Surgeon Reveals Why You Don't Need Health Insurance | Dr. Elisabeth Potter

0:00 You've been fooled. [music] You don't actually need insurance. >> Dr. Elizabeth Potter. >> Dr. Potter. >> Dr. Elizabeth Potter. >> An Austin surgeon and insurance company, [music] United Healthc Care are going head-to-head over a dispute between a cancer patients [music] overnight hospital stay after a procedure. Someone says, "Dr. Potter, United Healthcare is on the phone and they said they need to speak to you [music] right now. >> It's about the patient that's on the table unconscious right now that you are performing surgery on." >> They denied her overnight stay and she got a bill for $100,000. How can you justify $100,000? >> We're all asking that question. [music] Denial is a strategy and if you deny, then you spend less. They gave her the estimate for surgery and it was $240,000. My estimate was $17,000 [music] for the same surgery. Same patient, same zip code, same surgeon. We are at risk

0:46 of losing the [music] beautiful art and practice of medicine if we let it be bought and controlled by industry. And I refuse. I refuse. I will die at some point and it may be on that hill. >> [laughter] >> 2025 was a very big year for you and I want to go back and talk about that that one viral reel you walked out and I've watched it um part of the 26 million people that have watched that you you came out of the O and I want you to just talk to me about exactly what happened from the moment you met this patient to her being on the table to you getting the call from United. >> Sure. So this patient, lovely woman with breast cancer and we had planned to do her mastctomies on a certain day and to start her reconstruction and um there

1:35 was a patient actually that day I had four patients. That day I got a phone call and that well the phone call went to the operating room front desk which is crazy. Like I've never actually had this kind of a call for me go to the operating room and I knew something was going on because it was a nurse who came in the room, the nurse manager, very experienced woman. >> So you think this is a very urgent case? >> Yeah. Well, I didn't know what was going on. I was kind of noticing and we're still working and I'm with my partner and you know taking care of this patient and then someone says, "Dr. Potter, United Healthcare is on the phone and they said they need to speak to you right now." And I was like, "Huh?" They're like, "It's about patient so and

2:21 so." And I'm like, >> "It's about the patient that's on the table unconscious right now that you are performing surgery on." >> So, so yeah. Well, it's actually So, it's about a patient who is in the next room. >> Okay. >> Already under anesthesia having her mastctomies. >> Cuz I'm doing four surgeries and I'm finishing my third. And it was about the patient in the fourth room who was already under anesthesia having her mastctomies. and I was going to go into that room later when they were ready for me and do her reconstruction. And I'm finishing my third case. And immediately I just was like, "Come on, you guys are not going to pay for this. You're trying to come up with some reason. They're trying to do something because they there's a history here where insurance companies tried to not pay for deep flap surgery." And that

3:07 happened in the early 2000 2020s. And I fought that fight. went to DC, hired lobbyists, went to CMS, hired, you know, public hearings, really had to lay it out for people like this surgery needs to be here. We need to be able to perform this elegant surgery. So, there was a history and I and I said to my partner, I need to take this call because if they don't if they don't pay for this, like she's going to get a giant bill, right? >> But don't you have prior authorization? >> Yes. >> We had got done everything ahead of time. Of course, there's no way we would have gotten to the room. But there's so received a call like this and I'm just like what is going on right so we're at a safe point in the procedure there's another surgeon present we're

3:53 finishing and I I walked I scrubbed out and I walked out about 12 ft away from the patient I was operating on right outside the doors and I returned the call and I had a three-minute phone call and it was just it wasn't rude The gentleman was polite. He was just entitled to my time. And he knew, Dr. Potter, when I I called back and Dr. Potter, you know, we need to know the patient's diagnosis. And I'm like, this is your member >> who's asleep. >> She has breast cancer and a lung abscess, by the way, and she's having masectomies, and you don't know her diagnosis. And he said, "That's another department."

4:39 And I was like, "What dystopian event is happening here? This sacred room that I just walked out of that you reached me in an operating room with vulnerable people. >> You're members. People have contracts with you and you don't know. What else don't you know about her, >> right?" >> So, you're basically saying that United Healthcare is not even seeing patients as patients. they're just seeing them as uh sardines. [laughter] >> It's, you know, it was it was such a a moment of this system is much too big and impersonal and I feel like I'm having to protect my patient from her insurance company in

5:25 this moment. And it shouldn't be that way because I've actually always been a proponent of insurance, of care through insurance. I've wanted insurance to be available and and I take insurance like I want the system to be a good system. I don't want to be spending my my days and nights working in a system that's broken. >> Why do you think they do treat them like that? >> It's money. It's money. I mean, I think that they were trying at that in that point to deny something. And I've I've come to understand that denial is a strategy because think about it. I mean, if you have patients facing medical events and you deny a treatment usually ahead of

