Episode 91 Recap – What it takes to make healthcare reforms, a conversation with Dr. Gus Geraci, MD.
The Print Version of Episode 91 of the FLATLINING Podcast
In this episode, Matthew and Ron sat down with Dr. Gus Geraci, MD. Dr. Geraci has over 20 years of clinical experience in Family Medicine, Emergency Medicine, and Urgent Care, and over 30 years of administrative experience, physician management, and leadership in Managed Care. He is a Senior Medical Administrator, Public Speaker, and Consultant. You can find him here. He also operates a website that lets professionals rate their health employers anonymously to help other medical professionals find good healthcare employers and avoid bad ones.
This podcast covered a wide range of topics, from the state of the independent practice of medicine to the best ways to tackle prior authorization and denials, and closes with a short discussion on electronic medical record (EMR) systems.
Matthew started the discussion about Dr. Geraci’s road to becoming a physician. He shared that growing up he always had an interest in science and as he entered college, he realized he liked helping people and talking to people. He thought he would enter the field of talk therapy. So he earned his degree in psychology. But noted that while he was in school in the 1970s, there was an explosion of drugs to treat mental health, so he entered medical school thinking he wanted to be a psychiatrist. This would allow him to do both talk therapy but also have the pharmaceutical treatment option available to him with patients.
Once in medical school, he realized he enjoyed the wide array of patients he was seeing, young, old, men and women. This led him to focus on family practice medicine. After his residency, he practiced family medicine, and emergency medicine and eventually ended up in administration. He explained that he realized that as a family physician, he might have a panel of a couple of thousand patients to help, but as an administrator, he could help hundreds of thousands of patients improve their care. Dr. Geraci, jokingly said that many clinicians refer to administration as the “dark side”, he enjoyed his career working with patients from this position for over thirty years. He retired about four years ago and has been providing consultation services lsince.
Matthew shared that physicians frequently mention burnout when they discuss reasons for leaving clinical practice. He noted that Dr. Geraci sounded as though his transition to administration was more of a mission than burnout. Dr. Geraci said it was a bit of both. He shared his story of when he launched his independent practice at “exactly the wrong time.” He said he had a sound 5-year business plan but, had not predicted the 20% increase in malpractice insurance, and increases in wages due to inflation. He and two partners made a go of it for several years. He said they were all moonlighting to make ends meet. Just as they were on the cusp of making it, and leaving their moonlighting jobs behind, their newly signed physician opted for employment with a large healthcare system at the eleventh hour for an additional $2500 per year. He said after this and careful analysis he and his partners decided to close the practice and go their separate ways.
Matthew asked Dr. Geraci if he was worried about the often talked about looming physician shortage based on his experience as an independent clinician and if it is going to accelerate the physician shortage in the U.S. Dr. Geraci said, “I don’t worry about it, I think it is happening.” The reality is that about 80% of physicians in the country are now employed versus being independent he said. “When I graduated residency in ‘83, that would have been more like 20% were employed and 80% were independent.” He shared that when he graduated the idea that you would go work for a hospital or health system wasn’t on the radar. He said you graduated and opened your practice. Dr. Geraci thinks this trend will continue even with some states still holding out below that 80/20 threshold. He said you are likely to see more physicians move into concierge service where instead of taking care of several thousand patients, they will take care of five hundred.
He continued “Not only are numbers going down because physicians like myself have left practice, but they are also going to take care of fewer patients.” Though he said he doesn’t like to generalize, he pointed out that the new generation of physicians doesn’t work as hard, and they value work-life balance. He reflected that as he was raising his family, he often neglected them because he was busy with his practice. Where the newer physicians of today don’t want to do that, he said.
The conversation transitioned to Ron welcoming Dr. Geraci to the program and discussing how they initially met through some shared online conversations. Ron complimented Dr. Geraci on his decorum with his online presence, noting that someone had gotten very personal with Dr. Geraci early in the discussion of one of Dr. Geraci’s posts. Ron said he appreciated that he did not lower himself to this person’s comments. He also complimented Dr. Geraci that his online conversational style demonstrated intelligence and not only well thought out answers, but also that he listened to what people were saying. Something rare in the online forums today, he said.
The discussion began about prior authorization and insurance company denials. Ron noted that there can be bad actors on both sides, sharing a story about when he was at Cigna, and they had a physician who appeared to grossly over-order MRI’s. The physician’s practice owned an MRI machine. Ron asked Dr. Geraci, how we get to the place where maybe doctors don’t get to order everything they want, and insurance companies don’t deny prior authorizations as a matter of doing business.
Dr. Geraci thanked Ron for his comments and said he thought there was “too much hate” and “not enough of trying to find the middle ground.” Dr. Geraci said that he had put a fair amount of thought into the prior authorization/denial problem. He went on to describe his work with a medical association of a particular specialty that was trying to establish standards of care in response to the wide variety of responses to prior authorizations they were getting from various insurance companies. “They could not agree as a group of specialists practicing the same specialty, as to what they were going to find acceptable to them.” So that effort went by the wayside, he said. The other effort was the idea to create a committee at the state medical society to review doctors who have concerns that are brought to them versus the state medical board. “That did not go over well,” he said.
