Meidas Health, Episode 12: Changemakers Take on Goliath (i.e., the American Health Insurance Industry)

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1:23with that trend. We've had former FDA commissioners. We've had incumbent secretaries of health for major states across the country. We've had senior leaders at the WHO come here. And they're coming here for a reason, because they know that we have reach. They know that people listen to Midas Health. They know that people are listening to the Midas Touch Network, arguably the nation's leading podcast based on some metrics. So thank you for being here. Without further ado, I have two colleagues, physician colleagues who are making serious waves and really changing what's ailing the American healthcare system, and that's our health insurance system.

2:01Dr. Elizabeth Potter and Dr. Warris Bokhari. I'm going to bring them both on here. I'm so thrilled that Elizabeth and Warris are with Midas Health. Thanks for being here. Thanks for having us. It was great to be here. Thanks. So both of you are clinicians by training. Dr. Potter, you're a board-certified plastic surgeon that does kind of a lot, you know, across the spectrum, supporting patients with a variety of different needs. Morris, you have a very interesting background spanning clinical technology, everything in between. And you're both entrepreneurs as well. I don't know how you found the time.

2:36But I'm going to first kick it to you, Elizabeth. Just tell us a little bit about yourself, the stuff that maybe people just don't know. And, you know, how did you land up doing what you're doing, fighting the good fight? Sure. So I'm Elizabeth Potter. I live in Austin, Texas, and I'm a reconstructive plastic surgeon. So that means I did the traditional plastic surgery training and then additional training in microsurgery at MD Anderson to treat patients affected by breast cancer. So 90 % of my work is treating those patients. And that's simply because there's not enough of me doing this work in the country.

3:09So I take care personally of about 40 % of the women in Central Texas. And also I take care of women from around the country who can't find access to breast reconstruction through insurance. typically you know women drive from Mississippi Alabama across states because they can't find someone who's willing to take insurance reimbursement and perform breast reconstruction for them which is provided for under the Women's Health and Cancer Rights Act so you know reimbursement drives access saying something's covered doesn't mean that a patient has access to it and that's really where I started in advocacy and then it sort of went to a different level earlier this year when I had a video go viral where I was called out of the operating room by a representative from UnitedHealthcare to discuss some mundane details about a woman who was having a mastectomy.

3:54She was actually asleep on the table. And it was absurd. It was as absurd as it sounds. And I just posted about that experience that day and then unfolded a series of events which included United discrediting me in the press and saying that I had lied about that call, which I certainly did not lie about. And there was plenty of evidence to show it. And then a series of other events. So I'm just, I'm in the thick of it because I care about patients. I listen to my patients. I know what they need and I'll take on anything that gets in the way. Kind of love that. And, you know, for all our listeners out there, if you just Google Dr.

4:34Elizabeth Potter and that moment, you can Google any sort of prompt here, but viral video, whatever it might be, I've seen it. I'm sure many of you have seen it. It is compelling. And it's the reason why, you know, Dr. Potter is doing the work that she's doing. She really believes in it. And I thought that video was really compelling. Thank you for doing that. I want to dive deeper on all these things, but Boris, I want to bring you in. Tell us about Claimable and how you got to found Claimable and what does it do? Thanks, Vin. So maybe I just start with this kind of assumption or this kind assertion of what brings Elizabeth and I kind of into the same realm, which is at some point in your life you realize it's probably easier to change your mind than change the system.

5:21But if you can't change your mind because you're not wrong, then you're left with the only thing to do is to actually try and change the system. Because what else are you going to do? And it would be easy for us to say, actually we're wrong, maybe we should do things differently, but all of the evidence is actually not pointing in that direction. So for me, this was born of a long observation of US healthcare over the last, I guess, 15 years and seeing what was happening here with medical bankruptcy, restriction access, or access restriction, sorry, meaning that even if patients were covered, they were left with inappropriately high cost shares or driven to bankruptcy.