6:10 time, right? You deny a surgery, a lot of times people don't fight back. These are vulnerable, depleted people. they are not going to then engage oftentimes and say no I'm going to go to bat for myself a lot of times they just >> they give up >> they give up and we see that in terms of the denial rates so I've I've come to understand that this is it's a strategy I mean if you deny then you spend less >> well most people in that vulnerable stage are pretty much they're they're sitting at the intersection of illness and insurance what are you you How are you meant to and maybe you've maybe you're young, you're 42. How are you meant to keep fighting this when you're

6:57 the primary bread winner, >> you've got two kids at home, your wife depends on you, maybe you've got a mortgage at that point, what are you going to do? >> That's so perfectly said, and this is what I say. Insurance is not what you think it is. It's not what I thought it was. It's not the key to care. M I want to get into denial and everything else, but I want to close the the scenario you were. So, tell me this. You were on the phone and how did it end? >> I basically said um I've got to get back to my patient >> and um you have the information you need. I sent it before >> because what from what I recall from looking over the notes, she um you wanted her to stay overnight. Of course, there was a question about >> what do you expect? There was a question

7:43 and it was they wanted me to justify why she needed to stay overnight and >> you just you're getting surgery, you've got a lung abscess and now I have to I have to fight to say to you, hey, I can't go home. I have to stay overnight. >> Can just just the basic Yeah, that that is that is human rights gone wrong. >> Yes. A woman under anesthesia, breast being removed currently, abscess in her lung. her doctor has said she needs to stay overnight after this procedure and the insurance company is saying, "I need you to really explain why in the moment." It's the absurdity. The absurdity combined with the calmness like this person didn't think this was going to make me upset

8:28 and that was almost worse. Just the fact that we are having to prove ourselves over and over. The the diagnosis isn't enough. The fact that the patient has a contract with you that says that if she has a mastctomy, she gets care. The fact that I am a fellowship trained, board-certified plastic surgeon and an expert in this, none of it is enough for you. You still need to call me >> and ask me one last time. >> Mhm. >> One more time. And here's the thing. If I hadn't taken that call, they would have denied it. And by the way, they denied it anyway. They denied her overnight stay and she got a bill for $100,000. >> To stay overnight in a hospital in the United States, it costs $100,000. >> Oo. And now Yeah. This is the This is

9:17 the >> what? >> Enterprise. >> That is like >> living out the word criminal, but >> Mhm. >> hotel night >> with care. >> Mhm. I can't I can't understand that. How can you justify $100,000? >> I'm asking that question. We're all asking that question of hospitals and insurance companies. >> So, you hang up the phone. Okay. You head back into the O. Yeah. >> You do the surgery and then you walk out and you were just frustrated. You get on your phone and what did you say? >> I finished the day, took care of all those ladies and I just I just wanted someone to know what I had experienced. >> Yeah. And I didn't have, you know, a huge following at that point, but I wanted just to record that moment. I wanted someone to listen and understand. I felt so demoralized. I felt so

10:05 demoralized as the person who who thinks of themselves as trying to do the right thing. to have the company that's between me, me and my patient call me and and question me and try to harm her and to feel like my job is now also to run defense. It's not just to be a micros surgeon. It's to also be like on the lookout for anything that an insurance company could try to pull. >> It just felt so wrong. So yeah, I recorded it and um and posted it and I didn't I did not expect the response. >> What was the response? >> Well, right away right away people just heard it and

10:52 listened and played it and shared it and doctors and patients and just people felt like it was wrong and they had their stories that were kind of similar. Wrong on whose part? >> On the part of the insurance company. >> Okay. >> Yeah. I mean, the next day I walked in, my phone was kind of I didn't really know that it was viral, but my phone was kind of buzzing, you know, and an orthopedic surgeon sort of patted me on the back and was like, "Way to go." And I was like, "Huh?" You know, what's up with that? So, I mean, I realized in a day or two how much attention it had gotten, but because I was back doing micro surgery, you know, the next day >> and the comments that I got and the messages of this is just it's off the rails, isn't it? And it was off the

11:37 rails and everything I said was true. >> Mhm. So, what happened after that? United Healthcare sent you, was it 12 pages? >> Six pages or so. Yeah. a cease and desist kind of letter from a very powerful um law firm out of Washington DC that represents Russian oligarchs and big pharma. And they told me that um I needed to retract my statements, take down the video, say that I had lied, accuse me of being a bad doctor, say that I had, you know, fermented violence because I wasn't like reading all the comments and deleting everything that said they were bad. you know, it was just ridiculous. So, yeah, I got that and it was terrifying and and also clarifying.

