How Doctors Actually Get Paid: The Frustrating Truth About Health Insurance and Claims

And all the while , right , america's US healthcare system is amongst the worst in the world , despite the rising cost of healthcare . And so tonight we're going to talk a little bit about reimbursement .

It's going to be a short session tonight , but I want to make sure that we talk about , in the economics of this , specifically the mechanics of how physicians get paid and what controls the flow of dollars and why physicians are so frustrated by the reimbursement process , so frustrated by the payments process .

And for you guys , as future physicians , it's super important to understand these economics , because the reason we're in this situation is because for so long , physicians ignored the economics of it . They just want to treat patients , but in the end it leaves them in a position where they can't treat the patients they want to treat . So we're at the intro .

We'll get right into it y'all . Today is the day , guys , you're going to take your future into your own hands . You're going to dominate , you're going to be successful . No excuses , just dominate . All right , guys . Thank you so much for joining me . We are live action here , and so we're talking healthcare economics . Right , how does it work ? How does it work ?

How does it work ? And there's been a lot of back and forth about whether insurance companies are right , whether physicians are right . Is it a combination ? And I think to really get into the healthcare economics , we have to understand how all this stuff came to be about .

And , as so often happens in life , I hear this a lot in order of students , where something goes terribly , terribly wrong and they said OK , yes , but that wasn't my intention , and I think that's kind of .

The issue in health care is that there's a lot of initiatives , a lot of systems , a lot of things that take place in health care with the best of intentions , but in the end , the outcome isn't what we intended , and now we're stuck with it .

And so , when it comes to our health care system , the economics of healthcare , it is all driven by the fact that we have a system of healthcare that's predicated on health insurance .

That is the big crux of it , and so our healthcare system is built on health insurance , on an antiquated system , and we can't shake it loose and , as a result , it doesn't fit our modern day needs and we're left with a very lopsided , backwards system that really doesn't serve anybody . And I know on last session I really bashed the insurance companies .

But I can't really fault the insurance companies because they're doing the best they can as for-profit companies in the environment they were given . But at the same time it's like , ah , we got to find something that works .

And it is the health insurance companies that are lobbying to keep the system in place because it keeps them in business , it keeps them making money when we could really make wide scale changes .

And I think this goes for a lot of people , for when you're getting into medicine you ignore the economics , you ignore the politics and you're just like I just want to treat patients . And it's a bad mentality to have because the politics and the money is going to drive how you're able to practice .

And for me , I recognized early on the significance of the economics of health care . I recognized the significance of the politics of health care , the significance of the administration of health care and recognizing that doctors were not in charge .

And so , for me , the way I look at health care and this is the simplest I can put it If health care was a McDonald's , where would the physician work in that McDonald's ? Who do you think the physician is ? Of all the employees at McDonald's ? Who is the physician in the cog that makes McDonald's work ? Are they the CEO ?

Are they the manager at that location ? Are they the cash register clerk ? Are they working drive-thru ? Where is the physician in the scope of McDonald's ? And while I wait for you guys right , we're live action , spencer , what's up ?

While I wait for you guys to answer that question , excuse me one second While I wait for you guys to answer that question , what I would like to ask you guys right and kind of preview for you guys is that someone made a comment this week after my first session that oh my gosh , how can you just not be talking about this because someone gets shot in

insurance ? And who are you to talk about these things ? And I think it's super important to understand who I am and recognize that when I talk about stuff , guys , I'm only talking about it because I know what the truth is , I know what the facts are and I want to share them with you because I want you guys to have that same truth .

Right , I'm a truth bringer to you guys . And so , for me , I have , as an undergrad , I have a minor in business management , so I understand business . On the continuation of that , right , I went on and got my master's in public health with a focus in health service administration , health services management .

So in running a hospital , I worked for multiple years in consulting , doing healthcare consulting , negotiating contracts , doing billing , all these things , working with the California Office of Statewide Health Planning and Development , working with the healthcare leaders , working with OSHA , our hospital accreditation board , doing all these things .

So I've seen the backside of it . Then you fast forward right , I am a physician , I am an anesthesiologist , but I'm not just any old anesthesiologist , I am a practice owner . So I own an anesthesia group and yes , daniel , we are live action , but I own an anesthesia group .

And so , therefore , because I own an anesthesia group , I understand what it takes to make a profitable group .

I understand what billing is because I bill every single week and I was actually going to pull up a whole billing sheet right here , but I was like , ah , I'm going to be a stone too far Insurance companies are going to get mad at me , but we're going to break down what happens in this billing process , so you guys understand this , okay .

So , from all angles , guys , I am expert in this stuff , I understand the mechanics of this and so it's important that we all see it together . So Spencer says how do you see billing ? Insurance differs between doctors and mid-levels . I'm becoming more interested in psychiatry , but I'm worried about sustainability and the big question of mid-level providers .

If you guys don't know what a mid-level provider is in healthcare and this is actually a good jump off Can we start here ? Okay , so in healthcare , I talked about how we have an antiquated system .

So we are so heavily reliant on insurance because at the time that we were developing our now modern healthcare system , we were looking at healthcare and accessing healthcare . As you only went to the doctor when you were very sick right For my older people when you grew up , right ? If you're sick , right , you just rub some Robitussin on it .

My dad was peroxide , everything . I'll put peroxide on it . I'll be all right , I'll put the peroxide on it . You know what ? Just drink a lot of water , drink some orange juice . I used to drink orange juice with garlic in it , that'll get rid of it . Right ?

You don't go to the doctor unless you're critically ill , and this is the way our healthcare system was back in like the mid-1900s , 1940s , 1950s , and so it was like you only went to the doctor if something was catastrophically wrong catastrophic issue and we need massive insurance coverage that we aren't bankrupted in a moment for that coverage .

And it's like , hmm , what should we do ? Well , how about insurance ? If we had insurance for health care when we had a major health event , this insurance company could step up and shoulder and protect us from this catastrophic loss , similar to how health insurance or how insurance works for cars . Right , every one of you guys has insurance for your cars .

Why , in case you get in a fat accident and the car is lost or you hurt someone or whatever , it's protecting you in extreme catastrophic circumstances . The problem is our healthcare system has morphed and that so many people aren't just having one catastrophic event and then dying .

People have catastrophic events that then that they didn't use to survive when we created the system , but now they're surviving . So people can have multiple heart attacks and survive . People can have multiple strokes and survive . People can get in crazy accidents and survive because our healthcare is so good now We've got such great technology , all kinds of things .

But the problem with that , then , is now you have a lot of people that live through things they otherwise wouldn't have lived with and need chronic , expensive care .

Yes , yes , we have more pharmaceutical interventions , we have more practical physical interventions now than we ever have , and so people who just live a certain way like , oh man , my back goes out every once in a while , I just live through it Now recognize , oh , I can go get physical therapy for my back , oh , I can go get a surgery for my back .

And so we have heavier , chronic utilization of healthcare services . And therefore , what ends up happening ? Whereas accessing healthcare was a singular event , has now become a sustained , prolonged , recurrent , expensive event where you need therapies and modalities to manage all these chronic conditions .

And the problem with that is that we're based on insurance and insurance is designed to be catastrophic coverage , yet we're using it for everyday treatment in a chronic environment and so , because it's not designed that way , it can't function effectively . Does that make sense ? The parallel , as I mentioned , is car insurance .

Imagine if you used car insurance the way you use health insurance , where every single time you had to put any dollars into your car gas oil change , tire breakdown , whatever happens . What if you didn't just pay for it out of pocket , you had to use your insurance . What would happen ?

Right , when you guys have ever made a car insurance claim , what happens to your insurance premium ? It immediately goes up right to cover those costs , those losses , because insurance companies don't expect to pay out .

But now in healthcare , insurance companies have to pay out all the time and for a long time , and so , because of that , they continue to raise the cost of health care and to prevent more losses , they continue to deny and cap and limit and slow the flow of utilization of health insurance . Does that make sense ?

