine, uh, and the, and the, you know, at least temporary opening of, of allowing phone calls to be encountered, that that really embodies coordination of care. And, um, and so the, that's here to stay, I think, in terms of, uh, using telehealth broadly, um, that includes telemedicine. But, uh, it changed in the sense that in some ways it created an efficiency because obviously the, the patient could stay at home, but the vi the encounter became, uh, as a consequence a bit more streamlined. Like, okay, you know, I can't examine you. Let's just go straight to the numbers. Um, how are your sugars? Are you getting on the scale every day? If you have, you know, problem managing the water in, you know, uh, with, with any organ failure, um, and, you know, activities of daily living and are you having side effects? And it, it sort of was a cut to the chase kind of encounter, if you will, with telemedicine. And I think there's a certain element that's here to stay and probably much more appropriate for chronic disease management, chronic you management of diabetes and, and, uh, uh, C O P D and a number of other conditions, whereas let's, you know, explain how you're functioning and, and, um, show me the numbers and tell me about the meds, and then let's do some tweaking and move on the, the, uh, part of the, um, uh, you know, it's interesting, be one, uh, one clinician said to me recently after the, you know, in the midst still of the pandemic is, you know, because everyone wore masks. We didn't have this big bad flu season. And, and so he brought up a really interesting point is this, that there needs to be sort of a, um, we probably all need to step back and say prevention really matters. Um, and it, and it's down to hygiene and self care, and there's probably other types of primary and secondary prevention that, that need to be reinforced because it has the potential to make a huge impact on, uh, uh, people's health and, and utilization.

Speaker 1:

So, Tripti, what do you think, do you think there that covid changed medicine? Mark brought up telehealth or this focus, this is a, a theme I've heard too, from other doctors, this, this, this focus on prevention, not that you didn't know it before<laugh>, but that it was out there. And you, you come at this in a little different perspective because you're a specialist and you're an anesthesiologist. What do you think

Speaker 3:

It, I think that, you know, this has created, has really, I mean, created an evolutionary shift in terms of, um, of the use of telehealth. If you look at the numbers of the amount, the number of, of, um, the Medicare numbers of pre covid versus, so like January of last year, February of last year, to compared to the numbers in, um, in June. I mean, they're just astronomical. I mean, there was, it was like a, I can't even, I don't even know the numbers to be honest with you off the top of my head, but they were just astronomical in terms of the number of telehealth visits that literally started overnight as soon as everything shut down. Um, my 83 year old mother was so thrilled that she could<laugh>, she could see her doctor on her iPad. It was like the best<laugh>, she was so happy. She was like, I still see him. And, um, and it was, and it, and she, you know, it was great. And it was, you know, it was good that it, it was very reassuring to her. Um, but I think that we, in order to continue this, and I think that this will continue because seniors are getting much more savvy with it, and they're comfortable with it. Um, there are a lot of, I have a, my, uh, my husband's cousin is a pediatrician, and she set up telehealth and she, she's, you know, all of her asthma patients, she made sure she was on the phone calling all of them saying, let's set up a telehealth visit in, you know, every three months so that we make sure that you're all on the right track. We know you can't come in. We know that this is difficult. Um, but I think that there has to be a change in the le there has to be a legislation change, whether it's, you know, on a federal level, um, you know, with C M s looking at the, you know, where the site of service is, you know, currently there is, you know, special, there is, um, a waiver because we are in the pandemic. Um, but once this ends, so, you know, does a physician have to be in an, in an office and, you know, where can the, where can the patient be? But it also brings up the whole issue of how do we get broadband to everybody mm-hmm.<affirmative>, because now we're finding that broadband is a social determinant of health. Yes. People, you know, you know, if we don't get broadband to the inner, you know, to the inner city and to, as well as to the, the, um, you know, to the rural areas, they will not have the opportunity to participate in this. And I think it's, you know, I think it's a great way for, as Mark was saying before, how do I lose, I lose touch with my patient. It could be because they, you know, you know, they don't have a ride. Um, and or is it that they're a hundred miles away from their specialists because they live in rural, you know, Missouri or Illinois? Um, but this will give them that opportunity to do so, but we really, but they have to have broadband otherwise, um, you know, there, I think that it's real, uh, you know, otherwise you're not gonna be able to give them what I think they deserve.