12:22 >> Yeah, >> because there were some people in the comments that were pretty much in favor of what happened to the um the old CEO. >> Yeah. The murder of the CEO. Yeah. >> And I mean, murder is evil and wrong. And um in no way do I condone that. And um but here's the thing. There were I don't know how many hundreds of thousands of comments and there were people reacting and bringing their own experience and they [clears throat] were having this conversation in a room as one as we do on social media where all of a sudden you you've met around an issue and you're exchanging exchanging information and it was like I was a doctor in the room with a patient who's just received

13:08 like terrible news or who is trying to grapple with a cancer diagnosis and it is not my job to tell them how to respond. It's It's my job to like listen and to understand where they are and think about that and then figure out how I can help them get through this. So, I'm like I'm reading the comments thinking, "Wow, this is really valuable information about the state of America. >> Look what people are saying. the cynicism, the fact that people could be celebrating the death of a person because of the harm that they feel that they or their loved ones have endured at the hands of insurance companies.

13:54 That is a really important piece of information that we all need to grapple with. So, yeah, it's not I felt like it wasn't my place to, you know, to say you should say that or you shouldn't say that. I'm just watching and reading and going, "Wow, we've got to do better." >> We as in who? >> All of us. America. America. I mean, it's not There's this huge There's this huge bully in the room. And yeah, they have all the power and all the money, but but we've got to stand up to this. We're all hurt. It's not just me and my patients in my practice. There are people all over the country hurting. >> You're one of the smartest people I know. One of the most passionate people

14:41 I know. Surely you knew the risks that were going to come after you decided to go against United Healthcare. Do you regret any of it? >> I do not regret it and I do not regret it. It has altered my life permanently and I found more clarity. I'm certainly in my purpose. I was meant to get that phone call and figure out how to respond and I'm still figuring out the best way to move forward. >> So, what happened to this patient? Did she have to pay 100,000? >> No. They erased her bill after the publicity. >> Wow.

15:26 >> Is that right? >> No. It's not the way things should be done. No one should be getting a $100,000 bill at all for that stay. >> I mean, what is that worth? Probably several thousand dollars with the the skilled staff that took care of her and the room and all of the things. But $100,000, we are we are letting someone just pillage our economy um under the under the flag of healthcare. This is absurd. >> It's absurd is one word. And I think it'll be the collapse of the of the economy one day, especially here in the US. >> Truly. And um and I think that's why I continue to lean in and and nobody has the answer to everything.

16:14 But getting to the heart of how bad it is is really an important part of figuring out our next step. >> I want you to tell everyone about your practice. You've mentioned to me offline that sometimes you're fearful. Um [clears throat] you've you've put yourself into debt to be able to keep your practice afloat. What's what's happening there? Tell us about that. >> So I'm all in >> to my practice. I'm completely committed to it. And um going against United Healthcare made that even more real because money that I expected to be able to make all of a sudden wasn't coming in. And then to keep my practice opened and to stay to stay the doctor who's the safety

17:00 net for so many women to get breast reconstruction, I had to, you know, cash in a 401k and sell things and um go into an immense amount of debt and risk bankruptcy and and live with that fear for a year and a half. like not just for a little bit of time, but for a a long time. Go to sleep knowing that um I've just drained all of my bank accounts to fight this company because I believe I have to stay alive to fight. I have to I have to keep this practice going. I mean, sure, I could should I could I have just closed up

17:45 shop and gone, "Wow, I made a point, but I'm not going to like invest more in who I am. Yeah, but like no, I I believe that I should be able to provide care to these women. I believe that I should be able to have my surgery center and um and create a better, less expensive way to provide highquality care for these women. So, it was really important to me to believe in myself and to invest in myself. And that was a good investment. It's a good investment. It's terrifying, but yeah, the hardest things to do every day is take your supplements. But what's

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20:06 it's very interesting coming from Australia where we have the national health care system. We've also got private healthcare in Australia too. And then you've got the UK. In the US something seems to be very different. There seems to be this disparity like a two-tier system. You've got the upper floor and then you've got the basement which is the basic care. Can you walk me through what this all means? >> Wow. That's a great um it's a great way to describe it. We do have a tiered system here in the US and basically we have no true safety net um in most countries that you've just described like there's a there's a safety net of care where the government has established a a floor of care that will be provided. So yeah, as a physician this isn't something that we learned about when I was training,

20:53 right? We learned about how to address a multitude of conditions, how to make really complex clinical decisions. We learned about some social determinants of health, maybe some things that might affect health, >> but not about >> how one patient in room one might have access to very different care just because of the insurance card they're carrying than the patient that I'm going to see in exam room 2. >> It's all based on the codes, right? It's a code system. It's a code system, but it's also a contract >> between who? >> Between the insurance company and the member. >> Because from my perspective, when somebody's given the opportunity, let's just say you've been told from your doctor, you need surgery. A lot of patients think, okay, this is a conversation between myself and my

21:39 doctor, >> but there is more people in that room at the time. >> Oh, yeah. And it should be between the patient and the doctor, but it's it's not because an insurance company can um make maneuvers that prevent that surgery from happening without even without leaving much of a trace. >> And it comes down to what does your contract say, right? It's not a they'll say it's not a medical decision that they're making. They're making a coverage determination. So, it all goes back to the contract you signed when you signed up for insurance. And those contracts are sometimes hundreds of pages long and they can carry, you know, clauses that say um, you know, we don't cover surgeries to prevent cancer or, you know, we we don't

