Health Law Talk Interviews Dr. Davida Packer

Intro (00:00:01):
Welcome to Health Law Talk, presented by Chehardy Sherman Williams health law. Broken down through expert discussion, real client issues and real life experiences, breaking barriers to understanding complex healthcare issues is our job.

Conrad Meyer (00:00:21):
And good morning, good afternoon whenever you’re listening to this. This is another edition of Health Law Talk here at Chehardy Sherman Williams, where we’re bringing you the best in healthcare discussion, policy regulation from the pinnacle here at Metairie, Louisiana, with myself, Conrad Meyer, the healthcare attorney and my co-host, the Ever-Present Omniscient, Rory Bellina.

Rory Bellina (00:00:42):
Good afternoon everyone. Good morning.

Conrad Meyer (00:00:44):
Good morning, good afternoon, right? And today we have a very special guest in the studio with us. We have Dr. Davida Packer. Davida, how are you?

Dr. Davida Packer (00:00:54):
Nervous

Conrad Meyer (00:00:57):
(laughs) Today is really something very interesting that I think Davida, you brought to my attention and to Rory’s attention about something that I think is really just starting to get discussed amongst physicians in a more open light and a topic that I think is very, very timely and something that needs to be discussed about moral injury in healthcare and the moral dilemmas that physicians face when they get out of residency. And they’re in the world in healthcare. And I know that you had a very, very specific journey, and I know that your journey was, it’s very personal. And so when we talk about moral injury, and I didn’t even know what that was, Rory, I

Rory Bellina (00:01:45):
Didn’t either. I had to listen and actually read about it to see what that actually meant,

Conrad Meyer (00:01:49):
Right? I didn’t know what that was. I

Intro (00:01:51):
Didn’t know what it was until she commented on my post.

Conrad Meyer (00:01:54):
Well, when you say she we’re going to get into that. And that’s one thing that I think our listeners need to understand. What are we talking about here? So with that being said, I want to turn it over to you, Davida. Okay. I want you to, and try, if I’m a resident about to go into the world of medicine, right? I’m leaving my trust tree of my residency program. My attending will no longer be there. I’m a PGY four. I’m looking at my contracts. I’m ready to go out in the world, and suddenly I’m faced with something I’ve never had to do before. And that’s the business of healthcare and how that might affect me as a practitioner, given that no one in my residency, no one in my med school has ever discussed with me the business of healthcare. So talk about that. What happens when physicians get out in the world and you could share whatever you want to share about your journey, when you leave that trust tree and you get out in the business side, what happens?

Dr. Davida Packer (00:02:58):
I imagine for most people, and I think there is a push towards for residencies to start that training. When I was in residency here in New Orleans, we had university and we had Earl Kay Long and we had U M C.

Conrad Meyer (00:03:16):
And

Dr. Davida Packer (00:03:16):
So you had these hospitals that are not really where you practice when you’re done. That is a weird model that is academic medicine. And some of the push towards the end of my residency was to get people out into the practices that are actually private practice and working as residents. You don’t really want to go there. They don’t let you do anything, but you realize that’s actually how it is. And we weren’t getting that training. And so a lot of people went out and just got slammed with the business. And you can’t really do it on your own anymore. You can’t put your shingle up and say, okay, orthopedics here. And so my background, I mean, I was a female orthopedist, not super common. There was definitely a push to be tough and not complain. So even if I had the complaints, they probably wouldn’t have come from me because a bunch of dudes around, can you guys complain for me? Because coming from me, I’m just whining,

Conrad Meyer (00:04:21):
Right?

Dr. Davida Packer (00:04:24):
And I had amazing group of guys, but did I really know what I was doing? And maybe some of it is just my personality. I kept stepping back and saying, maybe I don’t. And that was in a lot of ways, hard and hurtful. So I went through medical school into a residency program, came out, did a pediatric fellowship, came out, went into private practice in a smaller town in Florida. Some things that were doing there were like, this is illegal, this is fraud with billing. But it was like, this is how you keep the lights on. This is everybody does this. And I’m like, I just got fully boarded c I know these little kind of skirts to make sure that your billing works.

Conrad Meyer (00:05:16):
So wait, let me ask you that. I’m going to interrupt. So when you say make the billing work, keep the lights on, who’s telling you this?

Dr. Davida Packer (00:05:24):
Well, the people that are,

Conrad Meyer (00:05:27):
Is it other doctors or is it administrators?

Dr. Davida Packer (00:05:29):
Both. It kind of depends on in what form. So in that situation that I was describing to you that is in a private practice, I noticed that my signature was going out on PA visits.

Conrad Meyer (00:05:43):
Got it.

Dr. Davida Packer (00:05:44):
And I was like, I didn’t see that person with that. Well, a PA visit bills at 80% of a physician. So it was just their habit to

Conrad Meyer (00:05:54):
Sign, generate that,

Dr. Davida Packer (00:05:55):
An electronic signature. And I’m like, but I didn’t see them. And so I brought it to the administration, to whoever in the office, and they were like, I don’t know what to tell you. And then all of a sudden I’m having a meeting with all the partners, and then the first time it was like, well, this is the way we’ve done it for years. And I’m like, well, we’re not doing it with my name. And then the second month it was like, well, have you gotten over that yet? No, I haven’t. I know I don’t understand the business of it, but that’s a lie. And I don’t want to say, I saw this person. What if something goes wrong? I don’t. So I didn’t want a part of it. Third month they said, well, this is the practice. And I said, well, then I were resign and I did. And I walked

Conrad Meyer (00:06:45):
Three months.

Dr. Davida Packer (00:06:46):
So you can imagine how that looks to anywhere else. I try to get a job was

Conrad Meyer (00:06:50):
What’s

Dr. Davida Packer (00:06:50):
Wrong with me, and I’m not going to be a whistleblower. It’s way past 10 years ago now. And so that next job was kind of hard to get right, because something wrong with me, I was out for three months and couldn’t hack it. There was a lot of things that I could kind of swing it and change it. I went from a small town to Miami. And so, oh, I hated this small town from New Orleans. I couldn’t stand it. People in Florida kind of knew this practice, knew some of the habits, but it was like if I had kids that had started school, a husband that had a job, how do you just say, no, I quit.

Conrad Meyer (00:07:28):
You can’t.

Dr. Davida Packer (00:07:28):
They’re the only practice

Conrad Meyer (00:07:29):
In

Dr. Davida Packer (00:07:30):
Town doing what I did.

Conrad Meyer (00:07:31):
So the stress, I mean that obviously created a tremendous amount of stress.

Dr. Davida Packer (00:07:34):
Huge. And it was, I mean, if I had moved an entire family with me, I probably would’ve just kept leaving. Okay, well, alright, cosign it, fine. Whatcha going to do? Move your whole family again.

Conrad Meyer (00:07:48):
So that’s where the moral injury comes in.

Dr. Davida Packer (00:07:50):
That’s one of the first

Conrad Meyer (00:07:51):
Ones.

Dr. Davida Packer (00:07:52):
Yeah, I,

Conrad Meyer (00:07:53):
And that’s just one description of

Dr. Davida Packer (00:07:54):
What one would look like. And then for me was like that was not even three months out. I was already in a dilemma where I had to make a decision that would change my life very, you either do this or you have to bail, move, get a new job, sell your house that you just bought.

Conrad Meyer (00:08:16):
That’s incredibly difficult.

Dr. Davida Packer (00:08:18):
It was insane. But they’d probably laid the platform for all the other insane things I’ve done since then.

Conrad Meyer (00:08:26):
Well, so when you look at that, do you think what happened to you when you talked to other colleagues? I know you have a lot of friends. Was this an isolated incident or do you think this is pervasive, systemic?

Dr. Davida Packer (00:08:42):
I think it’s actually worse.

Conrad Meyer (00:08:44):
It’s worse

Dr. Davida Packer (00:08:45):
I think now. So if I think about when I graduated, the amount of people going into a private practice pretty soon. So almost everyone goes to fellowship, but then they may do another year or two in an academic type setting before they are out in a pon train, ortho southern ortho, like somebody that

Conrad Meyer (00:09:05):
The local groups here,

Dr. Davida Packer (00:09:06):
Local groups that are private, that are maybe affiliated with this hospital or that hospital, but they stand alone. They’re not some big conglomerate under Ochsner or under L S U.

Conrad Meyer (00:09:18):
And for those who are listening, we’re talking about a local market here in the New Orleans area. That’s right.

Dr. Davida Packer (00:09:23):
And so you go out, but now the amount of people that go out to that type of practice where you are not covered by a big group, you’re not an employee of a hospital system, those numbers are completely different. They flip flopped. And part of that is you can’t really,

Conrad Meyer (00:09:44):
When you say numbers, I mean, help me understand that. When you say the numbers of flip flopped, what does that mean?

