Speaker 1 00:00:00 We need to function together, right? We need to be on the same team and unite in our goals to improve the health of our country. And this is what the AMA does.

Speaker 2 00:00:16 Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell. I'm the assistant editor at Medical Economics, and I'd like to thank you for joining us today. This week's episode is part two of a two part conversation between medical economics editorial director Chris Mazzolini and, president of the American Medical Association, Doctor Bobby Mukkamala. This week, they're talking about what the AMA is doing in terms of pressing issues like prior auths, private practice, AI. If you missed last week's episode featuring part one of their conversation, they talked about Doctor Mukkamala's personal health journey, what the AMA's stance is on primary care, health policy and reimbursement. You can find that link in the show notes down below, you can also find it online at medicaleconomics.com and physicianspractice.com, or by searching "Off the Chart" wherever you get your podcasts.

Speaker 2 00:01:05 Thank you, Doctor Mukkamala, again for joining us for this very special two-part interview. And with that, let's get right into the episode.

Speaker 3 00:01:15 We've talked a bit already in passing about prior authorization. Obviously, it's something that's continues to be extremely frustrating to physicians of all specialties. what are some things that we can do to help fix this? You know, you hear a lot these days about, you know, I can help fix it. and but, you know, I imagine a situation where, you know, physicians are using AI to deal with the prior auth while the insurance companies are using AI to try to slap the the approvals away. And I just wonder, like, what are your thoughts on prior office and what can be done to to try to address this for our physicians?

Speaker 1 00:01:56 Yeah, yeah. I guess my, my gut reaction to prior auth is that it's not helping us take better care of our patients. Right. When when my patient comes in and they got a lump in their neck, and I tell them, you know what? You know, you used to smoke.

Speaker 1 00:02:13 There's probably a very good chance this is cancer. It feels like that to me. We need to get a Cat scan to to figure out what it looks like underneath, and then we'll figure out what to do about it. And they're freaking out. I mean, that's just terrible news to get. And they want to know. Okay, let's find out what it is. Let's get it out of my neck and give me treatment so that we can cure this thing. And I say, absolutely, that's what we're going to work on. But then the minute we walk out of that exam room, I've got to tell my medical assistant, you know what we need a CT neck with contrast rule out cancer. Boom. Immediately prior authorization is required. Right. Best case scenario can get on a computer to some. You know, the computer's got a dozen of these icons for a dozen different companies, insurance companies. And we got to click on the right one. We got to answer the questions. Sometimes it happens within a day or two.

Speaker 1 00:03:04 Sometimes it gets denied. And then we got to go and tell them, you know what? This guy's got a lump in his neck. He needs a Cat scan. This looks like cancer. And then the response is, what did you do? This, this and this? Did you put him on an antibiotic? Heck no. I didn't put him on an antibiotic. This guy's got most likely cancer. Delaying that by three weeks is just going to let it spread. And these are the things we have to deal with while we're trying to take care of patients. And that's exactly what the AMA is trying to reform by putting it where it belongs. And so the first thing is, if something gets approved by, you know, when I put it in for it, like this Cat scan 100% of the time, 99.9%, it's I can't even remember the last time we didn't have one approved, because this is my 25th year in practice. I've been around the block a few times. I know what to do with my patients, and yet I still have to go through prior authorization.

Speaker 1 00:03:49 I'm identified by the biggest insurance company in our state as being in the top third of otolaryngologist in the way that I practice, but I still have to go through prior authorization on every single one of those cases. That is just wrong. And so that's what the AMA is doing, is saying first. If the data doesn't even support having prior authorization like insulin, for example. Insulin has been around for how many generations? We're not right on the cusp of curing it. People need insulin for diabetes. And yet every 90 days they have to get prior authorization to get their insulin. And that's pretty darn cheap. The people that created insulin, that discovered it. Gave it away for free. And here we are now dealing with prior authorization for insulin. I understand prior authorization for the pill that I take, the IDE inhibitor for my cancer, because that's more than $200,000 a year. Okay, that I get. But come on, $60 worth of insulin getting prior authorization for that. That's just wrong. And so that's where we're trying to right size it to say, you know what? My tumor pill.