If that makes sense to you right now , like the video , let me know you're here . Comment Let me know we are live action , dr Pineset . Here we're talking about health insurance and we have to understand that again . The best intentions were like oh , we want to be covered If I have a heart attack .

I want that to be covered and my family not to go bankrupt , blah , blah , blah . But now I'm surviving a heart attack and I need long-term care . I need to be on all these medications , I need all these therapies ? They have cardiac . Did you guys know this ? They have cardiac rehabilitation therapy .

So you have a heart attack , we don't just send you out whatever . We put you with a person who trains up and strengthens your heart , like you would strengthen your knee .

And so we have this system that was designed to have catastrophic coverage , and now we use insurance all the time , and so what it has made insurance become is it's not just coverage , it's actually like a discount service . So you subscribe to insurance so that way all of the care you get chronically is cheaper than it would be otherwise .

And so because insurance companies know you're going to use the insurance that way , they have to charge more to cover everybody . Yes , yes , okay . So now that's the important setup here , and so I'm going to get to Spencer's question right here . So insurance companies had never .

The way our system was set up was never intended to be used chronically and all the time by people . But now people want access , they want it now , they want to fix all these things , they want services and they want expensive services . So insurance companies are like , listen , we'll go broke because these people , man , they're using it all up .

So we started to do what's called a managed care model , where the insurance companies start to say , listen , we're going to manage the flow of care and we're going to slow people's utilization down . That way , we can ration the funds and ration the care so as to avoid tons of usage and us all going out of business .

Yes , and we're going to get to Medicaid . In a second I'll break it down for you . Does that make sense to everybody ? Insurance was like whoa . Healthcare spending will get out of control if we don't limit some things . Let's cap some things , let's push some things back .

Let's set up a pecking order of how things have to go to slow the utilization of care , to keep costs contained , to keep our healthcare system sustainable . And so it became a system where we're trying to gatekeep and ration healthcare services to make the system sustainable . It's crazy , right ? So that's what happens Now in the attempt , right ?

Because now we're trying to control utilization and control costs in healthcare . So , in order to do this , what do you have to do ? You have to gatekeep . Who are the gatekeepers ? They're administrators . So , in order to do this , what do you have to do ? You have to gatekeep . Who are the gatekeepers ? They're administrators .

And so what you see is a rise in the amount of money put towards administrative costs in health care . This accounts , on the insurance side and on the provider side , for 15% of the overall costs spent in health care . And if you guys don't know the economics of it , we spend $4 trillion a year on healthcare in America .

That is more than the Department of Defense's budget . It is more than so many things . It is $4 trillion in healthcare guys . It's humongous , humongous $4 trillion . Of that $4 trillion , 15% is administrative costs , right off the top . So approximately , right , almost a quarter goes to administrative costs .

Out of every dollar spent , about a quarter goes to administrative costs . Then , out of that other 85% , it's split roughly a third , a third , a third where a third of the other expenditures go to pharmaceuticals . We call it drugs and devices , d&d Drugs and devices , so pharmaceuticals .

And then the fancy devices we like to use to do surgeries , to do home devices , all that kind of stuff . So drugs and devices , but the bulk of it is drugs . Then we have hospitals is another third and then we have healthcare workers , which is the other third .

And the reason I'm laying this out because we're going to get to Spencer's question this is the crux of it is that when you have healthcare expenditures , you have 100% of the healthcare pie . You're trying to contain the costs and the utilization of this service you look at in business . You're looking at what are elastic and what are inelastic factors .

So what are things that we can control the cost of ? Are you following me here ? So , as we want to control costs and want to gatekeep , administrative costs are necessary , not only necessary we must continue to increase them so that way we can better have a handle on care . And so insurance companies increase the size of their administrative departments .

Healthcare right , like , oh man , we got to figure out what's going on here . They increase their administrative size . We got more managers , we got more CEOs . All these things goes up , okay , because we need that . So 15% the drugs and devices are what they are and they're only getting more expensive . So we can't limit that .

That's actually increasing , taking more of the pie . Hospitals are bigger and fancier , right , and they have more utilization . More people are accessing them , more people are going and getting surgeries and all those things , so that cost is rising . So then where can you cut costs in healthcare guys ?

Come on the other third , which is the healthcare workers , and so you try to decrease what we're spending on healthcare workers and , as a result , this is what happens the healthcare , the predominant , the expensive healthcare worker , the predominant one right , the highest paid are the physicians .

And so , if you look at every other field , increasing , increasing , increasing , increasing , increasing , increasing salaries physician salaries , as adjusted for cost of living and for inflation , have either , across all specialties , has either stayed near stagnant , near maybe a little , stayed near stagnant , near maybe a little increase , near stagnant , or has actually fallen .

So you have physicians if they would have been in this specialty 20 years ago , they're making bucks who are now making less , despite everything being so much more expensive . The glory days of physician dump from you talk about the mid-1900s , into the late 1900s , 1980 , 1990 , physician salaries through the roof .

Physicians bring so much money , but then we had a shift and a cap on that , and so now physician salaries don't increase . Physicians aren't in control of what they're making anymore and they're very capped on what they make . And so you see these capped costs , yes , so now Spencer asked the question about mid-level providers .

So we have seen the proliferation of mid-level providers . We're talking about physician's , assistants , nurse practitioners , other advanced practice nurses , and in this issue we have CRNAs , right , a whole spectrum of mid-level providers .

You have all these mid-level providers and you're like , wait a minute , how do they fit in with what we're doing right In the field of psychiatry ? You have psychologists , you have certain therapists , you have counselors . You have all these support services . These are like mid-level providers that are coming into fields where , predominantly , you would see a physician .

Now you see a mid-level provider . Why does that happen , guys ? Because if we're trying to control the cost of healthcare workers , that third , the way to do it is to reduce the amount of physicians you're paying for and increase the number of other providers that are more affordable that you pay for . And so you see this all the time .

How many times do you guys make an appointment with an office and you only see the PA or the nurse practitioner ? How many times have you guys gone to urgent care and you see the PA or the NP ? And this is the model of healthcare because we're controlling cost , so we're promoting insurance companies promote the middle provider because they pay out less .

Hospitals and healthcare systems promote the middle provider because they have to pay out less in salary and it's a win-win-win . The only person who loses is the physician and potentially the patient who has some complex issue that's managed by a middle level provider . I think there are fantastic middle level providers .

I think having middle level providers is amazing because it does help control costs , but where we get into issues is when mid-level providers are practicing outside of their designed scope . So again , the best intentions , bad outcomes . And I'll give you a practical example of how this happens . Are you guys ready ? Maybe I shouldn't get into mid-level provider stuff .

Is that too deep in the weeds for some of you guys ? We'll do a separate video on middle-level provider creep . But the issue is , guys , is that they're being promoted because the economics of middle-level providers make sense for healthcare .

But the problem is is we're trying to focus so much on the economics that we're forgetting what middle-level providers are actually designed for and we're spreading them too far into a scope of area where they don't have the proper expertise to execute and that can be catastrophic to health care . And actually I'll give you guys a real practical example Urgent care .

How many of you guys see urgent cares on every corner , everywhere you go ? How many times do you guys see urgent cares everywhere , everywhere , everywhere ? The reason you see so many urgent cares is because they are ATMs , cash-making machines . Because if you're in urgent care , you have all these visits that come in that are billable visits .

You staff the clinic with mid-level providers , pas and NPs , so you pay them a certain wage . Then , right , these PAs and NPs have to be supervised by a physician .

Well , if you look at the laws around what supervision really is in these settings , it's only that the physician reviews a pool , a percentage of the overall patient seen , and only within a certain period of time . So it'll be like , okay , listen , this PA saw a hundred patients this month . Okay , and this is just again . This is again an example .

