Erin – Welcome to the Eva podcast. My name’s Erin. I’ll be your host where we explore all things health information technology, and Eva, the first interpretive health record system. So,without any further delay let’s get this episode started. Good morning, Dr. J.
Dr. J – Good morning, Erin. It’s great to talk with you.
Erin – All right, so today let’s talk about health insurance, which is not our favorite topic, but I would like to explore the recent blog post that I just released, which is Healthcare Duality, and when writing that blog, I realized that for me, healthcare duality and insurance go hand in hand. I’d like for you to take the floor, talk about your experience with health insurance, and then once we’ve talked about that, I wanna explore the kind of fear and questions that providers have when they make the transition from an insurance-based clinic to a cash-based clinic.
Dr. J – Right. Okay. So, first thing is health insurance is not what it says it is. It doesn’t ensure that you’ll be healthy. What it, what it’s for is to actually to pay for some of the charges that hospitals and other people do. That’s what health insurance does. It does not help you to be healthy. It does not think of problems that you have and solve them. That doesn’t happen. So, my, my status right now is I take no insurance at all in our practice. So, we’ve been doing that now for over 20 years. And, in the late eighties I had a house call service where I took care of little old people in their homes, and I thought it was a really noble, incredible thing to do. And I really enjoyed it. I had a great time with the, with the people I took care of, and we just had just a, a great time doing it. And I submitted bills to Medicare for house calls, so they said that must be fraud. Doctors don’t do house calls. And I wrote them back and said, no, I really did them, and they said, we need to see every chart that you’ve done this year. So, I had a stack of charts, I don’t know, three or four feet high. Sent ’em into Medicare and they reviewed ’em and said, oh, you actually did do the house calls, okay. So, after a lot of heartache, because it really was, it was so disappointing, I’d saved the system so much money and did such a, I, I think, such a good job, and really took care of those sweet people who are, you know, my people and then I just got this horrible response from the insurance industry that, in this case it was Medicare. Um I said, I’m not doing that ever again. I wrote them a scathing letter and said, well, heck with you, I’m never doing it again. And I meant it at the time. And I’ve never taken Medicare in my private practice since. And, that was the beginning of the departure with me from insurance. And now after having dealt with the, the reality of providers and insurance, it is the greatest obstacle, obstacle to quality care that there is. It’s worse than the EMR by far. Mm-hmm. EMRs are pain and they, they don’t work well except for Eva, but insurance is the major problem because doctors can’t do what they think best. They have to do what the insurance company allows. But if a patient has a contract with the doctor and they agree that the doctor will do what they think best, and as their charges are required, it’s a $100 or $500 or whatever, they agree on that, and then the doctor charges them that amount of money and they provide that service, the doctor can do anything that they want that’s reasonable and there’s no interference. So, the patient gets what they want when they want it in a customer service environment that’s really friendly and good. So, I, I, I have just decided every doctor that I work with and see I’m gonna recommend that they get off of insurance and go cash, and we’ve built our Eva software system to facilitate that process. Patient care, patient, patient care, so that it’s not about gratifying the insurance company or causing them to cough up some more money. Though you can use it for that at the end of the invoicing for Eva, it, it has a, a system you can submit the invoice to insurance, but that’s after you’ve done all your work and after you’ve determined what the patient needs and provided them the service, then you can submit that the insurance company and, and often patients get paid if they have out of network benefits, but that is completely outside of our focus or interest. We want doctors to succeed. We want them to be independent and allow them to be heroic in their communities where they’re providing service that nobody else will or can because they’re stifled by the insurance company.
Erin – So I wanna ask you, do you think the EMR came to fruition to support doctors meeting the needs, the charting and coding and billing needs or demands of insurance companies? From personal experience it seemed like a lot of my job in the various roles I’ve played as a nurse, you know, from operating room on the floor, in outpatient clinics, we spend a tremendous amount of time if our organization takes insurance focused on charting stuff so that it’s billed appropriately and especially in surgery, right? We spend so much time focusing on that surgical card and making sure that it’s correct, that we are using the correct amount of sutures, and, and, and that’s a tremendous amount of time in the surgical room versus actually helping with the procedure and being present for the provider and surgeons in the room and what they need for that patient. You know, I think a lot of patients don’t recognize that the reason why we spend so much time in front of a computer is so that they’re billed correctly because healthcare is expensive. And when we take away the time that we’re spending just charting via the construct of insurance, healthcare changes.
