The Maze of Health Insurance

Episode Transcript

Speaker 1 (00:00):
Eight oh seven thirteen ten WIBA Full Scope with doctor
Nicole Hemkiss, Wisconsin's direct care doctor. Of course, doctor Hemkiss.
She comes to us from Advocate, MD, a direct primary
care practice with offices. Let's see, we've got a west
side and Middleton east side on South fair Oaks. I
have south side right on the Madison Fitchburg line, right

(00:21):
in the beautiful Nature Preserve at thirty two to twenty
sign Road Jamesville for you South south siders like myself.
Ten twenty one Mineral Point Avenue. Doctors, eight physicians, eight
physicians at Advocate MD and doctor how you doing this morning?
And eight physicians, which leads me to believe we've got
some doctors coming on board very soon, don't we.

Speaker 2 (00:43):
Yes, So right now we have six doctors, and starting
next week, doctor Gina di Giovanni is starting with us.
We're very excited about that as she is a native
from Prairie, dw SoC And father was a retired surgeon
and mother is a retired nurse, so very excited to

(01:04):
have her. And then we will have doctor Jennifer Philbin
who's starting with us a couple months after that, so
that will make us an eight doctor practice that is.

Speaker 1 (01:12):
So cool and so exciting to see. And I was
last Saturday, I was driving around listening to listen to
you and I talked from a previous show and you
had mentioned, of course, the two new doctors coming on board,
and I had mentioned and I think it bears repeating,
and this is where I'm going with this, doctor. Is
the reason why you have more doctors at Advocate MD

(01:35):
is because you guys keep your patient panels very small intentionally.
Then there's a really really good reason for that, isn't there.

Speaker 2 (01:45):
Yes, So in large healthcare systems, you know, hospital owned
healthcare systems, which is the majority of primary care doctors
now across the country, but especially in the Madison, Wisconsin
Janesville area. So in these large healthcare systems, obviously the
health as incentivized to have the doctor see more and
more patients keep building their panel. I've actually heard that
there's health systems here locally that do not allow doctors

(02:08):
to close their panel. They have to continue to take
on new patients. So basically, even though they don't have
the appointments lots available, they just keep looking further and
further out. I just personally experience, you know, so because
of the medical practice. Obviously, I don't really go to
house side doctors very often, and my girls typically go
to one of our doctors in the practice. But I

(02:29):
had to make an appointment for one of my one
of my daughters, and I wanted to just see her
pediatrician and ask a question, and nine months to get
a well child stuck nine months. So it's just crazy
though that, you know, sometimes I commserate with the other
docs in our practice and I'm like, why do people
put up with this? Like why do people accept this

(02:51):
as the reality that we live in? Because there obviously
are alternatives, right, Like we are an alternative, you know,
there's other similar practices. But it's just crazy to me
that people are willing to say, like, Okay, I'll make
this appointment in December, so my kid could be seen
by a doctor in September, Like, oh, if I did
have concerns by then, it's either gotten better it's gotten
a lot worse, right, and then you've had to like

(03:12):
go to an urgent care and an emergency department. But yeah,
so in that large healthcare system, primary care doctors, like
family medicine doctors will typically have a panel of anywhere
from two thousand to three thousand patients. So let's say
on average, twenty five hundred patients, So twenty five hundred
people that are assigned to that doctor as they are

(03:33):
their primary care doctor. So those are the people that
are calling and trying to get an appointment with them.
That's why it is so difficult to get an appointment.
That's also why doctors have such full schedules on a
daily basis. Again, in this fee for service model, you know,
the system is financially incentivized and the doctor is financially
incentivized to see more patients. Right, So if I am
a doctor in one of these large systems, if I

(03:55):
see fifteen patients today, I'm going to make less money
than if I see twenty five patients today. That you know, unfortunately,
that is the reality, right. So like and instead of
you know, you could in theory extend your day out
to be a fourteen hour day, but most people aren't
going to do that, right, So instead, the appointments become shorter.
So what used to be maybe most docs had twenty