You have a hundred patients you saw , so we'll go a hundred percent . The physician to be called supervising physician must review 50% of all the cases and they must review them within 21 days or 30 days of them being seen .

But if you're a patient going to an urgent care and being seen with your urgent issue , but if you're a patient going to an urgent care and being seen with your urgent issue , how does a physician reviewing that file 21 days or 30 days later help you ? It doesn't , and so you get a lot of things that drop through the cracks . Right , that's the issue .

So , as we pommel gate and we push out all these middle-level providers , that's what happens , because we're trying to control costs . What also happens is that , physicians , right , when you're trying to control costs , is you have these insurance companies saying , hey , listen , physicians , we're only going to pay you for certain things , only certain things .

You didn't actually do any work here . All you did was sit there and you thought and blah , blah , blah , we're not going to pay you for your thinking , we're not going to pay you for your expertise , we we're not going to pay you for your expertise , we're only going to pay you when you do something .

And so what happens is is then physicians , in order to get paid , have to do something , have to document . Someone asked me a question earlier about ICD-10 codes . Right , these diagnosis codes ? Like what is that about ? Well , if you're a physician and you want to get paid , you have to be able to document . I did this .

If you can't document an ICD-10 code for something you did , then you don't get paid . That's how it works . And so , therefore , physicians are incentivized to do stuff . And this is the facts .

And this is the hard part of this , and this is why you saw physicians kind of going up because they get incentivized to do procedures , to do things , because that's the way the model works , it's how it goes .

And so you see this in modern day pan out , because if you guys someone just hung on the box like I've only ever seen a physician , this is a physician assistant for orthopedics or urology . And this is super true . If you guys make an appointment for a surgical subspecialty and you go to their office nine times out of 10 , you will see a mid-level provider .

Why ? Because the physician , in order to get paid , they get paid to cut . So an orthopedic surgeon gets paid so much because they cut , cut , cut , cut , cut . They don't get paid nearly enough to sit in clinic and advise patients .

And so what has happened is the proliferation of the mid-level provider for ortho , the mid-level provider for urology , the PA , because they can go into clinic , make a reasonable wage and doesn't drop their salary like it would a physician's being out in clinic . So you see this pushed in . Does this make sense to everybody , this mid-level proliferation ?

To answer Spencer's question ? So mid-level provider creep is a result of our system and the economics of it . That , ooh , it makes economical sense to have them do as much as possible and have physicians do as little as possible because they bill less . Yes , everybody understands where we're at right now . So that's what happens .

And so you see all these different procedures , like , oh , I think they can do it , they can do it , until something bad and catastrophic happens and it's like , ooh , wait , let's pull that back . This is terrible . And there are phenomenal middle-level providers , but they have to stay within their scope of practice , otherwise it's a recipe for disaster . So , anyway .

So the whole point of insurance now is to be a gatekeeper and to keep the costs of healthcare down . That's their function . And so now , how does that play into physician billing ? That's their function . And so now , how does that play into physician billing ? Here we go .

So if we can only control really the cost of that third of the pie , so let's reset this $4 trillion in healthcare . 15% of our healthcare expenditure is on administrative costs . Those are increasing every year , one third . So then the other 85%-third of that , 85 is on drugs and devices . Drugs are more expensive , devices and procedures are more expensive .

So you can't cut costs there , really , right ? Unless you , you know , you create a formula for drugs . What we do is create a formulary . So if you guys have ever noticed this , right , like you go you know oh yeah , I'm getting this drug . Like actually we've swapped it out for the generic . That's a cost control maneuver .

That's how we keep the cost of drugs down . Oh hey , you know what you want to try this drug . I'm like actually we've swapped it out for the generic . That's a cost control maneuver . That's how we keep the cost of drugs down . Oh hey , you know what you want to try this drug .

Well , you're going to try this drug first before you try that one , because that one's more expensive . It's a cost control measure , right , it's not bad . Device costs . So drugs and devices 31% . You can't really control that , so it keeps going up . You're trying to cap it , but you can't control it too much . Got to give people services .

The other cost , the third , is the hospital costs . Now , this is what's important . A long , long time ago , there was a huge issue with people having access to hospitals , and so there was a couple legislative maneuvers put into place to increase the number of hospitals , to increase the access to care .

Access to hospitals was problematic because , for example , you go all across town in emergency .

It's a problem , but it was extremely problematic in rural areas where there were no hospitals , and so you had a huge section of the population that weren't able to get quality access to quality care in a timely manner , and so there was legislation passed to promote getting more and more hospitals built .

Okay , so now we have all these hospitals , and then hospitals started to compete and they started becoming mega hospitals and they got all these things right , and so you got bigger and bigger hospitals , and so it's hard to contain hospital costs because hospitals are expensive and fancy and technology , all those kind of things .

So hospital costs are hard to control . That last third of the pie is healthcare worker pay . The biggest part of that is physician pay . And so how do you limit physician pay ? Well , you decide what physicians can and cannot do . The un-nuanced argument here is that physicians are greedy , so we have to stop them from being greedy and overbilling .

The nuanced aspect of this and I want you guys to really understand this , the nuanced understanding you have to have about this is that if you were to go and ask 90% of physicians right now how much a certain thing they do bills , they wouldn't know what the actual cost is , the true cost of it .

So , hey , listen , I'm a heart surgeon and I do a heart surgery . Most physicians wouldn't know what the true billed cost of that heart surgery is . What they know is the piece that they see of that total pie . Yes , and so if I'm a physician and I don't know and this is the problem with insurance , is there's a buffer there ?

We don't know what the exact cost of goods are . Both you as a patient , right ? If I ask you , hey , how much does a heart surgery cost ? I don't know , but my insurance covers a bunch of it and I have to pay this much .

The patients don't know what something costs and the physicians don't know what something costs and there's a buffer in the middle of the insurance company that sets a price . So when both sides don't know the cost , you can't make cost-wise decisions .

So if I'm a patient , I can't say you know what I should do , these procedures are about the same , I should pick the cheaper one , because you don't know what the cost is . As a physician , if you don't know the cost of the procedures , you can't choose the cost-effective option .

So you shouldn't say oh , you know what , we should start with this because this is less costly . You can't say that because you don't know what the cost is . And so , as physicians , we're like I like doing this procedure , I'm familiar with it , let's do this one . And the insurance company's like , nah , they gotta do that one first because that one's cheaper .

And that's what happens . The insurance company , they gatekeep , this is what happens . So this is important , right , so everybody understands . So the insurance companies there are guiding this care based on the cost of it .

When you have this happen and you have insurance companies deciding which procedure is most important , the problem is is that most insurance administrators are not clinical or not clinicians is the word I should use and therefore they are making a decision in a vacuum , away from the patient , about what a patient should be , should be getting , even though they've been

seen by a physician , and so they'll deny things . And the physician's like , oh my gosh , this is exactly what this patient needs . Why can't I get it to him ? And they're a frustration factor because you're man , I went to school for all these years and I can't give this patient the procedure I feel like they deserve .

I saw them , I know what they need and what . The insurance companies are using pooled data and not the exact specifics of the case , and they can't quite understand what they're getting into . And so there's a breakdown there there , at the end of the day , yes , insurance companies have to cover a bunch of stuff .

So then what they start doing is they're saying , well , listen , yeah , we'll cover these , but there are certain aspects that we're not going to cover . So , again , we're not going to pay you for this , we're going to pay you for this , we're going to pay you for this . And so the first squeeze , right , the big talk right now is anesthesia .

We're going to get this anesthesia stuff because it's really , but the first physicians to feel a big squeeze were primary care physicians . Why ? Because primary care physicians are not procedure-based . They're there to manage your conditions . They're there to talk with you , get your history , be thorough .

They have to get all this large sum of data , they have to make tough decisions about what care you need and they have to advise you and all this stuff . The sad part about healthcare is , because we're trying to control costs is that these providers aren't paid for those services . So when you have a primary care provider , they're billing .