Speaker 2:

Yes, Sarah, that's, that's one of the biggest, you mentioned earlier, unintended consequences. I, there's good things gonna come out of the pandemic, and I think this is a great example of one with the access to technology, and yet it's a double-edged sword because as Tripti mentioned, um, it's the access which will defacto create a two-tier system.

Speaker 1:

Yeah. The haves and the have nots. Yeah. And it is that there's, there's a new term, digital health equity didn't have that one before the pandemic never heard that before. I mean, we saw it also with education, but this idea, right, the have and have nots. And, and I like tricky that you said it's not just rural. There's, there's, um, broadband and cell deserts in urban areas, and they often align with, um, economic status or race and a way that's just, there is an equity issue. Um, so here's something I, this is, this leads into a really good question, which is, um, if you could talk to US lawyers or policymakers, what would you wanna let them know? Mark, I'll start with you.

Speaker 2:

Uh, I think, I think that, um, care coordination is, um, is, is going to become more of a thing. Um, and there's good and bad to it, but I, I think there's broadly a need for it. Um, and, uh, care is now everywhere and all different forms and data is, um, all over the place. And, um, uh, there is a need to have more, I think, direct to patient, direct to member, um, interactions and sharing of information. And I think that there's, there is a desire for, um, many individuals to share their information with family, um, even extended family and caregivers. And there are some, if you, you know, from a P H I perspective, uh, there's good reasons that those laws and policies are in place. Um, but there are also, it also in some ways makes it challenging and difficult. Um, if you just look at it from a cultural perspective, shared decision making, um, becomes ever more challenging. And, um, uh, I would, I would, um, sort of like to see, um, maybe a, a, a modification or a 2.0 version of, of HIPAA in some ways.

Speaker 3:

How

Speaker 1:

About you Tripti? What would you like to tell the policy makers and US health attorneys?

Speaker 3:

I, that's such a broad question,<laugh>,

Speaker 1:

Too much to say, okay, guys, stop regulating all this stuff. No,

Speaker 3:

Actually, and, and, and that, that would be part of it. I think that one is that, I think that the one thing that I would wanna say is that, um, physicians really are trying to do the best that they can under the circumstances that we have, regardless of what it is. And, um, and I really honestly believe as a practicing physician, um, as you know, as somebody who, and you know, is I'm, that deals with policymakers and, and with, um, surgeons and anesthesiologists and primary care physicians, we really have the best interest of the, of our patients at heart. We don't, I don't know of any physicians. I know they're out there, but you know, that really run a thousand extra tests because they're gonna put something in their pocket. Uh, you know what? I wish that wasn't there is all of the paperwork and, and like you said, the regulations, the amount of paperwork that is required in, you know, that, um, and time on the E H R, you know, the, is just astronomical. And it, what it, what does it do? It takes time away from our patients. I'm not saying that we should have our head in, in the sand. Uh, we, I, I think that we need to be at the table, but I think that that's part of it, that you need to invite us to the table. And because we have insights for efficiencies that will only help medicine as a whole. And if we continue to have people, you know, regulators say, you have to do this and you have to do that, and you have to check this box and, you know, otherwise you're not gonna get paid or it, it, it becomes counterproductive to what we need to do, which is take care of our patients. And if, I mean, sometimes you kind of wish kind of like, it's probably like the tax code<laugh>, I mean, you know, it's so complex that, you know, every once in a while you hear, oh, maybe we should just have a flat tax. And then it, you know, what does that do? You know, there's sometimes you're like, can you scrap this and start from ground zero? Well, we know we can't, but we have to start chipping away at all of the regulations and check boxes that we need to, that we, that we're required to do, um, so that we can go back to what we really should be doing, which is taking care of and spending time with our patients, being able to coordinate care for our patients and to be able to look at it, look at our patients more than just a hemoglobin or a lab value, but to really see everything that goes into what makes them well or what doesn't make them well.