22:26 cover experimental quote surgeries. And then, okay, well, what does experimental mean? Because in my world of reconstructive surgery, there's a procedure called a lymphoven venus bypass that you can perform to help prevent lympadeema >> in a woman's arm after she's had all of her lymph nodes removed in her arm pit and had radiation. >> So really high risk of having long-term swelling in your arm that can be really debilitating and painful for the rest of your life, right? And there's no cure, but we can prevent it if we do this bypass procedure where I I form a new pathway for that lymph to drain into the body. >> I learned to do that procedure 14 years ago. 14 years ago. And yesterday, I had a

23:12 phone call with an insurance company where the person on the other end of the line told me that that was an experimental procedure without data to support it. And there's lots of data to support it and still it's considered experimental. So just being labeled experimental, a surgery that we know could benefit this series of patients, this group of patients with a high chance of having a debilitating lifelong condition and it's a short procedure. I can do it in, you know, hour and a half. Um, just by saying it's experimental, >> case closed. >> Who labels it as experimental? So the higherups at the insurance company and they say they reference guidelines and I think that you know the way that those decisions are made in the US deserves some

23:59 scrutiny and then the insurance company can come back and say denied based on her policy and I'll have I'll say well I want a peerto-peer call. I want I want to speak with someone about this. that quite often. >> Quite often. And it's not just me. Um, one of my team members for this specific case spent 5 hours on the phone before I ever got on the phone. There's only several hundred of me in the country >> and I'm on the phone with an insurance company employee >> trying to explain, you know, science. >> Yeah. >> Right. So we are wasting a lot of valuable time, not just my time, all of our time. My very skilled employee, my

24:47 team member, five hours just to try to get me in front of somebody. Yeah. >> Do we have any stats on uh denial rates? >> Yeah. I mean, I think um the it it depends on which programs you're looking at, but like the Affordable Care Act plans, some you know, some denial rates are up at 20% nationally. That's for in network care. So say what I what I what I mean by that is that a patient could have a United plan >> y >> plan with United Healthcare through the exchange or through the affordable care act >> and they could see an in-et network physician meaning someone who said I want to participate with with you and with this plan and I I want to do everything for this patient and and then I submit. So I'm so they've already said we think that's a good doctor. we've let

25:33 her in the network >> and this is my patient who has that type of insurance and then I make my recommendation and 20% of the time they're saying no to the doctor's recommendation. One in five. >> One in five. >> How many uh breast reconstruction surgeons like yourself are part of the in network service? >> I don't know the exact number. Um and it's complicated because it's breast reconstruction. >> Yeah. >> Yeah. So plastic surgery is is is charged with looking out for breast reconstruction. That's the we're the group of doctors that perform breast reconstruction in the United States. For the most part, plastic surgeons are cosmetic surgeons and do work um for

26:20 cash, right? Cosmetic surgeries, elective surgeries. And there's a smaller group of plastic surgeons who are dedicated to doing reconstructive surgery. So there maybe 8,000 cosmetic surgeons in the country and that's you know a smaller number and certainly some plastic surgeons do both like they'll dabble in reconstruction or they'll do kind of half and half but when you talk about people who are really just experts in reconstruction there's not more than several hundred >> really and that's 10 years ago or 12 years ago when I set out to do what I'm doing now that's one of the reasons why I looked around and said women deserve erve to have experts doing their breast reconstruction, not someone who does a facelift, you know, at the beginning of

27:06 the week and some breast augmentations and a tummy tuck and then sort of does their good deed >> by doing breast reconstruction on Friday. >> This is might be a really good segue to talk about what it is that you actually do. And let's start with deep flap. Is that what it's called? The deep flap surgery. D I E P, by the way, not D E P. So, uh, let's talk about that. Let's talk about the the surgeries that you're mainly doing. I think you said you're doing today. You came in, guys. She came in today and she's done you had four patients this morning. >> Four cases. Yeah. >> Four cases this morning straight from the O to be here. So, talk to me about what your line of work actually is. >> So, I'm a reconstructive plastic surgeon. I'm trained in plastic surgery and I and I decided that I was just going to do reconstruction to be great

27:51 at that. And so, women who have breast cancer often times have mastctomies. like there's a surgical part of the treatment of breast cancer. Either they have a part of the breast or the entire breast removed. >> There's an act called the women's health and cancer rights act of 1998 which says that if a patient has a mastctomy that is covered by insurance, they are entitled to breast reconstruction and a symmetry procedure. >> That [clears throat] is the act that protects every single thing that I do. That is how I can provide for women to have this breast reconstructive surgery through insurance. >> Okay. So, there's a couple of types of breast reconstruction, but in general, three varieties. You can do breast reconstruction with an implant, a breast implant. Same thing as a cosmetic implant. >> Uh, silicone. >> Silicone or saline. Yeah.