They can bill a time interval . Okay , listen , yeah , this is a introductory visit , so it's longer , so I can bill for 45 minutes . Well , you know what . This is a follow-up , so I only get 15 minutes . Well , this is a complex follow-up , so I can bill for 30 minutes and it's just a rough estimate like that .

The problem is , if you , the patient , show up to a follow-up visit and you've got a new issue , how many times have you guys had your physician tell you , wait this visit ? We're only dealing with this . We can schedule you for another visit to talk about that .

And the reason they do that is because of billing , because they know if I sit here and I talk to you for an hour , I'm not going to get paid for any of that time , and it's just a sad reality , right ? They don't get paid for that time . It's really , really unfortunate . Physicians don't get paid for advising you to be healthy .

It's hard to bill for that , and so you are losing income . And so that's why you saw primary care physicians like , oh man , primary care doesn't pay enough . It doesn't pay enough because the things they do aren't procedure based , and so they can't get paid for that .

And it's a travesty , because that's really what our healthcare system needs is more counseling , more preventative time , more mental health talk , more mental health talk . Why can't your primary care provider sit there and talk to you about mental health ? And hey , what's going on in your life ? What are your stress ?

Why can't we have this long discussion about what's going on in your family ? Because we don't get paid for that .

So what ends up happening is that physicians become like teachers , where they do a lot of things that they aren't paid for because they know it's in the best interest of the patient , just like teachers know it's in the best interest of the kids for me to go out and buy all these supplies even though it's out of my meager pay . Same thing for physicians .

So I bet many of you guys didn't know that physicians many of them don't get paid for their administrative time . So , for example the big example you guys would be shook by this how many of you guys have an electronic healthcare system where you can message your physician ? I'm going to send my physician a quick message .

And how many times have you been told hey , listen , if you've got a problem , message your physician , message your physician , message your physician . They want to promote messaging the physician . Did you know that most physicians don't get paid when they respond to those messages , to those messages .

It's part of their responsibilities , but they don't get paid for all those messages . And you might say to yourself wait a minute , it's just one message . What's the big deal ? Well , if you're a physician and you keep a whole panel of patients 500 , 1,000 patients how many messages do you think you're getting every single day ?

Bing , bing , bing , bing , bing , bing , bing , how many times ? How many of you guys are encouraged to message your physician to get medication refills ?

Did you know that they get a decreased reimbursement for filling your medication , even though they have to take the time to look at your labs , look at your see what's been happening and make sure , hmm , does this make sense ?

So they have to do all this clinical thinking , but they get a decreased reimbursement because they didn't see you in person to make that charge , that change . That's outrageous , but it's a cost-controlling maneuver to help our system function . When you move into specialists , what ends up happening ? That are more procedure-based , that are higher pay ?

There becomes this public narrative of oh , these are greedy specialists , they're just trying to bill , they're trying to bill , they're trying to bill , they're trying to bill . And we fail to recognize the nuance , the layer in here , of what we're actually getting paid versus what we're actually doing , and anesthesia is the perfect example of this .

If you guys didn't see , recently an insurance company tried to have a policy where they were going to chomp down on these overbilling anesthesiologists , because anesthesiologists are paid partially and I'll break it down partially based on time . What they were saying was that anesthesiologists are milking the clock to get extra pay .

That was their argument , and this argument is nonsensical . It would never happen . I'll break that down for you too , but that was their argument . That these physicians were overbilling . I'll break that down for you too , but that was their argument , that these physicians were over billing .

And what these insurance companies fail to recognize is the nuance of the anesthesia job and the fact that there's so much that we don't get paid for already . And so to understand all this , you have to understand how anesthesia insurance billing works . Again , I'm a practice owner , I do billing . I understand this stuff .

For anesthesia , when you do a case , so let's just say oh , you know what we're gonna do a knee replacement . As an anesthesiologist , you get paid two ways . The first is you get paid a start units , so you get paid a certain amount of dollars based on what type of case it is . So you can imagine a heart case pays more than a knee case .

A brain case pays more than an elbow , whatever right you get paid on the difficulty of the case . They say , listen , this is a real hard one , we're gonna pay you a little bit more through this very difficult case . So you get a start value of the case . Then you get a second fee based on time increments of that case .

But the biggest payment comes from the start value of the case . So as an anesthesiologist , that's the case right . The biggest value is the start value . What is my incentive as an anesthesiologist ? Do I want cases to go long or short ? I want them to go short because I want to maximize the number of cases I do . So I have the maximum start value .

It is better to be . This is crazy . It'll blow your mind . You could do one heart case as an anesthesiologist and take you all day . That one case would pay you less at the end of the day than if you did colonoscopies all day for the same time interval . Why ? Because you could do 30 colonoscopies in the time that you do one cardiac case . Is that crazy ?

So it's the start value , not the overall time when the insurance company makes the argument that the anesthesiologists are milking the clock . It doesn't make sense economically from the anesthesiologist's perspective . Why do I want to do that ? I want to start with the next case . It also doesn't make sense from a hospital efficiency perspective .

Anesthesiologists don't have our own patients , if you guys understand what anesthesiologists do . We're a consultant specialty , so I don't have a panel of patients as an anesthesiologist do . We're consultant specialty , so I don't have a panel of patients and anesthesiologists . My patients are the surgeon's patients .

I never say , oh , my patient , no , no , no , the surgeon's patient , that's their patient . So the surgeons are in control of the patients and they decide who the anesthesiologist is , what department we're with . So the surgeons have to be happy with the anesthesiologist , otherwise it's a bad day . Surgeons get paid to cut , and it's the same premise .

The more they get paid , okay , you get a set fee for doing a knee , a set fee for doing whatever . So the surgeons want to do cases as fast as possible , get them done to have maximum productivity , as many cases as they can .

So if the anesthesiologist were just standing there with our hands like this , doing nothing , milking the clock , the surgeons wouldn't have us work and would fire us , would terminate us , would block us , all these things . So it's not logical that anesthesiologists would milk the clock for more time . Yes , the insurance company argues .

Well , listen , sometimes these cases are lasting this long and these cases are lasting this long . How can that be if it's the same surgical procedure ? Let me break it down . Anesthesiologists , how many of you guys think anesthesia does nothing ? I got so mad the other day because I'm like this is why everyone thinks anesthesia does nothing .

I was watching a show called New Amsterdam . My wife likes these medical shows Grey's Anatomy , all these kind of shows and I always have to turn them off because do you know who's never prominently featured in any of these shows ? The gosh darn anesthesiologist .

When's the last time you saw an anesthesiologist do something of impact and import right In one of these shows ? Never , you've never , seen an anesthesiologist . When you think about an anesthesiologist , people think about the guy who sits in the corner and does Sudoku and crossword puzzles and so forth . That's what people assume anesthesiologists do .

But what anesthesiologists do ? The reason it looks like we're doing nothing is because we get paid for our clinical knowledge and expertise and ability to avoid having to do something . Having to do something .

The same reason I'm an amazing pre-med coach is the same reason I'm an amazing anesthesiologist Because I'm a planner , I'm a preparer and I am a person who likes to sit down , think about something in a very thorough manner and then build a foolproof plan for success , whether it's getting you to medical school or it's getting a patient through a case .

And anesthesiologist is like a referee y'all In any sport . If you know the referee's name , that referee's a problem Because that means he's doing something out of the norm . And you're like what is this referee doing ? Throwing a flag right there . What's the referee calling that flag ? You're upset about something .

It's the same way with anesthesia Our job is to be invisible , like we're not doing nothing . A good anesthesiologist should look like they're doing nothing . And everyone knows right . You see , if you guys are in healthcare , you guys would know this right when you guys go into surgery rotation .