6:00And you'd have medications that you just literally couldn't afford if you had cancer, with nearly 50 % of cancer patients going bankrupt in two years. When you look at something like the rate of denials, you're looking at something like 850 million denials a year, of which less than 1 million of those denials are ever challenged. And the reason is, is because there's this absurdly high barrier that is put in place between the patient and the insurance company. And if you think about one of Elizabeth's patients, they're sick, they have cancer, they're dealing with a lot of uncertainty, and they're being forced to fight against these insurance bureaucrats.

6:35and their physicians are on their side, but at some point there's a limit to what their physicians can do. So we built a system that automated the appeals process and we started in immunological conditions such as rheumatology, Crohn's, UC. We added in migraine. We've just added in GLP-1s. We're adding in asthma in the next couple of weeks and really starting to bring better access to these therapies. And we're beating around 80 % of these denials, which suggests to me that about 80 % of these denials are inappropriate. And we've now started partnering with a litigator, which is interesting because we're finding systemic patterns and we're going to start bringing lawsuits against the carriers where patients have been badly impacted.

7:16How do people find out and or intersect with Claimable if they've been a victim or if they feel like they've been a victim of an unfair insurance denial? I wonder how they can work with your company? Honestly, like what we offer online, we've been very careful about QA, QC, like quality assurance and making sure everything we do is accurate. We cite accurate evidence. So, you know, we, we, we really cater to some fairly specific conditions at this point that is expanding quickly. That being said, I've been involved in everything from transplant to oncology. Whenever someone is at risk of serious harm, we get involved.

7:56Sometimes it's like an email from Mark Cuban, you know, five in the morning saying, Hey, have you seen this? And then, you know, we, we jump into it and try and help a family. And, you know, often these cases are extreme. We had a case here in California, which was a double lung transplant that got denied. We've had two liver transplants that we got involved with, both which got overturned. We had a case recently with a young girl who got hit by a truck where Signal were denying care. that we're actually denying neuro rehab for this kid. And it goes on and on and on and on. And where we can't help in an AI-driven fashion, we just get involved as good faith.

8:38We are actually looking at a nonprofit that we'll be talking more about in the coming weeks as well for families who are kind of at some multiple of the federal poverty level. You know, Elizabeth, just hearing Laura speak, I know that you are now also, So you're building on a lot of the leadership and those moments that you referenced earlier. Can you talk to our audience about what you're doing now at scale or trying to sort of build organically in this space? Sure. So, gosh, I just have to say, Wors is doing amazing things. And, you know, I had seen him from afar online and watched how he was making waves and making things happen for patients.

9:17And yeah, I honestly think that that's sort of, that's the spirit of where we're all engaging, right? The system isn't working for patients. And if we ask for permission constantly to help patients from entities that really aren't interested in delivering care, then we get held up and we don't wind up delivering what patients need. So all I'm doing really simply is just getting patients what they need and exploring options that aren't the traditional networks, right? And I'd say that I'm shedding light on the problematic system. So I feel that I know that folks have wondered how bad it is in insurance and how bad it is in healthcare.

10:03And what I'm doing is sharing the actual experience of someone who has been a good actor in the system. Right. So I have tried to provide cancer care and reconstructive care in network, in communities through insurance. And I set out to do that, to prove that case, that it could be done. I did not intend to tell the story that it would be extremely difficult or that that the system would work against that. I thought I would demonstrate to my colleagues that we could, in fact, work within the system and do good things for patients in the cancer world. and what I have found is exactly the opposite.

10:42So for instance, I mean, I took out my own personal loans. I built a surgery center to deliver excellent care in network through insurance because I saw women driving to me from around the country trying to get this care and they couldn't get into the big centers if they didn't have great insurance, right? So, you know, if you've got Medicare or Medicaid or TRICARE or some insurance that, you know, isn't really robust, processed you're denied at a lot of the big cancer centers so i said i can do this i have all the skills i've got my hands i've got my skill set i've got my team we can deliver this care let me build this center and do it and we'll be cheaper and better with outcomes that we can you know demonstrate and what i found is that the insurance companies don't want me to do that they don't want to contract with me just this morning i operated on a patient already today who wanted to spare her sensation after a mastectomy.