Speaker 1 00:04:50 My brain cancer pill. Yep. Prior authorizations. Fine. Get it to me fast though because I only get ten day supply. And if I have to travel the world as the AMA president and I run out because I'm going to be gone for more than ten days. My wife gets freaked out because she's thinking, oh my God, that thing's going to grow a little bit for every day that we don't take this pill. I don't know if that's the science, but that's really what's on our mind. and so it's the the amount of stuff that we get prior authorization for something that we don't even need prior authorization for because of the expense and the long, long nature of this disease, like diabetes. Those are the things we try to fix. And then something simple that I would love to see is, instead of ten icons on my medical assistant screen for the ten different insurance companies and the ten different groups of questions they ask about this Cat scan for this thing. If that was just standard, where there was one icon to click on and it asked, okay, how big is this thing? How long has it been there? What have you tried? And it's the same questions.

Speaker 1 00:05:48 That would be awesome right? That's right. Sizing prior authorization. It's one click, one group of questions, whether they carry, you know, this insurance card or that insurance card or any of them. That would be fantastic. And I think that's something that the government has a role. And I don't see the insurance companies volunteering and saying, you know what? That's a great idea. Forget your forget our icon. We're going to use this icon. And it's going to have all the same questions. I don't see that happening from them. That would be wonderful if people in Washington, D.C. and our state capitals, where the AMA is working every day, and all of those arenas to get something done to help patient care. That would be freaking awesome.

Speaker 3 00:06:26 Yeah, I think you got about a million physicians on your side with that one. one thing I want to ask about is that, you know, and the AMA has always done a really good job of tracking this. It's sort of like the ownership of practices.

Speaker 3 00:06:38 And we obviously know that there's been this trend of, you know, private practice is declining while more corporate ownership, hospitals, even private equity is sort of like emerging on the scene. And I'm just wondering, you know, what your thoughts are on private practice, on independent medicine? it sometimes feels quaint and old fashioned at this time, but but I do think, you know, we hear a lot from our physicians how important it is, you know, whether you're a practice owner or not. How important physician autonomy is. And I just wanted to get your thoughts on that.

Speaker 1 00:07:10 Yeah. No, it's it's such a critical point. I mean, physician autonomy is critical for good patient care. Right. And you're right. I mean, me in private practice, my wife and I in private practice. We are a dying breed. But it's not because it wasn't cool to be in private practice. And it's cooler to be employed. That's not at all the logic. It's like, you know what? This private practice ship is sinking.

Speaker 1 00:07:31 We better jump off. Right? And they jump into a situation where they're employed by some entity or there's pressure to be employed. I mean, I see hospitals pulling this all the time, that if you're not employed as one of their doctors, they're not sending any patients to you. That's just wrong. You know what I mean? And so that's the that's the consequence of the change in the culture within healthcare. From the previous generation. My parents generation, for example, never had to deal with it. That's when 70% of doctors were in private practice. Now it's 70% that are employed to get off the sinking ship. And what we got to do is we gotta we gotta improve the ship so it it stays afloat instead of sinking any further. And that's exactly what the American Medical Association does. We have a private practice physician section that looks at all of the hassles of being in private practice and tries to help them, help us to be able to maintain that practice. And what I would love to see, and what we're starting to see a little bit, is medical students that start to think about, you know what, I never thought about doing private practice, but I see doctor McCullough and I hear him on shows like this, and I'm interested in that.

Speaker 1 00:08:39 And they come by my office and they love it. Right. If you don't see it, you don't know what you're missing. And this gives them an opportunity to see what private practice is like. The American Medical Association gives them the opportunity to learn about this. and I think that's going to be critical, because when somebody acquires the practice for the wrong reason. Right. To generate profit by tinkering with the practice of medicine. Or to try to capture more market share. I mean, we had a hospital in my hometown, in the suburbs of Flint that basically bought every single primary care physician in the headline. You know, the newsletter says we want to improve the standards of care. We want to make sure that we're sticking to the science. That is absolute nonsense. Because what it's related to is making sure that every patient that gets admitted, every MRI scan that gets done, every lab test that gets done, it happens at their institution. And that's just the wrong motivation. If we're going to improve the care of our communities and maintain the physician's ability to do that instead of getting burnt out.

Speaker 1 00:09:43 It's this independence shouldn't be a punishment, right? It should be something that's allowed to thrive. And that's exactly what we deal with now with the AMA.

Speaker 4 00:09:55 Say, Keith, this is all well and good, but what if someone is looking for more clinical information. Well.

Speaker 5 00:10:02 Then they want to check out our sister site, Patient Care Online. The leading clinical resource for primary care physicians. Again, that's patient care online. Com.