Dr J – Well, and the the thing is too, that in the beginning when EMRs were first developed, the idea was the insurance industry wanted to be able to carefully track how things were being spent, how their money was being spent, and how their patients were being cared for. And I think to a degree, that’s a good, that’s a noble thing. In addition to that, it was also there so that the regulators and government could track what are doctors doing. But at no time were EMRs designed with number one goal to improve patient care. That was never the goal. The goal was to make the numbers fit. So,are we charging what we say we’re charging? Are we spending the time that we say we’re spending as the insurance companies getting the bang for the buck that they should get? It’s not for patient care, it’s for regulatory and for insurance companies to get their, their bidding done. So it’s no wonder now the doctors spend more than half their time in non-patient care activity, basically satisfying the insurance company so that they can get the piddling amount of money that they can get from ’em, which by the way, is going down every year. The, the payments are decreasing and decreasing and decreasing from Medicare, which is a standard everybody else goes by, while inflation is going up, so it’s a no-win situation for doctors. The only option if a doctor chooses to remain independent is to go cash. Everything else is a losing proposition. It’s just a question of when you might be able to survive for another year or two, maybe five if you’ve got deep pockets. But no independent doctor will continue to thrive in an environment that depends primarily on insurance. They’re just gonna die. And every doctor who I’ve worked with, who I’ve recommended go cash, certainly they’ve had some fears and some have refused because of their fear, but all those that have made the transition are thankful and most within two months are making as much money as they made before and feel like they’ve been freed from captivity. So,it’s, it’s, and it’s universal. I have not had any doctor who goes cash who’s not excited about it and thankful to me that I recommended that they do it. So, it’s, it’s workable. And staying away from insurance, it sounds just so scary to doctors cause they’re so used to it. And I think patients are really used to it, but it’s effective and it works and we’ve done it and every time that we do it with a doctor, it works. And it’s consistent. All you have to do is do a good job, and I think most doctors do.
Erin – I think it’s important to discuss the elephant in the room or the ethical dilemma that surrounds moving from an insurance-based clinic to a cash-based clinic. And, for me, the ethical question came to, came down to, am I limiting care to only individuals that can afford health care, and am I ok with that? And, for me I didn’t become a nurse because I only wanted to give care to certain people I became a nurse because I wanted to care for all people and the ethical dilemma of care only being provided to people who can afford it is when you really look at the bigger picture and what is going on, that is what we are doing. That is actually what health insurance is doing to patients. And I can say that because that’s exactly what happened to me as an individual before I was a nurse, I had insurance. I had to have an emergency back surgery, out of nowhere, and my insurance denied that my surgery was necessary, even though if I would’ve not had this emergency back surgery, I would have had some long-term consequences that would’ve affected my career and my life. So, you know, clinically I knew it was an emergency, I now know even more because I’m a nurse and I’ve worked in surgery in that. But I, my claim was denied because I was too young. I had no preexisting conditions that would indicate I had anything going on with my back. Nothing made any sense. I was not in a traumatic car accident, nothing of that sort. So, they denied it and I ended up with a massive medical bill for back surgery that I had to navigate the reality of that for many years afterwards, including what it did to my credit score, in buying a house and in qualifying for any sort of personal loan, and, and I had health insurance. I followed all of the rules. I did nothing that would not qualify me for an emergency back surgery, but I was still denied. And I was so lucky to have a surgeon that fought for me for years, and he actually said before my surgery, there is a high likelihood your insurance will deny this because this insurance in particular always denies this surgery, this is their pattern. And that was a moment for me where I thought, oh my God, what, what are we doing? And is health insurance is the way it’s actually operating, not the intention, not what people view it as, it is the way it’s actually operating day to day. Is it, is it ethical? And I don’t have the exact answer for this, but I wanna speak to what it means for providers to face this ethical question. And, and then also what it means if you continue to choose insurance at your own detriment to the point where you can’t afford your medical supplies in office, you can’t afford to pay your staff, you’re actually paying your staff and not paying yourself as a provider, and you end up closing your doors.