(04:16):
to thirty minute appointments, now those appointments are ten or
fifteen minutes, so they can fit in those twenty patients
a day, and unfortunately, that just doesn't give you enough
time with the patient. And so in our model, it's
very very different. Our doctors have a panel typically between
five hundred to six hundred patients or you know, between
four hundred to six hundred, and then they decide at

(04:37):
some point they're going to stop, and so that's when
we bring on another doctor so that they can start
taking on patients. So basically, you know, less than a
quarter of the size of these large health systems. So
that's why when you call to get an appointment with us,
it might be a couple of days, it might be
one week. It's never three months, it's never six months,
never nine months. And also when you come in to
see us, the doctor's going to spend you know, forty

(04:59):
five minutes to an hour with you. That does not
happen in the system. I have never as a patient
or a physician, other than when we start, you know,
being in the strict primary gear practice, I have never
been able to spend forty five minutes to an hour
with a patient that you know, anybody that says, you know,
sometimes I go to these I go to different presentations

(05:19):
and employer events, and you know, there's always the one
guy that raises his hand in the audience. He's like, well,
my doctor spends forty five And I was like, I
want to know where you go. I want to figure
out how they're doing that. Please let me know how
they're seeing twenty patients a day and spending forty five
minutes with each one of them. But yes, that's that
does not happen. So it is a very very different
level of care, different amounts of time, different level of

(05:43):
access that you get with our system, and we do,
you know, we definitely hear, as you mentioned, Sean, the concerns.
You know, I had a employee patient at one of
our open enrollment meetings, you know, raise his hand and
he was a little bit you know, agitated, and he's like, well,
I saw you opened up a new clinic in Fitchburg
and I and I know your doctors are getting busier
and you're bringing on other companies, and like, what if

(06:05):
I can't get an appointment with my doctor? And I go, well,
your doctor is no longer taking new patient That's why
we hired these other doctors. So you should never have
an issue getting an appointment with your doctor and That's
again the thing that is very unique about this because
I think all of us, including myself, have experienced frustration
with having to wait a long time to see a doctor,

(06:26):
you know, having to plan ahead. I mean who can
plan ahead nine months or six months or even a month,
you know, to figure out, you know, when you're going
to make this appointment. So I think that it is
very refreshing to know you have that kind of peace
of mind, reassurance that when you need medical care, because
sometimes it's unpredictable. I mean some things, you know, we

(06:46):
go in for an annual exam or a wellness exam,
we call it once a year, but there are obviously
things that arise, you know, issues that come up that
we need to see a doctor, and you don't want
to have to wait three months or six months or
nine months to see a.

Speaker 1 (06:59):
Doctor's as we talk about what you're able to do
at Advocate MD, and you know, highlighting that patients are
the priority, and I think sometimes people hear about well
that access has to come at a steep cost, that
this must be a very expensive option. And I think
for folks that have taken the time to explore direct
primary care and Advocate MD. You'd be pretty amazed at

(07:20):
how affordable it is. As a matter of fact, if
you head on over to Advocates DPC dot com, that's
Advocates DPC dot com, you can learn more about the practice.
You can learn about pricing. What does the cost to
become a member at Advocate MD. You will be absolutely
shocked when you see that. Again, head on over to
the website Advocates DPC dot com. Just imagine being able
to see your doctor when you need to see your doctor.
I know, it's a novel idea. It's pretty amazing what

(07:43):
they can do at Advocate MD and doctor as we
talk about kind of medicine in general and the insured system. Obviously,
there's been headlines recently involving an incident in New York
and some questions about and it kind of goes back
to some of these you know these I think you
read things online. There is a you know that stuff

(08:04):
and that that situation. Aside, there is a frustration on
the part of of people saying I'm paying for these things.
What am I getting for this?

Speaker 2 (08:12):
Is?