28:38 >> You can close flat in an aesthetic way, an aesthetic flat closure. So, flat chest wall, but you do some maneuvers to make it not asymmetric. Try to smooth out the contours for the patient. Or you can create a breast from the patient's own tissue from another part of their body. Y >> so I take tissue from the the abdomen, the belly. >> Yeah. >> What what is usually discarded at the time of like a a tummy tuck or abdominal plasty >> and I use that tissue to create a living breast. And when I release the clamps, that tissue comes to life. Blood flows and it's living on the chest wall. >> Why do you like this one better? >> Well, it's lifelong. An implant is a medical device. It's not a lifetime device. I mean, it can it can rupture.

29:24 >> They're not made to last forever. So, the FDA actually put together really specific guidance for women who are receiving breast implants so that they understand that implants can rupture. They can have um complications like infection. Um breast implant associated cancers. They're very rare but real. >> Breast implant sickness as well. >> Yes. BI, breast implant illness. Correct. And so, you know, implants are not perfect, but they serve a great purpose. >> I always tell my patients that I anticipate that we should be exchanging your implant around the 12-ear mark, and that's based on a lot of data on the main implants that are available on the market. Um, and there are plastic surgeons who disagree with me in saying that. There are a lot of folks who say, don't don't operate until there is a

30:10 problem. And I just think that doesn't make sense in healthcare. If a if an implant ruptures and causes scarring and reaction then and we could have prevented that by looking at the data and operating just before that usually happens. >> My patients with breast cancer I 100% recommend that we do that prophylactically before the problem. So every 10 to 12 years. >> Um but a deep flap once it's once it's alive and there it's their body and it lives there. So, I might worry about my implant patients a little bit forever. I worry about my deep patients like right after surgery, but then then I release them to go live their life and enjoy, right?

30:56 >> And there's there's also just so much about a woman who is facing losing her breasts and sometimes feeling that her body has betrayed her. >> Yeah. and then meeting her >> and being honest about that, not flippant, honest about the challenge and then saying, you know what, your body actually might have something to offer you. Your body that you you are experiencing right now as having betrayed you might actually help you. And that is like the beginning of healing. That's the reason why I'm in this work still. >> It's it's amazing the O, but it's those

31:44 it's those really deep experiences of women >> facing the loss of their breasts. >> Mhm. >> And going on to live in that skin and how you how you meet that moment. And deep flop surgery really is sometimes such a beautiful >> beautiful way to step into that. >> You're part of a minority that can do this this type of work. >> How does it feel knowing that you may not be able to provide this for a woman just purely based on economics and the healthcare insurance policies? >> That just fuels my fire. So now we're about a year on.

32:30 >> It's a year and a half. >> A year and a half. Where are we at now? Have you had any meetings at Congress? Have you gone? Have you like what's happening in that? >> So much so much has happened. Um, honestly, I think that we all feel a little bit differently about insurance companies. People know what a peerto-peer call is now >> because I've shared that. People know people know that doctors are and patients are on the same side fighting insurance companies. Um but yeah, I've had the chance to meet with a lot of folks at a lot of levels in state and national government. Um we've we had a rally in DC in May and we announced um that we're trying to come up with

33:15 something called the Speak Free Act and that's in in collaboration with FIGS, the company that came to my aid. >> Oh, that's beautiful. >> Yeah. So, yeah, I wouldn't be here without Figs. Yeah. >> When I So, when I say like I risked bankruptcy, um there were a couple of companies and people that came to help me and FIGS did. Mhm. >> Their CEO personally called and said, "We believe in you and um they helped me financially get through the last year." And not just that, they also said, "We believe in you and we want you to do advocacy with us and let's come up with a bill that prevents this from happening to other providers." So, we had a rally about that with that. I I hope that in the next couple of months, we'll be announcing the Senate sponsorship for that. Um that's moving. But more I mean

34:02 more importantly just the I've gotten to sit down with an executive from an insurance company and have an hourlong conversation with a major news outlet just going back and forth about insurance. Yeah. >> Right. So having these conversations in public and holding my own >> and and and showing America that doctors aren't just we're not just there to to do the surgery. We're actually here to defend the profession. Like we are at risk of losing medicine, the beautiful art and practice of medicine if we let it be bought and controlled by industry. And I refuse. I refuse. I I will die at some point. And it may be on that hill.

