Ron Howrigon and Matthew Handley discuss Affordable Care Act (ACA) subsidies, changes to the Medicare Physician Fee Schedule, and why the payers are going to push on provider groups to take pay cuts.

Watch: Why do insurance companies deny prior authorizations? Ron Howrigon explains on CBS Sunday Morning

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Articles mentioned in this program:

US Health Insurers Face Rising Uncertainty from ACA Subsidy Expiration - Fitch Ratings

4 GOP ideas for an Obamacare subsidies compromise - POLITICO

How much and why premiums are going up for small businesses in 2026 - Peterson-KFF Health System Tracker

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Learn more about what Fulcrum Strategies can do for your practice at FSDOC.com.

In this episode, Ron and Matthew discuss claims by current Health and Human Services Secretary Robert F. Kennedy, Jr. that there are no impending cuts to Medicaid and what physicians are really facing as a result of the Big Beautiful Bill. They also discuss the sudden change to Medicaid reimbursement in North Carolina.

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Matthew and Ron discussed the potential sale of Blue Cross, Blue Shield of Louisiana to Elevance, and fines related to a state version of the No Surprises Act. They also talked about recent fines imposed on payers by states for improper claim denial and payments, the prevalence of significant fines issued to insurance companies, and the potential benefits of a health plan in Michigan offering free visits with virtual providers through telehealth.

Blue Cross Sale and Market Concentration Discussion

Matthew and Ron discussed the potential sale of Blue Cross, Blue Shield of Louisiana to Elevance. Ron explained that the Blue Cross system operates differently in various states, with some being non-profit and others for-profit. He said that in Louisiana, Blue Cross is a non-profit entity, and selling to Elevance would mean that they would become for-profit, which would require the state department of insurance approval before any sale could go through.  Ron explained that the fact that this sale dissolved was likely because they were not going to get state approval. Ron said the reason Blue Cross plans want to convert to for-profit is because they don’t get lucrative stock options, and there are limits on their profit margins.

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Ron pointed out that Louisiana Blue’s CEO Bryan Camerlink stated in the Greater Baton Rouge Business Report they were “going to remain independent as long as we can” saying it sounded as though he was inferring that they were struggling financially. Which Ron said was laughable since Louisiana is the second least competitive insurance market in the U.S. He said “If you can’t make money as the Blue Cross Blue Shield entity in Louisiana, with almost no competition, something is seriously wrong.” Matthew asked Ron how insurance market competitiveness is determined, and Ron explained it is based on the Herfindahl-Herschman Index (HHI) a commonly accepted measure of market concentration. He said the HHI scores run from 0-10,000, 0 being fully competitive and anything over 2500 is considered a problem or highly concentrated and at possible risk of break up due to being a monopoly.  Louisiana’s insurance market is rated at 5300. Ron said the reason it is not broken up is that it is health insurance, and this industry is allowed to be more non-competitive.  Matthew said the new CEO, Bryan Camerlinck, stated that they are not planning to sell, but they want to shift into more Medicaid, Medicare, and self-funded insurance. Which, according to both Ron and Matthew, are more profitable and less risky products for a payer, then explained why that is.  

State and Federal No Surprises Act Fines Discussed

Matthew and Ron discussed recent fines imposed on payers by states for improper claim denial and payment. They highlighted a case where Cigna was fined $600,000 for failing to comply with Texas's State No Surprises Act. Ron explained that the Federal No Surprises Act does not supersede state laws, and only applies where there isn't a state law. He noted that Texas is one of several states with a state law so the Federal law only applies to self-funded businesses in Texas. Ron also said that the Federal government has chosen not to enforce fines under the Federal No Surprises Act, despite known problems with companies adhering to the law.

Discussing Insurance Company Fines and Deterrence

Ron and Matthew discussed the prevalence of significant fines issued to insurance companies for failing to process claims and provide benefits properly. Matthew highlighted a $546,500 fine issued to United Healthcare by Utah for selling unapproved health plans. He asked Ron how this could happen. Ron wasn’t familiar with the details of this case but said most fines are often well earned but occasionally they can seem arbitrary, citing a case when he was at Cigna, where they were fined for false advertising due to their building signage. Cigna paid the fine, but they did not have to change their sign. Ron and Matthew agreed that fines are often not a sufficient deterrent for large insurers given their profit margins. “Four million dollars is not even a rounding error for these companies, it’s really not a deterrent, it’s the cost of doing business,” Ron said. He pointed out that it is hard to think of an industry that has been fined by state and federal governments as frequently as the insurance industry for not doing what they exist to do.  

Free Telehealth Visits for the Uninsured

Matthew and Ron discussed the potential benefits of a health plan in Michigan, Priority Health, offering free visits with virtual providers through telehealth to uninsured Michigan adults. Matthew highlighted this as a possible instance of a payer doing something right, as it could potentially reduce the need for expensive emergency room visits. Ron agreed, noting that this approach aligns with the financial interests of the payer and the greater good of the people. They also discussed the possibility of using telehealth to catch health issues early and assist with public assistance applications, thereby reducing the need for costly hospital visits. Matthew wrapped up by thanking Ron for his insights into the business of the healthcare industry.

