[00:00:00] Kip Theno: Welcome to the Road to Care podcast hosted by SamaCare, where we will talk with key opinion leaders, physicians, administrators, manufacturers, venture capitalists, and legislators to get their insights on the state of health care today and where we see it evolving. SamaCare's prior authorization platform is free to clinics, ensuring patients get on the right therapy at the right time.
[00:00:20] Together, we can simply make things right.
[00:00:27] Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. Today our special guests are Nancy Ellis and Stacy Yonker. Nancy is an MBA, MHA, CHE, CRHC, CRMS, and CPMA. Nancy is a practice administrator at Piedmont Arthritis Clinic, a rheumatology practice, location in South Carolina.
[00:00:50] Nancy has over four decades of experience in healthcare administration across rheumatology, oncology, and orthopedics, and across private practice, hospital and home care settings.
[00:01:00] And Stacy is an MBA,CMPE, LSSBB, CRCMP, CRMS, and CMPM. And she is Chief Executive Officer at Sarasota Arthritis Center. And as CEO of Sarasota Arthritis Center, she has over a decade of experience in rheumatology.
[00:01:19] Currently she oversees all operations of the multi location 14 provider practice and Stacy and Nancy, super excited to have you today. How are you?
[00:01:27] Nancy Ellis: Thank you, Kip. We appreciate being asked and are excited to have this time with you today.
[00:01:34] Stacy Yonker: Happy to be here. Yes. And hopefully we can bring value.
[00:01:37] Kip Theno: We are glad I was super excited for this one because I know there's going to be some fireworks, some ground rules, keep the gloves up, no rabbit punches.
[00:01:45] We'll come out swinging. But first of all, Nancy and Stacy, thank you for joining. And I would love to start with your journey into healthcare and maybe Stacy will start with you.
[00:01:54] Stacy Yonker: Sure. A little over a decade ago, I by trade was in hospitality industry. So I have a love of people, and taking care and serving others.
[00:02:05] And I found my way into healthcare through Sarasota Arthritis Centers. I started as a patient care coordinator. So kind of dipping my toes and I just had a love of taking care of patients and getting them treatment. And rheumatology grew on me. I'm still init. Over the years I have just worked my way up, been biologics coordinator,I've been in billing. And, I just have a love of the rheumatology field in particular and patient care.
[00:02:37] Kip Theno: Well, thank you, Stacy. Nancy, how about your journey?
[00:02:41] Nancy Ellis: Well, my dad was a general practitioner. My mom was a nurse anesthetist. And growing up, there was never really any question in my mind that I was going to be in healthcare.
[00:02:50] It was just going to be what was I going to do? Growing up in East Tennessee in Sevierville at the time when I was little, I can remember seeing my dad pack saddlebags to go up in the mountains to take care of patients. And I remember, we would be paid with quilts or eggs or fish or whatever.
[00:03:09] So my introduction as to how healthcare process went may be a little different than a lot of other people's. I ended up going to graduate school because I learned pretty quick that I was good at managing the processes around things, but not the patients themselves. Then I worked in hospitals for a while when we moved here to SouthCarolina, I decided I wanted to work on the physician side of it and worked a little bit in oncology, worked a little bit in orthopedics, and then have found my home, I think, in rheumatology, I've been here for the last 16 years. I hope to retire here.
[00:03:52] Kip Theno: Wow. Well, thank you.
[00:03:54] And by the way,Nancy, I do think at some level we should go back to the barter system, right?Chickens, eggs, whatever, but we might get to that later, but I remember in our pre-show we had a profound conversation. You both shared with me your personal experiences, not only as healthcare providers and caregivers, but also as patients.
[00:04:12] And I think that's critically important. I was really moved by both of your stories. Can you talk about your experiences as patients and how do those experiences help you and inform you in your roles as providers? And Stacy, I'd love to start with you.
[00:04:25] Stacy Yonker: Sure, of course. They say there's a big tie between life changing events.
[00:04:31] I had been working at Sarasota Arthritis Center, for a couple of years and I had, at the time recently had a baby and after I had my youngest child, I started to develop symptoms, that were autoimmune related.
[00:04:46] And of course it was excellent. I worked where I needed a consult and I ended up developing psoriatic arthritis with some overlapping of Sjogren's. And to be able to workin the environment to know what the patients go through was extremely eyeopening for me and it really shifted my mindset on the importance of the patient experience and patient care.
[00:05:14] Because myself, it's scary to be told that you may have a really bad joint disease and you may not be able to work in the future. And so you're just hoping that you can get on medications that are going to prevent that, to ensure that you have that quality of life. So I can be there for my kids.
[00:05:32] Being in that space having to wait for the calls from specialty pharmacies and being told by my doctor that, "hey, this is the medication we want to put you on, but, your insurance says no. So here's the second choice." We really you look to your provider for the answers and to get on the treatment that is the best for you.But when your insurance is third party person that is, they've never met you they've never spoken directly to you starts to mandate what treatments best for you. It's very eye opening. It's very frustrating.
[00:06:07] And so it made me that much more wanting to fight for patients to have access to the treatments they need. And it's, shaped the way I operate today.
[00:06:17] Nancy Ellis: Yeah, I agree 100% with you,Stacy. I found out my family has a history of rheumatoid arthritis as well as ankylosing spondylitis but I was like, "Oh, yeah, that was in them. That's not going to be in me" kind of a thing and trying to figure out why I was hurting. Was it just because I was getting older? Is this normal? Arthritis is what it was. Then thinking back like all the times before when, very innocently, I would go, "oh, well how do you know when they fill out a rapid three, whether it's their RA, or whether it's their stove up from gardening kind of a thing."
[00:06:51] And I'm like,"oh, you know." Because now, now I've experienced, I know, you know, that difference kind of a thing and knowing all the things that I know from the administrative side, it was a odd journey for me when I started out in this as well, because having to work with the specialty pharmacy and work through the different layers of calls and know the right questions to ask and know how to say things to be able to get passed on to the next person.
[00:07:19] Average patients don't know those kinds of things. It was a difficult process for me and I workin it. I can't imagine what it's like for somebody who is just, they're scared and this is a completely foreign unnecessarily, in my opinion. complex system.
[00:07:38] Kip Theno: Thank you, Stacy, Nancy.
[00:07:39] And to that point, you did touch on something about all these choices and when patients get switched on medications, or maybe it's not the one initially prescribed and there's all these new innovations and new biologics coming out, and you've talked about this, choices should be a good thing, typically.
[00:07:54] You would think that's the case. The system gets so riddled with complexity, and Nancy, I know you really hammered this before, what is going to help solve that problem for the patients? And you guys are patients, so am I. Is it legislation? I mean, did the Affordable Care Act solve anything?
[00:08:10] Or, Are we just off target? What are your thoughts, Nancy?
[00:08:15] Nancy Ellis: I know when the Affordable CareAct first came out, I remember being really angry and thinking it wasn't going to be a good idea because what was the famous quote of , "you have to pass it so you can know what's in it." Or something like that.
[00:08:29] And I remember thinking, this is no way to do this, but I think over time, it at least opened up access in some ways. I mean, it had unintended consequences as well, and it changed our commercial insurance markets a lot. But I think overall it, it was a good thing. I think, this is all a process and you can have legislation and you can have regulations, but they need to be things that can be in place for more than the four years of one presidency or eight years of one president.We've got to know that you can depend on this is how it's going to be.
[00:09:06] A lot of the things that are happening are, in my opinion, abuses of the system. Stacy and I are both part of an organization called National Organization of Rheumatology Managers (NORM) in one of our speakers a couple of years ago, talked about a ERISA plans and they were like, did you know that in a ERISA plan, these things apply?
[00:09:27] And I think everybody in that room, we're just looking at one another going "no, we didn't know that the ERISA statutes could overlay the contractual statutes that you had in your contract that ERISA would win." And, there were a lot of protections out there that we had for billing and for our patients that we never even knew we had.
[00:09:47] And I think that the health insurance business out there does that on purpose, and makes it unnecessarily complex and they're not forthcoming with information. They're very much spin doctors with what they want you to focus on versus what is really the problem out there.
[00:10:08] Kip Theno: Yeah.
[00:10:08] Stacy, any thoughts to dovetail on that?
[00:10:11] Stacy Yonker: I 100% agree with Nancy. When we were hearing about like the ERISA plans, for example, I know my mind was blown and it just shows you how non transparent our healthcare system is. And it's so interesting because anytime there's a frustration with patients getting them treatment, there's some new regulation or we're not allowed to do this, you can't do that... Doctors, can't be just a clinician. Everything always ties back to the insurance, the payers, they have control. And with that control, it is detrimental to patient care. So I completely agree with Nancy's take on the situation.
[00:10:56] Our healthcare system should be focused on the patient and unfortunately it's not. We have it backwards right now, but hopefully, we can make an impact and make a change.There is a lot of push for legislation and there's a lot of organizations, of all different specialties rheumatology, GI and neurology and other specialties where, they are coming together to try to help make these changes.
[00:11:22] And I think we can do it if we band together.
[00:11:26] Kip Theno: Yeah, and I think you both know we had Christine Mann on the podcast, and she had talked about being up on Capitol Hill, and they were very receptive, they wanted to learn, they were engaged.But then if you think about that institutional knowledge that you two have,Christine had mentioned they were still thinking of infusions, as an example, just focused on oncology. Well now that's absolutely not the case if you just look at the infusion market and neurology and cardiology now and behavioral health and rheumatology. So clearly if we think with the premise that legislation works at a glacial pace and is not the silver bullet, then Stacy, what do you rely on?
[00:11:59] What is your practice or what are you doing to help deal with the complexities and combat the pain points with payers?
[00:12:07] Stacy Yonker: Yeah, I'll tell you, it has not been easy. It's been a long road and I think the road is going to continue on for many years to get to the ideal point if we even get to it.
[00:12:19] But we really had to refine our practices, at least in my practice, where, you have a very strong, strict system and things that we have like set appeal letters and different processes. We do utilize. some data software programs that help give us kind of real time feedback on claims and where they are in the appeal process.
[00:12:44] And it does help streamline, to try to get either denials overturned or, an appeal process in a timely fashion, or for us to follow up with the payer. Because a lot of times you can't rely on them to say, "Hey, by the way, you appealed 60 days ago and you're approaching the limits still hanging out there. Make sure you callus." They're never going to do that. They put a 100% of that onus on the practices that are already inundated. We can only have so many staff, right. So we have to find ways to be able to track what we're doing because everything again comes back to patient care. And if we can't get them get them approved for treatment, or, we administered an infusion and now the insurance is not covering it, it always affects the patient. So I do think technology is crucial going forward, but there's so much legislation right now that until there are also changes on the payer level, like there's delinking of PBMs from profits for certain things.
[00:13:50] I think that would be a huge help to the system. It's definitely going to be a struggle, but datais important, is the way, because if you don't know what you don't know, you know, then how can we take steps to improve it?
[00:14:05] If we don't know what's happening.
[00:14:07] Kip Theno: Stacy, you talk about data: Stacy and Nancy, what types of data, where do you get that data and how do you use that for the benefit of the patients and maybe productive and proactive conversations with payers to affect change?
[00:14:20] Stacy Yonker: Our practice, we utilize organizations like MGMA, they have a revenue cycle dashboard, they have data dive where people can provide for benchmarking.
[00:14:33] For E and M codes, for example, especially if you are a Medicare provider, you're always looking out for big brother and it's like, where do we fall? Are we coding appropriately?
[00:14:44] And, should we be changing the way we're doing things. And especially with legislation where payers can control, they're trying to force you to downcode, so you can get hit if you downcode, but then you can get hit if you upcode. So, it puts us in a really tight position because all the doctors want to do is just see their patients.
[00:15:03] They want to treat them. They want to help them. And the payers make it incredibly difficult to do that. So if we are able to have data, for example, like MGMA's dashboard, which we use in our practice, they provide the national benchmarking. So if I'm looking at what my providers are doing, I can compare it to what other practices are doing, and even Medicare themselves offer this kind of information so that you can see where you lie.
[00:15:31] None of us want to be an outlier because that obviously always poses a risk to the practice and you. Part of our jobs as managers is to reduce that risk while optimizing patient care. And there's definitely a lot of organizations, especially in rheumatology, that are really trying to provide more data and make it more readily available so that practices can use it to combat the payers.
[00:15:57] Kip Theno: Yeah.
[00:15:58] Nancy, how about you?
[00:15:59] Nancy Ellis: Well, I'm just sitting here shaking my head to everything that Stacy was saying. Right now when we think about data and healthcare, a lot of times we think about what we have to provide through the MIPS and MACRA, the required programs and the registries that are out there for those things, but the reality of the world, while that may be what we have to do on paper to satisfy and check a box with the federal government for that quality data, those measures there are not useful in the true taking care of patients. They are yes/no kinds of questions. They're just not helpful And how do you move the ball? And how do you move your practice to be a better practice? So data has two stories to me. It's you have the data that you have to provide to meet your regulations or legislation or whatever out there, the regulatory stuff, which would be my MIPS and macro the registries, all of those kinds of things.
[00:16:57] And then I have the data that we can get to. And some of it we have the ability to do in house through our EMR, we're able to pull different reports and look at things. But then we've also worked with our GPO and they are working with a company called TRIO. And TRIO is able to come in and they look at a lot of different data points in our system.
[00:17:18] And they're able to compare our stuff to other people who are with that GPO that are also on TRIO.And so we're able to see similar practices, even in our state to similar practices in a region, similar practices in the country, be able to start seeing that. And so we know what we're being judged against.
[00:17:38] And so if I'm looking at it and I'm like, Oh, their time to get somebody onto infusion is maybe two months and mine's six months. What are they doing differently? What can I do to look at that? What are the processes and steps in place that they have that help them get to that therapy faster?
[00:17:54] Stacy Yonker: Absolutely. I 100% agree withNancy. I'm also familiar with Trio Health and there is a really great thing that it does. For example, in gout patients, they can track gout and patients that may potentially be under-treated. Data should be used to help patient care or to get them to a better quality of life and not just be seen as something that we are required to do.
[00:18:22] Otherwise Medicare is going to takeaway some of your reimbursement, forcing clinicians and practices to report with threatening to take away money. That is never going to have a positive effect on patient care. It never will because now practices are just going todo it just to check off the boxes and at that point you don't know are we actually really thinking about the patient when we're responding or are we just saying yes, no, what's your number?
[00:18:51] Okay, check it off and moving on. So data should always be in a positive light to actually help patients and not just be a checklist. So I completely agree.
[00:19:03] Nancy Ellis: Yeah, you know, I think about when we are doing our reporting for the MIPS macro MVP, whatever it's called today. It's just a checkbox. Yeah, we've got to do it because the federal government tells us to.
[00:19:15] But it's the data that we're able to glean through our own data dives and through TRIO that really help us move the needle in terms of the patient experience. And, again ,you've got to think. Stacy and I are both with rather large practices and we have the sophistication to be able to get to some of this.
[00:19:32] If you're in a solo room office, you may not have the EMR that can run those kinds of reports. You may not have those kinds of things, but knowing what data you can get to and how you can build that into the story, to use for the care of the patients and, or for contracting when you've got to go out and go up against a health insurance company.
[00:19:53] All of those things are so very important. And a lot of people just don't realize the value of the data that they have agreed.
[00:20:02] Kip Theno: Yeah. And I was Nancy took the words out of my mouth. It sounds like data can be a positive hammer and it's a necessity. it's a must have, but you're right. There's probably a lot out there that don't have maybe the technology or the resources to get that data on their own and then put it in a format to be used.
[00:20:22] But it sounds like you have, and you've had positive results in presenting that cogent detail to make change. So for those that maybe don't have it, can you both just talk about some advice or examples of where they should be getting it or how they should be looking at and putting it together. Even as you said, Nancy, even the small practice, because to me, there's no small patient, right?
[00:20:44] So what are your thoughts on that?
[00:20:46] Nancy Ellis: I think that in a practice, there are some basic things that you should be looking at. It's like how long from date of service to when the claim goes out and that tells you how much time are you spending getting that claim to be ready to go out and that every day that it goes is just longer till you get reimbursed on it.
[00:21:07] I think looking at your denial rates is important. I think looking at the denial rates and codes reasons why behind that by payer is important. We realized when we were looking at some of that, that payer that was less than 1% of our business was responsible for 90% of our billing on the back end of denials and asking for records and delays and all of those kinds of things.
[00:21:32] And for us, it wasn't worth keeping them asa payer. And so being able to have all of that data and be able to present it to them and say, "Hey, we'd like to work with you, but these things need to change" and giving them the opportunity to change those. All of those things are very important. I think you've got to know what is your average days in AR?
[00:21:53] How long does it take you to get a normal claim paid? Medicare is supposed to be within, two weeks, if you're submitting electronically, is that really what's happening or for some reason are you at 21 days? Why is that? So, being able to look at some of those things and figure out what's going on and where in the process is the bottleneck or the holdup or whatever, that's really important.
[00:22:16] Stacy Yonker: Yeah, I absolutely agree. One of the things that I always stress too ,if we bring on new billers and new managers, some of those metrics is you have to know your payer contracts. You need to know what your contracted rates are because you think not every practice is independent.
[00:22:35] There are a lot of practices that are managed by an MSO or another organization. And, I've come across managers that have no idea what their payer contract reimbursement rates are because they're managed by a third party company, and I tell them right off the bat. So you have zero idea if you're even being reimbursed at the rate that you should.
[00:22:56] And we stress that you should always audit, you should know what your net fee collection rate is.You should know if you have a contract, for example, with Aetna and you're supposed to be reimbursed at 115% of Medicare fee schedule, let's say, you should be doing audits to your claims to make sure that you are actually receiving that your reimbursement rate is, it matches that contract of 115%.
[00:23:24] And you would be surprised at how many times and how many cases that you can start doing those internal audits and seeing what your reimbursement rates are. And they may be cutting off a few dollars off the top. And most practices would never know, the way the system is set up, the payers are not out there to make sure we make the money.