34:47 [laughter] I'm still trying to understand and I think we have to get into it a bit more what the moat of the insurance company is if it's not to help an individual. >> Can you talk to me about denials, prior authorizations, and the billing codes? >> Sure. Um, so when I as a physician want to offer a service to a patient and that patient has insurance, I have to ask the insurance company, make my case to them >> and um they can deny that care. >> Why >> exactly? >> Why why does that even happen? Why >> it's elective surgery and you want to just for fun um you want to do something

35:34 I don't know maybe in plastic surgery. Yeah. Great. >> Yeah. But say you need you need you know I need to do a breast reconstruction or a patient has an infection I need to do whatever I I have to submit to the insurance company >> and say [clears throat] may I please do this thing. It's completely ridiculous. And we have tolerated the development of a system where the person who has the best interest of the patient and the most training is not the one making the decision. >> It's it's just dollars and cents and it's it's a broken >> CFO. >> It's a CFO. Yeah. Yeah. >> Okay. So they >> so they can deny that's a denial and then I can appeal. >> Mhm. [clears throat] >> And the appeal process is lengthy. It takes time and it takes my time. >> It's not like I can just have my team appeal. I have to get involved. So as a

36:20 surgeon trying to keep my practice open then I spend hours along with my team making phone calls, taking meetings, writing letters to appeal the decision. >> Um and then maybe it's overturned. But in cancer maybe that takes too long >> because delay is harm. I mean, yeah. I mean, you're talking about like aggressive forms of cancer that can >> anything. I mean, delay is harm. And so, if we are delaying treatment decisions, we're also delaying treatment. >> Mhm. What's been the most um lengthy process that you've gone through? >> Over a year for a woman to get a mastctomy. >> What? >> A young woman. Yeah. It was awful. >> She couldn't get it. So, she was denied and then you appeal process took First

37:05 of all, she had a a genetic mutation and a strong family history, and she had breast cancer in one breast, and they would only approve the removal of the breast with cancer. So, this young woman with a genetic mutation and a strong family history had to keep her other breast, and she goes through chemotherapy and surgery and radiation, and this other breast, and she's worried all the time that cancer is going to come back in this other breast. Almost a year later, time for reconstruction. Okay, I'm about to do the reconstruction. I can only do that once. I only have one time to do deep flap surgery. I can't do it because I'm removing all of the belly. >> Either do both breasts or one, but it's done. >> Okay. >> So, I I I had to make this case and explain to the insurance company. Please understand the guidelines actually

37:52 support doing the surgery. I once I've once I've done this reconstruction for her, I can't do it again. please let me do this for her at this time and approve the mastctomy. And it took I think seven phone calls and then finally one evening I was able to get on the phone with an oncologist who worked for the insurance company and he said well of course of course you should be able to do that a year. A year >> a year and the right person. And then how did that patient end up? >> We did a reconstruction. >> Yeah. >> Yeah. and she's we did both breasts. She had her mastctomy and bilateral deflaps. >> From my understanding, this is all based on certain codes. >> Our system isn't designed to pay more

38:38 for better, which is crazy because you get what you pay for. >> It isn't designed for that, but >> it turns out that it is. >> Well, I mean, it's designed it is manipulated to make money for insurance companies, but not for the providers, right? So, I mean, I think the perfect example of that is um the the surgery that I do, deep plap surgery, there was an older version of that surgery >> and it was called a tram. >> Yeah. >> Yeah. And the CPT code currently 19364 >> for breast reconstruction [clears throat] includes a free tram and a deep as equivalent. >> How does that make sense? It makes no

39:25 sense. >> No. >> So, our current CPD system says that taking a woman's rectus muscle >> is valued the same as saving it. >> It's obscene and it couldn't be more clearly wrong. And when I fought that, all hell was unleashed on me. >> Like what? like um threatening phone calls from societies saying that I you know basically I got this letter in the mail saying okay we've decided to change the codes and now all breast reconstruction is going to be $1 amount and I'm like if you don't pay better pay more for the better surgery there will be a race to the

40:11 bottom no one is going to do this hard surgery for that reimbursement hard for the patient or hard for the doctor. >> So, perfectly said the the deep flap surgery is hard on me and easy on the patient. >> Well, yeah. I mean, as it should be, it it's longer. It's tedious. >> Micro surgery. >> It's so hard. It's hard on me, easy on the patient. I'm proud of it at the end of the day. Patient is better off. >> Trim flap surgery >> horrendous on the patient. Super easy for me to do. >> I just go in and cut the muscle out. Literally just cut through it. There's no there's no nothing delicate about that >> fast all the >> proportion of women having masectomies are still getting that one tra >> should be none but like I just I have a patient right now who had bilateral

40:57 trams in Houston just a couple years ago she can't sit up out of bed anymore because she doesn't have core strength and and the reason is they paid the same so there was no driving force for the doctor to do the better thing and it it's the truth like in market system. >> Why would the doctor choose to do tram? >> Yes. >> Over deep in this world in this society. >> Not all doctors are good people. Not all doctors are good people. Yeah. We need we need a we need at least for the reimbursement system >> to be rewarding healthy behaviors for patients. If we have a reimbursement system that is not making people do better, why do we even

41:44 have that system? [clears throat] >> Yeah. So, there's a push for the CPT system to go away and I support it. >> If you were to sit down today with the current CEO of United Healthcare, >> what would you say to him? I would say the fact that you don't love me, that you didn't know how valuable I was to you on that day, the fact that that phone call came through demonstrates something really wrong with your company. And I would I would love for you to take the time and visit my practice and see what we do. and after seeing that, think that I shouldn't be at the top of your list of

