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\u201cEvery time an insurance company calls me about a patient, they\u2019re telling me not to do something that I know is best for my patient.\u201d \u201cThere\u2019s a lot of inappropriate care that goes on. And so that\u2019s what insurers are trying to basically regulate.\u201d \u201cInsurance companies are making more and more money.\u201d \u201cThere is a business, and it\u2019s a very costly business.\u201d \u201cI don\u2019t want to work in a system that requires heroic effort to get to the appropriate outcome.\u201d [INTRIGUING MUSIC] \u201cO.K. Here we go. Do insurance companies prioritize profit over patient care?\u201d \u201cInsurance companies are making tens of billions of dollars every year denying you coverage.\u201d \u201cIt was like the insurance company telling me my life didn\u2019t matter.\u201d \u201cBreaking news \u2014 CEO of UnitedHealthcare care was shot and killed.\u201d \u201c41 percent of people aged 18 to 29 think the killing was either somewhat or completely acceptable.\u201d \u201c\u2019Sorry, my sympathy is out of network.\u2019\u201d \u201cThis incident and the reaction to it ought to be a wake-up call to this industry.\u201d [DRAMATIC MUSIC] \u201cDo insurance companies prioritize profit over patient care? I would say no. I think most insurance companies would believe that patient care is very important and optimal patient care is what they\u2019re trying to help deliver and that there are not going to be any profits if they don\u2019t take care of the patient. So I would say, no, they do not.\u201d \u201cGot it. I would say that, yes, they do prioritize profit over patient care. And I don\u2019t think there\u2019s anything wrong with making money in health care. When I think about finding the right point of balance, there\u2019s been a shift towards profit and away from this autonomous decision making for patients. I can think of some specific examples where I know what\u2019s right for my patient. And I don\u2019t even think it\u2019s more expensive. But an insurance company has told me, no, you can\u2019t do that thing. You can\u2019t do that type of breast reconstruction. And in most of those situations, it\u2019s really felt like that was about profit. When I look at what\u2019s happened over the last 13 years that I\u2019ve been in practice, insurance companies are making more and more money, and doctors are making less and less. And I see patients experiencing difficulties in getting care.\u201d \u201cWell, a lot of responses to that \u2014 one is that there is a huge increase in healthcare costs.\u201d \u201cAmerican healthcare costs are by far the highest in the world.\u201d \u201cWe spend two or three times what other countries do.\u201d \u201cThe number one reason why most Americans file bankruptcy is because of medical debt.\u201d \u201cAnd the insurance companies are basically hired to try to reduce those costs or try to keep those costs somewhat under control. And insofar as they do that, they\u2019re trying to make sure that the people who are insured are getting all the care that they need but no unnecessary care. And most of the drivers in the healthcare system, from an economic point of view, are drivers in the direction of doing more, spending more. That\u2019s the way people make money. You earn your living by basically doing procedures. So you\u2019re going to plan to do more procedures. And that\u2019s not to say that the procedures that you\u2019re doing are inappropriate. But at the margin, there\u2019s a lot of inappropriate care that goes on. And so that\u2019s what insurers are trying to basically regulate. But nobody really likes to talk about that much. Insurance companies don\u2019t like to talk about it because they don\u2019t want to be seen as the people who are denying care.\u201d \u201cI don\u2019t think that insurance companies should be in the position of policing bad doctors. I don\u2019t actually believe that there\u2019s that many bad actors out there in medicine. If insurance is there to control cost \u2014 when you look at it, one of the biggest waste sectors is the administrative burden and insurance.\u201d \u201cThe cost of administration is enormous to our healthcare system.\u201d \u201cMore than $260 billion are wasted on administrative complexity every year.\u201d \u201cInsurance companies aren\u2019t making health care any cheaper. And they say that they\u2019re protecting the public from fraud and abuse. I don\u2019t know that the majority of fraud and abuse in health care is on the side of doctors.\u201d [UNSETTLING MUSIC] \u201cThe biggest problem with our health care system is \u2014\u201d \u201cOh, the biggest problem. [SIGHS]: Lack of transparency. If we could only just really see the cost in real time, if we were able to budget our healthcare dollar with transparency, like Americans budget their dollar when they buy groceries, I feel like that would be a huge step forward. The fact that things are so obscured that it\u2019s not clear how to get an insurance plan, how to get a contract, if you\u2019re a physician, how much the procedure is going to cost, what is the rebate going to be on that medication \u2014 if we just had real-time market dynamics with transparency, I think we would have a healthier system. I wish that I could explain to you how healthcare pricing is set, but the truth is that it\u2019s all obscured.