[00:23:48] Processes for approving drugs, for example, if they delay one to two treatments because they make you appeal it, whether it's at the claim point or whether you're trying to get it authorized. They save millions of dollars, maybe even depending on how large the payer is hundreds of millions of dollars a year, so they're not out to always make sure let me make sure I'm paying you exactly what you should receive, we have to hold them accountable.
[00:24:17] And there are ways to do it, not necessarily with the dashboard but if you can just have a basic understanding of what your contract is, and look at your claim and see what your reimbursement rate is, we have to hold them accountable. And that's the least that some practices can do if they don't have access to a ton of, data capabilities or their EMR system may not be, the Rolls Royce in the industry.
[00:24:41] Nancy Ellis: I think healthcare in general is a weird business, because we are the only business where the person who orders the service doesn't pay for it. And the person who pays for it doesn't receive it. And the person who received the service really didn't want it in the first place. They didn't want to be sick.
[00:24:59] And so the way we've got the whole payment thing is weird. And then you have the insurance companies who are being unnecessarily complex with a lot of the things that they're doing. And they're betting on the fact that you've got, uh, 1 doc office, who's got maybe 3 staff people and that they don't have time to go in and appeal.
[00:25:19] And that, I asked for this prior authorization and they denied. We've seen things in the news about, AI and different things. being set up to deny the claims first or the prior authorizations first. And I mean those are games that they're playing, but they're playing those games with our health. And I, I think that that's wrong.
[00:25:41] So I think I'd said before, when we talked earlier that I have to get up every day and think of this as a game where I get really mad. And then my job in this game is just like, I want to groan when I hear a particular health insurance companies' name, I want them to groan when they say, "Oh, hell that letter's fromNancy Ellis."
[00:26:03] Kip Theno: Right? Well, yes, Nancy. I remember that. And I definitely want to talk about these algorithms. I've been reading a lot about them over the last couple of years. They're not new, seem to begetting more sophisticated. But in that segue, you had talked about the vertical integration of healthcare, really revolving around the increasing number of intermediaries between patients and their doctors. Can you talk about what you had said to us in the pre show and Stacy jump in at any time and what your solution was? I thought it was, I thought it was absolutely bold and I want our viewers to hear it.
[00:26:37] Nancy Ellis: Because of the way that I grew up, I look at healthcare as a relationship between the doctor and the patient, period. That patient has a need, a healthcare need, that doctor has been trained to take care of that need, that patient trusts that doctor, that doctor knows that patient and their history and whatever, and they're invested in them, and they do what needs to be done.
[00:27:03] The vertical integration now, you've got health insurance companies who are owning the physician practices and so they're owning the doctor that you're going to go see. They're owning the insurance that you use to go see that doctor. They own the pharmacy benefit manager that decides whether or not you get the treatment that that doctor wanted you to get.
[00:27:27] And then they own, like if you needed physical therapy, they may own the physical therapy things. If you need home health, they may own those. They may own infusion centers. They may own
[00:27:40] Stacy Yonker: specialty pharmacies,
[00:27:41] Nancy Ellis: specialty pharmacies. I mean, the list goes on and you as a patient don't know that because they all have different names.
[00:27:50] And in the last 15years, we've gone from being a healthcare system that had lots of options out there, I think, to basically now we're controlled, whether we realize it ornot, by about five different conglomerates for all of your healthcare kinds of stuff, and that everything falls up under one of them in one way, shape, form, or fashion, and to me, I think that that has been a problem in our healthcare system as well.
[00:28:18] Kip Theno: Nancy, you also had a bold solution, as I mentioned. I mean, there are well intended bureaucracies, but you had something that struck me as interesting and implementation aside, what was your idea?
[00:28:29] Nancy Ellis: I think today the problem is in the PBMs, because with the introduction of the Affordable CareAct, the health insurance plans were limited as to how much profit they could make off of a particular insurance product.
[00:28:48] And when that happened, they were like, okay, but we still have to make money. And that's when all of the PBMs came into place. And so these pharmacy benefit managers are sitting out there and you want to believe that, they're making all these great and kind and informed decisions, but they're not, they're doing things where they're getting rebates for whether or not they allow you to be on their formulary or not.
[00:29:11] There's some drugs that they have a high WAC and a low WAC for same drug, but they have it offered at two different prices. I still hadn't figured that one out. And it's within the PBM structure that most of the money is being made now. And it's also within that PBM structure, in my opinion, where I'm seeing a lot of the abuses happen.
[00:29:35] From us not being able to get our patients the treatments that they need. And so, and I don't see that that PBM function really does anything. I mean the doctors went to school and if you're prescribing something that's on label and they've got it on their formulary, then you should be able to get it without having to get a prior authorization or do step therapy or do any of these other utilization review things that they like to put out in front of you.
[00:30:02] All everything that they do is to keep you from getting the service as long as they get your money.They don't care. They don't want to have to pay it to us, though.
[00:30:13] Stacy Yonker: Absolutely. I, I will kind of go off on that as well that the PBMs, I think, as well are one of the major issues in our healthcare system.
[00:30:26] I understand the intent was for it to reduce waste I think, originally, maybe some of the intentions were clear but what it has become now is it justPBMs harm patient care. They limit access to medications. They often input complex prior authorization processes.
[00:30:46] You throw in all these step therapy practices. They then try to force you to use their own mail order pharmacies, like there's no transparency. It has a huge impact on independent pharmacies, which actually could offer more cost savings to patients. But of course, then the PBM or the insurance payer company, cause they're in a vertically integrated, they're not going to make the profits, right?
[00:31:08] So they don't want that. They want to keep all of the money and As much as they can, while the CEOs are laughing their way to the bank, making 20, 40 million a year while denying patient care. And it literally comes down to , with current legislation efforts and , until we de link profits from PBM, it actually increases the cost of patients, right?
[00:31:34] The formularies, you know, it's how much money am I going to make from the manufacturers so that I will offer your drug to patients. And, when in our space and rheumatology, we do infusions in house, so there's benefits that are pharmacy benefit versus medical benefit.Literally, we have to track things like ASP which is your average sales price and your reimbursement is off it, and we have drugs and treatments that we can't even provide to our patients anymore because if we did, it loses us money.
[00:32:08] And, no one is in the position, especially independent private practices, to be able to provide charity care, we don't get government funding, we don't receive grants we aren't tax free, we don't get the write offs and really, it all comes down to the PBMs because they control what medicines patients have to take.
[00:32:29] And we see it all the time in the prior authorization process where they give us two specific medications that a patient has to try and fail before the doctor can get their primary choice of treatment for that patient. And when you look into it, the reason they're offering those on formulary is because the particular manufacturer is offering them such a high rebate.
[00:32:52] to put, which is again, is more money in their pockets, to offer it that they take their ASP in the process. Um, but you know, the PBMs don't care. The insurance payers don't care because they're receiving 70, 80, 90 percent rebate for offering a certain drug. And so when we're looking at.
[00:33:11] What the issue is in our healthcare system.And people say that patients can't afford treatment. You know, it, it makes absolute zero sense that, Hey, here's your premium for your Medicare "disadvantage" plan that you only have to pay 10 bucks a month. But by the way, for you to receive treatment, $2000 a month.
[00:33:31] So there are no savings that are passed down to the patients at all with the way our system is set up right now. And it's the PBMs. It's the payers. Yeah.
[00:33:41] Nancy Ellis: I look at it and I'm thinking through like, okay, is it really, truly just a PBM issue? And, and they're just such a problem right now that nobody understands.
[00:33:52] And that's by design. I've had patients be denied for treatments and us be told that, well, it's not, medically necessary, and we're looking through and we're like, what do you mean? It's not medically necessary. Well, the patient hasn't maxed out at 50 milligrams of prednisone yet, and you're going, you're never going to give a patient 50 milligrams of prednisone.
[00:34:16] That's bad patient care. Yeah. And. And so you ask, can we see that policy where that's coming from? No, that's proprietary. And so they hide behind the proprietary wall. ButI think that there's also more games that they like to play. Going back to my game analogy of it's in the PBMs and it has to do with the drugs, but it happens on the health insurance side of it with the copay card.
[00:34:39] Accumulators and maximizers and happens on the health plan side in the plan design when they put in the alternative funding plan things for biologics and that basically they're selling a health insurance plan to a company saying basically we're not going to cover any of these biologics because they're going to go out and try to raid the manufacturers' foundations for free drug and that's their business model.And, it just makes no sense. It's like on one side, they're like, yeah, you have to pay us all this money to get the preferred placement. But then on the other side, it's like, we're gonna not even provide the service.
[00:35:19] So you're going to have to go get it, take it from them somewhere else. The whole thing is just unnecessarily complex. And my belief is, is that it has to do with the for profit motive in healthcare.
[00:35:34] Kip Theno: Yeah, I mean, Stacy and Nancy, that just everything you're saying is the incentives are misaligned.
[00:35:42] There's so many redundancies. Remember a time where it was the doctor treats the patient in front of them. I wonder then With those redundancies that are keeping patients from getting on the right therapy at the right time Those become useless in a way.
[00:35:59] How do you cut those out then? What is the next step? What can you all do? What can we do together to help fix that part before we go on to our last topic? I'm, really curious as to what you think needs to happen or is the inflection point just going to get worse? I
[00:36:13] Nancy Ellis: think that in general It's going to take patients, customers of the health insurance, customers of the PBM to get angry because right now when they don't get what they want, they see it as, well, my doctor didn't get that for me. They don't see it that their health insurance didn't get it for them, if that makes sense.
[00:36:39] And so there's a lot of anger with folks directed at. physicians that I think is misplaced because we can only do so much. And like the insurance company will say to us, well, we're not telling you, you can't use that. Well, yeah, you are effectively because you're saying a, you're either not going to pay for it, or you're going to pay for under levels that I can obtain it at.
[00:37:01] So, yeah, that's not the right argument there.
[00:37:05] Stacy Yonker: Yeah. Stacy, what are your thoughts? I, yeah, it's not, it's not easy and it's not going to be easy, but you know, people have to get angry and,I'll tell you, there's some organizations that are led by physicians and they are working really hard to get the system changed.
[00:37:24] And then there's management organizations that are doing the same thing to help advocate. And, I think those efforts are great, and I think it's a good step, but I agree withNancy until the patients have that transparent look into how the system works, and how it affects their care, they need to get angry, and, it has to take A systematic change where it takes the patients to basically to fight back in away to say, no, I am not going to purchase a plan from you. You don't take care of your patients. It causes more issues than it's worth. And until those, until a payer loses their clients and their client base. No one's going to, they're not going to make a change.
[00:38:17] So we, yeah, we have to educate the patients, and get everybody involved and they have to get angry.They have to get mad enough where they will write a letter and they will stop purchasing plans from there. They will go anywhere but the payers. I think that's the only way that we'll see a shift.
[00:38:37] Nancy Ellis: I think as consumers of the healthcare system and purchasers of those plans. Most 90 percent of us probably get them through our employers and so it's making sure that if you're angry as the patient that your employer knows that and knows why and that you can articulate why and that those stories get passed up to whoever's making the decisions for the plan because ultimately especially if it's a self insured plan they have a fiduciary responsibility to you to make sure that they're getting the best value for the money that they're giving. And you're seeing lots of different, lawsuits now where the employees are suing the employers based off of that fiduciary responsibility. Because we see our premiums go up 8, 10, 12percent every year, but we're getting less care for it.
[00:39:28] Stacy Yonker: Right. It's like, for what?
[00:39:30] Nancy Ellis: Right. So yes, the patients have to get angry, but employers have to get savvy and they can't just say, okay, they have to know all the details of that plan. They need to know what to ask for. They can't just come in and say, okay, well, what's it going to be this year?
[00:39:44] How much more am I going to have to pay?They need to know the details and they need to know how that's really going to impact their, their patients. They need claims data in terms of, you know, patients that are high cost and, you know, can we carve those patients out? They need to be able to be much more sophisticated about the way that they purchase it and the health insurance companies, these integrated conglomerates are banking on the fact that they know we don't know how to do some of that stuff and that once we figure it out, then they change the game.
[00:40:21] Kip Theno: Uh, this is, this is been such critical information. And I want to circle back to what you had mentioned you have experience with. I was shocked reading reports over the last year or two and even recently that, there are algorithms now even utilizing AI, as an example, to auto deny large percentage of claims, benefits, prior authorizations.
[00:40:41] That's oftentimes critical, life saving, rare disease therapies for patients. And you're dealing with this every day. I mean, that's a juggernaut and, there's no uniformity on payers, Nancy and Stacy, you know this too. Three payers might approve 99 percent of the time, the other seven on the same drug might deny 46 percent of the time.
[00:40:59] What are you doing about that? And what is the impact of the patients that you're seeing there?
[00:41:04] Stacy Yonker: I would say, I think there is a time and a place for AI. I can see where it can help automate some processes because, you know, the last 20years, right? The private physicians groups, they're receiving Medicare reimbursement cuts, every year, but yet they're being expected to do more work, to document more, to jump through more hoops, but then, receive 22 percent less than they did 15 years ago, which, , is insane, not even taking into account inflation and needing to keep good staff on hand, they have bills to pay, they're experiencing inflation as well.
[00:41:47] And so, I can seethe appeal of AI in the healthcare system, and I think it has a place. If it is augmenting care or if it is augmenting the workflow of a practice to help alleviate some of that resource burden that we experience, but on the payer side, AI could still be beneficial, but if their payer policies are explicitly set to deny care or to make it that much harder for patients to receive the treatment that they need to. AI should not be allowed, in my opinion. If you want to deny 22 percent of every claim that comes through or every prior authorization request, there should be a person that is sitting there looking at that patient. They should have a photo.
[00:42:38] We need to personalize it so that they can still sit and look at a patient and say, you know what, I can see you actually need it. But I have a metric that I have to meet because Aetna or United Healthcare, whatever tells me I have to, and I'm going to deny that care anyway.
[00:42:54] If they set it to AI doing it, we are now even completely dehumanizing the healthcare system even further and thinking of what Nancy said, like for her coming into the healthcare system, you know that the relationship, the patient and the doctor, and it was more humanistic, which is what healthcare should be. AI completely, at this point in the way they're utilizing it, removes the human. Because now there isn't even a person that needs to review a case, a computer's doing it, and computers can't feel emotions and they can't look outside of what their algorithms are set up to do. There needs to be an overhaul completely, beforeAI is fully utilized in the healthcare environment.
[00:43:41] Nancy Ellis: When I think about AI, I think about, okay, we have AI that's part of our electronic medical record. And so if we turn that on and we're letting it analyze what we're looking at and stuff.
[00:43:54] It may ask questions that may stimulate our doctor to go, Hmm, maybe I should look at this or, Hmm, maybe I should have, you should do that. And where it can augment, like Stacy said, I think that that's very helpful. I know when I use open source AI to goin and write a appeal letter to an insurance company, I can put in the basic facts and it can write it for me pretty quickly. And that's very helpful.That's time saving to me in the practice.
[00:44:22] But I think when the insurance companies get hold of AI, it's AI through the filters and algorithms that they want it to be, but then also end up denying 60 percent of everything the first time around.
[00:44:39] Because they're betting that you don't have in a doctor's office, you don't have staff to fight that or to appeal it and they're betting that the patient will just go, "Oh, well, you know, somebody will write that off." And they have, and they can get away with it.
[00:44:56] We've got to get where we feel like we have the power back to fight back against that and go, no, that's not okay. As a provider, a lot of times we don't want to rock the boat because, oh, if I, if I, you know, the, the squeaky wheel out there, that insurance company could drop me and that could mean bad things for me.
[00:45:15] Or, I could get on their poor provider list or whatever. And, you don't want to be on those things, but they have that big stick to threaten you with, and as providers, we don't feel like we have anything to fight back with, but that's where the data comes in, that's where getting the patients involved in their care, that's, that's important where they can get their employers involved in their care.It's where you can advocate on the state and national levels. All of these things may be slow, but it's all got to start somewhere.
[00:45:47] Kip Theno: Yeah. Well, Stacy and Nancy, listen, you have exposed a lot here. We are going to get this out to the masses.
[00:45:53] I want to thank you for being on the Road to Care podcast. And I hope you get it out to the masses and keep fighting the good fight. We appreciate you two so much. I learned a ton today. I know our listeners will as well. Stacy how do our listeners out there reach out to you for more information?
[00:46:07] What's your contact?
[00:46:08] Stacy Yonker: Of course, of course. I have aLinkedIn , if anybody would like to connect, you can just look me up, as well as if anyone wants to take discussions further, I'm happy to provide my email.So it's my first name, Stacy, stacy@arthritiscenters.net, and happy to have those discussions. Nancy is an amazing advocate as well. And we'll cut it to you straight for that. So, definitely looking forward to connecting.
[00:46:37] Kip Theno: Nancy, how about you? What's the best way for folks to reach you?
[00:46:40] Nancy Ellis: I have LinkedIn, so anybody can reach out to me through that if they would like, but my email here within the practice is Nancy, nancy.ellis@piedmontarthiritis.com.
[00:46:57] Kip Theno: Well, thank you, Nancy and Stacy.You know, the tagline for the show is together we can make things right. Thank you for being on the Road to Care podcast. And we're looking forward to getting this out there in mass. Thank you so much.
[00:47:07] Stacy Yonker: Thank you. It was a pleasure.
[00:47:09] Keep up the good work.
[00:47:11] Kip Theno: Thank you for joining the Road toCare podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script to therapy operating system, we enable connectivity with clinics, peers, and manufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
[00:47:29] Enjoy the music written, produced and recorded by Jamestown.