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Further reading:

New Blue Cross CEO talks prospects of future sale, staying competitive - Greater Baton Rouge Business Report

9 payers recently fined by states - Becker's Payer Issues

Priority Health offering free telehealth to the uninsured - Becker's Payer Issues

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Fulcrum Strategies is a healthcare consulting firm specializing in payer contract negotiation and strategic planning for physician practices.  Our firm has helped over 5,000 physicians in groups of all sizes and specialties across the country to significantly improve their contract language and reimbursement rates, strategically plan for the future, and achieve business success.  Learn more at FSDOC.com.

In this episode, Matthew and Ron discussed the role of healthcare in the upcoming presidential election, focusing on the potential implications of Medicare drug pricing negotiation and changes to the Affordable Care Act. They also explored the challenges of cutting costs within the healthcare sector.

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Presidential Election

Given other issues like the economy and inflation, Matthew suggested that healthcare might not be a top priority for voters. Ron agreed, stating that while specific healthcare issues like drug prices or abortion could come up, healthcare overall was unlikely to be a major campaign issue. Ron said, “I wouldn’t be surprised if there is a presidential debate and there aren’t any questions about healthcare.” Ron doesn’t think there is a high level of interest in healthcare right now and finds this a little surprising with some of the upcoming “cliffs.” He pointed to the Medicare trust fund which, according to Ron will become insolvent in 2036 or more locally, the North Carolina state employees' health plan where the treasurer said it may not be able to pay its bills at the rate it is losing money. Matthew suggested this challenge may have been partly due to a pricing project he launched before the COVID-19 pandemic. Ron said that issues like immigration, crime, and inflation were more likely to feature prominently in Republican campaigns and predicted that regardless of which administration occupies the White House, they would likely ignore healthcare issues until faced with Medicare insolvency, saying these issues are hard to tackle and are often only addressed when they become serious.

Concerns Over Medicare Drug Pricing Negotiation

The team then discussed the potential issues with the Medicare drug price negotiation. As an economist, Ron expressed concerns about price controls, arguing that they could lead to unintended consequences such as limiting drug development or forcing the drug companies to do something else. “There is nothing that says these companies have to sell their product to Medicare,” he said. Ron asked rhetorically about what happens when a drug company creates a new amazing drug and decides not to sell it to Medicare, you end up with seniors not getting a drug they need. He acknowledged the need for a solution but noted the complexity of the issue, and in an election year, the solution doesn’t make for a good soundbite. Matthew agreed, highlighting the lack of discussion about healthcare policy. He cited the recent insulin price cap legislation and pointed out that drug companies had already announced similar measures before the legislation was enacted.

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Discussing ACA Changes and Medicare for All

The conversation shifted to potential changes to the Affordable Care Act (ACA) and the political implications of advocating for Medicare for all. Ron suggested that substantial changes to the ACA would be difficult, especially with a divided Congress. Matthew noted that Vice President Harris's views on Medicare for All seemed to have shifted since her Democratic primary run in the 2020 cycle. At that time she backed a Medicare for All approach and then made some adjustments he said.  Ron thought that this was likely a strategic move to try and steal a little “wind” out of Bernie Sanders’s momentum in the early days of that race. Then Senator Harris dropped out of the primary on December 3, 2019, before any votes were cast. Both agreed that voters are more focused on the economy than healthcare issues this go around.  

The Challenge of Cutting Costs in Healthcare

Matthew brought up the recent appearance of former Cigna executive Wendell Potter who explained that when dollars get moved around in the healthcare system, somebody screams because you are taking it from one to give to someone else. Ron added that each year there is about $4 trillion being spent inside the healthcare system.  He said if you could cut 10% of that, that is $400 billion, money that is now no longer somebody’s revenue.  He explained that one man’s revenue is another man’s expense. “There are whole industries that are not that size,” he said. Regardless of who that is, whether it be a pharmacy, hospital, or insurance company, they’re going to want to hold on to that revenue and that’s what makes this extremely difficult, he said.

Future Secretary of Health and Human Services (HHS)

The team wrapped up with some closing thoughts on the current HHS boss and future picks for the position. Matthew said regardless of who is elected he hopes they pick a competent secretary. He said not that he doesn’t think the former Attorney General of California Xavier Becerra isn’t intelligent, but healthcare is not his specialty. Matthew doesn’t think he knows how to run the other entities under HHS.  Ron agreed and compared his selection, to putting himself in charge of the Nuclear Regulatory Commission, something he joked that he is definitely not qualified for.  

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The FLATLINING Podcast team will continue to watch the news and events in the healthcare space. If you liked this episode, be sure to subscribe and catch the next conversation at the intersection of healthcare business, politics, and policy. You can find the FLATLINING Podcast wherever you listen to other great podcasts.

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Further reading:

Harris isn’t pushing Medicare for All anymore. Progressives say that’s OK. - Politico

Abortion rights and drug pricing program take spotlight at first night of DNC - STAT

Sally Pipes: How the GOP can get tough on health care - Boston Herald

Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

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Fulcrum Strategies is a healthcare consulting firm specializing in payer contract negotiation and strategic planning for physician practices.  Our firm has helped over 5,000 physicians in groups of all sizes and specialties across the country to significantly improve their contract language and reimbursement rates, strategically plan for the future, and achieve business success.  Learn more at FSDOC.com.