If the anesthesiologist is standing up or sweating or moving around , you know someone's about to die in this place . You know danger Is that death in the air , because the anesthesiologist should not be moving like that .

A skilled anesthesiologist is so skilled at mapping out all the potential dangers and avoiding all those dangers and setting the case up perfectly , that it looks like they're doing nothing , but it's because they spent all that time planning . That's what happens , and people don't understand the difficulty of what goes into anesthesia and planning a plan .

Because when you give anesthesia , the way anesthesia works is we're turning the brain off to allow the patient to be able to go through a surgery and not move , not be in pain and not remember what they just went through . Imagine how it would be if you could remember .

Oh , they burst my chest open and they were working on my heart Like it'd be awful , the pain , the horror , right . So it's my job to make sure that you go to sleep , you stay asleep and you don't remember getting your chest cracked open Like you was in an alien movie . Ah right , that's my job .

And so to do that , as an anesthesiologist , I have to make a plan to make that happen . And while it may seem straightforward , it's not , because when I turn the brain down to make you not respond , your brain and your nervous system actually control all of your organs . So when I turn the brain down almost off , it turns the organs down and almost off .

So your heart rate drops , your heart function drops , your breathing stops . You can't breathe for yourself during surgery , right ? Your GI system shuts off . Your kidneys and bladder don't work like they normally do .

All the major systems of the body shut down , slow down , and so it's my job as an anesthesiologist to turn them all down and then play puppeteer and be your organs during the case , making sure those organs do what they're supposed to do under my puppeteering .

And you do that in such a way that you see and you foresee oh , you know , the lungs are gonna turn off here , so I'm gonna pre-oxygen and give lots of oxygen to make sure the lungs aren't really impacted by the body . Boom and you move through the process . That's the way it works , right , and so it's your job to make this plan .

But the problem is is people don't understand the nuance of anesthesia , and so , as anesthesiologists , I only get paid to start the case and then the time interval . But the nuance is lost , and so we'll start here in the basics . Part of it Is for the insurance company .

They say listen , how can this procedure take this long for this patient and this long for that patient ? Well , every patient is unique because as anesthesiologists , I have to look at okay , what is the case ? So what does the surgeon need for me to deliver ? Okay . At the same time , how can I deliver that ?

I have to look at the patient and see what their baseline is and see what they can tolerate . And every patient is not the same and so therefore , their course of surgery and their course of response to anesthesia is different .

And so you might say wait a minute , let's just say you're doing a knee procedure , okay , listen , we're going to do a knee replacement . Okay , cool , knee replacement . A knee replacement in a 20-year-old , healthy guy who just happened to get his knee hit by a motorcycle that's easy . I can do it with my eyes closed , like this Okay .

A motorcycle , that's easy , I can do it with my eyes closed , like this Okay . But now if we're doing the same knee replacement in a 65 year old man who has smoked his whole life and has severe COPD , who had a heart attack six months ago , is that the same procedure ? What if that same patient had a GI bleed three months ago or a GI bleed this week ?

Maybe they were in a car accident ? I don't want to know right , what is that the same case ? And it turns out it's not , because if you have a severe COPD cardiac guy . I've got to go through all the charts . This is crazy . I don't get paid for any of this stuff .

Before every case , I have to go through all the charts and I have to look at all these reports . I do all these things . I have to coordinate the care . I said , listen , I still need this . I don't have this information . I don't know if I am safe . I have to do all this stuff and I don't get paid for any of that stuff .

I get a start unit and I get a time . So all this stuff that happens I don't get paid for it , none of it . But all that time I put in saves lives . And I'll give you guys the perfect example . You guys ready for this . This is how it went . This is last week . Okay , so I had a kid who's going to undergo a procedure .

It's an outpatient surgical procedure no big deal really for most kids , right ? But this is a kid . This kid is three years old . Here I have this patient . So I'm like , okay , before I see the patient again , I only get paid when I see the patient , start time and the time I have the patient . So here I have this patient . So let me do a chart review .

So I go into the chart and I'm going to this patient's chart and the first thing I see is patient cleared for surgery by cardiologist . Now you might be like , oh , that's cool . Cardiologist said he's good to go For me . I'm like whoa , I'm like whoa , why does he need cardiac clearance ?

So now I've got to go down a web of weaves to figure out why this patient had to go to cardiology . So I go back PCP visit . What happened ? Well , it turns out this PCP , the primary care provider pediatrician , heard that this three year old had a heart murmur . Now , it is very common for little kids to have benign heart murmurs . No big deal .

Oh , I heard a heart murmur , let it go . The next thing you do right , when you hear that heart murmur on another visit , you're like ah , I still hear it is . You order an EKG , an echocardiogram , right ? You order this and they put stickers on the chest and they look at the heart's electrical activity from the outside .

So it's like taking a picture from really far away . It's not hd . So their pediatrician ordered the ekg . The ekg showed that this kid had electrical activity consistent with right ventricular hypertrophy . Okay , so now you've had an abnormal sound and then the EKG could either be normal or not normal If it's not .

If it's normal , you're like , okay , go ahead whatever with your life , but now the EKG is abnormal . Uh-oh , uh-oh , it looks like you have right ventricular hypertrophy . I'm like , ooh , I hear right ventricular hypertrophy .

That freaks me out as an anesthesiologist because the right side of the heart is very difficult to manipulate and people with sick right hearts die in an instant . It's very , very quick , very fast cardiac collapse . Okay , so I see that . I'm like , ooh , let's keep reading this story .

So all this time I'm going through this whole chart , all these records , all this stuff we get to the cardiology visit . The cardiology visit was three days before this patient showed up in the clinic , so this was last Thursday , six days ago . They saw cardiology on Monday of last week . Cardiology note reads yes , I hear this patient's murmur .

It is blah , blah , blah , blah . They describe it like cardiologists . All these different sounds they're hearing right ? Yes , they have a murmur . Additionally , the EKG is concerning for right ventricular hypertrophy . Based on that , I am recommending that this patient undergo a cardiac echo .

So we're going to take an ultrasound and we're going to look inside at the actual heart to examine if there's something serious going on with the heart . Then they close the note by saying patient scheduled for procedure later this week . Outpatient minor surgery . Patient is okay to proceed . So I'm like , oh , that's not good , like uh-oh , that's not good .

This patient was cleared by cardiology Even though the cardiologist wants to order an echocardiogram to see if there's something more serious going on . So then the patient shows up in the office . They're there for the appointment . I'm checking this All the while . They're out there waiting . I'm delaying the day , not getting paid Right .

This whole chart takes about 20 minutes . I'm going through all this stuff . So then I'm like , oh gosh , I got to cancel this case today . They have an echo pending . They're going to look at this guy's heart . I don't want to die out here . It's an outpatient minor procedure .

So I walk out there and I try to explain to the family hey , listen , I'm your anesthesiologist , I was just reviewing the chart and your kid is three , is scheduled for an . Because of that we can't do this procedure .

And the mom proceeds to start yelling at me and it turns into a literally 30 minutes of the mom yelling at me , the dad yelling at me , the kid is crying . I'm trying to explain my position for why I'm canceling and she's upset with me because she's like if he has cardiology clearance , there's nothing wrong with the heart .

And so I'm trying to explain this process . Then I walk them through . Here's my chart review Bop , bop , bop , bop . They hear a weird sound . They didn't do an EKG to see if it's normal . It's not normal . You go to cardiologist . Yeah , it is concerning . I want further testing .

I can't put you to sleep because what if there really is pathology in your right heart ? It's bad . So this whole argument , this whole time it's been an hour now , right , 30 minutes , 20 minutes , chart review , 30 minutes of this . I get paid for none of that time . Additionally , this patient was scheduled for a three-hour procedure . I cancel the case .

I cancel the case . The surgeon's upset , he got cardiology clearance . Surgeon's mad at me , family's mad at me and I don't get paid for that hour . And guess what , guys , because I canceled the case , I don't get paid for the next three-hour block until the next patient gets there . So I lost out on four hours worth of income and everybody's yelling at me .