11:36And she said, a mastectomy removes the sensation to your breast. She's a really, you know, very smart woman, researched all of her options, knew that there was an option out there, nerve grafting. And we discussed that. And we tried to get her insurance company to cover that. And they said no. They said no again on multiple appeals. So she said, okay, well, what would it cost me if I wanted to pay for that myself? Because I really want to do this. and it's my one chance if I don't do it today, I won't ever be able to do it. Okay, so we went to the hospital and said, okay, hospital, what will this cost?

12:09For nerve grafting and some OR time, we're already going to be there doing mastectomies and doing reconstruction just to add this on. And they came back with$80 ,000 for this woman with breast cancer. And then they said, we'll do you a solid. We'll let you have it for$42 ,000. So I said, okay, I own a surgery center. It's me and you, whether it's the hospital or the surgery center, what would it cost me to do it? So went to my place and asked that question. And it was less than$20 ,000. Less than$20 ,000. And she ended up actually paying out of pocket because she wanted to preserve her sensation.

12:56so i'm fighting every day to make a business case for better care outside of the current systems um and what i'm finding is the work isn't just in in making the case for it because i've got lots of data to show many stories just like that one it's in telling the public that the system doesn't want to save them money and provide better care so you know what's interesting about that Elizabeth and worse. I want you to react to this, but one, what Elizabeth just said is so compelling and I thought that was so well stated, but it feels like the conversation we've been having about insurance amongst the public has not been that Elizabeth and the stories that you've been telling, making it real.

13:45It's been, when we talk about it vis-a-vis health policy, it's who's not covered? Why are we not covering them? Every two to four years, we're going to incrementally draw back Medicare or Medicaid or commercial insurance for a certain subsegment of the population. And that's the conversation that gets had, these macro statistical-based conversations, not really focused on storytelling. And it also feels like it's the type of conversation that a lot of people hear and look at and say, well, that doesn't apply to me. And yet here you are telling a story that I think is broadly applicable to anybody likely with good insurance is that this can happen to you.

14:25And Morris, I'm wondering to your point, I wanted to pose this to you. Do you feel that there's an every, every person, and I wasn't going to say every man, but this is an every man, every woman, every child experience that this, the things that you and Elizabeth are fighting for on behalf of patients, this is an every person problem. them now. Yeah. I mean, I get the claim files back on cases, right? So I actually see what the insurers say behind patients' backs. So there is a woman in California who we fought to get a lung reception for stage four non-small cell lung cancer. The only available care that actually did that surgery was MD Anderson in Texas, who passionately believed that she was a great candidate.

15:12She'd responded really well to chemotherapy, almost no detectable disease anywhere else. The insurer based in California denied the care and we got the claim, we got the claim file back. And what they described her as was a cancer victim, number one, which I thought was horrifying. The second thing that they said is any surgeon, any thoracic surgeon can debulk a tumor. And then the third thing that they did is that they had a bariatric surgeon, which to your listeners as an obesity surgeon actually review the case. So it was improper in three dimensions, right? My own case, which was in the New York Times last week for my inhalers, I'm asthmatic, and I fought Aetna to get coverage from my inhalers during the LA wildfires.

15:53They said that they granted me a courtesy exemption. And I found out about this in, I guess, in the Times, or maybe I just wasn't paying attention, but breathing is not a courtesy, It's actually a necessity. So I found that to be like a staggering admission and also completely ignored the law, which was actually under California and New York law, like New York law where my plan was purchased. They had exactly three days to respond to what I put in as a formulary exception, after which it would have been considered self-executing under law. So the little that patients understand about how their plans operate is staggering.

16:30And this happens all the time. you know i invite our listeners uh we i know we get a lot of feedback on social i i get often direct via email uh you know i'm getting to know dr potter i have known worse for for a little while now but i do know that the two of them this this just comes right out when you first interact with them that they are willing to help anybody and so if you are a loved one or somebody that in your neighborhood is experiencing one of these insurance denials, let me know. I'll share it with Elizabeth and Morris and we'll see what we can do. But tell us these stories because again, you know, Elizabeth, this is an every person problem.