Podcast produced by JFACTOR, visit https://www.jfactor.com/
Together, we can make healthcare right. Here are some of the outstanding healthcare organizations and associations championing patient health mentioned in this episode:
[00:00:00] Kip Theno: Welcome to the Road to Care podcast hosted by SamaCare, where we will talk with key opinion leaders, physicians, administrators, manufacturers, venture capitalists, and legislators to get their insights on the state of health care today and where we see it evolving. SamaCare's prior authorization platform is free to clinics, ensuring patients get on the right therapy at the right time.
[00:00:20] Together, we can simply make things right.
[00:00:27] Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. Today our special guests are Nancy Ellis and Stacy Yonker. Nancy is an MBA, MHA, CHE, CRHC, CRMS, and CPMA. Nancy is a practice administrator at Piedmont Arthritis Clinic, a rheumatology practice, location in South Carolina.
[00:00:50] Nancy has over four decades of experience in healthcare administration across rheumatology, oncology, and orthopedics, and across private practice, hospital and home care settings.
[00:01:00] And Stacy is an MBA,CMPE, LSSBB, CRCMP, CRMS, and CMPM. And she is Chief Executive Officer at Sarasota Arthritis Center. And as CEO of Sarasota Arthritis Center, she has over a decade of experience in rheumatology.
[00:01:19] Currently she oversees all operations of the multi location 14 provider practice and Stacy and Nancy, super excited to have you today. How are you?
[00:01:27] Nancy Ellis: Thank you, Kip. We appreciate being asked and are excited to have this time with you today.
[00:01:34] Stacy Yonker: Happy to be here. Yes. And hopefully we can bring value.
[00:01:37] Kip Theno: We are glad I was super excited for this one because I know there's going to be some fireworks, some ground rules, keep the gloves up, no rabbit punches.
[00:01:45] We'll come out swinging. But first of all, Nancy and Stacy, thank you for joining. And I would love to start with your journey into healthcare and maybe Stacy will start with you.
[00:01:54] Stacy Yonker: Sure. A little over a decade ago, I by trade was in hospitality industry. So I have a love of people, and taking care and serving others.
[00:02:05] And I found my way into healthcare through Sarasota Arthritis Centers. I started as a patient care coordinator. So kind of dipping my toes and I just had a love of taking care of patients and getting them treatment. And rheumatology grew on me. I'm still init. Over the years I have just worked my way up, been biologics coordinator,I've been in billing. And, I just have a love of the rheumatology field in particular and patient care.
[00:02:37] Kip Theno: Well, thank you, Stacy. Nancy, how about your journey?
[00:02:41] Nancy Ellis: Well, my dad was a general practitioner. My mom was a nurse anesthetist. And growing up, there was never really any question in my mind that I was going to be in healthcare.
[00:02:50] It was just going to be what was I going to do? Growing up in East Tennessee in Sevierville at the time when I was little, I can remember seeing my dad pack saddlebags to go up in the mountains to take care of patients. And I remember, we would be paid with quilts or eggs or fish or whatever.
[00:03:09] So my introduction as to how healthcare process went may be a little different than a lot of other people's. I ended up going to graduate school because I learned pretty quick that I was good at managing the processes around things, but not the patients themselves. Then I worked in hospitals for a while when we moved here to SouthCarolina, I decided I wanted to work on the physician side of it and worked a little bit in oncology, worked a little bit in orthopedics, and then have found my home, I think, in rheumatology, I've been here for the last 16 years. I hope to retire here.
[00:03:52] Kip Theno: Wow. Well, thank you.
[00:03:54] And by the way,Nancy, I do think at some level we should go back to the barter system, right?Chickens, eggs, whatever, but we might get to that later, but I remember in our pre-show we had a profound conversation. You both shared with me your personal experiences, not only as healthcare providers and caregivers, but also as patients.
[00:04:12] And I think that's critically important. I was really moved by both of your stories. Can you talk about your experiences as patients and how do those experiences help you and inform you in your roles as providers? And Stacy, I'd love to start with you.
[00:04:25] Stacy Yonker: Sure, of course. They say there's a big tie between life changing events.
[00:04:31] I had been working at Sarasota Arthritis Center, for a couple of years and I had, at the time recently had a baby and after I had my youngest child, I started to develop symptoms, that were autoimmune related.
[00:04:46] And of course it was excellent. I worked where I needed a consult and I ended up developing psoriatic arthritis with some overlapping of Sjogren's. And to be able to workin the environment to know what the patients go through was extremely eyeopening for me and it really shifted my mindset on the importance of the patient experience and patient care.
[00:05:14] Because myself, it's scary to be told that you may have a really bad joint disease and you may not be able to work in the future. And so you're just hoping that you can get on medications that are going to prevent that, to ensure that you have that quality of life. So I can be there for my kids.
[00:05:32] Being in that space having to wait for the calls from specialty pharmacies and being told by my doctor that, "hey, this is the medication we want to put you on, but, your insurance says no. So here's the second choice." We really you look to your provider for the answers and to get on the treatment that is the best for you.But when your insurance is third party person that is, they've never met you they've never spoken directly to you starts to mandate what treatments best for you. It's very eye opening. It's very frustrating.
[00:06:07] And so it made me that much more wanting to fight for patients to have access to the treatments they need. And it's, shaped the way I operate today.
[00:06:17] Nancy Ellis: Yeah, I agree 100% with you,Stacy. I found out my family has a history of rheumatoid arthritis as well as ankylosing spondylitis but I was like, "Oh, yeah, that was in them. That's not going to be in me" kind of a thing and trying to figure out why I was hurting. Was it just because I was getting older? Is this normal? Arthritis is what it was. Then thinking back like all the times before when, very innocently, I would go, "oh, well how do you know when they fill out a rapid three, whether it's their RA, or whether it's their stove up from gardening kind of a thing."
[00:06:51] And I'm like,"oh, you know." Because now, now I've experienced, I know, you know, that difference kind of a thing and knowing all the things that I know from the administrative side, it was a odd journey for me when I started out in this as well, because having to work with the specialty pharmacy and work through the different layers of calls and know the right questions to ask and know how to say things to be able to get passed on to the next person.
[00:07:19] Average patients don't know those kinds of things. It was a difficult process for me and I workin it. I can't imagine what it's like for somebody who is just, they're scared and this is a completely foreign unnecessarily, in my opinion. complex system.
[00:07:38] Kip Theno: Thank you, Stacy, Nancy.
[00:07:39] And to that point, you did touch on something about all these choices and when patients get switched on medications, or maybe it's not the one initially prescribed and there's all these new innovations and new biologics coming out, and you've talked about this, choices should be a good thing, typically.
[00:07:54] You would think that's the case. The system gets so riddled with complexity, and Nancy, I know you really hammered this before, what is going to help solve that problem for the patients? And you guys are patients, so am I. Is it legislation? I mean, did the Affordable Care Act solve anything?
[00:08:10] Or, Are we just off target? What are your thoughts, Nancy?
[00:08:15] Nancy Ellis: I know when the Affordable CareAct first came out, I remember being really angry and thinking it wasn't going to be a good idea because what was the famous quote of , "you have to pass it so you can know what's in it." Or something like that.
[00:08:29] And I remember thinking, this is no way to do this, but I think over time, it at least opened up access in some ways. I mean, it had unintended consequences as well, and it changed our commercial insurance markets a lot. But I think overall it, it was a good thing. I think, this is all a process and you can have legislation and you can have regulations, but they need to be things that can be in place for more than the four years of one presidency or eight years of one president.We've got to know that you can depend on this is how it's going to be.
[00:09:06] A lot of the things that are happening are, in my opinion, abuses of the system. Stacy and I are both part of an organization called National Organization of Rheumatology Managers (NORM) in one of our speakers a couple of years ago, talked about a ERISA plans and they were like, did you know that in a ERISA plan, these things apply?
[00:09:27] And I think everybody in that room, we're just looking at one another going "no, we didn't know that the ERISA statutes could overlay the contractual statutes that you had in your contract that ERISA would win." And, there were a lot of protections out there that we had for billing and for our patients that we never even knew we had.
[00:09:47] And I think that the health insurance business out there does that on purpose, and makes it unnecessarily complex and they're not forthcoming with information. They're very much spin doctors with what they want you to focus on versus what is really the problem out there.
[00:10:08] Kip Theno: Yeah.
[00:10:08] Stacy, any thoughts to dovetail on that?
[00:10:11] Stacy Yonker: I 100% agree with Nancy. When we were hearing about like the ERISA plans, for example, I know my mind was blown and it just shows you how non transparent our healthcare system is. And it's so interesting because anytime there's a frustration with patients getting them treatment, there's some new regulation or we're not allowed to do this, you can't do that... Doctors, can't be just a clinician. Everything always ties back to the insurance, the payers, they have control. And with that control, it is detrimental to patient care. So I completely agree with Nancy's take on the situation.
[00:10:56] Our healthcare system should be focused on the patient and unfortunately it's not. We have it backwards right now, but hopefully, we can make an impact and make a change.There is a lot of push for legislation and there's a lot of organizations, of all different specialties rheumatology, GI and neurology and other specialties where, they are coming together to try to help make these changes.
[00:11:22] And I think we can do it if we band together.
[00:11:26] Kip Theno: Yeah, and I think you both know we had Christine Mann on the podcast, and she had talked about being up on Capitol Hill, and they were very receptive, they wanted to learn, they were engaged.But then if you think about that institutional knowledge that you two have,Christine had mentioned they were still thinking of infusions, as an example, just focused on oncology. Well now that's absolutely not the case if you just look at the infusion market and neurology and cardiology now and behavioral health and rheumatology. So clearly if we think with the premise that legislation works at a glacial pace and is not the silver bullet, then Stacy, what do you rely on?
[00:11:59] What is your practice or what are you doing to help deal with the complexities and combat the pain points with payers?
[00:12:07] Stacy Yonker: Yeah, I'll tell you, it has not been easy. It's been a long road and I think the road is going to continue on for many years to get to the ideal point if we even get to it.
[00:12:19] But we really had to refine our practices, at least in my practice, where, you have a very strong, strict system and things that we have like set appeal letters and different processes. We do utilize. some data software programs that help give us kind of real time feedback on claims and where they are in the appeal process.
[00:12:44] And it does help streamline, to try to get either denials overturned or, an appeal process in a timely fashion, or for us to follow up with the payer. Because a lot of times you can't rely on them to say, "Hey, by the way, you appealed 60 days ago and you're approaching the limits still hanging out there. Make sure you callus." They're never going to do that. They put a 100% of that onus on the practices that are already inundated. We can only have so many staff, right. So we have to find ways to be able to track what we're doing because everything again comes back to patient care. And if we can't get them get them approved for treatment, or, we administered an infusion and now the insurance is not covering it, it always affects the patient. So I do think technology is crucial going forward, but there's so much legislation right now that until there are also changes on the payer level, like there's delinking of PBMs from profits for certain things.
[00:13:50] I think that would be a huge help to the system. It's definitely going to be a struggle, but datais important, is the way, because if you don't know what you don't know, you know, then how can we take steps to improve it?
[00:14:05] If we don't know what's happening.
[00:14:07] Kip Theno: Stacy, you talk about data: Stacy and Nancy, what types of data, where do you get that data and how do you use that for the benefit of the patients and maybe productive and proactive conversations with payers to affect change?
[00:14:20] Stacy Yonker: Our practice, we utilize organizations like MGMA, they have a revenue cycle dashboard, they have data dive where people can provide for benchmarking.
[00:14:33] For E and M codes, for example, especially if you are a Medicare provider, you're always looking out for big brother and it's like, where do we fall? Are we coding appropriately?
[00:14:44] And, should we be changing the way we're doing things. And especially with legislation where payers can control, they're trying to force you to downcode, so you can get hit if you downcode, but then you can get hit if you upcode. So, it puts us in a really tight position because all the doctors want to do is just see their patients.
[00:15:03] They want to treat them. They want to help them. And the payers make it incredibly difficult to do that. So if we are able to have data, for example, like MGMA's dashboard, which we use in our practice, they provide the national benchmarking. So if I'm looking at what my providers are doing, I can compare it to what other practices are doing, and even Medicare themselves offer this kind of information so that you can see where you lie.
[00:15:31] None of us want to be an outlier because that obviously always poses a risk to the practice and you. Part of our jobs as managers is to reduce that risk while optimizing patient care. And there's definitely a lot of organizations, especially in rheumatology, that are really trying to provide more data and make it more readily available so that practices can use it to combat the payers.
[00:15:57] Kip Theno: Yeah.
[00:15:58] Nancy, how about you?
[00:15:59] Nancy Ellis: Well, I'm just sitting here shaking my head to everything that Stacy was saying. Right now when we think about data and healthcare, a lot of times we think about what we have to provide through the MIPS and MACRA, the required programs and the registries that are out there for those things, but the reality of the world, while that may be what we have to do on paper to satisfy and check a box with the federal government for that quality data, those measures there are not useful in the true taking care of patients. They are yes/no kinds of questions. They're just not helpful And how do you move the ball? And how do you move your practice to be a better practice? So data has two stories to me. It's you have the data that you have to provide to meet your regulations or legislation or whatever out there, the regulatory stuff, which would be my MIPS and macro the registries, all of those kinds of things.
[00:16:57] And then I have the data that we can get to. And some of it we have the ability to do in house through our EMR, we're able to pull different reports and look at things. But then we've also worked with our GPO and they are working with a company called TRIO. And TRIO is able to come in and they look at a lot of different data points in our system.
[00:17:18] And they're able to compare our stuff to other people who are with that GPO that are also on TRIO.And so we're able to see similar practices, even in our state to similar practices in a region, similar practices in the country, be able to start seeing that. And so we know what we're being judged against.
[00:17:38] And so if I'm looking at it and I'm like, Oh, their time to get somebody onto infusion is maybe two months and mine's six months. What are they doing differently? What can I do to look at that? What are the processes and steps in place that they have that help them get to that therapy faster?
[00:17:54] Stacy Yonker: Absolutely. I 100% agree withNancy. I'm also familiar with Trio Health and there is a really great thing that it does. For example, in gout patients, they can track gout and patients that may potentially be under-treated. Data should be used to help patient care or to get them to a better quality of life and not just be seen as something that we are required to do.
[00:18:22] Otherwise Medicare is going to takeaway some of your reimbursement, forcing clinicians and practices to report with threatening to take away money. That is never going to have a positive effect on patient care. It never will because now practices are just going todo it just to check off the boxes and at that point you don't know are we actually really thinking about the patient when we're responding or are we just saying yes, no, what's your number?
[00:18:51] Okay, check it off and moving on. So data should always be in a positive light to actually help patients and not just be a checklist. So I completely agree.
[00:19:03] Nancy Ellis: Yeah, you know, I think about when we are doing our reporting for the MIPS macro MVP, whatever it's called today. It's just a checkbox. Yeah, we've got to do it because the federal government tells us to.
[00:19:15] But it's the data that we're able to glean through our own data dives and through TRIO that really help us move the needle in terms of the patient experience. And, again ,you've got to think. Stacy and I are both with rather large practices and we have the sophistication to be able to get to some of this.
[00:19:32] If you're in a solo room office, you may not have the EMR that can run those kinds of reports. You may not have those kinds of things, but knowing what data you can get to and how you can build that into the story, to use for the care of the patients and, or for contracting when you've got to go out and go up against a health insurance company.
[00:19:53] All of those things are so very important. And a lot of people just don't realize the value of the data that they have agreed.
[00:20:02] Kip Theno: Yeah. And I was Nancy took the words out of my mouth. It sounds like data can be a positive hammer and it's a necessity. it's a must have, but you're right. There's probably a lot out there that don't have maybe the technology or the resources to get that data on their own and then put it in a format to be used.
[00:20:22] But it sounds like you have, and you've had positive results in presenting that cogent detail to make change. So for those that maybe don't have it, can you both just talk about some advice or examples of where they should be getting it or how they should be looking at and putting it together. Even as you said, Nancy, even the small practice, because to me, there's no small patient, right?
[00:20:44] So what are your thoughts on that?
[00:20:46] Nancy Ellis: I think that in a practice, there are some basic things that you should be looking at. It's like how long from date of service to when the claim goes out and that tells you how much time are you spending getting that claim to be ready to go out and that every day that it goes is just longer till you get reimbursed on it.
[00:21:07] I think looking at your denial rates is important. I think looking at the denial rates and codes reasons why behind that by payer is important. We realized when we were looking at some of that, that payer that was less than 1% of our business was responsible for 90% of our billing on the back end of denials and asking for records and delays and all of those kinds of things.
[00:21:32] And for us, it wasn't worth keeping them asa payer. And so being able to have all of that data and be able to present it to them and say, "Hey, we'd like to work with you, but these things need to change" and giving them the opportunity to change those. All of those things are very important. I think you've got to know what is your average days in AR?
[00:21:53] How long does it take you to get a normal claim paid? Medicare is supposed to be within, two weeks, if you're submitting electronically, is that really what's happening or for some reason are you at 21 days? Why is that? So, being able to look at some of those things and figure out what's going on and where in the process is the bottleneck or the holdup or whatever, that's really important.
[00:22:16] Stacy Yonker: Yeah, I absolutely agree. One of the things that I always stress too ,if we bring on new billers and new managers, some of those metrics is you have to know your payer contracts. You need to know what your contracted rates are because you think not every practice is independent.
[00:22:35] There are a lot of practices that are managed by an MSO or another organization. And, I've come across managers that have no idea what their payer contract reimbursement rates are because they're managed by a third party company, and I tell them right off the bat. So you have zero idea if you're even being reimbursed at the rate that you should.
[00:22:56] And we stress that you should always audit, you should know what your net fee collection rate is.You should know if you have a contract, for example, with Aetna and you're supposed to be reimbursed at 115% of Medicare fee schedule, let's say, you should be doing audits to your claims to make sure that you are actually receiving that your reimbursement rate is, it matches that contract of 115%.
[00:23:24] And you would be surprised at how many times and how many cases that you can start doing those internal audits and seeing what your reimbursement rates are. And they may be cutting off a few dollars off the top. And most practices would never know, the way the system is set up, the payers are not out there to make sure we make the money.
