Healthcare System Audit From Back Office Supervisor “Ron”

Given Integrating Presence’s long list of healing modalities and resources; occasionally providing commentary about care during Denny K Miu‘s Saturday “Mindfulness of Qi : Mindful Fitness & Yi Jin Jing” and “Mindful Practice for Everyone : Each Differently Abled”; and an upcoming “Ask Us Anything” guest who focuses on redefining care, it seems appropriate to interview “Ron”.

Ron is not his real name. He previously worked several (supervisory) roles in quality and project management on the revenue cycle side within an emergency department, within a directed mission department, at a large healthcare system.

Along with a brief bio and role descriptions some of the topics we get into include:

• Physicians basically only spending 7 minutes per patient, per visit for one item
• Personal responsibility
• Prominence of Medicare and Medicaid
• Push for profits and efficiency often times over quality of care
• Related insurance industry undertakings and operations including details and examples
• Leadership
• Potential solutions:
  • Food availability and equality
  • Nurse practitioners and physician assistants
  • Reimbursements based on quality of outcome

---

---

The raw unedited YouTube transcription of this podcast:

easiest way

[Music]

this is josh devil from integratingpresence.com and as some of you know denny came you

and i do a monthly ask us anything this coming month we’re having on a guest

who’s talking about redefining caregiving and so i thought i’d sit down virtually with

ron here which is not his real name ron why don’t you mention well a brief bio in

what you where this all fits and how it’s related sure yeah when it comes to

questions of redefining health and health care and how people operate in that space of course a lot of the

attention is focused on insurance government roles the the impact of major

hospitals your private physician things of that nature and there’s a lot of opinions around that there’s a lot of

politics around that and i think everybody has their own vantage point so

maybe what we can talk about is a little bit of the vantage point that i could provide as someone who

has worked in hospital systems and for a major player across multiple

states uh you know nearly eight to 10 billion dollars in annual revenue so a

pretty large health care system where i had the opportunity to work as a frontline person on the revenue cycle

side within an emergency department within a hospital direct admission department also had the

opportunity to supervise and manage teams within that direct hospital

climate as well as several roles in quality and project management within

the revenue cycle organization of what we might call a back office type of concerns and that’s where we’re

getting into contracts authorizations insurance company behavior client behavior things of that nature so

just some of the things that we’ve seen some of the things that might be questions uh in regard to you know how

does this work how could it be better what are some of the obvious flaws that you see both

not necessarily from a medical standpoint because i’m not clinical but from a bird’s eye view of seeing how the

clinical side works and then as well as that how the insurance and people’s approach to

things impacts their care and then we can connect that to really what is the broader agenda and

purpose of having a healthcare system what should it look like and are we on the right path to that

this is a perfect setup yes all those things are of of great interest especially in the hour we’re in as well

so yeah um please dive right in yeah so i think the first thing is when

we talk about health care and we talk about health so much of what we experience in a

actual clinical setting especially if you’re getting into this is an emergency or this is urgent

or sadly even if you are setting up an appointment with your primary is focused

on the old pay for seat for service model so while there have been movements and the

government through cms claims that they’re really looking for quality and outcomes one of the things that’s a bad

rock is if you go in to see your physician you’re going to be asked for your top issue of today you know what is

it that we’re dealing with today and that’s going to be if you’re lucky a seven minute visit with your physician

now you might be there for 45 minutes you might wait for 15 before you get back you might wait for 10 while you’re

in the room but at best you’re talking about seven minutes with the physician and half of that they’re going to spend

typing notes into the computer so not a lot of focus holistically there if you

have any kind of an urgent need again it’s going to be one primary item and we know

from a health standpoint that there are multiple factors that

integrate and if you are operating by piecemeal you’re really not going to get

the kind of advice or get the kind of treatment that’s going to enable you to connect the dots together it would take

certainly more than seven minutes to take any kind of a chronic condition and talk through the diet and exercise

requirements as well as limitations but the system itself is more or less set up

to drive you to how can we look at one item today and then how can we

medicate that by giving you a prescription so that these numbers start to look better and that’s that seems to