17:11You could have Cadillac gold-plated insurance and yet this could still happen to you. It is an every person problem. And I think even just the fact that I'm sitting here with you says something. I am a full-time reconstructive surgeon. I operated this morning. I'm going to go to clinic later today. I did not plan to do this. You guys are amazing and I love talking with you, but I'm a doctor. Doctors are having to engage with media to tell the public that there's a big problem brewing. I mean, Um, the, it's just, it's appalling to me that medicine has gotten to this point. The number of times that patients reach out to me and tell me that they've had difficulty just getting basic care, um, basic cancer care, um, the number of times where I have had to, you know, fight for a patient to get, you know, routine cancer care for patients to get mammograms, to schedule cancer surgery.

18:13when I have to justify my plan to a pediatrician on a phone call with an insurance company. It's completely upside down and we're not going to be able to fix it from the inside out, right? It's clear that insurance companies aren't self-regulating to a better course, right? Right. So, yeah, it's I'm I don't I don't mean to be dramatic, but I am sounding the alarm. I'm sounding the alarm. I'm saying I have doctors reach out to me regularly who say, OK, Elizabeth, you're in private practice. So I'm my own practice. I'm my own boss. And that's why I can sit here today and talk with you. 70 percent of physicians are employed and many physicians who are employed are not free to post on social media or take interviews or say anything that could be deemed as critical of their institutions including their hospitals or their group or the insurance right so i'm speaking for for a lot of people saying this doesn't feel right to doctors in America.

19:30And, you know, even if that's even if that's the only thing that the doctors are able to say, like, hey, help me. I'm trying my best. And the system is at odds with providing great care. It's that intersection of, you know, doctors who want to take great care of their patients and the industry, which has a fiduciary responsibility to their shareholders to maximize profits. And we have met in the middle and things are just dissolving. What is... Go ahead. Please, Boris, please. Things haven't improved, right? So the three of us have a background in science. So if you were to take a scientific approach to this, we've run the experiment for like a long time.

20:16Nothing is getting better. So as Elizabeth's saying, the system will not self-correct. We have to change it. And it is really up to our generation to change it. One for ourselves when we actually become fully reliant on the system to look after us, but also for the generations behind us as well who are going to need it. So that to me is incumbent upon us and kind of brings urgency to my work and our work every day to show up for patients. So that's really interesting to me. And the second thing is that every single defense of insurance is in defense of a payment model, right? The payment model doesn't serve patients.

20:53It doesn't serve providers. And right now it's not even serving the shareholders, right? You look at what's happening on Wall Street and you're getting CEOs from these insurance companies being turfed out. Like Karen Lynch from CVS, she got removed and replaced. Andrew Wheddy stepped down. This isn't an accident. This isn't coincidence. It's because these companies are not doing well or what they're meant to do. Something has to change. So what do you think, what has to change? And I say that because, you know, all of us, Elizabeth, your point on independence and being able to speak freely, I couldn't agree more that I wish more of our colleagues had freedom to do that.

21:34And you're right, a lot of them don't. And a lot of them would probably want to be in a forum like this talking about these issues. They just can't. And that's a version of sort of corporate suppression of freedom of speech. And it happens all the time. I but but I do I posing the question of both of you and Elizabeth perhaps you can begin what what needs to change and and I I'd love for you to be specific in this world in which we just saw the one big beautiful bill quote-unquote come out and do all the things that you know we've seen every four to eight years incrementally claw back things and coverage and access make things worse I frankly I feel like that's dumbed down these nuanced conversations and giving cover to what commercial insurers are doing to every person across the country which is the things that you guys are fighting against you know these these policy debates distract us and at least that's my opinion and so you know what are the things that you think we should be doing now having you've been at this now for a while wondering what way have you noticed certain trends or things that we're not talking about in our lives.

22:45public discourse? I love that question. And I'm all about some practical advice. What can Americans do right now? What can businesses do right now? And the number one thing is, okay, open enrollment period's coming up. Okay. So let's challenge the insurance companies out there to demonstrate who the good actors and the bad actors are. I would say if you've been hearing a lot about an insurance company as a bad actor, then for large employers, reconsider who you are contracting with. That level of pressure will act more quickly than government ever could. The market can change this more than government can.