[00:23:48] Processes for approving drugs, for example, if they delay one to two treatments because they make you appeal it, whether it's at the claim point or whether you're trying to get it authorized. They save millions of dollars, maybe even depending on how large the payer is hundreds of millions of dollars a year, so they're not out to always make sure let me make sure I'm paying you exactly what you should receive, we have to hold them accountable.
[00:24:17] And there are ways to do it, not necessarily with the dashboard but if you can just have a basic understanding of what your contract is, and look at your claim and see what your reimbursement rate is, we have to hold them accountable. And that's the least that some practices can do if they don't have access to a ton of, data capabilities or their EMR system may not be, the Rolls Royce in the industry.
[00:24:41] Nancy Ellis: I think healthcare in general is a weird business, because we are the only business where the person who orders the service doesn't pay for it. And the person who pays for it doesn't receive it. And the person who received the service really didn't want it in the first place. They didn't want to be sick.
[00:24:59] And so the way we've got the whole payment thing is weird. And then you have the insurance companies who are being unnecessarily complex with a lot of the things that they're doing. And they're betting on the fact that you've got, uh, 1 doc office, who's got maybe 3 staff people and that they don't have time to go in and appeal.
[00:25:19] And that, I asked for this prior authorization and they denied. We've seen things in the news about, AI and different things. being set up to deny the claims first or the prior authorizations first. And I mean those are games that they're playing, but they're playing those games with our health. And I, I think that that's wrong.
[00:25:41] So I think I'd said before, when we talked earlier that I have to get up every day and think of this as a game where I get really mad. And then my job in this game is just like, I want to groan when I hear a particular health insurance companies' name, I want them to groan when they say, "Oh, hell that letter's fromNancy Ellis."
[00:26:03] Kip Theno: Right? Well, yes, Nancy. I remember that. And I definitely want to talk about these algorithms. I've been reading a lot about them over the last couple of years. They're not new, seem to begetting more sophisticated. But in that segue, you had talked about the vertical integration of healthcare, really revolving around the increasing number of intermediaries between patients and their doctors. Can you talk about what you had said to us in the pre show and Stacy jump in at any time and what your solution was? I thought it was, I thought it was absolutely bold and I want our viewers to hear it.
[00:26:37] Nancy Ellis: Because of the way that I grew up, I look at healthcare as a relationship between the doctor and the patient, period. That patient has a need, a healthcare need, that doctor has been trained to take care of that need, that patient trusts that doctor, that doctor knows that patient and their history and whatever, and they're invested in them, and they do what needs to be done.
[00:27:03] The vertical integration now, you've got health insurance companies who are owning the physician practices and so they're owning the doctor that you're going to go see. They're owning the insurance that you use to go see that doctor. They own the pharmacy benefit manager that decides whether or not you get the treatment that that doctor wanted you to get.
[00:27:27] And then they own, like if you needed physical therapy, they may own the physical therapy things. If you need home health, they may own those. They may own infusion centers. They may own
[00:27:40] Stacy Yonker: specialty pharmacies,
[00:27:41] Nancy Ellis: specialty pharmacies. I mean, the list goes on and you as a patient don't know that because they all have different names.
[00:27:50] And in the last 15years, we've gone from being a healthcare system that had lots of options out there, I think, to basically now we're controlled, whether we realize it ornot, by about five different conglomerates for all of your healthcare kinds of stuff, and that everything falls up under one of them in one way, shape, form, or fashion, and to me, I think that that has been a problem in our healthcare system as well.
[00:28:18] Kip Theno: Nancy, you also had a bold solution, as I mentioned. I mean, there are well intended bureaucracies, but you had something that struck me as interesting and implementation aside, what was your idea?
[00:28:29] Nancy Ellis: I think today the problem is in the PBMs, because with the introduction of the Affordable CareAct, the health insurance plans were limited as to how much profit they could make off of a particular insurance product.
[00:28:48] And when that happened, they were like, okay, but we still have to make money. And that's when all of the PBMs came into place. And so these pharmacy benefit managers are sitting out there and you want to believe that, they're making all these great and kind and informed decisions, but they're not, they're doing things where they're getting rebates for whether or not they allow you to be on their formulary or not.
[00:29:11] There's some drugs that they have a high WAC and a low WAC for same drug, but they have it offered at two different prices. I still hadn't figured that one out. And it's within the PBM structure that most of the money is being made now. And it's also within that PBM structure, in my opinion, where I'm seeing a lot of the abuses happen.
[00:29:35] From us not being able to get our patients the treatments that they need. And so, and I don't see that that PBM function really does anything. I mean the doctors went to school and if you're prescribing something that's on label and they've got it on their formulary, then you should be able to get it without having to get a prior authorization or do step therapy or do any of these other utilization review things that they like to put out in front of you.
[00:30:02] All everything that they do is to keep you from getting the service as long as they get your money.They don't care. They don't want to have to pay it to us, though.
[00:30:13] Stacy Yonker: Absolutely. I, I will kind of go off on that as well that the PBMs, I think, as well are one of the major issues in our healthcare system.
[00:30:26] I understand the intent was for it to reduce waste I think, originally, maybe some of the intentions were clear but what it has become now is it justPBMs harm patient care. They limit access to medications. They often input complex prior authorization processes.
[00:30:46] You throw in all these step therapy practices. They then try to force you to use their own mail order pharmacies, like there's no transparency. It has a huge impact on independent pharmacies, which actually could offer more cost savings to patients. But of course, then the PBM or the insurance payer company, cause they're in a vertically integrated, they're not going to make the profits, right?
[00:31:08] So they don't want that. They want to keep all of the money and As much as they can, while the CEOs are laughing their way to the bank, making 20, 40 million a year while denying patient care. And it literally comes down to , with current legislation efforts and , until we de link profits from PBM, it actually increases the cost of patients, right?
[00:31:34] The formularies, you know, it's how much money am I going to make from the manufacturers so that I will offer your drug to patients. And, when in our space and rheumatology, we do infusions in house, so there's benefits that are pharmacy benefit versus medical benefit.Literally, we have to track things like ASP which is your average sales price and your reimbursement is off it, and we have drugs and treatments that we can't even provide to our patients anymore because if we did, it loses us money.
[00:32:08] And, no one is in the position, especially independent private practices, to be able to provide charity care, we don't get government funding, we don't receive grants we aren't tax free, we don't get the write offs and really, it all comes down to the PBMs because they control what medicines patients have to take.
[00:32:29] And we see it all the time in the prior authorization process where they give us two specific medications that a patient has to try and fail before the doctor can get their primary choice of treatment for that patient. And when you look into it, the reason they're offering those on formulary is because the particular manufacturer is offering them such a high rebate.
[00:32:52] to put, which is again, is more money in their pockets, to offer it that they take their ASP in the process. Um, but you know, the PBMs don't care. The insurance payers don't care because they're receiving 70, 80, 90 percent rebate for offering a certain drug. And so when we're looking at.
[00:33:11] What the issue is in our healthcare system.And people say that patients can't afford treatment. You know, it, it makes absolute zero sense that, Hey, here's your premium for your Medicare "disadvantage" plan that you only have to pay 10 bucks a month. But by the way, for you to receive treatment, $2000 a month.
[00:33:31] So there are no savings that are passed down to the patients at all with the way our system is set up right now. And it's the PBMs. It's the payers. Yeah.
[00:33:41] Nancy Ellis: I look at it and I'm thinking through like, okay, is it really, truly just a PBM issue? And, and they're just such a problem right now that nobody understands.
[00:33:52] And that's by design. I've had patients be denied for treatments and us be told that, well, it's not, medically necessary, and we're looking through and we're like, what do you mean? It's not medically necessary. Well, the patient hasn't maxed out at 50 milligrams of prednisone yet, and you're going, you're never going to give a patient 50 milligrams of prednisone.
[00:34:16] That's bad patient care. Yeah. And. And so you ask, can we see that policy where that's coming from? No, that's proprietary. And so they hide behind the proprietary wall. ButI think that there's also more games that they like to play. Going back to my game analogy of it's in the PBMs and it has to do with the drugs, but it happens on the health insurance side of it with the copay card.
[00:34:39] Accumulators and maximizers and happens on the health plan side in the plan design when they put in the alternative funding plan things for biologics and that basically they're selling a health insurance plan to a company saying basically we're not going to cover any of these biologics because they're going to go out and try to raid the manufacturers' foundations for free drug and that's their business model.And, it just makes no sense. It's like on one side, they're like, yeah, you have to pay us all this money to get the preferred placement. But then on the other side, it's like, we're gonna not even provide the service.
[00:35:19] So you're going to have to go get it, take it from them somewhere else. The whole thing is just unnecessarily complex. And my belief is, is that it has to do with the for profit motive in healthcare.
[00:35:34] Kip Theno: Yeah, I mean, Stacy and Nancy, that just everything you're saying is the incentives are misaligned.
[00:35:42] There's so many redundancies. Remember a time where it was the doctor treats the patient in front of them. I wonder then With those redundancies that are keeping patients from getting on the right therapy at the right time Those become useless in a way.
[00:35:59] How do you cut those out then? What is the next step? What can you all do? What can we do together to help fix that part before we go on to our last topic? I'm, really curious as to what you think needs to happen or is the inflection point just going to get worse? I
[00:36:13] Nancy Ellis: think that in general It's going to take patients, customers of the health insurance, customers of the PBM to get angry because right now when they don't get what they want, they see it as, well, my doctor didn't get that for me. They don't see it that their health insurance didn't get it for them, if that makes sense.
[00:36:39] And so there's a lot of anger with folks directed at. physicians that I think is misplaced because we can only do so much. And like the insurance company will say to us, well, we're not telling you, you can't use that. Well, yeah, you are effectively because you're saying a, you're either not going to pay for it, or you're going to pay for under levels that I can obtain it at.
[00:37:01] So, yeah, that's not the right argument there.
[00:37:05] Stacy Yonker: Yeah. Stacy, what are your thoughts? I, yeah, it's not, it's not easy and it's not going to be easy, but you know, people have to get angry and,I'll tell you, there's some organizations that are led by physicians and they are working really hard to get the system changed.
[00:37:24] And then there's management organizations that are doing the same thing to help advocate. And, I think those efforts are great, and I think it's a good step, but I agree withNancy until the patients have that transparent look into how the system works, and how it affects their care, they need to get angry, and, it has to take A systematic change where it takes the patients to basically to fight back in away to say, no, I am not going to purchase a plan from you. You don't take care of your patients. It causes more issues than it's worth. And until those, until a payer loses their clients and their client base. No one's going to, they're not going to make a change.
[00:38:17] So we, yeah, we have to educate the patients, and get everybody involved and they have to get angry.They have to get mad enough where they will write a letter and they will stop purchasing plans from there. They will go anywhere but the payers. I think that's the only way that we'll see a shift.
[00:38:37] Nancy Ellis: I think as consumers of the healthcare system and purchasers of those plans. Most 90 percent of us probably get them through our employers and so it's making sure that if you're angry as the patient that your employer knows that and knows why and that you can articulate why and that those stories get passed up to whoever's making the decisions for the plan because ultimately especially if it's a self insured plan they have a fiduciary responsibility to you to make sure that they're getting the best value for the money that they're giving. And you're seeing lots of different, lawsuits now where the employees are suing the employers based off of that fiduciary responsibility. Because we see our premiums go up 8, 10, 12percent every year, but we're getting less care for it.
[00:39:28] Stacy Yonker: Right. It's like, for what?
[00:39:30] Nancy Ellis: Right. So yes, the patients have to get angry, but employers have to get savvy and they can't just say, okay, they have to know all the details of that plan. They need to know what to ask for. They can't just come in and say, okay, well, what's it going to be this year?
[00:39:44] How much more am I going to have to pay?They need to know the details and they need to know how that's really going to impact their, their patients. They need claims data in terms of, you know, patients that are high cost and, you know, can we carve those patients out? They need to be able to be much more sophisticated about the way that they purchase it and the health insurance companies, these integrated conglomerates are banking on the fact that they know we don't know how to do some of that stuff and that once we figure it out, then they change the game.
[00:40:21] Kip Theno: Uh, this is, this is been such critical information. And I want to circle back to what you had mentioned you have experience with. I was shocked reading reports over the last year or two and even recently that, there are algorithms now even utilizing AI, as an example, to auto deny large percentage of claims, benefits, prior authorizations.
[00:40:41] That's oftentimes critical, life saving, rare disease therapies for patients. And you're dealing with this every day. I mean, that's a juggernaut and, there's no uniformity on payers, Nancy and Stacy, you know this too. Three payers might approve 99 percent of the time, the other seven on the same drug might deny 46 percent of the time.
[00:40:59] What are you doing about that? And what is the impact of the patients that you're seeing there?
[00:41:04] Stacy Yonker: I would say, I think there is a time and a place for AI. I can see where it can help automate some processes because, you know, the last 20years, right? The private physicians groups, they're receiving Medicare reimbursement cuts, every year, but yet they're being expected to do more work, to document more, to jump through more hoops, but then, receive 22 percent less than they did 15 years ago, which, , is insane, not even taking into account inflation and needing to keep good staff on hand, they have bills to pay, they're experiencing inflation as well.
[00:41:47] And so, I can seethe appeal of AI in the healthcare system, and I think it has a place. If it is augmenting care or if it is augmenting the workflow of a practice to help alleviate some of that resource burden that we experience, but on the payer side, AI could still be beneficial, but if their payer policies are explicitly set to deny care or to make it that much harder for patients to receive the treatment that they need to. AI should not be allowed, in my opinion. If you want to deny 22 percent of every claim that comes through or every prior authorization request, there should be a person that is sitting there looking at that patient. They should have a photo.
[00:42:38] We need to personalize it so that they can still sit and look at a patient and say, you know what, I can see you actually need it. But I have a metric that I have to meet because Aetna or United Healthcare, whatever tells me I have to, and I'm going to deny that care anyway.
[00:42:54] If they set it to AI doing it, we are now even completely dehumanizing the healthcare system even further and thinking of what Nancy said, like for her coming into the healthcare system, you know that the relationship, the patient and the doctor, and it was more humanistic, which is what healthcare should be. AI completely, at this point in the way they're utilizing it, removes the human. Because now there isn't even a person that needs to review a case, a computer's doing it, and computers can't feel emotions and they can't look outside of what their algorithms are set up to do. There needs to be an overhaul completely, beforeAI is fully utilized in the healthcare environment.
[00:43:41] Nancy Ellis: When I think about AI, I think about, okay, we have AI that's part of our electronic medical record. And so if we turn that on and we're letting it analyze what we're looking at and stuff.
[00:43:54] It may ask questions that may stimulate our doctor to go, Hmm, maybe I should look at this or, Hmm, maybe I should have, you should do that. And where it can augment, like Stacy said, I think that that's very helpful. I know when I use open source AI to goin and write a appeal letter to an insurance company, I can put in the basic facts and it can write it for me pretty quickly. And that's very helpful.That's time saving to me in the practice.
[00:44:22] But I think when the insurance companies get hold of AI, it's AI through the filters and algorithms that they want it to be, but then also end up denying 60 percent of everything the first time around.
[00:44:39] Because they're betting that you don't have in a doctor's office, you don't have staff to fight that or to appeal it and they're betting that the patient will just go, "Oh, well, you know, somebody will write that off." And they have, and they can get away with it.
[00:44:56] We've got to get where we feel like we have the power back to fight back against that and go, no, that's not okay. As a provider, a lot of times we don't want to rock the boat because, oh, if I, if I, you know, the, the squeaky wheel out there, that insurance company could drop me and that could mean bad things for me.
[00:45:15] Or, I could get on their poor provider list or whatever. And, you don't want to be on those things, but they have that big stick to threaten you with, and as providers, we don't feel like we have anything to fight back with, but that's where the data comes in, that's where getting the patients involved in their care, that's, that's important where they can get their employers involved in their care.It's where you can advocate on the state and national levels. All of these things may be slow, but it's all got to start somewhere.
[00:45:47] Kip Theno: Yeah. Well, Stacy and Nancy, listen, you have exposed a lot here. We are going to get this out to the masses.
[00:45:53] I want to thank you for being on the Road to Care podcast. And I hope you get it out to the masses and keep fighting the good fight. We appreciate you two so much. I learned a ton today. I know our listeners will as well. Stacy how do our listeners out there reach out to you for more information?
[00:46:07] What's your contact?
[00:46:08] Stacy Yonker: Of course, of course. I have aLinkedIn , if anybody would like to connect, you can just look me up, as well as if anyone wants to take discussions further, I'm happy to provide my email.So it's my first name, Stacy, stacy@arthritiscenters.net, and happy to have those discussions. Nancy is an amazing advocate as well. And we'll cut it to you straight for that. So, definitely looking forward to connecting.
[00:46:37] Kip Theno: Nancy, how about you? What's the best way for folks to reach you?
[00:46:40] Nancy Ellis: I have LinkedIn, so anybody can reach out to me through that if they would like, but my email here within the practice is Nancy, nancy.ellis@piedmontarthiritis.com.
[00:46:57] Kip Theno: Well, thank you, Nancy and Stacy.You know, the tagline for the show is together we can make things right. Thank you for being on the Road to Care podcast. And we're looking forward to getting this out there in mass. Thank you so much.
[00:47:07] Stacy Yonker: Thank you. It was a pleasure.
[00:47:09] Keep up the good work.
[00:47:11] Kip Theno: Thank you for joining the Road toCare podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script to therapy operating system, we enable connectivity with clinics, peers, and manufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
[00:47:29] Enjoy the music written, produced and recorded by Jamestown.
Podcast produced by JFACTOR, visit https://www.jfactor.com/
Together, we can make healthcare right. Here are some of the outstanding healthcare organizations and associations championing patient health mentioned in this episode:
[00:00:00] Kip Theno: Welcome to the Road to Care podcast hosted by SamaCare, where we will talk with key opinion leaders, physicians, administrators, manufacturers, venture capitalists, and legislators to get their insights on the state of health care today and where we see it evolving. SamaCare's prior authorization platform is free to clinics, ensuring patients get on the right therapy at the right time.