Speaker 3 00:10:14 So you can't you can't go through a day without hearing about artificial intelligence these days. And you know there's a lot of promising aspects of it where, you know, maybe I can assist physicians with doing the job of a, of a physician. And, you know, maybe there's ways I can help with drug development and device development and all of these things. So I'm wondering like, both, you know, yourself and from the AMA standpoint is, is what do you feel the role of AI is in medicine? And like, what can we do to ensure that AI is there to help physicians?

Speaker 1 00:10:54 Yeah, I think it's pretty cool.

Speaker 1 00:10:56 I think this is a good development. but it just depends on how it evolves, right? When I when I looked at electronic health records, when they first came out, I was like, this is pretty cool. We don't have to have thousands of paper charts and worry about somebody in my office staff, you know, putting the patient whose last name begins with an Em accidentally in the end section and now is spending hours trying to find that chart. Electronic health records. Pretty cool solution to that. But now the lack of interoperability, the fact that I still have to use a fax machine to send other doctors the note, because the systems aren't communicating properly, is something that had a lot of cool potential, but fails in many ways. And I think that's the potential for artificial intelligence. We at the AMA refer to it as augmented intelligence. Help me to help my patient write. But that's something that I think is going to be it's going to need a lot of attention, because that's going to be an exponential growth right from one year to the next.

Speaker 1 00:11:55 It's not going to be a slow linear growth. We're seeing that already. And so there's excitement, but there's also a little bit of anxiety. From the physician's perspective, you know, from things like, you know what, if this thing gets developed and it isn't right. Right. I mean, there was a study that came out a while ago that people with diabetes, they looked at all these people in the hospital with diabetes and the computer. The eye machine decided to discharge this group of patients earlier because their sugars were fantastic compared to the other ones. And those were the sickest patients with diabetes. Why did the computer say that? Because according to the numbers, this person is under great control. They don't need us anymore. Send them home. Well, the reason was they were getting checked every hour instead of every like 4 to 8 hours. And that's a failure in the program. And how do we know if that's going to happen? We don't. Right. We need transparency. We need physicians involved in the development of it.

Speaker 1 00:12:48 And we need to know when it's being used. Right. Because if it's on my computer and the hospital decided to put it there, you know, and I didn't even know about it. Right. Or the, the, the software that we bought as a hospital and me using as a doctor had I within it, and we didn't even know that's a problem. And so there is a way that we need to be very prudent about getting this into help me and not hurt me and not hurt my patients. And the AMA is all over that. We have a lot of principles, and those are things we're changing every year. everything from, you know, from the creation of it to the liability, who's at fault if this thing screws up? Is it the doctor that didn't even know it was there? Is it the institution that put it in there? Is that the person that wrote that program? These are all very important things. And so I'm excited. but we're paying a lot of attention to make sure that what does evolve from it is helpful, not harmful.

Speaker 5 00:13:44 Hey there folks. My name is Keith Reynolds. I'm the editor of Physicians Practice, and for today's P2 Management Minute, we're looking at ways to reduce your malpractice risk. First, cultivate strong physician patient bonds. Patients who feel heard, respected, and informed are less likely to pursue legal action encouraged clinicians to spend an extra moment listening, making eye contact and summarizing each visit clearly. Next, prioritize clear, thorough communication. Miscommunication often triggers malpractice claims. Provide patients with straightforward explanations and written visit summaries and if an adverse event occurs. Address it promptly and empathetically. Patients appreciate honesty and transparency. Finally, document everything in real time. Accurate, detailed records can make or break your malpractice defense. Train your staff to document thoroughly. Avoid excessive reliance on EHR templates and regularly review your practice's documentation standards. For more essential practice management tips to keep your practice protected and productive. Visit Physicians Practice. Thanks for watching.

Speaker 3 00:14:48 When we ask our physician audience about, you know, the things that tick them off, let's say one of the number one things is, you know, they're worried about scope of practice.

Speaker 3 00:14:57 They're worried about, you know, not that that there's disrespect towards nurse practitioners and physician associates and other members of the care team. But I think there's general concern out there among physicians about, you know, just the blurring of the lines between a physician and, you know, a non physician provider. And I'm just I know the AMA has stances on this. So I'm just wondering, you know, how you feel we should, you know, go forward as a physician as a medical profession, navigating these relationships and but also ensuring that physicians, you know, remain physicians, if you know what I'm saying.