Speaker 1 (08:13):
You know, you hear of like insurance denials and you
know these very you know headlines of like oh, we're
only going to cover the you know, partial anesthetic and
other and you're you're going, wait, what is what is
happening with this? I know we talk about things like
health shares and other options for folks. One of the
things though, that that when it comes to things like
access and affordability. I know, for you at Advocate Emity,

(08:35):
affordability and keeping the prices something something that people can
afford has been a priority. You haven't done an increase
in in uh IN membership in many years.

Speaker 2 (08:46):
Doctor, Yes, that is true. I was having that conversation
with somebody the other day and they were trying to
tell me why I should encrease that. I can't remember
what they said now, but yeah, So we have not
increased our crisis since the practice started. That was in
January twenty nineteen. So we're about to enter into twenty
twenty five. We are not going to increase our prices

(09:09):
in twenty twenty five. That includes for individuals, families, and businesses.
That is a rare thing, I would say. I mean,
I think the cost of everything is going up, and
including health insurance. Obviously the cost of health care is
going up. I remember, you know when all this inflation
stuff started a couple of years ago. I remember having
a conversation with somebody about this and telling them that,

(09:31):
you know, we had not increased our prices in five years,
and his response was something like, well, I guess for
your practice, your costs don't really go up. And I
kind of looked at him with like, like a really,
like the cost of everything goes up, right, Like, so
you know, you know, rent and supplies, and you know
what you pay your staff, and all of these things

(09:52):
increased on a you know, a yearly, monthly basis. So so, yes,
our costs go up, you know. I think the value
that we provide people, they're getting a very good deal
with what they pay for their membership, So I think
that we could increase our prices. But the idea and
the goal behind it has always been to be able

(10:13):
to provide people access and to make this an affordable
option that people can purchase alongside of some sort of
a catastrophic coverage, whether that's health insurance, whether that's a
health share, you know, whether they're offered an employer based
plan and they do this alongside of that, you know,
so that there are different options, but we want to
make this affordable so that you know, average working class

(10:37):
people can afford this. It's not a concierge medicine for
only people that are rich. And that's I think what
we've done talks.

Speaker 1 (10:44):
Morning with doctor Coole Heemkiss of Advocate MD. Of course
the website Advocate DPC dot com. That's Advocate DPC dot com.
Delfromer to make it a point, become a member at
Advocate MD six eight two six eight sixty two eleven.
That's six eight two six eight sixty two eleven. Doctor.
One of the things that this I think that this
this this recent story out of New York has really highlighted,

(11:06):
is for people that weren't aware, is like claim rejection
and like how how often it is that some of
these insurance companies are actually denying claims and and those
kind of things. And I know one of the things
for you is is and kind of the name of
the name of Advocate m D is really advocating for people.
Is is understanding and it's it's bizarre to think about,

(11:29):
but it's uh, it's it can be tough to manage,
tough to navigate the insured world. And I know part
of the thing with Advocate MD and direct primary care
is you don't deal with insurance. There is not that. Well,
we don't. We're not gonna, you know, cover this or that.
What you guys do in the clinic is all membership
based and based on on being part of Advocate m D.

(11:50):
It's it's part of your membership, isn't it.

Speaker 2 (11:53):
Yes, So the membership includes you know, all of your visits,
so there's no copays, there's no charge for the visit.
So normally when you have a fee for service practice,
you know, whether I go in to see the doctor
for my annual or if I go in for an
urgent care issue, or I go in for a minor procedure,
not only am I paying a copay along with that,

(12:14):
but I am also paying there's also an office visit
charge right along with everything else. In this model of
direct primary care, there are never co pays. And then
when you come in to see us, you know whether
it's again your annual wellness exam, if it's a chronic
disease management, if it is an urgent care minor procedure.
All of those visits are included. We don't charge anything
for those visits. So the things that would be additional

(12:37):
and again at a very discounted wholesale price, would be
if you get lab work done, if you have a
medication dispensed from our office, if we do a procedure,
and for example, if we have to send that skin
biopsy out to the pathologists, or if we need to
order an X ray, anything that involves a third party,