The podcast starts with Matthew introducing and welcoming Traci, Christine, and Dan’s younger brother Tom. The siblings shared their early life in the Hurley household and how Dan was a smart and innovative problem solver at a very early age. Tom shared Dan’s solution to their dad’s moratorium on playing video games at a specific mall, sharing that Dan pointed out that their dad did not say they couldn’t visit the other mall in town, which happened to be a more treacherous bike ride than the banned location. His sister Christine said although the future Dr. Hurley was a problem solver, he was also a rule follower. She said he once, like many kids, decided to run away, reached a certain stop sign they were not allowed to cross, and could not bring himself to break their father’s rule at that particular border, and returned home. Christine shared that Dan was quite smart, so much so that one of his teachers stated he was answering all the questions in class, and he ended up skipping several grades.

Traci shared how they met and described their first meeting at the beginning of medical school. She said Dan was only 19 when he entered medical school. Explaining that from their first dinner outing with fellow students, they became fast friends. She said they were best friends and then started dating after about six months. “We were inseparable,” she said. People noted it was always “Traci and Dan” or “Dan and Traci.”

Ron asked about what it was like meeting this 19-year-old medical student and if it was intimidating. “It was hard to be intimidated by Dan, he was just so down to earth and goofy and funny. He just made everything so much more fun, and I think everyone in our class that knew him well would agree to that,” she said.

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Matthew asked Traci to share what it was like dating and attending medical school together. She said that dating was a natural progression of their friendship since they were together all the time anyway with their studies. “Studying usually looked like me spending hours in the library actually studying and Dan reading magazines and taking naps on the couch, really just wanting to be with me.”  Not wanting to make it sound like Dan did not work hard, Traci explained that he was one of those people who could read something one time through and remember it. She remembered that Dan would occasionally point out that she did better in school than he did. She chuckled and said she would remind him, “That is because I worked five times as hard.”

The couple dated for four years got engaged, and married a year later.  She said they had a religious difference; Dan had been raised Catholic and Traci was raised Jewish. “He was a lot more, I guess, observant in his religion than I was and it was very important to him to make sure that everything was done correctly in the eyes of the Church and there were things I had to think about as well, and if I was willing to do those things, so we did not rush it, we took our time.”  Traci shared that religion never was an issue between them and credited their mutual understanding and respect for each other and their beliefs.

Matthew asked Traci how Dan came to be an Otolaryngologist, and she said that he had an interest, like herself, in pediatrics, but during their clinical rotations it was clear that Ear, Nose, and Throat (ENT) is where he wanted to work. Ron recalled that Dan had pointed out that “He got the best of both worlds, since a decent part of his practice were kids.” Traci agreed, saying that he was one of the main physicians who saw children in their area, and he enjoyed that aspect of his practice as well as complex sinus disease.

Matthew shifted the discussion to Dan’s final years and asked the guests how their relationship changed when Dan received his cancer diagnosis. “One of the things that struck me most about his diagnosis was how selfless he was,” said Christine. Explaining, that when he received the news, he immediately called his siblings with instructions on how they could help his family as they worked through what was to come. “He wasn’t thinking about himself, he was thinking about his family. His diagnosis was never an elephant in the room,” she said. She said he kept his sense of humor to make it easier for everyone. Christine said that all the siblings were very grateful to Dan for not pushing people away. He wanted people to visit and planned a vacation with his siblings to Sedona Arizona.  

She emphasized that Dan never asked, “Why me?” with his diagnosis. She said his attitude was more “Why not me?” She explained that he thought that he was well-equipped to take on this challenge. She recalled Dan saying that he had a supportive family, he knew how to take on the insurance companies, and he had the medical knowledge and contacts to see this issue through to the end.  Christine explained, “For me, it was seeing his gratitude, his selflessness, that came out of that.” Although she always thought of her brother as a “Great guy” she said witnessing the degree of these attributes during his illness made her grateful for that time with him.

Tom echoed his sister’s description and shared a story about a time when Dan had received some bad news on his prognosis, and it was near Christmas. He said Dan was adamant that this news not “Cast a pall over the holiday” and did not want the focus on himself. Tom explained that since they lived in opposite ends of the country, they did not get to see each other as much as they would have liked, maybe once a year or so. “I saw a lot more of him actually in the last couple of years of his life, and I was very grateful for that,” he said. Tom said Dan’s approach of inviting people to visit during the last years of his life allowed him and others to have that extra time together. Christine added that the family is so grateful to Traci, noting that sometimes people want to withdraw when this type of situation enters a family, but Traci, she said, welcomed them along with Dan and it resulted in them getting to spend a lot of time with him the last 18 months of his life.

Traci reiterated to Christine and Tom that the feeling was mutual, saying the family was the “Rock” that she and her children needed to lean on in this difficult time. “We needed your support, and you guys were there for it,” she said.

Traci acknowledged Ron’s description of Dan as a “solutions guy” and said from the first diagnosis, Dan had a “let’s go” attitude. She said he made lists of who they needed to call, where the expert specialists in the country were, and so on. “From minute one, we were full speed ahead in trying to solve problems,” she said.  Traci described herself as more the worrier in their relationship whereas Dan was more logical and had a lot of faith which helped him, she said.  She thought his logical approach and matter-of-fact dialogue was Dan’s way of keeping her and the children calm. She said this was a very stressful time and “He just had a very calming way, it was very important for him to show the children he handled this with grace, both his illness and his death truthfully.”