be one of the problems because if you’re truly interested in establishing full health how are you going to get there

when we’re slicing portions of that out and just saying well what is your particular issue today you know are you

struggling with your diabetes was your cholesterol too high you know did you sprain an ankle some of these things are

acute and can be handled simply but others are actually you know more complex they’re more interwoven but that

doesn’t doesn’t blend well into being able to drop a claim and bill it out to an insurance company so we we do have an

issue there where the focus on on wholeness and well-being isn’t really a primary thing that’s built into the

system instead getting you in and out as quickly as possible so that we can code that and drop a claim and bill insurance

is really still the goal regardless of the lip service paid to quality of outcomes wow so we’ve got um basically

it’s structured for a one item thing from the client or are the patients

seven minutes and a prescription basically from what i gather this has been structured just for the convenience

of insurance companies is that too inaccurate to put or if it is when did this type of structure uh

system structure come about because you know you look back on old shows or you talk to grandparents and stuff and they

have more of a doctors and health care providers didn’t seem to operate this way for the most part i don’t know when

the time period would be yeah and that’s when we look at the trend line you know

there are things that we should highlight with the introduction of the medicare and

medicaid services uh one of the things that i think most most folks aren’t necessarily aware of

they see it in their end bill but they don’t know the origins is going back to

the way that those claims were paid so prior to some of the legislation in late

60s early 70s time period when we’re talking about reimbursement rates you know those old school doctors that were

running you know local clinics would be billing for the actual services rendered and this is very similar to

what you see if you go to a veterinarian it’s pretty similar to what you see if you go to a dentist office where you you

don’t have the same penetration of insurance companies and you don’t have the involvement of the federal

government into that sphere to the same extent so what happens if you go to the optometrist

whether you have insurance or not is you end up paying a fee that’s

relatively similar to what that optometrist actually wants to charge you so if it’s going to be 50 for an eye

exam and that’s what they’re looking for basically they charge 50. within medical insurance one of the

biggest problems that we have is the contractual rates that are set by the

federal government are set by the federal government itself so instead of paying the full charges what they’ll do

is they’ll pay their percentage and they set and cap those rates themselves so you end up

with percentages that can vary state by state if you’re looking at a medicaid program and they can vary service line

by service line for medicare but the bottom line is this the bill will be for a dollar and they’ll say we’re going to

pay 30 cents on that so what ends up happening predictably is if you actually needed a dollar then you’re only getting

paid 30 cents you’re going to raise those prices you know three to four times the rate of course the other thing

that happens when you’re not being paid the full amount is you have to start compensating for that so if i have four

patients in an hour and only one of the four are going to pay that i’m lagging behind in terms of the revenue i need to

make you know i have three slots to fill in terms of actual patient payments in order to keep the lights on in my staff

so what i have to do then is i have to start becoming more efficient at the same time that’s happening we know

there’s a general push in society and the organization i was working for very clearly

had a push toward profitability over people it was much more of an organization run from a business

standpoint a maximization of efficiencies and profit opportunities as compared to

taking care of patients at the start so you have difficulties in terms of your reimbursement you have these

capital rates where the actual bill is for ten thousand dollars but uh federal

legislation says well we’re only going to cover to 1500 and all that is a write-off if you

do not have insurance of course you’re not looking at any of those contractual rates you don’t have any of the benefits

uh from those government uh determinations instead you just get those really high bills and that’s part

of the the situation you see with individuals getting these forty thousand sixty thousand eighty thousand dollar

bills well if you have blue cross blue shield may have a contract they’re not paying that percentage if you have medicare

they’re not paying that percentage and that’s part of where the numbers get so high and why you don’t see the same type

of behavior in a dental environment say you need a root canal it’s expensive

but you’re not going to walk out of their own 20 000 because the three to four that it may cost or if you’re lucky

last is actually the amount that they’re trying to to recoup um yeah i don’t think i’m really uh disillusioned uh

about the environment as a whole i think for me it was just a particular thing for the organization i was working uh

for that i didn’t like the way that they were conducting business the that system that healthcare system had