Dr. Davida Packer (00:09:49):
I would say probably half, probably 50, 60% of people went to private practice within a year or two of graduating from their fellowship.

Conrad Meyer (00:09:59):
I would

Dr. Davida Packer (00:10:00):
Say now maybe it’s 20%.

Conrad Meyer (00:10:03):
So where are they going

Dr. Davida Packer (00:10:04):
Into hospital employed positions.

Conrad Meyer (00:10:09):
Okay. And are you hearing from your colleagues that are either in private practice or hospital systems that the same sort of pressure on profits? Money revenue is always at the front and center.

Dr. Davida Packer (00:10:24):
Absolutely. And enough people have had to sell their private practice to a hospital. They can’t deal, they get boxed out. So if you’re not going to be employed by the hospital, then you can’t operate here.

Conrad Meyer (00:10:40):
Why

Dr. Davida Packer (00:10:41):
You’re not an employee of the hospital. That’s our new policy. And so these huge hospital groups start you no longer. And in some ways it allows them to control some things that are good. We’re going to have quality measures. We want everyone have to have call or whatever. But you can’t have a private group. You can’t have three private orthopedist operating at a large conglomerate. We want our doctors. And if you’re not one of our doctors, then you can’t use our facilities. And so where do they go now? They have to have a surgery center.

Conrad Meyer (00:11:16):
You have to build a surgery center.

Dr. Davida Packer (00:11:18):
So then where do you do trauma surgery? Where do you do total hips that aren’t going to be going home the same day?

Conrad Meyer (00:11:26):
Right? Where you need an overnight stay.

Dr. Davida Packer (00:11:29):
So orthopedics wasn’t designed for that kind of breakout. And that’s what you see plastic surgeons have. The ones that don’t do reconstruction for breast cancer, that’s a separate world. But cosmetic surgery, it’s all in a surgery center because they don’t have to deal with the crap. They don’t have to deal, I mean, they don’t want to deal with the hospital.

Conrad Meyer (00:11:55):
And let’s talk about the dynamic that we’re talking about here, talking about moral injuries. So tell our listeners, especially because we do have a lot of providers who listen to the show. And so I want to know what that looks like because you’re a doctor, you’re a provider. And so even though you left, I get that, but you were in that mix for a very long time. What happened to you? Tell us if you can about, you talked about that one experience about the PA bills and the claims that you didn’t see. Are there any others and walk our listeners through about that dilemma. What does it look like to you and how the genesis of that?

Dr. Davida Packer (00:12:33):
Well, I mean, you can pick a day and there’s a story. That’s how bad it’s, and I think that some of it is doctors are too tired to talk about it. Some is, they’re scared to talk about it.

(00:12:45):
Some is. A lot of people wouldn’t listen. And I think Covid changed that now people just kind of realize that we’re not this high and mighty looking down on everybody else and we think we’re better than everyone else. And I mean, COVID really allowed doctors to become humans again. We actually care what’s happening to them and that they’re working so hard and they’re saving the planet kind of thing. And so we were all of a sudden allowed to have feelings again. But this isn’t new. I came out and was in practice for maybe three or four years before I realized I cannot do this forever. I can’t. And that’s a hard thing to swallow when you have that much invested just time-wise. But I was spending just so much time on the phone. There’s an example that I think of it actually, when I heard about this concept of moral injury was from a podcast that was sent to me about just the moral crisis of doctors and what are doctors going through. And it was the first time I heard someone that was not a doctor actually have a clue, was like, oh my God,

Rory Bellina (00:14:05):
Are you referring to the Jonathan Shay article? It was in the New York Times a month ago. Okay,

Dr. Davida Packer (00:14:10):
That’s where this, it’s from the story of a woman named Wendy Dean who was looking at why doctors are committing suicide and at such alarming rates. And it’s kind of spawned this conversation. Well, if you listen to what she had said about it and what he said about is that as soon as they had a platform and started talking, all of a sudden all these doctors came out of the woodwork. They don’t want to be on the record. They don’t want their name, but they would tell the story. And it’s like, well, why though? Because there’s some kind of, I don’t know. It’s the in club and if you are going to try to stand outside of it, it’s so hard to try to change the culture that has been this way for so many years and the people that are making money have so much more control.

(00:15:04):
Did doctors let it slip away from them 20 years ago when we should have said, okay, we’re not going to let anybody else manage us but us. That’s another fight. I don’t know how it started, but I was on, it took me a year to get a kid that has an unusual deformity in his leg to get his brace covered. So over the course of his lifetime, we are going to lengthen his leg over a foot. One leg is way shorter. One of the things you have to do is you have to keep their foot flat on the ground while you’re doing it so that when you’re trying to get the foot down, it’s not stuck on their toes. So you need to be in a brace until we get there.

Conrad Meyer (00:15:49):
Okay.

Dr. Davida Packer (00:15:49):
Insurance company wouldn’t prove it because it’s an unusual A F o because he doesn’t

Conrad Meyer (00:15:55):
Wait. What is a f o? So we

Dr. Davida Packer (00:15:56):
Don’t,

Conrad Meyer (00:15:57):
Do you remember what that is?

Dr. Davida Packer (00:15:58):
Yeah, no. It’s an unusual brace that holds the foot up.

Conrad Meyer (00:16:01):
Got

Dr. Davida Packer (00:16:01):
It. Were

Conrad Meyer (00:16:02):
They saying it was experimental?

Dr. Davida Packer (00:16:04):
No, they were saying that the special modifications weren’t necessary,

Conrad Meyer (00:16:08):
Weren’t medically necessary. Okay.

Dr. Davida Packer (00:16:09):
Right when you can get an off the shelf posterior splint.

Conrad Meyer (00:16:13):
I see.

Dr. Davida Packer (00:16:13):
Right. So these are the hard splints that go on the back of your leg just to hold your leg in neutral position. So you can’t point your toes. Right. So it goes around the back of your heel and there are ones that are kind of off the shelf. This kid was born without a tibia, so he has not normal anatomy. There’s no way that anything off the shelf is going to work. The biggest problem that I had with the insurance company is they didn’t know what any of the helias were. Femoral tib, fibular. They didn’t know what it was. So he had tibial helia. And at some point, I remember on a recorded line saying, look it up on Google and call me back and hung up the phone. It was like, how are you going to tell me what’s not indicated?

Conrad Meyer (00:17:08):
We

Dr. Davida Packer (00:17:08):
Are one of the only centers. So I worked for the Palley Institute in Limb Deformity. I was a pediatric orthopedist, and they also didn’t know if they really were believing me. I’m like, why You’re at a Google me too and then call my office and ask for Dr. Packer. It took a year to get that brace made. That cost, I don’t know. I mean it cost the patient a thousand dollars, but in plastic it was like 10 cents. And

Conrad Meyer (00:17:40):
When you say it took a year, it took a year for the insurance company to approve or pre-auth the brace for that patient.

Dr. Davida Packer (00:17:46):
Right.

Conrad Meyer (00:17:46):
Okay.

Dr. Davida Packer (00:17:47):
So their surgery is now delayed because of this family. So when you’re part of my medicine, every corner of medicine has their little nuancey things, but they weren’t from Florida. So these patients, when you’re lengthening, they have to live at the facility. So one parent is with that kid in Florida and the other parents at home with the other kids in Wisconsin, wherever they are. And they’re waiting and waiting as soon as we get the support

Conrad Meyer (00:18:14):
For a whole year.

Dr. Davida Packer (00:18:15):
It took a year. And one of the nicest letters I ever got was thanking me for a brace.

Conrad Meyer (00:18:22):
When you’re talking, when you’re talking, I mean that sounds extremely frustrating.

Dr. Davida Packer (00:18:27):
It was every day, every day.

Conrad Meyer (00:18:29):
Who on the other side, on the insurance side, who are you talking to? Is it some frontline rep? Was it ever another provider? Did they ever have another provider on the other end of the line or on the insurance company? Or was it only just reps?

Dr. Davida Packer (00:18:45):
You would have to get things escalated? So I would say, I mean there’s a reason why I know this language and most doctors don’t unless they are on the phone making the fight, which is I demand it peer to peer. Oh, well guess what? There’s hard to get a peer to peer when no one else does limb deformity in the country, but my practice.

Conrad Meyer (00:19:04):
So you’re not even talking to someone with the same specialty. So it’s like talking to apples and oranges here.

Rory Bellina (00:19:09):
We just did our podcast last week. I don’t know if it’s been published yet, but the one on peer-to-peers in Louisiana, the changes to that,

Conrad Meyer (00:19:16):
Correct. On the pre-auth?