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Ron said that listening to the family talk about Dan and his final days helped put the rest of the picture together for him of a man he only got to know at the end of his life. Ron told how Dan reached out to him when he read an article Ron was quoted in concerning insurance company medical denials. He said Dan asked if he could spare some time for a call. Ron described getting on the Zoom call and seeing this gentleman getting treatment in a hospital bed. He shared his amazement about Dan’s attitude of wanting to help others that face medical denials from their insurance company like he was. It was the fact that Dan was taking time away from his treatment to try and help others that amazed Ron most, he said. Hearing how unselfish Dan was, Ron said he doesn’t think he could do what Dan did but often finds himself asking himself, “What would Dan do?”

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Matthew recalled his conversation with Dan and noted that he was very “matter of fact” about his diagnosis and seemed at peace with it. That seemed to give him the ability to focus on how he could help others, he said. Traci said their experience with his insurance company denials wasn’t the first time, the couple had to deal with this issue a few years earlier with one of their kids. She said their attitude was at first, “Here we go again.” His sister said she thought it lit a fire under him, saying that Dan had shared with her that he had always wanted to fight for insurance reform, and thought that now was the time to do it and so he went to law school. Christine described Dan as not one to seek the limelight and as a very private person, but he was willing to step out for the sake of other people and share his story. Tom shared that he had heard Dan talk about insurance reform earlier and said he cared a lot about patients and how they interact with their insurance company and had asked what they might do about it. “The diagnosis and what came after it was just sort of a catalyst that took it to a new level,” and noted that Dan would never say “This isn’t the best time for me to do this.” Tom explained that Dan looked at this situation and thought that it is going to compel him to do something, and he wasn’t going to wait until it was convenient.

Ron shared his amazement that Dan attended law school all to help patients he would never know or treat, but still had them on the forefront of his mind while he fought his cancer and the insurance company.  He said what struck him about Dan, was that it was not about him, it was about those who would come after him. Ron said he told Dan once that he wanted to make sure others understood how courageous he was. He said Dan corrected him, saying “That’s not what this is about, it’s about the patients who are not going to have to do this because of whatever groundwork I do.”  Traci agreed and emphasized that this effort was never about him. She shared Dan was a lifelong learner and law school was something he wanted to do. He loved to read and attending law school was not a surprise to her. She said after the surgery that removed half of his pelvic bone, he was sitting around and told her that he “Might as well take the LSAT and see how I do.” She said she responded with an “OK” he then applied to one school and got in with a scholarship and he took that as sign, she said.

Matthew said that Dan had written a letter to several of the insurance company's medical directors as part of his appeal to denied prior authorization requests. Ron read the letter that expressed Dan’s thoughts on how the insurance company's medical director’s decisions impact patients’ lives. Dan’s letter said how they as physicians are making medical decisions on patients they have never seen or treated. He talked about the hours practicing physicians must dedicate to prior authorizations or appealing denials. He said that these precious hours not used to treat or counsel patients have untold negative impacts on them and their doctors. He talked about the negative effects on patients fighting the denials and how many cannot pay out of pocket as he has done so they go without care.

Dan described his disease, his family, and his goals for changing a system that he saw as not having the patient at the center. “I want to bring transparency and accountability to delays caused by medical decision-making in the authorization process,” he said.  A process, he explained, that was put in place by insurance companies and their reviewing doctors. He addressed the lack of experience and specialty among insurance company medical directors, and their lack of knowledge adding days or weeks to needed treatment for patients.

The letter described his philosophy about medical guidelines, and how they are to be balanced with experience and individual attributes of the case that is before a physician.  “Guidelines are no substitute for experience and clinical judgement,” and pointed out that a non-practicing pediatrician upheld his denial for treatment even after a phone call with a nationally respected sarcoma expert. To illuminate his point, Dan shared the story of the “Miracle on the Hudson” pilot Capt. Chelsey Burnett “Sully” Sullenburger. Who in 2009, during U.S. Airways flight 1549, safely landed his plane on New York’s Hudson River after birds took out both engines. Dan explained that Capt. Sullenburger didn’t just blindly follow the guidelines, he combined procedures with his vast experience to save all aboard that flight. Dan said the passengers benefited from Sully’s expertise, just as he is trying to benefit from his physician’s expertise.

In the letter, Dan noted the physician’s specialty as oncology and pointed out that he had never seen Dan as a patient. Then described the difficulty he had in tracking him down, finding him only after filing a required written request to the insurance company and then finding his name at the back of a 100-page document. Dan pointed out that all this work was to get one CT scan approved so it could be applied to his deductible, even after paying $1500 per month in premiums.  He reminded the physician that cancer patients will get many scans and complex treatments and said he was lucky that he knew how to fight this unfair system, most people don’t.

Dan closed the letter with, “If I can help even a few patients who don’t have a voice from being harmed emotionally or physically by an unethical system I will have partially succeeded in my goal.”

Matthew asked Traci as a physician how this journey with Dan has affected her perspective on prior authorizations and the denial process. She said that her perspective has changed quite a bit. She said she had done some prior authorization with her practice, and she recalled her and Dan having discussions about the challenges, where Dan would share now and again that he had been on a “Peer to Peer” call with a medical director and that the physician deciding the authorization would not even be an ENT doctor.  She said Dan would ask the medical director for his phone number, which he did not want to give out. Dan would then say he needed it so he could have his patient make an appointment with them since they seemed to know what was better for his patient than he did. Chuckling, she said the authorization would then get approved. After hearing all those stories from her husband, Traci said they were living through this scenario “Over and over and over again.”