changes uh in the top leadership position within my time period we had a complete flip in terms of the

c-suite and the mentality that went along with that had changed so when i was first joining with the

organization there was a different mentality and more of a

patient-oriented concern and then that changed and refocused on the profitability and then things of that

nature so personally i still think there’s a lot of value a lot of good available in those systems but the board

has to appoint people and select people who are actually going to put patients first so

i still think it’s a good industry i just i think that it can be vulnerable to individuals running it for their own

their own headlines or their own uh personal well-being as opposed to the organizations that seems pretty common

with folks in your situation that yeah the leadership comes and goes and some are more conducive to

you know goodness well-being and actual care and health than than other leadership teams like you mentioning

before that seems to be a pretty common criticism across the board what are some

kind of fixes or solutions or maybe some right questions we need to be asking to

short of scrapping the whole thing which i don’t think is going to happen anytime soon or even be possible i mean if so it

would have to be some kind of bridge or transition so if if that’s something you

would happen to be for then yeah what would be kind of a transition what kind of uh solutions seem more obvious and

then maybe which ones don’t seem as obvious and then short term through long term i

think there are two things that jump to mind to me one is an item of personal responsibility

and possibility and that’s in the domain of diet and food availability just when

we look at the impact that diet has on overall health outcomes and well-being

for individuals we know that the links are there we know that the proper decisions uh in terms of diet and

what to eat what not to eat what kind of items we should be consuming has a tremendous end impact but we also know

that there’s pretty heavy involvement of the government and subsidizing the types of things that we shouldn’t be uh

we shouldn’t be eating so you know if you make you know your murder zero a list of all the things that are going to

cause you harm you’re going to have things that are ultimately all in some way subsidized from your you

know your corn to your cheese your high fructose corn syrup cattle ranches all of the things that

essentially taste really good and they create this just incredible plate for you when when you’re hungry but the

actual contents of it are not very good so we should be asking some questions about why our government uh props up so much of a

diet and so much of an agricultural system that is not beneficial for us personally as consumers i think you know

as our representatives the the government really should be looking for how can we

provide a healthier population how can we push things in a better direction within that you have questions of food

availability and equality you know we know when we get into socioeconomic status the lower you are

in that ses ranking the higher the probability is that you’re going to have a wider range of chronic diseases and

the less likelihood that you’re going to have good access to high quality food and nutrients so it’s

not a mistake that you see high rates of type 2 diabetes and metabolic syndrome

in poverty-stricken areas it’s a result of yes exercise but just as much the

quality of the food that’s available in the local environment so ron let’s say i’m your

gp your general practitioner and start talking about food won’t i just refer

you to a nutritionist i think from what i’ve seen that’s a pretty limited sphere of opportunity uh going

back to the the general uh structure of sort of rushing people through most of the food problems that we have

we have a correlated uh generic drug that’s gonna work for that so you’ve got your cholesterol you’ve got your blood

pressure drugs you’ve got your metformin for your diabetes that’s particularly more common what you

will typically see with a nutritionist is somebody who’s new to a particular disease a lot of times you’re going to

see that more limited to someone with like an onset of type 1 diabetes where you have to now regulate this blood

sugar and diet some of the autoimmune diseases you’ll have that opportunity sometimes

if you’re having dermatology issues then you can do some of the food sampling but it’s not a

particularly common thing for people to actually delve into other than just to say your diet should

be better but in terms of nutritionists i think that’s a great direction to go in and to have

those individuals available particularly because the the food itself is so complicated you know it’s easy to say eat a certain

way but we find very quickly because foods aren’t made of just one ingredient that

when you increase the amount of carbs you know and decrease the amount of fat then you got a problem with that or if you have to

keep low carbs then suddenly you’re looking at foods that are potentially going to have too much fat like

putting together a balanced diet is a challenge but it’s even more of a challenge when companies and local

organizations of local farmers things like that are competing against

others who have subsidies and so they’re not playing on a level playing field and then if you bring in some of the

difficulties that uh that may come in with having to use certain type of seeds

in order to qualify for bank loans we know that it’s not as easy

to to approach things on a large scale for that quality so i mean that that’s one