Rory Bellina (00:19:18):
Yes. Yes.

Conrad Meyer (00:19:20):
So we did one, and I know you don’t know this Davida yet. I think we did publish it, but we’ll see. Anyway, it came with a new legislation that came out in this session on new pre-authorization rules that requires peer-to-peer communication on pre-auth. And

Rory Bellina (00:19:36):
It has to be someone in a

Conrad Meyer (00:19:39):
Field, in a field. So you can no longer, if you’re talking as you as an orthopedic surgeon, you’re not going to be talking to a podiatrist or a cardiologist. You’re going to be talking to someone on a peer-to-peer level. But that is, and the patient’s caught in the middle in this for the whole year

Dr. Davida Packer (00:19:57):
As soon as we get the go. So their finances are stripped to bare minimum. You’ve got one parent not working,

Conrad Meyer (00:20:06):
Paying

Dr. Davida Packer (00:20:06):
Rent in a state they don’t live in just sitting and waiting for surgery while the other parent is managing however many other kids there are. You know what I mean? And it’s like, so then after clinic for three hours, I’m on the phone with this and everyone wants to know why I didn’t see more patients or why I didn’t bill more, why my records aren’t complete. And just I was like, I cannot do it.

Conrad Meyer (00:20:28):
That’s got to be stressful.

Dr. Davida Packer (00:20:32):
And to see, well, people that are cash pay get on the schedule first. This emergent thing has insurance problems. It’s emergent,

Conrad Meyer (00:20:43):
I

Dr. Davida Packer (00:20:43):
Don’t care. Just everything. Every little thing became that way a fight. And

Conrad Meyer (00:20:52):
That wasn’t an isolated incident. You’re talking about other patients on insurance. It

Dr. Davida Packer (00:20:55):
Was an every day.

Conrad Meyer (00:20:56):
One

Dr. Davida Packer (00:20:57):
Of the things, so I left the practice of medicine five years ago and went to law school. I knew I couldn’t do that, but I was like, there’s got to be some other way that I can change this. I’ve got to be a voice. One of the things besides insurance companies is lawyers is they change the way the doctors practice. And you guys in general, doctors and lawyers just don’t communicate well. They don’t know the other’s profession. They think they do. And there’s so much miscommunication. And I mean you have generally kind of type A people on both sides. They’re both good at what they do. They did well in school. I mean, it’s a similar personality. You don’t really want to be scolded by someone else. And so the communication breakdown is just, I think feeds it. And so you’re documenting all this stuff because you’re worried about getting sued and all of that is not taking care of patients. You’re documenting for the insurance company. You’re documenting to make sure that the lawyers stay off your back. You’re documenting to make sure that your administrator thinks that you saw enough patients today because you billed not a level three, you billed a level five because you have the documentation to prove it whether you did the work or not. Right. If I did a level five work, but only bill of three, I still did level five work. I just don’t feel like documenting up to a five. And it’s just

Conrad Meyer (00:22:33):
Explain that so people understand what that means.

Dr. Davida Packer (00:22:35):
So

Conrad Meyer (00:22:37):
For those of you, so

Dr. Davida Packer (00:22:37):
In orthopedics, I mean the joke is we’re kind of dumb orthopods and all we care about is the bones. Well, mostly yes. And if you come in for a broken ankle, then that’s all we do want to really take care of. I don’t know. It’s not part of your ankle treatment, whether you had a cold or you have allergies or just all of those questions they ask you, we all know what they are. You have this huge form. Does anybody in your family have heart disease cancer? Not very much of that, especially in pediatrics, is going to change

Conrad Meyer (00:23:14):
What

Dr. Davida Packer (00:23:14):
I’m doing for your broken ankle. However, for me to get the full amount of a new visit, I have to have three points of each one of those things or five points of your past medical history or there’s data points. They just want data to be able to say, you okay, we think that you did a 15 minute visit. We agree. And I care about two sentences that I actually wrote. And if you look at another orthopedist, if I send them the records, they’re jumping down to where it’s not the insurance documentation or the lawyer documentation. It’s like, well, that’s one sentence or two. Everything else is for someone else

Rory Bellina (00:23:59):
In the New York Times article that we referenced that the moral crisis of American doctors, they talk about Dr. Shea who kind of came up with these three criteria for what he defined as moral injury when there’s a betrayal of what’s morally correct by someone who holds legitimate authority in a high stakes situation. So for you, when did that moral injury start? Did you ever experience anything in med school or residency or did it really start until after that? I’d love to know when did the,

Dr. Davida Packer (00:24:34):
I would say

Rory Bellina (00:24:36):
They

Dr. Davida Packer (00:24:36):
Give a great example in that, right? In that podcast they talked about other people’s first experience with it. And I would say no. I did experience it in residency, but you don’t own it. And so your first year out from residency, they talk about first year jitters. It’s like you think you know how to do everything and you’ve been operating for years and you’re great. And then there’s nobody. There’s no little bird on your shoulder saying yes, no. And now it’s really your call. And when for me as a surgeon, that’s good enough and I close up. I don’t want to keep operating and tweaking things. I’m calling, we’re done and close. The first time I can think of was near. I don’t know that the very first one was actually the example I gave you in the first practice I went to. But that was the first one where I had to step out and say, I Davida Packer making the choice because I’m now attending as a resident. I can think of things that were like, geez, if you got somebody else, you’d be in a better position. But I’m not able to change that. I don’t have control of it.

Rory Bellina (00:25:50):
I’m sorry, go ahead.

Dr. Davida Packer (00:25:51):
I think that’s the first really for me would be once I wasn’t attending that the decision was solely mine.

Rory Bellina (00:25:58):
When you were in med school or residency, when did it first start to be oppressed upon you and your classmates about billing and patient encounter times and how quick you need to rotate through a schedule?

Dr. Davida Packer (00:26:12):
Never. Not once.

Rory Bellina (00:26:15):
So that didn’t start until you were out and then all of a sudden it was told to you, here’s your schedule of 60 patients that you’re expected to see in two hours.

Dr. Davida Packer (00:26:24):
Correct. I mean, it started, we were talking about phasing in private practice training. So I think that’s probably different for residents now, but it was something that the American Academy of Orthopedic Surgeons, everybody’s academies were realizing they’re coming out and it’s just like to a sledgehammer. I mean, you just had no

Rory Bellina (00:26:47):
Training on billing or E H R

Dr. Davida Packer (00:26:51):
Coding. So we went to Epic when I was in, I always say it was epic. It was being in a state hospital. They were going to pull funding. So we went to electronic medical record the last second they could. And so we had a certain amount of it, and some of it was the coders, right? So we weren’t necessarily coding for billing purposes. We were coding to monitor our cases. So I did 10 femur cases, I did 20 tibia cases. I need to be able to code that correctly for some other type of bean. But if you coded it wrong, then the coders, I don’t know where they were in the hospital, could actually

Conrad Meyer (00:27:42):
Some bunker somewhere. They’re

Dr. Davida Packer (00:27:43):
In the basement

Conrad Meyer (00:27:44):
With windows. They got ’em in the bunker with no windows, but

Dr. Davida Packer (00:27:46):
They have the red button where it’s like, don’t let her practice anymore. She hasn’t done her

Conrad Meyer (00:27:50):
Bills.

Dr. Davida Packer (00:27:52):
And it’s like, so you learn, it’s learn from being beaten, right? It’s like you keep making my life more of a problem, more time consuming if I don’t just use the code that you like or use the modifier that you like or make sure that I have these five points of whatever that up code. And it was just like, oh God, I just want to take care of patients.

Rory Bellina (00:28:16):
So there had to have been a moment, and I am sorry if it’s hard for you to remember, but there had to have been a moment when you realized this is not what I went to school for. I went to school to learn and to treat patients, not to properly document, to get the highest reimbursement and to churn patients as fast as possible. Did you have a moment like that where you really turned your stomach and you thought, this is not what this is supposed to be?

Dr. Davida Packer (00:28:45):
Many. I don’t know if there was one. I mean, that’s the thing is that it’s so ingrained and it’s like, well, but who else is going to do this? This is the way medicine is. I and I have really cool kids. My kids were awesome. And it’s like

Conrad Meyer (00:29:05):
How you let that go? You can’t let that go.

Dr. Davida Packer (00:29:07):
You

Conrad Meyer (00:29:07):
Can’t let it go. Oh,

Dr. Davida Packer (00:29:08):
I did. Well you did.