[00:00:20] Together, we can simply make things right.
[00:00:27] Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. Today our special guests are Nancy Ellis and Stacy Yonker. Nancy is an MBA, MHA, CHE, CRHC, CRMS, and CPMA. Nancy is a practice administrator at Piedmont Arthritis Clinic, a rheumatology practice, location in South Carolina.
[00:00:50] Nancy has over four decades of experience in healthcare administration across rheumatology, oncology, and orthopedics, and across private practice, hospital and home care settings.
[00:01:00] And Stacy is an MBA,CMPE, LSSBB, CRCMP, CRMS, and CMPM. And she is Chief Executive Officer at Sarasota Arthritis Center. And as CEO of Sarasota Arthritis Center, she has over a decade of experience in rheumatology.
[00:01:19] Currently she oversees all operations of the multi location 14 provider practice and Stacy and Nancy, super excited to have you today. How are you?
[00:01:27] Nancy Ellis: Thank you, Kip. We appreciate being asked and are excited to have this time with you today.
[00:01:34] Stacy Yonker: Happy to be here. Yes. And hopefully we can bring value.
[00:01:37] Kip Theno: We are glad I was super excited for this one because I know there's going to be some fireworks, some ground rules, keep the gloves up, no rabbit punches.
[00:01:45] We'll come out swinging. But first of all, Nancy and Stacy, thank you for joining. And I would love to start with your journey into healthcare and maybe Stacy will start with you.
[00:01:54] Stacy Yonker: Sure. A little over a decade ago, I by trade was in hospitality industry. So I have a love of people, and taking care and serving others.
[00:02:05] And I found my way into healthcare through Sarasota Arthritis Centers. I started as a patient care coordinator. So kind of dipping my toes and I just had a love of taking care of patients and getting them treatment. And rheumatology grew on me. I'm still init. Over the years I have just worked my way up, been biologics coordinator,I've been in billing. And, I just have a love of the rheumatology field in particular and patient care.
[00:02:37] Kip Theno: Well, thank you, Stacy. Nancy, how about your journey?
[00:02:41] Nancy Ellis: Well, my dad was a general practitioner. My mom was a nurse anesthetist. And growing up, there was never really any question in my mind that I was going to be in healthcare.
[00:02:50] It was just going to be what was I going to do? Growing up in East Tennessee in Sevierville at the time when I was little, I can remember seeing my dad pack saddlebags to go up in the mountains to take care of patients. And I remember, we would be paid with quilts or eggs or fish or whatever.
[00:03:09] So my introduction as to how healthcare process went may be a little different than a lot of other people's. I ended up going to graduate school because I learned pretty quick that I was good at managing the processes around things, but not the patients themselves. Then I worked in hospitals for a while when we moved here to SouthCarolina, I decided I wanted to work on the physician side of it and worked a little bit in oncology, worked a little bit in orthopedics, and then have found my home, I think, in rheumatology, I've been here for the last 16 years. I hope to retire here.
[00:03:52] Kip Theno: Wow. Well, thank you.
[00:03:54] And by the way,Nancy, I do think at some level we should go back to the barter system, right?Chickens, eggs, whatever, but we might get to that later, but I remember in our pre-show we had a profound conversation. You both shared with me your personal experiences, not only as healthcare providers and caregivers, but also as patients.
[00:04:12] And I think that's critically important. I was really moved by both of your stories. Can you talk about your experiences as patients and how do those experiences help you and inform you in your roles as providers? And Stacy, I'd love to start with you.
[00:04:25] Stacy Yonker: Sure, of course. They say there's a big tie between life changing events.
[00:04:31] I had been working at Sarasota Arthritis Center, for a couple of years and I had, at the time recently had a baby and after I had my youngest child, I started to develop symptoms, that were autoimmune related.
[00:04:46] And of course it was excellent. I worked where I needed a consult and I ended up developing psoriatic arthritis with some overlapping of Sjogren's. And to be able to workin the environment to know what the patients go through was extremely eyeopening for me and it really shifted my mindset on the importance of the patient experience and patient care.
[00:05:14] Because myself, it's scary to be told that you may have a really bad joint disease and you may not be able to work in the future. And so you're just hoping that you can get on medications that are going to prevent that, to ensure that you have that quality of life. So I can be there for my kids.
[00:05:32] Being in that space having to wait for the calls from specialty pharmacies and being told by my doctor that, "hey, this is the medication we want to put you on, but, your insurance says no. So here's the second choice." We really you look to your provider for the answers and to get on the treatment that is the best for you.But when your insurance is third party person that is, they've never met you they've never spoken directly to you starts to mandate what treatments best for you. It's very eye opening. It's very frustrating.
[00:06:07] And so it made me that much more wanting to fight for patients to have access to the treatments they need. And it's, shaped the way I operate today.
[00:06:17] Nancy Ellis: Yeah, I agree 100% with you,Stacy. I found out my family has a history of rheumatoid arthritis as well as ankylosing spondylitis but I was like, "Oh, yeah, that was in them. That's not going to be in me" kind of a thing and trying to figure out why I was hurting. Was it just because I was getting older? Is this normal? Arthritis is what it was. Then thinking back like all the times before when, very innocently, I would go, "oh, well how do you know when they fill out a rapid three, whether it's their RA, or whether it's their stove up from gardening kind of a thing."
[00:06:51] And I'm like,"oh, you know." Because now, now I've experienced, I know, you know, that difference kind of a thing and knowing all the things that I know from the administrative side, it was a odd journey for me when I started out in this as well, because having to work with the specialty pharmacy and work through the different layers of calls and know the right questions to ask and know how to say things to be able to get passed on to the next person.
[00:07:19] Average patients don't know those kinds of things. It was a difficult process for me and I workin it. I can't imagine what it's like for somebody who is just, they're scared and this is a completely foreign unnecessarily, in my opinion. complex system.
[00:07:38] Kip Theno: Thank you, Stacy, Nancy.
[00:07:39] And to that point, you did touch on something about all these choices and when patients get switched on medications, or maybe it's not the one initially prescribed and there's all these new innovations and new biologics coming out, and you've talked about this, choices should be a good thing, typically.
[00:07:54] You would think that's the case. The system gets so riddled with complexity, and Nancy, I know you really hammered this before, what is going to help solve that problem for the patients? And you guys are patients, so am I. Is it legislation? I mean, did the Affordable Care Act solve anything?
[00:08:10] Or, Are we just off target? What are your thoughts, Nancy?
[00:08:15] Nancy Ellis: I know when the Affordable CareAct first came out, I remember being really angry and thinking it wasn't going to be a good idea because what was the famous quote of , "you have to pass it so you can know what's in it." Or something like that.
[00:08:29] And I remember thinking, this is no way to do this, but I think over time, it at least opened up access in some ways. I mean, it had unintended consequences as well, and it changed our commercial insurance markets a lot. But I think overall it, it was a good thing. I think, this is all a process and you can have legislation and you can have regulations, but they need to be things that can be in place for more than the four years of one presidency or eight years of one president.We've got to know that you can depend on this is how it's going to be.
[00:09:06] A lot of the things that are happening are, in my opinion, abuses of the system. Stacy and I are both part of an organization called National Organization of Rheumatology Managers (NORM) in one of our speakers a couple of years ago, talked about a ERISA plans and they were like, did you know that in a ERISA plan, these things apply?
[00:09:27] And I think everybody in that room, we're just looking at one another going "no, we didn't know that the ERISA statutes could overlay the contractual statutes that you had in your contract that ERISA would win." And, there were a lot of protections out there that we had for billing and for our patients that we never even knew we had.
[00:09:47] And I think that the health insurance business out there does that on purpose, and makes it unnecessarily complex and they're not forthcoming with information. They're very much spin doctors with what they want you to focus on versus what is really the problem out there.
[00:10:08] Kip Theno: Yeah.
[00:10:08] Stacy, any thoughts to dovetail on that?
[00:10:11] Stacy Yonker: I 100% agree with Nancy. When we were hearing about like the ERISA plans, for example, I know my mind was blown and it just shows you how non transparent our healthcare system is. And it's so interesting because anytime there's a frustration with patients getting them treatment, there's some new regulation or we're not allowed to do this, you can't do that... Doctors, can't be just a clinician. Everything always ties back to the insurance, the payers, they have control. And with that control, it is detrimental to patient care. So I completely agree with Nancy's take on the situation.
[00:10:56] Our healthcare system should be focused on the patient and unfortunately it's not. We have it backwards right now, but hopefully, we can make an impact and make a change.There is a lot of push for legislation and there's a lot of organizations, of all different specialties rheumatology, GI and neurology and other specialties where, they are coming together to try to help make these changes.
[00:11:22] And I think we can do it if we band together.
[00:11:26] Kip Theno: Yeah, and I think you both know we had Christine Mann on the podcast, and she had talked about being up on Capitol Hill, and they were very receptive, they wanted to learn, they were engaged.But then if you think about that institutional knowledge that you two have,Christine had mentioned they were still thinking of infusions, as an example, just focused on oncology. Well now that's absolutely not the case if you just look at the infusion market and neurology and cardiology now and behavioral health and rheumatology. So clearly if we think with the premise that legislation works at a glacial pace and is not the silver bullet, then Stacy, what do you rely on?
[00:11:59] What is your practice or what are you doing to help deal with the complexities and combat the pain points with payers?
[00:12:07] Stacy Yonker: Yeah, I'll tell you, it has not been easy. It's been a long road and I think the road is going to continue on for many years to get to the ideal point if we even get to it.
[00:12:19] But we really had to refine our practices, at least in my practice, where, you have a very strong, strict system and things that we have like set appeal letters and different processes. We do utilize. some data software programs that help give us kind of real time feedback on claims and where they are in the appeal process.
[00:12:44] And it does help streamline, to try to get either denials overturned or, an appeal process in a timely fashion, or for us to follow up with the payer. Because a lot of times you can't rely on them to say, "Hey, by the way, you appealed 60 days ago and you're approaching the limits still hanging out there. Make sure you callus." They're never going to do that. They put a 100% of that onus on the practices that are already inundated. We can only have so many staff, right. So we have to find ways to be able to track what we're doing because everything again comes back to patient care. And if we can't get them get them approved for treatment, or, we administered an infusion and now the insurance is not covering it, it always affects the patient. So I do think technology is crucial going forward, but there's so much legislation right now that until there are also changes on the payer level, like there's delinking of PBMs from profits for certain things.
[00:13:50] I think that would be a huge help to the system. It's definitely going to be a struggle, but datais important, is the way, because if you don't know what you don't know, you know, then how can we take steps to improve it?
[00:14:05] If we don't know what's happening.
[00:14:07] Kip Theno: Stacy, you talk about data: Stacy and Nancy, what types of data, where do you get that data and how do you use that for the benefit of the patients and maybe productive and proactive conversations with payers to affect change?
[00:14:20] Stacy Yonker: Our practice, we utilize organizations like MGMA, they have a revenue cycle dashboard, they have data dive where people can provide for benchmarking.
[00:14:33] For E and M codes, for example, especially if you are a Medicare provider, you're always looking out for big brother and it's like, where do we fall? Are we coding appropriately?
[00:14:44] And, should we be changing the way we're doing things. And especially with legislation where payers can control, they're trying to force you to downcode, so you can get hit if you downcode, but then you can get hit if you upcode. So, it puts us in a really tight position because all the doctors want to do is just see their patients.
[00:15:03] They want to treat them. They want to help them. And the payers make it incredibly difficult to do that. So if we are able to have data, for example, like MGMA's dashboard, which we use in our practice, they provide the national benchmarking. So if I'm looking at what my providers are doing, I can compare it to what other practices are doing, and even Medicare themselves offer this kind of information so that you can see where you lie.
[00:15:31] None of us want to be an outlier because that obviously always poses a risk to the practice and you. Part of our jobs as managers is to reduce that risk while optimizing patient care. And there's definitely a lot of organizations, especially in rheumatology, that are really trying to provide more data and make it more readily available so that practices can use it to combat the payers.
[00:15:57] Kip Theno: Yeah.
[00:15:58] Nancy, how about you?
[00:15:59] Nancy Ellis: Well, I'm just sitting here shaking my head to everything that Stacy was saying. Right now when we think about data and healthcare, a lot of times we think about what we have to provide through the MIPS and MACRA, the required programs and the registries that are out there for those things, but the reality of the world, while that may be what we have to do on paper to satisfy and check a box with the federal government for that quality data, those measures there are not useful in the true taking care of patients. They are yes/no kinds of questions. They're just not helpful And how do you move the ball? And how do you move your practice to be a better practice? So data has two stories to me. It's you have the data that you have to provide to meet your regulations or legislation or whatever out there, the regulatory stuff, which would be my MIPS and macro the registries, all of those kinds of things.
[00:16:57] And then I have the data that we can get to. And some of it we have the ability to do in house through our EMR, we're able to pull different reports and look at things. But then we've also worked with our GPO and they are working with a company called TRIO. And TRIO is able to come in and they look at a lot of different data points in our system.
[00:17:18] And they're able to compare our stuff to other people who are with that GPO that are also on TRIO.And so we're able to see similar practices, even in our state to similar practices in a region, similar practices in the country, be able to start seeing that. And so we know what we're being judged against.
[00:17:38] And so if I'm looking at it and I'm like, Oh, their time to get somebody onto infusion is maybe two months and mine's six months. What are they doing differently? What can I do to look at that? What are the processes and steps in place that they have that help them get to that therapy faster?
[00:17:54] Stacy Yonker: Absolutely. I 100% agree withNancy. I'm also familiar with Trio Health and there is a really great thing that it does. For example, in gout patients, they can track gout and patients that may potentially be under-treated. Data should be used to help patient care or to get them to a better quality of life and not just be seen as something that we are required to do.
[00:18:22] Otherwise Medicare is going to takeaway some of your reimbursement, forcing clinicians and practices to report with threatening to take away money. That is never going to have a positive effect on patient care. It never will because now practices are just going todo it just to check off the boxes and at that point you don't know are we actually really thinking about the patient when we're responding or are we just saying yes, no, what's your number?
[00:18:51] Okay, check it off and moving on. So data should always be in a positive light to actually help patients and not just be a checklist. So I completely agree.
[00:19:03] Nancy Ellis: Yeah, you know, I think about when we are doing our reporting for the MIPS macro MVP, whatever it's called today. It's just a checkbox. Yeah, we've got to do it because the federal government tells us to.
[00:19:15] But it's the data that we're able to glean through our own data dives and through TRIO that really help us move the needle in terms of the patient experience. And, again ,you've got to think. Stacy and I are both with rather large practices and we have the sophistication to be able to get to some of this.
[00:19:32] If you're in a solo room office, you may not have the EMR that can run those kinds of reports. You may not have those kinds of things, but knowing what data you can get to and how you can build that into the story, to use for the care of the patients and, or for contracting when you've got to go out and go up against a health insurance company.
[00:19:53] All of those things are so very important. And a lot of people just don't realize the value of the data that they have agreed.
[00:20:02] Kip Theno: Yeah. And I was Nancy took the words out of my mouth. It sounds like data can be a positive hammer and it's a necessity. it's a must have, but you're right. There's probably a lot out there that don't have maybe the technology or the resources to get that data on their own and then put it in a format to be used.
[00:20:22] But it sounds like you have, and you've had positive results in presenting that cogent detail to make change. So for those that maybe don't have it, can you both just talk about some advice or examples of where they should be getting it or how they should be looking at and putting it together. Even as you said, Nancy, even the small practice, because to me, there's no small patient, right?
[00:20:44] So what are your thoughts on that?
[00:20:46] Nancy Ellis: I think that in a practice, there are some basic things that you should be looking at. It's like how long from date of service to when the claim goes out and that tells you how much time are you spending getting that claim to be ready to go out and that every day that it goes is just longer till you get reimbursed on it.
[00:21:07] I think looking at your denial rates is important. I think looking at the denial rates and codes reasons why behind that by payer is important. We realized when we were looking at some of that, that payer that was less than 1% of our business was responsible for 90% of our billing on the back end of denials and asking for records and delays and all of those kinds of things.
[00:21:32] And for us, it wasn't worth keeping them asa payer. And so being able to have all of that data and be able to present it to them and say, "Hey, we'd like to work with you, but these things need to change" and giving them the opportunity to change those. All of those things are very important. I think you've got to know what is your average days in AR?
[00:21:53] How long does it take you to get a normal claim paid? Medicare is supposed to be within, two weeks, if you're submitting electronically, is that really what's happening or for some reason are you at 21 days? Why is that? So, being able to look at some of those things and figure out what's going on and where in the process is the bottleneck or the holdup or whatever, that's really important.
[00:22:16] Stacy Yonker: Yeah, I absolutely agree. One of the things that I always stress too ,if we bring on new billers and new managers, some of those metrics is you have to know your payer contracts. You need to know what your contracted rates are because you think not every practice is independent.
[00:22:35] There are a lot of practices that are managed by an MSO or another organization. And, I've come across managers that have no idea what their payer contract reimbursement rates are because they're managed by a third party company, and I tell them right off the bat. So you have zero idea if you're even being reimbursed at the rate that you should.
[00:22:56] And we stress that you should always audit, you should know what your net fee collection rate is.You should know if you have a contract, for example, with Aetna and you're supposed to be reimbursed at 115% of Medicare fee schedule, let's say, you should be doing audits to your claims to make sure that you are actually receiving that your reimbursement rate is, it matches that contract of 115%.
[00:23:24] And you would be surprised at how many times and how many cases that you can start doing those internal audits and seeing what your reimbursement rates are. And they may be cutting off a few dollars off the top. And most practices would never know, the way the system is set up, the payers are not out there to make sure we make the money.