\u201d \u201cThe price for the same procedure at the same hospital, it varies enormously.\u201d \u201cThe same simple blood test, $19 over here, $522 just a few blocks away.\u201d \u201cThere just isn\u2019t transparency.\u201d \u201cDoctors don\u2019t even know what\u2019s happening with our billing processes.\u201d \u201cYou go out to eat at a restaurant. The price of food is right there on the menu. Why is it that when it comes to many medical procedures, we only find out the price afterward?\u201d \u201cI have started my own ambulatory surgery center, and I can see the costs there. Now I also see, because I can see the pricing, that the hospital has been overcharging four or five times what it\u2019s costing me to do these surgeries in an outpatient setting.\u201d \u201cWell, I think that\u2019s a very good point. And certainly, we have a nontransparent system. And there are steps being taken to try to make that more transparent.\u201d \u201cWe will have maximum price transparency, and costs will come down incredibly.\u201d \u201cWhen you can see the cost of care before you receive it, you can shop for the lowest-cost, highest-quality treatments, which will drive down the cost of care by promoting market competition in the process.\u201d \u201cLaws that have been passed and further proposals in Congress are bringing that about slowly. And I agree with that, that transparency\u2019s a real issue. From my point of view, the big problem with our healthcare system is access. There are just too many people who don\u2019t have access to good health care. And we continue to have a system that\u2019s very expensive and getting more expensive. Access, in many ways, was improving over the course of the last 15 years and now is taking a reverse turn. And there\u2019s going to be more people who are uninsured.\u201d \u201cLawmakers made deep cuts to safety net programs, including Medicaid.\u201d \u201c12 million Americans are expected to lose health insurance.\u201d \u201cAccess to care is \u2014 we\u2019re at a crisis point in America. When patients are paying 10 percent of their take home paycheck for an insurance premium and then being diagnosed with breast cancer and coming to see me and finding that you don\u2019t have an insurance product that has adequate facilities or doctors in network and that the premiums are so high or your copays are so high that you can\u2019t afford that care \u2014 it\u2019s getting harder and harder to get care through insurance. Insurance companies should have a say in what treatments patients receive.\u201d \u201cI think that most doctors would disagree with that, but let me try to make the case why they should have a say. If you think about it, there\u2019s a big group of people \u2014 maybe it\u2019s a big group of employees. Maybe it\u2019s us as citizens. Maybe it\u2019s us as the entire country. We\u2019ve all sort of thrown in together to provide a certain amount of money that\u2019s being put aside, and then that\u2019s going to cover the care for those of us who get sick. That community, since we\u2019ve all put our money off together for this insurance policy, that community really wants that money to be spent wisely. Research over the course of many years has outlined that there\u2019s unnecessary care that occurs. And we as a community wouldn\u2019t want to have the money go to that. So the insurance company gets the responsibility quality of policing that, of taking the steps to make sure that the care is appropriate. So things like prior authorization \u2014\u201d \u201cPrior authorization.\u201d \u201cPrior authorization.\u201d \u201cPrior authorization.\u201d \u201cYou and your doctor have selected a new medicine to treat your condition. But before you can fill your prescription, you may need your health plan\u2019s approval. It\u2019s a process known as prior authorization.\u201d \u201c\u2014 that\u2019s interfering with the relationship between the doctor and the patient, because they\u2019ve already decided that they want to proceed with this particular procedure. But the insurance company is coming in from the outside to say, does that fit the evidence? And they\u2019re doing that \u2014 it feels like the insurance company, but it\u2019s basically not the insurance company. It\u2019s basically the community of people who put all this money in together to provide care for people who are sick and who want to make sure that the care is being rendered appropriately and with the best medical evidence. So that\u2019s the way the insurance company would see it.