The experience paid off when their internationally recognized Oncologist doctor had Dan in a trial in Santa Monica, California. Traci shared that one day their physician came to Dan and asked him to speak to his human resources people because he was on peer-to-peer calls with gastrointestinal physicians at the insurance company and told them that they don’t know what they’re talking about. “In typical Dan fashion he puts a presentation together,” she said. Dan had contacts on their human resources and benefits team that helped him connect with the insurance company's medical director. Traci explained that instead of Dan telling this doctor to fix the problem, he provided him with this presentation and offered to help the medical director improve their prior authorization process.

According to Traci, in that presentation, Dan mentioned a very helpful insurance company nurse. She had followed up with Dan after his previous surgery to see how treatment and recovery efforts were going. When she asked if there was anything she could help with he said yes and explained the prior authorization conundrum regarding his PET scan.

Traci said that this request was nowhere in this nurse’s job description, but she promised to look into it and would try to help get it approved. In Dan’s presentation to the medical director, Traci said he mentioned this nurse and some other data personnel who were helpful. After hearing Dan’s presentation and acknowledging he would get the presentation to those working to improve their processes, the medical director suggested that this nurse be his Critical Care Coordinator. “Our critical care coordinator was this amazing woman that was so caring and so helpful to us that every time we got a denial she would help us get it in front of somebody who needed to see it and help us get approved what we could get approved so that was a huge help to us,” said Traci.  

Ron said that he understood that this story was more than just getting one PET scan approved, and asked Traci to share some of the more egregious prior authorization challenges they faced during this journey.  She shared that during one of his 24-hour chemo treatments his blood count dropped, and he needed a white blood cell augmenter that required an “Urgent” prior authorization. In insurance speak, “Urgent” meant a 72-hour turnaround for approval, this was a Friday she said, and they needed it now because with his blood count dropping it was likely he was going to end up in the hospital over the weekend without it. She said he was simultaneously receiving radiation treatment, so they were traveling between the two locations. Tired of waiting, she said they decided to pay for it out of pocket. Eventually, someone was able to get ahold of their critical care coordinator and she was able to get it put through so he could get the medicine.

Traci explained about another time that Dan’s radiation treatment had been denied and there was a specific date to begin receiving this treatment.  She said the appeal had been pushed back several times and again their critical care coordinator stepped in to work on it. Moving ahead on their own and the same day they were walking into the lobby of the radiation treatment center, they received a call that it had been approved.  Simultaneously Dan received an automated call that the radiation treatment had been denied.

Traci went on to share that the earlier chemo treatments she spoke about were at first denied, then approved, and later that summer his chemo-immunotherapy was initially denied then approved. The worst was yet to come, “After he passed away and he [had] got the chemo, we got a letter saying that the medical director at EviCore overturned it and said it was not medically indicated after he knew it was approved and he got it, we are talking about $80,000 worth of chemo-immunotherapy.”  Ron pointed out that none of these treatments were out of the norm, explaining that these are the best tools that the medical team had to combat Dan’s disease.  But his ire was on the medical director, who knew the treatment had been approved but went back in and denied the approval, i.e. payment of $80,000 worth of care. Adding insult to injury, the letter was dated on the same day that Dr. Dan Hurley passed away.

Traci said she tried to do what Dan would do and attempted to find this physician, who she said was an oncologist, to see if he had treated someone with dedifferentiated chondrosarcoma. She explained that chondrosarcoma is rare and Dan’s subtype, “dedifferentiated”, is even rarer, which means there are not distinct guidelines for treatment. In the end, she determined he was retired and only worked for EviCore. Traci said that it is highly unlikely that the medical director was a sarcoma expert. She said Dan’s treatment plan was developed and approved by the Mayo oncologist in their hometown of Phoenix in collaboration with their oncologist in California, who is an international sarcoma expert.  

Ron pointed out that EviCore is owned by an insurance company which can lead some to wonder what their motivation is. He said that a skeptic might say that if EviCore approved too many treatments then the insurance company will find someone else to do their third-party review for prior authorizations. Ron said that sending a letter like that in his mind, is emotional abuse, given that the Hurley family was mourning the loss of Dan. Ron emphasized that this was not a one-time PET scan that did not get approved, but a “Constant battle for both of you that extended past his passing. That in my opinion is unacceptable behavior.” He said he knows this type of situation was a motivating factor in why Dan wanted to change this process so someone in the future would not have to go through the same thing.

Matthew asked Traci and the family what was going on now to carry on Dan’s efforts and if anything had changed.  Traci said Dan had met with an attorney and said they had been in contact with her to discuss how best to move forward with this. “He wanted to bring transparency and accountability to the physicians on the insurance side who deny, and delay care as recommended by the patients chosen physician.” Traci emphasized that it is about holding physicians accountable for their decisions who claim that they are not “medically indicated” and the fact that these medical directors should be considered “practicing medicine.” This is a difficult spot to be in for a patient, she said. Traci pointed out that Ron had said in the past that a medical director signing a denial letter should be treated the same as practicing medicine, and “That’s what Dan would have wanted as do I.”

Traci said they are doing some advocacy through the Chondrosarcoma Foundation. She said the foundation has set up an endowment fund in Dan’s name to help patients navigate through denials and they are working on a case now. She said the president of the foundation, Jeff Kramer, is wonderful and has embraced what Dan was trying to do, and “We are so appreciative of that.”