[00:23:48] Processes for approving drugs, for example, if they delay one to two treatments because they make you appeal it, whether it's at the claim point or whether you're trying to get it authorized. They save millions of dollars, maybe even depending on how large the payer is hundreds of millions of dollars a year, so they're not out to always make sure let me make sure I'm paying you exactly what you should receive, we have to hold them accountable.
[00:24:17] And there are ways to do it, not necessarily with the dashboard but if you can just have a basic understanding of what your contract is, and look at your claim and see what your reimbursement rate is, we have to hold them accountable. And that's the least that some practices can do if they don't have access to a ton of, data capabilities or their EMR system may not be, the Rolls Royce in the industry.
[00:24:41] Nancy Ellis: I think healthcare in general is a weird business, because we are the only business where the person who orders the service doesn't pay for it. And the person who pays for it doesn't receive it. And the person who received the service really didn't want it in the first place. They didn't want to be sick.
[00:24:59] And so the way we've got the whole payment thing is weird. And then you have the insurance companies who are being unnecessarily complex with a lot of the things that they're doing. And they're betting on the fact that you've got, uh, 1 doc office, who's got maybe 3 staff people and that they don't have time to go in and appeal.
[00:25:19] And that, I asked for this prior authorization and they denied. We've seen things in the news about, AI and different things. being set up to deny the claims first or the prior authorizations first. And I mean those are games that they're playing, but they're playing those games with our health. And I, I think that that's wrong.
[00:25:41] So I think I'd said before, when we talked earlier that I have to get up every day and think of this as a game where I get really mad. And then my job in this game is just like, I want to groan when I hear a particular health insurance companies' name, I want them to groan when they say, "Oh, hell that letter's fromNancy Ellis."
[00:26:03] Kip Theno: Right? Well, yes, Nancy. I remember that. And I definitely want to talk about these algorithms. I've been reading a lot about them over the last couple of years. They're not new, seem to begetting more sophisticated. But in that segue, you had talked about the vertical integration of healthcare, really revolving around the increasing number of intermediaries between patients and their doctors. Can you talk about what you had said to us in the pre show and Stacy jump in at any time and what your solution was? I thought it was, I thought it was absolutely bold and I want our viewers to hear it.
[00:26:37] Nancy Ellis: Because of the way that I grew up, I look at healthcare as a relationship between the doctor and the patient, period. That patient has a need, a healthcare need, that doctor has been trained to take care of that need, that patient trusts that doctor, that doctor knows that patient and their history and whatever, and they're invested in them, and they do what needs to be done.
[00:27:03] The vertical integration now, you've got health insurance companies who are owning the physician practices and so they're owning the doctor that you're going to go see. They're owning the insurance that you use to go see that doctor. They own the pharmacy benefit manager that decides whether or not you get the treatment that that doctor wanted you to get.
[00:27:27] And then they own, like if you needed physical therapy, they may own the physical therapy things. If you need home health, they may own those. They may own infusion centers. They may own
[00:27:40] Stacy Yonker: specialty pharmacies,
[00:27:41] Nancy Ellis: specialty pharmacies. I mean, the list goes on and you as a patient don't know that because they all have different names.
[00:27:50] And in the last 15years, we've gone from being a healthcare system that had lots of options out there, I think, to basically now we're controlled, whether we realize it ornot, by about five different conglomerates for all of your healthcare kinds of stuff, and that everything falls up under one of them in one way, shape, form, or fashion, and to me, I think that that has been a problem in our healthcare system as well.
[00:28:18] Kip Theno: Nancy, you also had a bold solution, as I mentioned. I mean, there are well intended bureaucracies, but you had something that struck me as interesting and implementation aside, what was your idea?
[00:28:29] Nancy Ellis: I think today the problem is in the PBMs, because with the introduction of the Affordable CareAct, the health insurance plans were limited as to how much profit they could make off of a particular insurance product.
[00:28:48] And when that happened, they were like, okay, but we still have to make money. And that's when all of the PBMs came into place. And so these pharmacy benefit managers are sitting out there and you want to believe that, they're making all these great and kind and informed decisions, but they're not, they're doing things where they're getting rebates for whether or not they allow you to be on their formulary or not.
[00:29:11] There's some drugs that they have a high WAC and a low WAC for same drug, but they have it offered at two different prices. I still hadn't figured that one out. And it's within the PBM structure that most of the money is being made now. And it's also within that PBM structure, in my opinion, where I'm seeing a lot of the abuses happen.
[00:29:35] From us not being able to get our patients the treatments that they need. And so, and I don't see that that PBM function really does anything. I mean the doctors went to school and if you're prescribing something that's on label and they've got it on their formulary, then you should be able to get it without having to get a prior authorization or do step therapy or do any of these other utilization review things that they like to put out in front of you.
[00:30:02] All everything that they do is to keep you from getting the service as long as they get your money.They don't care. They don't want to have to pay it to us, though.
[00:30:13] Stacy Yonker: Absolutely. I, I will kind of go off on that as well that the PBMs, I think, as well are one of the major issues in our healthcare system.
[00:30:26] I understand the intent was for it to reduce waste I think, originally, maybe some of the intentions were clear but what it has become now is it justPBMs harm patient care. They limit access to medications. They often input complex prior authorization processes.
[00:30:46] You throw in all these step therapy practices. They then try to force you to use their own mail order pharmacies, like there's no transparency. It has a huge impact on independent pharmacies, which actually could offer more cost savings to patients. But of course, then the PBM or the insurance payer company, cause they're in a vertically integrated, they're not going to make the profits, right?
[00:31:08] So they don't want that. They want to keep all of the money and As much as they can, while the CEOs are laughing their way to the bank, making 20, 40 million a year while denying patient care. And it literally comes down to , with current legislation efforts and , until we de link profits from PBM, it actually increases the cost of patients, right?
[00:31:34] The formularies, you know, it's how much money am I going to make from the manufacturers so that I will offer your drug to patients. And, when in our space and rheumatology, we do infusions in house, so there's benefits that are pharmacy benefit versus medical benefit.Literally, we have to track things like ASP which is your average sales price and your reimbursement is off it, and we have drugs and treatments that we can't even provide to our patients anymore because if we did, it loses us money.
[00:32:08] And, no one is in the position, especially independent private practices, to be able to provide charity care, we don't get government funding, we don't receive grants we aren't tax free, we don't get the write offs and really, it all comes down to the PBMs because they control what medicines patients have to take.
[00:32:29] And we see it all the time in the prior authorization process where they give us two specific medications that a patient has to try and fail before the doctor can get their primary choice of treatment for that patient. And when you look into it, the reason they're offering those on formulary is because the particular manufacturer is offering them such a high rebate.
[00:32:52] to put, which is again, is more money in their pockets, to offer it that they take their ASP in the process. Um, but you know, the PBMs don't care. The insurance payers don't care because they're receiving 70, 80, 90 percent rebate for offering a certain drug. And so when we're looking at.
[00:33:11] What the issue is in our healthcare system.And people say that patients can't afford treatment. You know, it, it makes absolute zero sense that, Hey, here's your premium for your Medicare "disadvantage" plan that you only have to pay 10 bucks a month. But by the way, for you to receive treatment, $2000 a month.
[00:33:31] So there are no savings that are passed down to the patients at all with the way our system is set up right now. And it's the PBMs. It's the payers. Yeah.
[00:33:41] Nancy Ellis: I look at it and I'm thinking through like, okay, is it really, truly just a PBM issue? And, and they're just such a problem right now that nobody understands.
[00:33:52] And that's by design. I've had patients be denied for treatments and us be told that, well, it's not, medically necessary, and we're looking through and we're like, what do you mean? It's not medically necessary. Well, the patient hasn't maxed out at 50 milligrams of prednisone yet, and you're going, you're never going to give a patient 50 milligrams of prednisone.
[00:34:16] That's bad patient care. Yeah. And. And so you ask, can we see that policy where that's coming from? No, that's proprietary. And so they hide behind the proprietary wall. ButI think that there's also more games that they like to play. Going back to my game analogy of it's in the PBMs and it has to do with the drugs, but it happens on the health insurance side of it with the copay card.
[00:34:39] Accumulators and maximizers and happens on the health plan side in the plan design when they put in the alternative funding plan things for biologics and that basically they're selling a health insurance plan to a company saying basically we're not going to cover any of these biologics because they're going to go out and try to raid the manufacturers' foundations for free drug and that's their business model.And, it just makes no sense. It's like on one side, they're like, yeah, you have to pay us all this money to get the preferred placement. But then on the other side, it's like, we're gonna not even provide the service.
[00:35:19] So you're going to have to go get it, take it from them somewhere else. The whole thing is just unnecessarily complex. And my belief is, is that it has to do with the for profit motive in healthcare.
[00:35:34] Kip Theno: Yeah, I mean, Stacy and Nancy, that just everything you're saying is the incentives are misaligned.
[00:35:42] There's so many redundancies. Remember a time where it was the doctor treats the patient in front of them. I wonder then With those redundancies that are keeping patients from getting on the right therapy at the right time Those become useless in a way.
[00:35:59] How do you cut those out then? What is the next step? What can you all do? What can we do together to help fix that part before we go on to our last topic? I'm, really curious as to what you think needs to happen or is the inflection point just going to get worse? I
[00:36:13] Nancy Ellis: think that in general It's going to take patients, customers of the health insurance, customers of the PBM to get angry because right now when they don't get what they want, they see it as, well, my doctor didn't get that for me. They don't see it that their health insurance didn't get it for them, if that makes sense.
[00:36:39] And so there's a lot of anger with folks directed at. physicians that I think is misplaced because we can only do so much. And like the insurance company will say to us, well, we're not telling you, you can't use that. Well, yeah, you are effectively because you're saying a, you're either not going to pay for it, or you're going to pay for under levels that I can obtain it at.
[00:37:01] So, yeah, that's not the right argument there.
[00:37:05] Stacy Yonker: Yeah. Stacy, what are your thoughts? I, yeah, it's not, it's not easy and it's not going to be easy, but you know, people have to get angry and,I'll tell you, there's some organizations that are led by physicians and they are working really hard to get the system changed.
[00:37:24] And then there's management organizations that are doing the same thing to help advocate. And, I think those efforts are great, and I think it's a good step, but I agree withNancy until the patients have that transparent look into how the system works, and how it affects their care, they need to get angry, and, it has to take A systematic change where it takes the patients to basically to fight back in away to say, no, I am not going to purchase a plan from you. You don't take care of your patients. It causes more issues than it's worth. And until those, until a payer loses their clients and their client base. No one's going to, they're not going to make a change.
[00:38:17] So we, yeah, we have to educate the patients, and get everybody involved and they have to get angry.They have to get mad enough where they will write a letter and they will stop purchasing plans from there. They will go anywhere but the payers. I think that's the only way that we'll see a shift.
[00:38:37] Nancy Ellis: I think as consumers of the healthcare system and purchasers of those plans. Most 90 percent of us probably get them through our employers and so it's making sure that if you're angry as the patient that your employer knows that and knows why and that you can articulate why and that those stories get passed up to whoever's making the decisions for the plan because ultimately especially if it's a self insured plan they have a fiduciary responsibility to you to make sure that they're getting the best value for the money that they're giving. And you're seeing lots of different, lawsuits now where the employees are suing the employers based off of that fiduciary responsibility. Because we see our premiums go up 8, 10, 12percent every year, but we're getting less care for it.
[00:39:28] Stacy Yonker: Right. It's like, for what?
[00:39:30] Nancy Ellis: Right. So yes, the patients have to get angry, but employers have to get savvy and they can't just say, okay, they have to know all the details of that plan. They need to know what to ask for. They can't just come in and say, okay, well, what's it going to be this year?
[00:39:44] How much more am I going to have to pay?They need to know the details and they need to know how that's really going to impact their, their patients. They need claims data in terms of, you know, patients that are high cost and, you know, can we carve those patients out? They need to be able to be much more sophisticated about the way that they purchase it and the health insurance companies, these integrated conglomerates are banking on the fact that they know we don't know how to do some of that stuff and that once we figure it out, then they change the game.
[00:40:21] Kip Theno: Uh, this is, this is been such critical information. And I want to circle back to what you had mentioned you have experience with. I was shocked reading reports over the last year or two and even recently that, there are algorithms now even utilizing AI, as an example, to auto deny large percentage of claims, benefits, prior authorizations.
[00:40:41] That's oftentimes critical, life saving, rare disease therapies for patients. And you're dealing with this every day. I mean, that's a juggernaut and, there's no uniformity on payers, Nancy and Stacy, you know this too. Three payers might approve 99 percent of the time, the other seven on the same drug might deny 46 percent of the time.
[00:40:59] What are you doing about that? And what is the impact of the patients that you're seeing there?
[00:41:04] Stacy Yonker: I would say, I think there is a time and a place for AI. I can see where it can help automate some processes because, you know, the last 20years, right? The private physicians groups, they're receiving Medicare reimbursement cuts, every year, but yet they're being expected to do more work, to document more, to jump through more hoops, but then, receive 22 percent less than they did 15 years ago, which, , is insane, not even taking into account inflation and needing to keep good staff on hand, they have bills to pay, they're experiencing inflation as well.
[00:41:47] And so, I can seethe appeal of AI in the healthcare system, and I think it has a place. If it is augmenting care or if it is augmenting the workflow of a practice to help alleviate some of that resource burden that we experience, but on the payer side, AI could still be beneficial, but if their payer policies are explicitly set to deny care or to make it that much harder for patients to receive the treatment that they need to. AI should not be allowed, in my opinion. If you want to deny 22 percent of every claim that comes through or every prior authorization request, there should be a person that is sitting there looking at that patient. They should have a photo.
[00:42:38] We need to personalize it so that they can still sit and look at a patient and say, you know what, I can see you actually need it. But I have a metric that I have to meet because Aetna or United Healthcare, whatever tells me I have to, and I'm going to deny that care anyway.
[00:42:54] If they set it to AI doing it, we are now even completely dehumanizing the healthcare system even further and thinking of what Nancy said, like for her coming into the healthcare system, you know that the relationship, the patient and the doctor, and it was more humanistic, which is what healthcare should be. AI completely, at this point in the way they're utilizing it, removes the human. Because now there isn't even a person that needs to review a case, a computer's doing it, and computers can't feel emotions and they can't look outside of what their algorithms are set up to do. There needs to be an overhaul completely, beforeAI is fully utilized in the healthcare environment.
[00:43:41] Nancy Ellis: When I think about AI, I think about, okay, we have AI that's part of our electronic medical record. And so if we turn that on and we're letting it analyze what we're looking at and stuff.
[00:43:54] It may ask questions that may stimulate our doctor to go, Hmm, maybe I should look at this or, Hmm, maybe I should have, you should do that. And where it can augment, like Stacy said, I think that that's very helpful. I know when I use open source AI to goin and write a appeal letter to an insurance company, I can put in the basic facts and it can write it for me pretty quickly. And that's very helpful.That's time saving to me in the practice.
[00:44:22] But I think when the insurance companies get hold of AI, it's AI through the filters and algorithms that they want it to be, but then also end up denying 60 percent of everything the first time around.
[00:44:39] Because they're betting that you don't have in a doctor's office, you don't have staff to fight that or to appeal it and they're betting that the patient will just go, "Oh, well, you know, somebody will write that off." And they have, and they can get away with it.
[00:44:56] We've got to get where we feel like we have the power back to fight back against that and go, no, that's not okay. As a provider, a lot of times we don't want to rock the boat because, oh, if I, if I, you know, the, the squeaky wheel out there, that insurance company could drop me and that could mean bad things for me.
[00:45:15] Or, I could get on their poor provider list or whatever. And, you don't want to be on those things, but they have that big stick to threaten you with, and as providers, we don't feel like we have anything to fight back with, but that's where the data comes in, that's where getting the patients involved in their care, that's, that's important where they can get their employers involved in their care.It's where you can advocate on the state and national levels. All of these things may be slow, but it's all got to start somewhere.
[00:45:47] Kip Theno: Yeah. Well, Stacy and Nancy, listen, you have exposed a lot here. We are going to get this out to the masses.
[00:45:53] I want to thank you for being on the Road to Care podcast. And I hope you get it out to the masses and keep fighting the good fight. We appreciate you two so much. I learned a ton today. I know our listeners will as well. Stacy how do our listeners out there reach out to you for more information?
[00:46:07] What's your contact?
[00:46:08] Stacy Yonker: Of course, of course. I have aLinkedIn , if anybody would like to connect, you can just look me up, as well as if anyone wants to take discussions further, I'm happy to provide my email.So it's my first name, Stacy, stacy@arthritiscenters.net, and happy to have those discussions. Nancy is an amazing advocate as well. And we'll cut it to you straight for that. So, definitely looking forward to connecting.
[00:46:37] Kip Theno: Nancy, how about you? What's the best way for folks to reach you?
[00:46:40] Nancy Ellis: I have LinkedIn, so anybody can reach out to me through that if they would like, but my email here within the practice is Nancy, nancy.ellis@piedmontarthiritis.com.
[00:46:57] Kip Theno: Well, thank you, Nancy and Stacy.You know, the tagline for the show is together we can make things right. Thank you for being on the Road to Care podcast. And we're looking forward to getting this out there in mass. Thank you so much.
[00:47:07] Stacy Yonker: Thank you. It was a pleasure.
[00:47:09] Keep up the good work.
[00:47:11] Kip Theno: Thank you for joining the Road toCare podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script to therapy operating system, we enable connectivity with clinics, peers, and manufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
[00:47:29] Enjoy the music written, produced and recorded by Jamestown.
Podcast produced by JFACTOR, visit https://www.jfactor.com/
Together, we can make healthcare right. Here are some of the outstanding healthcare organizations and associations championing patient health mentioned in this episode:
[00:00:00] Kip Theno: Welcome to the Road to Care podcast hosted by SamaCare, where we will talk with key opinion leaders, physicians, administrators, manufacturers, venture capitalists, and legislators to get their insights on the state of health care today and where we see it evolving. SamaCare's prior authorization platform is free to clinics, ensuring patients get on the right therapy at the right time.