42:30 doctors that you want your members to see. The fact that you don't know how great of a doctor I am demonstrates how broken insurance is. Yeah, that's what I would say. >> In the hopes for what? What change are you looking for? >> Well, I mean, I think Well, that's that's just what I want to say. >> [laughter] >> Yeah, >> that's what I want to say. I want to say like, you know, you're not as great as you think you are. >> You're not. You may make a lot of money, but you don't know. You don't h you're not close enough to the problem. Like, you're not on the assembly line. >> The fact that you don't know how good I am >> means you have gotten way too big >> and in hopes that they would rethink how

43:15 far away they are >> from the problem. It makes me see that the biggest obstacle to patient outcomes and survivability isn't the expertise of the doctor, which is what a lot of people think. It's actually a system. That's so true. And it's sad. It's really sad. And and I think that we can still course correct here. We still can course correct because insurance isn't necessary for patients to get good care. It's just it's gotten in the way and we have to get it out of the way. Um, but yeah, the biggest obstacle for my patients currently to get the treatment that I'm recommending is navigating big medicine. It's navigating insurance. It's navigating

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44:49 without changes to participants exercise routine. That is insane. Performance is not only about pushing harder. You also have to support the cellular machinery underneath it. If you want to do this, go to timeline.com/neur. will get 20% off when you subscribe and save. In this country, you're one disease away from complete bankruptcy. We are um some we are so ahead in technology, >> in science. >> We have a trillionaire who is um betting on the fact that maybe one day we'll live on Mars or the moon, god knows what planet. And yet a 42year-old

45:34 who's got two kids, who's the primary bread winner of the household, married, can come home one day and say to his wife, I've, you know, I've had a migraine for the past 5 days. >> I have to go and get an MRI cuz that's what's indicated after 5 days of having a chronic migraine. >> Goes to get his MRI. He's diagnosed with a glyopblasto, >> most aggressive form of brain cancer. And in that moment, he is left with the decision of what do I do? And I am now at the mercy >> of this CFO who's never been to medical school at a massive corporation. I'm at the mercy of him and his

46:22 decisions on how the rest of my life and the life of my kids are going to be. That is the country that we are living in. That is the American dream. >> It's heart-wrenching. And as you as you tell that story, which is a real story that really happens every day to people, >> I'm just struck by there's always a fight and the fight should be against the disease. We as a country can't force people in that vulnerable situation to fight the system too. It's cruel. >> It's cruel. And maybe the reason I feel so passionately about this is because I'm always trying to get to the heart of the matter. And I feel like I feel like

47:10 honesty is so important. And even even when it's honestly bad, just trying to like uncover >> what's there. It's not that I I think we can cure every disease, but there is an honorable good way to treat people who are facing disease, who are in pain, and this is not it. Let's just talk to everybody listening now. What do they do the moment that their doctor says, "Okay, great. We're going to greenlight you. You need this surgery." What are the top five things that people need to know in order to get the best care possible, but also be able to bypass the denial process if they can? >> Okay. So, before the diagnosis, start recording every visit >> with your with whatever recording device works. >> Okay.

47:56 >> Yeah. I think start to understand that you are going to need your records accessible to you in a way that the system may not make them accessible to you. Document everything. Document, you know, ask for the clinic notes. Ask for copies of the orders that are sent. You want to know what what is the what's the code that you're sending in from your doctor. Ask these questions. >> What if the doctors like just can't be bothered? Like don't >> find a new doctor. >> Okay? >> Find a new doctor because this is your livelihood. >> If they don't do this right then and you're stuck with a bill, this is important stuff. Like you need to be able to ask their business manager. Someone in their office should be able to give you the notes and give you the codes that they're doing. >> What's the importance of recording every conversation? I I feel really strongly about this and I I think that this honestly could be the thing that changes

48:42 I'm going to say I it could be the thing that changes healthcare because I think there's a lot that happens behind closed doors in medicine that [clears throat] patients deserve to know about and they deserve a record of. And if we had accounting not just of what insurance companies are doing but what doctors are doing too. Mhm. >> I think that everyone behaves better when they're being watched. >> I love that. Okay, let's go. That's step number one. Record >> step number two, you're going to have a procedure. You want to ask for the cost of the procedure at the point of care. You want an itemized estimate for your procedure >> before you have it. >> That's everything. Surgeon, anesthesia,

49:30 anesthesiologist, nurse, everything. Is that what you're saying? Itemized everything. I'm saying all of it and it will blow the mind of the hospital and they may say we don't have to provide that and then you will say yes you do. >> You are supposed to provide that. Let's talk to the current administration about the rules that they've enacted to make that accessible. So ask for an itemized estimate and [clears throat] um I did this recently with a patient and first we asked the CMO this chief medical officer of the hospital for the itemized estimate. He said we don't do that. So, we called the the financial line of the hospital and the patient asked for that estimate and they said, "Of course we do that. We have to do that under the law." And they gave her the estimate for surgery. And it was $240,000.