Conrad Meyer (00:29:10):
It’s hard,

Dr. Davida Packer (00:29:10):
Right? Eventually I did. But they beat it

Rory Bellina (00:29:13):
Out of me. You were so far in, you are four years of med school, residency, fellowship, two

Dr. Davida Packer (00:29:19):
Fellowships,

Rory Bellina (00:29:19):
Two fellowships, student loans, just the whole thing. So

Conrad Meyer (00:29:24):
It’s like a trap.

Rory Bellina (00:29:25):
You’re so far in for you to get to the end and you realize, wait a second, this isn’t what I thought it was. But

Conrad Meyer (00:29:32):
Where do I go?

Rory Bellina (00:29:32):
I can’t go backwards in time. 10 years.

Dr. Davida Packer (00:29:37):
So when I saw this podcast, I mean, it really struck me. I don’t know how to explain it other than I just felt motivated when I left medicine. I wanted to do something to make it different that didn’t destroy me. So I can’t do this. I know I can, but how can I make it better for the people that are willing to stay in? And I realized when I heard this podcast that I haven’t done anything towards that. What am I doing to help people? And I still think as part of where I landed, I defend good medicine, stay away from good doctors, bad doctors get out. I think that’s a whole nother issue that’s part of this. But

Conrad Meyer (00:30:27):
If there wasn’t a breakfa moment, I mean this is just built up over time,

Dr. Davida Packer (00:30:32):
And it was like, where was that energy? But then also, why are people telling me I wish I would’ve. And I realized when people ask me, why did you quit? There’s a long answer. It’s a very long answer. What’s the short answer? I could,

Conrad Meyer (00:30:49):
I

Dr. Davida Packer (00:30:49):
Don’t have kids.

Conrad Meyer (00:30:51):
I

Dr. Davida Packer (00:30:51):
Don’t have a husband, I don’t have a house. I don’t have a, well, I do now, but at the time I was still kind of a resident where I could move and I could make a change.

Conrad Meyer (00:31:01):
You had the freedom

Dr. Davida Packer (00:31:01):
And I don’t know anyone else who has the experience. They gave medicine enough time to say, I really can’t do this, or it’s really not what I thought it was. I kept thinking, oh, I’m doing the wrong practice, or I’m in the wrong niche of ortho. Or I’ll just keep winding my way around until I find the perfect spot. Not many people at 36 can decide to go to law school.

Rory Bellina (00:31:27):
What did your friends and classmates say when you made this decision?

Dr. Davida Packer (00:31:32):
Most of them didn’t find out right away because it was, I’m not embarrassed about it now, but I was then it was quitting. It was defeat. It was, I can’t handle it. Oh, it was a girl we always know she’d quit ortho. She’s not tough enough. In some ways I felt bad about, so ortho is a pretty sought after residency was like someone didn’t get a spot. I got it, but that person’s mad. You got it and you didn’t use it, you wasted it. But I still try to use it.

Conrad Meyer (00:32:12):
You’re using it in a different way now.

Dr. Davida Packer (00:32:14):
Yeah, very different way now. And I think my relationship with doctors from a legal platform is completely different. I think they trust me more. I just tell ’em how it is. Come on guys. We know,

Conrad Meyer (00:32:26):
Right?

Dr. Davida Packer (00:32:26):
I know. And it’s, let me explain to you what’s happening here, why you got brought into this suit so that you’re not an empty chair, which no doctor knows what that means. And they were like, oh, okay, well why have we never had this conversation? Why have we never talked about why things happen the way they happen in law? Because doctors don’t have time. They’re too busy.

Conrad Meyer (00:32:51):
I’m going to pivot for a second. We went back, you mentioned earlier, we talked about the insurance companies and getting pre-auth and the tremendous amount of time that took for patients. We’ve talked about the billing on the EMRs that you had to use to be able to get your highest reimbursement about the various levels of your E N M visits for your patients. Let’s talk about how physicians are actually compensated. And I know Rory and I can talk about this because for years, over a decade now, at least maybe more all of the, I think you and I do, I think together at least 20 or 30 contracts a year.

Rory Bellina (00:33:37):
Absolutely.

Conrad Meyer (00:33:38):
And so all of our comp models that I know I have seen, and you and I have talked about this, it’s always production base. And that’s a move from the,

Rory Bellina (00:33:47):
It gets to that.

Conrad Meyer (00:33:48):
It gets to that,

Rory Bellina (00:33:48):
Yes. But that’s the end goal for Moose Systems,

Conrad Meyer (00:33:51):
Correct?

Rory Bellina (00:33:51):
I think,

Conrad Meyer (00:33:52):
Right,

Rory Bellina (00:33:52):
Is to get to that production based model.

Conrad Meyer (00:33:54):
And what that looks like for the listeners out there is some sort of relative value unit work, relative value unit type base where if you’re a new doc at a residency or fellowship, that’ll start you on a guarantee. Sort of like doesn’t debate. You got to start up, you have to build up your practice. So nobody has a practice when they walk out the door, right? When you get to your first job. And so they give you a base, they do a two year base usually. And then after second year, then they switch you to this production model. And of course they don’t tell you in the base letter, and I’m talking about large systems groups are a little different because groups have a difficult time tracking RVs. So if you can find a group, if you can find a group that has the capacity to bring you in, but normally not. You said davida, you’re going to a system, you’re going to a hospital or you’re going to a system. One of the two, right? 80% of the time, 20%. You might get a group, but the W R V U contracts set a target value at some point in time later. And with a clawback, if you don’t hit that target, then you get clawed back on your base. So it’s a draw contract. Would you agree with that?

Rory Bellina (00:35:01):
Yes. Yep.

Conrad Meyer (00:35:02):
And so now you’ve got back, now I’m circling back to Davida. Now you’ve got another layer of competition. You follow me? So now you’ve got, in addition to the pre-auth that you got to get to get approved, in addition to all of the challenges you’re facing now from a business standpoint of coding levels in your records, that coding level requirement is a target that you have to meet in your compensation contract or you get clawed back.

Dr. Davida Packer (00:35:32):
Well,

Conrad Meyer (00:35:33):
Did you see that in your practice? And have you heard about that? I’m just curious. Tell me about what that means to you.

Dr. Davida Packer (00:35:38):
We had,

Conrad Meyer (00:35:40):
That was a long way around

Dr. Davida Packer (00:35:41):
The

Conrad Meyer (00:35:41):
Barn.

Dr. Davida Packer (00:35:42):
Well, first I was getting stuck a little bit on figuring out the pre-auth and the billing coding things

Conrad Meyer (00:35:52):
You’re

Dr. Davida Packer (00:35:52):
Talking about just for the hospital, but Well, the

Conrad Meyer (00:35:54):
Hospital, but also some employers that track RVs. But I guess my point is, is that when you start bringing all of the things together, like the pre-auth with insurance companies, the e and m visit coding level. So you get that higher level reimbursement that you have to talk about the things you don’t really even care about. You now your overall contract with the group or that system requires you at some very near point in time to reach a certain R V U level or you get clawed back. So in your mind,

Dr. Davida Packer (00:36:24):
It’s always there.

Conrad Meyer (00:36:24):
Where is the moral issue now you’re seeing patients to push things because if I don’t do this, I’m going to not going to reach my target. Have you heard about that with your

Dr. Davida Packer (00:36:34):
Well, I’ve had it happen.

Conrad Meyer (00:36:35):
Oh, well, tell us about that.

Dr. Davida Packer (00:36:37):
So one of the things is that you’re not only working on pre-auth just for surgery. It’s also to get an M R I or to get a brace or to get their medication. So those are four different entities. One doesn’t fix the others. And so

(00:36:54):
A minor problem in coding, which I think I should code it as a, the coders think it should be B. Well, that sets off a whole different problem of if I shut them up by giving ’em the code they want, now the BRACE company is going to decline it. Or I can’t get the M R I or I can’t get a CT because some other box checked put it down a different. So it’s huge how much those things are. And each entity doesn’t talk to each other. So just because I got your surgery approved doesn’t mean your brace was approved or your medications afterwards. Three different people. So after I get through all of that, I’d get a call from admin saying, your numbers are low,

Conrad Meyer (00:37:40):
Your R V U numbers are low.

Dr. Davida Packer (00:37:41):
And it’s like, I’m new.

Conrad Meyer (00:37:42):
And

Dr. Davida Packer (00:37:44):
You’re exactly what you’re saying. I’m salaried, but I’m trying to build a practice. I’m trying to learn. I’ve got these old guys around me that know how to do everything. So if I had downtime, I would go operate the guy that’s been operating for 50 years and I can’t bill for that. There’s no RVs. So it looks like I’ve been sitting on my butt and admin wants to know why my numbers are low.

Conrad Meyer (00:38:10):
How frustrating is that?

Dr. Davida Packer (00:38:11):
It was just infuriating. So if I tell ’em to buzz off, what do you do? What

Conrad Meyer (00:38:17):
Do you do?