Ron recalled a conversation he had with Dan where he said that he did not object to questioning doctors and acknowledged that they are not perfect, but he emphasized the patient needed to be at the center of the conversation and if a medical director for an insurance company had information that Dan didn’t have, then he wanted him to call so they could talk about what was best for the patient. Ron said Dan’s focus on transparency, open dialogue, and accountability was a “Very interesting approach.”

Ron said that some states are now looking at reforms and North Carolina has some legislation to address what Dan was working toward. “If we can get this thing started in a few states it will spread to other states and hopefully nationally.” Ron said this cause is the right thing to do for patients because there is too much money involved to expect that insurance companies will change on their own.  

Matthew wrapped up by asking Dan’s family what inspirations they take away from Dan’s life that might be helpful for others. “Above all else, Dan has taught me how to be a better person,” said Traci. She said Dan was truly a good person and always tried to do the right thing and do everything with humor. She acknowledged her bias, but “He made the world a better place, he really did.” Christine agreed, saying he even used his humor in his diagnosis, noting he went out and “Got matching canes with my dad who is 88.” She shared that Dan always said, “’If I could just help one person by this’ and he has already helped multiple people.” Christine said that she knows someone locally who has been helped. This person read articles by Ron and Wendell Potter and decided she could fight her denial. Christine credited this awareness as giving people courage, and Dan would have been happy to see this. Tom explained that many of us may want to do good things but are intimidated or don’t know what to do or how to start. But with Dan, “If he saw something that he could do, he would just do it.” He said that he would like to be more like Dan in this way and maybe we might all make this our inspiration as we take on the challenge of insurance reform and prior authorizations. Tom said there are things that need our help, and maybe we could bring more of a spirit of helpfulness. He said so now, “I am just going to do it and not hesitate.”

Ron closed saying that he did not think Dan ever thought “I am only one guy, what can I accomplish?” He noted that Dan did not seem to worry about having a large impact and was more about making at least a small impact. Ron said he did not seem to get hung up on the size of the problem but approached a big problem by tackling the first small one, then the next, and so on, not ever giving a thought that he would be around to see the final outcome.

Matthew thanked the guests for spending time on the podcast with them to raise awareness of this issue and reminded patients that they too can fight their insurance company denials.

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Original interview with Dr. Dan Hurley

Matthew and Ron spoke to Dr. Hurley last year on the FLATLINING Podcast after he was diagnosed with dedifferentiated chondrosarcoma and his insurance company had denied payment for radiology scans that would have aided his treatment.

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Further reading:

Dan Hurley, M.D. Endowment Fund - CS Foundation

CLICK HERE to listen to our original conversation with Dr. Hurley

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Fulcrum Strategies is a healthcare consulting firm specializing in payer contract negotiation and strategic planning for physician practices.  Our firm has helped over 5,000 physicians in groups of all sizes and specialties across the country to significantly improve their contract language and reimbursement rates, strategically plan for the future, and achieve business success.  Learn more at FSDOC.com.

Matthew noted that in the story, the pediatric specialty problem seemed to come to light when the issue affected them. He said the story highlighted parents struggling to get appointments for routine physicals and specialty care. Sometimes they waited months and in one case over a year in advance, he said.  Ron agreed saying that often something like this is a theoretical problem until it affects you, he said. Ron pointed out that they have discussed this topic a lot on the podcast and stressed that we can’t just wait to problem is personal. He said this problem is affecting multiple specialties, and the statistics are “scary”.

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Ron described a recent survey of physicians that asked if they would recommend to their children that they enter medicine. He said two-thirds of physicians said they would not recommend the medical profession to their kids. Ron said that is troubling, noting that becoming a doctor used to be one of the things parents were most proud of.  There is a projection, he said, that by 2036 we will be 86 thousand physicians short. Ron said that the problem goes deeper because the combination of all medical schools in the U.S. graduate just under 30 thousand physicians a year. He pointed out that it would take three years to catch up to this shortage if no other physicians left the practice of medicine, and the population did not grow. Ron shared one other alarming report that said 25 percent of students in medical school or nursing school are considering quitting. The other disturbing statistic he said was that 61 percent of students in nursing or medical school are not going to use their degrees for direct patient care. Rather they would work for insurance or pharmaceutical companies or some other business, Ron said. Put all these factors together and it will take much longer than three years to solve the shortage problem, he said.

Matthew pointed to one of the solutions the team at Fulcrum Strategies is familiar with and was highlighted in the PBS story, the reimbursement rate for physicians. He noted that pediatricians often see a mix of patients who are on commercial insurance and government insurance, generally Medicaid. According to Ron, Medicaid in most states reimburses at a lower rate than Medicare, and Medicare is lower than commercial insurance and is often the target of Congressional budget cuts, he said. Additionally, Medicaid rates often track with Medicare, so when you read about Medicare cuts, you will also see cuts to Medicaid reimbursement, he said.

This all becomes problematic for new pediatricians after years of training and entering the workforce later in life and carrying $200,000 to $300,000 in debt, he said. Ron continued, “It’s no wonder that almost two-thirds of folks in training are saying ‘I am not going to practice medicine, I will never dig myself out of this hole that I got,  I got to do something else that pays better.’”   

