Health care from the trenches: Change must come from us [PODCAST]

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“We, as a profession, must accept some blame for many of the developing problems in health care delivery. No, I am not suggesting that we caused the problem. I am stating that we have had ample opportunities to manage the debacle and even to reverse some of the disturbing trends, yet we rarely allow our voices to be heard.

Is health care reform impossible? It certainly isn’t. But we, as doctors, need to step up to the plate, to stand up to the growing bureaucracy in the system, and make sure our voices are heard. The change will be long, slow, and painful, but we can’t allow the system to continue to swallow us whole. The change must come from us.”

Alejandro Badia is an orthopedic surgeon and author of Healthcare from the Trenches. He can be reached at Healthcare from the Trenches and on Facebook and Instagram @badiahandtoshouldercenter.

He shares his story and discusses his KevinMD article, “Health care from the trenches: Change must come from us.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Alejandro Badia. He is an orthopedic hand surgeon, and he’s the author of the book “Healthcare from the Trenches”. He wrote an article from that book, also titled “Health care from the trenches: Change must come from us.” Alejandro, welcome to the show.

Alejandro Badia: Thank you, Kevin. Real pleasure to be here.

Kevin Pho: We’ll get into your article and book in a little bit, but first off, can you share your story and your journey to where you are today?

Alejandro Badia: Sure. I’m actually an immigrant. I was born in Cuba and went to New Jersey, grew up there, a public school kid. I was fortunate enough to attend Cornell, and I always had the dream of being a surgeon since childhood. I trained in New York, then Pittsburgh, and I came to Miami 25 years ago because I wanted to come somewhere where I could use my Spanish and actually build an international practice, which has been fun. So the journey has been terrific.

Somewhere along the way, I realized that there are some real issues with how patients come to me and our colleagues, and I started something called OrthoNOW, which has really been my biggest challenge thus far in my career.

Kevin Pho: All right. Well, tell us a little about OrthoNOW. I believe that’s an orthopedic urgent care center, but tell us a little bit about that initiative.

Alejandro Badia: Sure. I came to realize about 10 years ago that virtually every patient who came to see me had been to a few places before, and because of lack of expertise, it didn’t make sense, because the diagnosis was either missed or delayed. And I also thought, what an incredible cost that was. It’s sort of like somebody coming to me for an eye problem. I was even an ER doc in New York for a while, but I don’t know a lot about the eye. It just seemed to me, why are people with complex wrists or shoulder pain being seen by three other physicians? I thought there must be a better way.

I realize that urgent cares are a growing, important part of our health care infrastructure, but they don’t really have the expertise for orthopedic problems, and I decided to start a network. I’m still looking for the right strategic partner, but I think that this is something we’re going to see as part of our health care system: specialty centers where people can access particular problems, getting to the right expert at the right time.

Kevin Pho: So this enterprise obviously needs some business aspects to help grow it. Now, do you also have a business background in addition to your orthopedic surgery background?

Alejandro Badia: I do not, and that has been one of the suggestions I could make for those who are entrepreneurs inside. I didn’t realize that I was an entrepreneur until a little too late. I would really encourage people to seek more business background, or at least surround yourself with the right people. I made some bad decisions. The project is actually doing quite well, but I could have saved myself a lot of angst if I’d done what you just suggested.

What I do have is a marketing savviness. For some reason, I don’t know where I learned that. But certainly when it comes to contracts or P&L statements, I mean, I still struggle.

Kevin Pho: All right, so let’s transition now into your KevinMD article and book, and they’re both titled “Health care from the trenches.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to share it?

Alejandro Badia: Well, I had started writing a book kind of chronicling this journey. OrthoNOW is one example of how difficult it is to impact change in our health care system. You keep hearing in all the media about the problems with health care, and I don’t think we’re really addressing the core problem with the inefficiency of how it’s delivered. So I started to compile a book with about 25 contributors. I was in the midst of that when all of a sudden a pandemic hit. I was lecturing in Australia, and I came back, and we went on lockdown, and I said, “Well, this is my chance.” So I finished. I wrote about 85 percent of the book from mid-March to June, when it was released on Amazon.

One of the messages of the book is that we really have to work together much better. I comment in the book that we learn to be very competitive in organic chemistry, right, in our undergraduate years, but we never let go of that, and I’m not sure why. I think that the day a hospital administrator learns how to do a hip replacement or cardiovert somebody, then we should worry as physicians. But we have a unique skill, and we need to embrace that and come together to have an impact on health care reform, because right now we don’t. It is the politicians, it is a big insurance executive. It is people who are a necessary part of the health care infrastructure, but not the key part. The key part is you and I, the people who actually deliver the care. Perhaps it’s because we’re so busy, perhaps it’s because we don’t feel that we can contribute much, and we kind of hide our head, put our head in the sand. I think that needs to change.