Dr. Davida Packer (00:38:17):
I mean, beat your head against your desk. I mean, what can you do?

Conrad Meyer (00:38:23):
Is this the problem that we just described with the R V U chasing the R V U? I’m going to call that the chasing the R V, right? How prevalent is that?

Dr. Davida Packer (00:38:35):
It’s been prevalent

Conrad Meyer (00:38:36):
For how long?

Dr. Davida Packer (00:38:37):
I went to, I would say, I guess I was 20 13, 20 14, that the practice that I was joining was, there’s big conglomerates taking over and the bean counters are watching. And there was an older spine surgeon that was just a guru, right? I mean, he would just get everyone to leave him alone. He would just bill a level one. He doesn’t want to learn electronic medical records. He wants to just take care of patients. He wants to write his notes. And he would put something in electronic medical record that would equal a one,

Conrad Meyer (00:39:16):
Which is the lowest form, the

Dr. Davida Packer (00:39:18):
Lowest form that you could bill. Basically, I’m not doing anything but check a box. There’s something

Conrad Meyer (00:39:24):
Here.

Dr. Davida Packer (00:39:25):
And so admin caught onto it and they were like, you have to start billing appropriately. And he said, well, I’m not going to. I’m going to take care of patients. And if you want to have something like a scribe or somebody with me that wants to learn all that, that’s fine. But I cannot take care of people the way I take care of them. And that at my numbers, it’s seeing 15 people in the morning and 15 in the afternoon when they’re spine patients.

Conrad Meyer (00:39:54):
What happened to him?

Dr. Davida Packer (00:39:56):
He quit.

Conrad Meyer (00:39:58):
Wow. They

Dr. Davida Packer (00:39:58):
Said, do it or get out.

Conrad Meyer (00:40:01):
So that’s the push coming from administration

Dr. Davida Packer (00:40:03):
In 2014.

Conrad Meyer (00:40:05):
And it’s got you think it’s still going on today?

Dr. Davida Packer (00:40:08):
I think it was in its infancy then.

Conrad Meyer (00:40:10):
You think it’s everywhere

Dr. Davida Packer (00:40:11):
Now. So the people that were like him that were from a generation that didn’t have electronic medical record, that didn’t have RVs, they didn’t have all this. Very few were left practicing. They did. They finally just said, I wash my hands of it and I’ll leave. Well, I mean, I can recently think of a problem that occurred that if they would’ve had an old surgeon around somebody that knew how to practice before Epic told you what you needed to do, right? There’s all these warnings and medication

Conrad Meyer (00:40:47):
And you’re talking about the medical record itself, it flags you with warnings. Yeah.

Dr. Davida Packer (00:40:50):
Yeah. So not necessarily Epic, the brand, but not

Conrad Meyer (00:40:54):
Epic. But the medical record can flag it,

Dr. Davida Packer (00:40:56):
Right? And it’s artificial intelligence. It can make connections that you may not be making it can.

Conrad Meyer (00:41:03):
So now we have medical records practicing medicine, right? Is that right? Rory got ai like chat, medical record chat, G P T, medical record. Gosh bless.

Rory Bellina (00:41:11):
They’re pretty impressive on what they can flag and catch.

Conrad Meyer (00:41:16):
Well, that also goes back to, and I’m cutting you off a little bit on the E M R side, because on Epic, I know about templates and all of us heard about templates over here on the lawyer side. I’ve seen it, and I know you’ve seen it, another method of efficiency to not get bogged down in the medical record but still cover your bases. How is that? And I’m going to get back to the RVU thing, but lemme stop

Dr. Davida Packer (00:41:41):
That. That covers your rvu.

Conrad Meyer (00:41:42):
That covers your RVU thing. I

Dr. Davida Packer (00:41:43):
Say the template covers your rvu. That’s why they’re so prevalent. But that is another reason I feel like as a lawyer, I can read records really

Conrad Meyer (00:41:49):
Problematic. I mean problematic, huh?

Dr. Davida Packer (00:41:51):
It is. Oh, I can read records really fast. I know where templating is and where it isn’t

Conrad Meyer (00:41:56):
On the review of systems. I mean just cut and paste.

Dr. Davida Packer (00:41:59):
Yeah, I can jump in to a medical record and see what the doctor actually wrote in pretty quickly and ignore templates. I made them for myself. I know how they work, and so I can just blah, blah, blah, blah, blah, blah, blah. Oh, right there. This one sentence is the meat.

Conrad Meyer (00:42:15):
So back to rvu. So you think that this RVU chasing the RVU for physicians is systemic and it’s everywhere.

Dr. Davida Packer (00:42:22):
Oh, it’s everywhere.

Conrad Meyer (00:42:23):
What have you heard from your colleagues that will even talk about this regarding how this relates to their moral decision-making for patients?

Dr. Davida Packer (00:42:33):
I mean, they’ll talk about it to me, but they’re not going to talk about it in public because

Conrad Meyer (00:42:37):
What does that look like?

Dr. Davida Packer (00:42:39):
I can or

Conrad Meyer (00:42:40):
Sound like

Dr. Davida Packer (00:42:41):
It sounds like defeat. It sounds like I want to help people, but I can’t. And I can tell you there’s people in this community that we’re sitting in right now that are on the fence that they’re trying to figure out how can I help people but not have to make a living doing this? How can I make a living doing something else and then do orthopedics on the side? I can’t.

Conrad Meyer (00:43:08):
Do you think that’s going on right now? Even in the New Orleans area? I

Dr. Davida Packer (00:43:11):
Can tell you.

Conrad Meyer (00:43:12):
So if it’s in here, it’s all over the country.

Dr. Davida Packer (00:43:14):
It’s everywhere.

Conrad Meyer (00:43:15):
Oh, wow.

Dr. Davida Packer (00:43:16):
I think just covid allowed doctors to maybe be a little human. I mean, people think like, oh, you make so much money and you’re just complaining. No, really no one does. Well,

Conrad Meyer (00:43:28):
Let me hit that for a second. The money, I hear that too. Rory and I have talked about that in the past. The perception of people

(00:43:36):
And surgeons, I’ll just use orthopedics as example. They make 600, 700, 800,000, 500,000. That’s a lot of money. Given that in all the things that we talked about here, and we haven’t even touched private equity yet. I mean, we haven’t even got to that, which is on our side. We’ve seen that as a boon in the last five years, I would say. Or more so given the issue or the perception of the public that these physicians, whether specialist or not, make a tremendous amount of money more so than the general public. Do you think physicians, if you could wave a magic wand because we talk about how do we cure this? What if the magic wand said, we’re not going to get paid 500, 600, 700,000, let’s pay you 300,000. But you’re not going to have to code and do all these unnecessary, you can see patients again. Do you think it would be a reimbursement that you think people would be like, you know what, if you cut the red tape,

Dr. Davida Packer (00:44:36):
I’d go back,

Conrad Meyer (00:44:36):
I’d go back.

Dr. Davida Packer (00:44:37):
I’d go back.

Conrad Meyer (00:44:38):
You think that would cut the stress even if they made less money, but less headache?

Dr. Davida Packer (00:44:42):
Most people would take it and wrong.

Conrad Meyer (00:44:43):
Really?

Dr. Davida Packer (00:44:44):
I mean, it was not, wow. If you didn’t go into this for money, you didn’t. And you guys write contracts. When’s the last time you wrote a contract for half a million for an orthopod?

Conrad Meyer (00:44:54):
Easily? I thought easily

Dr. Davida Packer (00:44:56):
For not spying.

Conrad Meyer (00:44:58):
Oh, well, not spying. No, no, not spying.

Dr. Davida Packer (00:45:00):
See, but see, oh, well now we’re just a regular orthopod. Well get down to the

Conrad Meyer (00:45:05):
No, I mean the spine is different. I’m talking about an employed orthopod on a spine, back spine. I agree.

Dr. Davida Packer (00:45:11):
Okay, so what about an employed

Conrad Meyer (00:45:14):
Hand

Dr. Davida Packer (00:45:16):
Pediatric orthopedist?

Conrad Meyer (00:45:18):
Oh,

Rory Bellina (00:45:19):
I know of a few. But they’re in

Dr. Davida Packer (00:45:21):
Systems.

Conrad Meyer (00:45:21):
They’re in systems. Everyone’s in systems. They’re no more, right?

Dr. Davida Packer (00:45:24):
Pediatric, you kind of have to be. So I want to take care of kids. Kids don’t have great insurance.

Conrad Meyer (00:45:29):
Sometimes

Dr. Davida Packer (00:45:30):
They do,

Rory Bellina (00:45:30):
Mostly

Dr. Davida Packer (00:45:31):
They don’t.