Matthew asked Ron, what else besides raising Medicare/Medicaid rates, which would likely raise our taxes, could be done to address the shortage problem. Ron said that the money part is one piece of the puzzle, but most physicians did not go into medicine strictly for the money, physicians talk a lot about their “passion” for medicine and wanting to “help people.”  Ron said the first thing to do is return “respect” to the profession.

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He said this is done by “getting the insurance companies out of their exam room and telling them how to practice medicine.” It’s all the “hassle-factor” stuff of endless paperwork and “mother-may-I?” requirements that insurance companies burden the physician with that don’t have anything to do with delivering the best care. He said the other factor is the financial, the message that is sent from Congress every year by lowering the Medicare/Medicaid reimbursement rates is demoralizing. He said, “You can’t expect someone who gets many times half of their money from federal funding, Medicare/Medicaid, to feel good about it when every year the message you send them is ‘You are overpaid and deserve a pay cut’ because when you cut the reimbursement that is what you are saying.”  Ron pointed out that recipients of Social Security get a cost-of-living adjustment every year, but Medicare reimbursements don’t. Nothing against seniors, he said, but pointed this out for a comparison.  

Lastly, we as a society need to improve our respect for the physician and what they are doing, he said. He pointed out the frustrations he has heard from physicians dealing with ill-informed patients either arguing over vaccinations or some other treatment that shows no clinical value. It’s not that we have to look at them as God, he said, but let us as patients respect what they bring to the table in their care of us or one day they may not be there, he said.  

Matthew pointed out the diverse political leanings of physicians as a voting block and pondered if a solution might be that they decide to stop seeing new Medicare/Medicaid patients, and asked Ron if this could solve the problem. Ron said it could, but that he did not think physicians would want to do that and harm patients. Additionally, he said, opponents would point to them and possibly say, “They are holding seniors hostage” and be painted out to be the bad guy. Ron said he is not pro or con union, but said imagine if all physicians formed a single union and they decided after another Medicare cut to have a one-month walkout on Medicare/Medicaid patients. That might bring the point home to legislators he said.  Or they could decide not to have a contract with Medicare, for example, he said. Ron said he is not advocating that, but “If we don’t solve this problem in a way that maintains the profession, it will solve itself.” There just won’t be access, he said, and as a country, we are not used to that and won’t like it.

Ron closed by encouraging us to be sure to thank our physicians and medical staff for what they do, we often thank servicemembers and rightly so, he said, but thanking your physician for their care of you will go a long way to encouraging them in their care of the rest of us.  

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Further reading:

The causes and consequences of a decline in doctors going into pediatric care - PBS News

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Fulcrum Strategies is a healthcare consulting firm specializing in payer contract negotiation and strategic planning for physician practices.  Our firm has helped over 5,000 physicians in groups of all sizes and specialties across the country to significantly improve their contract language and reimbursement rates, strategically plan for the future, and achieve business success.  Learn more at FSDOC.com.

Matthew starts the discussion by asking Ron about 2020 candidate Harris’ previous support for Senator Bernie Sanders’ Medicare for All plan, and her track record on healthcare as a U.S. Senator. He asked if she would continue President Biden's healthcare policies.

Ron doesn’t think she is a staunch believer in Medicare for All, like Sen. Sanders. He feels she is more of a politician and her actions will depend on “Which way the winds are blowing.” Ron likened her approach to sailing, where you tack with the wind, changing your direction to get the best air. He said when you look at candidate Harris, she came out supporting Bernie Sanders’ Medicare for All program. Then when she realized that wasn’t working, she moved away from that program to a more left-center approach. He said, “There were items she tacked either way on.”  He thinks she would look at the make-up of the Congress, and what kind of mandate, if any, she gets from the general election to determine her approach on healthcare.  Barring any massive Democrat win, Ron thinks she will stick to Biden’s approach of not taking a hard stance anywhere on healthcare issues and remaining more left of center than Sanders would be on healthcare.

Matthew brought up candidate Harris’ program called “Kamala Care” and pondered if it would be resurrected. He described it as a plan that would be implemented over ten years, versus Sanders’ four years, and would include payers on some level. He pointed out that when she was the Attorney General of California, she filed several Amicus Briefs in support of the Affordable Care Act (ACA) when it was being attacked in the courts.

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In a recent Forbes Magazine article, which detailed her “tacking” approach to healthcare policy, she co-sponsored Sanders’ Medicare for All bill but then developed her own version that included a Medicare Advantage type of program. Ron pointed out the ten-year implementation as a political move by Harris, giving her the option to say she passed universal coverage but doesn’t have to see it implemented in her tenure. Similar to the ACA where they passed it then had eight years to implement, he said.

Matthew asked if Harris is elected, “Can we give up any hope of the No Surprises Act (NSA) being enforced?”  Ron doesn’t see her stepping up to enforce NSA, mainly since it doesn’t do anything for her politically. He thinks that enforcement will be more based on lawsuits and the recent Chevron court decision. Ron thinks that “If Trump wins, they will enforce it.” Because it was a law passed under his administration, he said.

The discussion shifted over to the Biden Administration's approach to drug price capping. Matthew referred to a MedPage Today article and asked Ron if a Harris administration would like to continue this effort. Ron said he thought she would, since she has talked in the past about matching U.S. drug prices to what they are sold for overseas etc. The problem is going to be the recent Chevron decision, he said. Since these tactics are regulatory, which the Chevron decision affected, it is unlikely that she will get legislation passed that would accomplish her goals, Ron said.