of the things i think is a is a potential where people can have more control um what i see

totally is and i was you know and i don’t know if it’s changed since i’ve heard last that doctors really don’t

spend much time uh receiving training and education on food and diet compared

to all the other things they train and study with yeah and that’s that’s really the case and and i’ll say

in the years that i worked in an emergency room and and i was present for

hundreds of evaluations uh because my role just kind of permitted me to be in in the vicinity uh and they’re just

there really weren’t conversations happening around food you know if somebody comes in for high blood pressure obviously they’re gonna say oh

you should watch your sodium but how to make that practical and how to push that forward holistically that’s

not really addressed i haven’t heard it addressed it’s not that there aren’t some physicians who are doing it the

problem is it just it takes a while to work through that plus you have to be you know kind of educated in that area

yourself and we know there’s the joke of course about the quality of hospital food and things like that where it’s

really not prioritized because it’s a reductionist model you know we’re not

we’re not trying to solve everything with kale it’s saying well we go down to the cellular level what’s out of balance

let’s put it back in balance and you know in all fairness this is not necessarily the medical profession’s

fault or you know they can give you advice on how to solve it but it really is is more of a question of politics uh

and an economy for you know citizens to ask our government why are you why are

you subsidizing this business inside of that business when this isn’t leading to healthy outcomes

what about the quality of the drinking water the air things like that i’m not sure if this is true or not i

heard it but i definitely i never bothered to fact check but i did hear that russia was focused on converting their

agriculture food from regular you know western style agricultural to an organic

agriculture within the next uh five to ten years and it was classified as a

national security issue because of the impact it has on the actual citizenry so i’ve heard that i don’t know if that

is true or it’s just something that i heard from someone who heard it from somebody but that’s a factor in how we uh where we’re

at when we go to the doctors in regard to things that i i think help

one of the trends that’s emerging from the medical field and seems to be growing is an increased uh use of nurse

practitioners and physician assistants that are overseen by attendings or a primary with

technical setting but don’t require the same level of schooling and the same investment up

front in order to get to that level and i think that’s a really good trend because for a lot of individuals access

to care is the primary issue you know and being able to

go through relatively simple things and have somebody there who can give them decent advice and and for many people

struggling with chronic issues from lifestyle choices and from medication elements they may not have

really had the opportunity to sit down and speak with someone about that in depth the more that we integrate nurse

practitioners and physician assistants who are well versed in the basics but aren’t

necessarily going to be making diagnoses on extremely complex cases the more opportunity there is for

healthcare to be available for everybody the model itself it does lend to a restricted number of end

physicians we know in any given year like right now we’ve just started another

term you know at all the medical schools we know that there’s a certain amount of applicants and there’s a there’s a

certain amount that’s accepted quite a few people would like to be doctors quite a few people apply to

medical school and don’t necessarily make it through and don’t qualify as physicians but that doesn’t mean that

those individuals weren’t capable of providing quite a bit in that domain and in that sphere but we’ve set up a lot of

somewhat arbitrary rules around how we do our training and what those requirements are in order to actually

produce a general physician you know someone who is able to just handle the

day-to-day uh you know and that is unfortunate because those restrictions into who can go to medical school and

how high you have to score on your tests and the types of residency programs and things you have

to do just to become a doctor some of that is pretty darn extraordinary when

you’re not necessarily going to be dealing with super complicated cases

day in and day out a lot of it’s going to be the same sort of thing over and over again you know when it’s flu season

this flu season when it’s a science infection it’s a sinus infection and when you’re diagnosing diseases and

you’re working within the you know pharmaceutical model oftentimes you’re just prescribing a broad spectrum

antibiotic and you may have not even been right about what you thought it was but since it’s broad spectrum you know

it works and and you get the good outcome so i think it’s a it’s a positive when we

start expanding the domain of health care practitioners whether it be nutrition is coming on board and being

connected to that in a better way or broadening the field of who qualifies

as a practitioner the food thing is very interesting and i’m going to restrain myself from the the gmo organic comments

but yeah it seems fairly obvious to me i was just curious how many did you have any nutritionists on staff there