Conrad Meyer (00:45:31):
Right.

Rory Bellina (00:45:32):
But you’re most likely going to tie yourself to a pediatric system.

Dr. Davida Packer (00:45:36):
I mean, I can tell you the offers are in the two hundreds,

Conrad Meyer (00:45:38):
Right?

Dr. Davida Packer (00:45:39):
You think that they are all of a sudden tripling within 10 years?

Conrad Meyer (00:45:43):
No.

Dr. Davida Packer (00:45:43):
So okay, 200. I mean, let’s be real. 200 a year is not a bad salary.

Conrad Meyer (00:45:47):
No.

Dr. Davida Packer (00:45:49):
So let’s figure out what’s an equal salary. Should it be equal to what you owe in debt?

Conrad Meyer (00:45:53):
No. I guess the thing I was thinking of was to the choice, right? Rory, and you and I have talked about this in the past with, and Davida, I’m going to share this with you, but the choice, in other words, if we could wave a magic wand, kind of like what the government did with Covid and telemedicine. Rory and I in the background have watched telemedicine regulation evolve literally over years. And the infighting between various groups about how to bill, what the sea distance site, originating site, all those factors. And when covid hit within five days, it was gone in five days. It was

Rory Bellina (00:46:29):
Magical.

Conrad Meyer (00:46:30):
It was like a gift. And so now I’m looking at the physician moral injury. We haven’t even hit yet private equity yet. And if we could wave magic wand and say, doctor, you’ll not have to sit on the phone for hours on pre-auth. You’ll no longer have to do a specific amount of data points for e and m coding. However, you could spend more than six and a half minutes with a patient, be able to be able to talk to them. However, your reimbursement on your personal level is going to be cut 40 to 50%, but you’ll have no more red tape. What do you think would happen?

Dr. Davida Packer (00:47:10):
I’d walk back into practice.

Conrad Meyer (00:47:12):
How do you think physicians would accept that? Or would they accept that?

Dr. Davida Packer (00:47:15):
Almost? I mean, there’s always going to be somebody that wants money, right? But when you take, why’d you go to med school? Why did you go into this? Why are you here? I want to help people. If you said, do you want to just help people for less money and not deal with all the bullshit? I don’t know any doctor that would say that wouldn’t literally sign right there. I don’t even need to hear anymore. No, we don’t need to figure out. We don’t need to go back and forth and jockey agreements,

Conrad Meyer (00:47:42):
Sign

Dr. Davida Packer (00:47:43):
Here. Done. Go. Interesting. Take it.

Conrad Meyer (00:47:45):
That’s a very interesting thing.

Rory Bellina (00:47:46):
So when we talked, I’ve talked to people on the insurance side and I’ve obviously talked to a lot of providers and they both kind of point the finger at each other.

Conrad Meyer (00:47:54):
They do.

Rory Bellina (00:47:54):
The insurance companies will say, well, we have to constantly adjust our reimbursement rates because things are changing, costs are going up, costs are going down. Doctors should be more efficient in completing procedures with robotics. And then physicians will say, well, we’re having to change our practice schedule and style because of the reimbursement rates. So there’s just this never ending kind of loop of fingers being pointed back and forth at each other. What’s your take on that? When you practiced? Was it your system or your admins that you were in? Or do you think it’s the insurance industry?

Dr. Davida Packer (00:48:32):
I don’t know if there’s one. I mean, I think that each one is capitalized on the other. And some of that is law too. I mean, there’s a certain amount of C y A in every chart that is not really for the insurance company. It’s not for the patient. It’s not for me to talk to another doctor about, this is for me to cover my ass so I don’t get sued because I didn’t say whatever. So there’s that piece of it too. And so one of the things in why I don’t feel like I abandoned medicine. So my concern very, back in the beginning, you asked me what did other people think when I did this? I was very concerned that people would think I was a traitor or I don’t even know the right word for it, but just like

Rory Bellina (00:49:16):
Then you became a lawyer, which is worse. And

Dr. Davida Packer (00:49:18):
Then I became a plaintiff lawyer.

Conrad Meyer (00:49:20):
We bring that up.

Dr. Davida Packer (00:49:23):
So that was, I figured the last stab of any friendships still existing.

(00:49:31):
But I was very lucky to end up in a firm. It only takes good cases. And seeing that I’m like, I think this is how it started actually was. We won’t throw out our dirty laundry. We won’t say this doctor is bad. And there’s not a lot of documentation. So with lawsuits, now you have to start documenting more and documenting more. And then the insurance companies figure out how to tag that and make it that we need this amount of documentation to be X amount of dollars. And so the two of them just fed off each other and doctors let it happen. But if you would’ve said, this guy’s bad and forced him out, would lawyers have gotten the ground they got and getting documentation and getting you to document for thousand things? Otherwise you’re going to be sued? Well, you set up that platform for insurance to come in and make a template off of it. Oh, he skipped A, B and C level one. And so you see this kind of feed of, so if when malpractice occurs and you do have a bad doctor, if they would’ve just said He’s bad and get out, would we have gotten here? And that’s the only way I can, chicken or egg. I have no idea who came first. But everybody’s

Conrad Meyer (00:50:52):
Really

Dr. Davida Packer (00:50:52):
Padding each other.

Conrad Meyer (00:50:53):
Well, lemme just tell you this. So now I’m going to get into the PE because in the last, I think I would say five to seven years, Rory, is that accurate? Even pre covid, we’ve seen an influx of private equity. You already had the issue and you brought it up about no more. Very hard to go into a private group, even family at the gatekeeper level.

Dr. Davida Packer (00:51:18):
How many small dentists do you see?

Conrad Meyer (00:51:20):
Don’t see anybody.

Dr. Davida Packer (00:51:21):
Very,

Conrad Meyer (00:51:21):
Very few. The dentists may be a little different, but I think on primary care physicians, I mean, I don’t know about you r I don’t know any solo groups on PCPs at all. Now in a system, all of them are at least in our market. And so there’s nothing left. And so now PE comes in private equity and they start looking at the more lucrative practices to buy up because they want to get in on the healthcare market. And we’ve done several PE deals. I know you have, have people in our firm have. And when the deal with the PE firms is, is because they’re private equity and not another provider, they can come in and offer a multiple on the business at a much higher level to entice these older physicians who want to retire. Okay, let me go ahead and take my pot of gold now and then leave the younger docs to deal with the administrative levels of private equity. Do you know, and Davida, this is, I guess I’m ask you this, do you know any colleagues that are currently in private equity arrangements? And if so, and what has their experience been pre private equity, post private equity?

Dr. Davida Packer (00:52:35):
Well, I can think of one that was in private practice and came out into a private equity situation.

Conrad Meyer (00:52:47):
What was that like?

Dr. Davida Packer (00:52:49):
Miserable. And it was like, I’m either going to go back to private practice or I’m going to quit.

Conrad Meyer (00:52:55):
What happened? Do you have any detail if you don’t know?

Dr. Davida Packer (00:52:58):
Some of it is, but I mean it’s a common thread thread. It’s the same thread of,

(00:53:04):
So people when you were in private practice, you had some control over how you see things when you see them. That in pediatrics, for example, one of the quick in my world, a quick turnaround is people that are in towing, your little girls walking with their toes pointed in, you just grow and get over it. And especially in some communities, they still think you need to wear braces. And so they would put 15 of these appointments on. For me, that’s frustrating because I’m not doing any orthopedics. But if I bring a case on of tibial hem, Amelia, I’m going to be in that room for an hour. It is the same billing. And so people that are in private practice can make that choice. No, I’m going to take an hour to see this patient and I’m going to bill this, whatever. This is what I went into this for. This. When you go into the big machine, when you go into the Walmart of medicine, they’re like, Nope, we’re going to do 15 one. Let’s say you get one point for each one, you get 15 one, you get one, you have to go do the 15. No. Yes. Well, I don’t schedule, right? I’m not the scheduler.

Conrad Meyer (00:54:20):
So

Dr. Davida Packer (00:54:21):
How does that happen? Well, they just changed the people that answer the phones. You only get certain things funneled your direction.

Conrad Meyer (00:54:29):
So let me ask you this. I’m going to say a statement, and Rory, I’m looking at you and I’m looking at Davida. I want you to know, what do you think when I say this? In today’s healthcare delivery systems, medical physicians have full autonomous medical decision making. Do you agree or disagree?

Dr. Davida Packer (00:54:47):
Disagree. 1000% disagree. They do. That’s

Conrad Meyer (00:54:52):
Scary.

Dr. Davida Packer (00:54:53):
So they do. They have brains. They have a thought,

Conrad Meyer (00:54:57):
Right?

