Podcasts about rvus

Is it possible to deliver life-changing news—with compassion—without sacrificing precious time or the physician's own well-being? It's a burning question for healthcare professionals everywhere, and the impact of getting it right goes far beyond the exam room. Not only does compassionate communication ease patient anxiety and foster loyalty, but it also drives better outcomes, even in the face of a system that pressures doctors to prioritize speed and productivity (those infamous RVUs!). As the demands on clinicians mount, many struggle with “compassion fatigue,” and patients often experience rushed, impersonal conversations when they need empathy and understanding most. This episode offers a solution—and hope—for both sides of the stethoscope. You should listen to this episode because my guest, Dr. Rachel Hitt, delivers a masterclass in patient communication. As Chief of Breast Imaging at Tufts Medical Center and Medical Director of Patient Experience for Tufts Medicine Integrated Network, she brings more than 20 years of clinical expertise and a passion for improving the way difficult news is shared with patients. Dr. Hitt is not only a practicing clinician; she's a certified facilitator in healthcare communication and a certified patient experience professional, dedicating herself to coaching and elevating the next generation of physicians. Her insights are practical, inspiring, and applicable well beyond healthcare—for anyone who faces moments of tough conversations and wants to make those moments matter. Here are three powerful questions Rachel answers on the show: Why do so many healthcare professionals struggle with delivering difficult news compassionately—and how can they overcome barriers like exhaustion, lack of time, and institutional pressure? What is the ART model for patient communication, and how does it transform a monologue into a meaningful dialogue, even when sharing devastating diagnoses? How do small gestures—like a brief pause, gentle touch, or simply asking permission to enter—impact patient experience, loyalty, and even the bottom line for hospitals and health systems? Listen in and subscribe! Find this episode on Apple Podcasts and Spotify, and catch all future episodes on your favorite podcast platforms: Apple Podcasts Spotify (Available wherever you get your podcasts—just search for “Delighted Customers”!) Meet Dr. Rachel Hitt Dr. Rachel Hitt, MD, MPH, is the Chief of Breast Imaging at Tufts Medical Center and Medical Director of Patient Experience for the Tufts Medicine Integrated Network. With more than two decades of experience, she has touched thousands of lives, guiding patients and their families through some of their most vulnerable moments. Rachel graduated from Harvard Medical School and completed her residency in radiology and fellowship in breast imaging at Massachusetts General Hospital—two of the nation's most prestigious medical institutions. She also holds a Master's in Public Health from the University of Michigan and is a certified facilitator in healthcare communication through the Academy of Communication and Healthcare. Rachel is a Certified Patient Experience Professional (CPXP), and she's equally comfortable in academic medical centers and private practice settings. She has dedicated much of her career to teaching, coaching clinicians, and speaking at conferences about how medical professionals can improve the patient experience—“chunking and checking” information, meeting people where they are, and nurturing authentic, empathetic relationships. Connect with Rachel on LinkedIn. References and Show Notes Academy of Communication in Healthcare Dr. Steven Tresiak's “power of 40 seconds” research (Ted Talk) LinkedIn: Dr. Rachel Hitt Book reference: "All Business is Personal" by Dr. Joseph Michelli (from prior episodes) RVU (Relative Value Units) model in healthcare Techniques for improving patient loyalty and experience Thanks for listening—subscribe and share if you want more episodes just like this!

No money, no mission. Understanding coding is the key to funding care and making your practice sustainable. In this episode of BackTable OBGYN, host, Dr. Mark Hoffman, chats with Dr. Jon Hathaway, associate professor at IU School of Medicine and coding specialist. They discuss the intricacies of medical billing, the impact of coding knowledge on revenue, and the systemic gaps in residency training regarding financial literacy. ---SYNPOSISDr. Hathaway shares his journey from mastering coding to becoming a national expert, providing a crash course on CPT, RVU, and ICD codes, and emphasizing the importance of accurate billing for the sustainability of healthcare practices. The episode offers valuable insights into the challenges and opportunities in medical coding and the broader financial aspects of healthcare.---TIMESTAMPS00:00 - Introduction 02:03 - Dr. Hathaway's Journey into Coding04:11 - Understanding the Financial Side of Healthcare07:10 - The Disconnect in Healthcare Payments11:26 - The Complexity of Medical Billing18:11 - The Role of CPT, RVU, and ICD Codes24:03 - The Process of Approving New Procedures32:38 - Understanding the Value Update Process33:47 - Case Study: Cystoscopy in Hysterectomy Codes35:26 - Survey Participation and Its Impact36:12 - Roles and Responsibilities in ACOG38:12 - Challenges of RVU-Based Compensation42:08 - Specialty-Specific RVU Valuation48:42 - Comparing OB and GYN Reimbursements50:02 - Envisioning an Ideal Healthcare System55:10 - Maximizing Billing Efficiency59:46 - Final Thoughts

The way docs are paid can make patients sicker...or can lead to healthier ones. The payment schemes most docs work under incentivize them to fix patients, while others motivate them to prevent illness—and geriatrician Dr. Jonathan "Nathan" Flacker is here to explain why. This episode rips the curtain off RVUs, fee-for-service traps, and the real reason your doc is rushing through your visit (hint: it's not personal, it's math). We dig into ChenMed's wild idea: what if clinics got paid to keep you out of the hospital? Turns out, when money flows toward health instead of procedures, everyone wins. Except maybe the $400M proton beam facility (for the record, we love proton beams, but you might not need them if you can avoid cancer altogether). Is concierge-style medicine only for the wealthy? What happens when you build “rich person care” for low-income seniors? And how many patients can a doc see well before it all breaks? If you're dreaming of a career where you actually help people instead of just clicking boxes—this one's a wake-up call. Also: Love calls, RVU debt, and why pajama time should be illegal.

Welcome to The Second Skillset podcast series! In this second episode, our panelists discuss how to build the business fluency needed to engage in the strategic and financial decisions that shape your practice and service line. The conversation covers key financial concepts such as relative value units (RVUs), contribution margin, and value-based care models. Listeners will learn how to collaborate effectively with administrators using business cases and data-driven insights and apply a simple framework to propose and evaluate operational initiatives in their clinical setting.  Subscribe to PracticeMadePerfect|  

Dr. Joseph McCollom and Dr. Ramy Sedhom discuss precision palliative care, a new strategy that aims to align palliative care delivery with patient and caregiver needs instead of diagnosis alone. TRANSCRIPT ADN Podcast Episode 8-22 Transcript: What Is Precision Palliative Care? Rethinking a Care Delivery Problem Dr. Joseph McCollom: Hello and welcome to the ASCO Daily News Podcast. I'm your guest host, Dr. Joseph McCollom. I'm a GI medical oncologist and palliative oncologist at the Parkview Packnett Family Cancer Institute here in Fort Wayne, Indiana. So, the early benefits of palliative care for patients with cancer have been well documented, but there are challenges in terms of bandwidth to how do we provide this care, given the workforce shortages in the oncology field. So today, we'll be exploring a new opportunity known as precision palliative care, a strategy that aims to align care delivery with patient and caregiver needs and not just diagnosis alone. Joining me for this discussion is Dr. Ramy Sedhom. He is the medical director of oncology and palliative care at Penn Medicine Princeton Health and a clinical assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine. Our full disclosures are available in the transcript of this episode.  Dr. Sedhom, it's great to have you on the podcast today. Thank you so much for being here. Dr. Ramy Sedhom: Thank you, Joe. It's a pleasure to be here and lucky me to be in conversation with a colleague and friend. Yes, many of us have heard about the benefits of early palliative care. Trials have shown better quality of life, reduced symptoms, and potentially even improved survival. But as we know, the reality is translating that evidence into practice, which is really, really challenging. So Joe, both you and I know that not every patient can see palliative care, or I'd even argue should see palliative care, but that also means there are still many people with real needs who still fall through the cracks. That's why I'm really excited about today's topic, which we'll be discussing, which is precision palliative care. It's a growing shift in mindset from what's this patient's diagnosis or what's this patient's prognosis, to what matters most for this person in front of me right now and what are their individual care needs. I think, Joe, it's very exciting because the field is moving from a blanket approach to one tailored to meet people where they actually are. Dr. Joseph McCollom: Absolutely, Ramy. And I think from the early days when palliative care was kind of being introduced and trying to distinguish itself, I think one of the first models that came to clinicians' eyes was Jennifer Temel's paper in The New England Journal of Medicine in 2010. And her colleagues had really looked at early palliative care integration for patients with advanced non–small cell lung cancer. And in that era – this is a pre-immunotherapy era, very early targeted therapy era – the overall prognosis for those patients are similar to the population I serve as a GI medical oncologist, pancreatic cancer today. Typically, median overall survival of a year or less. And so, a lot of her colleagues really wanted her to track overall survival alongside quality of life and depression scores as a result of that. And it really was a landmark publication because not only did it show an improvement of quality of life, but it actually showed an improvement of overall survival. And that was really, I think, revolutionary at the time. You know, a lot of folks had talked about if this was a drug, the FDA would approve it. We all in GI oncology laugh about erlotinib, which got an FDA approval for a 2-week overall survival advantage. And so, it really kind of set the stage for a lot of us in early career who had a passion in the integration of palliative care and oncology. And I think a lot of the subsequent ASCO, NCCN, COC, Commission on Cancer, guidelines followed through with that. But I think what we realized is now we're kind of sitting center stage, there's still a lot of resource issues that if we sent a referral to palliative care for every single patient diagnosed with even an advanced cancer, we would have a significant workforce shortage issue. And so, Ramy, I was wondering if you could talk a little bit about how do we help center in on who are the right patients that are going to have the greatest benefit from a palliative care specialist intervention? Dr. Ramy Sedhom: Thanks, Joe. Great question. So you mentioned Dr. Temel's landmark 2010 trial published in the New England Journal of Medicine. And it is still a game changer in our field. The results of her work showed not only improved quality of life and mood, but I think very surprisingly at the time, a survival benefit for patients with lung cancer who had received early palliative care. That work, of course, has helped shape national guidelines, as you've shared, and it also helped define early, as within 8 weeks of diagnosis. But unfortunately, there remains a disconnect. So in clinical practice, using diagnosis or stage as the only referral trigger doesn't really match the needs that we see show up. And I think unfortunately, the other part is that approach creates a supply demand mismatch. We end up either referring more patients than palliative care teams can handle, or at the opposite extreme, we end up referring no one at all. So, I actually just wanted to quickly give, for example, two real world contrasts. So one center that I actually have friends who work in, tried as a very good quality improvement incentive, auto-refer all patients with stage IV pancreas cancer to palliative care teams. And while very well intentioned, they saw very quickly that in a two-month period, they had 30 new referrals. And on the palliative care side, there were only 15 available new patient slots. On the other hand, something that I often see in practice, is a situation where, for example, consider the case of a 90-year-old with a low-grade B-cell lymphoma. On paper, low-risk disease, but unfortunately, when you look under the microscope, this gentleman is isolated, has symptoms from his bulky adenopathy, and feels very overwhelmed by many competing illnesses. This is someone who, of course, may benefit from palliative care, but probably doesn't check the box. And I think this is where the model of precision palliative care steps in. It's not really about when was someone diagnosed or what is the prognosis or time-based criteria of their cancer, but it's really fundamentally asking the question of who needs help, what kind of help do they need, and how urgently do we need to provide this help? And I think precision palliative care really mirrors the logic and the philosophy of precision oncology. So just like we've made strides trying to match therapies to tumor biology, we also need to have the same attention and the same precision to match support to symptoms, to context of a patient situation and their caregiver, and also to their personal goals. So I think instead of a blanket referral, we really need to tailor care, the right support at the right moment for the right person to the right care teams. And I think to be more precise, there's really four core elements to allow us to do this well. So first, we really need to implement systematic screening. Let's use what we already have. Many of our centers have patient reported outcomes. The Commission on Cancer motivates us to use distress screening tools. And the EHR is there, but we do very little to flag and to surface unmet care needs. We have seen amazing work from people like Dr. Ethan Bash, who is the pioneer on patient-reported outcomes, and Dr. Ravi Parikh, who used to be my colleague at Penn, now at Emory, who show that you could use structured data and machine learning to identify some of these patient needs in real time. The second piece is after a systematic screening, we really need to build very clear referral pathways. One very good example is what the supportive care team at MD Anderson has done, of course, led by Dr. Eduardo Brera and Dr. David Huey, where they have, for example, designed condition-specific triggers. Urgent referrals, for example, to palliative care for severe symptoms, where they talk about it like a rapid response team. They will see them within 72 hours of the flag. But at the same time, if the unmet need is a caregiver distress, perhaps the social work referral is the first part of the palliative care intervention that needs to be placed. And I think this helps create both clarity and consistency but also it pays attention to that provider and availability demand mismatch. Third, I really think we need to triage smartly. As mentioned in the prior example, not every patient needs every team member of the palliative care team. Some benefit most from the behavioral health intervention. Others might benefit from chaplaincy or the clinician for symptom management. And I think aligning intensity with complexity helps us use our teams wisely. Unfortunately, the greatest barrier in all of our health care systems is time and time availability. And I think this is one strategic approach that I have not yet seen used very wisely. And fourth, I really think we need to embrace interdisciplinary care and change our healthcare systems to focus more on value. So this isn't about more consults or RVUs. I think it's really about leveraging our team strengths. Palliative care teams or supportive care teams usually are multidisciplinary in their core. They often have psychologists, social workers, sometimes they have nurse navigators. And I think all of these are really part of that engine of whole person care. But unfortunately, we still are not set up in care delivery systems that unfortunately to this day still model fee for service where the clinician or the physician visit is the only quote unquote real value add. Hopefully as our healthcare systems focus more on delivery and on value, this might help really embrace the structure to bring through the precision palliative care approach. Dr. Joseph McCollom: No, I love those points. You know, we talk frequently in the interdisciplinary team about how a social worker can spend 5 minutes doing something that I could not as a physician spend an hour doing. But does every patient need every member every time? And how do we work as a unified body to deliver that dose of palliative care, specialized palliative care to those right patients and match them? And I think that perfect analogy is in oncology as a medical oncologist, frequently I'm running complex next-generation sequencing paneling on patients' tumors, trying to find out is there a genetic weakness? Is there a susceptibility to a targeted therapy or an immunotherapy so that I can match and do that precision oncology, right patient to the right drug? Similarly, we need to continue to analyze and find these innovative ways like you've talked about, PROs, EHR flags, machine learning tools, to find those right patients and match them to the right palliative care interdisciplinary team members for them. I know we both get to work in oncology spaces and palliative and supportive spaces in our clinical practice. Share a little bit, if you could, Ramy, about what that looks like for your practice. How do you find those right patients? And how do you then intervene with that right palliative oncology dose? Dr. Ramy Sedhom: So Joe, when I first started in this space as a junior faculty, one thing became immediately clear. I think if we rely solely on physicians to identify the patients for palliative care, we're unfortunately going to be very limited by what we individually, personally observe. And I think that's what reflects the reality that many patients have real needs that go unseen. So over the past few years, I've really worked with a lot of my colleagues to really work the health system to change that. The greatest partnership I've personally had has been working with our informatics team to build a real time EHR integrated dashboard that I think helps us give us a broader view of patient needs. What we really think of as the population health perspective. Our dashboard at Penn, for example, pulls in structured data like geriatric assessment results, PHQ-4 screens, patient reported outcomes, whether or not they've been hospitalized, whether or not these hospitalizations are frequent and recurrent. And I think it's allowed us to really move from a reactive approach to one that's more proactive. So let me give you a practical example. So we have embedded in our cancer care team, psycho-oncologists. They share the same clinic space, they're right down the hall. And we actually use this shared dashboard to review weekly trends in distress scores and patient reported outcomes. And oftentimes, if they see a spike in anxiety or worsening symptoms like depression, they'll reach out to me and say, “Hey, I noticed Mrs. Smith reported feeling very anxious today. Do you think it'd be helpful if I joined you for her visit?” And I think that's how we could really use data and teamwork to offer and maximize the right support at the right time. Like many of our other healthcare systems, we also have real-time alerts for hospitalizations. And I think like Dr. Temel's most recent trial, which we'll discuss at some point, I'm sure, it's another key trigger for vulnerability. I think whenever someone's admitted or discharged, we try to coordinate with our palliative care colleagues to assess do they need follow-up and in what timeline. And we know that these are common triggers, progression of disease, hospitalizations, drops in quality-of-life. And it's actually surprisingly simple to implement once you set up the right care structures. And I think these systems don't just help patients, which is what I quickly learned. They also help us as clinicians too. Before we expanded our team, I often felt this weight, especially as someone dual trained in oncology and palliative medicine, as trying to be everything to everyone. I remember one patient in particular, a young woman with metastatic breast cancer who was scheduled for a routine pre-chemo visit with me. Unfortunately, on that day, she had a very dramatic change in function. We whisked her down to x-ray and it revealed a pretty large pathologic fracture in her femur. And suddenly what was scheduled as a 30-minute visit became a very complex conversation around prognosis, urgent need for surgery and many, many life changes. And when I looked at my Epic list, I had a full waiting room. And thankfully, because we have embedded palliative care in our team, I was able to bring in Dr. Collins, the physician who I work with closely, immediately. She spent the full hour with the patient while I was able to continue seeing other patients that morning. And I think that's what team-based care makes possible. It's not just more hands on deck but really optimizing the support the patient needs on each individual day. And I think last, we're also learning a lot from behavioral science. So many institutions like Penn, Stanford, Massachusetts General, they've experimented with a lot of really interesting prompts in the EHR. One of them, for example, is the concept of nodes or the concept of prompt questions. Like, do you think this patient would benefit from a supportive care referral? And I think these low-level nudges, in a sense, can actually really dramatically increase the uptake of palliative care because it makes what's relevant immediately salient and visible to the practicing physician. So I think the key, if I had to maybe finish off with a simple message: It's not flashy tech, it's not massive change against staffing, but it's having a local champion and it's working smarter. It's asking the questions of how can we do this better and setting up the systems to make them more sustainable. Dr. Joseph McCollom: I appreciate you talking about this because I think a lot of folks want to put the wheels on in some way and they don't know where to get started. And so I think some of the models that you've been able to create, being able to track patients, screen your population, find the right individuals, and then work within that team to be able to extend, I think when you have an embedded palliative care specialist in your clinic, they expand your practice as a medical oncologist. And so you can make that warm handoff. And that patient and that caregiver, when they view the experience, they don't view you as a medical oncologist, someone else as a palliative care specialist, they view that team approach. And they said, "The team, my cancer team took care of me." And I think we can really harness a lot of the innovative technological advancements in our EHR to be able to prompt us in this work. I know that Dr. Temel had kind of set the stage for early palliative care intervention, and you did mention her stepped palliative care trial. Where do you see some of the future opportunities as we continue to push the needle forward as oncologists and palliative care specialists? What do you see as being the next step? Dr. Ramy Sedhom: So for those who are not familiar with the stepped palliative care trial, again, work by Dr. Temel, I think it's really important to explain not just the study itself, but I think more importantly, what it's representing for the future of our field. First, I really want to acknowledge Dr. Temel, who is a trailblazer in palliative oncology. Her work has not only shaped how we think about timing and delivery, but really about the value of supportive care. And more importantly, I think for all the young trainees listening, she had shown that rigorous randomized trials in palliative care are possible and meaningful. And I think for me, one quick learning point is that you could be an oncologist and lead this impactful research. And she's inspired many and many of us. Now let's quickly transition to her study. So in this trial, the stepped palliative care trial, patients with advanced lung cancer were randomized into two groups. One group followed the model from her landmark 2010 New England Journal of Medicine paper, which was structured monthly palliative care visits, again, within eight weeks of diagnosis. The second group, which is in this study, the intervention or the stepped palliative care group, received a single early palliative care visit. Think of this as a meet and greet. And then care was actually stepped up. If one of three clinical triggers happened. One, a decline in patient reported quality of life as measured by PROs. Two, disease progression, or three, hospitalization. And the findings which were presented at ASCO 2024 were striking. Clinical outcomes, very similar between the two groups. And this included quality-of-life, end-of-life communication, and resource use. But I think the take-home point is that the number of palliative care visits in the stepped group was significantly lower. So in other words, same impact and fewer visits. This was a very elegant example of how we can model precision palliative care, right sizing patient care based on patient need. So where do we go from here? I think if we want this model to take root nationally, we really need to pull on three key levers: healthcare systems, healthcare payment, and healthcare culture. So from a system alignment, unfortunately, as mentioned too often, the solution to gaps in palliative care is we need more clinicians. And while yes, that's partly true, it's actually not the full picture. I think what we first need to do and what's more likely to be achieved is to develop systems that focus on building the infrastructure that maximizes the reach of our existing care teams. So this means investing in nurse navigation, real-time dashboards with patient-reported outcomes and EHR flags, and again, matching triage protocols where intensity matches complexity. And the goal, as mentioned, isn't to maximize consults, but to really maximize deployment of expertise based on need. The second piece is, of course, we need payment reform. So the stepped palliative care model only works when it allows continuous patient engagement. But unfortunately, current pay models don't reward or incentivize that. In fact, electronic PROs require a very high upfront financial investment and ongoing clinician time with little to no reimbursement. Imagine if we offered bundled payments or value-based incentives for teams that integrated PROs. Or imagine if we reimbursed palliative care based on impact or infrastructure instead of just fee-for-service volume. There is a lot of clear evidence that tele-palliative care is effective. In fact, it was the Plenary at ASCO 2024. Yet we're still battling these conversations around inconsistent reimbursement, and we're always waiting on whether or not telehealth waivers are gonna continue. So I think most importantly is we really need to recognize the broader scope of what palliative care offers, which is caregiver support, improving navigation, coordinating very complex transitions. To me, and what I've always prioritized as a champion at Penn, is that palliative care is not a nice to have, and neither are all of these infrastructures, but they're really essential to whole person care, and they need to be financially supported. And last, we really need a culture shift. We need to change from how palliative care is perceived, and it can't be something other. It can't be something outside of oncology, but it really needs to be embraced as this is part of cancer care itself. I often see hesitancy from many oncologists about introducing palliative care early. But it doesn't need to be a dramatic shift. I think small changes in language, how we introduce the palliative care team, and co-management models can really go a very long way in normalizing this part of patient care. And I'm particularly encouraged, Joe, by one particular innovation in this space, which is really the growth of many startups. And one startup, for example, is Thyme Care, where I've seen them working with many, many private practices across the country, alongside partnerships with payers to really build tech-enabled navigation that tries to basically maximize triage support with electronic PROs. And to me, I really think these models can help scale access without overwhelming current care teams. So precision palliative care, Joe, in summary, I think should be flexible, scalable, and really needs to align based on what patients need. Dr. Joseph McCollom: No, I really appreciate, Ramy, you talking about that it really takes a village to get oncology care in both a competent and a compassionate way. And we need buy-in champions at all levels: the system level, the administrative level, the policy level, the tech level. And we need to change culture. I kind of want to just get your final impressions and also make sure that we make our listeners aware of our article. We should be able to have this in the show notes here as well to find additional tools and resources, all the studies that were discussed in today's episode. But, Ramy, what are some of your kind of final takeaways and conclusions? Dr. Ramy Sedhom: Before we wrap up, I just want to make sure we highlight a very exciting opportunity for residents considering a future in oncology and palliative medicine. Thanks to the leadership of Dr. Jamie Von Roen, who truly championed this cause, ASCO and the ABIM (American Board of Internal Medicine) have partnered to create the first truly integrated palliative care oncology fellowship. Trainees can now double board in just two years or triple board in three with palliative care, oncology, and hematology. And I think, Joe, as you and I both know, it's incredibly rewarding and meaningful to work at this intersection. To close our message, if there's one message I think listeners should carry with them, it's that palliative care is about helping people live as well as possible for as long as possible. And precision palliative care simply helps us do that better. We need to really develop systems that tailor support to individual need, value, and individual goals. Just like our colleagues in precision oncology mentioned, getting the right care to the right patient at the right time, and I would add in the right way. For those who want to learn more, I encourage you to read our full article in JCO, which is “Precision Palliative Care As a Pragmatic Solution for a Care Delivery Problem.” Joe, thank you so, so much for this thoughtful conversation and for your leadership in our field. And thank you to everyone for listening. Thank you all for being champions of this essential part of cancer care. If you haven't yet joined the ASCO Palliative Care Communities of Practice, membership is free, and we'd love to have you. Dr. Joseph McCollom: Thank you, Ramy, not only for sharing your insights today, but the pioneering work that you have done in our field. You are truly an inspiration to me in clinical practice, and it is an honor to call you both a colleague and friend.  And thank you for our listeners for joining us today. If you value the insights that you've heard on the ASCO Daily News Podcast, please subscribe, rate, and review wherever you get your podcasts. Thanks again. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Follow today's speakers:   Dr. Joseph McCollom @realbowtiedoc Dr. Ramy Sedhom @ramsedhom Follow ASCO on social media:   @ASCO on X (formerly Twitter) ASCO on Bluesky  ASCO on Facebook   ASCO on LinkedIn   Disclaimer: Dr. Joseph McCollom: No relationships to disclose Dr. Ramy Sedhom: No relationships to disclose