at the hospital we had one and that individual worked essentially a per diem

type situation so if you were admitted to the hospital

really for onset of type 1 diabetes then you would set up an appointment with

this individual you’d fill out a 10-page questionnaire on your dietary habits and then she would have like one or two

counseling sessions with you to talk about monitoring you know your carbohydrates and watch out for simple

sugars and you know monitor the glucose and your a1 numbers keeping those in

good shape and things of that nature but um that was the often the extent of it they’re very

very few conditions other than type 1 diabetes would ever come in to see her

and there was only one person on staff and and she wasn’t there all the time if she had an appointment book and so if

there were appointments on tuesday she’d be there but it’s not as if that was a standard part of it to say

let’s do multi-dimensional rounding uh let’s have a team that can really interface with people on all

levels you know and it’s it it’s very expensive but you know if you were

uh on some kind of you know gold plan you know you’re you’re jeff bezos or something and you’re going into your own

you know private wing of the hospital you know they’re going to bring in a full multi-disciplinary team and you’re

going to have more there than just one position it’s it’s kind of like they’ll load up on

physician specialties so you can have a pulmonologist in there you can have cardiologists in there you can have the

hospitalist that has the admission is overseeing your stay and and they’ll stack those guys up

as much as they need to but some of the day-to-day things that actually are the building blocks of why someone’s sick

you don’t have that as much so you’re not going to have a nutritionist on those rounds you’re not going to have a physical therapist or

exercise physiologist like there’s not even really such a thing

within the medical sphere you have to be like on a sports team to have a doctor who’s there to also

help with your your physical stuff so you know those are things that they reflect personal responsibility but what

that ends up happening is the patient comes in you treat a portion of the illness control that to some extent

but you haven’t addressed anything root cause so then they’re going to keep on coming back and that works for the

medical system because again we want to treat one symptom for today we want to have a

visit for seven minutes that we booked for 15 and drop a claim and build that out for

and to be able to have a metric and a traceable outcome which you don’t really have if what you’re documenting is a

20-minute conversation about overall health and well-being plus in all fairness how many patients are actually

going to comply with those recommendations anyway you know you could have like the patch adams clinic where you know it’s we’re gonna

you know heal with laughter and we’re gonna do all these positive things what percentage of people are actually going

to benefit from such an open-ended environment what percentage would just simply list and say yeah then yeah it

sounds great and then not go and do it anyway in many ways the medical model

is around because it works if i just have to take a pill and that’s all i have to do yeah i might do that if i had

to change my entire lifestyle probably not great point seems so obvious once it’s thrown out there but it’s not not

on the forefront of many people’s minds that have to go visit doctors and whatnot i thought it was fascinating too

to actually kind of find out how the food industry and the subsidies

actually kind of intersect with the health care system because

trying to find our you know suss out the bolts and nuts behind you know how that

how that would work and of course a lot of this does boil down to the money and how much that affects everything the uh

i was just curious too about how how many staff members are on the physician side oh

um because i was just trying to get a reference point for like there’s only one nutritionist for how many you know

other um physician related employees oh yeah that that’s a good point yeah so it that particular location had about

450 beds so it would be one nutritionist for 450

potentially admitted patients uh plus the volume coming in through an outpatient environment which includes an

er so it’s it’s pretty stacked uh in terms of you’re talking a ratio of five

ten thousand to one uh in terms of opportunity to actually meet a patient

so that’s the physician number that tends to vary because

most of these organizations are working with physician groups that are external vendors so you’ll have a vendor

that provides ed physicians you know just like any other like a maid service where you know

i’m gonna have i know i’m going to have three maids here to help clean tomorrow i don’t know which three so i contract

out to make sure that i always have three positions available so that that comes up

it’s a good question too because you’re talking about ratios and you know what

number of patients is handled by any particular clinician and how much time does that provide you know a

physician in an er environment is usually going to carry 12 to 15 patients

at any given time and that’s assuming a normal level of inflow you know if we have a

you know really heavy fluid season or if there’s an accident nearby things like that obviously the number is going to spike but on a normal day you’re going