Dr J – Yeah. Well, it’s, I think that’s the, one of the great questions besides fear which limits doctors, is like, am I gonna be able to survive if I do this? The other one is morally, you know, I’m a doctor, I’ve been given by so many people, such a blessing of learning and so many people giving me their time to making me good, to make me good at what I do, you know, teaching me over the years. And so I have quite an investment in me from society and the whole medical world, and it would be unconscionable for me just to say, well, none of that matters, I need to take care of myself. The ethics of it are, are pretty clear. You don’t, you don’t have the right as a physician or as a provider who’s been trained and really given all that we are given to be great, to just turn your back on culture and say it doesn’t matter. What does matter is that if you intend to remain independent, you will inevitably be shut down and not provide any care at all. So, you have to decide, rather than letting the government or the law of the jungle, triage your patients, you triage ’em, and patients who want to get taken care of will either come up with the money to get paid for, or you’ll take care of them for free, liike we do. We give 20% of our care away every, so, we have a huge charitable giving component to our practice. One of the doctors down the street who I used to refer to liberally because he’s a brilliant internist I called him to refer a patient who was a little complicated for me, and his office was closed. And I called a few more times and turns out they were permanently closed. So, I called him on his cell phone and asked what happened? And he said, well, you know, in January, Medicare delayed their payments, so I had to pay the rent, by out of pocket. And I said, oh, that’s a bummer. I said, then what happened? He said, well, in February, they cut the rates by 6% or 8%, or whatever the number was, it was a large amount. He said, so then I really wasn’t making enough money to pay to, even if the payments came to make, pay the rent. So, I paid the rent again outta my pocket, and then the next month, payments were slow and down. I had to pay the nurses, and the following month I couldn’t even pay my own salary, so I just had to close the doors. But I didn’t want to do it because ethically, I couldn’t leave my Medicare patients behind. And I said, well, why didn’t you just quit doing Medicare? He said, well, I couldn’t do it ethically, morally, I felt bad. And I said, well, now you’re closed, how do you feel about that ethically, now that you’re not taking care of any Medicare patient who wanted to pay you, they can’t see you at all. There’s, there’s no access to you at all because you, you put your stake in the ground in the wrong place. You made a decision to not accommodate the reality of the situation. You’re not gonna be able to stay open if you continue to take insurance, right, you’re cutting everybody off who chooses to pay for the care that they’re getting? Everyone a 100%. So, whether they can pay or they can’t pay, whether you want to give it for free like we do or not, it’s, it’s closed. So, you have to make a decision as a provider, am I gonna allow the system to crush me or am I gonna slide out from under that and look at like the light at the end of the tunnel and, and actually head towards the light and say, okay, there is a way to do this contract honestly with patients, having them pay you cash for your service and do a great job for them so they, they keep coming back, which is a novel concept in medicine. But like any Neiman Marcus kind of Four Seasons environment, you provide excellent service, people are happy to come back and pay you for that service. And the better your service, the more you’ll, you’re able to charge. And it’s convenient and it’s high quality and ethically it’s entirely satisfying. So…
Erin – absolutely,
Dr J – that’s what I think. And, and will it limit access to, to care? Only to people who choose not to get it. Only people who don’t wanna make any sacrifice to receive care. So, if they want to ask for help for free, we’re willing to do it on a limited basis, but we will.
Erin – Right.
Dr J – And if they need a payment consideration, we’ll do that. So, it’s very rare when we say no to somebody on the basis of money. Very rare. It happens, but mostly that’s people who choose not to pay anything.
Erin – You know, I’m one for inspirational stories. I think we all are. And to hear that a provider has to close their doors, someone who had the courage to leave a larger organization to go out and try to create a system of care because their system of care is making a huge difference in patients’ lives. You know, generally people who leave to go independent practice are not doing it for money. They’re doing it because they wanna give the kind of care that they believe they can give and they, they think, they’ve had patients so happy with the kind of doctors that they are, or provider type, that they wanna do it independently and they should be able to do that. But It’s extremely expensive to do that. And to get to the point, just like any new business, right, medical’s no different, you have three years where you’re essentially making nothing and you have to make sure that you’re playing that balancing game correctly and how insurance kind of tilts the scale, i’s really unfortunate and I, I hope that, you know, we can continue to make the point that If you are taking insurance, you are pricing your services and your supplies at such a high rate because you’re hoping to get reimbursed and you don’t know if you will, and then if you don’t get reimbursed or that patient gets declined, that patient is then responsible for that price, that way, higher price, right? Versus if you bypass that insurance, you can actually create a realistic pricing structure for patients. So going cash does not mean you have entered the wild west and you can do whatever you want, it actually makes you more accountable. It, it makes it so that your patients are also your customers in that you have to be transparent about what you are charging for, and you can, with a system like Eva, show them everything you’ve charged for down to a bandaid. And instead of like, or larger organizations that I’ve worked with, charging $40 for a