50:15 And I said, "Let me see what I can do that for my surgery center. I'll give you an itemized estimate before surgery." And my estimate was $17,000 for the same surgery. Same patient, same zip code, same surgeon. This is the power of numbers. Ask for the numbers upfront and shop. >> What was the difference between yours and theirs? What was the excess amount? >> I mean 17 and 240. Yes. The >> if if it was the exact same thing, what what was the difference? >> Oh, no. That's just overcharging. That is that is how broken the system is. We have we have turned over the checkbook to the insurance companies and the hospitals. So, so we need transparency

51:02 in terms of cost and and there are laws in the Senate right now. The patients deserve price tags act is in the Senate right now. We can get this signed this fall so that you can have itemized estimate and itemized bill afterwards and you can compare them to say you said this and you paid this, right? >> And you can say, okay, well that's not fair. we we agreed upon this. We don't have that now. Patients don't have access to that. And then employers or people who are providing insurance don't have access to the difference between what for instance the hospital or the insurance company settled to pay and what they charged. >> So maybe they charged $240,000 but

51:48 they're going to settle on 20. [snorts] >> Right? >> So where does the excess go? Insurance company. >> So yes. And then and then what if the insurance company can go to the employer and say, "Oh, but I've just saved you $210,000, $230,000, whatever it is." Like, and then they say, "Oh, I by the way, I have a clause in my contract where if I save you a lot of money, I get half of it." I'm not kidding you. The American public is getting fleeced. >> Criminal. It is criminal. The Patients Deserve Price Tags Act is a real thing >> that we need to pass and we need it to not get watered down in rulem. >> So, >> so itemize everything. >> Itemize everything. >> You have a right. >> Just do the work. >> Do the work. Yeah. Ruffle the feathers. >> Um,

52:34 >> number three, appeal. >> Three, >> appeal. >> Appeal everything. >> So, if you get denied, I'm going to How do I appeal? >> You just say, "I want to appeal." And you should say, I want, if you're a doctor, you should say, I want a specialty matched appeal and I want it expedited. Those two things, specialty matched and expedited. If you're a patient, you just keep appealing and you you ask your doctor to appeal and you the the number of over denials that are overturned on appeal is dramatic, dramatic. And you you just have to keep pushing. And you can even if they if they deny again you can ask for an outside appeal and there are companies that will come in and it this is it's a war of attrition

53:20 but in the current environment just persist that's the way to get what you need and to not get fleeced. >> Wow. >> Support the patients deserve price tags act. I I would say right now maybe the most important thing a patient can do is resist. Even if it's in your conversation, if it's just keeping awareness up that no, we are not going to tolerate this through another election. This will be the issue at the top of the ballot. We are not going to continue to put up with this. Just know that we're going to change this through through constant pressure and like a cultural shift.

54:05 >> You know, the time when doctors didn't didn't talk about money because it was um you know, it was not healing and not building trust. It was transactional. Like that time is gone. Mhm. >> To be a good doctor, you have to weigh in on the healthcare economy. You have to weigh in on what your patients are experiencing. So, yeah, I don't think you get to [panting and gasps] I don't think we get to say like, um, I'm just going to do the right thing and I'm going to leave that to someone else anymore because we've, you know, the fox is in the hen house. >> Yeah. >> And we've got to fix it. My final question is, if you had the attention of every American for 60 seconds, what

54:52 truth about healthc care's insurance system would you feel morally morally obligated to tell them? Insurance wasn't a bad creation, but it's not what you think it is. and you don't actually need it to get good health care. We can remove insurance from the equation and still have patients who need doctors and providers and facilities where they can get that care. We don't need insurance.

55:39 I think if we can all accept that that could be true and imagine a future where the government supports a baseline level of healthcare and we have a competitive market where healthcare can thrive outside of insurance. That's morally what I need you to understand. You've been fooled. You've been fooled. You don't actually need insurance. It's not what we thought it was. It's not what it used to be. We can build something different. >> How can we support you

56:26 >> with what you're doing? >> I would say you're moving mountains from, you know, left, right? You're you're doing so much. What can what can we all do? I mean, follow along. I'm, you know, on social media. >> We're going to put like social media handles as well, but >> there's got to be something else that you're doing. >> I mean, honestly, I'm I am spending a lot of time advocating and I think the Patients Deserve Price Tags Act needs to get passed without getting watered down. So, I would Yes, we can. I would call So, we need for Americans to call their Congress people, their senators especially to support that act. Um, I would say lean in and get involved. Don't think that you

57:11 are unable to make a difference. It's hard for me to ask for help, but the help that I need is um I need you to fight with me. I don't want anyone else to have to be, you know, the first one through the wall. I don't want anyone to take the beating that I've taken, but I do really want you to follow. That's what I need. Dr. Elizabeth Potter, thank you for being part of the Euro Experience podcast. It's a blessing. >> [clears throat]