(12:58):
that would be built again at a very discounted wholesale price,
because that again is a is an additional charge outside
of our clinic that's being incurred, you know, from this
this outside vendor. But the stuff that is within our
clinic that does not involve an outside person, that stuff
is included in your membership charge. So it's it's really nice.
Everything is transparent. People know the cost of everything ahead

(13:19):
of time, you know. And and back to your your
pointer you mentioned, Sean, So people have probably this story
is out about the United Healthcare CEO being shot or
gunned down in Manhattan. Uh, and it's it's very you know,
obviously unfortunate any violent crime that happens. You know, I
think though we can look at this in a way

(13:42):
to say, I guess it. To me, it exemplifies the frustration,
the anger that people have towards insurance companies. You know,
I think they found some some shell casings that say
deny deposed, deny. Do you remember what it is pose
den I defend a pose. Yeah, So I guess those

(14:02):
are insurance claims that you see on your denials and
maybe if you're involved in a lawsuit with the insurance.
In United Healthcare is probably the most sued insurance insurance group.
They are the largest health insuran in our country. They
have basically set up a monopoly in not only in
which they own the majority of the health insurance, but

(14:25):
they also own the TPA, so the third party administrator
that that facilitates the paying out of claims. They also
own one of the largest home health agencies. They also
own the PBM, so the pharmacy benefit manager that decides
which prescriptions that you are allowed to get on your
formulay and how much those will cost based on in

(14:46):
many cases, you know, perverse incentives to prescribe certain medications
because those PBMs are getting vouchers or kickbacks on those
brand name drugs. So they own all of that. They
own the stratus of health care in terms of having
their hand in everything, and that obviously creates very perverse
incentives and a you know, you can't be objective in

(15:10):
the way claims are paid out. And if you go
back to when I don't actually look this up, but
you know, health insurance has been around for a while,
but not in the current form that it is today. Right,
So the health insurance that our parents had when they
you know, had us, that you know, you know, delivered
us as babies was not what it is today. You know,
we used to have these things called indemnity policies or

(15:32):
truly catastrophic health insurance, which you know, the ACA changed
a lot of this and made it even more difficult
for people to have it. Actually kind of almost made
it illegal to have a purely catastrophic health insurance policy
because it made health insurance include all of these things
that many people won't use and made it much more expensive.
But let's go back twenty thirty, you know, years or longer,

(15:58):
so you could actually have a health insuran policy that
covered you, for example, if you needed to go to
the hospital, if you needed surgery, if you need cancer treatments,
these extremely expensive things that for someone the average person
to pay for these things would bankrupt you. So those
things are what we need health insurance for But unfortunately, obviously,
as we've talked on the program, it's morphed into this

(16:19):
thing where you know, you go to get your blood
pressure checked at the at the you know, outpatient clinic,
you give them your insurance card. You go to get
a blood test, you give them your insurance card. You
you know, you sprain your ankle, you go to the
urgent care clinics, they take your insurance card. So that
has kind of morphed into this gigantic thing that encompasses
all health care. But back to this United Healthcare. You

(16:41):
know what insurance companies, You know, Sean, when you think
of insurance companies and you think of, you know what,
what do you think the purpose of health insurances?

Speaker 1 (16:51):
I know what I want thought? Is that doing that
you've learned over the years of what it acts? Is
my original what I remember the naivete when I first
I remember the first job that offered health insurance. I thought,
oh my goodness, I you know, I'm covered, I can
get in, I can actually be treated, and you know,
any type of issue I could run into, I've got

(17:11):
this coverage. Now. It was kind of like that golden ticket.
And then you really quickly realize that was not there.
But yeah, I think I think a lot of Again,
my first experience or thought of insurance years ago was
it's a great thing to have because it's gonna it's
gonna keep me healthy, it's gonna keep me safe, it's
going to keep me protected if if Gosh forbid, something
serious ever happens to me. And I haven't seen that

(17:33):
play out though, so there.