OBGYN Briefs - Understanding the RUC's Role in Healthcare Costs Every procedure has a price, but how is it set? In this BackTable OBGYN Brief, Dr. Mark Hoffman and Dr. Amy Park welcome back Dr. Barbara Levy, a clinical professor at George Washington University and UCSD, to discuss her work with the key organizations influencing medical billing and reimbursement. They explore Dr. Levy's extensive involvement with ACOG, AMA's CPT Editorial Panel, and the RBRVS Update Committee (RUC), offering an overview of the complex systems governing coding and reimbursement in medicine. From how new procedures receive codes to the financial impact on physicians, this brief offers valuable insights for OBGYN practitioners navigating the world of medical billing and coding. TIMESTAMPS 00:00 - Introduction  00:48 - Personal Anecdotes and Career Beginnings 02:01 - Understanding Medical Reimbursement 03:17 - Roles and Responsibilities in Medical Committees 05:34 - The Coding Process Explained 09:16 - The Role of the RUC and CPT Editorial Panel 15:16 - RVUs and Practice Expenses 17:48 - Final Thoughts CHECK OUT THE FULL EPISODE OBGYN Ep. 55 https://www.backtable.com/shows/obgyn/podcasts/55/insights-on-obgyn-coding-reimbursements

How can interventional radiologists turn their unique capabilities into revenue? Dr. Matt Hawkins, interventional radiologist and Health Policy and Economics councilor at the Society of Interventional Radiology (SIR), joins host Dr. Ally Baheti to discuss how interventional radiologists can prove (and get paid for) the value that they bring to hospitals. --- This podcast is supported by: Medtronic Emprinthttps://www.medtronic.com/emprint RADPAD® Radiation Protectionhttps://www.radpad.com/ --- SYNPOSIS The doctors discuss key physician reimbursement models, including the Hospital Outpatient Prospective Payment System (HOPPS) for hospital outpatient and Diagnosis-Related Groups (DRGs) for hospital inpatient, as well as strategies for negotiating subsidies. Dr. Hawkins covers key strategies for proving the value of IR to hospitals, emphasizing the importance of moving beyond work RVUs and focusing on the technical revenue generated for hospitals. The discussion underscores the critical role that IR plays in trauma, transplant, and cancer care. Lastly, Dr. Hawkins highlights SIR's economic initiative emphasizing the importance of accurate documentation and coding in order to turn our clinical impact into measurable value. --- TIMESTAMPS 00:00 - Introduction01:58 - Understanding Professional and Technical Reimbursement04:49 - Hospital Reimbursement Structures07:59 - Quantifying Value and Negotiating Contracts15:55 - Economic Arguments for IR in Trauma, Transplant, and Cancer23:01 - The Importance of IR Leadership in Mixed IRDR Groups25:13 - Challenges and Strategies for Independent IR Practices28:41 - Maximizing Revenue Through Evaluation and Management (E&M)36:40 - Navigating Coding and Documentation for Better Negotiation38:54 - Financial Literacy and Business Strategies

Healthcare is drowning in inefficiency - 80% of data is noise, and clinicians waste precious time on tasks that don't improve patient outcomes. But AI is flipping the script. Imagine diagnosing lung cancer in seconds instead of digging through hours of records, or boosting revenue (RVUs) while actually enhancing care quality. Uncover the real barriers to AI adoption and how new platforms are cutting through vendor lock-in to make AI tools accessible in weeks, not months. From radiology to care coordination, AI isn't just the future - it's the lifeline healthcare needs today.

Listen to Part 2 of this 4-part Women in Cancer Surgery podcast series on finance hosted through SurgOnc Today®. In this episode, Women in Cancer Surgery Committee Members, Drs. Maggie DiNome and Andrea Barrio, are joined by Karen Price, Senior Revenue Manager - Department of Surgery, at Duke University. They will focus on an in-depth discussion of coding strategies and tips to improve billing, understand the use of relevant modifiers, and the use of time-based billing.

Strap in for a wild ride through the Medicare mess threatening radiation oncology in 2026. From a bizarre AMA survey that thinks we're just radiology's quirky cousin, to ASTRO's head-scratching distractions, we break down the...break down?Recorded at midnight in the Vermont Mountain Basements™, this episode unpacks the Byzantine world of CPT codes, RVUs, and a 40% practice expense gut punch that could turn off the lights. OOTB is produced by Photon Media.Contact: jason@becktamd.com

SummaryIn this interview, Dr. Susan Trocciola, a cardiothoracic surgeon, discussed her experiences with locum tenens work and expert witness consulting. Dr. Trocciola shared her journey from traditional employment to locums after facing challenges in finding the right job fit and dealing with personal health issues. She emphasized how locums work has allowed her to achieve better work-life balance, earning twice as much while working half as much compared to her previous full-time job. Dr. Trocciola detailed her approach to determining value in locums work, recommending rates starting at $2,500 per day, and discussed the importance of establishing boundaries with locums companies. She also shared insights about her expert witness work, explaining how it has made her a better doctor through improved documentation practices. The discussion highlighted the benefits of locums work in providing flexibility, better patient care options, and opportunities for professional growth.ChaptersIntroduction and Background of Dr. Susan TrocciolaDr. Trocciola introduced herself as a cardiothoracic surgeon trained at prestigious programs including Cornell, NYU, and Texas Heart. She shared her journey through traditional employment challenges, personal health issues, and eventual transition to locums work.Benefits of Locums WorkDr. Trocciola discussed how locums work has transformed her approach to medicine, allowing her to focus on patient care rather than RVUs. She shared an example of prioritizing patient care over personal convenience in a recent case. Determining Value in Locums WorkDr. Trocciola explained her approach to establishing value in locums work, recommending working with multiple companies to understand market rates and emphasizing the importance of negotiating fair compensation. Navigating Locums AssignmentsDr. Trocciola shared insights about identifying good locums companies, establishing boundaries, and recognizing when to leave assignments that aren't a good fit.Expert Witness WorkDr. Trocciola discussed her journey into expert witness work, how it has improved her practice, and the importance of honesty and thorough documentation in both expert witness cases and clinical practice.Future Plans and Work-Life BalanceDr. Trocciola expressed her desire to reduce clinical work and increase expert witness work, emphasizing the importance of maintaining work-life balance and having time for personal activities.Action ItemsDr. Trocciola recommends starting locums assignments with shorter commitments to allow for better evaluation and negotiation opportunitiesDr. Trocciola advises establishing a minimum daily rate of at least $2,500 for locums workDr. Trocciola suggests working with multiple locums companies to understand market rates and negotiate better contractsDr. Trocciola emphasizes the importance of thorough documentation in both clinical practice and expert witness work

February 28, 2025 Scott, Mark, and Dr. Ray Painter break down the challenges of securing fair compensation for extra work performed in urology procedures when using modifier 22, unlisted codes, or Category III codes. They discuss effective strategies for communicating with payers and contract administrators, ensuring proper documentation, and negotiating fair work RVU adjustments.Free Kidney Stone Coding CalculatorDownload NowPRS Billing and Other Services - Book a Call with Mark Painter or Marianne DescioseClick Here to Get More Information and Request a Quote Join the Urology Pharma and Tech Pioneer GroupEmpowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.https://www.prsnetwork.com/joinuptp Click Here to Start Your Free Trial of AUACodingToday.com   The Thriving Urology Practice Facebook group.The Thriving Urology Practice Facebook Group link to join:https://www.facebook.com/groups/ThrivingPractice/ 

Send us a textThere's a lot to consider when it comes to RVUs (Relative Value Units). In this episode, Captain Integrity Bob Wade breaks down wRVUs & more with Matt BonDurant, Co-Founder & SVP at ProCARE. Hear what a Comp RVU is, the nuts & bolts of RVUs, why RVUs are so complicated, how to approach benchmark data, and Bob's story from Philmont Scout Ranch. Learn more at CaptainIntegrity.com

 February 14, 2025 Scott, Mark, and Ray discuss questions that came into the PRS Network Community.Our doctor's occasionally use the ESWL (Extracorporeal Shock Wave Lithotripsy) for bladder stones. Insurance requires a laterality modifier. I am not sure if we can bill for it or not. If we can bill for it, what is the correct way to do it?Can you please clarify the relaxation of the in person requirement for supervision in 2025? As I read it and as I understand that you have explained it, this is a new rule stating essentially that if I am a physician supervising a nurse practitioner, the in person supervision is waived and I only need to be available via telecommunication. Am I interpreting this correctly? My coders are pushing back saying that this only applies to telehealth visits not in person visits for my supervisoion of a nurse practitioner.Coding Challenging Stone Cases: Is there a CPT code I'm missing here? What financial incentive is there to use the suction/vacuum technology and perform FANS/DISS for larger stones? Just the 22-modifer? Seems like from a billing/time perspective, it's not worth tackling larger stones with either FANS or DISS. Does the 22-modifier really make that much difference? Can you provide an example of generally what additional time (ie double/triple, etc) actually generates for additional RVUs? Free Kidney Stone Coding CalculatorDownload NowPRS Billing and Other Services - Book a Call with Mark Painter or Marianne DescioseClick Here to Get More Information and Request a Quote Join the Urology Pharma and Tech Pioneer GroupEmpowering urology practices to adopt new technology faster by providing clear reimbursement strategies—ensuring the practice gets paid and patients benefit sooner.https://www.prsnetwork.com/joinuptp Click Here to Start Your Free Trial of AUACodingToday.com   The Thriving Urology Practice Facebook group.The Thriving Urology Practice Facebook Group link to join:https://www.facebook.com/groups/ThrivingPractice/ 

Understanding RVUs and the Future of Pediatric PaymentsIn this episode, sponsored by Hippo Health and Freed.ai, the hosts engage in a detailed conversation with Chip Hart, an expert in managing pediatric practices. They discuss the concept of Relative Value Units (RVUs), their origins, and their impact on pediatricians and primary care physicians. Chip explains how RVUs affect billing and physician compensation, the disparities they introduce, and their contribution to physician burnout. The discussion also explores alternative payment models, such as value-based care, and the complexities of implementing them in pediatric settings. The episode concludes with insights into the future of pediatric compensation and the importance of recognizing and properly valuing primary care in pediatrics.00:00 Introduction and Sponsor Message00:46 Welcoming Chip Hart02:03 Understanding RVUs05:33 Impact of RVUs on Pediatricians08:47 Challenges with Value-Based Care18:21 Disparities in Healthcare23:57 Physician Burnout and Systemic Issues32:29 AI Solutions and Future Outlook33:23 Fee-for-Service Model Concerns34:30 Misunderstandings and Overbilling in Medical Practices35:12 Specialist Overuse and Financial Implications37:24 RVU Impact on Pediatric Practices40:12 Medicaid and Medicare Payment Structures44:14 Challenges with RVU-Based Compensation55:12 Value-Based Contracts and Pediatric Care01:02:21 Direct Primary Care and Financial Models01:09:04 Final Thoughts and Call to ActionSupport the show

In this episode, Drs. Patrick Georgoff, Teddy Puzio, and Jason Brill are joined by special guest Dr. Pat Murphy, who helps us delve into the evolving field of acute care surgery (ACS), exploring its history, challenges, and the nuances of defining full-time employment in this demanding specialty. The discussion highlights the origins of ACS as a response to unmet emergency surgical needs and its three foundational pillars: trauma surgery, emergency general surgery, and surgical critical care, with additional roles like surgical rescue evolving over time. Dr. Murphy share insights into the workload, including night shifts, call schedules, and the toll on surgeons' health, emphasizing the importance of fair compensation, equitable shift distribution, and transparency in job expectations. The episode underscores the value ACS surgeons bring to hospitals, likening them to essential infrastructure like firefighters, with their impact often unrecognized in traditional productivity metrics like RVUs.    Dr. Murphy would like to thank the many collaborators who made this volume of work possible including the many acute care surgeons who have taken the time to participate in the research and their dedication to patient care and surgeon wellbeing Learning Objectives: 1)        Define and understand the evolution of acute care surgery as a surgical subspecialty, including its historical development, key components (trauma, surgical critical care, emergency general surgery, surgical rescue), and its unique role within the surgical landscape. 2)        Analyze the concept of "full-time equivalent" (FTE) for acute care surgeons, considering factors such as call schedules, shift length, service demands, and the impact of varying case volumes and intensities on workload. 3)        Discuss the challenges of defining and measuring the value of acute care surgeons, considering factors beyond traditional productivity metrics (e.g., RVUs) such as the impact of surgical rescue, patient safety, and the value of 24/7 availability in preventing adverse outcomes. 4)        Explore the importance of recognizing the unique demands and contributions of acute care surgeons, including the impact of high-stress environments, irregular schedules, and the importance of work-life balance and clinician well-being on long-term sustainability within the specialty. This episode of Big T Trauma was sponsored by Teleflex, a global provider of medical devices. Learn more at teleflex.com and at the Teleflex Trauma and Emergency Medicine LinkedIn page. ***SPECIALTY TEAM APPLICATION LINK: https://docs.google.com/forms/d/e/1FAIpQLSdX2a_zsiyaz-NwxKuUUa5cUFolWhOw3945ZRFoRcJR1wjZ4w/viewform?usp=sharing Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen BIG T Trauma Series: https://app.behindtheknife.org/podcast-series/big-t-trauma

In this episode, Dr. Kristan Staudenmayer discusses the critical intersection of healthcare economics and trauma surgery. She emphasizes the need for surgeons to understand financial aspects to advocate effectively for their patients. The conversation explores the role of the Healthcare Economics Committee, the challenges posed by Relative value units (RVUs) in measuring surgical work, and the importance of building tools for advocacy in healthcare economics.TakeawaysSurgeons often lack training in healthcare economics.Understanding finance empowers better patient care.RVUs do not accurately reflect the work of acute care surgeons.Financial literacy is essential for effective advocacy.Value in healthcare is a complex and multifaceted concept.Billing practices need improvement among surgeons.The workload of trauma surgeons is often invisible to others.Advocacy tools are being developed for better communication with leadership.Research is needed to address workforce issues in acute care surgery.