Speaker 1 00:15:37 Yeah, absolutely. And I think that the North on the compass of this issue is improving the health and maintaining the health of our country. Right. And so when I look at it like this morning, I'm an ENT doc. I had, I think 11 surgeries this morning. Most of them were kids getting their tonsils taken out. And today, in many days something changes, right? The anesthesia.

Speaker 1 00:16:01 It's something that doesn't go quite right. The oxygen level, instead of being at 98%, is now down to 70%. You know, the patients, you know, the heart rate's going up. They're not quite as red and pink as we like it. They're a little bit gray or blue. I want an anesthesiologist available so that when the blankets the fan, they be there, you know, 60s they're in the room and they've done tens of thousands of hours of this as opposed to having the independent practice of, in this situation, a nurse anesthetist that after, you know, going through the process of their training, which is less than the training of a medical student and then an anesthesia residency and then the practice of anesthesia. I don't want them to have to do it on their own. I don't want them to be allowed to do it on their own. I want the people with the most training to be involved in every aspect of healthcare, whether that's putting a kid to sleep for their tonsils or whether that's managing somebody that comes in with a lump in their neck.

Speaker 1 00:16:54 Right. So a nurse practitioner, for example, to be a nurse practitioner. You can finish that in less than two years of classes and 600 hours of training, compared to four years of classes after your bachelor's degree and 10,000 hours of training to be a doctor. And so what do we want for the future of our country? We want those groups to function as a team so that this person that comes across something that they're not quite familiar with, they're not sure what to do, can express that wide open, because there's a doctor that's in the room down the hall in the building, a phone call away to be able to help, to say, you know what? That lump is something that, you know, they live on this lake, they have this allergy, there's this bacteria. I think this is an infection. Maybe we should try this first or there's nothing to cause that. They don't need an antibiotic. They need a scan. Right. That's the wisdom that comes from tens and thousands of hours of training, not 600 hours of training.

Speaker 1 00:17:51 Getting your degree and going to one of the states that allows the independent practice of somebody like that. We need to stay as a team if we're going to improve the health of our country. Taking that team apart is not going to do that. It's going to take us in the wrong direction. And we see that already. There's plenty of data to say that cost goes up. If you're not sure what's going on, you're going to order a bunch of tests to try to figure out what's going on. And so the cost goes up. Access doesn't go up. I live in the southern part of Michigan, right? I don't know if my hands are showing up. Right. But I live down here. Up here is where we need patients taken care of. And the theory is, boy, if we had more people that take care of those patients, if we let non doctors go up there to practice, that would be better. But what happens in that situation? People stay where everybody else wants to stay.

Speaker 1 00:18:35 Nobody's going with that new authority to take care of patients anywhere else. Right. And so that map, it doesn't improve access to care. So these are all the different reasons that we need to function as a team if we're going to go the right direction in our country.

Speaker 3 00:18:49 Last question is anything you want to say to the physicians out there as you take on this new challenge?

Speaker 1 00:18:56 Yeah. You know, it's, there's so much that we need to improve on in the health care of our country. Some things that are natural, like Covid comes out and you're like, Holy crap, what are we going to do to dealing with government, mishandling of how to improve the health of our country. And we just talked about many examples about that just now. And so what I would say to my colleagues, the other, you know, 999,999 to get to that million number, I would say, look, we need to function together, right? We need to be on the same team and unite in our goals to improve the health of our country.

Speaker 1 00:19:33 And this is what the AMA does. And so I would tell those people, and I see them every day that either aren't aware or are very, you know, they're very doubtful that I would say this to so that they join for our goal of being a healthier country.

Speaker 3 00:19:49 Doctor Bobby Mukkamala, thanks so much for joining me today. I really appreciate your time and your insight.

Speaker 1 00:19:53 Yeah, thanks for having me, I appreciate it.

Speaker 2 00:20:03 Once again, you just listen to part two of our two part conversation with American Medical Association President Doctor Bobby Mukkamala. If you haven't already, be sure to check out part one of the conversation about his personal health journey, the AMA's stance on primary care, health policy and physician reimbursement that's available down below online at medicaleconomics.com and physicianspractice.com, and wherever you get your podcasts. My name is Austin Littrell, and on behalf of the whole Medical Economics and Physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss future episodes.

Speaker 2 00:20:33 Also, if you'd like the best stories that Medical Economics and Physicians Practice published delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart: A Business of Medicine podcast, is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Littrell. Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.