Dr. Geraci then walked us through his idea of developing a body or council to review doctors’ activities. He said he is always reluctant to involve the government, but a reviewing body made of physicians with like specialties. He went on to point out that the physician who insulted him online had a good point. That you should “code” mistakes. He also said this physician pointed out that the time spent working on appeals should be coded. Dr. Geraci then focused on the physician who is consistently receiving denials from the payers. Noting that the payers don’t share data about their denials or appeals, but if “requests” and “denials” were tracked and then the aggregate data was rolled up to a third party to analyze you could look for trends. He said, generally speaking, an individual physician doesn’t have enough request/denial actions to be statistically significant, but if you came across a physician who consistently gets denials across different carriers, then that would raise a red flag for someone to look into.
Ron offered then you could do the same thing for insurance companies, where they would have to report requests they received, denials they issued, and appeals that were overturned. Dr. Geraci agreed and called it the “flip-code”. “The flip-code is the amount of time spent on appeals, denials, peer to peers, etc.” he said. He went on to explain that this same third-party entity could analyze insurance companies’ number of appeals and question why some insurance company has a high rate of denials and/or overturned in appeals. The discussion continued noting that both sides, the physician and the insurance company, have some bad actors, but the transparency allows for better clarity of what is going on.
Ron said the insurance companies should be held accountable for making medical decisions even though they say they are only making administrative decisions. He said when he was on the carrier side, they would make statements when they denied coverage for a procedure that “We are not denying care, we are denying payment” he explained that everyone knows that when you deny payment for care, you are denying care. You need some kind of accountability he said and follow it up with some sort of fine or penalty on the carrier.
Ron and Dr. Garuci then turned to the attempts made at standards of care across specialties to ease the friction with insurance companies. They noted how often physicians can’t agree, but also how insurance companies won’t agree among themselves what procedures would be covered or not covered. The challenge, said Dr. Geraci, is that the payers often want to be proprietary and that doesn’t lead to much efficiency. You even see this same trend on the topic of credentialling, where insurance companies won’t standardize it among themselves.
Dr. Geraci said he thinks the solution lies in the transparency of the criteria of coverage. He noted that several insurance companies are very clear, putting their criteria on the internet for medical directors and employers to review, while others don’t. This transparency, if carried over to things like denials, appeals and the doctor information discussed earlier, would be valuable to the “buyer of healthcare,” he said. That buyer is the employer, the federal or the state government he said.
Ron asked Dr. Geraci what could be done to speed up appeals when care is urgent. He said the insurers own the process and the criteria, so if you could get everyone across the provider/insurer landscape unified on the process, with the computing power available, it would change all this for the better. But how it gets paid for is another question, he said.
Ron said he thinks insurance companies’ medical directors should be held medically responsible for the denial of care if the insurance company denies a medically necessary procedure. Dr. Geraci, said it is a good thought, but it’s the lawyers that have designed these contracts to insulate the insurance company medical directors from “direct clinical responsibility.” He said the solution is what was already discussed in the coding conversation. Stating that a good insurance company should be evaluating its processes and looking for the anomalies in its medical director's denials or the appeal overturn rates that are outside normal parameters. This could indicate either a problem with the physician or a problem with the criteria, he said. Dr. Geraci summarized it by saying “The solutions are transparency, a methodology for tracking both sides, [and] the amount of work required.” He said it would be great to know if insurance company A causes 30% more work than insurance company B when a practice is working on prior authorizations, then insurance company A should have to increase their reimbursement rate since they are costing the practice more.
Matthew, noting that Dr. Geraci was the first to employ an electronic medical record (EMR) system in the state of Pennsylvania, asked Dr. Geraci if AI was going to change EMRs for the better. He said he thinks that AI is not ready for prime time for EMR. He did say that when he used his EMR, it made him more efficient, faster, and able to close at the end of the business day with notes complete. The problem he said is, that the government and the EMR vendors have interfered asking the EMR to do things it wasn’t designed to do. Some systems can do more, but they can get expensive, he said. The expense also inhibits CEO’s from getting what may be best for them operationally he explained.
Matthew wrapped up by asking Dr. Gerci about what he is excited about in the future of healthcare. He admitted that he is pessimistic, and he thinks it will get worse before it gets better. He said he is an optimist and believes it will get better eventually. Ron agreed and said he believes there are still a lot of incredibly committed good people delivering care and we saw what our delivery system can do during COVID. Dr. Geraci agreed, but countered that there are some physicians out there that are looking at their watches and who were raised in a generation of shiftwork, and do the minimum necessary for patients till the end of their shift.
Ron thanked Dr. Geraci and said he is always sure to read his posts because it makes him think even if he doesn’t agree with him all the time, but knows it comes from a place of reason and intelligence.