“Labor is supposed to happen naturally. It's not this big medical intervention that occasionally happens naturally. It's this natural process that occasionally needs medical intervention.”Paige Boran is a certified nurse-midwife from Fort Collins, Colorado. She and her colleague, Jess, practice independently at A Woman's Place. They have rights to deliver babies at the hospital but are not employed through the hospital system so they are not subject to physician oversight. Their patients benefit from a low-intervention environment within a hospital setting but without the restriction of hospital policies.Lily Wyn, our Content Creator and Social Media Admin, joins us today as well! Lily shares why she chose Paige to support her through her current VBAC pregnancy. Lily is a beautiful example of how to diligently interview providers, keep an open mind, process past fears with the provider you choose, and what developing a relationship looks like to create an empowering birthing experience. Paige shows us just how valuable midwifery care can be, especially when going for a VBAC. If you're looking for a truly VBAC-supportive provider, this is a great episode on how to do it! The VBAC Link's VBAC Supportive Provider ListA Woman's PlaceHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details Paige: Yeah, so I'm a certified nurse-midwife. I work in northern Colorado in Fort Collins at A Woman's Place. We're a small midwifery-owned practice. Right now, there are just two CNMs. That's the whole practice. It's just me and my colleague, Jess, who owns it which is really cool because we get to push the boundaries because we are not really locked into the hospital system. We are able to catch babies there but we are not actually employed through the bigger hospital systems which is nice because we don't have that physician oversight and stuff like that. I think we are able to do a lot more and honor that midwifery care model which is really cool. Sometimes people feel locked into policies and their overseeing physician and things like that but when it's just two midwives, we get to do what we want and what feels best for the patient. I really like that. That was a big thing when I first got into the certified nurse midwifery world. I was like, where do I want to work? I had offers from bigger hospital systems and it just didn't feel like the right fit so working at a small, privately-owned practice felt like the right answer for me so I was able to practice in a way I felt was right for people. I didn't want to be locked in by a policy and overseeing physicians. I just wanted to grow with other midwives. Meagan: Yes. I love that so much. I don't know. Maybe I should say I know it feels to me– I don't know it as an actual fact, but that feels like a unique situation and a unique setup to me. We don't really have that that I know of here in Utah. We either have out-of-hospital CPMs or we have in-hospital CNMs who are just hospital. I know that one hospital system is trying to do the attached birth center, but it is still very different. They are still the hospital umbrella midwives I guess I could say. So is that unique or is that just something that feels like it?Paige: I think it's unique because where I came from in Florida, if you were a CNM, you 100% practiced in the hospital which we do but it was that you were owned by a larger group of physicians essentially. Florida was working towards independent practice when I was there. Colorado is an independent-practiced state for nurse practitioners which is really cool because we don't have to have that oversight. I don't know if Florida ever got there but I know it varies state to state on if you have to be overseen by a physician or not. Honestly, that's why a lot of people when they are ready to become a midwife, if they don't have independent practice rights as a CNM even if they are a nurse, they will go for a CPM which is a certified professional midwife because they actually have more autonomy to do what they want outside of the hospital because they are not bound by all of the laws and stipulations which is interesting. Meagan: Exactly. I think that's a big thing– the CPM/CNM thing when people are looking for midwives. Do you have any suggestions about CPM versus CNM? If a VBAC mom is looking at a CPM, is that a safe and reasonable option?Paige: Absolutely. Yes. I think CPMs and CNMs are both reasonable, safe options. They both have training in that. They both can honor your holistic journey. I would say the biggest thing is who you feel most connected to because I think trusting your team, you will have people who have the worst birthing outcome and horrible stories but they are like, “I look back and I feel so good about it because I trusted my team.” I think that is what's important. If a CPM seems like your person and that's who you are going to trust, then that's who you should go for whereas a CNM, if that seems like that's your person and who you trust, I think that would be a good route too. I think a lot of people think, “Oh, they do home births. They must catch babies in a barn and there is no regulation. Even sometimes when I say, “midwife,” people are like, “What? Do you dress like a nun and catch babies in a barn?”Meagan: Yes, this is real though. These are real thoughts. If you are listening, and not to make fun of you if you think this, this is a real thing. This is a myth surrounding midwifery care, especially out-of-hospital midwives where a lot of people think a lot of different things. Paige: Absolutely. Meagan: I think I had a chicken chaser or something where a dad was like, “Do you chase chickens?” I was like, “What?” He said, “Well, that's what the midwives do so that's what the doulas do.” I'm like, “What? No, we don't chase chickens.” Paige: That is such old-school thinking but realistically, midwives started in the home and that was their history. It's cool that they've been able to step into the hospital and bring some of that back into the hospital because I think that is needed. Meagan: It is needed, yeah. Paige: We are starting to see that physicians are starting to be a little bit more holistic and see things in the whole picture, but I'm glad that the midwives did step into the hospital because I think that needed to be there but I'm so glad that people are still doing it at home because I think that is such a good option for people. Meagan: Yeah, so talking abou the midwives in the hospital, a lot of people are talking about how they are overseen by OBs. Is this common? Does this happen where you are at? You kind of said you are separated but do the hospital midwives in your area or in most areas, are they always overseen by OBs? Paige: Not necessarily. It would vary state to state and hospital to hospital. We actually just got privileges and admitting privileges a couple of years ago. Actually, my boss, Jess, who owns the practice where I work, had worked in Denver where they were allowed to admit their patients and everything. They didn't have to have any physician oversight but when she was there, she had to have physician oversight. She was like, “It's an hour drive north, why would that make a difference?” It was the same hospital system so she fought when she bought the practice and the physician who owned it prior left, she was alone and she had to have that physician oversight so she fought for independent practice privileges and she got it. Some of the midwives at first weren't so happy about it because they had liked being overseen by the doctor and someone signing off on all of their things. Some of the midwives were like, “Finally. We should be able to practice independently.” It's going to vary at each place. But I think that's a good thing to ask, “If something is going wrong, will a physician just come unannounced into my room in the hospital?” That's not the case with ours. We have to invite them in and if we are inviting them in, we've probably had a conversation multiple times with the patient where it's like, we need to have this. Meagan: Yeah. For the patients who do have the oversight of the OBs, do you have any suggestions? I feel like sometimes, at least here in Utah with my own doula clients when we have that situation, it can get a little confusing and hard when we've got an OB over here saying one thing but then we've got a midwife saying another. For instance with a VBAC candidate, “Oh, you really have a lower chance of having a VBAC. I'll support it. I'll sign off, but you have a really low chance,” but then the midwife is like, “Don't worry about that. You actually have a great chance. It is totally possible.” It gets confusing. Paige: Yeah, and it's like, who do you trust in that scenario? I think that's where evidence comes in because I think midwives and physicians both practice evidence-based but some people may have newer evidence than others. I've worked with OBs who probably roll over in their grave when I say certain things because it wasn't the old way but it is the new way. If somebody can come in with their own evidence and they're like, “I've looked into this and I think I'm a good candidate for x, y, and z,” I think physicians respond well to that because they are like, “Okay, they've done their research. Maybe I need to do some research.” Meagan: Yeah. Paige: When they have that thought, they know that this is an educated person and I can't just say whatever I want and they're going to take my word as the Holy Bible. Meagan: Yeah. No, really. Exactly. It always comes down to education and the more information we can have in our toolbelt or in our toolbox or whatever it may be, it's powerful so I love that you point that out. I think it's also important to note that if you do have two providers saying different things, that it's okay to ask for that evidence. “Hey, you had mentioned this. Can you tell me where you got that from or why you are saying that?” Then you can discuss that with your other provider. Paige: Yeah, and following intuition too. I think you can have all of the evidence in the world. What is your gut telling you too? Who do you trust more and what feels right in your body in the moment? I think we are all experts of our own bodies and there's a lot that goes into a VBAC and stuff like that. It's more than just the evidence. People have to feel mentally and physically ready for it too. I wish more people focused sometimes on the mental and spiritual aspect of it because I think a lot of people get ready physically but maybe mentally they weren't prepared for the emotional switch there. Meagan: Totally. Thinking about that, Paige, I mean Lily, tell us a little bit about why you went the midwifery route. I know you really wanted to find the right provider. Lily: Yeah. So I think for me, I have always been drawn to midwifery care. I was a little bit of a birth nerd prior to even working for The VBAC Link or even having my own kiddos. Prior to my son, we had a miscarriage and an ectopic pregnancy so I experienced OB care with my ectopic. I was bounced around a lot in a practice and had OBs who were great and equally some OBs where it was such a rushed visit that I had an OB miss an infection in my incisions because my pain was dismissed and just some really tough stuff. When it came to getting our rainbow rainbow baby, I was like, I really don't want to be in a hospital at all. I want midwives. That's the route that we went. The very brief story of my son is that he flipped breech 44 hours into labor and that's when we legally had to transfer to the hospital and I had my Cesarean. So in planning my VBAC, I planned to go back to the birth center and was a little devastated when it was out of our financial means this time. I was so panicked. I remember texting you, Meagan, and being like, “What do I do? I can't be at the birth center anymore and I don't want to be in a hospital.” We interviewed another birth center that's about an hour away that is in network with our insurance and talk about trusting your gut, it just didn't feel right. It didn't feel warm and fuzzy. Those are the feelings I got with our first birth center. I loved them so much and I still do. Then I met with Paige and her practice partner, Jess, and I came in loaded to the teeth. I was prepared to fight with someone because that's what I had in my brain and that's what I expected. I sat down with them. They met me after hours after clinic. I sat down with my three pages of questions and by the way, if you are listening and you have questions, we have a great blog on it and some social media posts of the questions that I specifically used. We talked for over an hour and every question I asked, they just had the ultimate answer to. I felt so at peace after talking with both of them and I remember telling my husband going into it, “I'm really worried that I'm going to like these people because I don't want to deliver at a hospital and then I'm going to have to choose a far away birth center that is out-of-hospital or providers that I like but it's a hospital.” It just feels like everything has been serendipitous for us. Our hospital opened a low-intervention portion of their birth floor so I'll still get to have the birth tub and all of the things, but truly have just been blow away by Paige and have just buddied up. She's dealt with all of my anxiety in pregnancy and VBAC and all of my questions. It just feels like such holistic care compared to my experience with OBs in the past. Meagan: That is so amazing and I was actually going to ask how has your care been during this pregnancy? It sounds like it's just been absolutely incredible and exactly what you needed. I remember you texting me and feeling that, oh crap. I don't know what to do. What do I do? You know? I just think it's so great that you have found Paige. Did you say that Jess is your partner? Paige: Yes. Meagan: Jess, yeah. I'm so glad that you found them because it really does sound like you are exactly where you need to be. Lily: Yeah. It made a huge difference for me and I just tell Paige all the time I truly didn't know that care in a hospital setting could look the way that it does. I feel like I'm getting– I experienced birth center care. I had an out-of-hospital experience until we transferred and I can say with confidence that my care has been the same if not better with Paige and just having the conversations and the good stuff and feeling really safe and confident. One thing that they pointed out that I thought was great when I went in and asked all of my questions is that Jess looked at me and she was like, “Okay, it sounds like you have a lot of anxiety around hospital transfer.” And I did. With my son, that was my worst fear and it came true. I had a lot of anxious, what if I have to transfer? She was like, “The thing is there is no transferring. We can induce you if you need to be induced and we can come with you into the OR with your Cesarean if that ever happened to be another thing.” For me, that brought a lot of peace to know that no matter what, the provider that I know and feel comfortable with is going to be with me. I again, didn't expect to feel that way, but it's been a really great reassurance for me personally. Meagan: Yeah. It's the same with a doula. Knowing that there's someone in your corner that you know who you've established care with who can follow you to your birth with you in your journey is just so comforting. So Paige, I wanted to talk about midwifery care and also just lowering the chance of Cesarean. Sometimes people do choose midwifery care specifically because they are like, “I think I have a lower chance of a Cesarean if I go the midwifery route.” Can we talk to that a little bit?Paige: Yes, that's true. A lot of people know that there are benefits to midwives but I think when people think of midwives, it's just like, “Oh, it's just a better experience. I trust my team more.” That's definitely there. There have been studies and people felt more at peace and empowered through their birthing journeys with midwives than they did with OBs. It's been studied but there is also a decrease in C-section risk. Your C-section risk drops 30-40% when you have a midwife which I think is a pretty significant drop. Meagan: Yeah. Paige: Yeah, especially when we look at the United States at our birthing outcomes and birthing mortality and C-section rates, it is way too high for as developed of a country as we are. I think that's really where midwifery care is stepping in and starting to help lower those rates to get it down to where it should be. The World Health Organization has been nominating and promoting midwifery care because it really is the answer to how we get these C-section rates lowered and these bad outcomes lowered. Midwives also have lower chance of an operative vaginal birth. That would be with forceps or a vacuum or an episiotomy so lower chances of those things as well. Lower chance of preterm birth which is interesting and probably because one, we do take lower-risk people. I think that's true but also because we are looking at it holistically. We are looking at everything. We are not just looking at you as a sick person. A lot of people look at pregnancy as an illness and pregnancy is not an illness. It's just a natural part of life and we've got to look at the whole picture of life if we're just going to look at the one thing too. I think that helps to reduce preterm birth risk. We also have lower interventions just overall. We're more in tune with people's bodies and we want to honor what their bodies are meant to do. Labor is supposed to happen naturally. It's not this big medical intervention that occasionally happens naturally. It's this natural process that occasionally needs medical intervention. The midwifery model is so important. I think when you go to the traditional medical model, you look at the present illness so they see pregnancy as an illness. What can go wrong? Don't get me wrong. There are a sleu of things that can go wrong in pregnancy and you do have to watch for them. But I think with midwifery care, you know when to use your hands but you also know when to sit on them. Meagan: Yes. Oh my gosh. I love that so much. I feel like we need– we used to get quotes from our podcast episodes and turn them into t-shirts and I feel like that is a t-shirt podcast quote-worthy. Oh my gosh. It's a worthy quote. That is amazing and it's so true though. Paige: It is. Meagan: It's not to rag on OBs. You guys, OBs are amazing. They are wonderful. They do an amazing job. We love the. But there is something different with midwifery care. You mentioned preterm birth. I remember when I was going through my interview process to have my VBAC after two C-section baby and I finally established care mid-pregnancy because I switched. That was one of the things in the very beginning that my midwife was like, “Let's talk about things. Let's talk about nutrition. Let's talk about supplements. Let's talk about where you are at.” It was just honing in on that which I was surprised by because I figured she'd be like, “Let's talk about your history. Let's talk about this,” but it was like, “No. Let's talk about what we can do to make sure you have the healthiest pregnancy,” but also started commentingo n mental stuff. It helped me get healthy in my mind. I just would never have had that experience with OB where they wanted to learn what I was scared about and what I was feeling and all of those things. Not only was I learning how to nourish myself physically, but mentally and it was just a really big deal. I do feel like it played a big impact in my labor. Paige: Yeah. A lot of people discredit how much nutrition and debunking fears and stuff like that can go because I think a lot of that– I mean, we look at nutrition-wise and we could avoid almost all of preeclampsia with nutrition alone which is incredible. I'm like, “I really think you should read Real Food for Pregnancy and people are like, “Oh, but it's such a big book,” and I'm like, “But it's so important to know this information about what we should be putting in our bodies.” 100 grams of protein– you've already got it. Meagan: I want to see how many pages for it. It's got, okay. We've got 300 pages but it has recipes and all of these amazing things in the end so it's not even a full book. Paige: Yes. People are like, “Oh man, I don't know if I want to read the whole thing,” but I'm like, “It's so important.” I think when people do read it, they come back and are like, “Did you know that I could decrease my risk of this if I ate more Vitamin A?” I'm like, “Yes. That's why I wanted you to read this book.” It is a wealth of information and I have such healthier pregnancy outcomes when people follow that high protein diet and looking at micronutrients with their Vitamin A, their choline, and all sorts of things. Meagan: Yeah. All of the things that we talk about a lot here on the podcast because we are partnered with Needed and we love them so much because we talk about the choline and the Vitamin A and the Vitamin B's and the Vitamin D's. Lily Nichols, not this Lily on the podcast today, she also wrote Real Food for Gestational Diabetes and that's another really powerful book as well. But yeah. It's just hard because OBs don't tend to have the time. I think some OBs would actually love the time to sit down and dig deep into this but they don't have the time either. I do think that's a big difference between OBs and midwives. What does your standard prenatal look like? When a mom comes in, a patient comes in, what do you guys do through a visit? Paige: Yeah. We follow the standard what everywhere in America does like once a month roughly in the first trimester and second trimester then when you hit 28 weeks, every 2 weeks, and then when you hit 36 weeks, every week. If you go to 41, we'll see you twice in that week. We follow those stipulations but our appointments are a little bit longer. When you are in a big practice, a lot of time it's driven by RVU use so the more patients somebody can see, the more they are going to get paid and the bigger their bonus is at the end of year. A lot of people feel like they are running through the cattle herd and they've been in and out in 15 minutes if that. At my practice, it's a little bit different because we are not RVU based. We're not getting any bonus. We're not trying to see as many patients as we can. Will we ever be the richest at what we do? No, but that's okay with me and Jess. We are small on purpose and we love to take the time. At Lily's appointments, we always book her for at least 30 minutes because we know that me and her like to talk. We've done an hour for some people because we know there is always going to be that long conversation. Don't get me wrong though, that fourth mom whose had three vaginal births and going for her fourth, she may be like, “Paige, there's really nothing to talk about today and that's okay.” Sometimes they are 15 minutes. Sometimes they are 30. Sometimes they are an hour. Our first appointment is always an hour because there is just so much to dive into with how we can be preparing ourselves, what does your history look like especially if they are brand new to our practice and we've never met them before, starting to build that relationship early on. It just depends on how far along they are, who the person is, and those things. But I do like that I can spend as much time as I need. Sometimes I tell my people, “Bring a book because I tend to get behind because I tend to talk to people longer than I book for,” but that's okay. We know that we can do that because we are a smaller practice. I think when people are thinking about what kind of care they want, they should probably consider how are these people paid? Is it by how many they can see in a day? Because you're probably going to get a different level of care than a practice that isn't drive by those RVUs. Yeah, that's a really good point. I feel like my shortest visit with my midwife was 20 minutes. Paige: Yeah. Lily: Yeah. Meagan: Which to me is pretty dang long because when I was going with my other two daughters, I think it was probably 6-7 minutes if that with my provider. I mean, it was get in. My nurse would check my fundal height and all of that and then oh, the doctor will be in here. Then came in, quick out. Yeah. It is really, really different. Lily: I know for me too, I love that we don't just talk about nutrition and things like that but even in my last appointment, I was talking with Paige about the things that can be triggering coming back into labor and going back into a hospital so my ectopic pregnancy was at the hospital that I'll be delivering at and I had to go into the emergency room and the way that you go to labor and delivery after hours is through the ER so Paige and I were talking. She was like, “I can just meet you outside. We will badge you in and we will avoid the emergency room if that feels triggering.” It's just those things that you don't get with an OB necessarily to talk through tiny little triggers. They are probably generally less accommodating to those little things of, “Well that's just the standard. You're going to have to get over that and just go through the ED and come on up.” I think that's been huge. I also have a dear friend who is going to school to be an OB. I told Paige at my last appointment that she may possibly be at my birth. She's my crunchy friend so she'll be a great OB but I have such a desire to be like, “Come see a VBAC. Come see it so that you have it in your brain and you know that they can be safe and look at what can be done,” so I think that is so huge too as we continue to train and uplift our next generation of providers. What does that look like to show them? I think her internship or something is going to be a midwife and OB partnership practice which is really cool but I'm like, “Yes. Come. Come to my birth. Please. I want you to see all the things.” That's really cool too and that Paige is open to, “My friend might be there.” Meagan: Yeah. Paige: Bring whoever. Meagan: I love that. I love that you were pointing out too this next generation of providers. Let's see that birth and VBAC is actually very normal and very possible because there's a lot of people who have maybe seen trauma or an unfortunate situation which could have happened because we blasted them with interventions or could have happened out of a fluke thing. You don't know all of the time. But I do think if we can keep trying to get these providers, these new provider to see a different light, we will also see that Cesarean rate drop a little bit. We really, I always tell people that we have a problem. They're like, “It's really not that big of a deal.” I'm like, “No, it's a very big deal. It's a very, very big deal. We have a problem in this medical world.” I do believe that it needs to change and midwifery care is definitely going to impact that. I hope that what you were saying in the beginning how policies don't trump a lot of the midwives. I wanted to ask you. This isn't something we talked about, but is it possible to ask your midwife, “Hey, what policies do you lie under?” Is that appropriate? Paige: Yes. Actually, that was one of my favorite things when Lily came in to meet and greet us. She came and she was like, “What are the policies for a VBAC?” We dove into that. We've been diving into that and what are we going to be okay with and what are we not going to be okay with? That's the beauty is that I'm not employed by the larger hospital system that I work under so I feel like a policy is not a law. I feel like there is informed consent and I think informed consent is so important but at the same time, there is informed declination and you should be able to decline anything. That's true. We can never force anybody into surgery. We can never force anybody into anything. I think a lot of people aren't having those conversations where it's actually informed so then people are like, “Oh, they are just refusing everything.” I hate the word refuse because no, they are not refusing it. They are declining it because they are informed. They know the risk. They have all the information at their fingertips and they know that this is the best decision for them and their baby and we have to honor that. That's why I'm really glad that I'm able to practice in that way, but I do know I've met and I've worked with people who feel like they are boxed in and have to follow those policies. We've started to talk about what our policies are with TOLACs and VBACs and things like that. One of them is that they are supposed to have two IVs. I've already gone against that before and I've had a beautiful, unmedicated VBAC. She walked in. I said, “We've talked about it. She was also laboring outside when we talked about it. It's not an issue when you come in. You know what? When we get up there, I'm just going to tell them that you know why they recommend two IVs and you are declining.” She walks in and she's clearly going to have this baby within the hour. I told the nurse, “We're not doing the IVs. We've talked about it. We're going to decline them.” That was the end of the discussion. We didn't have to talk about it again which was nice. She shouldn't have had to advocate in that moment for herself. We've already had those conversations. Meagan: Yes. Paige: Another one is continuous monitoring and the whole idea is if you start to rupture, that's how we are going to catch it. The baby is going to tank and that's how we are going to save the baby's life. Don't get me wrong. I think continuous monitoring can be really valuable for a lot of things but it's actually not evidence-based. We have not improved neonatal outcomes with continuous fetal monitoring. We've talked about that with Lily and she's going to opt for intermittent oscillation and I think that's very appropriate because she plans to go unmedicated. Let's be honest, if you are unmedicated and your uterus starts to rupture, moms will tell me that something is not right. This is beyond labor. Her saying that and being aware of that, we would notice it a lot sooner than we would the baby tanking kind of thing. Meagan: Yeah. I do know that with uterine rupture, we can have decelerations but like you were saying, there's usually so many other signs before baby is actually even struggling and I know a couple of uterine rupture stories where providers didn't believe the mom that something was going on because that one thing wasn't happening. The baby wasn't struggling. Paige: Yes. Meagan: It's like, you guys! When it comes to continuous fetal monitoring in the hospital, people have to fight to have that intermittent. It's yeah. Anyway. These policies are not law. I love that you said that too. There's another t-shirt quote. Paige: I think people should start asking if they are planning a VBAC, start asking what is the policy and start thinking, is that what they want? I do have some moms who are like, “No, I want the two IVs because it's hard for me to get a stick,” and they need that backup in case. That makes them feel more at peace but other people are like, “It makes me feel like a patient. I don't like it.” People don't like needles and that's okay. They have that right to say no. I tell people that in a true emergency, we will get an IV in you if something really, really bad were to be happening. That's part of training if somebody walks in off the street. We're not going to be like, “Oh, when was the last time you ate? Sorry, you can't have the surgery.” We know something bad is happening right now. We will get the IVs. We will do all of the things. Getting the IVs really won't save as much time as people think it will. Meagan: Yeah, and there are other things. Say we are having our baby and we are having higher blood loss than we would like or we have some concern of some hemorrhaging, there are other things that we can do. We can put Pitocin in a leg. We can do Cytotec rectally. There are things that we can do. We can get that baby to our breast and start stimulating and try to help that way. There are things that we can do while we are waiting for an IV, right? Paige: Yes. I tell people that all the time. Most of the postpartum hemorrhage meds that we use can be given without an IV. There is only one that truly has to be given through an IV and that's TXA but the rest can all be given other routes. A lot of times, those work better than IV Pitocin. Sometimes the ion Pitocin works better. Sometimes the ion Methergine works better. It's not this, oh we have to have a little just in case kind of thing because if there was a just in case moment, yes. We can be working on the IV and doing other things. I have to be kind of secretive about it. I have tinctures and stuff with shepherd's purse and yarrow. Those things actually have great evidence. They are really helpful for postpartum blood loss. I have a lot of moms who are more interested in doing something more holistic and natural before they try medication. Cypress essential oil, you can rub that in. I'll have doulas use my cypress roller and give them a massage while I'm trying to manage the hemorrhage and that cypress oil can help a lot too. Sometimes going back to our instinctual, old medicine that we have been using well before medicine was used for birth. Meagan: Yeah. This is a random question for both of you. Lil, I really wonder if you have seen it or heard about this too because you are so heavily in our DMs. This is going to be weird. People are going to be like, what? But I did this. We did this because we weren't sure. We cut the umbilical cord and put it in our mouth. It's really weird. Paige is like, what? You put it down in the gum area like in between your teeth and your cheek. It sits there. Okay, you guys. I've seen it just a couple of times, myself included. Yes, I put my umbilical cord in my mouth. Yes, it's weird. Paige: That's okay. Meagan: It felt like a little gummy. It was fine. I wasn't chewing on it. It was just sitting there. But anyway, it's weird but with my other client too we did it and all of her hemorrhaging symptoms just went away. Paige: That's cool. Meagan: I know this is really random but we just cut a little piece of our umbilical cord and put it in their mouth. Paige: That's so interesting. So a piece of the umbilical cord or the entire thing once it's clamped and cut and still attached? Meagan: They clamped and cut it, cut a piece, and put it in my mouth. Paige: I would be so willing to try that. I mean, what is there in that nun? Meagan: I don't know. I don't know, but it did diminish the hemorrhaging symptoms. Paige: Cool. Meagan: So very interesting, right? Okay, so are midwives restricted when it comes to VBAC on what they can accept? Lily, you are a VBAC. I was a VBAC after two C-sections. You can obviously take Lily. Could you accept me?Paige: Yes. Luckily in midwifery care, at least in Colorado, there is a lot of gray for certified nurse midwives. It's not always black and white. VBACs are okay but there is no direct, “Oh, if you have this many C-sections, we can't do it.” I think that's because ACOG also strangely doesn't have an opinion on that. They actually agree. There is limited evidence beyond one C-section. My practice has done several VBACs after two Cesareans. I don't think we've ever done one for a third or greater than two probably because I think those people a lot of times don't even consider VBAC and they just already have been seeing their doctor for their repeat C-section with each pregnancy. But I'd love to see more people going for a VBAC after multiple Cesareans because I think VBACs after two Cesareans have a whole different level of feeling empowered after that. I thin that's really cool and even special scars and stuff, there is really limited evidence on all of these things and I'd like to see more people pushing the limits a little bit. Especially since I am in a hospital, I do have an OB hospitalist on call 24/7 at the disposal of my fingertips if I need them. We are close to an OR so I think if for somebody the fear is there and they are like, “I just don't know if it's more risky because of this,” I think it's worth it to try because the more people who go for it and are successful, the better evidence we're going to get from it. Meagan: Yeah. That is exactly what I am thinking. There's not a lot of evidence after two Cesareans because it's just not happening. It hasn't really been studied and a lot of that is because people aren't even given the option. Paige: Yeah. I'll have people where it is their third or fourth C-section and they were never even given that option. They were told, “Oh, I was told I have CPD.” I'm like, “The chances of you actually having CPD are low.” Then you look at their records and it was fetal distress or something like that. Yeah. CPD is so rare. I've heard it so many times. “Baby is never going to come out of that pelvis ever.” That breaks my heart every time I hear it because there are times when I'm like, I don't know and then an 8-pound baby comes out. We can't go off of those things because the body does what it's supposed to in those moments. Don't get me wrong. Things do go wrong and C-sections do happen sometimes but yeah. To hear everybody has CPD just because they've had three C-sections, I'm like, I don't know. That would be quite a few people. Way more than we know are true. Meagan: Yeah. We're all walking around with tiny pelvises. That's just what everyone thinks anyway.Lily, being in our DMs, hearing the podcast, understanding and seeing so many of these people and what they say, do you have any advice for them when they are looking for their provider or just any advice in general? Do you have any advice from a VBAC-prepping mom? Lily: Yeah, I think for me, it is to go into it open-handed. I think we hear so many horror stories about providers often and I think that's why I went into looking for a provider with both fists up ready to fight and what has surprised me the most is just I think I said earlier that I didn't know hospital care could look like this. I remember we even posted something and I had posted on The VBAC Link that a hospital birth can be equally as beautiful as an out-of-hospital birth and there were people arguing and people saying, “No, absolutely that's not possible. That's not a thing.” Gosh, how discouraging if we go into things thinking that we can't have beautiful outcomes in different settings. Certainly, there are areas around our country that need improvement. There's not a low-intervention floor at every hospital and there are not midwives who are doing what Paige is doing everywhere but I think the more that we seek out that care and look for that care and advocate for that care, the more we will see it. As much as it sucks that we have to be our advocates, it's also a really cool opportunity that we pave the way for VBAC moms and the moms who have never had a C-section that we are paving the way for care that doesn't end up in a Cesarean. I would just say to be open-handed and yes. You can be prepared to fight and you can be prepared with your statistics. Be prepared to ask the why behind questions, but ultimately, I think that care can be so much more than we expected if we go into it thinking, Gosh, well what can I get out of this and how can I make these things happen? Like Paige said, we've had lots of conversations around, Well, this is the policy, but the policy is not the law. I'm here to support you in that. At our last appointment, she was like, “Hey, make sure you bring your doula to your appointment where we are going to talk about your birth plan because I want to make sure that she is there, that we all hear each other, that we are on the same page.” I think that's helpful too. And then having a doula. My doula was my doula with my C-section. She was with us. She was whoever was on call at the birth center actually and again, I think it was so serendipitous because she is a VBAC mom. I think I needed her then and I'm so stoked to have her now that she is just a really special human who I know is also always in my corner and constantly texting her like, “Oh my gosh, look at the new birth rooms. Oh my gosh, I had this great conversation. Oh my gosh, I'm so excited.” I think having your doula there to be your partner in advocacy is really helpful too. Meagan: Yes. Okay, that's a good question too when it comes to doulas and midwives. Sometimes I think people think that if I'm hiring a midwife, I don't need a doula and then we of course know that a lot of people just mistake doulas and midwives together. But Paige, how do you feel about doula care and working with doula care? Is it necessary? How do you work together as doula and midwife?Paige: Yes. I love doulas. I wish everybody had access to a doula truly because doulas, just like midwives, have been studied and they have better birth outcomes, more empowered births, and all of the things. Doulas are so important and doulas and midwives work really closely. I think a doula is there with that constant presence, that constant helping with anything and a really good advocate which I think is important especially if you don't have a good relationship with your provider maybe or you don't know who you're going to get. Maybe you see 7 different providers and you get who you're going to get when you're in labor. So to have that doula there to constantly be advocating for you is such an important piece. Yeah, I really wish everybody could have access to a doula because it just makes a world of difference. I can't think of any bad outcomes I've ever had when a doula was present. It's just a different level of care. Usually, people who have sought out a doula have also taken the time to seek out and do all of the things that are going to make a healthier pregnancy and a better birthing outcome. It's why I think everybody deserves doula care. It's because it does lead to better outcomes. Midwives are always known to work closely with doulas and really support them. It's a team effort. Meagan: Yeah. Yeah. We love our relationships with our midwives here. It's really great to just know how we work and know how we need to support the client and it is sometimes hard when we go to a hospital and we don't know who we are getting. And sometimes that OB or that midwife we have worked with before and sometimes it's a whole new face so it does bring us comfort to know that the client and the family know us and we know them and we can all work together. I love that. Okay, do either of you guys have anything else that you would like to say to our beautiful VBAC community before we go? Paige: I don't think so. Yeah, thank you so much for having me. This was wonderful and I just hope that everybody who is thinking about a VBAC really does their research and looks for the best provider and really finds that perfect fit because there are so many good providers out there– OBs, midwives, professional midwives, all the things. Meagan: I agree. It's okay to interview multiple people. It's also okay that if mid-pregnancy, the end of pregnancy, during, and even in labor that if something is not feeling right, you can request a different provider. You can go out and start interviewing again and find that provider that is right for you. Paige: Yes. Meagan: Well, thank you Paige and Lily for joining us today, and thank you so much for doing so much in your community. I really love your setup and hope that we can see that type of setup happening in the US because it just feels perfect in a lot of ways. Yeah. Yes. I'm loving it. Okay, ladies. Well, thank you so much. Paige: Thank you. Lily: Yeah, thanks, Meagan. Meagan: Bye. Lily: Bye!ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

Women's health has a history of being underfunded in the United States, leading many women to receive suboptimal care. In this episode of the BackTable OBGYN podcast, hosts Dr. Mark Hoffman and Dr. Amy Park engage in a detailed discussion with Dr. Louise P. King, a minimally invasive gynecologic surgeon, and Christopher Robertson, a law professor at Boston University, regarding the inequitable reimbursement structures that persist within the field of OBGYN. --- SYNPOSIS The guests emphasize the systemic discrepancies between gynecologic and other surgical disciplines. The conversation delves into the origins of these disparities, the complexities of revising current codes and creating new codes, and potential legislative and legal remedies to address gender-based inequities. The guests also stress the importance of patient care outcomes and the role of proper reimbursement in enhancing healthcare delivery. --- TIMESTAMPS 00:00 - Introduction 06:28 - Background on RVUs and Disparities in OBGYN 12:39 - Gender Disparities in Medical Billing 18:00 - Efforts to Address Inequities 31:22 - RUC Structure and Surgical Specialties 32:42 - Billing and Reimbursement Inequities 35:15 - Diagnosis Related Groups 36:42 - Turnover Times and Gender Disparities 40:21 - Advocacy and Legislative Solutions 48:23 - Legal Approaches for Change 52:44 - Conclusion --- RESOURCES Watson KL, King LP. Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care. Obstet Gynecol. 2021 Apr 1;137(4):657-661. doi: 10.1097/AOG.0000000000004309. PMID: 33706362. Robertson, Christopher T. and Kupke, Annabel and King, Louise P., Structural Sex Discrimination: Why Gynecology Patients Suffer Avoidable Injuries and What the Law Can Do About It (May 9, 2024). Emory Law Journal, Forthcoming, Boston Univ. School of Law Research Paper Forthcoming, Available at SSRN: https://ssrn.com/abstract=4800783 or http://dx.doi.org/10.2139/ssrn.4800783

In this episode, we dive into the most pressing questions from our audience about medical compensation trends, including regional comparisons between anesthesiologists and CRNAs, the impact of inflation on RVUs, and the benefits of including annual salary increases. Join us as we provide concise answers and insights into how various medical specialties are navigating these challenges. Jon invites individuals to contact Contract Diagnostics through phone, chat, or email for personalized assistance, visit www.ContractDiagnostics.com

For a full transcript of this episode, click here. “Anyone who isn't confused really doesn't understand the situation.” That's a quote by Edward R. Murrow and very apropos. I started thinking about this conversation that I had had with Brian Klepper, PhD, because so much going on right now—so many discussions and dissections taking place about primary care financial struggles, about what is value in healthcare. And the RUC (Relative Value Scale Update Committee) is, at a minimum, an underlying factor; but yet it doesn't come up. Almost ever. Merrill Goozner called the RUC the AMA's (American Medical Association's) “dark secret,” and I can see why. Just one procedural note before I roll tape with Brian Klepper. We're gonna go a little rogue today because you kind of got to understand what the RUC is before I can get into the two points I really want to make about it. So, here's my outrageous plan, which will shake up our standard Relentless Health Value format. Today, I'm gonna make the points I want to make after the interview, not before, like usual. I will, however, just mention the two points so you can keep them in mind as I talk with Brian. Here's the first point, and it's about the doomed financials of primary care. Why is it that primary care has a lot of times no business model unless part of the business model includes driving profitable downstream utilization? And when I say utilization, do I mean services with bigger RVUs (relative value units)? Why, yes, I think I do. We'll dig into this later. Here's my second point, and it's my view on the nature of any postulations that the “value of healthcare services” is equivalent to the prices that we pay for said services. Again, more on that later, but here is my original conversation with Brian Klepper. Brian Klepper is a longtime healthcare analyst and former CEO of the National Business Coalition on Health. Also mentioned in this episode are Merrill Goozner and Elizabeth Mitchell. People who have written about primary care: Scott Conard, MD; Paul Buehrens, MD, FAAFP; Larry McNeely; Primary Care Collaborative; Nisha Mehta, MD; Dan Mendelson; Tony Lin, MD; Juliet Breeze, MD; Raymond Tsai, MD; Linda Brady; Guy Culpepper, MD; David Muhlestein, PhD, JD   You can learn more in this article and on the AMA Web site.   Brian Klepper, PhD, is principal of Worksite Health Advisors and a nationally prominent healthcare analyst and commentator. He speaks, writes, and advises extensively on the management of clinical and financial risk, on high-performance healthcare, and on realizing the potential of primary care. His current focus is on high-performing healthcare organizations that consistently deliver better health outcomes at lower cost than usual approaches in high-value niches and how, integrated with advanced primary care, they can be configured into turnkey comprehensive high-value health plans that can disrupt the status quo.   02:29 What is the RUC? 06:26 Why is primary care not the “easy” specialty? 09:42 What are three low-value things per RUC? 10:33 EP436 with Elizabeth Mitchell. 10:38 What is a root cause of why primary care doesn't get paid more? 12:50 Why doesn't value equal money?   You can learn more in this article and on the AMA Web site.   @bklepper1 discusses #TPA and #primaryhealthcare and #mentalhealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation   Recent past interviews: Click a guest's name for their latest RHV episode! Elizabeth Mitchell, David Scheinker (Encore! EP363), Dan Mendelson, Dr Benjamin Schwartz, Justin Leader, Dr Scott Conard (Encore! EP391), Jerry Durham (Encore! EP297), Kate Wolin, Dr Kenny Cole, Barbara Wachsman  

I am delighted to reconnect with Dr. Casey Means today. Dr. Means is the Co-founder of Levels, a health technology company dedicated to reversing the global metabolic health crisis. She is also the co-author of the book Good Energy, along with her brother Callie Means.  In our discussion today, we dive into mitochondria and metabolism, looking at the impact of cognitive dissonance and the reductionistic philosophies of medical specialization. We explore the effects of siloing, the challenges posed by our broken medical system, the Flexner Report, the role of RVUs, the effects of insulin resistance on metabolic health and mitochondrial dysfunction, and the symptoms commonly seen in women. Dr. Means also offers her insights on advocacy, continuous glucose monitors, and the labs she finds impactful, and she shares the incredible story of her mother's health journey.  Good Energy is an outstanding book that will benefit every listener and clinician, and I will often recommend it. IN THIS EPISODE YOU WILL LEARN: How energy gets created in the body The link between insulin resistance and acne How insulin resistance impacts fertility How underpowered parts of the brain and neurological system can show up as depression or anxiety, potentially leading to dementia The problem of our siloed, reactive, and specialist-obsessed culture The importance of getting your biomarkers tested and learning simple strategies to improve your metabolism, based on the results  What are the conditions encompassed by the metabolic spectrum disease?  The labs that Dr. Means finds most impactful Dr. Means shares her thoughts on continuous glucose monitors. The benefits of looking at your basic eating patterns in a non-judgmental and curious way before implementing any changes Dr. Means shares the powerful story of her mother's health journey.   Bio: Dr. Casey Means Casey Means, MD, is a Stanford-trained physician and co-founder of Levels, a health technology company with the mission of reversing the world's metabolic health crisis. Her book on metabolic health, Good Energy, comes out in May 2024 with Penguin Random House. She received her BA with honors and MD from Stanford, was President of her Stanford class, and has served on Stanford faculty. She trained in Head & Neck Surgery before leaving traditional medicine to devote her life to tackling the root cause of why Americans are sick. She has been featured in The New York Times, The New Yorker, The Wall Street Journal, Forbes, Women's Health, and more.  Connect with Cynthia Thurlow Follow on Twitter Instagram LinkedIn Check out Cynthia's website Submit your questions to support@cynthiathurlow.com Connect with Casey Means On her website Good Energy  Newsletter signup On Instagram, Twitter, TikTok, YouTube, and LinkedIn Good Energy, by Casey and Calley Means, is available from Amazon and most anyplace good books are sold.

In this episode, Dr. Mark Royer, private practice otolaryngologist and medical director of ENTLocums.com, joins BackTable to discuss salary negotiation for physicians. Dr. Royer begins by using his personal career journey to highlight the importance of negotiation skills. Then, he describes how to develop these skills. Throughout the episode, Dr. Royer emphasizes the importance of knowing one's value as a surgical subspecialist and tailoring your strategy to best suit your employer's perspective and your needs. Relevant topics covered include selecting a practice, starting salaries, RVUs, locums, and non-compete agreements. Dr. Royer concludes by encouraging otolaryngologists to reflect on what they truly want out of their careers as they approach the negotiation table. --- SHOW NOTES 00:00 - Introduction 01:22 - Salary Negotiation 05:24 - Dr. Royer's Journey from Residency to Entrepreneurship 10:16 - Negotiating Your Salary: Essential Tips and Strategies 26:27 - Different Approaches to Negotiation: Hospital vs. Private Practice 28:40 - Exploring the World of Locum Tenens 31:59 - Mid-Career Physician Negotiations and Raises 41:26 - Mastering Negotiation Tactics and Strategies: Tips from “Never Split the Difference” 47:38 - Navigating Non-Compete Clauses & Final Thoughts --- RESOURCES ENT Surgery Solutions, LLC: https://www.entlocums.com/ BackTable ENT Episode 57, “Locums Opportunities in ENT with Dr. Allison Royer:” https://www.backtable.com/shows/ent/podcasts/57/locums-opportunities-in-ent BackTable ENT Episode 107, “How Do I Negotiate My Physician Contract? Part I with Michael Johnson Jr., Esq:” https://www.backtable.com/shows/ent/podcasts/107/how-do-i-negotiate-my-physician-contract-part-i BackTable ENT Episode 108, “How Do I Negotiate My Physician Contract? Part II with Michael Johnson Jr., Esq:” https://www.backtable.com/shows/ent/podcasts/108/how-do-i-negotiate-my-physician-contract-part-ii “Never Split the Difference” by Chris Voss: https://www.amazon.com/Never-Split-Difference-Negotiating-Depended/dp/0062407805

On today's show…  • How do I choose the right tax preparer?  • Why didn't my automatic payment come out for my mortgage?  • Should we move closer to our parents?  • Should I count on hitting my RVUs?  • Should I buy into my surgery center?  • I am 10-years from retirement, should I cancel my life and DI insurance?  • How do we combine finances in my second marriage? Listen in to hear the answers then ask your own question by emailing us at podcast@physician family.com   ARE YOU GETTING ALL THE TAX BREAKS YOU REALLY DESERVE? To find out, get your copy of The Overtaxed Doctor's Retirement Investing Checklist at https://physicianfamily.com/go GOT A QUESTION? Write to us at podcast@physicianfamily.com. NOTICE Physician Family Financial Advisors Inc., a registered investment advisor, has reasonable belief that the information and content as a whole does not include any false or materially misleading statements or omissions of facts regarding services, investments, or client experience. Information presented is for educational purposes only and does not intend to make an offer or solicitation for the sale or purchase of any specific securities, investments, or investment strategies.  Investments involve risk and unless otherwise stated, are not guaranteed. Information expressed does not take into account the specific situation or objectives of individuals and is not intended as recommendations appropriate for all individuals. Listeners are encouraged to seek advice from a qualified tax, legal, or investment adviser to determine whether any information presented may be suitable for their specific situation.  Past performance is not indicative of future performance.

On today's show… • How do I choose the right tax preparer? • Why didn't my automatic payment come out for my mortgage? • Should we move closer to our parents? • Should I count on hitting my RVUs? • Should I buy into my surgery center? • I am 10-years from retirement, should I cancel my life and DI insurance? • How do we combine finances in my second marriage? Listen in to hear the answers then ask your own question by emailing us at podcast@physician family.com ARE YOU GETTING ALL THE TAX BREAKS YOU REALLY DESERVE? To find out, get your copy of The Overtaxed Doctor's Retirement Investing Checklist at https://physicianfamily.com/go GOT A QUESTION? Write to us at podcast@physicianfamily.com. NOTICE Physician Family Financial Advisors Inc., a registered investment advisor, has reasonable belief that the information and content as a whole does not include any false or materially misleading statements or omissions of facts regarding services, investments, or client experience. Information presented is for educational purposes only and does not intend to make an offer or solicitation for the sale or purchase of any specific securities, investments, or investment strategies. Investments involve risk and unless otherwise stated, are not guaranteed. Information expressed does not take into account the specific situation or objectives of individuals and is not intended as recommendations appropriate for all individuals. Listeners are encouraged to seek advice from a qualified tax, legal, or investment adviser to determine whether any information presented may be suitable for their specific situation. Past performance is not indicative of future performance. Disclaimer: See marketing disclosures at www.physicianfamily.com/disclosures.

This is a transcript of a podcast episode featuring Dr. Nabilah Noor, a urogynecologist, discussing the lessons she learned in developing her practice after completing her fellowship. The key topics covered include understanding compensation models and revenue generation, effective time management strategies, maximizing efficiency in the operating room, building a strong professional network, and achieving work-life balance. Dr. Noor shares her insights on leveraging her team, delegating tasks, pre-planning for clinic and surgery days, communicating clearly with staff, and prioritizing self-care to avoid burnout. The conversation highlights the importance of adapting to the specific needs and resources of one's practice environment while maintaining focus on providing quality patient care. Chapters 00:01:28Introduction and Background The host, Dr. Amy Vertings, introduces the guest, Dr. Nabilah Noor, a urogynecologist employed in a large hospital network. Dr. Noor shares her educational and training background, including medical school at Duke University, residency at Mount Sinai, and fellowship at Beth Israel Deaconess Medical Center. She explains her decision to join her current practice, driven by the desire to maintain a busy surgical volume and operate regularly. 00:06:32Lesson 1: Understanding Compensation Models and Revenue Generation Dr. Noor discusses the importance of understanding the compensation model in her practice, which is based on relative value units (RVUs) and revenue generation. She learned to identify the revenue-generating activities, such as surgical cases, and prioritize seeing patients who could potentially convert to surgery. Dr. Noor worked closely with her team, including physician assistants and schedulers, to streamline the patient flow and ensure efficient use of resources. 00:21:00Lesson 2: Effective Time Management Dr. Noor shares her strategies for effective time management, including pre-planning clinic notes, utilizing downtime between surgeries, and dedicating specific times for administrative tasks. She emphasizes the importance of not taking work home and maintaining a work-life balance. Dr. Noor also highlights the value of leveraging her team's skills and delegating tasks to the appropriate personnel. 00:29:27Lesson 3: Maximizing Efficiency in the Operating Room Dr. Noor discusses her approach to maximizing efficiency in the operating room, which involves pre-planning surgeries, visualizing potential challenges, and ensuring the availability of necessary instruments and equipment. She emphasizes the importance of clear communication with the surgical team and requesting specific staff members who work well with her to streamline the process. Dr. Noor also highlights the value of remaining calm and in control during challenging situations. 00:35:10Lesson 4: Building a Strong Professional Network and Collaboration Dr. Noor emphasizes the importance of building a strong professional network and collaborating with colleagues from various specialties. She discusses the value of clear communication, setting boundaries, and accommodating each other's schedules when working on combined cases. Dr. Noor also acknowledges the support of her family, including her husband and parents, in helping her balance her professional and personal responsibilities. 00:41:45Closing Remarks Dr. Noor concludes by encouraging surgeons not to give up on their careers due to burnout or workplace challenges. She emphasizes the importance of adapting to different practice models and environments while maintaining confidence in one's abilities. Dr. Noor expresses her willingness to share her experiences and insights with others in the field. Action Items 00:07:24Understand the compensation model and identify revenue-generating activities to prioritize in your practice. 00:23:31Implement effective time management strategies, such as pre-planning clinic notes, utilizing downtime, and delegating tasks to appropriate team members. 00:31:04Pre-plan surgeries, visualize potential challenges, and ensure the availability of necessary instruments and equipment to maximize efficiency in the operating room. 00:35:22Build a strong professional network and collaborate with colleagues from various specialties, communicating clearly and accommodating each other's schedules. 00:36:45Seek support from family and loved ones to achieve a healthy work-life balance and avoid burnout. 00:41:17Adapt to different practice models and environments while maintaining confidence in your abilities as a surgeon. 00:41:00Share your experiences and insights with others in the field to help them navigate the challenges of developing a successful surgical practice.

Last month, the MedSLP Collective hosted a free four-day workshop to help medical SLPs accomplish more by doing less! This week, we're going to share Day 2 of the workshop on the Swallow Your Pride podcast! Let's face it, productivity can be a bit of a maze, with each facility and setting having its own unique calculations and expectations. But fear not, my friends, in today's episode we're breaking it all down.  Tune in so you can hear Kristin Dolan, a seasoned speech pathologist with over two decades of experience under her belt, share her experiences and expertise. With a deep understanding of productivity from both the clinical and managerial perspectives, Kristin offers her wisdom on the inner workings of productivity in our field. Kristin and Theresa define the differences between productivity & efficiency, share 10 tips to improve your efficiency, and illustrate how you can map out your workdays with the help of a free productivity calculator.  From deciphering productivity formulas to exploring strategies for efficiency and effectiveness, we're on a mission to demystify the process and empower you to thrive in your role. Interested in listening to the entire workshop? You can catch the entire workshop HERE: medslpcollective.com/effectiveslp Timestamps: Understanding Productivity (00:00:00) Accessing Workshop Recordings (00:00:59) Highlighting Productivity Tips (00:02:15) Leadership and Teamwork Method (00:03:26) Discussion on Productivity (00:06:20) Understanding Productivity and Efficiency (00:09:32) Empowering Therapists (00:13:51) Value-Based Systems (00:19:51) Understanding Productivity Calculation (00:22:46) Efficiency in Patient Treatment (00:23:30) Adapting to Patient Needs (00:25:37) Challenging Productivity Expectations (00:29:21) Differentiating Managers and Leaders (00:31:43) Understanding RVUs in Productivity (00:34:22) Maximizing Efficiency with RVUs (00:38:35) Tools for Efficient Documentation (00:41:12) Balancing Efficiency and Quality in Documentation (00:43:35) The importance of taking time to review repetitive tasks (00:45:35) Improving department effectiveness (00:46:04) Utilizing downtime forms for concise documentation (00:47:27) Reducing decision fatigue and time management (00:49:39) Delegating tasks and setting priorities (00:50:02) Analyzing time usage and efficiency (00:54:48) Understanding productivity calculations and advocating for change (00:55:20) Managing non-billable but required activities (00:57:31) Efficiency tools and resources (01:00:07) MetaSLP Collective membership and support (01:03:14) The post 322 – Understanding & Calculating Productivity vs. Efficiency appeared first on Swallow Your Pride Podcast.

Have you thought about the evolving role of surgeons in today's complex healthcare environment? The latest BOSS podcast features the inspiring Dr. Frank Opelka, a true leader in the field of surgery. We left residency thinking that we were the leaders of the team. Our jobs told us that our value is in wRVUs. With the rise of AI, the reality is that information will be a leading influence on the team, and without proper understanding and supervision, we could be led with misinformation. From predictive medicine to the value of surgeons in a changing system, Dr. Opelka's expertise sheds light on a whole new dimension of patient care. “Medicine is not getting less complicated over time. It's getting more complicated, because our understanding of the science keeps growing. But our patient complexity is also growing. ” -Dr. Frank Opelka Key Takeaways Gain insights into the evolving landscape of surgery and stay ahead of the curve in healthcare advancements. Discover the importance of transparency in healthcare and how it can positively impact patient outcomes and satisfaction. Learn strategies to help patients attain their goals in care, leading to improved overall well-being and recovery. Explore the benefits of surgeon coaching for professional development and enhancing surgical skills. Uncover the potential of AI in shaping the future of surgery and its impact on patient care and surgical outcomes. About Dr. Frank Opelka Frank Opelka, MD FACS is a recognized expert in healthcare quality and health policy. He is currently the primary consultant having founded Episodes of Care Solutions, LLC. Dr. Opelka is the immediate past medical director for quality and health policy for the American College of Surgeons. He has served the College in various quality and policy roles for over 30 years. His expertise stretches from payment policy to systems design, quality measurement, and includes healthcare informatics. His roles have included an advisory capacity and surgical representative to various health policy and quality committees throughout the Washington DC landscape. He has testified and advised both houses of the US Congress as well as served in an advisory role to four presidential administrations and a long list of federal agencies. Dr. Opelka's early work involved standing up the Relative Value Update Committee, known as the RUC. In his recent work, he has moved away from defining surgeons by RVUs and promotes the value of a surgeon for the many contributions surgeons bring that are outside the boundaries of RVUs. Dr. Opelka served on the Medicare Episode Grouper development project that created open standards for defining surgical episodes of care. He currently serves as the chair of the board of the PACES Center which is the non-profit organization that continues to promote physician-defined episode definitions for use in price transparency. Dr. Opelka is involved in several consultant projects to better align surgical quality to meet the patients needs in finding care, to aid surgeons in driving improvement, and to assisting payers in understanding aligned incentives to reward care. In addition, Dr. Opelka's work in informatics highlights the importance of expertise in a generative AI world of knowledge management. He insists we are on the cusp of a knowledge explosion in healthcare and the importance of specialists to find the "signal" amidst all the "noise" has increasing relevance. It is less about EHRs and registries and more about trusted knowledge. He supports policy efforts to secure knowledge bases that are filtered by experts before seeking generative AI analytics. Finally, Dr. Opelka is an author and public speaker with countless contributions in texts, peer-reviewed journals, editorial staff and policy manuscripts. Key Moments 00:00:02 - Introduction and Guest Introduction 00:03:07 - The Complexity of the System 00:07:10 - Overcoming Barriers in Healthcare 00:12:45 - Trustworthy Knowledge Sources 00:16:38 - Current Data Pools and Future Considerations 00:17:07 - Enhancing Data Integrity 00:18:49 - Health Information Exchange 00:20:29 - Patient Goal Attainment 00:23:38 - Transition to Patient-Centric Care 00:30:38 - Predictive Medicine and Knowledge Management 00:34:11 - The Future of Medical Education and Residencies 00:35:26 - The Role of AI in Healthcare 00:37:33 - Developing Surgeons as Leaders 00:39:12 - The Role of a Surgeon Coach 00:43:24 - Dr. Opelka's Projects and Future Endeavors

“Wherever you're working, whatever setting you're working in, whatever profession you are, if you're working with humans, you should be trauma-informed.” Rachel Archambault, MA, CCC-SLP dropped ALL the mics within the first three minutes of our discussion in today's episode of the Swallow Your Pride Podcast! Trauma-informed care, empathy, and just the human touch are all crucial in our profession, but there's an obvious tension between meeting productivity standards and providing this level of care. It's palpable. Does our current productivity model harm the quality of care we can provide? What does trauma-informed care look like, and what can we actually do to make it work without stressing over time-based codes and RVUs? Tune in to this week's discussion and see what Rachel has to say about it and join her call to action! Get the show notes: https://syppodcast.com/311 Timestamps: Introduction (00:00:02) Discovering Trauma-Informed Care (00:01:33) Challenges in Implementing Trauma-Informed Care (00:04:23) Advocating for Change (00:06:01) Impact of Trauma-Informed Care (00:09:14) Six Pillars of Trauma-Informed Care (00:13:35) Looking at the conversation through a trauma-informed lens (00:14:15) Trust and transparency in provider relationships (00:15:23) Fostering trust and transparency with clients (00:16:58) Peer support, collaboration, and mutuality (00:17:26) Empowerment, voice, and choice in therapy (00:20:21) Consideration of cultural, historical, and gender issues (00:23:09) Personal experiences with trauma-informed care (00:24:50) Trauma-informed care (00:28:03) Cultural and religious considerations (00:29:33) Resources for trauma-informed care (00:31:38) Training and implementation (00:34:14) Connect with Rachel (00:35:38) The post 311 – Compassion Over Metrics: Prioritizing Trauma-Informed Care as Medical SLPs appeared first on Swallow Your Pride Podcast.

Welcome back to Common Sense Medicine! This is a great interview with a physician who is working in the intersection of the care navigation space. Patient-centered care can mean a lot of things to a lot of people. For me, it means that patients are heard in their care journeys and feel as though they have agency in a system which is often confusing and not at all “human-centered.” My guest today is trying to change that through providing a better solution care navigation in cancer care. Dr. Hillary Lin is a Stanford-trained, board-certified internal medicine physician and the Co-founder and CEO of Curio, a HealthTech startup addressing health equity and outcomes via Al-enabled navigation. Dr. Lin has contributed to neuroscience and oncology with her peer-reviewed research work. She is a frequent speaker and advisor for programs, including Headstream Innovation and Cornell BioVenture eLab. In her personal life, she enjoys immersive experiences and has completed over 200 escape rooms worldwide.Video Version[00:59] Hillary's background in medicine, and Curio's start * She entered medicine because she was passionate about the “human experience,” she knows how complicated life can be and how important health is * It's about all of the aspects around health that you also have to manage when you are sick and not just the disease itself* There's too much focus on the facts of medicine and the facts of biology and it sucked out the “soul” of medicine for her * We're asked as physicians to remember more facts and be computers rather than a person to help guide the journey (AI can help here)* Drove her to specialize in oncology because she wanted to be deep in the process of answering existential questions, but when she got there she found out it's mostly running in and out of bedrooms and clinic rooms. She was trained in internal medicine at Stanford and then went to Columbia for a brief time in an Oncology fellow role* You don't get time to sit down with the patient that much* She found that she wasn't answering the existential questions she wanted to, so she went to digital health innovation and sampled the smorgasbord of what she could be doing, and finally she landed on cancer care navigation[06:16] What is so compelling about care navigation for patients? * Took her a long time, she was seeking for years to land in a field to innovate in* In the beginning, as a relatively new founder, like many founders, she went straight to where the problem was—when founders do this, they try and create a tech-enabled clinical platform for whatever they want to solve quickly. She thinks this is the first-order solution, rather than the final state* They found that with more serious healthcare concerns, a lot of it comes down to navigation problems / concerns. Health literacy, access, and equity are prevalent in the U.S. where we have a convoluted system. It's very hard for them to get optimal treatment and care[08:44] All about Curio—what is it & how does it help their end customers? * Problem they're solving: Help patients get the resources they need in order to optimize their health * The tooling behind that (which is growing) is vast, and it's growing in real time Shree's note: the tooling now may be different then when we recorded this podcast in November 2023* One example of a tool is a natural language parsing tool to provide the opportunity to explain a problem and can connect to a in-person navigator to find those services, or use the AI to find them a personalized service which can help them find the solution for their specific issue * The next level of that is to guide them through the steps to get the resources that they need. Instead of having a case manager or a social worker on the line, they can use the AI to navigate the next level * The key thing to understand is a B2B company which works with health delivery platforms, non-profits, patient support services, and similar entities. 80-90% of the time, there is a human in the loop, such as a social worker or another personnel* Rather than focusing on just a patient assistance program in a specific zip code, you can use Curio to add additional parameters (i.e., age, family members, etc.) to add greater “precision level resourcing” for cancer patients* There's also a level of communicative support which uses generative AI to help individualize to the patient's health literacy level in an SMS or email communication[14:35] What are patients most using Curio for? * Financial assistance is by far the largest problem which patients face with a cancer diagnosis, and financial toxicity is the main focus of Biden's Cancer X initiative* It takes up to 80% of people's bandwidth and mindshare. Cancer care is so incredibly expensive that people max out their deductible pretty quickly. There's also legal type of concerns especially with their employers (i.e., leaves of absences)* In an earlier rendition, Curio was a mental healthcare company. They found that for cancer care, mental health is a secondary concern, after people are able to pay for their medications and their base needs. There are a lot more resources to tackle mental health than other issues though[18:12] Curio's business model * They sell to intermediaries, navigation and utilization discovery services. The ecosystem has become very bloated with point solutions for digital health that benefits administrators get burned out* Shree's take: Curio is really trying to differentiate their navigation solution based on its personalization through partnerships. For example, if you have a MSK issue, Curio will basically tell you which piece of education you need to read for your particular issue* They use both human / automated version of finding those resources, but they prefer a partnership because then it is more intricately tied to the experience of navigating care* They use a tiered utilization pricing model for Curio's care navigation solutions. They align well for utilization based pricing model because sometimes there's very low utilization of those benefits [27:16] What do oncologists think about this tool? * Trust is key to get buy-in from various providers. They are trying to establish strong relations with patient advocacy groups—this is not to just have their logo on their website, but to have relationships with them * Hospitals don't reimburse for care navigation services, so it's pretty awesome to see that patients are getting these services outside the hospital. Doctors don't get paid (RVUs) based on them helping the patient navigate the system; social workers are strapped for their time. If patients find Curio or another tool, it can be a real game changer for them* They are also working on the pharma side where they are focused on getting patients more adherent onto their treatment, and focusing on patient engagement. Pharma companies want to know why patients aren't continuing on their treatment (i.e., copay, adverse events, etc.) so it's actually pretty helpful for them to understand where in the patient journey they are losing the consumer[32:49] Does Curio help with finding second opinions? * They work with advocacy groups to help find second opinions for their patients. In fact, in Hillary's opinion, a lot of doctors do value second opinions and look to get them from academic institutions (i.e., you have one oncologist at an academic institution and one in a community setting) * They are working on getting a database for clinical trials so patients can use that to find trials which are very helpful to them. Patients are very skeptical of trials, so according to her, getting patients there is 90% of the issue* A lot of the convincing happens at the education level and the risks and benefits of the trial[40:16] What is different about Curio? * Shree's note: I read an market map of the Generative AI in healthcare space, where they talked about how the care navigation space is becoming crowded—so I asked Hillary about her opinions in the care navigation nicheNavigation companies, such as Navvi Health, Collective Health, Auxa, and Talktomira, focus on helping employees and patients navigate their healthcare benefits and options. However, these companies face challenges like overcoming vendor fatigue and budget constraints in the current economic climate. Interestingly, these companies have the largest amount of funding in this category and the lowest amount of median funding per company, which implies the category is more saturated and less capital intensive then other patient-facing categories. We're excited to see how generative AI can streamline user experiences, interpret health information, and guide patients more holistically, potentially reducing readmissions and encouraging proactive care.* Curio is good at patient engagement, which a lot of digital health companies have not been successful at (according to Hillary)* Each product / feature release has to be laser-focused on that particular use case—they are trying to solve problems with technology rather than with humans * A lot of care navigation companies are human first, with technology enablement, where she thinks it has to be reversed—tech first, with human enablement at points, so that it can scale* Now with generative AI, this scalable solution is now possible[45:48] What is the future of Curio? * They are trying to provide a broader layer of tech for the vision of healthcare—a human person is more than their disease, so they have to have a broad way to access that care * Rather than becoming verticalized, they want to go more horizontal—focus on nutrition, wellness, or other places[47:04] Why go into Digital Health? * It took her years to get her legs underneath her as an entrepreneur. She believes we're living in a world where healthcare is stuck in an outdated mode of manual labor* Looking very closely at other industries, all other industries are moving towards this idea of personalization, but why can't we focus that on scaling up healthcare for a lot more people? This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.shreenadkarni.com

In this episode of The Nurse Practitioner Podcast, Julia Rogers, DNP, APRN, CNS, FNP-BC, FAANP discusses having a voice in the payment system based on RVUs for CPT® codes. Physician Fee Schedule: https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-relative-value-files/rvu23b _________________________________________________________________ Podcast Sponsored By: Dakins Wound Cleanser When it comes to treating persistent, hard-to-heal, or complex wounds, you need a solution you can trust. Dakin's Wound Cleanser is an FDA approved device for wound cleansing and management. It's powerful, cost effective, and easy to order. Studies have shown this formulation to be effective in killing 99.99999% of MRSA, VRE and biofilm-forming bacteria within 30 seconds! (Barsoumian et. al) Visit http://shop.getdakins.com/affiliates/default.aspx?Affiliate=4&Target=Home to request a sample today!

Healthcare transparency is essential for patients to make informed decisions, yet price disparities in the industry remain a major issue. In this podcast episode, we explore how financial incentives and contracts between hospitals and insurance companies can misalign the incentives of brokers, employers, doctors, and patients. We discuss the importance of understanding the influence of these incentives and the need for accountability in developing an equitable healthcare system. Through transparent communication and a focus on an equitable system, we can help ensure that patients receive the care they need and deserve.Episode Outline:(00:00:02) Healthcare Transparency(00:04:42) Price Disparity in Healthcare(00:09:37) Health Insurance Incentives(00:14:21) Doctor Compensation Metrics(00:19:05) Incentive MisalignmentQuotes:(00:03:21) The thing that boggles my mind about healthcare is that in most of healthcare, neither the consumer, which in healthcare is the patient, nor the provider of the goods or services, which in most cases is the doctor, neither one of those parties know what the price is going to be until long after the services are already rendered.(00:09:10) You might only be paying a copay or you might only be paying your $200 and $5500 out of pocket that's falling off of your coinsurance. And they have no idea until they get the EOB what the build charges were and what the allowed charge was. So I think they're so disconnected from how much health care actually costs.(00:12:23) But I'm going to put it really bluntly and I think I got this from Dave Chase, this little metaphor here. But imagine for a minute if fire departments only got paid when there was a fire, they would want as many fires to occur as possible. And the bigger the fire, the more money they get.(00:17:22) And not only that, I think to deny that you're influenced by the financial incentives is to deny you're human. I mean, we've operated on financial incentives long before currency even existed.(00:21:08) I challenge you, if you are not already, if you're a consultant, even if you're a patient, if you're an employer, figure out what you can do. What one thing can you do differently to turn that incentive around?Social Post:Are you tired of feeling like you have a healthcare hangover? We've all been there. That's why we created the Healthcare Hangover podcast. We dive into the headaches we've been encountering in the healthcare system that are leaving us feeling a little hungover. In our latest episode, we talk about the importance of healthcare transparency. We heard a story about a patient who was charged $475 for an X-ray at a hospital, when they could have gotten the same X-ray at a chiropractor's office for less than $75. We also spoke with a hernia surgeon who was able to do the same procedure for $7,200 instead of the $20,000 quoted by a local general hospital. Tune in to the Healthcare Hangover podcast to learn more about the importance of healthcare transparency and how it can save you money.Are you curious about how doctors are paid? Tune in to the latest episode of The Healthcare Hangover podcast to find out! From patient volume to RVUs, David Contorno and Emma Fox break down the complex system of doctor pay and how it influences health care decisions. Plus, they discuss how traditional brokers are put in an unfair position and how financial incentives can be used to deliver better outcomes. Don't miss out on this eye-opening episode! #TheHealthcareHangover #DoctorPay #HealthcareAre you tired of the broken healthcare system? Tune in to the latest episode of The Healthcare Hangover to learn how the system was designed to benefit certain people and how you can help turn the incentives around! From the perverse incentives of commission-based compensation to the Cigna CEO's 20 million dollar salary, David Contorno and Emma Fox will take you through the details of the current system and how you can help build an alternative. Don't miss out! #TheHealthcareHangover #BrokenHealthcareSystem #IncentivesBlog Post:The healthcare system is broken, and it's time to start fixing it. In this episode of Healthcare Hangover, hosts David Contorno and Emma Fox explore the lack of price transparency in healthcare, and how providers are taking advantage of patients by charging them more than necessary. Insurance companies make money by renewing plans every year, regardless of how much they pay out, and people often think that more expensive care results in better outcomes, which is not true. Unfortunately, people often cannot afford their out-of-pocket costs, leading to debt or even lawsuits. Insurance companies do not provide any positive benefits to doctors, employers, or patients, and people have been led to believe that they need health insurance to get quality health care, which is false. The hosts also discuss how fire departments operate on a fixed budget, while health care systems make more money the sicker people are. Health insurance companies have a massive workforce that they pay very little to, and they have bonus programs for brokers that are available on their websites. Hospitals are not changing their practices due to lack of consumer demand, and MRF (Machine Readable File) is not human readable, requiring a middleman to translate the data. Additionally, hospitals often put programming on their website to prevent spiders from finding the data. David Contorno and Emma Fox also discuss how cash prices are almost always the lowest prices on hospital spreadsheets, and the disparity between prices for the same procedure from different carriers is outrageous. Commercial carriers pay the highest reimbursement rate to hospitals, and patients are disconnected from the cost of healthcare due to copays and coinsurance. To illustrate this, David Contorno visited a chiropractor for an X-ray of his shoulder and was asked if he was okay with the price before the X-ray was taken. The X-ray cost $75 at the chiropractor's office, but the same X-ray would have cost $475 at Atrium, the hospital system next door. Michael Reinhorn, a hernia surgeon in the Boston area, charges $7,200 for hernia surgery, while a local general hospital charges $20,000. The hosts also compare the healthcare system to the veterinary system, noting that veterinarians often give customers options and prices up front before giving any treatment. Doctors, on the other hand, are typically paid based on two metrics: patient volume and RVU (Revenue Value Unit). Patient volume is the number of patients seen in a day, with some doctors having minimum patient volume requirements of up to 30 patients per day. RVU is a measurement of how much revenue a doctor is helping generate for the health system, often in areas outside of their office. Doctors are incentivized to prescribe opioids to deal with pain, and to send patients to the most expensive care, regardless of whether it is the appropriate treatment. The most likely outcome of back surgery in the US is a second back surgery. Additionally, traditional brokers are paid more when they retain their book of business and cross-sell additional products that benefit the carrier they represent. Healthcare and health insurance employees often think they are doing good, even though the results they keep delivering are bad. The company bills their clients and has a performance bonus for achieving the client's goals of paying less for healthcare. Ultimately, the hosts conclude that people should focus on changing one thing at a time to build an alternative system that is more affordable. The Cigna CEO made 20 million dollars last year, and the sicker people are, the more money they make. It's time to start demanding more transparency and accountability from health insurance companies, and for patients to take control of their own healthcare. We have the power to create a system of trust between providers and patients, and to make healthcare more affordable and accessible.Episode Links:Connect with Emma FoxWebsiteEmma's WebsiteConnect with David ContornoLinkedInWebsiteOther MaterialsThese materials help you promote your podcast. Quotes can be used for audio & video grams or quote cards. Blog and social posts will help your website and social media presence.

In this episode, co-hosts Drs. Ally Baheti and Mike Barraza interview Dr. Ted Wen of Texas Radiology Associates and Dhruv Chopra of Collaborative Imaging about perspectives and helpful technology when managing an independent radiology practice. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- SHOW NOTES Dr. Wen shares reasons why he and his colleagues chose to keep their practice independent. The fast-growing group spent eight years doing due diligence about private equity (PE) to decide if that was the right model for them. Dr. Wen met with PE firms around the country to explore the process of transitioning into PE practice ownership and its implications for current colleagues and future physician hires. Selling to PE would disproportionately benefit senior partners, who were ready to be bought out, over junior partners who would not qualify for the same deal. Additionally PE management could have the power to raise minimum RVU requirements and enforce highly restrictive noncompetes. Texas Radiology Associates ultimately decided that in order to compete in the radiology marketplace as an independent practice, they needed to make significant investments in technology to better serve their patients. They started to connect with Collaborative Imaging to pursue this mission. Dhruv notes that PE has the potential to bring in financial support, strategic relationships, and pathways to growth, but he also warns the audience that not all PE contracts are transparent nor designed to benefit physicians. Workflow, staffing, and collaboration with referring doctors can be extremely difficult when firms value cost savings and RVUs over patient care. All of these stressors have negatively impacted the radiology burnout rate. Dhruv describes the start of Collaborative Imaging, in 2018, as an attempt to integrate a revenue cycle management (RCM) system with radiology workflow at Texas Radiology Associates. This provided a cost-efficient solution that frees up funds to invest in other areas of the practice. Collaborative Imaging is currently working on an AI-driven system to notify patients of actionable findings that come up in their imaging. They are also exploring technology that will adapt the style of radiology reports to different referrers' preferences. Both guests discuss the common inefficiencies that independent radiology practices face, including RCM, clarification over patients' payment plans, and office wait times. Collaborative Imaging is working with practices around the country to build solutions. Radiology groups can contribute a percentage of their revenue into Collaborative Imaging and receive dividends, or they can license the RCM solution. --- RESOURCES Ep. 277- Private Equity and the Radiology Job Environment with Dr. Ben White: https://www.backtable.com/shows/vi/podcasts/277/private-equity-the-radiology-job-environment Texas Radiology Associates: https://texasradiology.com/ Collaborative Imaging: https://collaborativeimaging.com/

Medication non-adherence leads to preventable hospitalizations and costs US healthcare $500 billion each year. Bruce Berger explains how motivational interviewing can help, with Jim Cagliostro.    Episode Introduction  Bruce explains that motivational interviewing is still the most effective intervention for substance abuse, why adherence hasn't improved in 40 years, and why discharge counseling should be provided the day before patients leave hospital. He also shares how MI interventions reduced the patient dropout rate from 13% to 1.2%, saving $93 million for one biotech company in four months, and urges healthcare leaders to stop objectifying patients.      Show Topics   Motivational interviewing (MI) began in the 1970s Why MI is not about motivating patients  All of us are sense-makers Genuinely connecting with what's emotionally important to patients Restricting patient time is at the heart of burnout Healthcare needs to stop objectifying workers and patients     03:54 Motivational interviewing (MI) began in the 1970s Bruce explained how MI was originally developed to treat people with substance abuse problems.  ‘'Well, motivational interviewing was first developed by a clinical psychologist named William Miller, and it was developed back in the '70s to actually treat people with substance abuse problems. And here's the irony, Jim, to this day, it is still the most effective intervention for substance abuse, and yet, we hardly hear about it in healthcare. We've got an opioid crisis, we've got substance use and rarely do you hear people talking about using motivational interviewing to intervene. And I've done a number of webinars on this. And here's one of the reasons why, we are huge in healthcare on evidence-based medicine, but not evidence-based communication. And in fact, this year, for the first time, the American Council on Pharmaceutical Education is including motivational interviewing as part of their accreditation standards. I'd like to think I'm part of the reason why, because I wrote a five-page single-space letter saying, how can you talk about evidence-based pharmacy and medicine, but not evidence-based communication?''   05:17 Why MI is not about motivating patients  Bruce said people might know how to communicate, but often lack the skills to be effective. ‘'And we graduate people who think everybody knows how to communicate, but that doesn't mean they know how to do it effectively. And so, what MI is, motivational interviewing is a set of skills and a way of being with patients. It's kind of a misnomer, it's not about motivating patients, it's an interview, in a sense, to explore the patient's motivation. "Okay, now you've found out you've got diabetes and the doctor has told you, "You got to take this medicine, watch what you eat, get some exercise." What do you think about all this? In other words, how important is it to you to get your blood sugar down? Tell me in your own words, what does having diabetes mean to you?" The idea behind motivational interviewing, because it's patient-centered, and you asked how is it different than what we do? We have this literally crazy idea in healthcare that we're driving the bus and the patient's a passenger, the reality is the patient has always driven the bus, what we're trying to do is influence the route. Does that make sense?''   09:33 All of us are sense-makers  Bruce said changing your approach to patients helps to overcome non-adherence.  ‘'….all of us are sense-makers. Even as we're talking right now, we're deciding whether we make sense of each other based upon what we bring to the conversation. So we're trying to train people to listen for, how is this patient making sense? And in their sense-making, what information is either missing or misinformation? Let me give you a really simple example. Patient with high blood pressure says, "I don't know why I need this medicine. I feel fine.'' Now most healthcare professionals will look at the patient and say, "Listen, you can't tell when your blood pressure's up. You can't feel when it's up." And they might as well just say, "Stupid," at the end of that sentence. We would say, "Because you're feeling okay, you're really wondering, why do you need this medicine?" What's the patient going to say now? Exactly. And what will they have learned? That I've listened to them without judgment. Now I'm going to say, "That's a reasonable thing to ask. Would you mind if I shared some thoughts? And I'd like to hear what you think." You notice the sharing?'' We're negotiating here. And so, now I would tell the patient that, "Unfortunately, high blood pressure is one of those conditions that doesn't have any symptoms, and the first symptom is stroke or heart attack. This medicine can greatly reduce your risk of having a stroke or heart attack even when you feel okay." I'm now not going to say, "Therefore, you need to take it," I'm now going to say, "Where does that leave you in terms of thinking about taking the medicine to reduce your risk?" So I've listened to what the patient has said, I've heard in their sense-making that their sense is that if you feel okay, everything's okay. My job is to help them understand how you can feel okay and be at risk.''   18:34 Genuinely connecting with what's emotionally important to patients  Bruce said it's important to understand what's meaningful to patients. ‘'….we had an asthma patient that wasn't using her daily inhaler. She said, "I just hate being reminded that I got this thing." And I said, "Let me ask you something. What could you do?" I said, "If your asthma was under control, what would that allow you to do that you find difficult now?" She teared up and she said, "I could play tennis again." Now we found out what's important to her. It doesn't matter what's important to me, she's only going to be motivated by what's important to her. And so, we then start talking about steps that she could take to play tennis again by using the medication, and she became adherent, but you had to explore what was meaningful to her….. And I'm not talking about being false, I'm talking about genuinely connecting with what's emotionally important to the patient, and you've got to do that in order to really have influence in a positive way. And so saying to that patient, "You love your grandkids. You miss not being able to spend time with them. You want a future where you can spend time with them." And you see what I'm doing? I'm helping build pictures.''   22:53 Restricting patient time is at the heart of burnout Bruce explained why healthcare has a systems problem which affects patient care and adherence.   ‘'One industry is moving in a totally opposite direction (to other industries), healthcare. There are so many toxic systems out there that are putting profits ahead of people, people meaning their workers and the patients. We are watching burnout at a level we've never seen before because healthcare systems are basing staffing on things like number of prescriptions dispensed, number of immunizations given, RVUs, "Oh, you should only be spending 11.2 minutes with the patient and no more, even if the patient needs more time in order to have an effective outcome." Somebody asked me the other day, "Well, what am I supposed to do if I only have, at most, 30 seconds with a patient?" Well, no amount of motivational interviewing training can solve that problem, that's a systems' problem. There's a couple of videos on YouTube with me showing what happened with an asthma patient. The patient's daughter had been in the emergency room three times that year because the mother wouldn't allow the daughter to use the chronic inhaler because she looked it up and saw it was a corticosteroid, she misunderstood what that steroid was. She didn't want her daughter using a steroid. Everybody chastised her at the emergency room. I showed her understanding and in fact, said to her, "You're really worried about your daughter using a drug that you think can harm her." And for the first time somebody understood her. After we were done, the whole conversation took six minutes, the kid had not been in the emergency room for at least three years after that……And what's really horrible is we have people that are graduating from nursing school, pharmacy, school and medicine, they have a code of ethics, they have standards of practice that put patients first, and yet they go to work for organizations that set up a moral conflict for them because if your primary goal is to put patients first and the staffing makes it impossible, this is the heart of burnout and chronic stress.''   31:50 Healthcare needs to stop objectifying workers and patients Bruce said if healthcare workers are objectified, they objectify patients, and care suffers.  ‘'…if there's one message that I would give leaders in healthcare, it was you have got to stop objectifying your workers and patients. In other words, when you treat people as objects or like they're replaceable, anybody could do the job, the job's interchangeable, and you don't even give them an opportunity to have input into what's happening, you're objectifying them. And objectification begets objectification. Oftentimes, when we objectify healthcare workers, they objectify patients. It's no longer a human being, it's the diabetic in 214, that's not a person. And I'm saying, objectification is a major source of organizational problems in the delivery of care. The people in charge have got to start allowing for input on how to fix these problems and the people that are working in them and take them seriously. Right now, they're not.''   Connect with Lisa Miller on LinkedIn Connect with Jim Cagliostro on LinkedIn Connect with Bruce Berger on LinkedIn   Check out VIE Healthcare and SpendMend    You'll also hear:    Bruce's inspiration behind motivational interviewing: ‘'We've got data that shows that for the past 40 years, the rate of non-adherence to medication regimens hasn't changed at all, it's almost 50% in year two of a chronic illness. And I wanted to understand better what's going on.'' Why MI is a meeting of experts: ‘'You as a patient are an expert on what you know and understand about the illness. I need to be listening for where the gaps are.'' How MI interventions reduced the patient dropout rate from 13% to 1.2% and saved Biogen $93 million, in four months.  Discharge counseling should be carried out the day before patients leave hospital: ‘'They're a captive audience, they'd want to talk to somebody. When they're ready to get out of the hospital, they don't want to listen to us going through their med list.'' Essential healthcare leadership advice: ‘'Human beings are hardwired relational. If leaders get that, they will treat the people they lead much differently. They'll know they couldn't have gotten to that place without so many people helping them.''     What To Do Next:   Subscribe to The Economics of Healthcare and receive a special report on 15 Effective Cost Savings Strategies.   There are three ways to work with VIE Healthcare:   Benchmark a vendor contract – either an existing contract or a new agreement. We can support your team with their cost savings initiatives to add resources and expertise. We set a bold cost savings goal and work together to achieve it.  VIE can perform a cost savings opportunity assessment. We dig deep into all of your spend and uncover unique areas of cost savings.  If you are interested in learning more, the quickest way to get your questions answered is to speak with Lisa Miller at lmiller@spendmend.com or directly at 732-319-5700.  

Listen to ASCO's Journal of Clinical Oncology essay, “But Where is My Doctor? The Increasing and Relentless Fragmentation of Oncology Care,” by David Mintzer, Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital. The essay is followed by an interview with Mintzer and host Dr. Lidia Schapira. Mintzer stresses the need for oncologists to make an effort to maintain relationships with patients as cancer care becomes more fragmented. TRANSCRIPT  Narrator: But Where is My Doctor? The Increasing and Relentless Fragmentation of Oncology Care, by David M. Mintzer, MD (10.1200/JCO.23.00805) For the past 7 years, I have cared for Michael, a man with pseudomyxoma peritonei. He has undergone two aggressive surgical resections with hyperthermic intraperitoneal chemotherapy and endured multiple chemotherapy regimens, all of which resulted in questionable benefit. Recently, his health has declined due to progression of his cancer, and he has had frequent admissions for infectious complications, obstructive symptoms, and several fistulae. I had always been his attending on previous admissions unless I was away, but when I last saw him, he asked me why I had not been his doctor this time. Even before he asked, I felt guilty for not being there for him.  For most of my career, I would see my own inpatients on a daily basis, rounding before, and sometimes after office hours. Currently, owing to system changes that likely have evolved with most practices and hospitals, only one of us sees inpatients on the teaching service, with the rest being off service. This happened long ago for our obstetrical, primary care, and other subspecialty colleagues, but for as long as possible, I held onto the belief that in oncology, we and our patient relationships were different. While most of the kerfuffle over the past few years in medicine relates to the electronic medical record and its effect on our lives and on physician-patient interactions, I think the fragmentation of care—while less frequently acknowledged—has been as relentless and impactful though more insidious. While most published articles on fragmentation define it as patients receiving care at more than one hospital, my focus is on the fragmentation of care within our own practices and institutions. Our patients are at their sickest and most frightened, thus most in need of us, when they are hospitalized. But now, instead of providing care with a consistent presence, patients are regularly passed back and forth from the outpatient to inpatient teams, then sometimes to the palliative care team, and then perhaps to a hospice team or, for those with the best outcome, transitioned to a survivorship team. While all these practitioners are kind and competent, they are not a constant.  When I am covering our inpatient service, I do not know the detailed medical history of the majority of patients who have been cared for by my colleagues. Can I seriously be expected to know their complex oncologic and other medical issues, let alone their psychosocial needs, in any appropriate depth when I walk in on a Monday to start the week covering 16 new patients?  I can be empathetic and do my best to communicate with their outpatient physician, but both emotionally and medically, it is never the same as being cared for by someone one has known and trusted throughout one's disease trajectory. Our relationship with the house staff is also fragmenting. We used to spend a month at a time as teaching attending, giving us a chance to get to know our students, interns, and residents. This has now been reduced to a week, and with our house staff rotating on an every 2 week schedule, we may work with a resident or intern for just a couple of days before one of us rotates off service. Furthermore, they spend much of teaching rounds staring into their smart phones and computer screens feverishly trying to complete their electronic workload.  As practices have become larger and medical teams more complex, care has become less personal and often less efficient. If the patient calls with an issue or sends a message, it is notclear to them, and often to us, who will be assuming responsibility for their concern. Should it be directed to my administrative assistant, our triage nurse, the nurse navigator, the palliative care nurse, my nurse practitioner, an off-site call center nurse, or myself? The inbox proliferates; the toss-up for ownership of the message begins; six people now read what used to be handled by one or two.  While I was an initial enthusiast for the early integration of palliative care alongside primary cancer care, I now also fear that it has further removed us from some of our most important interactions and deepest responsibilities. The inpatient oncologist used to be the one to provide symptomatic and supportive care and run the family meetings. Our house staff now routinely consults palliative care for even the simplest pain management issues, and we increasingly outsource goals of care and other serious discussions to our palliative care teams, who do not have a longstanding relationship with the patient or their family nor a complete understanding of their disease trajectory and past and future treatment options. Nor do I if it is not my patient and I am just the covering attending of the week. Too often it seems that palliative care has replaced us in some of the roles that used to be integral to our practice as oncologists, and we seem to have eagerly stepped back from some of these responsibilities. Our interactions with our colleagues have also fragmented. Mostly gone are the days when we would sit down in the hospital cafeteria with other physicians from other specialties for coffee or for lunch after grand rounds. And the days when we would review films with our radiologists or slides with our pathologists are mostly long gone. Our tumor boards provide some interaction, but since the pandemic, these tend to be virtual and less intimate. I mourn the loss of our sense of a hospital community. There have been some definite benefits to the fragmentation of care, which is why it has evolved and why we have accepted the bargain. As we increasingly subspecialize, we can get better and more focused on what we do which helps us cope with the explosion of data and new information across every area in our discipline. Some of us can devote more quality time to research, and it has also made our professional lives easier in some ways. How nice not to have to trek to the hospital to see very sick inpatients every day, but rather just a few weeks a year. How much easier to have someone else take charge of difficult end-of-life discussions. There is no point in bemoaning the loss of the old ways of more personalized care, as there is no going back. The current generations of physicians will not feel this loss of inpatient/outpatient continuity having grown up in an already changed environment, just as they will never have known a world before the electronic medical record. Patients have also accepted our absence from their bedside with less resistance than I would have expected, perhaps knowing from the rest of their care experience how depersonalized it has become—not that they have had much say in the matter. The changes in the delivery of health care will likely accelerate as we enter the medical metaverse and how we will navigate artificial intelligence while maintaining our emotional intelligence remains to be seen. The continued emphasis on increased efficiency and throughput of physician efforts—structuring medicine as a fragmented assembly line—runs counter to what is so meaningful to the physician-patient relationship—a function of time spent developing personal connections. As we continue our efforts to keep up to date with the rapid expansion of medical knowledge in our field, we also need to make equivalent efforts to maintain our personal and emotional connections with patients. As we have less frequent direct contact due to so much fragmentation of care, we need to make the time we do have with them more impactful. And sometimes that means going over to the hospital to see Michael after a long office day, although you are not on service. It is the right, human thing to do, and still gratifying—for all of us. Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lydia Schapira, Associate Editor for Art of Oncology and a Professor of Medicine at Stanford University. Today we are joined by Dr. David Mintzer, Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital. In this episode, we will be discussing his Art of Oncology article, “‘But Where's My Doctor?': The Increasing and Relentless Fragmentation of Oncology Care.”  At the time of this recording, our guest has no disclosures.   David, welcome to our podcast, and thank you for joining us. Dr. David Mintzer: Thank you for the invitation, Lidia. Dr. Lidia Schapira: It's a pleasure to have you. I'd like to start these conversations by asking our authors if they have any books they want to recommend to listeners or if they're currently enjoying anything we should all know about.  Dr. David Mintzer: Well, I just finished David Sedaris's most recent book, which is a series of essays. I get a big kick out of him. I think I often mesh with his sense of humor and a little bit of cynicism, a lot of truth, but heartfelt and always amusing. Dr. Lidia Schapira: I love his work. Thank you. That's a great recommendation, especially for the summer.  So let's dive into your essay and your perspective, which is really such an important topic for us. You talk about the fragmentation of care and how it's impacted our practice, our relationships, and even our joy in the work that we do. Can you talk a little bit about your feelings about this? Dr. David Mintzer: Certainly. So I've been practicing medical oncology for a long time, about 40 years, so I've seen a lot of change. Favorably, most of that change is certainly in the good sense. We have so much more to offer our patients in terms of therapies that are more numerous, more effective, and less toxic. But there's been a price, I guess, to pay with those changes. We've all become more subspecialized, and the care has increasingly fragmented. And I was stimulated to write this essay because I've been disturbed to some degree by some of the changes. I think they are inevitable. I didn't want to write a piece just about how far I had to walk to school every day, uphill both ways, and complain. But I got a sense that others might have shared these observations and feelings, and I just kind of wanted to get them down.  Dr. Lidia Schapira: One of the things that you said that really resonated with me is when you talk about patients being at their most vulnerable and at their sickest and most frightened when they're hospitalized, and that's when they need us. And what you say here, what I'm interpreting that you're saying, is that by not showing up at bedside, in a way, we're abandoning them. And that is something that feels terrible to us as well, those of us who really value that presence and that relationship. Can you talk a little bit about how you're dealing with that and how you see your colleagues dealing with that? Dr. David Mintzer: Well, it's a bit of a Catch-22. Yes. I think a lot of this is driven by guilt, by not being there for patients that we cared for sometimes for many years and know well. And although this happened in university hospitals a long time ago, in our hospital it was relatively recent, that it was recommended in part for house staff accreditation regulations to have only one attending on service at a time, which is understandable so as not to confuse the house staff.  But in doing so, we're not there for our patients every day. And so you're kind of torn between running over to the hospital after a long day when you're exhausted and seeing your patients and fulfilling what feels like some responsibility, and also feeling that this is no longer my role, this is no longer the way medicine is practiced. It's not efficient. I don't get paid if I go over, someone else is collecting the RVUs. And in addition to that, the concern that the patients may not be getting not just the optimal emotional care, but even the medical issues. Certainly, the doctors covering are good and do their best, but they don't know these patients. They don't know their whole history, they don't know their complications in the past. That's the trade-off we make.  Dr. Lidia Schapira: Let's talk a little bit about those relationships that we invest in so heavily in oncology. Oncology is different than many other fields and we've always valued the time we spend with patients and forming those relationships. Can you talk a little bit about how you see those relationships threatened when you as the oncologist and the person who's given them guidance for the entire trajectory of their illness can't be present just when they're at their sickest and most vulnerable?  Dr. David Mintzer: So care of cancer patients certainly takes a village and we have tremendous support with so many different practitioners, including our nurse practitioners, our palliative care nurse practitioners, palliative care attendings, nurse navigators. But as we introduce all of these people, we actually have less direct contact time with patients. We're less likely to be the ones to call them on the phone or even answer their email. And one of the great things about practicing oncology is not just the science and what we can do for patients medically, but these bonds and relationships we form. It's been chipped away at rather insidiously, but I think rather steadily over 20 years.   Medicine thinks it's so scientific and advanced and technological. But I always kind of reflect that we're probably 20 years behind every other industry, whether it's banking or going to the supermarket or the clothing store or the hardware store. You used to go to your neighborhood pharmacist and you knew him and he would give you advice or your hardware store guy would give you some advice about how to fix something. So those industries lost their personal relationships a long time ago. We're really far behind them, but we're catching up. So now everything is done more remotely, more on the phone, and as I said, there's less direct contact time, which I think we all miss. But we're different. We're different from going to your local banker or grocer or bookstore dealer.   This is medicine. These are important medical events for patients. They're very emotionally fraught, they're complicated. And so what may be adaptable to other industries, even though it seems to be being forced upon us, is not as adaptable in medicine. Now, maybe there is some respite for this. I saw recent data that telehealth is going down. We thought telehealth was going to be here to stay with COVID and everyone was going to love it. And yet it's interesting, although it may be partly regulatory and partly because of the end of the epidemic, but I get a sense that both physicians and patients are a little bit less interested in it. I think that shows that we might be a little bit different from other industries, but we'll see how that plays out. Dr. Lidia Schapira: Absolutely. I couldn't agree with you more, but you talk about relationships also with trainees, for instance, that part of this fragmentation and these new schedules that we have also limit the contact you have with the house staff when you are assigned to be the doc on service. Perhaps you don't know all these patients very well, but you also bring up the fact that you don't get to know your trainees very well either because they're coming and going with different schedules. So what I took away was sort of a sense of loss, a bit of a lament that a lot of things are being lost in this super fragmentation. Can you address that a little bit, perhaps for our listeners?   Dr. David Mintzer: Yes, I think that's exactly right. So the fragmentation that I describe is not just in patient care, although that's probably the most important to all of us, but the fragmentation with kind of the extended family that was our hospital community. We've gone now to a nuclear family. So if we're a specialist in one particular area, we still have kind of a nuclear family. But my sense is we've lost that extended family, meeting people in the cafeteria after ground rounds, dealing with other subspecialists. And if you're only in the hospital a few weeks a year, you just have less contact, passing people in the hallway, meeting them at conferences, reviewing films, as I said, with radiologists, reviewing slides with pathologists. We're all too busy, we're all sitting in front of our computers at lunch, we're all doing conferences on the phone, driving home from work, but we have less time with each other. And that holds also true for students and residents who now rotate very quickly. Dr. Lidia Schapira: Let's talk a little bit about one of the other points that you make in this very thoughtful essay, and that is that you say that you were an early enthusiast of the integration of PalCare, but now you find that certainly, the younger generation seems to be outsourcing symptom management and communication very early to PalCare. And as a result, perhaps from the patient's perspective, care becomes even more fragmented. And that's sort of a bit of a loss all around. We're not able to do some of the things that we enjoy too, in terms of family meetings and communication, but also everybody's becoming more deskilled. Talk a little bit about that. Dr. David Mintzer: Yes, I was an early enthusiast for palliative care, and I still am an enthusiast, don't get me wrong. You can't criticize palliative care. It's like criticizing mom and apple pie. But the idea was, and still is, of course, that you would work in conjunction with a palliative care specialist, that they would be called in, say, on the very difficult cases, cases that needed particular expertise, or to spend more time. And certainly, that happens, and I have tremendous respect for my palliative care colleagues. But what's happened, as you note, is that we've kind of outsourced it. It's much easier to have someone else have that difficult conversation, particularly if you're just covering a patient that belongs to someone else, you're just seeing them for a few days during the week, you don't feel comfortable in doing so. And so I'm concerned that we've abdicated our responsibility in many of these important discussions and left it to the palliative care team who, by the way, are overwhelmed because there aren't enough of them now that they are getting all these consults for almost everything.   We should, as oncologists, still be able to run the meetings, to refer patients to hospice, to discuss goals of care. But as we all become more specialized, as we become busier, we have less time and we've built this metaphorical moat between our offices and the hospital, I find that we're just doing it less and less, and I feel some guilt about that and also some loss. Dr. Lidia Schapira: David, you say in your essay, we have accepted the bargain. What I hear from you today and what I read and inferred in reading the essay when it came to us, is that there are feelings of guilt, there's less joy, there's feelings that somehow this bargain isn't so good for us after all, even though at some level it makes our work a little bit more simple and our hours perhaps a little bit more predictable. So can we think together a little bit about what lies ahead and how we get over this deep ditch that we seem to be in?  Dr. David Mintzer: Well, as you say, there's both benefit and loss involved with this and it does make our lives easier. If you're seeing relatively healthy outpatients month after month in the office, you get to feel oncology is not so bad and you can kind of put that two-week hospital rotation when everybody's in the ICU and having multiple unfixable problems and poor palliation behind you. So you can almost kind of go into denial. And it does make your quality of life easier to be able to just go to the office and go home most weeks of the year.  How are we going to deal with this going forward? I mean, we do have to make the effort. I don't think it's going to go back. I don't think writing this article is going to change the way medicine is structured. This is a more efficient way and in some ways, it may be safer and more high reliability, which are kind of the watchwords. So I'm worried. I don't know where it's going. I think it is going to be a little less personal. But my point is we have to be aware of it and in doing so make the time we have with patients more impactful, be a little bit more aware of our need to support them. Maybe if you're not at the hospital every day, go over once or twice a week, or certainly when there's a big change in event.  Dr. Lidia Schapira: Do you think we could use technology to sort of stay in touch and pay a social visit via FaceTime? Or remain connected to our patients, even if it is in a social function, but somehow, for their sake and for ours, remain connected when they're in hospice when they're hospitalized. But we're not the attending of the month.  Dr. David Mintzer: Certainly, the way we communicate has changed. I remember being a young attending and I was working at a small community hospital, and one of the surgical attendings would just call their patient on the weekend on the phone, but wouldn't bother to come in. And I thought, my gosh, that's terrible. What kind of impersonal, awful medical care is that? But indeed, now, calling or more likely, texting, communicating, emailing with patients may work.  What's coming with virtual or augmented reality or whether EPIC can eventually just plant a chip in our brain and we can all be online all the time, I don't know. But yes, any type of communication helps. I've often said that there's nothing like an unsolicited phone call to a patient to encourage them. Just, “Hey, you didn't call me, but I'm calling you. I was thinking about you. How are you doing?” So, yes, staying in touch by whatever means, I think can be greatly beneficial and mean a lot to the patient, even if it's a brief text or phone call. Dr. Lidia Schapira: Yeah, even encouraging your trainees if you have residents or fellows working with you to go with you to that unsolicited visit or participate in that, I think that sort of would model the kind of behavior that we would want if our loved one is the patient, right?  Dr. David Mintzer: For sure.  Dr. Lidia Schapira: And that's always a good question because what we hear from patients is how much they value and love their oncologists when there is a strong connection. So let's perhaps finish the conversation by going back to Michael, your patient. How did you and Michael resolve this? Dr. David Mintzer: Honestly, we haven't resolved it. So when he's in the hospital, he's now cared for by whoever's on service at the time. Fortunately, he hasn't been in the hospital lately, but I will make an effort to go over and stay in touch with him. Dr. Lidia Schapira: I'm sure Michael would appreciate your presence.   Are there any other thoughts that you would like to convey to our listeners or readers? We have dealt with some of these futuristic issues in Art of Oncology before, including one essay I remember was published years ago where there was sort of this very impersonal imagining of what it would be like for an oncology patient to basically be seen by a series of robots along the chain without this human connection. And it was really terrifying to read. So thank you for reminding us about what is lost for us as well as what is lost for patients, something that we all need to go back and revisit, I think, as we think about the future. Any final thoughts, David, for listeners? Dr. David Mintzer: So as a physician who's getting close to the end of their career, I don't want to come off as just protesting against change. We need change. You know, change is crucial, but I think it's not really been clear to a lot of people how much this has been eroded over time -  that our direct contact and the fragmentation has impacted us and our patients and other caregivers. And this separation between inpatient and outpatient, I think, is becoming steeper. Our palliative care nurses used to go over to the hospital and see the inpatients as well as the outpatients, or our physical therapists, or our nutritionists. Now everyone is divided. I still think it's a great job. I love caring for patients. I love the teams that I work with. And as medicine gets better, though, we just have to be on guard to stay in touch with our patients and our feelings.  Dr. Lidia Schapira: I really appreciate your perspective. Thank you so much for sharing it with us.   And until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO Shows at asco.org/podcasts.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Show Notes:  Like, share and subscribe so you never miss an episode and leave a rating or review. Guest Bio:  Dr. David Mintzer is a Chief of Hematology and Medical Oncology at the Abramson Cancer Center of Pennsylvania Hospital.  Additional Reading:  Ars Brevis, by Dr. George Sotos

In this episode, host Dr. Aparna Baheti interviews Dr. Bill Julien about the evolution of the outpatient based lab (OBL), its role in expanding patient access to IR care, and its relationship with other IR practice models around the country. --- CHECK OUT OUR SPONSORS Boston Scientific Ranger DCB https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/ranger.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_ranger_1_2023&cid=n10012340 BD Advance Clinical Training & Education Program https://page.bd.com/Advance-Training-Program_Homepage.html Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Julien is one of the initial OBL founders in the United States. In 2001, he started his current practice, South Florida Vascular Associates in an effort to practice independent IR. At this time, he struggled to get hospital privileges due to exclusive diagnostic radiology contracts, so he placed a C-arm in his office out of necessity. Eventually, he built a formal angio suite. As a result, patients enjoyed the efficiency and comfort of office based procedures, and he enjoyed physician autonomy and freedom from hospital politics. Dr. Julien notes that overtime, CMS has recognized the value of an office-based intervention and saw that IRs could practice high-quality care at a lower price point with higher patient satisfaction, leading to improved Medicare reimbursements. Since the conception of his OBL, Dr. Julien has seen practice structures change, especially with the influence of venture capital firms and the pressure to generate RVUs. Additionally, though some voices have pushed for more IR involvement in the clinical sphere, there has not been much progress made in advocating for IR hospital privileges. This is a significant barrier to independent IR practices, since some states require that an IR has hospital privileges before opening an OBL. Dr. Julien says that this dilemma is unique to IR, since other specialties, such as vascular surgery and cardiology, are not affected by exclusive contracts to the same extent. He believes that IR societies and leading voices should actively challenge the legal basis of these contracts and support interventionalists who want to stay independent. We highlight recent SIR and ACR position statements on this topic. Finally, Dr. Julien offers advice to IRs who are seeking to enter the OBL setting. He encourages them to perform and learn from as many procedures as possible, find ways to develop and maintain clinical skills, identify mentors, and ensure that their restrictive covenants are not too stringent. --- RESOURCES South Florida Vascular Associates: https://www.southfloridavascular.com/ Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/ SIR Position Statement on Exclusive Contracts: https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/standards_pdfs/exclusive_contracts_policy_final_approved_9-21-15.pdf ACR Position Statement on Exclusive Contracts: https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdf Line Monkey MD- “The IR Startup:” https://linemonkeymd.com/the-ir-startup/ Line Monkey MD- “Pseudoexclusive Radiology Contracts:” https://linemonkeymd.com/pseudoexclusive-radiology-contracts-our-downfall/#comment-2087

Discussion topic: Getting paid through the Medicare system Introduction to CPT codes and HICPICS codes Medicare's payment process for healthcare providers Future guests and topics related to Medicare reimbursement Mention of the Aging Here newsletter and interview opportunities Differentiating between CPT codes and ICD-10 codes History and purpose of CPT codes Explanation of RVUs (Relative Value Units) and how doctors are paid Simplified process of submitting CPT codes to Medicare for payment Potential fraud issues in fee-for-service Medicare Importance of documentation and medical necessity for CPT codes Challenges with lack of comprehensive guidelines for new codes Providers struggle with the interpretation and utilization of CPT codes. Some codes are rarely utilized, while others require expertise to maximize billing. Coding rules can be complex, with restrictions on code combinations and frequency of billing. Providers face the risk of financial penalties or legal consequences for incorrect coding. Medicare is a significant payer and requires compliance with its rules. Physicians, nurse practitioners, and physician assistants primarily use CPT codes. Modifiers can be used to bill for additional services or special circumstances. Hospice CPT codes exist separately from Part B coding. CPT codes have RVUs (Relative Value Units) that determine payment. RVUs are divided into work RVUs, which assess the labor involved in a procedure. Work RVUs consider time, technical skill, physical effort, mental effort, judgment, and stress. Work RVUs are subject to negotiation and lobbying each year. The conversion factor translates RVUs into payment amounts. The conversion factor is subject to annual adjustments and can significantly impact reimbursement.

In this episode, host Dr. Aparna Baheti interviews Dr. Bill Julien about the evolution of the outpatient based lab (OBL), its role in expanding patient access to IR care, and its relationship with other IR practice models around the country. --- CHECK OUT OUR SPONSORS Boston Scientific Ranger DCB https://www.bostonscientific.com/en-US/medical-specialties/vascular-surgery/drug-eluting-therapies/ranger.html?utm_source=oth_site&utm_medium=native&utm_campaign=pi-at-us-de_portfolio-hci&utm_content=n-backtable-n-backtable_site_ranger_1_2023&cid=n10012340 Philips SymphonySuite https://www.philips.com/symphonysuite --- SHOW NOTES Dr. Julien is one of the initial OBL founders in the United States. In 2001, he started his current practice, South Florida Vascular Associates in an effort to practice independent IR. At this time, he struggled to get hospital privileges due to exclusive diagnostic radiology contracts, so he placed a C-arm in his office out of necessity. Eventually, he built a formal angio suite. As a result, patients enjoyed the efficiency and comfort of office based procedures, and he enjoyed physician autonomy and freedom from hospital politics. Dr. Julien notes that overtime, CMS has recognized the value of an office-based intervention and saw that IRs could practice high-quality care at a lower price point with higher patient satisfaction, leading to improved Medicare reimbursements. Since the conception of his OBL, Dr. Julien has seen practice structures change, especially with the influence of venture capital firms and the pressure to generate RVUs. Additionally, though some voices have pushed for more IR involvement in the clinical sphere, there has not been much progress made in advocating for IR hospital privileges. This is a significant barrier to independent IR practices, since some states require that an IR has hospital privileges before opening an OBL. Dr. Julien says that this dilemma is unique to IR, since other specialties, such as vascular surgery and cardiology, are not affected by exclusive contracts to the same extent. He believes that IR societies and leading voices should actively challenge the legal basis of these contracts and support interventionalists who want to stay independent. We highlight recent SIR and ACR position statements on this topic. Finally, Dr. Julien offers advice to IRs who are seeking to enter the OBL setting. He encourages them to perform and learn from as many procedures as possible, find ways to develop and maintain clinical skills, identify mentors, and ensure that their restrictive covenants are not too stringent. --- RESOURCES South Florida Vascular Associates: https://www.southfloridavascular.com/ Outpatient Endovascular and Interventional Society (OEIS): https://oeisweb.com/ SIR Position Statement on Exclusive Contracts: https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/practice-resources/standards_pdfs/exclusive_contracts_policy_final_approved_9-21-15.pdf ACR Position Statement on Exclusive Contracts: https://www.acr.org/-/media/ACR/Files/About-ACR/2022-2023-Digest-of-Council-Actions.pdf Line Monkey MD- “The IR Startup:” https://linemonkeymd.com/the-ir-startup/ Line Monkey MD- “Pseudoexclusive Radiology Contracts:” https://linemonkeymd.com/pseudoexclusive-radiology-contracts-our-downfall/#comment-2087

From non-competes and relocation to compensation thresholds and parental leave, negotiating your contract can be complicated.  Join Alex, Avery, Biddy, Erin, Jon and Sam as they share their stories, insights and strategies regarding the ins and outs of navigating your contract.  OUR CO-HOSTS Alex Jenny Ky, MD, FACS, FASCRS New York, NY Dr. Ky has been in practice for 22 years and is one of the busiest surgeons in her hospital.  She is a former president of the New York Colon and Rectal Society and currently serves as president-elect of the Chinese American Medical Society.  Married for 29 years, she is the proud mom of 3 children and in her spare time she enjoys playing golf and squash. Avery Walker, MD, FACS, FASCRS El Paso, TX Avery Walker is dually board-certified in General Surgery and Colorectal Surgery. He earned his medical degree at the University of Illinois in Chicago, his General Surgery residency at Madigan Army Medical Center in Tacoma, Washington, and his Fellowship in Colon and Rectal Surgery at The Ochsner Clinic in New Orleans. A former active-duty officer in the United States Army, Dr. Walker served 13 years as a general and colorectal surgeon with his most recent duty station in El Paso, TX at William Beaumont Army Medical Center. While there he was the Chief of Colon and Rectal surgery as well as the Assistant Program Director for the general surgery residency program. He currently practices colon and rectal surgery at The Hospitals of Providence in El Paso, TX. Dr. Avery Walker is married and has two daughters aged 13 and 9.   Biddy Das, MD, FACS Houston, TX (Twitter @BiddyDas) Dr. Bidhan “Biddy” Das has board certifications for both colon and rectal surgery, and general surgery. His passion for medical education and medical process improvement has resulted in book chapters and publications, and national and regional presentations on those subjects. Highlighting his medical expertise on fecal incontinence, he has been featured on patient education videos and national and international television and radio as a featured expert on these colorectal conditions. Dr Das also has a particular interest in surgeons redefining their careers -- he serves as both a software consultant and private equity consultant in Boston, New York City, and Houston.   Erin King-Mullins, MD, FACS, FASCRS Atlanta, GA (Twitter @eking719) Dr. Erin King-Mullins is a double board-certified general and colorectal surgeon. She graduated summa cum laude from Xavier University of Louisiana. After obtaining her medical degree at Emory University in Atlanta, she completed her internship and residency in general surgery at the Orlando Regional Medical Center in Florida. Her fellowship training in colorectal surgery at Georgia Colon & Rectal Surgical Associates concluded with her joining the practice and serving as Faculty/Research Director for the fellowship program until her transition into private practice with Colorectal Wellness Center. She has a husband with whom she shares an amazing, blended family of 4 daughters. The kids keep them pretty busy, but their favorite times are spent on warm sunny beaches.   Jonathan Abelson, MD, MS Arlington, MA (Twitter @jabelsonmd) Dr. Abelson was born and raised in Scarsdale, New York in the suburbs of New York City.  He has 2 older brothers and both of his parents are dentists.  Dr. Abelson went to college at University Pennsylvania, took 2 years off between college and medical school to work in healthcare consulting.  He then went to medical school at University of Virginia, returned to New York for general surgery residency at Weill Cornell on the upper east side of Manhattan.  Dr. Abelson then did colorectal fellowship at Washington University in St. Louis and am now at Lahey clinic in Burlington, Massachusetts for my first job after training.  He is 2 years into practice and has a wife and two sons. His wife works in wellness consulting and they have a dog named Foster who we adopted in St. Louis.   Sam Eisenstein, MD La Jolla, CA  (Twitter @DrE_UCSD) Sam Eisenstein is an Assistant Professor of Colon and rectal surgery and director of Inflammatory Bowel Disease surgery at UC San Diego Health.  He has worked there for the past 8 years after graduating both residency and fellowship at The Mount Sinai Medical Center in New York.  Sam is best known as the founder and organizer of the IBD-NSQIP collaborative, a large multi institutional data collaborative examining outcomes after IBD surgery, but he also is involved in several clinical trials for perianal Crohn's and has extensive experience with stem cell injections for anal fistulae. He is also on the scientific advisory board for the Crohn's and Colitis Foundation for his work on the next big IBD data collaborative, IBD-SIRQC (Surgical Innovation, Research and Quality Collaborative).  Sam has a Wife and 3 kids (6,8, and 3) and spends most of his free time running around after them these days, but also enjoys traveling and getting out into nature with his family.

On this episode of BackTable Urology, Dr. Jose Silva and Dr. Jay Simhan, director of reconstructive urology at Fox Chase Cancer Center, discuss how urologists can demonstrate their value to hospital systems. --- SHOW NOTES First, Dr. Simhan explains the changing nature of urology practice. He opts for the term “health systems urologist” over “private practice urologist” because many urologists are managed by smaller medical groups that are owned by larger hospital groups. He notes that this multi-tiered system of management can cause tension around decision making and increase senior leadership turnover when hospital finances change. Then, Dr. Simhan explains the four ways that doctors can generate value, which is clinical productivity, departmental service, academics or research, and teaching. Clinical productivity is often measured by the RVU system, which assigns a certain number of value units to a procedure. Hospital systems may encourage urologists to choose surgical procedures over office-based procedures to increase RVUs. Although RVUs are arbitrarily set by the Centers for Medicare & Medicaid Services (CMS), each hospital or medical group can increase the number of RVUs per procedure to their own discretion. Dr. Simhan believes that urologists should band together to negotiate fair RVU systems. Finally, they end the episode by discussing concrete ways to demonstrate value as a urologist. Generally, minimizing complications and maximizing RVUs is helpful. Dr. Simhan advises urologists who are joining a new system to build their name and referral network to earn a long term contract. Usually, there is no RVU requirement in the first employment contract. In the later years, he recommends putting in the effort to understand productivity metrics and downstream costs and revenues in order to maximize earnings and potential.

This is a conversation about physician compensation, which is often oddly misaligned from the way that the whole physician or provider organization is getting paid. Now, first thing to point out: There are lots of different kinds of physicians doing all kinds of different things. As with most everything in healthcare, lumping everybody together and making general proclamations about what is best is a really cruddy idea. With that disclaimer, if you think about the main models of physician compensation, there are two; and this is oversimplified, but let's call one fee for service (FFS), which is really getting paid for generating RVUs (relative value units)—in short, getting paid for volume. The more you do (especially the more expensive things you do), the more you get paid. And then we have getting some kind of capitation payment. A capitated payment is some kind of per member per month-ish flat payment to ideally keep patients healthy, and you will make the most money if you can figure out how to have the least volume of expensive stuff. As an individual doc getting a salary to care for a patient panel of a certain size, let's just consider commensurate with that. These incentive models obviously have a big impact on any given doctor's ability to get paid to do things that they think they should be doing. For example, the current fee-for-service RVU fee schedule frequently rewards those doing the stuff a lot of specialists do much more than those doing primarily cognitive work, including those doing work for patients who aren't sitting in the exam room at the time—like a PCP arranging for a patient to go to hospice or answering patient portal questions. In my opinion, the goal here should be to pay docs and others fairly for providing high-value care. These payments also should actually be proven to actually incent that high-value care. Here's the obvious problem: Neither of these two things, either the quantifiable definition of high-value care and/or the best way to pay for it, has any kind of canon. There are no rules which are considered to be particularly authoritative and definitive here, really. So, what is the downside of not aligning physician compensation models to what good looks like, meaning to the kind of care that patients really need in that particular community? A couple of downsides for you: One is moral injury. Not the only reason, but a reason for moral injury is getting paid in misalignment with what is best for patients. That sucks. You want to help your patients as best you can, and then you can't earn a living and/or you get in trouble with the boss if you do what you think is right. This can cause real mental anguish for especially PCPs but also others who see the need to do anything that doesn't have a billing code. Here's another downside to not worrying about physician compensation, and it's for plan sponsors (employers, maybe) who are trying to get integrated care or a medical home for their employees. I was talking to Katy Talento about this. She was telling me that in ASO (administrative services only) contracts, there are often line items for value-based care and for capitated payments. So, good news? Well, let's follow the dollar here, because we wind up with a disconnect that doesn't help patients but certainly can earn a nice little kitty for those who can get away with it. Here's where that dollar goes: This VBC (value-based care) or capitated payment kitty may go to a health system that the ASO says is to be a medical home for employees or plan members. But the PCPs mainly who are treating members in those medical homes are getting paid, it often turns out, fee for service with maybe some quality kickers. So, the plan is paying a value-based care payment, but the PCPs are getting paid FFS. Is anyone shocked when the members report that they don't actually feel like they are getting integrated care, that they are getting rushed in and out because maximizing throughput becomes a thing when you're getting paid for volume? Dan O'Neill also talks about this at length in episode 359, because IPAs (independent physician associations) are doing kinda the same thing. Getting so-called value-based care contracts with MA (Medicare Advantage) plans or CMS or employer groups, I'd imagine, and then paying all the individual practices or the solo practitioners fee for service and scooping up the excess payments themselves, most docs manage to provide high-enough-quality care that the contract holder can scoop up the profit off the capitation without actually having to share the capitation to achieve this high-enough-quality care. In this healthcare podcast, I am digging into all of this physician compensation ballyhoo with Rachel Reid, MD, MS. She was an author on a study at the Center of Excellence on Health System Performance at RAND. This study specifically set out to look at how health systems and provider organizations (POs) affiliated with those health systems incentivize and compensate the physicians who work there. Short version: Yeah, it's confirmed. Most docs are paid using the classic RVU productivity measures representing a big chunk of their compensation, even PCPs. There's frequently some kickers or extra payments to achieve some kind of quality metric, but this is the icing, not the cake. The cake is still very fee for service-y. This is true regardless of how the physician organizations, the provider organizations themselves are getting paid by payers. I asked Dr. Rachel Reid a bunch of questions about this, but one of them was (this seems weird, a weird misalignment), Why is this happening? And Dr. Reid listed out five reasons beyond the macro existential question of what is value and do we even know how to change human behavior to get it. 1. The payment is not big enough from the payer for the physician organization to go through all the time and trouble and risk frankly of changing the whole comp model. 2. The value-based payment arrangements that do exist at the organizational level often have a fee-for-service chassis with an icing of quality payments or some kind of value payment on top of it. So, maybe there's actually more alignment than we might think. 3. It's hard to try to change comp models—it's a thing. And there is risk in messing it up. 4. Inertia. The ever-present inertia. 5. We know what we want to move from, but what exactly are we moving to? And this “What do we want to move to?” is going to change for PCPs and for every single different specialty and could even vary by patient population. I then also asked Dr. Reid what could be done by plan sponsors, for example, to pay docs in alignment with the goals of the contract; and she said, write physician comp expectations into the contract. Something to think about. We dig into all of this today. Shows that you should, for sure, listen to for additional insights include the one with Dan O'Neill (EP359) as aforementioned. Also the show with Brian Klepper, PhD (AEE16), where we dig into how the RUC is behind some of these FFS rates. Also episode 391 with Scott Conard, MD. My guest today is Rachel Reid, MD, MS. She is a physician policy researcher at RAND Corporation and a primary care physician at Brigham and Women's Hospital.   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.     Rachel Reid, MD, MS, is a physician policy researcher at the RAND Corporation. Also a practicing primary care physician, her research focuses on measuring cost, quality, and value in healthcare. She has particular interest in the primary care delivery system, physician payment and compensation, and delivery and payment system reform. Dr. Reid has been engaged in the RAND Center of Excellence on Health System Performance, assessing health systems' compensation and incentives for physicians, leading work related to assessing low-value healthcare delivery, and measuring primary care spending. She is the principal investigator on an NIH-funded grant assessing novel Medicare billing codes for transitional care provided after hospital discharge. Prior to joining RAND, Dr. Reid worked in the Research and Rapid Cycle Evaluation Group at the Centers for Medicare & Medicaid Services' Innovation Center. Her clinical work has included ambulatory primary care and hospital-based internal medicine. She is an associate physician at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School. Dr. Reid received her AB in biochemical sciences from Harvard University and her MD and MS in clinical research from the University of Pittsburgh School of Medicine.   07:13 What did Dr. Reid's recent study show about how doctors are currently being paid and incentivized? 08:11 Why Dr. Reid decided to do the study in the first place. 09:49 What are the main foundations of what doctors are paid on? 10:31 Why is value-based compensation still just the “icing” on the cake? 13:08 What is the biggest value add for doctors, and does it vary between specialties? 14:32 Why wouldn't a physician organization change their comp models? 19:55 Are we at a moment of evolution? 20:20 “Tying dollars to measured quality gaps doesn't necessarily produce results.” 20:42 EP295 with Rebecca Etz, PhD. 22:04 “I don't think there's a current gold standard for how to pay doctors.” 25:37 Job one: What are we trying to incent? 31:28 From the payer or insurer perspective, what's the leverage they have to change doctor compensation?   You can learn more about Dr. Reid, her publications, and the work she has done on the RAND Web site.   Rachel Reid, MD, MS, of @RANDCorporation discusses on our #healthcarepodcast how doctors get paid. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Amy Scanlan, Peter J. Neumann, Stacey Richter (EP400), Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry

In this episode of BackTable ENT, Dr. Varun Varadarajan speaks with Michael Johnson, a business lawyer, about advice for negotiating academic and hospital employment contracts. --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs: https://earnc.me/0aliK0 --- SHOW NOTES First, the doctors talk about the RVU system of compensation used by many hospitals and academic centers. They discuss what the price per RVU means and additional bonuses after the expected RVU goal is met. Michael adds that it may be beneficial to negotiate for more resources to earn more RVUs instead of negotiating more compensation, as the former strategy can lead to higher compensation. Additionally, he notes that subspecialty clinicians and surgeons have more leverage to negotiate their contracts if they are the first subspecialists in a large system. He recommends that physicians start negotiating at least a year in advance of their anticipated start date. They also discuss the compensation models based on productivity versus a flat salary. Then, the doctors explain how to handle verbal offers from academic centers. Michael recommends talking to multiple employers at a time when starting the hiring process in order to weigh multiple options. However, he recommends physicians to be upfront about where they are interviewing with each employer. He notes that some academic institutions will send a letter of appointment, and not an employment contract, but physicians can still negotiate for firm deal breakers in the letter of appointment. He then explains different clauses in the contracts, such as restrictive covenants (non-compete and non-solicit clauses), non-disclosure agreements, and malpractice tail insurance. He advises against comparing salary offers to the MGMA compensation data, as different jobs require different obligations. Instead, he recommends making sure that the compensation matches the job obligations. Finally, the doctors end the episode with reviewing common employer tactics, such as pressuring doctors to sign contracts quickly and only offering negotiation on the base salary and signing bonus. Michael explains that it is worthwhile to engage in higher levels of administration in the negotiation process if necessary. --- RESOURCES Michael Johnson's Website: https://www.michaeljohnsonlegal.com/physician-contracts/ Michael Johnson's Instagram: https://www.instagram.com/physiciancontracts/ Episode 45- Private Equity: Savior or Existential Threat? https://www.backtable.com/shows/ent/podcasts/45/private-equity-savior-or-existential-threat

The early 1970's saw the start of the medical specialty we now know as oncology. How does one create standards and practices for patient care during that time? Dr. John Glick is a pioneer during the dawn of oncology. He says that early work involved humanity, optimism, and compassion, all of which were the foundation of his career. Dr Glick describes the clinical experiences that drove him to oncology (4:28), his rapport with patients, which was portrayed in Stewart Alsop's book Stay of Execution (9:21), and his groundbreaking work developing the medical oncology program at the University of Pennsylvania (12:22). Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. John Glick: None More Podcasts with Oncology Leaders    Oncology, Etc. – In Conversation with Dr. Richard Pazdur (Part 1) Oncology, Etc. – HPV Vaccine Pioneer Dr. Douglas Lowy (Part 1) Oncology, Etc. – Rediscovering the Joy in Medicine with Dr. Deborah Schrag (Part 1)  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org.   TRANSCRIPT Disclosures for this podcast are listed in the podcast page. Pat Loehrer: Welcome to Oncology, Etc. This is an ASCO education podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of our podcast is to introduce listeners to interesting people and topics in and outside the world of oncology. Today's guest is someone well-known to the oncology community. Dr. John Glick is undoubtedly one of oncology's most highly respected clinicians, researchers, and mentors. I've always viewed John as the quintessential role model. I will add that for me, he proved to be a role model even before I met him, which hopefully we'll talk about a little bit later.   To attempt to summarize John's career in a paragraph or two is really impossible. Suffice it to say, he is to the University of Pennsylvania Cancer Center what water is to Niagara Falls. You can't have one without the other. After completing his fellowship at NCI in Stanford, John joined the Penn faculty in 1974 as the Ann B. Young Assistant Professor. Some five decades later, he retired as the director of one of the most highly respected comprehensive cancer centers in the nation. Among his many notable accomplishments, I will comment on just a few. He established the Medical Oncology program at Penn and subsequently directed the Abramson Cancer Center from 1985 to 2006. Interestingly, he established the Penn Medicine Academy of Master Clinicians to promote clinical excellence in all subspecialties across the health system. He's been a driving force in philanthropy at Penn Medicine, culminating in his role as Vice President Associate Dean for Resource Development.  Over the past several decades, he has helped raise over half a billion dollars for Penn Med. We need you on our team, John. As a clinician scholar, John's research has helped shape standards of care for both breast cancer and lymphomas. For example, he pioneered the integration of adjuvant chemotherapy and definitive breast irradiation for early-stage breast cancer. In 1985, he chaired the pivotal NCI Consensus Conference on adjuvant chemotherapy for breast cancer. He also was a driving force in a clinical landmark study published in The New England Journal some 20 or so years ago about the role of bone marrow transplant for advanced breast cancer. Most impressive of all, in my opinion, is John's legacy as a mentor to multiple generations of medical students, residents, and fellows.   So, John, we want to thank you for joining us and welcome. Thought we might start by having you tell us a little about your early life, your family, your parents, where you grew up, and how you got into medicine. Dr. John Glick: Well, thank you for having me on the podcast, Pat and David, it's always a pleasure to be with you and with ASCO. I grew up in New York City in Manhattan. My father was a well-known dermatologist. He was my role model. And from the age of eight, I knew I wanted to be a doctor. Nothing else ever crossed my mind. But having seen my father's many interests outside of medicine, I realized from very early that there was much more to medicine than just science. And that really induced me, when I went to college, to major in the humanities, in history, art history, and I actually took the minimum number of science courses to get into medical school. That probably wouldn't work today, but it was the start of my interest in humanism, humanities, and dealing with people outside of the quantitative sciences.  Dave Johnson: So that's reflected in how we all view you, John. You're one of the most humanistic physicians that I know personally. I wonder if you could tell us about your interest in medical oncology, and in particular, as one of the pioneers in the field. I mean, there wasn't really even a specialty of medical oncology until the early 1970s. So, how in the world did you get interested in oncology and what drew you to that specialty? Dr. John Glick: Well, I had two clinical experiences that drove me into oncology. The first, when I was a third year medical student at Columbia PNS, my first clinical rotation in internal medicine, I was assigned a 20-year-old who had acute leukemia, except he was not told his diagnosis. He was told he had aplastic anemia, receiving blood and platelets, and some form of chemotherapy. And I spent a lot of time just talking to him as an individual, not just taking care of him. And we became friends. And he was then discharged, only to be readmitted about two weeks later. And in the elevator, the medical assistant had his admission sheet, and unfortunately, it was facing the patient, and it had his diagnosis, acute leukemia. So he came into the ward and he confronted me. "Why didn't you tell me I had acute leukemia?" Well, I couldn't say the attendees forbade me to do that. So I took what today we would call ‘the hit', and apologized. But it stimulated me to reflect that honesty with patients was extremely important, and that oncology was just in its infancy. We knew nothing about it. It was not considered even a specialty. I don't think we used the word "oncology."  But that inspired me to take an elective in my fourth year at PNS, at an indigent cancer hospital called the Francis Delafield Hospital. It only took care of indigent cancer patients, and there were wards, twelve patients in a ward, six on each side, and nobody would go see the patients. It was almost as if they were afraid that if they were to touch the patient, they would get cancer. And I started talking to the patients, and they were human beings, but nobody had told them their diagnosis. Nobody had told them if they were terminal. And there were a few patients who were getting a new drug at that time for multiple myeloma called melphalan, and they actually had relief of some of the symptoms, of their bone pain. But I realized that there was a huge void in medicine that I could possibly help to fill.  And that was the era of Vietnam, and so I applied to the National Cancer Institute to become a commissioned officer in the Public Health Service to avoid the draft, to be on a service with, at that time, some very notable oncologists Vince DeVita, Ed Henderson, Paul Carbone. I had read some of their papers, and I was lucky to be accepted. And I was a clinical associate at the National Cancer Institute. And that was life-changing because there every patient was considered to be potentially curable. The advances at that time using MOPP for Hodgkin's disease, C-MOPP for lymphoma, some treatments for leukemia. George Canellos pioneered the use of CMF for metastatic breast cancer. It was an amazing, amazing experience. That was in 1971 to ‘73. Oncology did not become a true specialty till ‘73, but my two years at NCI were formative.  However, I realized that there was something missing in my training. Everybody was considered curable, but I had never seen a patient with metastatic colon cancer, metastatic lung cancer. The radiotherapists there did not like to teach clinical associates, and I knew that there was a place called Stanford. And Stanford had Saul Rosenberg in medical oncology for lymphomas and Henry Kaplan in radiotherapy. So, everybody was going to California, and my wife and I packed up and went to California and spent a year at Stanford, which, combined with my training at the NCI, led me to the principles that guided my career in oncology; humanity, optimism, reality, compassion, and a love for clinical trials.  I was very, very fortunate to be there at the dawn of medical oncology shortly after I decided to go to Penn, which at that time did not have a medical oncologist. In fact, I was the only medical oncologist at Penn for four years and did every consult in the hospital for four years, much to the chagrin of my wife. But I was fortunate to have great mentors in my career: Paul Carbone, Vince DeVita, Saul Rosenberg, Henry Kaplan, among many, many others. And that impressed me about the importance of mentorship because my career would never have been where it was or is without these mentors. Pat Loehrer: John, just to echo what Dave said, you've been such a tremendous mentor for us. Dave and I particularly, you took us under your wings when you didn't know who we were. We were people in the Midwest. We weren't from any place shiny, but we really appreciate that. Dave Johnson: So, John, I mentioned at the very beginning that I met you before I met you, and the way I met you was through Stewart Alsop's book, Stay of Execution. He portrayed you as an extraordinarily caring individual, and it tremendously impacted me. It was one of the reasons why I chose oncology as a specialty. I realize it's been 50 or more years ago and most of our listeners will have no idea who Stewart Alsop was. And I wonder if you might share with us a little bit of that experience interacting with someone who was particularly well-known in that time as a columnist for The New York Times.  Dr. John Glick: His brother Joe Alsop and Stu Alsop were two of the most famous columnists at that time. Joe Alsop was a hawk right-winger who lived in the Vietnam War. Stewart was charming, was a centrist Democrat, wrote the back page for Newsweek for years. He and I had very similar educational backgrounds and interests. And we functioned on two different levels—one as a physician-patient, and then we became friends. And he and his wife adopted us into the Georgetown set.  And I received a lot of criticism for socializing with a patient. But over the years, I've been able to become friends with many of my patients, and I've been able to compartmentalize their medical care from our friendship. And I use the analogy if I was a doctor in a small town and I was the only doctor,  I'd be friends with people in town, with the pastor and likely the mayor. But I have always believed that patients can become your friends if they want it and if they initiated it.   Taking care of Stewart Alsop was an amazing, amazing experience. We didn't know what he had. People initially thought he had acute leukemia. In reality, he had myelodysplastic syndrome, but that hadn't been described yet. He had a spontaneous remission, which I rarely see, probably due to interferon released from a febrile episode, all his blasts went away in his marrow. One of my children's middle name is Stewart. But professionally and personally, it was an incredible experience. It taught me the importance of being available to patients. They had my home phone number. We didn't have cell phone numbers in those days. We had beepers, but they didn't work. And from that point on, I gave my home phone number to patients, and I actually trained my children how to answer the phone. “This is Katie Glick. How can I help you? My father's not home. You need my father? Can I have your phone number? I'll find him and he'll call you back.” Patients still remember my children and their way of answering the phone. Pat Loehrer: One of the things you did do is create this medical oncology program at Penn, which has graduated some incredible fellows that have become outstanding leaders in our field. But can you reflect a little bit about the process of creating something that was never created before, like a medical oncology program? Dr. John Glick: Well, I came to Penn, my first day. Person who recruited me was on sabbatical. I asked where my office was and there was no office. There was an exam room. There was a clinic for indigent patients which we scrubbed by hand. There was another office for patients who paid. Within two months, I had abolished that. We had one– I hate to use the word clinic, people still use the word clinic today, but one office that took care of all patients, irregardless of means.   I saw every oncology consult in the hospital for four years. But I had a mentor, not only Buz Cooper, but fortunately, Jonathan Rhoads was Chairman of Surgery, and he was also Chairman of the President's Cancer panel. And what he said at Penn in surgery became the law. And then when we introduced lumpectomy for breast cancer and radiotherapy, he endorsed it immediately. All the other surgeons followed suit. I don't think there's any hospital in the country that adopted lumpectomy and radiotherapy for breast cancer as quickly. And the surgeons were instrumental in my career.  Now, I was taking care of gliomas, head and neck cancers, and it was difficult. If I had a colorectal patient, I'd call Charles Moertel at Mayo Clinic and say, “What do I do?” I was there when Larry Einhorn in 1975 presented his data on testicular cancer with the platinum. Unbelievably inspiring, transformational. It also showed the importance of single-arm studies. You didn't have to do randomized studies because the results were so outstanding. And so in my career, I did both single-arm studies, proof of principle studies, and then many randomized trials through the cooperative groups.  But the first four years were very difficult. I didn't know what the word ‘work-life balance' meant in those days. If somebody was sick, I stayed and saw them. It was difficult introducing new principles. When I first mentioned platinum after Larry's presentation, I was laughed out of the room because this was a heavy metal. When patients were dying, they died in the hospital, and I wanted to hang up morphine to assist them. The nurses reported me to the administration. I had to fight to get the vending machines for cigarettes out of the hospital. So there were a lot of victories along the way and a lot of setbacks.  It took me several years to have an oncology unit of six beds, and now I think we have 150 or 160 beds and need more. So it was an interesting and, in retrospective, a wonderful experience, but I didn't know any better. Fortunately, I had a great wife who was working at Penn and then at Medical College of Pennsylvania, and she was incredibly understanding, never complained. And I think my kids knew that on Tuesdays and Thursdays, don't bring up anything difficult with dad because he's had a really tough day in clinic. Dave Johnson: We were not in that era, but we were very close. And many of the struggles that you had were beginning to dissipate by the time we were completing our training. But it was still a challenge. I mean, all those things. I gave my own chemotherapy for the first few years I was in practice. I don't know that our colleagues today who have trained in the last, say, 10 or 15 years, actually realize that that was what we did. Most of the chemo was given in the hospital. It was not uncommon in the early days to have 20, 30, 40 inpatients that you would round on because there just wasn't an outpatient facility. But the corporate mind made a big difference, allowing us to give drugs like platinum in the outpatient arena. You span all of that era, and so you've seen the whole panoply of change that has taken place.  John, the other thing you did that has impressed me, in part because of my time as a Chair of Medicine, is you created this Academy of Master Clinicians. Can you tell us a bit about that and what was the motivation behind that?  Dr. John Glick: Ben had a strategic plan, and one of the pillars was talking about valuing clinical medicine and clinical excellence. But there was no implementation plan. It was sort of just words and left in the air. And I was no longer director of the cancer center, and I realized we had a lot of awards for research, awards for education, and no awards for clinical excellence. So I created the idea of having an academy and master clinician spend six months talking to all constituencies, chairs of various departments, directors of centers to get a buy-in. Wrote a three-page white paper for the dean, who approved it immediately. And then, as typical at Penn, I raised all the money for it. I went to one of my patients who was an executive at Blue Cross. I said I need $500,000 to start this program. And then subsequently, I raised $4 million to endow it. Today, it is the highest honor that a Penn clinician can receive.  You could be on any one of our multiple tracks. You have to see patients at least 60% of the time. You not only have to be a great doctor, you have to be a humanist. So the world's best thoracic surgeon who has a demeanor in the operating room that is not conducive to working with a nurse as a team doesn't get in. We emphasize professionalism, mentorship, citizenship, teaching, national reputation, local reputation, and clinical excellence. And so we've elected over 100 people, maybe 3% of the Penn faculty. We give an honorarium. We have monthly meetings now by Zoom. We have monthly meetings on various topics. We never have a problem getting any dean or CEO to come talk to us.  We were the first to do Penn's professionalism statement. The school subsequently adopted, and it's become the highest honor for a Penn clinician. It's very competitive. It's peer-reviewed. The dean has no influence. And we're very proud that 40% of the members of the academy are women. We have a high percentage of diversity compared to the numbers on our faculty, but you really have to be elected on merit, and some people that you might expected to be members of the academy aren't. It's one of the things I'm proudest of. It will go on in perpetuity because of the money we've raised. I think many of my accomplishments as a researcher will fade, as they typically do, but I'm very proud of the Academy, and I'm very proud of the people that I've mentored. Dave Johnson: It speaks to your values, John, and I think it's one of the reasons why you're so widely admired. Thank you for creating that. It proved to be a model for other institutions. I know that for a fact. One would think that valuing clinical care would be preeminent in medical schools, but in fact, it's often ignored. So again, I know that your colleagues at Penn appreciate your efforts in that regard.  Tell us a little about your term as ASCO president. What are you most proud about and what were your most difficult challenges? Dr. John Glick: Well, the most difficult challenge was that ASCO was in transition. I had to fire the company that ran the meeting. We had to decide that ASCO was going to hire a CEO. We hired John Durant, made a small headquarters, tiny staff, and did a lot of the work as being chief operating officer myself. It was the year that email was just getting started, and ASCO wasn't using it. So every Saturday from 8:00 to 6:00, I came into the office and my secretary wrote letters inviting people to be on the program committee or various committees. But it was a society in transition. The growth of membership was huge. The meeting sites had to be changed. We emphasized science. Some of the things that we did are still in existence today.  We formed the ASCO ACR Clinical Research Methods course. It's still given. That's one of our real highlights. We forged relationships with other societies, the National Coalition for Survivorship. We made the ASCO guidelines much more prominent. And I remember that we were going to publish the first guidelines on genetic testing for breast cancer, and the MCI went up in absolute arms, so I arranged a meeting. I was at the head of the table. On my right were Francis Collins, Richard Klausner, Bob Wittes, and a few other people. Then the ASCO people who wrote the guideline were on the left, and they didn't want us to publish it. They thought it was premature to have a guideline about genetic testing. And what I learned from that meeting is that you can agree to disagree with even the most prominent people in oncology and still maintain those relationships. But we did what's right, and we published a guideline on the JCO. There were so many wonderful things that happened at ASCO that I can hardly restate all that happened I guess 27 years later. It was exciting. ASCO was still young. There was a lot we had to do, and we could do it. You could just go ahead and do it. It was exciting. It was gratifying. It was one of the most fun years of my life. Dave Johnson: I mean, that transition from an outside company in many respects, controlling the premier activity of ASCO, its annual meeting to ASCO, taking that on, that defined ASCO, and that's what I remember most about your time as president. It was a bold move, and the hiring of John Durant was brilliant. I mean, he was such an incredible individual, and it was great that you guys were able to pull that off. Pat Loehrer: Thank you for what you've done.  You've had a number of your mentees if you will, and colleagues that have gone on to prominent positions, including, I think, at least three directors of NCI Cancer Centers. Can you just talk briefly how you would describe your mentoring style because you've been so successful? Dr. John Glick: First, there are two aspects. One is when people come to you, and then when you go to people, you sense they're in need. The key aspect of mentoring is listening. Not talking, listening. Looking for the hidden meanings behind what they're saying, not telling them what to do, presenting options, perhaps giving them clues on how to weigh those options in pros and cons, being available for follow-up. Mentoring is never a one-time exercise. Not criticizing their decisions. You may disagree with their decision, but it's their decision, especially if they've considered it. Being proud of the mentee, being proud of their accomplishments, following them over the years. And when they've gotten in trouble or failed to get the job that they wanted, always be there for them, not just in the good times, but in the times that are difficult for them professionally. I think that's one of the most important things.  Even today, I mentor three or four clinical department chairmen, and people ranging from full professors to newly appointed assistant professors. Now that I'm retired, mentoring is the one activity that I've really retained. It's extraordinarily satisfying, and I'm proud of the people that I've mentored. But it's their accomplishments, and the key aspect of mentoring is never to take credit. Dave Johnson: I'll give you credit for mentoring me, and I appreciate it. You were very instrumental at a very decisive point in my career when the old Southeast Cancer Group disbanded, and we were looking for a new cooperative group home. And you were instrumental in helping my institution come into the ECOG fold, and not just as a very junior member, but really as a player. And I'll never forget that, and we'll always appreciate that very much. Pat Loehrer: Ditto on my side, too. Dave Johnson: John, you mentioned that you're retired. What do you like to do in your "free time” if you're not mentoring? Dr. John Glick: Life is good. My daughter says I have a disease, O-L-D. My grandson says, “He's not old; he's almost 80. Look how well he's done.” “Here's $20.” I'm having fun. We are fortunate to have homes in different places. We spend the summer up in the Thousand Islands on the St. Lawrence River, spring and fall down in Charleston, then lots of time in Philadelphia. We travel. I play golf poorly. I'm getting a chance to read history again, go back to one of my great loves. I'm with my children and grandchildren more. I lost my first wife. I've been remarried for about twelve years, and I'm enjoying every moment of that. I'm not bored, but I do wake up in the morning with no anxiety, no realization that I have to herd sheep or herd cats. I have no metrics, I have no RVUs,  not behind of the EMR.  Dave Johnson: You're making it sound too good, John.  Dr. John Glick: We're having fun. And I have not been bored. I've not been down in the dumps. Each day brings a different aspect. We see a lot more of our friends. I exercise. I deal with the health problems that people get when they get older, and I have plenty of those. Seeing doctors takes a lot of time, but I'm grateful that I'm having these few years of retirement. I'm one of the people who is most fortunate to have attained everything they wanted to do in their professional life, and now I'm trying to do some of the same in my personal life. Dave Johnson: John, Pat and I both love to read. We love history. You mentioned that you're reading some history. Is there a book that you've read recently that you might recommend to us? Dr. John Glick: “the Last of the Breed” {With the Old Breed} It's about a private in the Pacific campaign who was not a commissioned officer; it's just a grunt on the ground. It brings the horrors of the Pacific island campaigns to life. But there's a huge number of books, some historical fiction. I'm a great fan of Bernard Cornwell, who's written about the Medieval times, Azincourt, 1356. I'll read two or three books a week. I'm devoted to my Kindle. Dave Johnson: If you could go back in time and give your younger self a piece of advice, what would that advice be?   Dr. John Glick: Try and achieve more of a work-life balance. I didn't have any choice. If I didn't do the consult, it didn't get done. That's not the situation today. But I have a second piece of advice, don't treat medicine as a 9 to 5 job. If a patient is sick, stay with the patient. Give the patient your home or cell phone number. Remember, medicine is not just a profession, but it can be a calling. Too few of our physicians today regard medicine as a calling. And even if you're employed, as most of us are by an academic or other institution, do what's right for the patient, not just what's right for your timesheet or the EMR. Remember that the patient is at the center of all we do and that medicine is a calling for some people, as it was for me. Dave Johnson: Great advice, John. Great advice.  Well, I want to thank Dr. Glick for joining Pat and me. This has been a delight. You're one of our role models and heroes.  I want to thank all of our listeners of Oncology, Etc., which is an ASCO educational podcast where we will talk about oncology medicine and other topics. If you have an idea for a topic or a guest you'd like us to interview, please email us at education@asco.org. To stay up to date with the latest episodes and explore other educational content of ASCO, please visit education.asco.org. Thanks again. Pat, before we go, I've got an important question for you. I've been trying to school you recently, and you've failed miserably. So I'm going to ask you, why is it that McDonald's doesn't serve escargot? Pat Loehrer: I can't do it. I don't know. I give up.  Dave Johnson: It's not fast food. Pat Loehrer: I like that. It's good.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experiences, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    

How do you get paid for what you do, and why is it so complicated? Healthcare more than any other industry has a huge amount of complexity in how its professionals get paid for services they have rendered. Join me for this episode on reimbursement where we break down exactly how you get paid through your insurance contracts, and how your work is valued by payers.Link to CMS site referenced in this episode: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-FilesPurchase your copy of Jill's book here: Physician Heal Thy Financial Self Join our Medical Money Matters Facebook Group here: https://www.facebook.com/groups/3834886643404507/ Original Musical Score by: Craig Addy at https://www.underthepiano.ca/ Visit Craig's website to book your Once in a Lifetime music experience Podcast coaching and development by: Jennifer Furlong, CEO, Communication Twenty-Four Seven https://www.communicationtwentyfourseven.com/

October 28, 2022Mark and Scott discuss the Day 1 agenda for the Urology Coding and Reimbursement Seminar what we included and why it's important right now. Urology Advanced Coding and Reimbursement Seminar Day 1 Agenda8:00 PreService/Front Office: Strategies to promote, maintain, and enhance optimal front office workflow - How to make the Front Office work for you.10:15 E/M 2023 Interactive Session: Making sense of the new rules to maximize efficiency and productivity.12:00 Lunch - Optimizing patient place of service-clinic, ASC and inpatient1:00 Annual Update - Medicare Policy: How upcoming Medicare changes will affect your practice operations and revenue.2:00 Global Package and Modifiers: Getting paid more for what you already do3:15 The Business of Urology: Coding, Billing, and Business Metrics, RVUs, Productivity Measurement, Market Trends, Contracting, Private Equity, QHP CompensationUrology Advanced Coding and Reimbursement Seminar  - Registration OpenLas Vegas, NV - December 2-3, 2022New Orleans, LA - January 27-28, 2023Register NowCompliance PlansQuestions or need help, please send us an email: info@prsnetwork.comJoin the discussion:Urology Coding and Reimbursement Group - Join for free and ask your questions, and share your wisdom.Click Here to Start Your Free Trial of AUACodingToday.com 

We all know that there is a tension between being the empathetic physician that you want to be and getting your charts done so you don't stay at the office until 9pm. We also know that patients hate it when their doctor never looks up from the computer. Is there anything we can do?We can't get rid of RVUs or fix the whole healthcare system (at least not today), but there are a few very effective techniques for fostering connection with our patients without upending our whole schedule. Here are six techniques that will supercharge your connection with your patients without adding time to your visits.Reach out anytime!Dr. Chiaramontewww.integrativepalliative.com Do you wish that you had more tools to give great care to your patients with complex or serious illness? A new CME program will be starting soon that will give you the skills and confidence that you're looking for to help your most challenging patients. Sign up and I'll let you know when the next course is open: https://trainings.integrativepalliative.com/tiipm-keep-in-touch. Programs will also be starting soon for loved ones of people with serious illness. Sign up at the link above if you'd like to know when registration is open.Please review this podcast wherever you listen and forward your favorite episode to a friend! Thanks for helping me spread the word about heart-centered care for people with complex and serious illness.

Show Notes - All Things Afib - Episode 17 (16) - Medicare Cuts!!!! with Dr. Brett Gidney Medicare is slashing reimbursement for AFib procedures during a time of record-setting inflation and an increasing number of patients (currently 6 million) suffering from AFib. From an RVU (Relative Value Unit) of 26.44 in 2021, the payment is being reduced by FORTY PERCENT to 15.88 in 2023. AFib is becoming more and more widespread, in fact, there are predicted to be 20 Million AFib patients by 2050. Afib can often be fixed very easily, REDUCING the burden on the healthcare system, as likelihood of stroke, dementia, and other morbidities are reduced by AFib management. There are only 1500 EPs in the U.S. right now, and Medicare cuts are actually DE-INCENTIVIZING more doctors from entering this specialty, because they cannot get fairly compensated for their work. Did you know Medicare pays the same amount for an EP to sit in their office and read 3 echocardiograms, as they would get to do a complex AFib procedure/operation?! Join me and my guest Dr. Brett Gidney to discuss how and why these cuts are happening, and what you can do today to join the fight to reform these Medicare payments. Dr. Brett Gidney is a cardiac electrophysiologist leading the charge to reform Medicare payments to EPs. He practices throughout the central coast of California from Thousand Oaks up to Santa Maria. He is board certified in clinical cardiac electrophysiology focusing on complex cardiac arrhythmia management. Dr. Gidney spends the majority of his time in the hospital setting performing procedures, such as cardiac ablation, to treat abnormal heart rhythms. He is particularly interested in very low or no radiation exposure facilitated by 3D mapping and ultrasound technologies. All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California. Discussion points: ● Dr. Brett Gidney introduction● The reduction of RVUs– 2021 to 2023 – reduced 40% - bundling/cuts● EP is a tiny specialty, only 1500 in the US today● AFib procedures REDUCE the burden on the system● Who is advocating for these cuts? The RUC and it's role● Affect on caseloads/day to day practice● De-valuing physician services vs. equipment costs● Will this be the spark that leads to the formation of lobbying groups?● 501(c)6 vs. 501(c)3● Reduced access to underserved populations● The EPAdvocacy.org foundation will soon be up and running● Reach out to your congressperson and senator, let them know we need reform! Resources: Dr. Brett Gidney LinkedIn Dr. Brett Gidney Twitter Find Your Representatives Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

How ChenMed is Changing the Currency of Primary Care Dr Faisel Syed, National Director for Primary Care at ChenMed, shares some provocative thinking about addressing primary care from outside the fee-for-service model. The currency of healthcare delivery right now is billing more in order to generate more RVUs. Learn how ChenMed's full-risk model and moral vision are leading them to honor seniors with affordable VIP care. All that, plus the Flava of the Week about the lessons that Jared learned from the Creator Economy Expo. What can healthcare learn from content entrepreneurs? Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen/

Last week's show was with Wayne Jenkins, MD, from Centivo; and we talked about how insurance design, when not done well, can lead, in a nutshell, to mental and physical health problems for employees. This is a great lead-in to the conversation in this healthcare podcast with Dan O'Neill. And before I get into why it's a great lead-in, let me just start here—and don't roll your eyes. What is value-based care? Consider this delineation: There's value-based payments, and then there's the type of care that these payments incentivize. You would hope that a value-based payment would result in care that was of value (ie, great patient outcomes and patient satisfaction at a fair total cost of care). But those are two distinct things—the payment and the care. If we change the payment model but the provider behavior doesn't change in a way that actually improves patient outcomes and care, then what are we doing here? Or the converse: If we do not change the payment model, then how does anyone expect the care paid for is going to change? Employers or carriers who just meander along with the broad PPO network happily paying as much for low-value care as for high-value care and happily paying centers of excellence as much as non–centers of excellence … how is a provider who wants to spend time and money building out a practice to deliver better patient outcomes, how can they do that without overcoming some pretty fundamental business model challenges? This whole concept is one that my guest today, Dan O'Neill, has talked about and will talk about in this episode. Dan says the first step is for insurers, IPAs, managed care organizations to take an absolute chainsaw to their network management bureaucracy. There must be a clear door to a value-based payment model. It must be that if you're a provider or you're a physician practice (primary care practice, in particular), and you want to go down a value-based care path, there has to be a clear door and a pathway for you. I think I have a non-perfect litmus test for anybody with a value-based payment program who wants a heuristic to check if their value-based payment program is actually meaningfully impacting models of care in the marketplace: If most of the provider organizations who are part of that value-based program still incentivize and pay their doctors using FFS incentives like RVUs (relative value units), I'd step back and think about that for a piece. Contemplate that doctors, who are responsible for care decisions, still have every incentive to do everything that they would have done had the provider organization just been paid FFS. What's the point of value-based payments that extract exactly zero behavior change? And that is not a rhetorical question. So, back to the conversation from last week with Dr. Wayne Jenkins citing all of the things that can go horribly wrong when an employer's benefit designs are misaligned with the financial realities of their workforce. You get what you pay for, and I don't just mean that in terms of the dollars outlaid, since we all know in healthcare prices and quality have nothing to do with each other—I mean, in terms of what you choose to pay for and how you choose to pay for it. That's the macro of this whole thing, but indulge me as I get into the micro for just one sec. Let me just remind everybody about Goodhart's Law: “When a measure becomes a target, it ceases to be a good measure.” More on the why of this in the interview with Rishi Wadhera, MD, MPP, on the hospital readmission reduction program (EP326) and also what happens when we don't adhere to Goodhart's Law as we evaluate PCPs, which Rebecca Etz, PhD, talks about in EP295.   In this episode with Dan O'Neill, we go through where we're at on the continuum of value-based payments and how those payments are impacting the care, value-based or otherwise, that is incentivized by those payments. We tick through four gradations of value-based payments: A pure volume contract (otherwise known as FFS [fee for service]) A clinician bonus for achieving quality measures A piece of the savings (ie, MSSP [Medicare Shared Savings Program]) Global risk My guest, Dan O'Neill, is chief commercial officer over at Pine Park Health. Besides over a decade in healthcare tech and services, he was a policy fellow at the National Academy of Medicine and worked in the Senate on the Senate Health Committee. You can learn more at dponeill.com or connect with Dan on LinkedIn. Daniel O'Neill, MA, MS, currently serves as chief commercial officer for Pine Park Health, a value-based primary care group that delivers on-site care in senior living communities. Prior to that, Dan was a health policy fellow at the National Academy of Medicine, working primarily in the US Senate on legislation focused on surprise billing, anti-competitive contracting practices in the commercial market, and price transparency. Dan has also worked as a senior vice president with Change Healthcare and as an advisor to venture-stage healthcare services and technology firms. At Pine Park, Dan is responsible for risk-based contracting with IPAs and insurers and for the group's participation in CMS value-based care models, including direct contracting. Dan's research is available in NEJM Catalyst and on the Health Affairs blog, and he holds graduate degrees from Johns Hopkins University and Stanford University.   05:06 What is the spectrum of value-based contracts? 07:24 Why don't value-based contracts at the organizational level always trickle down to the provider level? 11:25 What are the two things that need to happen to drive outcomes in value-based healthcare? 15:24 How do insurers play into improving value-based contracts? 19:46 “There's a strong case to actually clamp down on prices.” 23:47 “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” 24:03 What's the first step to making value-based contracts more accessible? 24:27 What's the second step to making value-based contracts accessible? 25:23 Why are the incentives to change American healthcare pretty weak? 27:10 “Organizational change is just exceedingly difficult.” 28:45 What should you do if you want to start pushing organizations toward value-based contracts? 32:42 EP351 with Eric Bricker, MD.  You can learn more at dponeill.com or connect with Dan on LinkedIn. @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What is the spectrum of value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why don't value-based contracts at the organizational level always trickle down to the provider level? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What are the two things that need to happen to drive outcomes in value-based healthcare? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth How do insurers play into improving value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “There's a strong case to actually clamp down on prices.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Right now, we're still in a place where if you want to do something other than fee for service … you have to fight like hell.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the first step to making value-based contracts more accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What's the second step to making value-based contracts accessible? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth Why are the incentives to change American healthcare pretty weak? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth “Organizational change is just exceedingly difficult.” @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth What should you do if you want to start pushing organizations toward value-based contracts? @dp_oneill discusses #vbc on our #healthcarepodcast. #healthcare #podcast #valuebasedpayments #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento, Stacey Richter (INBW33), Stacey Richter (INBW32), Dr Steve Schutzer (Encore! EP294), Lisa Trumble, Jeb Dunkelberger, Dr Ian Tong, Mike Schneider, Peter Hayes, Paul Simms, Dr Steven Quimby, Dr David Carmouche (EP343), Christin Deacon, Gary Campbell, Kristin Begley, David Contorno (AEE17), David Contorno (EP339), Nikki King, Olivia Webb, Brandon Weber