23:26If large employers around the country say, I will not contract for my employees with a company who is consistently seen as a negative actor in the healthcare community in America, that will move the needle. That will drive change. So open enrollment's coming. I would say do that. And I would say if you're a company out there that feels like, I don't want to be thrown in the mix with bad actors. Okay, come to the public. Come on this show. Send your CEO. Talk about what you're going to do different for the American people quickly. That means they should buy your product and be in your network because we can drive of network change.

24:02We can. I also think, let's start talking about the direct care model. I mean, fee-for-service worked for a long time and there were problems with it, but we can get back to something like that, again, through employers. Not through, you know, patients having to pay out of pocket for cancer care, but through networks of doctors contracting directly with employers, bypassing insurance completely, and saying, like I can, I can price out breast reconstruction for Walmart. If they would like for me to perform all of their breast reconstruction, I'm happy to do that and I will save them, I bet, over 50%.

24:36So Elizabeth, I'm going to interrupt you there. When you say direct care, can you speak a little bit more about, so does that mean for our listeners out there, physician practices, however big or however small, directly contracting for payment with employer expertise, as you just mentioned? Sure. So you might've heard of concierge care and concierge care, when someone decides they wanna pay a certain doctor to provide care for them and they don't wanna go through the insurance network, then we all kind of know what that is, right? So I live in a world where that doesn't really work because people are inundated with this devastating financial situation when they have a cancer diagnosis, okay?

25:19So all of a sudden coming up with the cash to pay for cancer care doesn't sit well with me as someone who takes care of patients with cancer. So I walk that back and I say, what do we really need? You have a patient who needs a doctor and a facility and treatments. You don't actually need an insurance company. So what direct care is, is a way of putting those things together outside of the insurance company. It takes some forethought and it takes some willingness to change. It might seem like it's going to take risk for a company, But honestly, companies like I know Mark Cuban's company is doing this.

25:52There are companies around the country who are exploring direct care because it makes more sense for their patients. It saves them money. And, you know, I think that it's better for the health of the physician system. So if we can empower physicians to know their value, and I think a lot of physicians don't, to know what they're bringing to a patient and put a value on that and then take that value to the employer and say, you know, I see, for instance, my EOBs, my explanation of benefits for breast trick instruction when my patients have microsurgery. And some of them say, you know, that the care that we delivered cost$250 ,000 for a three-day stay in the hospital.

26:40And I am positive that that is not anywhere near the cost. And that's why I built the surgery center to show it. So direct care is saying, okay, let's get real specific like Americans are when they have to write their budget. Let's actually talk about how much does anesthesia cost and a surgeon and a bed for 12 hours and the medications and let's add it all up and then let's come up with some markup that provides me the ability to make some money and keep my doors open. And let's tell Walmart just to contract directly with me instead of going through United or some other company that's taking a piece of the pie like an ATM.

27:18Like it's just like an ATM. There's literally no value add coming from these insurers. If anything, there's active value destruction. And also because of the way self-funded plans work, which means a large employer, typically a thousand employees or more, the employer is actually on the hook for the liability if the insurer does something wrong, right? Under ERISA, the Employment Retirement Investment Savings Act, the employer becomes liable. And so, and I would contend that none of these employers actually know what these insurers are doing to operate their plans. Because every time we've involved an employer in one of these complete nightmare cases that gets sent to me, the employer says, yeah, sure, I want to help.

28:00How can I help? And they overrule the insurer. I've seen it time and again. So I think there's something there for sure on direct care. I think direct primary care can really work. For sure. You know, I tried imposing, I tried exploring that when I worked in insurance and the idea of there not being any claims coming from primary care and managing risk in the community and keeping things out of the hospital, I think it blew the tops of their heads off. I don't think they could actually understand it, that, you know, there was another way of doing this. And now if you could actually say like, look, we know what's needed in a community per capita.