Speaker 2:

And trip tripti, I that well said, and I, I think that's one of the promises of value-based, uh, care and value-based contracting and, you know, a renewed, uh, push, if you will, to capitated payments for, I'll just use primary care as an example. Um, I think that the, the newer models do show promise. Um, it's still a lot of work, but, um, if, if fundamentally a practicing, you know, physician is paid, um, you know, gets a cap check and is, and is responsible for managing the flock, if you will, I think when, when that starts to reach a critical mass, I think it's one of the key things that'll help, uh, with the, the fee for service hamster wheel. And, and I, and I really do hope allow that clinician to slow down a little bit and spend more time with the neediest patients and have a little bit of time, uh, to think about, uh, okay, who in my panel really needs more attention and care and I need to reach out and bring'em back in?

Speaker 1:

I think this is one reason why I enjoyed working on ACOs in the beginning, was the idea that, that we were getting different voices at the table and getting to hear and work with physicians and having the physicians tell us, Hey, maybe this would actually be easier if we did this, or This is how we feel about that. Uh, it was something that I, I found very rewarding. Um, one, one thing that this leads me to think about, and Mark, you and I have talked about this in the past, which is the idea of physician burnout, and then one thing that I have to imagine is after this pandemic, there's a lot of people that feel burned out, but I have to imagine physicians are feeling rather burned out. Um, uh, do you think it will have gotten worse? And what do we do about it?

Speaker 2:

It, it's, it's very real and it's very big. And, um, you know, I was talking to a group of, of clinicians last night, and, um, it's really, uh, sorry, it sounds weird, but, um, it was a very emotional conversation with a group of primary care clinicians who were just freely talking about how proud they were of keeping their practice open. Um, it, it was, um, it was impressive. And their, their stories are just amazing. Having most of their staff out sick, afraid quit. Um, you know, there's, there's physicians in the network who died this year. Um, there are practices that closed, and those that are open are, um, you know, they're not paying themselves and, um, they're not gonna be able to pay themselves for a while. And, um, it's, it, it really is, um, it, it really is a, um, a problem. And it's, um, I don't think, I don't think it's just gonna snap back to pre pandemic. Um, I think for a lot of, a lot of smaller practices in particular, um, you know, financially this was a big hit, uh, just aside from burnout aside and, um, and, uh, uh, I'm afraid that, um, uh, that too many will sort of, uh, either sell or, or decide to just, um, you know, go work for somebody else or, you know, take their, their surname off the door of their practice.

Speaker 3:

What, what do you think Trip D about burnout? Um, I think that it's going to get worse. And I think that we're going to start seeing, and I've seen P T S D and I, you know, unfortunately, physicians have never been good at taking care of themselves. It's not in, we are, we are the ones who were supposed to take care of each other. I remember in residency I had pneumonia and I, my, my primary care doctor said, you can't go back to work. And I'm like, oh, yeah, I have to. Well, little did I realize that she called my chairman, and my chairman called me into his office and said, you're not going to be here for the next, it was a Thursday. He goes, you're not gonna be here until Monday. Go home. That's it. Um, because that's what I thought was expected of me. Um, physicians at the moment, I think are still in crisis mode. We learn how to esp, we learn how to, how to adapt. You compartmentalize, you put your head down and you work, and you don't look up until you can, until things start to kind of let up. And with the continuous waves up and down, I know my colleagues are still in crisis mode, I'm afraid to see what happens when things start to slow down on a regular basis, where people will then have to kind of step back and see and take, take note of their emotions. And what's happened over the last year, 18 months, two years, depending upon how long this lasts, there has to be a, a shift in me in medicine to say that it is okay to get help. And that starts with, um, it starts at a local level, but it also has to be seen in state regulations and statute where when we have to, um, credential for hospitals the way that some of those credentialing forms are written, it doesn't, it asks, have you ever been treated for any mental health issue? Now, we all know that there can be situational depression. You have a family member that dies, a spouse, a hu you know, a a parent that can, or a child, God forbid, that can really affect you and you need help, and it should be okay, and it is okay to get help, but you shouldn't be penalized for it for getting help. The question that should be asked is, are you being treated for a mental health issue that will affect you being able to practice? And that's a, coming from a physician, and I know that I'm speaking to a lawyer,<laugh><laugh>, well, but I, no,

Speaker 1:

I You should do that. I think that's nothing wrong. You know, it's interesting because this, the legal profession is, should, is not as traumatized. And, and I think us, the health lawyers that I know are so supportive of physicians and frontline workers and EMTs, and we don't even know what to do. We wanted to support everybody. You know, Tripti, that's why I wanted to go out and talk about this because it's like we have to hear, we have to hear from people that are really living this. Um, but, you know, lawyers have that same problem of not putting their head up and not taking care of themselves. And, you know, the profession has to come to, to grips with it. And right now there's a lot of guilt from lawyers because, especially health lawyers, because we're like, well, we're not the ones caring for the patients, so we should just keep going. We have to help. We, you know, there's, the doctors are in the hospital and we have to go, like, you hear, or we have to go work until like three in the morning because we know there's other people out there. We have to support everybody. Um, so, but the idea that maybe people can be human like this, right? And we are fallible and you know, I, I think if, if that can come out of like this podcast or these conversations, I think that would be huge because how could you be good for everyone else if you're not like, good for yourself? And

Speaker 3:

We have to give kindness and grace to each other. And, but we also have to be able to start looking at mental health as some, as, as a part of medicine as a whole, just like it is cardiac disease and diabetes and everything else. And it's okay to get help and it should not be, and no one should be penalized for going to get help.

Speaker 1:

Yeah.

Speaker 2:

And, and we, you know, one of the, we've talked about telemedicine and, and there's, you know, sort of digital means of communication and, and yes, technology will advance, but you know, one of the most important things for a, a physician is no matter how bad your day is, the patient that gives you a hug and says, thank you is, you know, it's a, it's an emotional B12 shot for, for the clinician. And, um, that's one thing that I think that keeps most physicians going, no matter how difficult things get.

Speaker 1:

Well, that's a nice reminder to the audience, to thank your Doctor<laugh> and your nurses and all the other people out there, um, to wonderful things for us out there working hard. Um, so as we wrap up, I would like to know why you went, why you became a doctor, if that's okay. In a couple sentences. Um, mark, why don't I start with you?

Speaker 2:

I, uh, I wanted to help people and it just sounds, you know, uh, so general and such a thing that a, you know, a child would say, but I, but that's it. Um, I, I didn't really have an agenda, so to speak, um, but I, um, I, I remember just having an overwhelming pull, um, to help people. And, uh, and I could have done other things. There's a intangible, um, there, but, um, uh, but it, it's, it was a good match because, um, my clinical career and then, uh, what I'm doing now, working with physicians is, um, uh, incredibly meaningful professionally, but personally mostly.

Speaker 1:

How about you? Trip d

Speaker 3:

I went into medicine, um, initially, um, because it was kind of expected of me because of who my parents. Um, I'm Asian. It was something that I was supposed to do, although my dad kept saying that I wanted to be a doctor since I was five. I don't remember it, but that's okay.

Speaker 1:

<laugh>,

Speaker 3:

<laugh>. But I'd have to say that I grew into it and I grew to love it. I think that, um, there is a sacred trust that is given to you when you become a physician, where a patient opens up their heart, their mind, and their body to you, and they, and it is, it is a gift that, um, I am thankful that every patient has given me, and it is an honor for me to be able to take care of my patients. I think I, I, it never, that's never lost upon me with every patient that I have. Um, because it's you, you are at your most vulnerable when you are ill. And for me, when the patient is going into surgery, it is one of the most anxiety ridden times, um, that they will, that they, that they will have. And if I can hold their hand and give them a little, um, special juice to make it a little better for them so that it is as pleasant as it can be, um, then I know that I've, I've at least done something good for someone in this world. And, you know, I think that this world can use a little bit of happiness and a little bit of help, and I'm glad that I am able to give that, you know, every once in a while.

Speaker 1:

Well, that's a wonderful way to end this podcast where we wanted to hear what physicians were thinking about all the legal changes and, and changes in healthcare delivery during C O V D, but I think going back to where it begins, which is why you were drawn to the profession in the first place, is just a really wonderful way to end. So I would like to thank Mark and Trip D for joining us today, the audience for joining us today. And, um, have a wonderful day. Thank you.

Speaker 3:

Thank you.