to be juggling 12 to 15 at a time the entire day and so what are your limitations there

we’re going to run some tests and see nurses are typically handling three in

an ed and up to 10 to 12 on a medical floor for admitted patients

higher number on the medical floor because they’re stable you know so if i work in a cardiac unit and i have eight

patients with all due respect to the individual eight people involved they’re probably going to be relatively similar

so we’re monitoring values we’re rounding and making sure that everything is okay but we’re not dealing with distinct new

things that are coming up so you’ll see a higher ratio of patients to individual

nurses but at the end of the day that ratio controls the staffing so if

we are going to have uh one nurse for every eight patients on the medical floor

then if we have 16 patients vetted then we’re going to have two nurses if we have

nine we were probably gonna end up seeing one and and they’re going to start fixing nurses out that

means that there isn’t the extra time so the time to actually go through and maybe do some of those more ambitious uh

things that a physician or nurse might like to and with that extra time i have to always remember that that extra time

is very closely and carefully accounted for and as soon as it starts to appear

they send people home to make sure that there isn’t any waste in that system and again that goes back to the efficiency

trying to max the profits and maximizing the profits goes back to the

capped rates that you see from government payers and it also goes back to some of the underhanded

techniques that insurance carriers on the commercial side like a uhc and blue cross

will do where they’ll authorize services and then not pay because they say something changed or wasn’t medically

necessary or they’ll set up systems that make it more difficult to get notifications to them so that they can

deny on technical merits to say we weren’t notified therefore even though our you know this

person came in they were in an automobile crash they were an anonymous patient because of the trauma

nevertheless you didn’t notify us so we’re not going to cover this day there’s an awful lot of money

healthcare providers lose that insurance companies keep in their pocket except

for of course the bonus that goes to the ceo that comes from games that they play in little schemes around authorization of

services patients don’t typically see that part of it because it is an internal battle between

the healthcare system and the insurance company and so when there’s a denial or

whatnot for an authorization issue or a partial denial it just gets written off but that write-off is a loss of revenue

and that loss of revenue then means you have less and less margin means you can’t afford to have doctors and nurses

not doing anything other than treating patients and treating patients in the strictly medical model now that we’ve

delved into a few things on the administrative side and covered the physician side what else in an overview

does the administration deal with and then i guess just in general how does the how does the board i guess

overseeing everything and the administration and the physicians where did they come into so i’m thinking maybe

there’s some of the standard hiring and firing practices anything that’s

outsourced versus in-house let’s see what are some other um just general

areas of the whole thing that haven’t been mentioned yet well you’ve got you know when it comes to the administrator

it’s a unique business model because the patients don’t ever come to see

an administrator you know they’re not there to see somebody in a back office they’re not there to speak a hospital

present they’re there to see a doctor and because of that the face of the business and the purpose of the business

is separated from the people who are supposed to sort of be making sure that it’s run well and

as a result there is bloat there there are incompetencies that come in because

the standalone business operation of how we would monitor those authorizations how we would pursue claims and

contracting and make sure that we are availing ourselves of our full legal rights those things are not necessarily

the top priority for back office staff so much as it is hey it’s a friday

afternoon yet and that happens because they’re not running an independent company patients are still going to

doctors doctors are still doing the best that they can but behind that it’s one of those things

where there’s a hole in the bucket and and there are a lot of missed revenue opportunities you know

the system i was working for we would see multiple mistakes made by individuals

responsible for securing authorizations and uh i could think of one employee

whose work i occasionally checked wasn’t in my department just one of the functions so i would see some of the

authorizations that she failed to do on admissions and and this one employee just on a handful of cases i randomly

audited uh cost the company cost the healthcare system at least two million dollars and that’s in actual payments

not just in what would have been charges driven down by a percentage and that’s one person so administratively when you

look at what is it we’re doing how are they handling it what’s the culture and expectation and

the standard for taking care of the business taking care of the patients

because there’s such a separation of whom we’re coming in to see versus who’s

actually handling the back end process and there’s a lot of people in that business that you wouldn’t come to see