Dr. Davida Packer (00:54:57):
It’s not what they get to do

Conrad Meyer (00:55:00):
Because of these external factors,

Dr. Davida Packer (00:55:02):
Right?

Conrad Meyer (00:55:03):
Who’s talking about this?

Dr. Davida Packer (00:55:05):
No one.

Conrad Meyer (00:55:07):
Wow.

Dr. Davida Packer (00:55:08):
So when I saw that post, when I saw this podcast, I was like, why am I not doing anything? And so I put a post up and there are people that have wondered why I didn’t quit. I’ve never been able to put it into words. Here, listen to this. This is it. This is scratching the surface. And I quit five years ago. So the amount of people that came out of the woodwork and we’re like, thank you. If you figure out what’s next, I want to help. Great. Do you want them to know your name? I don’t know yet. Well, no one’s going to hurt me now. I don’t practice medicine anymore, so I can’t get forced out or my call schedule. So all of a sudden, terrible. Or I can’t get an OR schedule or the people that are calling in to schedule, you call for an orthopedics appointment. The good cases, where do they get funneled to? Well, that’s not causing problems.

Conrad Meyer (00:56:06):
And I’m looking for a legal answer here in a discussion. Rory and Davida, one of the things that Louisiana has done, and it’s going on across the country is direct care models. And I don’t know if people know what that means. It’s like, imagine concierge M D V I P, things like that, and I know what that’s going to spur. I can say, well, it’s for the haves and the have not. There’s a disparity there. Now, direct care model is different. The issue that I’ve seen, this is a systemic multifaceted issue. You got insurance companies who now have been collecting more data points because of defensive medicine tactics by physicians who then have to document tremendous amounts to cover themselves for liability purposes. Where insurance companies now say, we’re not going to reimburse you until you cover these data points because now you’ve told us what it is.

(00:56:57):
And then you’ve got administrators and private equity who are saying, in order to keep our lights on because of the decreasing reimbursement, you need to chase the RVU like never before, regardless of your moral compass as to your duty to patients that you took. And I mentioned whether it’s pharmacy or D M E, we can talk about that. And I asked you about, could we just cut the red tape and would physicians accept that if they could actually see patients? And the answer was yes. So here it is, direct care model. And what the issue was, was because if you tried to do direct care with patients, the state regulatory, and this is where lawyers come in, would come in and the D O I, the department of insurance would say, well, no doctors, you can’t do that kind of model because you’re acting like an insurance company, so you can’t do that.

(00:57:42):
They have now cut regulation, I think it’s over 20 states now, and I’ve read Louisiana’s direct care statute and statutes, and it basically allows more focused on primary care. But I’m wondering, could you apply this to other specialty practices? I mean, is it worth it given the state of reimbursement to where you can contract directly with patients to pay a per member per month rate? And for that, you enunciate all of the services they get. Here’s what you’re going to get. And we will never bill insurance. We will never bill them. You just come in, we’ll give you expedited appointment. We cut the red tape, we’re going to document it, but no claims will ever be filed. Have you heard of that?

Dr. Davida Packer (00:58:27):
I heard. What bothers me about it is you’re not a Chevy, right? I mean, the amount of things that don’t fit into a box in a human.

Conrad Meyer (00:58:35):
It’s

Dr. Davida Packer (00:58:35):
Not like you have a contractor and you go, okay, for six years, we’ll fix whatever goes wrong with your car. Well, that can be a huge amount of things. And when you’re in that model, so the problem is, okay, let’s say I’m internal medicine and I’ve got exactly what you’re saying. Well, the practice brings in a hundred thousand dollars. If I spend a lot trying to chase something that might not be your problem, but I don’t know, I’m going to get an M R I, I’m going to do all this stuff and I’m whittling away. It stops you from wanting to do that because then your lights aren’t on for all these other people you’re supposed to

Conrad Meyer (00:59:12):
Take care of. So it’s a capitation model that I’m kind of referring to. It’s a capitation model. So that in and of itself is not going to work because then you’re sort of limiting the care given your member per month and the size of your panel. So kind of like some homeowners,

Dr. Davida Packer (00:59:28):
Some medicine specific, right?

Conrad Meyer (00:59:31):
And I’m saying that, so right now, I’m kind of equating this to homeowner insurance right now, because in Louisiana, we’re in a crisis mode, right? Nobody wants to write. And so my point is, what about having a direct care model, but then having a higher level of catastrophic coverage that covers that? And then are we just back to the same model? Okay, well fine, we have a baseline model, but then the risks associated that you saying aren’t going to fit in that capita model. You have a higher deductible type policy, does that, and the bell’s going off, we hit an hour, right? Mean, do you see what I’m saying? Mean? I’m trying to solve and see if I can solve an issue? And I don’t know if it’s solvable because there’s so many facets.

Rory Bellina (01:00:12):
I think of that as a consumer though, is you’re back to the insurance model.

Conrad Meyer (01:00:17):
Back to the insurance.

Rory Bellina (01:00:17):
You’re not as great as it would be, like you said, to have the membership. And that includes everything. Just like Davida mentioned, at some point, if you’ve got something really going on with you that doctor’s going to say, look, I’ve done everything I can. You’re going to have to go to a system. Now I’m handcuffed. And what do you do if you canceled your insurance?

Dr. Davida Packer (01:00:38):
So one thing just to throw a wrench in how you’re thinking about that is when I was in California for fellowship,

(01:00:46):
That is somewhat the model they’re doing to work around horrible healthcare. And what it is is that in California, if you want to see any doctor, that’s worst seeing for dermatology. I mean, even internal medicine, rheumatology, these things are not emergent. It’s cash pay. You can fight with your insurance company, you can do the billing. They don’t. So it’s like, yeah, we might not get as many patients. They don’t want to do it themselves or they can’t afford to do it themselves. I don’t care. I don’t want to do it, so I don’t You do it. Our fee is $200. But then, so people that are essentially wealthy just pick the doctors they want, pay cash they want, and they carry a catastrophic prop plan only for car accidents, essentially. So it’s like if I get into a major car accident and I’m taken to U C L A, I have coverage for that. Everything else I pay cash for.

Conrad Meyer (01:01:43):
Well, then you get into the haves and the have nots.

Dr. Davida Packer (01:01:45):
But who else can do that?

Conrad Meyer (01:01:46):
Not many people,

Dr. Davida Packer (01:01:47):
Right?

Conrad Meyer (01:01:48):
You’re talking about the top.

Dr. Davida Packer (01:01:49):
But I mean, if you had every option in the world, how do you deal with it? That’s how you deal with it. How do you make doctors want to show up for work every day? Ask the people that are in that platform, which are cash pay doctors that have, what have they done to be cash pay? They got rid of all the insurance paperwork. Crap.

Conrad Meyer (01:02:12):
It’s interesting. I mean, I guess when you’re looking at it,

Dr. Davida Packer (01:02:16):
Why do I have to do all that? I

Conrad Meyer (01:02:17):
Want happy doctors. And you know what? As a patient from the consumer standpoint, Rory, when I go into my physicians, and it’s so funny because people call me and they’ll say, oh, I went to an orthopedic surgeon and they told me that I’m going to have to get cut. And I’m like, well, I don’t know if I really need to get cut, but they told me I had to get cut. I said, well, you went to a cutter. I mean, you went to someone, hammer nail job is to cut. So of course they’re going to say, well, you need to get cut in the back of my brain, knowing all of the stuff we talked about, because I think that nobody’s talking about this, nobody, our doctors, is the moral injury, the moral dilemma that we’re talking about is the lack of true autonomy and control for their patients.

Dr. Davida Packer (01:03:05):
Next time you see, I’ll leave you with this.

Conrad Meyer (01:03:07):
What’s that?

Dr. Davida Packer (01:03:08):
Next time you see a note from primary care doctor, because you get them, we all see what four pages now? At least three pages.

Conrad Meyer (01:03:17):
What’s

Dr. Davida Packer (01:03:17):
A small note? Take a sharpie, cross out everything that is for billing or for a lawyer and tell me what’s left and how much time it would’ve taken to write that. If that’s all I had to write,

Conrad Meyer (01:03:32):
I think the impression

Dr. Davida Packer (01:03:34):
It’s in

Conrad Meyer (01:03:35):
The impression would be the only thing left.

Dr. Davida Packer (01:03:37):
So if you are

Conrad Meyer (01:03:38):
The initial complaint, the review of for

Dr. Davida Packer (01:03:41):
Broken ankle, put in cast love, Davida,

Conrad Meyer (01:03:45):
Right? Right.