\u201d \u201cI hear you. I think they would see it that way. I think I see it very differently. I think insurance is so important, first of all. As someone who does breast reconstruction, everything that I do is provided for under the Women\u2019s Health and Cancer Rights Act, which says that insurance covers your breast reconstruction if you have a mastectomy that\u2019s covered by insurance. So that has been life changing for women affected by breast cancer. So I agree. I think insurance can be a really great thing. And I think insurance is initially thought of where you have communities of farmers who put their money in a bucket and say, if one of us gets harmed, if one of us needs help, we\u2019re all there for each other, and we\u2019re going to draw out of that bucket. That is a beautiful ideal. It\u2019s not what we have in American insurance today. Every time an insurance company calls me about a patient, they\u2019re telling me not to do something that I know is best for my patient. I wish that when I, for instance, had a peer-to-peer call \u2014 Hello. This is Dr. Elisabeth Potter. Who is this?\u201d \u201cHey. This is Dr. Potter. So you\u2019re calling to ask me for reasons why she stayed in the hospital beyond the first day? \u2014 I wish that that call was with somebody who was qualified to talk to me about breast reconstruction. But it\u2019s so often someone who\u2019s never done that type of surgery.\u201d \u201cI did a peer to peer. That means I call the insurance company, then they transfer me to a physician. Now, this is supposed to be a peer, someone that understands sports medicine. Well, they put me in touch with a physician who was an internal medicine physician.\u201d \u201cThe doctor who called me was not a surgeon. And I actually asked the doctor, do you know what a DIEP flap is? And the doctor said no.\u201d \u201cThis is called a peer to peer, but you\u2019re not a surgeon. You\u2019ve never done a shoulder replacement. How are you the designated peer from the insurance company who literally has the decision to dictate whether this patient\u2019s care is going to be approved or not?\u201d \u201cThe ideal, I agree with. But in practice, I think that that trust needs to be built back by the insurance company.\u201d \u201cYeah, difficult to do, I think. There are going to be these conflicts. And that person who you\u2019re talking to on that peer-to-peer call when there\u2019s a prior authorization for procedures that you\u2019re doing, they should have consulted the literature pretty carefully. And they should be ready and able to talk with you about what your planned course is. And there are rules, and there are laws that oversee much of what goes on in prior authorization. And they have to adhere to those things. So it\u2019s unfortunate that your experience is that you\u2019re not seeing a lot of that. But from the other side, I can tell you that most of the people who are doing those peer-to-peer discussions feel like they\u2019re productive and it\u2019s just somebody who\u2019s basically sort of dug in on what they want to do as opposed to what the medical literature might say is the appropriate thing to do. I don\u2019t see how to ameliorate that situation. Well, I can take it to an empirical level and say, to somebody who\u2019s buying the insurance, like a big company, you tell them, we\u2019re willing to take away prior authorization, but it will cost 5 percent to 8 percent more in terms of what your total cost for insuring your employees are. They usually are going to say, let\u2019s keep prior authorization in place. In some ways, you can break it down into a set of marketplace decisions. And most people are opting \u2014 in fact, universally opting \u2014 to keep prior authorization in place.\u201d \u201cIt keeps coming back to money. As a physician, I just land on the side of, O.K., it may cost too much. You, insurance company, that\u2019s your business to sort that out. I just have to go to sleep at night knowing that I tried to do the very best thing for my patient. If it costs that much, you need a system that costs less.\u201d \u201cWell, I think you hit the crux of the matter, which is really that there is a business, and it\u2019s a very costly business, and it\u2019s a business that more and more people are finding that they can\u2019t afford. And that\u2019s not a good thing. You would agree with that. And that comes up hard against your desire to do what you think is right for your patient and sometimes coming into conflict with those who are trying to police what the costs are.\u201d \u201cI\u2019m a physician. I was a professor of medicine and law and public health at the Harvard School of Public Health and the Harvard Medical School for about half my career. And I was convinced that the healthcare system was not doing well simply because it cost too much.\u201d \u201cWhat is really going on with healthcare costs?\u201d \u201cInsurance companies are asking for big premium increases.\u201d \u201cIn my particular case, our premiums went up over 30 percent this year. How is that justifiable?