Kevin Pho: So can you tell me a story of how that competitiveness and relative isolation of physicians has failed to impact the health care system, to our detriment?

Alejandro Badia: Sure. I tend to be kind of a micro-level guy. In other words, I think a lot of things can be represented by anecdotes and vignettes. I will tell you, just close to home, when I started OrthoNOW, I found that in my own community it was very difficult to get my colleagues to engage. They all thought it was a great idea, and I said, “Well, why don’t we beat the drum with our patients? Because it doesn’t do you any good if they go and sit in a hospital ER with an ankle sprain or a wrist fracture for six hours. Let’s work together to do this, and in the end, it’ll actually benefit you,” meaning my fellow colleagues, because I only do from here to here, right? And there are a lot of others, and I’m actually not even in network with a lot of carriers. So the truth is, it really helps a community, and it benefits other clinicians, and yet I couldn’t get the real collaboration. To me, I said, “Boy, this is typical.”

I spoke to a friend in Australia, I remember. He had the same problem. He has a meeting that he organized, an academic meeting, and people come from all over the world, but he has trouble getting colleagues in his own city. He tells me, “I have a good relationship with them. When I run into them at the hospital, we have a coffee.” But there is a real problem with collaboration. It’s a very stark reality, and I think that we need to think about it. Hopefully this generation following us will likely have a different mindset, and maybe we can work together and make an impact.

Kevin Pho: One of the problems that you identified with our health care system was issues with health care delivery. What are some of the biggest issues with health care delivery that you see?

Alejandro Badia: Well, I think there are way too many middlemen. For example, I have a section in my book entitled “Authorization is a four-letter word,” because I think it’s one of the most absurd concepts that came out in the ’80s, and I talk about the development of that and other issues. Just taking that as one example, imagine that somebody who has no medical training has to put a rubber stamp and assign a number to something that you or I deem necessary. It doesn’t mean we’re infallible. It doesn’t mean that we don’t need oversight, because I do believe there are bad apples, and I believe there are people who maybe overutilize. But wouldn’t it be smarter to assign people who are knowledgeable to do the oversight, rather than somebody sitting at a desk?

Every step of the way, when I see a patient and I need to do an imaging study, I may need an authorization. When I’m going to do a surgical procedure, I need the authorization. When that patient obviously needs therapy to get their shoulder motion and function back, I need an authorization for that. That is an incredible waste of time and money, because that person providing the authorization is simply doing their job, but they get a salary and benefits, and they are also an impediment to the process. So I think that is one example. If we could really eliminate that, that in and of itself would accelerate health care delivery, I strongly believe.

Kevin Pho: I think a lot of the problems with our health care system are that there are so many entrenched interests. So if you make major changes in our health care system, someone is going to get financially hurt. Now, what is your vision in terms of the ideal health care system, and how would you start changing our current system to fit your vision?

Alejandro Badia: One start, of course, based upon what you just said, may be difficult, but I really believe that health insurance companies should be nonprofit. I don’t think they should be answering to Wall Street. Now, I am a capitalist. I fled Cuba with my family, OK? So I have no problem with a health care company CEO making a lot of money if they’re doing good and that company is efficient and making money, and they should make money. But I don’t think they should be answering to Wall Street and shareholders. I think that money should be put back into health care delivery, and they can compete. I believe in the free market in health care. So those insurance companies should compete, much like they do in Germany.

I gave away part of the last chapter, but I gave one example from a book I read called “The Healing of America.” It was a tremendous book. So Germany was a good example. Why not have insurance companies be nonprofit? Then they’re competing really on their efficiency rather than their profits. So that alone would change it.

I also believe that we should get patients to the right clinician at the right time. I believe that our primary care clinicians are vital, because they’re going to follow, I think, every person. I ran into my internist yesterday in the hallway between surgeries, and I said, “I have to go. You need to check some levels.” And that’s vital. But when it comes to specific things where we all know that there is a specialist for that, that ends up being very cost-effective. We actually don’t order more tests. It’s already been proven that specialists actually order fewer tests, because there’s a certain gestalt you have when you sit with that patient of a certain demographic, with a certain history, confirmed by a physical exam and maybe a particular imaging study, and that will save a lot of money.