Speaker 2 (17:36):
Yeah, there's a very smart one of the the uh
forefathers of the direct primary care movement as a doctor
in Michigan, Chad Savage. You know, he presents that a
lot of the DPC conferences when I first started. Great guy,
you know, very smart guy gives great presentations. In One
of his sayings that he likes to present is that

(17:58):
the intention of health insurance was to prevent financial calamity,
and now health insurance is the financial calamity, right, because
you pay so much for your health insurance. But even
further than that, like let's say you paid a ton
for your health insurance and they actually paid out on claims.
Now you pay a ton for your health insurance and
they don't pay out your claims, right, So insurance is
actually financially incentivized to not pay out claims. Right, So,

(18:22):
how can insurance companies make more money, charge you more
money for your premiums, and pay out the fewest amount
of claims that they possibly can? Now, how do they
accomplish that strategy by paying out the fewest amounts of
claims possible? Make it difficult to file claims? Right, so
make doctors and patients jump through hoops, prior authorizations, pre certifications.

(18:45):
You know, United specifically is involved in class action lawsuits
currently because they deny claims. I think United was the
one where basically they were instructing their claims adjusters to
deny claims basically without even reviewing them. Deny it the
first two or three times, and then when it comes
to like the third time, then you can review it.
Because this is a tactic that you know, eventually, maybe

(19:06):
the doctor gets tired of filling out the paperwork or
the patient you know, you know, gets frustrated, and so
they just like give up on it, like Okay, fine,
I guess I don't need that surgery. I guess I
don't need that medication. Right, So, so the strategy is
to deny claims and basically create barriers to care. They
can also do that by you know, wasting a bunch

(19:27):
of time, right, so they can run out the clock
of like, Okay, well we're gonna uh this approval for
this cancer treatment. It has to go through a committee,
it has to go through a period a peer with
a doctor, it has to be reviewed by our nurse.
You know, all of these things that you know, a
person that is waiting for cancer treatments that now is
having to wait for weeks or months, and that person

(19:50):
is getting sicker. So I mean, you can, you can?
I mean, thank god, I have never had to personally.
I mean, I've experienced denied claims yet, but I've never
had to experience, you know, a life threatening illness where
a claim is being denied for me to either have
a surgery that I need or to have a cancer treatment.
And I have not had family that have experienced that,

(20:11):
but I have had patients that have experienced it, and
I can fathom the level of frustration and anger that
that would elicit. You know, I don't know if you've
ever experienced claims denials, John, I.

Speaker 1 (20:27):
I think knock on wood that says I have. I
think I don't know if I've told you this. I
have never been in a hospital as like a like
a page. I've never broken a bone when you were born, Yes,
I was so, Yeah, so I should qualify so.

Speaker 2 (20:43):
You don't remember that far back.

Speaker 1 (20:46):
Yeah, since the day I was born. I've never been
back in a hospital for and again I knock on
wood for for anything like that. So I would what
I find fascinating to us. We talked this morning with
doctor Nicole Hemkiss of Advocate, MD, the website Advocate DPC
dot com. That's Advocates DPC dot com. Something else that's
been brought to light. I've seen some doctor sharing some

(21:07):
letters over the years that they've written to some of
these insurance companies about about how their their patients were
being denied coverages. And there was one that just really
stuck with me about a doctor who had a young
cancer patient, uh, and the insurance company was denying his
anti nausea medication. And and this doctor, I think it

(21:28):
starts off by I think he refers to him as butt,
heeads deer butttheads and kind of explains like like your
guys must know better than me as doctor, and I'll
just let this little this little kid know that it's
all in his head and he should just feel fine.
I mean it is. It is very cold and very heartless.
And his doctors that see this stuff, it's it's a
really hard thing. What kind of happened there? Used to

(21:48):
I remember there was like this this prom you know,
we talked about these big systems. There was early on,
I don't know if it was marketing or not, but
like this promise that this whole idea was going to
make healthcare more efficient, more affordable, better access with these
giant like if you have everything under one roof and
your insurance and the pharmacy and the and the and

(22:10):
your primary care doctor and the and the and the
outpatient and the impatient and all that stuff, like we
had this there's like this promise early on. I remember
this that like this was going to make things better
for the patient. Where did everything kind of go wrong?