standard bandaid, you can actually charge five, right? Cause five would include some of your time or three, or you can create a pricing structure that is accessible to the demographic you want to work with. So, I’ve worked with a provider who, she offers direct primary care at an incredible rate. And she has customers flying in the door because she offers a low monthly rate for primary care, a low accessible monthly rate for primary care so that patients can get what they need. In a state where they are, they have no primary care doctors. It is a year, a six month to a year wait for primary care doc, so she’s provided a service to individuals at a cheaper rate than what they get back for their insurance. And so entering the cash world doesn’t mean you have to make these decisions that cripple patients financially. It actually empowers you to make smart financial decisions that empower your patients and their ability to get care cause they’re gonna pay for care anyway like that the care is getting paid for some how in some way. If we right now with the system that we have that exists, if we have a clinic move into a cash-based model, they are empowered to choose the pricing structure and choose what that pricing structure is like for different kinds of individuals, right? Whether they’re very low income or really high income, you get to make that business choice and generally those going into independent practice, if they’ve taken that big of a risk, they’re looking to make healthcare accessible and to be able to give really good care. So that brings me to Eva. Eva allows you to do all of this. Eva allows you to be accountable, clear, and outline every bit of service, and then you actually give all of that clarity to your patient, so your patient sees everything that you’re charging for. And not only that, there is a record of all of those charges in their patient portal. So you’ve created a transparent healthcare system, right? Cause they see all of their notes, they see everything, all of their results, all of their billing. It’s completely transparent. So what it does is it helps the patient understand and make a decision on care. Is this care worth the value, do I wanna keep coming here? Yes. Do I not? Great. You don’t have to. And it also allows you to answer the phone and a prospective patient come in and say, how much do you charge for this? And you straight up say, we charge this and they say, hey, I can’t afford that. And you can say, these are our payment options. And they can say, that doesn’t work for me. And you can go, great, I know of another place that maybe you could go to or you could say okay, well what would work for you? And you can kind of negotiate on that level. You have complete freedom there. And I think having a system like Eva to do that, that’s worth me spending my time educating and sharing it with others.
Dr J – There’s so many things that are like, so obvious and normal in culture in our, when you go to Home Depot and you get a receipt, it says, you know, 1 ½ inch screws, $4.50. That stuff is just so logical and it’s so missing from the healthcare equation except for Eva. But Eva was developed in, in our practice since 2003. With the first blush was how do we do a better job figuring out how to take care of patients well? How do we do a better history? How do we develop that? And we developed an algorithm an AI to, to manage that. And then it continued to grow until it’s a comprehensive practice management system from really understanding the patient well, providing the information so rapidly that instead of an hour long interview, it’s about a minute worth of time that it requires to really understand the patient’s key issues so that the, the, the time saving, there is money that the patient actually, it, it, it’s given back to the patient. So, for that time that they spend doing the online survey questionnaire that money’s given back to them so that we can dial in on what’s the exact problem and get to the root of the problem. And then as we proceed through that whole process, it’s all driven by what makes our patient care better. How do we do a better job for the patient? How do we communicate that information better? The 21st Century Cures Act, which you referred to, is that that law that everybody’s charts have to be open as of last spring. Almost a year ago now, and, and nobody’s are fully open, like, ours and Eva is an entirely open system where the, the portal actually is just the patient, patient access to the entire record as well as it just, and a pretty way to get there. It’s just prettier. But all of the technology that we developed is the patient first. Patient first, and the insurance company’s like whatever their arrangement is with insurance, that’s their business. And any way that we can facilitate that by providing them with the paperwork for what we did, we’re happy to do it, but we’re not gonna let the insurance company influence how we take care of a patient. So, if a patient has a need that the insurance company doesn’t see as something to pay for it doesn’t inhibit us from doing it with the patient’s permission. Hey, is it okay if we do this? Great. We ask every time we do anything, we ask, is it okay? It’s gonna be a couple hundred dollars or $40, or whatever it is we ask. We get permission. We do it just like scanning your bag of screws and nails at Home Depot. Yep, that’s what I want. Okay. And you pay it. And because we do it the way we do, it’s extremely efficient. The patient gets excellent care in a cost effective way. And as a practice, we make very, very good income. Our, our income’s really good because we don’t waste it on burning all this insurance time. We’re on the phone with the insurance company saying, please let me do the test on the patient. We don’t have to do that. We just make the agreement with the patient that will do what we need that’s best for them. And if at any point it becomes something that they can’t manage financially, that we can’t help them with, then we refer them onto a specialist in the regular system and, and the regular system has to absorb that. But that’s a rare occurrence. It’s really rare.
Erin – I just wanna mention that you’ve had patients for a very long time. You’ve had patients in your clinic seeing you for a long time.
Dr J – not old.