\u201d \u201cAnd I felt like the only entities in health care that had responsibility for oversight of costs were the insurance companies. And so I made a big career switch in the middle of my career to go over and work on the insurance side, simply to attempt to address this problem surrounding the cost of health care. I loved being in the hospital, and I loved taking care of patients. So it was a big decision to decide to move over to the insurance side. And many people who I work with saw it as going over to the dark side, but I had great hopes for the kind of good that we might be able to do. A moment in my career when I had to make a decision that challenged my morals and ethics was \u2014\u201d \u201cOof.\u201d \u201cI\u2019m going to let you have that one first.\u201d \u201cOh, heavens. Well, I had one this year, I guess the one that sticks out in my mind quite a lot. I was called while I was in the operating room, performing breast reconstruction, by an insurance company. They didn\u2019t know the patient\u2019s diagnosis. They didn\u2019t know she had breast cancer. They wanted me to justify her overnight stay. This has become absurd. I chose to speak out. I posted a video that I didn\u2019t think would be widely viewed. It was. I got a phone call into the operating room saying that UnitedHealthcare wanted me to call them about one of the patients who was having surgery today, who was actually asleep, having surgery. It\u2019s 2025, and insurance just keeps getting worse.\u201d \u201cDr. Elisabeth Potter made national news for publicly calling out health insurance companies.\u201d \u201cVideo has now been viewed over 13 million times.\u201d \u201cMillions of people got a front-row seat to the bureaucratic madness doctors wrestle with every day.\u201d \u201cThis is exactly what is wrong with insurance companies.\u201d \u201cAnd the insurance company kind of came after me for that.\u201d \u201cUnited sought to discredit her and is denying coverage for her surgery center.\u201d \u201cUnitedHealthcare demanded she remove a video from her social media channels, accusing her of making false claims.\u201d \u201cAnd then it informed Dr. Potter that it wasn\u2019t accepting new surgery centers well before she posted any videos.\u201d \u201cThat was one of those moments in my career as a physician when I thought, to take care of these women, I can\u2019t just be silent. And it almost cost me my business. Being honest about the problems that I see for my patients and being outspoken about that, that was a difficult decision this year but also a rewarding one, like the hard things usually are.\u201d \u201cI would say that an area of the insurance company stepping in to stop care, the really hard cases over the years I worked at CVS Health, I would see those. But in most of the circumstances, the really hard cases, we end up erring on the side of the patient and the doctor and going forward with them. I would say that from a moral point of view, the biggest issue for me over the years was when I went to work for CVS, we had a big retail pharmacy. And it was all supposed to be part of health care, but we sold a lot of cigarettes. And how can you continue to sell cigarettes and consider yourself a healthcare company? And I thought I\u2019d be able to insist that we get rid of cigarettes when I first joined the company. And of course, that didn\u2019t turn out to be the case. So my dilemma over the years was, am I really going to eventually accomplish anything here? And how much longer do I struggle with it? So over the years, you continue to build the case for getting rid of cigarettes. And eventually, we were able to remove them.\u201d \u201cCVS will stop selling all tobacco products.\u201d \u201cIt will lose about $2 billion annually.\u201d \u201cBut in making the decision, the company said, we\u2019ve come to the conclusion that cigarettes have no place in a setting where health care is being delivered.\u201d \u201cIt does give, I think, a nice contrast to the perspectives that we have. When I\u2019m working in an insurance company, I\u2019m thinking of a big group of people. When you\u2019re taking care of patients, you\u2019re thinking about that patient right in front of you.\u201d \u201cWhen I\u2019m taking care of the patient in front of me, I\u2019m thinking about all of the patients who are in that same situation. And I\u2019m speaking here for all of the doctors who\u2019ve reached out and who want to be heard. O.K. Doctors perform unnecessary procedures because there is a financial incentive to do so.\u201d \u201cI don\u2019t think there\u2019s any doctors who tell a patient that they should have a procedure who are thinking to themselves, I know this is inappropriate, but I really would like to earn $500, $1,000, $1,500 by doing it, so I\u2019m going to go ahead and recommend it. On the other hand \u2014 and I know you\u2019ve been in practice for a long time, but I\u2019ve been around this healthcare system for 40 or 50 years now. And all the literature, including research that we\u2019ve done ourselves, would suggest that there are multiple motivations why people do things, but there\u2019s always an economic motivation as part of that. And at the margin, you can usually predict what\u2019s going to happen by looking at what the economic incentives are. And I hate to bring harsh, capitalist, market-based concepts into a discussion about patient care. But nonetheless, they\u2019re there. Our system is a fee-for-service system.