they wouldn’t be able to run their own business and the model that they follow wouldn’t be successful so

that that’s something that’s a concern when you look at it from the inside is you know it’s bad enough that the

insurance company is playing games but you really shouldn’t be making it easier i never

really observed any significant difference in the quality of care in regard to internal versus external i

certainly have heard people with spousey opinions of you know like oh that’s this is a contractor group so they don’t care

much but if it was internal i don’t think it makes too much of a difference at least in my observations because

there’s such a high standard required for physicians you know to get through that training to get into that field

outside of a few with difficult personalities where that personality might interfere with care you don’t see

a drop off like you would in other areas where we’re outsourcing say our customer service isn’t going to be domestic it’s

we’re going to send it international and we’re going to give people funny names and nobody’s going to be able to understand sort of their accents

you don’t really experience that the pressures don’t change in terms of if you have a vendor say in

an er they’re paid per patient under most models so there’s some incentive to

cycle through patients as quickly as possible but the truth is how do you know if that’s impacting

their care if you had people in-house they would also be pressured by the administrator to see as

many patients as possible for the revenue so you can kind of look at that either way and say well hey they might

even be less responsive to that pressure because at least they don’t work for the

hospital that they’re actually stationed at so there’s nobody physically in their face that can be telling them hurry up hurry up so they can conduct their

business appropriately and then go back to their boss you know off-site and and sort of share that they did things as

they should so i haven’t seen that being a major thing i think the

the real challenge for the board of direct is to continue to push an evolution into

the reimbursement based upon quality of outcomes the quality of outcomes really is dependent

on the quality of care as well as those inputs and things that we’ve touched on in terms of personal lifestyle choices

of the diet exercise and making those more accessible as choices uh

for individuals who may not know the pathway or have the opportunity how can that be created

if we actually were looking at an environment where you were reimbursed for quality of care you know say at a

primary patient came in they had these three chronic conditions that can be influenced can be ameliorated uh

reimbursement rates going up uh from the the government sponsors as well as hopefully commercial carriers as those

numbers begin to drop that would be good that’s where they’re heading but it’s still you know pretty much still uh

coded off and then billed out just fee for service fee for service so

i think that’s you know from the political standpoint from the interfacing with the economic portion uh

continuing to put forth the idea that the more we can invest in holistic care

and going beyond just a strictly medical model the better outcomes you’re going to get for the patients and

understanding that it’s an area that both patients and probably physicians could use

additional educations of how to address things beyond you know having the

medication as your intervention for pretty much everything sure and i’m hearing this more and more and i think

the writing’s on the wall now and they’re starting to see the writing on the walls as far as more holistic

systems well thanks for doing this and is there anything else you’d like to leave us with no no i i don’t think so i

think it’s a it’s an interesting topic and you know i think we’re all very much concerned that we i think we get lost

sometimes in worrying about particulars of the insurance and what should be and should

people have it or not and you know there there’s a deeper uh need there just for how do we make

ourselves healthy and how do we benefit our community the best that we can and

looking for a model that is is based upon that and you know allocating the funds where they need to to be and kind

of making sure that we we balance out the the money uh that that’s floating

around there to make sure that we were able to do that we shouldn’t uh somebody who’s worked on the revenue side you

know it’s a little frustrating to see you like if you look at the stock value of a uhc unh trading going up you know

250 300 over the course of five years great and i know there’s acquisitions to it

but it’s not so great if you have those profits happening um that are coming from premiums and they’re coming from

non-paid bills to healthcare providers it’s not so great if it’s happening in an environment where patients are only

getting seven minutes with their physician where small rural hospitals are having to close because

they can’t afford to pay the bills and things of that nature so we have to be mindful that as much as we love

profit we need to make sure that the system works for everybody and because health

is so integral to our day-to-day experiences both for us and and for others as our health impacts

them that’s something that i look at and think we shouldn’t politicize as much as

we should just look at it and make sure that at the end of the day uh the health care system has the

needs to actually pursue quality of care uh because they certainly can’t do that if they’re not getting paid for the care

that they render indeed lots of great points thanks again for doing this all right thank you