Speaker 2 (22:22):
Doctor? Well, I think you have conflicting goals, right, and
I mean efficiency could be measured in different ways. I mean,
you know, efficiency in terms of saving saving money versus
you know, delivering care in an expedient way. I think
that what happened with health insurance as they became larger

(22:46):
is they realized, they realized ways to save more money,
or it was denying care to patients. I don't know
that it was always this way, but it definitely is
this way now. And just as we were even talking,
I was thinking about different examples of things, and you know,
I'll give you an example that's very common. So, you know,
I see a patient here in the clinic. Let's say
if I was an insurance based doctor, which thank god

(23:09):
I am no longer, but you know, and they have
you know, chronic glow back pain. They have ridicular symptoms
going down their leg, they have numbness in their foot.
This person needs an MRI. So again I have to
I'm an insurance based doctor, I have to fill out
the prior authorization or the pre certification that gets sent
into the insurance. They deny it. They you know, they say,
you know, insufficient evidence. Send for their medical records. You know,

(23:31):
we send some other medical records, We write up another note,
we send it back to them. They deny it. They
request a peer to peer So that means that I
have to get on the phone with a doctor that's
located in you know, Timbuk two, who's never seen this person,
who's never sat across from this person, has not examined them,
doesn't know them. You can't, you know, look into their
eyes and tell them they can't have this MRI. But

(23:53):
they want you to do that. And so you get
on the phone with this person, You talk to them
for fifteen twenty minutes or longer if you can actually
reach them, and then if you're lucky, in rare cases,
they'll they'll approve it. In some cases they'll slay. Yeah,
I still don't think. I don't I think they need it.
So a person, I mean, just wrap your head around
that one. That doctor has never seen that patient, and

(24:16):
purely based on them looking at some notes in a computer,
they're going to decide what medical care they receive, not
the not their treating physician. As if I get any
sort of kickback by referring them to get to this MRI.
You know, it's it's crazy to think. And I was
also thinking of an example when I used to work
in the rural ers. I remember having a gentleman. You know,
we frequently get things like chest pain coming in, and

(24:38):
so you do the EKG, you do the blood tests,
you check their cardiac enzymes, and so in this particular case,
if they have risk factors and they have anything abnormal,
you admit them, they get a stress test. I remember
this particular gentleman was so concerned about his insurance coverage,
and his particular insurance required him to have a prior
authorization for any admission, even if it was an emergency

(24:59):
admission to the hospital. So he sat in the hospital
most of the night in the emergency department, and we
were trying to call his insurance, of course in the
middles and I just probably know when you're going to reach.
And so to make a long story short, rather than
this person getting the necessary medical care that he needed,
potentially he's having a heart attack and you he might
need a procedure done, rather than him doing that, he

(25:23):
opted to leave the emergency department and go home because
he was too worried about the bills that he might receive.

Speaker 1 (25:29):
Wow, that's scary stuff. And what's scary too about a
doctor is I know there's people listening this morning that
are like, Yeah, I've heard things like that, or I've
had something like that happen to me. One of the
great things, especially when it comes to primary care, is
there are great options direct primary care and Advocate MD
is definitely something to check out. If you haven't checked

(25:49):
out the website yet, head on over there. Advocate DPC
dot com. That's Advocate DPC dot com. Affordable access, actually
getting into see your doctor when you need to see
your doctor again, that's Advocate MD. And the telephone number
six SO eight two six eight sixty two eleven. That's
six SOH eight two six eight sixty two eleven. Doctor Hempkis.
It's always great chatting with you. I have a fantastic

(26:10):
day and enjoy the weekend you too, so thank you.
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