\u201d \u201cFee for service.\u201d \u201cFee for service.\u201d \u201cFee for service.\u201d \u201cDoctor says I did the following things to the patient. And the doctor then sends that bill to the insurer, and the insurer pays it. There\u2019s an incentive for the doctor to do more things to the patient than necessary.\u201d \u201cThe more patients you can get through the hospital, in and out of the operating rooms with efficiency, the profit is higher.\u201d \u201cPeople make more money by doing more things. And so more things happen. I don\u2019t want to say that doctors do things inappropriately just to earn money. But I do want to say that there are financial incentives that are driving behavior. So I hope that that\u2019s a reasonable distinction.\u201d \u201cYeah. I think it is. I think that we don\u2019t have nationalized health care. We don\u2019t have socialized medicine. We have a business of health care in America. So of course, of course incentives can influence anyone to do things. But do I think that physicians on the whole make decisions based on finances, like treatment decisions? No, I do not. And I think that my medical license is on the line there. So I will say that if you\u2019re going to trust an entity, I would rather put the treatment decision in the hands of the doctor who has taken the oath to care for the patient rather than the company who has a fiduciary responsibility to shareholders to maximize profits.\u201d \u201cI agree with you completely. And that\u2019s why for years, I\u2019ve preferred an approach where we use value-based or managed care.\u201d \u201cValue-based care.\u201d \u201cValue-based payments.\u201d \u201cInstead of reimbursing physicians for each individual service they render, value-based care ties reimbursement to the quality and effectiveness of the care provided.\u201d \u201cWe basically take a certain amount of money for each patient and assign that to a primary care doctor and the patient. And then the primary care doctor is responsible for making sure the patient gets all the care that\u2019s necessary. When that patient needs breast surgery, for example, that\u2019s a discussion between you and the primary care doctor. Now, that\u2019s a sort of fabulous world that we\u2019re never really going to have. But I would much rather leave those kinds of decisions about what\u2019s necessary in the hands of the doctors. And I think a value-based approach, as opposed to a fee-for-service approach, brings the appropriate incentives to do that. There are two options available for surgery. One option costs $10,000 and is adequate. Option two costs $30,000 and is far superior. Which one should an insurance company cover?\u201d \u201cI love this. So immediately, my mind goes to, what\u2019s our time horizon? Who\u2019s thinking about the lifetime of the patient? So, for instance, implant-based reconstruction in the setting of radiation for women who have breast cancer, super high complication rate, super high failure rate. In fact, Medicare spends more money on implant rework than they do on natural tissue reconstruction. Natural tissue reconstruction is a really high upfront cost, but very high satisfaction and longevity and fewer complications long term, cost less long term. So which thing should the patient have? Number one, I think it should be the patient choice. I think that if a patient wants, in consultation with their physician, to have a certain type of surgery, that it should be not about the money but about the outcome that they decide is best. But if there are two truly similar options, but one is more expensive and has a better outcome, I think that what we\u2019re seeing is sometimes insurance companies seem to be making decisions that are kind of shortsighted that think of the patient only in the term of their policy. As a physician, when I\u2019m talking to a patient, I\u2019m thinking about how they are going to live with this surgery for the rest of their life. And so I would invest in the surgery that has the better outcome long term.\u201d \u201cThat\u2019s interesting you say that. I think the question is \u2014 this was like you got something that\u2019s adequate, but then you got something that\u2019s far superior that\u2019s more expensive. And the history of the American healthcare system is that if it\u2019s far superior, we redefine the standard of care, and then that standard of care is what has to be adhered to. So the insurance company is really not stepping in to define the standard of care. The standard of care is really defined by the physicians themselves and by the medical establishment. So in many ways, I think that the harder question is really the one you raised at the end, which is, how long does the insurance company really care about these things? And that\u2019s one bad thing about our system of insurance in this country, is that a lot of it\u2019s based on employment. And that might have been appropriate when that first began to occur back in the 1940s and 1950s, when people stayed with the same employer for 15 years. But now people your age, for example, they spend a little less than two years with any one employer. So no one has the long game in hand. But having said that, the insurance company\u2019s nonetheless basically structured upon the standard of care. And if the standard of care is that this particular procedure is superior, that\u2019s the one that they\u2019re going to have to pay for.\u201d \u201cYeah. I think in practice, though, I see insurance companies telling me to do inferior surgeries. So, for instance, a patient had breast cancer on one breast and had advice from her breast surgeon to have bilateral mastectomies. And that was well supported in the literature as a risk-reducing surgery. And her policy did not support having a contralateral mastectomy. We really had to fight to get this insurance company to live up to the standard. But the insurance company said, we simply don\u2019t cover contralateral mastectomies. I do see insurance companies, in practicality, I see them telling me what surgeries I can and can\u2019t do.\u201d \u201cThat\u2019s unfortunate. I hope it\u2019s not an insurance company I worked for. But be that as it may, most of the major insurance companies have very clearly stated clinical practice bulletins about what\u2019s acceptable care and what\u2019s not going to be paid for. That\u2019s meant to be very adherent to what is the existing standard of care. So if you went to the American Society of Plastic Surgeons and asked them what the standard of care is, that standard of care should be part of what you find when you read the clinical policy bulletins that the insurers have. So that\u2019s a bad case that you\u2019re talking about. But I would say for most insurance companies, it\u2019s not going to pay for them to have a clinical policy that\u2019s outside of the standard of care because those cases would all be overturned, and you\u2019d just have wasted administrative costs.\u201d \u201cThey\u2019re not always overturned, though, because so many denials aren\u2019t appealed. Applying resistance to the patient and the physician often does result in that treatment not happening. You\u2019re talking about women who are at their lowest moment. They have no energy. I\u2019m the only person. Like, I\u2019m meeting them, and I\u2019m saying they\u2019ve denied it, but I\u2019m going to do my best. And I\u2019m going to spend literally a year trying to get this done. There\u2019s so much wrong with that. I don\u2019t want to work in a system that requires heroic effort to get to the appropriate outcome. I want to work in a system that is so well-designed and so intent on doing the right thing for the patient that it\u2019s easy to do the right thing, not hard. So this process of iterative appeals and conversations, it\u2019s so cumbersome. And it\u2019s one of the things that\u2019s driving physicians out of medicine.\u201d \u201cGrowing problem of doctor burnout.\u201d \u201cMany contributing factors to doctor burnout, but a big one is the prior authorization requirement of many insurance plans.\u201d \u201cYeah. It highlights a real point of pain in the system now.\u201d \u201cYeah. I agree with you about that. There\u2019s tremendous pain in the system. But I wanted to go back to what you said. With your patients, I\u2019m presuming that if you feel like it\u2019s necessary, you do go ahead and make every effort to try to get that done. You actually go ahead and appeal and go through the prior authorization process.\u201d \u201cWe do all of it. And I employ two people full time doing that.\u201d \u201cGenerally, I\u2019m here to support what it is insurance companies do, but they don\u2019t take into account your costs on your side of putting together the materials that are necessary to get the prior authorization done. And at least in this day and age, one would hope that much, much more of that could be done through a digital electronic process than to have you have to have two people who are basically pulling records and going back and forth.\u201d \u201cThank you. The best way to get healthcare costs under control is \u2014 that\u2019s a good one.\u201d \u201cAt least from my point of view, the only real way to get healthcare costs under control is for the government to basically name what the rates of payment are going to be. I don\u2019t see much of a future for what\u2019s called commercial insurance, simply because I think the costs are rising fast and are going to continue to rise. To put it in perspective, today, in most hospitals, a commercial insurance company will pay three times as much as Medicare pays and maybe four to five times as much as Medicaid pays for the same procedure. And so I believe that eventually, the government will have to name what those prices are going to be in order to get the costs under control.\u201d \u201cI think that the best way to control costs in health care right now would be more competition. We have seen the near decimation of the independent provider. So previously, 75 percent of physicians were independent, and now 75 percent are employed. It\u2019s becoming so difficult for the small practices to exist and to compete with the larger, consolidated practices.\u201d \u201cWell, the insurance industry is consolidated. So the healthcare industry has to consolidate so they can compete with them. Basically, this ends up driving up prices.\u201d \u201cWhen there\u2019s less competition in a marketplace, prices go up.\u201d \u201cWe need to create a culture of healthy competition in health care. And that\u2019s very American of me, right? Competition brings out the very best in me. And I think that doctors know best what their patients need. And if you simply allow for doctors to do things like I\u2019ve tried to do, to build a surgery center, to have a small business that thrives on their main street \u2014 right now, we have what looks like a monopoly. And I would love, instead of going to the government being in control \u2014 and Medicare has \u2014 there are lots of problems with that system. I would rather see more independent providers so that the consumer, the patient, can shop more.\u201d \u201cI think those are both good and appropriate sentiments, but just take a different point of view. The reason why there aren\u2019t as many independent practitioners anymore is because if you join a hospital, you can get paid more because the hospital has a certain amount of market power and, as a result of that, negotiates for better rates for the physicians. The hospitals realized that as they got bigger, they were able to exert leverage vis-\u00e0-vis the insurers. And today, in most metropolitan areas, you have a lot of concentration of the insurers, but you have much more concentration of the large hospitals. And that\u2019s why the hospital rates have increased so much more dramatically than have the rates that are paid by government. So those market incentives are basically what\u2019s sweeping up the individual private practitioner. So there is something that\u2019s very attractive about the situation you have where you\u2019re an independent person. You\u2019ve got consumers choosing to come to you, and you\u2019re providing good service for them. And you don\u2019t want to have a boss from the outside telling you what to do. And that\u2019s admirable, and in many ways, it\u2019s very American. But the sweeping forces of the market in health care over the course of the last 30 or 40 years are just blowing that away. So I don\u2019t see it going back to an era where we\u2019ve got a lot of private practitioners and choice by consumers. But I could be wrong.\u201d \u201cYeah. I hope you\u2019re wrong. And I think it has to go back.\u201d \u201cThe Affordable Care Act was beneficial to the health of Americans.\u201d \u201cAbsolutely. No doubt about it.\u201d \u201cWe are done.\u201d [CHEERING] \u201cPre-existing conditions, I mean, yeah, definitely beneficial.\u201d \u201cTens of thousands of uninsured Americans with pre-existing conditions will finally be able to purchase the coverage they need.\u201d \u201cI mean, more access for more people, I\u2019m a huge fan.\u201d \u201cToday, almost 50 million people have gotten quality affordable health through the ACA, and the percentage of people without insurance has been nearly cut in half.\u201d \u201cI\u2019m not a huge fan of some very specific things about the Affordable Care Act. And the number one would be the limitations on expansion of physician-owned hospitals.\u201d \u201cDo you know physicians aren\u2019t allowed to own hospitals? This was part of the Affordable Care Act.\u201d \u201cIf you\u2019re going to let UnitedHealthcare own hospitals, if you\u2019re going to let private equity own hospitals, why don\u2019t you let physicians own hospitals?\u201d \u201cI\u2019m not all about making money. I\u2019m literally the least wealthy plastic surgeon you will ever meet. I take everything Medicare and Medicaid. I do surgery for free. I am in this for the karma. And my karma bank is full. So I am a huge fan of expanding access. But I also want to be free to be my best. And I don\u2019t like it when the government tells a physician you can\u2019t own a hospital. That\u2019s like telling a baker they can\u2019t own a bakery. You think that I\u2019m going to cherry pick patients? No. I\u2019m a doctor. Trust me to doctor well.\u201d \u201cWell, the physician-owned hospital issue it\u2019s obviously one that\u2019s very important to you, but a relatively small issue in health policy. But I would just say I think that much of the reasoning underlying that \u2014 and I\u2019m not sure it was good, and it looks like the new administration wants to change things in that regard. But they were worried about physicians taking the cases that make a lot of money out to those centers and leaving the hospitals basically impoverished. But putting that aside, I was very impressed by what you said. The Affordable Care Act is usually associated with expansion of Medicaid \u2014\u201d \u201cThe Affordable Health Care Act expanded Medicaid to cover additional 20 million people \u2014\u201d \u201c\u2014 and creation of the exchange insurance markets.\u201d \u201cThese exchanges will be a marketplace where individuals, families, and small businesses can purchase health insurance.\u201d \u201c\u2014 both of which greatly expanded access to health care. And that, I think we can agree, is a wonderful thing. But what you said about preexisting condition, that was a critical change. And it crystallized what I thought was an enduring change in the way in which Americans looked at things, that you shouldn\u2019t be able to deny care. And insurance companies could for many, many years. You could deny an insurance policy for somebody who had a preexisting condition. And the ACA wiped all of that out. And I thought that was like evidence that our healthcare system was finally becoming a really humane thing. So I\u2019m greatly saddened to see the changes that are occurring right now.\u201d \u201cPresident Donald Trump officially signed the controversial One Big Beautiful Bill Act.\u201d \u201cMore than 5 million Americans could lose Medicaid because of newly passed work requirements.\u201d \u201cTens of millions in the United States will see their health insurance costs soar, pricing many out of healthcare coverage entirely.\u201d \u201cWe were improving access, and it was crystallized by this let\u2019s get rid of the pre-existing condition clause. And now I see it sort of turning backwards. One easy fix to improve the healthcare system would be \u2014\u201d \u201cPoint-of-care pricing. Again, with the market, I want us to know what we\u2019re spending and what went on. When you go to the doctor, I want to know exactly what this costs, what I\u2019m paying, period, so that I can shop.\u201d \u201cI was going to say transparency because you had raised that before. And it should be an easy fix, right? It should be the kind of thing where the government can insist, as they have, that everyone make their prices known. And that\u2019s going to inform individuals. Most people have no good idea about how much health care costs. I do some writing about cancer and cancer drugs. And the administration\u2019s now talking about we\u2019ll give everybody $1,500 in an HSA and \u2014\u201d \u201cPut extra money straight into the Health Care Savings account. You go out and buy your own health care. Let the money go directly to the people where they can buy their own health care.\u201d \u201cAn average person who has multiple myeloma is on two or three drugs, each of which costs over $200,000 a year. So they just have no sense about what the costs are associated with our healthcare system. And I think transparency, like you said, point-of-care pricing, would be a great thing. And I think that most people in the insurance industry would agree with you on that one.\u201d \u201cAwesome. Oh, O.K. Over the course of this conversation, I have changed my mind about \u2014\u201d \u201cI always struggle with physician complaints about what insurance companies do, simply because in a lot of circumstances, I think the physicians are used to doing these things, and they want to do these things. And they\u2019re not willing to listen to the insurance companies outline that this is not part of the standard of care and this is an unnecessary cost. So I tend to think, because my last 15 years in work were in insurance companies, the insurance companies are trying to be reasonable, but the doctors just aren\u2019t. But then to meet somebody like you, who\u2019s obviously a very reasonable person and someone who\u2019s clearly and transparently committed to her patients, it makes me reconsider some of the issues, some of the more policy issues surrounding these kinds of things that insurance companies do, like prior authorization. So I really appreciate that.\u201d \u201cThank you. I think likewise. Sitting across the table from someone on the insurance side, if you will, to hear that there are humans on the other side, trying to reach the same goal, that gives me hope. So I\u2019d say if there was a part of me walking into this conversation that was feeling very tired and like, are we going to get somewhere positive? Are we going to change health care? Then that part of me is a bit changed. So I appreciate that very much. You definitely \u2014 I needed this conversation. And I hope that there are more to come.\u201d \u201cThank you. So did I.\u201d \u201cIt wasn\u2019t so bad.\u201d [INTRIGUING MUSIC]<\/p>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"
\u201cEvery time an insurance company calls me about a patient, they\u2019re telling me not to do something that I know is best for my patient.\u201d \u201cThere\u2019s a lot of inappropriate…<\/p>\n","protected":false},"author":1,"featured_media":8413,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","enabled":false},"version":2}},"categories":[7],"tags":[1316,491,1590,9139,727,9138,57],"jetpack_publicize_connections":[],"yoast_head":"\n