Matthew noted that there has not been much if any discussion on healthcare policy so far in this election cycle. He said what we are likely to get from Harris is the typical talking points about “making it affordable for all Americans” and her support of the ACA. The kind of messaging we seem to get when there is no plan, he said. Matthew thinks that unless healthcare polls as a topic, we are not likely to hear more this election cycle. Ron agreed, saying healthcare is clearly not in the top ten of issues. He said that if there is a second debate, he would not be surprised if there is not a single question on healthcare. If there is, he said, it will be short. Matthew pointed out that the first debate did not have any healthcare questions.

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Ron lamented that a topic that affects so much of the U.S. economy won’t be discussed. If it is, it will be likely about abortion or Roe v. Wade not discussion of healthcare at a cost level, he said. Ron predicts that the election will result in a divided Congress, making it very difficult to get things done on healthcare. He noted that we had not heard much in the way of plans from either party as we have in past elections.

Matthew asked Ron to tell us about a recent New York Magazine article he was in and what was the aim of the story. Ron said the article was centered around insurance company denials for medical treatment. Ron, as a former Cigna executive, has been a frequent source for stories on this topic. This most recent one also featured Wendel Potter, the former VP for Communications for Cigna who appeared in a recent FLATLINING Podcast. Ron said he is pleased that outlets are shedding light on this practice of using artificial intelligence and other methods to deny care and increase profits. He said he explained how this happens, but he also liked how New York Magazine showed how different people dealt with getting denied and how the average consumer fights back to get their claims paid or the care they need. Ron said he provided perspective on “How it happens, here’s what I think is wrong with it, and here’s what you need to do.”

The article highlighted several people’s successful pushback against insurance company denials. In light of this, Matthew pointed to several large lawsuits against the insurance companies on medical denials and asked Ron if we are likely to see “millions and millions of disputed claims” that will affect the current process. Ron doesn’t think that this is the answer, mainly because the insurance companies make the appeal process so difficult for the average consumer to navigate successfully. Additionally, he said, if it is still profitable for insurance companies to deny, they will. He provided a hypothetical that if only 10% of denials are appealed, and they are all awarded positively, then 90% of the denials were never paid out, then the insurance company still is profitable, he said.

The article touched on the NSA and according to Matthew, it seemed to indicate that its application of the law has improved. He asked if hospital-based non-participating physicians and the lack of residual enforcement are contributing to some patients still getting bills from providers when the care should have been covered by payers. Regarding the NSA, Ron said that he liked that patients were “pulled out of the middle.” One of the problems is enforcement he said, “When somebody is not playing by the rules, who enforces it?” Many state departments of insurance don’t enforce NSA stating that it is federal law, not state, and CMS doesn’t know how to enforce it, he said. “Hopefully that will get better over time.”, he said. It appears that there is more enforcement against the physician who bills inappropriately because the payers will enforce that, he said. For the payers that are not in compliance, Ron said he doesn’t know who is enforcing that. All this adds to the confusion for patients, he said.

Matthew interjected the issue of medical debt into this broader discussion of medical denials for reimbursement and asked if it could become moot if medical debt relief becomes the norm. Ron countered by emphasizing that the public needs to understand that one person’s debt is another person’s revenue. He said that you can’t continue to waive away debt because it will just grow back. Explaining that if someone provided a service, that service has actual physical costs, like medicines or salaries. So, when you waive the debt, you are hurting that service provider, who may in the future decide not to provide that service, he said. If you did this for Emergency rooms, for example, you would likely see hospitals stop providing emergency service if they were not going to get compensated for it, he said.

The article also discussed Explanation of Benefits (EOB) reform. The EOB are those confusing statements patients get that are supposed to explain the procedures and associated costs with your doctor visit. Matthew asked Ron to elaborate on what EOB reform is and if it will help with improper denials.  Ron explained that EOBs often read like Greek, full of codes no one understands and that is by design from the insurance companies he said. He said the first step is to make them understandable to the average person and if you don’t agree with them, clear instructions on how to appeal.

Ron said when we think about all the things we can do online in other industries that want to serve you as a customer, compared to your insurance company it’s hard to understand why we can’t do the same for EOBs. He compared it to Amazon, where I can see where my package is, but with my insurance company, I can’t see what step my appeal to a denial is at, or how much of my deductible is left. Ron pointed out that the insurance companies don’t want us to have that level of self-service online. This is because, which has been discussed before, is that the patient is not the customer, the employer is. Matthew wrapped up by pointing out that knowing what claim is being discussed in the EOB would be helpful as well.

Be sure to check more from FLATLINING here.

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Listen to the FLATLINING Podcast from Fulcrum Strategies wherever you listen to podcasts and have every episode delivered to your email by subscribing at www.FLATLINING.net.

Further reading:

Where Kamala Harris Stands on Key Healthcare Issues - Medpage Today

In Denial - New York Magazine

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Subscribe to the FLATLINING Podcast on Apple Podcasts, Spotify, the iHeartRadio app, Amazon Music, Google Podcasts, Stitcher, Pandora, TuneIn, and Audible.

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Follow Ron on LinkedIn.

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Fulcrum Strategies is a healthcare consulting firm specializing in payer contract negotiation and strategic planning for physician practices.  Our firm has helped over 5,000 physicians in groups of all sizes and specialties across the country to significantly improve their contract language and reimbursement rates, strategically plan for the future, and achieve business success.  Learn more at FSDOC.com.