Dr. Davida Packer (01:03:46):
So if I was a cash pay person, why would I need to document any of that

Conrad Meyer (01:03:52):
Other professional liability purposes be the only thing I can think of,

Dr. Davida Packer (01:03:55):
The only thing I need to document is the orthopedist, the actual things I care about.

Conrad Meyer (01:03:58):
Right?

Dr. Davida Packer (01:03:59):
Right, right. Non-operative fracture, X-rays look good. Maintained in cast follow up two weeks.

Conrad Meyer (01:04:07):
If you could wave a magic wand, I’ve gave him my thought. You’re the physician. I’m not the physician. You’ve seen this, you’ve dealt with this. You’ve talked about this. We’ve gone over a lot of different things that are controlling doctor’s minds and practice patterns. Literally, what would you do?

Dr. Davida Packer (01:04:24):
I don’t know. I don’t know. I think there’s a solution at this point. And part of the reason I walked away was because I cannot do this. I cannot practice medicine this way. I’ll find another way to help you guys. I’ll be back when I do. I don’t know.

Conrad Meyer (01:04:44):
Wow.

Dr. Davida Packer (01:04:44):
I think it has to implode. I mean, there’s so

Conrad Meyer (01:04:47):
Many. What does that look like?

Dr. Davida Packer (01:04:50):
If covid would’ve last for another year, we might’ve seen our healthcare figure itself out. It didn’t last long enough. But how many people quit? I mean, right now, I don’t

Conrad Meyer (01:05:01):
Know

Dr. Davida Packer (01:05:02):
Right now in our town getting an M R I or a CT or an x-ray outpatient, not in the hospital, but if you could just go to a freestanding facility, it’s taking a week. There’s not enough radiologists reading. Why? Because they don’t want to. No one wants to do this anymore. It’s painful. They’re getting sued. They didn’t document enough. They didn’t bill enough. It wasn’t coded correctly. It wasn’t whatever it is, just not worth it. I’ll do something elses. And when it almost killed me to go every day, and people were making comments like, well, it’s the profession you chose. Okay, I’ll choose different.

Conrad Meyer (01:05:44):
And you did.

Dr. Davida Packer (01:05:45):
And for me, it was before Covid. But I mean, there was no way I would’ve made it through the Covid, just how there was a lot of people that gained respect, but there was a lot of people that said, well, you chose to be a nurse or you chose to be a doctor.

Conrad Meyer (01:05:58):
Yeah. I mean, we get that too. You have student loans. Most doctors have student loans. Most lawyers have, all of us have student loans. And if you leave the profession, what else can you do? Because those loans aren’t dischargeable in bankruptcy. They stay with you

Dr. Davida Packer (01:06:14):
Until you die. I still owe $180,000. Oh

Conrad Meyer (01:06:16):
My gosh. So, wow.

Dr. Davida Packer (01:06:20):
So how do you do that with kids?

Conrad Meyer (01:06:22):
I don’t know.

Dr. Davida Packer (01:06:22):
A house and Yeah, I did this. I walked because it could,

Conrad Meyer (01:06:27):
This is the moral injury we’re talking about.

Dr. Davida Packer (01:06:29):
Yeah.

Conrad Meyer (01:06:34):
Wow. Can

Dr. Davida Packer (01:06:34):
You imagine what my life would be like if I didn’t? I mean, it’s like I don’t know how people go home and still like their kids. At the end of the day, it’s just everybody’s whining about something and then you go home and they’re actually too and allowed to whine. But you’ve heard it all day. It’s like, how do marriages survive? How do kids grow up happy and healthy? Do you ever see a baseball game? No, you’re not.

Conrad Meyer (01:07:01):
You’re not there unless you’re a

Dr. Davida Packer (01:07:02):
Shift worker.

Conrad Meyer (01:07:03):
That’s sad. Well, any thoughts, Rory? I mean, I don’t want to keep,

Rory Bellina (01:07:10):
I don’t know. Yeah, I don’t know what the,

Conrad Meyer (01:07:13):
I’m just like, I got a cloud of questions. I’m like, how do we solve the problem? Definitely A plus B does not equal C here. We’re just not, I feel like we’re putting a square peg in a round hole and trying to jam it through. And I know a lot of colleagues that are struggling internally with this. I mean, I can’t imagine they’re talking to their partners or, I mean, this is just an internal stress bomb.

Dr. Davida Packer (01:07:47):
It is. And the other problem is, when do you have time to sit and talk about it? It is such a big problem. And you already have negative time, so you have a problem. You don’t have a solution to that Nobody has a solution to. No one’s talking about, it’s so complex. There’s no way that one conversation fixes it. Can you start that

Conrad Meyer (01:08:07):
Right? No, we’re not going to.

Dr. Davida Packer (01:08:08):
When you’re already just pulling your own hair out

Conrad Meyer (01:08:10):
To

Dr. Davida Packer (01:08:11):
Make it through your kid’s birthday, you just can’t. I mean, don’t even let yourself think it, because I cannot go down it.

Conrad Meyer (01:08:20):
Well, let me just say this. First off, Rory, and I want to thank you profusely. I’ve known you for a long time. I thank you for coming and talking about this because it’s not easy. And I really want to thank you for that. And I know our listeners, when they hear this, it might strike a chord with them. And so I know they will. Thank you. And I know you’re right. This is not a one conversation deal. And so I would like to bring you back to talk about this further because I think it is an extremely important topic that no one talks about that I know Rory and I see on a daily basis from the legal standpoint, from various purchase. And you know what? I want to hear listeners, I want y’all, any of the listeners here who are providers, anybody who’s listening to this, anybody who this struck a chord with, I would love for you to contact Rory or myself. Okay. Because I would love, if you want to talk about it, whether you want to come on the show or not, or contact

Dr. Davida Packer (01:09:21):
Me

Conrad Meyer (01:09:21):
Or contact Davida. So with that said, Davida, would you feel comfortable giving your email address out or does that Yeah, it’s

Dr. Davida Packer (01:09:30):
Very easy. Davida Packer at Gmail.

Conrad Meyer (01:09:32):
There we go.

Dr. Davida Packer (01:09:35):
I mean, some of it is knowing how to, I would never, and I’ve tried to be very careful not to let any of the friends that do confide in me, their kind of story get out in a way that anybody would know it was them. But I get it. And I don’t have to be scared anymore. No one can hurt me so I can speak, tell me your story and let me figure out a way to do something with it. That is what I left medicine for. I haven’t found exactly the way back yet. I don’t know the fix, and I still don’t know how I’m going to participate in the fix, but I’m trying.

Conrad Meyer (01:10:09):
Well, let me say this. For those listening who are providers that would want to talk to Davida, she gave her email. We would love to talk to you, even if you don’t want to come on the show just to talk to you about this. You can reach me in my email CMM like charlieMichael@chehardy.com, and Rory, yours is

Rory Bellina (01:10:26):
R Belina, R B E L L I N

Conrad Meyer (01:10:29):
A@chehardy.com. We really think this is an important issue. We would love to hear from you. Please do not be shy. If you hear this and you’ve gotten this far, because this is probably one of the longest episode we did,

(01:10:41):
We would welcome you to send us an email to talk to us about that. And if you do want to come on the show to talk about your issue and what you’re seeing, we would welcome that because I think a lot of providers, we have reached a lot of providers here. I think this is a lot more common than what’s being discussed. I think Davida has shown that. I know, Rory, you have shown that we’ve discussed it, so please, please feel free to reach out to us and come on the show. Davida, thank you so much.

Rory Bellina (01:11:08):
Yes, thank you. Great.

Conrad Meyer (01:11:09):
I mean, this has been fantastic.

Dr. Davida Packer (01:11:11):
Great. Sorry for snapping away

(01:11:12):
About

Conrad Meyer (01:11:12):
No, no, not at all. We really appreciate that. And for those of you who are listening, thank you for joining us for another episode of Health Law Talk. We at Chehardy Sherman, really thank you for the opportunity to bring you the latest and greatest in healthcare policy, social issues, regulatory, compliance, transactional, and you name it, we bring it to you. Look forward to hearing from you. Y’all have a great day. Enjoy.

Intro (01:11:33):
Thanks for listening to this episode of Health Law Talk, presented by Chehardy Sherman Williams. Please be sure to subscribe to our channel. Make sure to give us that five star rating and share with your friends. Chehardy Sherman Williams is providing this podcast as a public service. This podcast is for educational purposes only. This podcast does not constitute legal advice, nor does this podcast establish an attorney-client relationship. Reference to any specific product or entity does not count as an endorsement or recommendation by Chehardy Sherman Williams. The views expressed by guests on the show are their own, and their appearance does not imply an endorsement of them or their entity that they represent. Remember, please consult an attorney for your specific legal issues.