So I believe getting rid of the middlemen and getting the patient to the right clinician at the right time, in and of itself, will save so much money that this discussion about insuring the uninsured will go away. We’ll have so much money left over as a safety net, because I do believe that countries have a moral obligation to take care of the less fortunate, and I think that we will have more than enough money, certainly in this economy, to be able to do that. I’m hoping President Biden will understand that.

Kevin Pho: So if you look at health care systems across the world, we have so many different varieties, ranging from a single-payer system to what we have here in the United States. In your opinion, what is the ideal role of government in terms of regulating our health care system?

Alejandro Badia: Well, I think oversight is important. I mean, they do that. You can’t go fishing or hunting without a license, right? Because there has to be some control. And I think it’s important to have an entity that has the interest of all the people. The problem is, you alluded to it earlier, there are so many folks with interests who have money. We’ve become a political system where money will buy you into a discussion, and that’s really sad.

I think that if government does the right oversight and is a facilitator rather than an impediment, allowing the free market, like in so many other areas where the free market works well. Not that our system is perfect. I know capitalism is under a little bit of attack currently, but I think that history has shown that you need incentive; you need a motivation. And I think if you look at the systems, even just our neighbors to the north, there are problems. I have plenty of snowbirds who come down from Canada because it takes them eight months to get an MRI to determine there’s a rotator cuff tear, and by the time I see them, I may not be able to repair that. To me, that’s a big moral problem.

Kevin Pho: So President Biden is taking the approach of strengthening the Affordable Care Act and hopefully better regulating the health insurance companies. Now, does that approach solve some of the issues that you’re talking about?

Alejandro Badia: I don’t think so. I really see it as ultimately adding more bureaucracy. I think when you have more bureaucracy, you have more waste, and you have more obstacles to being able to deliver care. I think we all see that. All of us in the trenches who see patients, no matter what type of system you’re in, can pretty much agree that if we can get people out of our way, between us and the patient, most physicians will do the right thing, will want to do the noble thing. And if we’re paid fairly, really, there’s not going to be much incentive to do things that you shouldn’t do. But there should be oversight.

I think what just happened with the pardoning of these folks, you know, I’m embarrassed sometimes to say I practice in Miami, because it is the Medicare scam capital of the country. I think it’s really shameful, and some people were just pardoned who did this, an ophthalmologist who, I mean, it’s just, I remember when it happened. To think that we just give these people a hall pass sends the wrong message, and that’s where I would think government really has an important role. It is the oversight. There are going to be bad apples in any profession, but I want to be, not arrogant, but let’s just say confident enough to say that I think we’ve been screened. We’ve been weeded out a lot during our careers. So I think most people who train and study for 12 to 14 years after high school are pretty committed to what they’re doing. So I think that we need help, and that’s why we need to come together and really send that message.

Kevin Pho: We’re talking to Alejandro Badia. He is an orthopedic hand surgeon, and he wrote the KevinMD article “Health care from the trenches: Change must come from us.” Alejandro, one of the things that you mentioned is that physicians really don’t speak with a unified voice. We have a lot of competing medical societies. The American Medical Association, which purports to speak for all physicians, only has about 20 to 25 percent of us enrolled as AMA members. Now, what is your solution to help physicians speak with a unified voice, so we can advocate for our profession better?

Alejandro Badia: You know, I’ll tell you, Kevin, I wish I had that answer. People asked me that. I wrote the book because I felt people needed to know, and it’s not written for institutions, by the way. “Healthcare from the Trenches” is written for society, for patients to understand, and I’m hoping that somebody who reads this book may be inspired to do something. It’s not going to be me; it’s just not my skill set. But I really think that there are going to be some people who will step forward and take a leadership role and say, “You know what, the AMA is not necessarily speaking for all of us.”

But before that happens, we have to do better, even at our community level, about coming together. I’m not sure if that’s going to change, but I think people need to think long and hard about that, because if we can’t get along in our own hospital system, our own town, it’s going to be very hard at a national level. And we can see the insurance payers are all aggregating. I mean, there are now five major payers. Think about how many physicians there are and how many of us are united. How can we come to the table with them if we’re not uniting? But I’m hopeful. I am. I think that now social media and podcasts such as yours, Kevin, which I applaud you for, are one of the vehicles to be able to do that.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Alejandro Badia: The take-home message is that we must collaborate as clinicians to deliver the best care for patients. And I think we need to educate patients that they need to be really informed about their clinical problem and seek the right clinician at the right time. That alone can really help them at a micro level and can help us at a societal level.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Alejandro Badia: Thank you, Kevin. Appreciate it.

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