[00:00:20] Together, we can simply make things right.
[00:00:27] Hey everybody, welcome back to the Road to Care podcast hosted by SamaCare. Today our special guests are Nancy Ellis and Stacy Yonker. Nancy is an MBA, MHA, CHE, CRHC, CRMS, and CPMA. Nancy is a practice administrator at Piedmont Arthritis Clinic, a rheumatology practice, location in South Carolina.
[00:00:50] Nancy has over four decades of experience in healthcare administration across rheumatology, oncology, and orthopedics, and across private practice, hospital and home care settings.
[00:01:00] And Stacy is an MBA,CMPE, LSSBB, CRCMP, CRMS, and CMPM. And she is Chief Executive Officer at Sarasota Arthritis Center. And as CEO of Sarasota Arthritis Center, she has over a decade of experience in rheumatology.
[00:01:19] Currently she oversees all operations of the multi location 14 provider practice and Stacy and Nancy, super excited to have you today. How are you?
[00:01:27] Nancy Ellis: Thank you, Kip. We appreciate being asked and are excited to have this time with you today.
[00:01:34] Stacy Yonker: Happy to be here. Yes. And hopefully we can bring value.
[00:01:37] Kip Theno: We are glad I was super excited for this one because I know there's going to be some fireworks, some ground rules, keep the gloves up, no rabbit punches.
[00:01:45] We'll come out swinging. But first of all, Nancy and Stacy, thank you for joining. And I would love to start with your journey into healthcare and maybe Stacy will start with you.
[00:01:54] Stacy Yonker: Sure. A little over a decade ago, I by trade was in hospitality industry. So I have a love of people, and taking care and serving others.
[00:02:05] And I found my way into healthcare through Sarasota Arthritis Centers. I started as a patient care coordinator. So kind of dipping my toes and I just had a love of taking care of patients and getting them treatment. And rheumatology grew on me. I'm still init. Over the years I have just worked my way up, been biologics coordinator,I've been in billing. And, I just have a love of the rheumatology field in particular and patient care.
[00:02:37] Kip Theno: Well, thank you, Stacy. Nancy, how about your journey?
[00:02:41] Nancy Ellis: Well, my dad was a general practitioner. My mom was a nurse anesthetist. And growing up, there was never really any question in my mind that I was going to be in healthcare.
[00:02:50] It was just going to be what was I going to do? Growing up in East Tennessee in Sevierville at the time when I was little, I can remember seeing my dad pack saddlebags to go up in the mountains to take care of patients. And I remember, we would be paid with quilts or eggs or fish or whatever.
[00:03:09] So my introduction as to how healthcare process went may be a little different than a lot of other people's. I ended up going to graduate school because I learned pretty quick that I was good at managing the processes around things, but not the patients themselves. Then I worked in hospitals for a while when we moved here to SouthCarolina, I decided I wanted to work on the physician side of it and worked a little bit in oncology, worked a little bit in orthopedics, and then have found my home, I think, in rheumatology, I've been here for the last 16 years. I hope to retire here.
[00:03:52] Kip Theno: Wow. Well, thank you.
[00:03:54] And by the way,Nancy, I do think at some level we should go back to the barter system, right?Chickens, eggs, whatever, but we might get to that later, but I remember in our pre-show we had a profound conversation. You both shared with me your personal experiences, not only as healthcare providers and caregivers, but also as patients.
[00:04:12] And I think that's critically important. I was really moved by both of your stories. Can you talk about your experiences as patients and how do those experiences help you and inform you in your roles as providers? And Stacy, I'd love to start with you.
[00:04:25] Stacy Yonker: Sure, of course. They say there's a big tie between life changing events.
[00:04:31] I had been working at Sarasota Arthritis Center, for a couple of years and I had, at the time recently had a baby and after I had my youngest child, I started to develop symptoms, that were autoimmune related.
[00:04:46] And of course it was excellent. I worked where I needed a consult and I ended up developing psoriatic arthritis with some overlapping of Sjogren's. And to be able to workin the environment to know what the patients go through was extremely eyeopening for me and it really shifted my mindset on the importance of the patient experience and patient care.
[00:05:14] Because myself, it's scary to be told that you may have a really bad joint disease and you may not be able to work in the future. And so you're just hoping that you can get on medications that are going to prevent that, to ensure that you have that quality of life. So I can be there for my kids.
[00:05:32] Being in that space having to wait for the calls from specialty pharmacies and being told by my doctor that, "hey, this is the medication we want to put you on, but, your insurance says no. So here's the second choice." We really you look to your provider for the answers and to get on the treatment that is the best for you.But when your insurance is third party person that is, they've never met you they've never spoken directly to you starts to mandate what treatments best for you. It's very eye opening. It's very frustrating.
[00:06:07] And so it made me that much more wanting to fight for patients to have access to the treatments they need. And it's, shaped the way I operate today.
[00:06:17] Nancy Ellis: Yeah, I agree 100% with you,Stacy. I found out my family has a history of rheumatoid arthritis as well as ankylosing spondylitis but I was like, "Oh, yeah, that was in them. That's not going to be in me" kind of a thing and trying to figure out why I was hurting. Was it just because I was getting older? Is this normal? Arthritis is what it was. Then thinking back like all the times before when, very innocently, I would go, "oh, well how do you know when they fill out a rapid three, whether it's their RA, or whether it's their stove up from gardening kind of a thing."
[00:06:51] And I'm like,"oh, you know." Because now, now I've experienced, I know, you know, that difference kind of a thing and knowing all the things that I know from the administrative side, it was a odd journey for me when I started out in this as well, because having to work with the specialty pharmacy and work through the different layers of calls and know the right questions to ask and know how to say things to be able to get passed on to the next person.
[00:07:19] Average patients don't know those kinds of things. It was a difficult process for me and I workin it. I can't imagine what it's like for somebody who is just, they're scared and this is a completely foreign unnecessarily, in my opinion. complex system.
[00:07:38] Kip Theno: Thank you, Stacy, Nancy.
[00:07:39] And to that point, you did touch on something about all these choices and when patients get switched on medications, or maybe it's not the one initially prescribed and there's all these new innovations and new biologics coming out, and you've talked about this, choices should be a good thing, typically.
[00:07:54] You would think that's the case. The system gets so riddled with complexity, and Nancy, I know you really hammered this before, what is going to help solve that problem for the patients? And you guys are patients, so am I. Is it legislation? I mean, did the Affordable Care Act solve anything?
[00:08:10] Or, Are we just off target? What are your thoughts, Nancy?
[00:08:15] Nancy Ellis: I know when the Affordable CareAct first came out, I remember being really angry and thinking it wasn't going to be a good idea because what was the famous quote of , "you have to pass it so you can know what's in it." Or something like that.
[00:08:29] And I remember thinking, this is no way to do this, but I think over time, it at least opened up access in some ways. I mean, it had unintended consequences as well, and it changed our commercial insurance markets a lot. But I think overall it, it was a good thing. I think, this is all a process and you can have legislation and you can have regulations, but they need to be things that can be in place for more than the four years of one presidency or eight years of one president.We've got to know that you can depend on this is how it's going to be.
[00:09:06] A lot of the things that are happening are, in my opinion, abuses of the system. Stacy and I are both part of an organization called National Organization of Rheumatology Managers (NORM) in one of our speakers a couple of years ago, talked about a ERISA plans and they were like, did you know that in a ERISA plan, these things apply?
[00:09:27] And I think everybody in that room, we're just looking at one another going "no, we didn't know that the ERISA statutes could overlay the contractual statutes that you had in your contract that ERISA would win." And, there were a lot of protections out there that we had for billing and for our patients that we never even knew we had.
[00:09:47] And I think that the health insurance business out there does that on purpose, and makes it unnecessarily complex and they're not forthcoming with information. They're very much spin doctors with what they want you to focus on versus what is really the problem out there.
[00:10:08] Kip Theno: Yeah.
[00:10:08] Stacy, any thoughts to dovetail on that?
[00:10:11] Stacy Yonker: I 100% agree with Nancy. When we were hearing about like the ERISA plans, for example, I know my mind was blown and it just shows you how non transparent our healthcare system is. And it's so interesting because anytime there's a frustration with patients getting them treatment, there's some new regulation or we're not allowed to do this, you can't do that... Doctors, can't be just a clinician. Everything always ties back to the insurance, the payers, they have control. And with that control, it is detrimental to patient care. So I completely agree with Nancy's take on the situation.
[00:10:56] Our healthcare system should be focused on the patient and unfortunately it's not. We have it backwards right now, but hopefully, we can make an impact and make a change.There is a lot of push for legislation and there's a lot of organizations, of all different specialties rheumatology, GI and neurology and other specialties where, they are coming together to try to help make these changes.
[00:11:22] And I think we can do it if we band together.
[00:11:26] Kip Theno: Yeah, and I think you both know we had Christine Mann on the podcast, and she had talked about being up on Capitol Hill, and they were very receptive, they wanted to learn, they were engaged.But then if you think about that institutional knowledge that you two have,Christine had mentioned they were still thinking of infusions, as an example, just focused on oncology. Well now that's absolutely not the case if you just look at the infusion market and neurology and cardiology now and behavioral health and rheumatology. So clearly if we think with the premise that legislation works at a glacial pace and is not the silver bullet, then Stacy, what do you rely on?
[00:11:59] What is your practice or what are you doing to help deal with the complexities and combat the pain points with payers?
[00:12:07] Stacy Yonker: Yeah, I'll tell you, it has not been easy. It's been a long road and I think the road is going to continue on for many years to get to the ideal point if we even get to it.
[00:12:19] But we really had to refine our practices, at least in my practice, where, you have a very strong, strict system and things that we have like set appeal letters and different processes. We do utilize. some data software programs that help give us kind of real time feedback on claims and where they are in the appeal process.
[00:12:44] And it does help streamline, to try to get either denials overturned or, an appeal process in a timely fashion, or for us to follow up with the payer. Because a lot of times you can't rely on them to say, "Hey, by the way, you appealed 60 days ago and you're approaching the limits still hanging out there. Make sure you callus." They're never going to do that. They put a 100% of that onus on the practices that are already inundated. We can only have so many staff, right. So we have to find ways to be able to track what we're doing because everything again comes back to patient care. And if we can't get them get them approved for treatment, or, we administered an infusion and now the insurance is not covering it, it always affects the patient. So I do think technology is crucial going forward, but there's so much legislation right now that until there are also changes on the payer level, like there's delinking of PBMs from profits for certain things.
[00:13:50] I think that would be a huge help to the system. It's definitely going to be a struggle, but datais important, is the way, because if you don't know what you don't know, you know, then how can we take steps to improve it?
[00:14:05] If we don't know what's happening.
[00:14:07] Kip Theno: Stacy, you talk about data: Stacy and Nancy, what types of data, where do you get that data and how do you use that for the benefit of the patients and maybe productive and proactive conversations with payers to affect change?
[00:14:20] Stacy Yonker: Our practice, we utilize organizations like MGMA, they have a revenue cycle dashboard, they have data dive where people can provide for benchmarking.
[00:14:33] For E and M codes, for example, especially if you are a Medicare provider, you're always looking out for big brother and it's like, where do we fall? Are we coding appropriately?
[00:14:44] And, should we be changing the way we're doing things. And especially with legislation where payers can control, they're trying to force you to downcode, so you can get hit if you downcode, but then you can get hit if you upcode. So, it puts us in a really tight position because all the doctors want to do is just see their patients.
[00:15:03] They want to treat them. They want to help them. And the payers make it incredibly difficult to do that. So if we are able to have data, for example, like MGMA's dashboard, which we use in our practice, they provide the national benchmarking. So if I'm looking at what my providers are doing, I can compare it to what other practices are doing, and even Medicare themselves offer this kind of information so that you can see where you lie.
[00:15:31] None of us want to be an outlier because that obviously always poses a risk to the practice and you. Part of our jobs as managers is to reduce that risk while optimizing patient care. And there's definitely a lot of organizations, especially in rheumatology, that are really trying to provide more data and make it more readily available so that practices can use it to combat the payers.
[00:15:57] Kip Theno: Yeah.
[00:15:58] Nancy, how about you?
[00:15:59] Nancy Ellis: Well, I'm just sitting here shaking my head to everything that Stacy was saying. Right now when we think about data and healthcare, a lot of times we think about what we have to provide through the MIPS and MACRA, the required programs and the registries that are out there for those things, but the reality of the world, while that may be what we have to do on paper to satisfy and check a box with the federal government for that quality data, those measures there are not useful in the true taking care of patients. They are yes/no kinds of questions. They're just not helpful And how do you move the ball? And how do you move your practice to be a better practice? So data has two stories to me. It's you have the data that you have to provide to meet your regulations or legislation or whatever out there, the regulatory stuff, which would be my MIPS and macro the registries, all of those kinds of things.
[00:16:57] And then I have the data that we can get to. And some of it we have the ability to do in house through our EMR, we're able to pull different reports and look at things. But then we've also worked with our GPO and they are working with a company called TRIO. And TRIO is able to come in and they look at a lot of different data points in our system.
[00:17:18] And they're able to compare our stuff to other people who are with that GPO that are also on TRIO.And so we're able to see similar practices, even in our state to similar practices in a region, similar practices in the country, be able to start seeing that. And so we know what we're being judged against.
[00:17:38] And so if I'm looking at it and I'm like, Oh, their time to get somebody onto infusion is maybe two months and mine's six months. What are they doing differently? What can I do to look at that? What are the processes and steps in place that they have that help them get to that therapy faster?
[00:17:54] Stacy Yonker: Absolutely. I 100% agree withNancy. I'm also familiar with Trio Health and there is a really great thing that it does. For example, in gout patients, they can track gout and patients that may potentially be under-treated. Data should be used to help patient care or to get them to a better quality of life and not just be seen as something that we are required to do.
[00:18:22] Otherwise Medicare is going to takeaway some of your reimbursement, forcing clinicians and practices to report with threatening to take away money. That is never going to have a positive effect on patient care. It never will because now practices are just going todo it just to check off the boxes and at that point you don't know are we actually really thinking about the patient when we're responding or are we just saying yes, no, what's your number?
[00:18:51] Okay, check it off and moving on. So data should always be in a positive light to actually help patients and not just be a checklist. So I completely agree.
[00:19:03] Nancy Ellis: Yeah, you know, I think about when we are doing our reporting for the MIPS macro MVP, whatever it's called today. It's just a checkbox. Yeah, we've got to do it because the federal government tells us to.
[00:19:15] But it's the data that we're able to glean through our own data dives and through TRIO that really help us move the needle in terms of the patient experience. And, again ,you've got to think. Stacy and I are both with rather large practices and we have the sophistication to be able to get to some of this.
[00:19:32] If you're in a solo room office, you may not have the EMR that can run those kinds of reports. You may not have those kinds of things, but knowing what data you can get to and how you can build that into the story, to use for the care of the patients and, or for contracting when you've got to go out and go up against a health insurance company.
[00:19:53] All of those things are so very important. And a lot of people just don't realize the value of the data that they have agreed.
[00:20:02] Kip Theno: Yeah. And I was Nancy took the words out of my mouth. It sounds like data can be a positive hammer and it's a necessity. it's a must have, but you're right. There's probably a lot out there that don't have maybe the technology or the resources to get that data on their own and then put it in a format to be used.
[00:20:22] But it sounds like you have, and you've had positive results in presenting that cogent detail to make change. So for those that maybe don't have it, can you both just talk about some advice or examples of where they should be getting it or how they should be looking at and putting it together. Even as you said, Nancy, even the small practice, because to me, there's no small patient, right?
[00:20:44] So what are your thoughts on that?
[00:20:46] Nancy Ellis: I think that in a practice, there are some basic things that you should be looking at. It's like how long from date of service to when the claim goes out and that tells you how much time are you spending getting that claim to be ready to go out and that every day that it goes is just longer till you get reimbursed on it.
[00:21:07] I think looking at your denial rates is important. I think looking at the denial rates and codes reasons why behind that by payer is important. We realized when we were looking at some of that, that payer that was less than 1% of our business was responsible for 90% of our billing on the back end of denials and asking for records and delays and all of those kinds of things.
[00:21:32] And for us, it wasn't worth keeping them asa payer. And so being able to have all of that data and be able to present it to them and say, "Hey, we'd like to work with you, but these things need to change" and giving them the opportunity to change those. All of those things are very important. I think you've got to know what is your average days in AR?
[00:21:53] How long does it take you to get a normal claim paid? Medicare is supposed to be within, two weeks, if you're submitting electronically, is that really what's happening or for some reason are you at 21 days? Why is that? So, being able to look at some of those things and figure out what's going on and where in the process is the bottleneck or the holdup or whatever, that's really important.
[00:22:16] Stacy Yonker: Yeah, I absolutely agree. One of the things that I always stress too ,if we bring on new billers and new managers, some of those metrics is you have to know your payer contracts. You need to know what your contracted rates are because you think not every practice is independent.
[00:22:35] There are a lot of practices that are managed by an MSO or another organization. And, I've come across managers that have no idea what their payer contract reimbursement rates are because they're managed by a third party company, and I tell them right off the bat. So you have zero idea if you're even being reimbursed at the rate that you should.
[00:22:56] And we stress that you should always audit, you should know what your net fee collection rate is.You should know if you have a contract, for example, with Aetna and you're supposed to be reimbursed at 115% of Medicare fee schedule, let's say, you should be doing audits to your claims to make sure that you are actually receiving that your reimbursement rate is, it matches that contract of 115%.
[00:23:24] And you would be surprised at how many times and how many cases that you can start doing those internal audits and seeing what your reimbursement rates are. And they may be cutting off a few dollars off the top. And most practices would never know, the way the system is set up, the payers are not out there to make sure we make the money.