Erin – It’s incredible. For a business to have customers come back for 20 years speaks a lot to that business. For patients to continue to see a provider for 20, 15, 10 years even 5, speaks a lot to that provider to be able to do both, speaks to the health of your practice.
Dr J – We have the, we have the bandwidth because we, because we charge for the service that we provide, we have the bandwidth to have we, we have the office cleaned regularly by professional staff. We have really high quality. We put blankets on patients when it’s was cool outside. We, we take care of them. And it’s not a, a, a spa policy fluffy thing, it’s, it’s actually caring for the patient’s needs. And because of that, we do have patients who’ve been with us for 20 or 30 years because we’ve never failed to do that. And we always, it’s always the patient first. And if you do that, you don’t need to market as hard if at all. And you don’t need to worry about, about getting patients, retaining them, because If you really care for people, that’s an attractive model. People they’re looking for that, they want to be cared for, they don’t want to be processed or managed. They wanna be cared for. And if you’re doing insurance, you’re basically managing what the insurance allows. If there’s anything left over financially at the end of it, you’re probably using it to give your staff a raise cause you know, you can’t really, you can’t afford to keep up with the marketplace in terms of salary, supplies, staff, building. It’s just, it’s nearly impossible and it will be. I’m just saying, I mark my words within the next several years, independent practices that are, that depend on insurance for payment will close. They’ll just close all primary care and introductory level care practices. They’re just gonna close because you, there’s no way outside of an integrated, big system that you’re gonna be able to survive. And I think that’s probably the goal of large systems is get all the, all the patients funneled through their, their systems. So they get all the MRIs and they get all the surgery, and they get all the hospitalization, and they get all that that financial. benefit. I think the patient should benefit from care. Doctors should take care of the patient. The patient should be healthier, stronger, and they should get what they need sooner. Not, it’s not a cow to milk patients or people.
Erin – Yeah, no. We don’t need any more processing at this point.
Dr J – Never processing.
Erin – Well, that’s how Eva came to be really, Eva was born from you leaving the larger institution, opening an independent practice and needing a system to support you giving the kind of care you wanted to give, the best kind of care you could give and what you knew, and to grow with that. And then also to support your business, to keep your doors open, to pay for the staff you needed to pay, to pay yourself, and to pay for all of your supplies, your rent, your electricity, everything. Right? And so you created Eva, and I love that I’m a part of the Eva team now because I get to take Eva to any provider that says, hey, I need help, or I’m interested in streamlining my processes so that I can give the best kind of care possible at an affordable rate that I get to determine and keep my doors open and long-term patient relationships. Can you help me do this? Is this possible? And I say, absolutely. Let me help you do it. I get the greatest joy in creating something for great healthcare providers out there that allows them to continue to give care and also provide accessibility to patients in the way that they can. That’s, that right there is why I’m here. Being able to do that, it is giving care to providers. It is what I love to do as a nurse, to support the provider. To support the provider relationship. That’s why I went into surgery. So Eva. Eva is the way that I can care for really good doctors, and to me that’s rewarding. If I can care for really good doctors, then I’m helping care for patients. And at this point, I think healthcare providers really need that support. They need a system that helps care for them so that they can continue to give the best kind of care that they can. So Eva helps me take care of them.
Dr J – It’s, it’s medicine for the practice. Yeah. So I, it’s interesting though, it’s, I, as we’re finishing, it’s just like, I think to, for providers just to hear the primary thing that keeps providers from, from making the switch is they’re just afraid that it won’t work. They’re afraid that they’re gonna go broke or that people are gonna think that they’re jerks or, or whatever, and I will just tell you, I’ve seen many physicians make the transition. I’ve lived in cash world for, you know, a couple of decades and very successfully and very happily. And the other thing is the, is the moral, like, well, what about the world that we’re taking care of? We can’t take care of everything, but we can take care of our patients. So I think if as long as you keep focused on, take care of the patient that’s in front of you and do the best job that you can, you’ll be as busy as you can tolerate and you’ll do a great job and morally you’ll be doing the right thing because taking care of the patient in front of you is the right thing. And Eva will help you do that. And we’ve designed all the program and the process to just compliment that whole thing. And we only bring up the cash insurance thing because if you don’t do that, it’s hard for any system to work and you’re just gonna fail. And we don’t want you to fail.
Erin – We want success for independent providers and their entire staff. All right. Thanks so much for your time, Dr. J.
Dr J – We’ll talk soon. Erin – Sounds great. Well, that’s it for today. Thanks for joining me on the Eva podcast. I’m Erin, your host, and I’ll see you next time.