But was that chart review ? Was that counseling the patient ? Was all that stuff important , potentially life-saving . Well , it's not even particularly life-saving . It actually is life-saving Because you fast forward to this week I'm chart reviewing because I want to see this echo , because I got yelled at . I got yelled at .

Well , the kid went and had the echo this week . Guess what ? The echo showed that this kid has a valvular abnormality that's resulting in regurgitation on the right side of the heart and his right ventricular hypertrophy . And so now , right , the next thing is they got to go work this up and see . Wait , is it a lung issue ? Is it a core heart issue ?

There's an issue with the right side of the heart . So imagine if I didn't one , do the chart review . Two , supersede the cardiologist's clearance for the procedure . Three , be willing to have the patients yell at me . Four , be willing to have the surgeon yell at me . Five , be willing to lose out on four hours of income . What would have happened to this kid ?

But the insurance company doesn't pay me for that . That's the difference , guys . That is what happens Today . Okay , is a wonderful , glorious day . I had a patient who was assigned to me said pincet only , pincet only , pincet only . Why ? Because this kid . I say kid , he's a 24-year-old adult man who's over 100 kilos , so he's over 200 pounds .

And he's severely autistic , nonverbal , self-injurious , violent . So this guy's over 200 pounds , nonverbalikes to hurt himself and hurt others . They assign him to me Because I've developed a reputation For being able to handle Difficult situations Gracefully . This case Standard case Right Should take two hours , two hour case .

But this guy this is so important , guys , right , super bad behavior . So what does that mean ? We gotta try to control . This is so important , guys , right , super bad behavior . So what does that mean ? Well , we got to try to control this behavior . So how do we do that ? We medicate them .

This kid is on four different psychoactive medications , okay , four different medications to help control his outbursts . He's on an antipsychotic . He's on a seizure medication , right , he's on a antidepressant . He's on an anxiety medication . He's on all these different medications . He's on a clonidine . He's on like four different medications for his psychological issues .

He's also on a muscle relaxant for his TNJ , and the way a muscle relaxant works is it turns the volume down . I mean muscle relaxants are also psychotropic drugs , blah , blah , blah . So he's on that . So now he's on five agents that affect the brain .

Additionally , you have this kid who's combative , who's self-injurious , will hurt other people and he previously took the other provider's hands , bit their fingers back , causing issue , having caused them to be out of work on the previous visit .

So now I have to be like , hmm , straightforward procedure , but I've got to make this procedure happen for this kid , and I'm the kid's last resort , because if I don't do it , nobody's going to do it . So I'm like , hmm , let me sit back and assess this . So I'm like , hmm , let me sit back and assess this Again .

I only get paid for start time and the time I'm actually in the room , but I'm not going to rush it . So I draw up ketamine . Ketamine is an amazing drug because it keeps the airway open , but it allows you to put people in an incapacitated , zombie-like state . I call it the K-hole , right , the ketamine hole , like a zombie .

My plan is I'm going to stick this kid with this ketamine dart and give him an intramuscular injection . I'm going to , like bam , walk up and stab him real quick and then he's going to fall asleep . Now , just a few weeks ago , a patient got very , very hurt when someone an anesthesiologist attempted . A ketamine dart is what we call it . Why ?

Because you can't just give someone a medication that knocks them out if they're big . And you're in the lobby or you're wherever this kid is so combative , he knows what's up . He's not coming in the office . So the kid is actually outside the office , in the hallway , so he won't come into the surgery center .

So we're not in the operating room , we're not even in the waiting room , we're out in the freaking hallway on the hard tile floor . So if you inject this guy with a large amount of ketamine , you put him out instantly . He'll slump and crack his head , do whatever . And this is what happened previously .

So the skilled anesthesiologist I am , I said no , I'm not going to do that . Here's what we do . I'm going to have a plan . So wait , how do I stick this big old 200-something pound person with this sharp needle ? They're gonna run from this . So I've gotta sneak attack them . So what do I do ?

I get a bunch of cotton balls and I take the cotton balls and I throw the cotton balls up into their face space and they're doing this with the cotton balls . And while they're doing that and the cotton balls fall , they're looking over here and while they're doing that , I take my needle out and I jam it in their leg .

Bam , get them right in the thigh , ah , stick the needle in there . Inside . That syringe is not the full recommended dose of ketamine that you would use as a pre-induction medication to put someone out , because I don't want this big old , two-and-something pound guy falling on the floor and bumping his head . So instead I gave him a third of that normal dose .

Not enough to knock him out , but it is enough to make him compliant . And so my plan is not knock him out to make him compliant , so I give him that medication . The medication doesn't kick in right away because it's a small dose , big guy . So he's like he's angry , he's upset . Nah , he's going around . I'm like , hey , you're okay .

So I'm just like maneuvering around making sure he doesn't hit his head and controlling him . Oh , yeah , he's upset , okay , oh , don't hit me . Keeping it light and we're just existing in the hallway . Now I start to see the eyes flicker a little bit . Oh , it's my favorite chance . Hey , bud , come over here , sit in the wheelchair . Sit in the wheelchair .

Sit in the wheelchair . No , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no , no . I'm like , oh . So I'm like , okay , he's out of the chair . So I'm like , okay , let's walk .

So now I'm walking behind the patient , I'm guiding him because now he feels in control . I'm guiding him to the operating room . So now we're walking to the lobby . Everybody's out there , hey guys , don't worry about this . Right ? I'm like no . So now we're standing there and we're just kind of existing . And then finally I'm like , oh , I see more eye flickers .

I get him on the bed . And all this time , over 20 minutes has passed Finally get him on the bed . He won't let me mask him down and put the anesthesia on and put him to sleep . No , I'm like , oh , wait more Four , five minutes , six minutes . Okay , finally he's like starting to come back .

So then I wrap my arm around him , protect him , love him close and slam the mask on . I'm holding him . I'm like , right now I'm doing all this For another three , three-ish minutes . He's asleep , we're out , kids asleep , parents aren't hurt , staff's not hurt , patient's not hurt , I'm not hurt , nobody's hurt .

But it took me over 30 minutes to get that induction done . A typical induction like that takes five minutes . It took me over 30 minutes , right ? So , like a normal if this kid was a typical kid who would cooperate and whatever the whole induction takes five minutes . It took me over 30 minutes . Guess what guys ?

I get a fixed fee , the start fee , and I get a small incremental bump for that extra time . But we don't consider that factor . So now instead of a five-minute induction we got a 30-minute induction . But now I've given this kid ketamine . He's on five different psychoactive medications . We do the whole procedure At the end of the procedure .

During the procedure , I have to tie all my medications down to get it just right , to hopefully get them up and out . But what happens in a lot of these cases ? They're on all these medications , so then they're snowed and then they wake up super slowly .

And my question to you is right if I were to drug you up , give you a bunch of drugs at your house , give you a bunch of drugs and then leave , would you want me to do that ? Give you the Michael Jackson treatment ? No , because you'd end up dead . Right ?

All these fentanyl overdoses , it's people giving themselves , being their own anesthesiologist , giving themselves fentanyl , and then no one's there to supervise and they die . And so I tell everyone anesthesiologists don't get paid to give medications .

Anesthesiologists get paid to monitor you to see that you tolerate that medication and that you stay alive after you take that medication . I love fentanyl . Everyone , I was like fentanyl is killing America . Fentanyl is my friend . I love fentanyl . Ooh , I can't get enough fentanyl , right . I love fentanyl . Why ? It's magic , oh , oh , it relieves .

It's great for blunting the airway response . It's great for pain management . I love fentanyl . If I could , oh , I just . I bathe my patients with fentanyl . Fentanyl for everybody . Everybody's getting fentanyl . Because it's amazing . It's amazing because I'm an expert in managing the effects of fentanyl on your body .