[00:23:48] Processes for approving drugs, for example, if they delay one to two treatments because they make you appeal it, whether it's at the claim point or whether you're trying to get it authorized. They save millions of dollars, maybe even depending on how large the payer is hundreds of millions of dollars a year, so they're not out to always make sure let me make sure I'm paying you exactly what you should receive, we have to hold them accountable.
[00:24:17] And there are ways to do it, not necessarily with the dashboard but if you can just have a basic understanding of what your contract is, and look at your claim and see what your reimbursement rate is, we have to hold them accountable. And that's the least that some practices can do if they don't have access to a ton of, data capabilities or their EMR system may not be, the Rolls Royce in the industry.
[00:24:41] Nancy Ellis: I think healthcare in general is a weird business, because we are the only business where the person who orders the service doesn't pay for it. And the person who pays for it doesn't receive it. And the person who received the service really didn't want it in the first place. They didn't want to be sick.
[00:24:59] And so the way we've got the whole payment thing is weird. And then you have the insurance companies who are being unnecessarily complex with a lot of the things that they're doing. And they're betting on the fact that you've got, uh, 1 doc office, who's got maybe 3 staff people and that they don't have time to go in and appeal.
[00:25:19] And that, I asked for this prior authorization and they denied. We've seen things in the news about, AI and different things. being set up to deny the claims first or the prior authorizations first. And I mean those are games that they're playing, but they're playing those games with our health. And I, I think that that's wrong.
[00:25:41] So I think I'd said before, when we talked earlier that I have to get up every day and think of this as a game where I get really mad. And then my job in this game is just like, I want to groan when I hear a particular health insurance companies' name, I want them to groan when they say, "Oh, hell that letter's fromNancy Ellis."
[00:26:03] Kip Theno: Right? Well, yes, Nancy. I remember that. And I definitely want to talk about these algorithms. I've been reading a lot about them over the last couple of years. They're not new, seem to begetting more sophisticated. But in that segue, you had talked about the vertical integration of healthcare, really revolving around the increasing number of intermediaries between patients and their doctors. Can you talk about what you had said to us in the pre show and Stacy jump in at any time and what your solution was? I thought it was, I thought it was absolutely bold and I want our viewers to hear it.
[00:26:37] Nancy Ellis: Because of the way that I grew up, I look at healthcare as a relationship between the doctor and the patient, period. That patient has a need, a healthcare need, that doctor has been trained to take care of that need, that patient trusts that doctor, that doctor knows that patient and their history and whatever, and they're invested in them, and they do what needs to be done.
[00:27:03] The vertical integration now, you've got health insurance companies who are owning the physician practices and so they're owning the doctor that you're going to go see. They're owning the insurance that you use to go see that doctor. They own the pharmacy benefit manager that decides whether or not you get the treatment that that doctor wanted you to get.
[00:27:27] And then they own, like if you needed physical therapy, they may own the physical therapy things. If you need home health, they may own those. They may own infusion centers. They may own
[00:27:40] Stacy Yonker: specialty pharmacies,
[00:27:41] Nancy Ellis: specialty pharmacies. I mean, the list goes on and you as a patient don't know that because they all have different names.
[00:27:50] And in the last 15years, we've gone from being a healthcare system that had lots of options out there, I think, to basically now we're controlled, whether we realize it ornot, by about five different conglomerates for all of your healthcare kinds of stuff, and that everything falls up under one of them in one way, shape, form, or fashion, and to me, I think that that has been a problem in our healthcare system as well.
[00:28:18] Kip Theno: Nancy, you also had a bold solution, as I mentioned. I mean, there are well intended bureaucracies, but you had something that struck me as interesting and implementation aside, what was your idea?
[00:28:29] Nancy Ellis: I think today the problem is in the PBMs, because with the introduction of the Affordable CareAct, the health insurance plans were limited as to how much profit they could make off of a particular insurance product.
[00:28:48] And when that happened, they were like, okay, but we still have to make money. And that's when all of the PBMs came into place. And so these pharmacy benefit managers are sitting out there and you want to believe that, they're making all these great and kind and informed decisions, but they're not, they're doing things where they're getting rebates for whether or not they allow you to be on their formulary or not.
[00:29:11] There's some drugs that they have a high WAC and a low WAC for same drug, but they have it offered at two different prices. I still hadn't figured that one out. And it's within the PBM structure that most of the money is being made now. And it's also within that PBM structure, in my opinion, where I'm seeing a lot of the abuses happen.
[00:29:35] From us not being able to get our patients the treatments that they need. And so, and I don't see that that PBM function really does anything. I mean the doctors went to school and if you're prescribing something that's on label and they've got it on their formulary, then you should be able to get it without having to get a prior authorization or do step therapy or do any of these other utilization review things that they like to put out in front of you.
[00:30:02] All everything that they do is to keep you from getting the service as long as they get your money.They don't care. They don't want to have to pay it to us, though.
[00:30:13] Stacy Yonker: Absolutely. I, I will kind of go off on that as well that the PBMs, I think, as well are one of the major issues in our healthcare system.
[00:30:26] I understand the intent was for it to reduce waste I think, originally, maybe some of the intentions were clear but what it has become now is it justPBMs harm patient care. They limit access to medications. They often input complex prior authorization processes.
[00:30:46] You throw in all these step therapy practices. They then try to force you to use their own mail order pharmacies, like there's no transparency. It has a huge impact on independent pharmacies, which actually could offer more cost savings to patients. But of course, then the PBM or the insurance payer company, cause they're in a vertically integrated, they're not going to make the profits, right?
[00:31:08] So they don't want that. They want to keep all of the money and As much as they can, while the CEOs are laughing their way to the bank, making 20, 40 million a year while denying patient care. And it literally comes down to , with current legislation efforts and , until we de link profits from PBM, it actually increases the cost of patients, right?
[00:31:34] The formularies, you know, it's how much money am I going to make from the manufacturers so that I will offer your drug to patients. And, when in our space and rheumatology, we do infusions in house, so there's benefits that are pharmacy benefit versus medical benefit.Literally, we have to track things like ASP which is your average sales price and your reimbursement is off it, and we have drugs and treatments that we can't even provide to our patients anymore because if we did, it loses us money.
[00:32:08] And, no one is in the position, especially independent private practices, to be able to provide charity care, we don't get government funding, we don't receive grants we aren't tax free, we don't get the write offs and really, it all comes down to the PBMs because they control what medicines patients have to take.
[00:32:29] And we see it all the time in the prior authorization process where they give us two specific medications that a patient has to try and fail before the doctor can get their primary choice of treatment for that patient. And when you look into it, the reason they're offering those on formulary is because the particular manufacturer is offering them such a high rebate.
[00:32:52] to put, which is again, is more money in their pockets, to offer it that they take their ASP in the process. Um, but you know, the PBMs don't care. The insurance payers don't care because they're receiving 70, 80, 90 percent rebate for offering a certain drug. And so when we're looking at.
[00:33:11] What the issue is in our healthcare system.And people say that patients can't afford treatment. You know, it, it makes absolute zero sense that, Hey, here's your premium for your Medicare "disadvantage" plan that you only have to pay 10 bucks a month. But by the way, for you to receive treatment, $2000 a month.
[00:33:31] So there are no savings that are passed down to the patients at all with the way our system is set up right now. And it's the PBMs. It's the payers. Yeah.
[00:33:41] Nancy Ellis: I look at it and I'm thinking through like, okay, is it really, truly just a PBM issue? And, and they're just such a problem right now that nobody understands.
[00:33:52] And that's by design. I've had patients be denied for treatments and us be told that, well, it's not, medically necessary, and we're looking through and we're like, what do you mean? It's not medically necessary. Well, the patient hasn't maxed out at 50 milligrams of prednisone yet, and you're going, you're never going to give a patient 50 milligrams of prednisone.
[00:34:16] That's bad patient care. Yeah. And. And so you ask, can we see that policy where that's coming from? No, that's proprietary. And so they hide behind the proprietary wall. ButI think that there's also more games that they like to play. Going back to my game analogy of it's in the PBMs and it has to do with the drugs, but it happens on the health insurance side of it with the copay card.
[00:34:39] Accumulators and maximizers and happens on the health plan side in the plan design when they put in the alternative funding plan things for biologics and that basically they're selling a health insurance plan to a company saying basically we're not going to cover any of these biologics because they're going to go out and try to raid the manufacturers' foundations for free drug and that's their business model.And, it just makes no sense. It's like on one side, they're like, yeah, you have to pay us all this money to get the preferred placement. But then on the other side, it's like, we're gonna not even provide the service.
[00:35:19] So you're going to have to go get it, take it from them somewhere else. The whole thing is just unnecessarily complex. And my belief is, is that it has to do with the for profit motive in healthcare.
[00:35:34] Kip Theno: Yeah, I mean, Stacy and Nancy, that just everything you're saying is the incentives are misaligned.
[00:35:42] There's so many redundancies. Remember a time where it was the doctor treats the patient in front of them. I wonder then With those redundancies that are keeping patients from getting on the right therapy at the right time Those become useless in a way.
[00:35:59] How do you cut those out then? What is the next step? What can you all do? What can we do together to help fix that part before we go on to our last topic? I'm, really curious as to what you think needs to happen or is the inflection point just going to get worse? I
[00:36:13] Nancy Ellis: think that in general It's going to take patients, customers of the health insurance, customers of the PBM to get angry because right now when they don't get what they want, they see it as, well, my doctor didn't get that for me. They don't see it that their health insurance didn't get it for them, if that makes sense.
[00:36:39] And so there's a lot of anger with folks directed at. physicians that I think is misplaced because we can only do so much. And like the insurance company will say to us, well, we're not telling you, you can't use that. Well, yeah, you are effectively because you're saying a, you're either not going to pay for it, or you're going to pay for under levels that I can obtain it at.
[00:37:01] So, yeah, that's not the right argument there.
[00:37:05] Stacy Yonker: Yeah. Stacy, what are your thoughts? I, yeah, it's not, it's not easy and it's not going to be easy, but you know, people have to get angry and,I'll tell you, there's some organizations that are led by physicians and they are working really hard to get the system changed.
[00:37:24] And then there's management organizations that are doing the same thing to help advocate. And, I think those efforts are great, and I think it's a good step, but I agree withNancy until the patients have that transparent look into how the system works, and how it affects their care, they need to get angry, and, it has to take A systematic change where it takes the patients to basically to fight back in away to say, no, I am not going to purchase a plan from you. You don't take care of your patients. It causes more issues than it's worth. And until those, until a payer loses their clients and their client base. No one's going to, they're not going to make a change.
[00:38:17] So we, yeah, we have to educate the patients, and get everybody involved and they have to get angry.They have to get mad enough where they will write a letter and they will stop purchasing plans from there. They will go anywhere but the payers. I think that's the only way that we'll see a shift.
[00:38:37] Nancy Ellis: I think as consumers of the healthcare system and purchasers of those plans. Most 90 percent of us probably get them through our employers and so it's making sure that if you're angry as the patient that your employer knows that and knows why and that you can articulate why and that those stories get passed up to whoever's making the decisions for the plan because ultimately especially if it's a self insured plan they have a fiduciary responsibility to you to make sure that they're getting the best value for the money that they're giving. And you're seeing lots of different, lawsuits now where the employees are suing the employers based off of that fiduciary responsibility. Because we see our premiums go up 8, 10, 12percent every year, but we're getting less care for it.
[00:39:28] Stacy Yonker: Right. It's like, for what?
[00:39:30] Nancy Ellis: Right. So yes, the patients have to get angry, but employers have to get savvy and they can't just say, okay, they have to know all the details of that plan. They need to know what to ask for. They can't just come in and say, okay, well, what's it going to be this year?
[00:39:44] How much more am I going to have to pay?They need to know the details and they need to know how that's really going to impact their, their patients. They need claims data in terms of, you know, patients that are high cost and, you know, can we carve those patients out? They need to be able to be much more sophisticated about the way that they purchase it and the health insurance companies, these integrated conglomerates are banking on the fact that they know we don't know how to do some of that stuff and that once we figure it out, then they change the game.
[00:40:21] Kip Theno: Uh, this is, this is been such critical information. And I want to circle back to what you had mentioned you have experience with. I was shocked reading reports over the last year or two and even recently that, there are algorithms now even utilizing AI, as an example, to auto deny large percentage of claims, benefits, prior authorizations.
[00:40:41] That's oftentimes critical, life saving, rare disease therapies for patients. And you're dealing with this every day. I mean, that's a juggernaut and, there's no uniformity on payers, Nancy and Stacy, you know this too. Three payers might approve 99 percent of the time, the other seven on the same drug might deny 46 percent of the time.
[00:40:59] What are you doing about that? And what is the impact of the patients that you're seeing there?
[00:41:04] Stacy Yonker: I would say, I think there is a time and a place for AI. I can see where it can help automate some processes because, you know, the last 20years, right? The private physicians groups, they're receiving Medicare reimbursement cuts, every year, but yet they're being expected to do more work, to document more, to jump through more hoops, but then, receive 22 percent less than they did 15 years ago, which, , is insane, not even taking into account inflation and needing to keep good staff on hand, they have bills to pay, they're experiencing inflation as well.
[00:41:47] And so, I can seethe appeal of AI in the healthcare system, and I think it has a place. If it is augmenting care or if it is augmenting the workflow of a practice to help alleviate some of that resource burden that we experience, but on the payer side, AI could still be beneficial, but if their payer policies are explicitly set to deny care or to make it that much harder for patients to receive the treatment that they need to. AI should not be allowed, in my opinion. If you want to deny 22 percent of every claim that comes through or every prior authorization request, there should be a person that is sitting there looking at that patient. They should have a photo.
[00:42:38] We need to personalize it so that they can still sit and look at a patient and say, you know what, I can see you actually need it. But I have a metric that I have to meet because Aetna or United Healthcare, whatever tells me I have to, and I'm going to deny that care anyway.
[00:42:54] If they set it to AI doing it, we are now even completely dehumanizing the healthcare system even further and thinking of what Nancy said, like for her coming into the healthcare system, you know that the relationship, the patient and the doctor, and it was more humanistic, which is what healthcare should be. AI completely, at this point in the way they're utilizing it, removes the human. Because now there isn't even a person that needs to review a case, a computer's doing it, and computers can't feel emotions and they can't look outside of what their algorithms are set up to do. There needs to be an overhaul completely, beforeAI is fully utilized in the healthcare environment.
[00:43:41] Nancy Ellis: When I think about AI, I think about, okay, we have AI that's part of our electronic medical record. And so if we turn that on and we're letting it analyze what we're looking at and stuff.
[00:43:54] It may ask questions that may stimulate our doctor to go, Hmm, maybe I should look at this or, Hmm, maybe I should have, you should do that. And where it can augment, like Stacy said, I think that that's very helpful. I know when I use open source AI to goin and write a appeal letter to an insurance company, I can put in the basic facts and it can write it for me pretty quickly. And that's very helpful.That's time saving to me in the practice.
[00:44:22] But I think when the insurance companies get hold of AI, it's AI through the filters and algorithms that they want it to be, but then also end up denying 60 percent of everything the first time around.
[00:44:39] Because they're betting that you don't have in a doctor's office, you don't have staff to fight that or to appeal it and they're betting that the patient will just go, "Oh, well, you know, somebody will write that off." And they have, and they can get away with it.
[00:44:56] We've got to get where we feel like we have the power back to fight back against that and go, no, that's not okay. As a provider, a lot of times we don't want to rock the boat because, oh, if I, if I, you know, the, the squeaky wheel out there, that insurance company could drop me and that could mean bad things for me.
[00:45:15] Or, I could get on their poor provider list or whatever. And, you don't want to be on those things, but they have that big stick to threaten you with, and as providers, we don't feel like we have anything to fight back with, but that's where the data comes in, that's where getting the patients involved in their care, that's, that's important where they can get their employers involved in their care.It's where you can advocate on the state and national levels. All of these things may be slow, but it's all got to start somewhere.
[00:45:47] Kip Theno: Yeah. Well, Stacy and Nancy, listen, you have exposed a lot here. We are going to get this out to the masses.
[00:45:53] I want to thank you for being on the Road to Care podcast. And I hope you get it out to the masses and keep fighting the good fight. We appreciate you two so much. I learned a ton today. I know our listeners will as well. Stacy how do our listeners out there reach out to you for more information?
[00:46:07] What's your contact?
[00:46:08] Stacy Yonker: Of course, of course. I have aLinkedIn , if anybody would like to connect, you can just look me up, as well as if anyone wants to take discussions further, I'm happy to provide my email.So it's my first name, Stacy, stacy@arthritiscenters.net, and happy to have those discussions. Nancy is an amazing advocate as well. And we'll cut it to you straight for that. So, definitely looking forward to connecting.
[00:46:37] Kip Theno: Nancy, how about you? What's the best way for folks to reach you?
[00:46:40] Nancy Ellis: I have LinkedIn, so anybody can reach out to me through that if they would like, but my email here within the practice is Nancy, nancy.ellis@piedmontarthiritis.com.
[00:46:57] Kip Theno: Well, thank you, Nancy and Stacy.You know, the tagline for the show is together we can make things right. Thank you for being on the Road to Care podcast. And we're looking forward to getting this out there in mass. Thank you so much.
[00:47:07] Stacy Yonker: Thank you. It was a pleasure.
[00:47:09] Keep up the good work.
[00:47:11] Kip Theno: Thank you for joining the Road toCare podcast hosted by SamaCare, the leader in prior authorization technology and services, where through a script to therapy operating system, we enable connectivity with clinics, peers, and manufacturers focused on optimizing patient care. Tune in next time as together we can make things right.
[00:47:29] Enjoy the music written, produced and recorded by Jamestown.
Podcast produced by JFACTOR, visit https://www.jfactor.com/
Together, we can make healthcare right. Here are some of the outstanding healthcare organizations and associations championing patient health mentioned in this episode:
