Rethinking Medicaid

Episode Transcript

Speaker 1 (00:00):
Eight oh eight thirteen ten Doubuiba in full scope with
doctor Nicole Hempkiss. Of course, doctor Hemkiss is Wisconsin's direct
care doctor. You can learn more about doctor Hemkiss, doctor Balen,
doctor Augy, doctor Shulman, who all my, oh my goodness,
I'm a doctor Qualley, I am so many Wait are
you up to eight doctors at Advocate MD?

Speaker 2 (00:22):
Aren't you including me?

Speaker 1 (00:25):
So cool?

Speaker 2 (00:25):
Is that?

Speaker 1 (00:26):
That is awesome? And of course the four locations these
have got down a little bit better. Middleton at thirty
two or five Glacier Ridge, east side of Madison, right
on one fifty seven selth Farroku, I have Fitchburg the
newest location, thirty two twenty syin Road, and of course
right just south of Dane County in Rock County, right
at ten twenty one Mineral Point Avenue, which is a

(00:47):
great location if you're in Rock County or southern Dane County.
And of course here in the Madison area, if you
can hear our voice, you are near an Advocate MD
clinic and the fantastic doctors. And we're going to talk
about some really groundbreaking legislation, the big beautiful bill, what
went through how that affects and it does have an
effect on a lot of different things, including healthcare in
the landscape or going to get some details from doctor

(01:08):
Hemkiss about some about some changing perspectives on on healthcare.
We'll get to that in just a moment, but first, doctor,
let's uh, by the way, great to talk to you
this morning. Let's talk a little bit about Advocate MD.
As we talk about the clinics, we talk about the
doctors at Advocate MD. Direct primary care is something that
that if you were to ask somebody that had never

(01:28):
heard of direct primary care, if you were to ask
them describe your perfect doctor patient relationship, how should primary
care be, they'd probably come up with with direct primary
care and what you're doing at Advocate Advocate MD. It's
really patient focused, isn't it.

Speaker 2 (01:45):
Yes, you know, in many ways, it's kind of good
taking a step back to the way healthcare used to be,
where you know, you knew your doctor, they knew you
and your family. You know, they spent more time with you.
They had the ability to you know, answer or your
phone calls after hours because they weren't you know, owned
by a large corporate healthcare system. They were you know,

(02:08):
typically private physicians. They took on smaller panels of patients
and that allowed them that kind of flexibility and autonomy
to really have those those deeper patient doctor relationships, and
so yes, they would take you know, within our practice
we have forty five minutes to an hour long appointments.

(02:28):
If you need something after hours, you can text or
call your physician, your doctor, not the nurse triage line
that's taking care of the after hours calls. So that's
a very old school in a way.

Speaker 1 (02:38):
It's very and it's such a cool thing too. With
that you mentioned, you know, getting to see your doctor,
getting in to see your doctor. The clinics are comfortable, convenient.
You're not you know, you're not just a number. You're
not Canada a card and sent in a maze like
at some places around around town. You literally get to
come into the clinic and get to see your doctor
right away. Again, you can learn more online the website.

(02:58):
It's a great resource. Advocates DPC dot com. That's Advocates
d PC dot com telephone number. Today's grea data To
make it a point, become a member at advocate emit
six h eight two six eight sixty two eleven. That's
six 'oh eight two six eight sixty two eleven And doctor,
let's talk about first off, Medicaid. And obviously it's a

(03:19):
giant program. It's a very very big program, and hospitals
have been kind of struggling with Medicaid and patients and
how that all works. It's really caused problems, I know,
a lot of the stuff caused problems also for the
smaller hospitals. Let's kind of get a layer of the
landscape and kind of how things have shifted with the

(03:39):
with the new big, beautiful bill, and how that's how
that's kind of leveled things out or kind of changed
things a little bit.