So when you go apneic and you stop breathing , you don't die . I got you . I jaw thrust you . I got you , I'll put a tube in . I got you . Oh , when your heart starts to slow down , don't worry , I got you . Let me give you a little bit of this ephedrine . Pump that heart rate up . Don't worry , you're good . You're good , you're all right .

You're all right . Oh , you know , I'm going to breathe for you . You're a bowel regimen baby . I manage the fentanyl , so I love it . Right , but you would never want to be sedated and have someone leave you . That's how people die . So if I'm an insurance company and I say , hey , listen , anesthesiologist , hey , this procedure should only take two hours .

If it takes you longer than two hours , we're not paying you . What does that do to the anesthesiologist ? That 30 something minute induction ? I'm not doing that , I'm just going to slam the ketamine . Maybe it's his head , maybe it doesn't , but I got to go . I got to go . The insurance company said I only have two hours , I only have two hours .

They don't consider this . Afterward patient snowed . He's on five different medications . I had you know what ? He snowed . Hey , my time's over Two hours . I got to go and I leave .

No , instead , I make sure that patient wakes up , is breathing independently , spontaneously , can protect their own airway , can follow instructions and can get themselves in the car without hurting someone All these things to make sure the patient is safe . Does it take longer than a normal case ?

Yes , am I milking the clock or am I treating the patient as they would want to be treated , as you'd want your loved one to be treated ? That's what's happening . But when you set arbitrary time limits , who gets the shaft ? The provider and the patient who's not being treated according to their specific condition .

You have to treat the patient , not the profile , the patient . That kid had a great outcome , guys . He got up , listened to my commands , got him in the wheelchair , got him in the car . He got himself in the car and he went home . Parents were happy as pie , mama's squeezing me . Oh , thank you so much . We thought we were going . Blah , blah , blah .

It was wonderful , it was a beautiful day . But think about things , guys Physicians are not greedy . Physicians work very hard , sacrifice a lot of years time learning all this stuff . Do you guys know how like ? This is going to be weird to say Can I say this to you guys ? Is this okay ? Is this a safe space like this video ? Right now ?

Let me know you guys still with me , we're at exactly an hour . Can I say this in real safe space ? I say this to my wife all the time and she's like yeah , you're right , I've seen you . She's like I've seen you do anesthesia . I know what's up . I said , man , I have learned a lot , I am very , very expert . She's like , yeah , you're right .

I said , yeah , I am . Sometimes I marvel at how hard I've pushed myself to learn so much . That's why I'm so proud of it , because I'm like my brain isn't the best brain . I became an elite studier because I committed myself to learning how to study and how to learn things fast and how to retain things and whatever .

It takes so much effort and strain and sacrifice to become a highly experienced physician . It's really sad to me when we belittle PhDs , when we belittle MDs and we devalue education and we act like , oh , just because you educated , I mean you know stuff .

Well , actually , that's kind of like the definition of education , like if I've educated , if I've trained in medicine , I kind of know my medicine . I'm not right .

If I'm willing to give four years of college , if I'm willing to give four years of med school , four years plus of residency , if I'm willing to do all these things and rack up hundreds of thousands of dollars in debt , I think I've earned the right to be able to use my knowledge to help my patients the best I can .

I'm proud of the fact that I'm an expert and I feel like our healthcare system and the healthcare economics devalues expertise , it devalues critical thinking , it devalues looking at the nuances of a patient and designing a specific plan to them , and this is why you see so many people rebelling against healthcare right now .

Right , and they want their concierge medicine . They want their right . The next wave of medicine is genetic-based medicine . We're talking about specifically treating the patient . So why , if we're talking about the future , the frontier of pharmaceuticals is in tailored medications why wouldn't the future of clinical care , of physician care , be patient-centric care ?

Why do we separate the two ? Why do we devalue the fact that I'm trying to do nuanced , high-level , specific care ? I believe in the art of anesthesia and , yes , not just waking a patient up . I want them to have the best day of their gosh darn life . I want them to want to have surgery every day . That's how good I want their day to go .

I want them to feel safe and comfortable . I want them to feel pain-free . I want them to feel like man . This was , I was , because you guys know , or you guys might not know , but if I told you you have to have surgery tomorrow , oh , you'd be scared , scariest day of your life . I've never had surgery before and it truly is .

That's why I love anesthesia , because it's the scariest day of their life and I get to go in there and I get to make them feel like it's going to be okay , here's my plan . I articulate it to them . It's the same thrill I get from working with students . I love it hard and I say , no , I got you . Here's the plan .

And when I see you guys' faces light up when you have a good plan , when I see you guys' faces light up when you get the acceptance , when you guys succeed and get the white , it's a beautiful thing because I'm like I did that . I created certainty .

I created surety , I created confidence , I created an opportunity for someone to have a great , tremendous experience . That's what being a physician is truly about . And so for you guys , as young people , recognize these economic pressures and , first and foremost , don't fall into economic pressures . Never be about the money , y'all . The money will sort itself out .

Always put the patient first . Yes , was I getting pressured to that case ? Yes , 100,000% . But you can't pressure me into doing something that's not in the best interest of my patient . Can't do it . And it's the same for insurance companies . This is how it goes right . So I mentioned I do all these cases . This is how the billing works .

As a physician , you have to pre-authorize what you do . Hey , listen . Yeah , I wanna do this surgery on you or I wanna do this , anesthesia . Okay , we gotta send down all the diagnosis codes and I have to write a narrative . It's called a narrative note . I have to write a story that persuades the insurance company of why my patient needs this care .

Then the insurance company writes back and says , hey , listen , you know what , we're not going to approve it , or whatever . A lot of times they approve it . Oh , here , preauthorization , we approve it . You're right , they need anesthesia . I They've already approved . They said listen , they need anesthesia , do the anesthesia . I do the anesthesia .

You would think they would just pay me in advance or they'd pay me when I did it , but they don't do that . I then have to send all the records , all the documents . I have to write further narrative .

I have to tick all these boxes and document the codes and then have a narrative that justifies why this code was applied , and blah , blah , blah Do that justifies why this code was applied , and blah , blah , blah , do all this stuff . Then I have to fill out their specific forms and use their codes .

I have to send all this to the insurance company , not electronically , snail mail . The insurance company then reviews it and they have 90 days to review it and they get back to me and say hey , listen , we're not really sure . Really , did you need to keep them asleep for that long ? You said you use ketamine . The patient was combative .

The patient was blah blah , blah . As I explained previously in my narrative , the patient was combative . The patient was blah blah blah . They needed this . I sent it back . Well then , why did induction take 30 minutes ?

It took 30 minutes because I couldn't just ketamine works very quickly , yes , but I couldn't just give them a full dose of ketamine because of this blah blah , blah . Well then , how come you washed them ? I had to wash them a little bit longer to make sure they were safe , because they're on all the like .

Why do I have to argue with you if you've already pre-approved it ? Why do I have to go and get at this ? And someone said doesn't Medicaid and Medicare , medi-cal , doesn't this stuff pay great , great . And the truth is , the sad truth is that government insurance pays less than what private insurance pays .

And this is why a lot of offices don't accept Medicaid and Medicare , because it's lower paying . That's why a lot of offices only accept private pay . They want the real , like regular insurance , not the government insurance . And that's the truth . And so what happens ? Who's on Medicare and Medicaid ?

The oldest , the poorest and the sickest the most vulnerable of our population are on this insurance . Is that what you want ? It's not what you want , right ? You have a lot of physicians who would love to take insurance , but it's just too complicated so they don't .

And I'm going to have a physician on either later this week or next week talking about how she only takes cash in her business , in her practice . And for me , as an anesthesiologist , I take government insurance , I'll take Medicaid , I will not take private insurance .

So if you are a patient and you don't have Medicaid because Medicaid has one set of systems and I can do that and I can handle that All these private insurance companies , they change their billing , they have all these intricate policies . It's too much legwork for a small practice like mine to have to do . So I don't accept private insurance .

I pre-auth and then they get the approval and then I tell the patient hey , even though you pre-authorized and they're approved this procedure , you have to pay me cash on the day of . Then you go claim and go through the process the physicians go through to get your money back . And it's amazing how many patients . I even write out a full script for them .

I give them all the codes . I said listen , read this line by line to the insurance company hey , my kid had blah blah blah on this date by this guy . Here's his national provider ID number . Here's his blah blah blah Like here are the ICD-10 codes , here's the length of intervals .

I give them all the whole script and you know what the insurance companies be saying Ah , we're not familiar with those codes . And it's this whole rigmarole . And the patients call me back like man , why is the insurance company doing this ? I thought they pre-authorized this . I'm all these hospitals .

This is the struggle of healthcare is that you have the economics don't always match with what the patients need , what the providers need . And sadly and this is like the craziest part about this is everyone wants to villainize insurance companies and I can't really villainize them for doing what they got to do .

But this system doesn't even work for the insurance companies and the way you know it doesn't work . And this is the last thing that we'll end here . Am I going too long ? Like the video , if you're still with me . Do you guys know ?

They create all these healthcare exchanges through the Affordable Care Act and if you guys have watched these healthcare exchanges , when it first came out , it was amazing because there were all these new insurance companies in the game , because now it's given them the opportunity to platform , to be able to see my eyeballs .

But over the time all these new insurance companies have actually folded and gone out of business , most of them . Why ? Because they can't compete on a scale administratively and capitalize with the existing insurance companies . And so what it shows you is right in any industry , if new companies can't enter , it tells you that the insurance companies are struggling .

And I make fun of it . I say , hey , listen , they're profiting like crazy . Yes , they are , but at the same time , do you know how hard they're working for that profit ? It is very hard to make money in health insurance now because we went from catastrophic coverage to having to cover all these little things for all time . Right .

And the biggest example of this , guys I mean I can give you guys a million examples Do you guys know what one of the biggest , what one of the biggest unforeseen costs of care is in healthcare right now ? Hiv medication . You guys see Magic Johnson right Over 30 years HIV medication . You guys see Magic Johnson right .

Over 30 years , hiv positive , thriving HIV was a death sentence , but now you have people taking very complex , very , not very expensive , but expensive HIV regimens for decades and decades and decades and decades . It's very expensive , but expensive HIV regimens for decades and decades and decades and decades . It's very expensive . You know what else is the ?

We don't the number one condition . You guys know what the most expensive condition is in health care obesity and obesity related conditions . Right , we're an obese society and the cost of caring for and keeping obese people alive is crazy . High blood pressure , right . Hyperlipidemia , right . High cholesterol , right .

Cardiac issues , pulmonary issues , obstructive sleep apnea you name it , go down the list . Debility , right . Deconditioning you name it Across the board . It costs us to manage all these chronic conditions .

And so I think , as we end and I'll close I'll say , yes , I blame the insurance companies , but I , more so , blame our system and the fact that we won't just tear it down and start anew to really get some things right and at the same time , we have to recognize , as people , things that we can do to cut down on costs .

And so we didn't really get to this , but maybe we'll do one more of these sessions . In addition to the interview , next week I'll do a couple of interviews , but where I talk about the real , true solutions and we'll get into the nuance , because it's very , very nuanced and I don't want to bore people to death .

I hope this has been entertaining but if we got into I haven't talked about really the specific like I could bore you guys to death on the specifics of this .

What I'm trying to do is keep this high level enough to where everyone can understand what I'm talking about and understand the big pictures of this , but understand enough of the meat to where they can like okay , that makes sense . That's . He's actually talking facts here .

But we're going to talk about some very nuanced solutions and all of these solutions , before I even give them to you next time , understand you're going to be like this guy is gosh darn nuts . Never in a million years will we do that .

And it's because , like in life , right for you guys as pre-meds , as students , the best decision , the best action very frequently is the hardest action . Becoming a doctor , I had to make lots of difficult decisions . I had to take lots of difficult pathways , I think lots of difficult pathways , a lot of paths that people want to take .

I had to go the road less traveled , the more difficult road .

But that is life , y'all , and that is health care , and we got to make some very difficult decisions and make some some changes that people , both on the patient side , on the care provider side , with their physician , middle provider , whatever , on the insurance side , on the administration side , no one's going to be fully happy .

We're going to have to compromise and come together and everybody's going to have to , everyone's going to have to suffer a little bit so that we can all sustain our healthcare and make it sustainable for their future . Yep , yeah , william says . As a transfer student , I'm really concerned about the cost of transferring to a university .

Y'all listen , life is expensive , but I've never regretted spending a dollar that was invested in me and my future . I've regretted buying expensive stuff , but I've never regretted paying to feed my brain . I've never regretted paying to nourish my body , because you only get one body , you only get one mind , you only get one life .

And so I encourage all of you guys , never be afraid to invest in your education , guys , because education is the way , education is the way , but , with that being said , with your education , you need to couple that up with experiences , with true knowledge . You have to become the expert . You have to know more than just what the book says .

You got to understand what that means in the real world and that's the key . And if you do that , guys I know he said nothing's guaranteed . You know , what is guaranteed , if you apply yourself , is that you'll be successful . People who apply themselves , people who work hard , they don't fail , they'll get there . So invest in yourself , guys .

Invest in your future . Don't spend frivolously . I know the social media culture got you gassed up . You see everybody in their fancy scrubs , everybody wearing fig scrubs . I don't own a single pair of fig scrubs A because I thought it was jacked up . That campaign they did way back when I did a video on that and I'm the only one who stood by it .

Everyone else is like , oh , discriminating against women . All those same cats got FIGS deals . Now you think FIGS isn't contacting me for a FIGS deal ? Yeah , I can't be modeling FIGS scrubs , but I refuse . I'll never wear FIGS . Why ? Because they wronged us back then . But secondly , it's a waste of money . Why would I buy those expensive scrubs ?

I can buy a cost affordable scrub . Don't let social media gas you up into spending all your money on stupid stuff . Spend money on yourself , invest on yourself and on your future , on your kid's future , on your family's future . That's where you put your money at y'all . All right , was this a good topic ? I'm kind of hoarse right now .

I'm going to hour and 15 minutes . I hope that everybody , everybody , everybody , everybody . No , no MCAT session for the end of the year . We got MCAT , we'll talk about it , but I appreciate y'all . We'll be back next week . I got some good interviews coming in with you guys . We're going to talk about this . I have some great stuff . Are you guys excited ?

We're going to do a lot of interviews on the Premium Productivity Podcast this upcoming year . I'm excited to bring you guys some voices . I'm excited to bring you guys some strategies , some stories of inspiration and I'm just excited to bring you guys more content . So I hope you guys are enjoying this . Please come support .

Every single Wednesday , there will be a new video on this channel , whether I'm live or I'm prerecorded . There will be a new video on this channel every Wednesday at least , and actually I'm gonna try to get up two videos a week . But I know that you guys need real stuff . I'm hoping to bring real stuff and we can talk about some things .

So , as always , guys , have a wonderful , wonderful day . If you guys want to get with me , if you're like this is Dr Pines , I need more of you . If you're like Cool Gray and you're in my MCAT course , right , and you're like , oh listen , if you want to be , get coached , you with me , it's amazing . So I hope that everyone has a wonderful evening .

I hope everyone's having a great holiday , staying positive , staying productive as we go , but I'm out of here . Everyone have a wonderful day . I'll see you , guys , next time . That's it for another episode of the Pre-Med Productivity Podcast . Show your love by smashing the like button and commenting in the box below . Today is the day , guys .

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Let me show you how to unlock it so you can dominate and make your dreams a reality . No excuses , just dominate .