Speaker 2 (03:46):
Yeah, so just to give you, you know, kind of
a little bit of explanation of Medicaid versus Medicare, and
I think sometimes those those two programs get confused. But
Medicaid is a specific program that does have financing, some
of it through the federal government, but some of it
is also financed through state governments, you know, and I
believe a lot of that money is kind of shifted
from the federal government to the state and then they

(04:07):
figure out how to distribute that. But it was initially
started as a program for people that were financially needy
and specifically children that were financially needy, so it had
a big emphasis on taking care of kids, you know,
eighteen and under, and then that kind of has slowly
shifted to where it encompasses more adults, pregnant women, things,

(04:30):
situations like that. But Medicaid historically has been very much
lower reimburse than other forms of insurance. So, you know,
you have Medicaid, which again is for people that are
financially in need, Medicare, which is historically for older adults
and also adults that have you know, medical disabilities, and

(04:52):
then you have private insurance, so you know, the vast
majority of people are on private insurance, you know. And
then there's all these different scenarios you could have. You know,
one is a primary, one as a secondary, so you
can have more than one form of these. You can
have Medicare and Medicaid. But anyways, the interesting part that
I think a lot of people don't understand is that
for most hospital systems, what they see the reimbursement, and

(05:14):
again this kind of trickles down to physicians too. The
reimbursement for things like Medicaid and Medicare is lower than
what the reimbursement for private insurance is you know, whether
that's an office visit, a procedure, surgery, you know, emergency department.
So you know, many times hospitals rely on private insurance

(05:35):
to see the majority of their revenue because the Medicaid
and Medicare reimbursements, again, those are set by the government,
so they will many times do this thing kind of
you know, we referred to as you know, sort of
cost shifting. And that's why, you know a lot of
times when we look at these charges from hospitals and like,
how the heck could this cost this much? Like how

(05:57):
does three days in a hospital cost, you know, fifty
thousand dollars or something like that, And again, I mean
it doesn't actually really cost that much. But part of
this too has to do with the fact that, you know,
the reimbursement for things like Medicaid is so low. So
if we look at it like a dollar, you spend
a dollar, and if we kind of try to put

(06:18):
these things into perspective, so let's say for every dollar
in health care money and healthcare spend, Medicaid is reimbursing
twenty cents on the dollar. Medicare. Let's say you know, again,
this varies, but let's say Medicare is reimbursing you know,
fifty cents or sixty cents on the dollar, and then
private insurance is reimbursing a dollar twenty, right, So it's

(06:41):
it's a very large you know, not to get too
much into the weeds of healthcare economics, but there is
a very large discrepancy there, and that's why in many cases, doctors,
you know, even private doctors and insurance based systems, not
in our system, insurance based doctors might decide I can
no longer afford to take Medicaid, like I can't run

(07:01):
my business, you know, with medicaid. You know, we see
this happening with things like nursing homes, rehab facilities, where
again it does what Medicaid is reimbursing them doesn't even
cover their cost. Again, Medicare is reimbursing at a higher level,
but still not as high as private insurance. So so
that's it's going to be. You know, the reason I

(07:22):
bring this up is because I recently read this kind
of commentary in in the Becker's Hospital Review where they're
talking about how this big, beautiful bill, which I don't
think you've read it, Sean, I haven't read the whole thing.
That I've read about two pages of it that affected
maybe affected my practice. But what the overall you know,

(07:45):
consensus seems to be is that there is a lot
of changes coming to Medicaid and how Medicaid is funded
through the federal government, and that there will be significant,
you know cuts. Again, I've I've heard some politicians talking about,
you know, that the intention is not to cut you know,
those who are actually in financial need. The intention is
to you know, cut a lot of the extraneous cost

(08:07):
or maybe more of the administrative costs, or more of
people that are using this system fraudulently, you know, which
can be both patients and doctors. Right, there's doctors that
do things building medicaid that is not legal. So so
anyways that these Medicaid cuts, I'm not exactly sure how
those translate to the patient itself, but there will be

(08:29):
it sounds like significant cuts, and people that were once
eligible for Medicaid maybe will lose their eligibility. So now
hospitals are having to kind of rethink how they do things,
you know, and and also figure out, well, so if
we get zero reimbursement for this percentage of people. Now,
you know, what are we going to do if or

(08:50):
if you let's say you have now a larger influx
of people coming into the hospital system that don't have
any insurance. You know, there again, there are not to
get too much into the weeds, there are special legal
protections that people have if you go in through an
emergency department. So hospitals cannot deny you care. If you
report to an emergency department and you have a medical need,

(09:11):
they have to see you regardless of your ability to pay. So,
you know, does this mean that emergency departments will get busier,
that people will be utilizing those instead of of other,
you know, healthcare settings. It's really unclear. But you know
what this Becker's Hospital review did is they interviewed the
CEOs of some hospitals and interestingly, you know, like one

(09:33):
of these was in Minnesota, and and so they kind
of asked them how they viewed this changing. You know,
how hospitals are run. You know, if they're having to
rethink you know, how they're doing things. And I think
in many cases, you know, when we're pressured, you know,
whether it's a financial pressure or some other you know,

(09:54):
supply and demand, you know, whatever it might be. Hospitals
are now having to kind of reprioritize things and figure out, like,
you know, how they're going to be able to survive
in this new healthcare you know environment, and not just
the Medicaid cuts, but obviously, you know, we see that
much and more, much more things are now being shifted

(10:15):
to outpatient settings versus in patient settings. You know, we
talked on the program. That's one of the large basis
of direct primary care is that we believe that you know,
ninety percent of healthcare maybe more, should be taken care
of in an outpatient setting, not in the walls of
a hospital system. Right because whenever you step foot into
the walls of a hospital, no matter what you are doing,

(10:36):
whether they're drawing your blood, whether they're doing your physical therapy,
whether you're talking to a specialist inside of their office
that's you know, owned by the hospital system, you know,
whether you're going in to get an MRI, all of
those things will cost exponentially more, same quality, same you know,
everything else being equal, the cost of that will be

(10:57):
more just because it's located inside of the hospit. So, yes,
we need to be shifting. You know. Interestingly, one of
the CEOs brought this up that you know, maybe more
you know, things are shifting down more to the outpatient setting,
and also just innately from the way that hospitals are paid,
there is this kind of perverse incentive to keep people
in the hospital longer. Right, And again, I don't want

(11:19):
to be cynical. I don't want I don't want to
you know, to to you know, judge, you know, to
say people are doing things that are you know, not
on the up and up. But but I definitely can
see how hospitals are not incentivized to kind of get
people well quicker and get them out quicker, you know,
if possible. Again, if as long as the insurance is paying,

(11:40):
you know, if somebody's paying for that hospitalization, you know,
why would they care if you stay two days versus
ten days if they're getting paid for it, right, and
they have the beds available. You know, we see this
happen too in a lot of rule settings that you know,
maybe aren't as busy, so in some ways they get
a little worried if their hospital beds are empty, right,
because then someone might question, do we need a hospital

(12:02):
in this community of three thousand people or you know,
eight thousand people. So so that was one of the
things that they talked about too in this article was
rural healthcare. But yeah, it's it's funny because you know,
I think one of the comments from the CEOs was that,
you know, we need to design systems that improve you know,

(12:22):
everyone's situation, the patient, the provider, the payer, and the
payer being like the insurance company, and the provider of
course being either the doctor or the hospital in the
in the patient. And I find that kind of an
interesting kind of pie in the sky sentiments because it's like, yeah,
let's just make it better for all of those people.
Right now. The situation is, in my opinion, good for

(12:45):
hospitals and insurance companies, right I mean, they're making billions
of dollars. The situation is really bad only right now
for the patient and in some cases the physician. But
the patient overwhelmingly is the one who's kind of getting
the the raw end of the deal right now. You know.

Speaker 1 (13:02):
One of the things is we look at some of
the you know, some of these CEOs that are in
this article, and I you know, I always kind of
take it with you know, I understand that there's a
lot of there's I mean, there is being a CEO
of a big healthcare any healthcare system, on some level,
there is a little bit of politicking that goes on.
And I know one of them had kind of mentioned about,
you know, focusing on a community nay needs and not

(13:24):
just for profit operations, and and to me, I'm like,
that would be great if that were true. And what
what I when I hear quotes like that, are lines
like that being mentioned, it almost feels like I get
very disappointed because I'm like, so, you're well aware of
the problem, but you're going to go back into work
today and continue to do and continue to to propagate

(13:46):
this issue, and rather than taking action, you just go, well,
I agree that it needs it gets that stuff gets frustrating.
And doctor, you had mentioned too about about some of
the the the emphasis when it comes to prevention versus
sick care, and and you talked about about some of this,
and I know, with for example, comparing you know, the

(14:07):
priorities of these big hospitals comparing them with kind of
the priority at Advocate MD and direct primary care. Something
you always talk about is the importance of prevention, and
I think one of the great benefits of direct primary
care and having that time with your doctor is having
those you know, those great conversations to really help you
make some adjustments in your lifestyle, are identifying things early on,

(14:29):
so rather than dealing with an illness, you're dealing with
with lifestyle things that can actually prevent those those illnesses
and keep you as far away from the hospital as possible.

Speaker 2 (14:42):
Yes, exactly. And I think that you know, if we
kind of there's a lot of parallels between you know,
preventive care, let's say, health if we call it healthy
care in the outpatient setting versus sick care, which typically
you know, of course takes place in an in patient setting.
So it's kind we're trying to kind of shift more
into this outpatient setting keeping keep people healthier so that

(15:03):
they don't need to go into a hospital, they don't
need to have, you know, a major surgery, you know,
for their heart, because they've had high blood pressure and
high cholesterol and diabetes for twenty years. Like, let's try
to help people improve those conditions so that they don't need,
you know, this catastrophic surgery, they don't have a catastrophic
event like a stroke or a heart attack. So I

(15:24):
think again that's where I view healthcare moving. But from
the standpoint of a hospital or a large healthcare system,
they don't get paid that way, right Like, again, I
don't want to be cynical, but you know, hospitals get
paid when people are sick, and the sicker they are,
in some cases, they make more. Right, They're building at
a higher level when you're in the intensive care versus
if you're on a regular hospital bed. Major surgeries bill

(15:48):
a lot more than you know, just having an outpatient visit.
So so there's perverse incentives. Not that you know, hospitals
of course are not making people sick, nothing like that,
but again they don't necessarily. I mean, why would you
emphasize to people that they should, you know, do all
these things to maintain health if really the endpoint is
for them to be in the hospital. That's where you're

(16:10):
really generating your money. There are so many examples of this,
I can't even start to tell you all of them.
But I mean, for example, obviously we have an obesity epidemic.
You know, we have a lot of people that are overweight.
You know, many of these people as we get older,
you know, we have joint issues. We have, you know,
back problems, you know, and so people get to a

(16:31):
point maybe in their fifties or sixties where they need
like a total joint replacement. These are some of the
most lucrative surgeries that hospitals perform. You know, total joint
replacements can be sixty eighty one hundred thousand dollars when
you look at these global fees, because that includes you know,
the doctor's charges, the hospital's charges, the anesthesia, the physical
therapy afterwards, all of the follow up. But again, if

(16:56):
I if I look at this and say, let me
get that person when they're in their thirsties and forties
and really help them try to figure out a way
that they can maintain a healthy, way that they can exercise,
that they can do all of these things. This isn't easy.
This is hard stuff, you know, and this is not
anything you can take a magic pill for. But if
we really spend the time and energy to do that

(17:17):
rather than you know, wait until they're in their fifties
sixties and they need a major surgery. But but you know,
why would we do that if that's the way we're paid.
We aren't paid that way. But if hospitals are paid
to do these surgeries. You know, again, where is the
emphasis on you know, diet and exercise and lifestyle goals,

(17:38):
you know, because that in theory, would prevent people from
needing these type of surgeries. So it is a very
it's it's not an easy fix. I think it's a
healthcare is a very complicated thing. You know. The other
part that I found interesting that they spoke about was
that just because systems are bigger doesn't necessarily mean they're better.

(17:58):
So we keep talking about, you know, all these mergers
and acquisitions of hospital systems, where it used to be
that there'd be a lot of just single independent community
hospitals they weren't owned by a larger corporation, and now
those have been swallowed up by big you know, healthcare
organizations that span multiple states, and so now you know,

(18:19):
you think the economies of scale, like, maybe that's better
for patients because now they spend less money on administration.
But what we've actually found is that in many cases
they become less efficient. You know, there's more a inursia there,
it's harder to make changes when changes are needed. And also,
you know, not every you know, a hospital operating in
Wisconsin is very different than a hospital operating in downtown Chicago,

(18:40):
which is different than California or Florida, you know, so
they have to know and understand the local healthcare environment.
So I think there's you know, it's kind of it's multifaceted.

Speaker 1 (18:53):
As we talk about this stuff too, doctor, it's hard
not to be cynical and not to you know, to
you think about things like lifestyle medicine and other things.
And then of course the incentive of having folks hospitalized,
and you know is I think a lot of times
we want to believe the best, and unfortunately, track records
and other things have shown shown otherwise. And as we

(19:14):
talk this morning, we get a chance to chat with
doctor Nicole Hempkis each and every week right here on
thirteen ten WIBA. Don't forget when it comes to primarycare,
there's a great option for you your family. If you're
an employer looking for great options for primarycare, it's something
great to offer your employees. Definitely check out Advocate MD
and Direct Primary Care. The website Advocates DPC dot com.
That's Advocate DPC dot com. Tellph number, Maake ap Point,

(19:37):
become a member at Advocate MD six oh eight two
six eight sixty two eleven. That's six oh eight two
six eight sixty two eleven. We'll continue our conversation with
doctor Cole Hempkiss of Advocate MD. We will do that
next right here on thirteen ten wib A eight twenty
nine thirteen ten wi b A and full scope with
doctor Nicole Hempkiss, Wisconsin's direct care doctor. Of course, doctor
Hempkiss comes to us from Advocate MD. The website Advocates DPC.

(20:00):
That's Advocates DPC dot com tel forh number six so
eight to six eight sixty two eleven. That's six so
eight to six, eight sixty two eleven. Wrapped up that
last segment mentioning if you're looking for some great options
for yourself, your family, or employers, your employees, if you're
an employee, what a great option it is to offer
Advocate MD and doctor let's talk about new patients. Advocate MD.

(20:23):
You guys do have openings right now, don't you.

Speaker 2 (20:26):
Yes, we are accepting new patients. We have some newer
physicians to our practice, doctor Philbin, doctor Di Giovanni who
are taking on new patients. Whether you want to go
to a specific clinic, all four of our clinics. You know,
you'd have the ability to go to if you have
any questions that come up, things that maybe we talked

(20:46):
about on the radio, or your specific medical issue that
you're not sure. If that's something that you know, you
can go and see us at Direct at the Direct
Premacure Clinic. You can always email me through our website
under the contact us.

Speaker 1 (20:59):
But again you head on over to the website ADVOCATESDPC
dot com. That's Advocates DPC dot com. You can email
the doctor correctly. You've got questions now accepting patients, they've
got openings for you. All the details on the website.
You can better become a member, make make an appointment
today six oh eight two six eight sixty two eleven.
That's six oh eight two six eight sixty two eleven.
Doctor Hamkins, thank you so much for your time this morning.

(21:20):
Enjoy the weekend and we'll talk real soon you too, Sean,
thank you, and again that website Advocates d PC dot
com and their telephone number six oh eight two six
eight sixty two eleven. That's six oh eight two six
eight sixty two eleven. News comes your way next here.
I'm thirteen ten wu ib A,