Nudge the Giant
[00:00:00] Ben Schwartz, MD: You got to start kind of nudging the giant. And I think from the physician standpoint, that is… the simplest thing is just educate yourself, understand what's going on, take an interest in it, and that's how you start. And then you go from there. And not everybody, you know, needs to go to DC and lobby, and not everybody needs to get an MBA and try to, you know, become an MD MBA administrator.
But I think just educating yourself on what's going on around you is the first step. And, you know, sharing podcasts like Relentless Health Value or, you know, keeping your ear to the ground is the first step. Knowledge is power.
[00:00:51] Stacey Richter: Waking up the sleeping giant that is physicians.
Why Physicians Sleep
[00:00:55] Stacey Richter: That is what I talk about today with Dr. Ben Schwartz. And look, just like employers who have been called the sleeping giant of healthcare for years, this term is both flattering, the giant part, and a lot or maybe a little offensive, the sleeping part. So you're welcome and very sorry in equal parts.
Now, this conversation began with Dr. Suhas Gondi in episode 523, who wrote an article in NEJM directed at physicians. He wrote this article with his co-author, Dr. Zirui Song, about the sleeping giant that is self-insured employers and imploring them to please wake up and take back the power and agency that paying for healthcare for something like 60% of Americans really should afford them.
The thing is, though, about employers being a sleeping giant, is that it's hard to take back power and agency. There's three Relentless Health Value episodes with Lauren Vela, [Episode 406], Lee Lewis, [Episode 508] and Elizabeth Mitchell [Episode 491] about the why it's hard for both internal inside the employer reasons, and then also external ecosystem market reasons why it is very hard to wake up. It's challenging for employers.
But in this latest episode, 523, with Dr. Suhas Gondi, I kinda turn the tables on him and say, "Well, if employers are sleeping giants, why not physicians? Why can't physicians also be sleeping giants who can take back their power and agency and go about the fixing of the American healthcare system?"
So do go back when you have a sec and listen to that opening salvo, that shot across the bow, if you will.
But I wanted to jump in deeper on this topic, so I shanghaied, successfully, Dr. Ben Schwartz, who I was justifiably confident would be able to take this conversation one layer deeper. Because look, doctors, all clinicians really, but let's just focus on physicians today, there are many who are suffering in the current regime.
But while I hear the rants and about the burnout and some pretty horrible stories, I don't see much flat-out revolting or coup d'etats, at least at the big-picture level. With the probable one exception of clinicians, physicians who listen to this show, who I would not discount at any level. It seems like for every physician picking up a torch, there are, like, a thousand others who don't seem to be.
Dr. Ben Schwartz and I first talk about all of the reasons why it is actually pretty tough for many docs to grab the reins and gallop off in a different direction. Then we list a bunch of directional ways forward despite the obstacles.
Dr. Ben Schwartz, my guest today, as I have mentioned multiple times already, is an orthopedic surgeon who is currently seeing patients in the office a couple of days a week at a safety net system.
He also works as a medical director at an MSK, musculoskeletal, company. And lastly, do not delay checking out his Substack, The Surgeon's Record, and his posts on LinkedIn, which are frequently very great.
With that, here we go. Here is my conversation with Dr. Ben Schwartz. My name is Stacey Richter. This is Relentless Health Value.
Thank you so very much to our series sponsor this year, Payerset. Also, thank you so much to Patient Rights Advocate, who gave us a lovely financial donation that is so helpful to keep this show on the air. Also, lastly, thank you so much to our founding sponsor, Aventria Health Group.
Dr. Ben Schwartz, welcome to Relentless Health Value.
[00:04:58] Ben Schwartz, MD: Thanks for having me back. Always a pleasure to join.
[00:05:01] Stacey Richter: Well, it is always a pleasure to speak with the likes of you. We often talk about the sleeping giant of employers, and it's not necessarily a compliment. It sort of is.
[00:05:12] Ben Schwartz, MD: I think the giant part is good. It's the sleeping part that we really wanna work on.
[00:05:15] Stacey Richter: Right.
Burnout to Action
[00:05:16] Stacey Richter: So let's talk about the waking up.
You know, you can think about physicians who are the ultimate deliverers of care here, and sometimes it feels like are getting pushed around maybe in a way that some might consider surprising. There's an epidemic of burnout. It seems like there's a lot of, like I'm on the Reddit too often, honestly, according to my phone.
There's definitely a lot of, like, you go in some of these subs, the rants are long and detailed.
[00:05:52] Ben Schwartz, MD: For sure. Yeah, I mean, I think it's, it's a catharsis. I think it's more effective when it leads to the next step and make it constructive and make change. And it's not easy, but I think it's more effective when that sort of, you know, anger, discontent, whatever you wanna call it, becomes constructive and leads to something more tangible and leads to action.
And I think if we see more of that, I think we're gonna see more... It's gonna be more effective to drive change.
[00:06:19] Stacey Richter: Why not just go give the administrative team the what for?
[00:06:22] Ben Schwartz, MD: But I think in practice there's a lot of structural factors that make that more difficult than it seems.
Employment Traps
[00:06:27] Ben Schwartz, MD: I mean, number one, you have to look at why are the vast majority of physicians employed now, and a part of that is because it's hard to remain independent.
It's a lot safer, or at least it's perceived to be safer, to be an employed physician. So I'll go be employed, and that's gonna allow me to focus on delivering healthcare, and that's why I got into healthcare in the first place. That's a reason why you might sell your practice to a private equity firm or go join a hospital.
You want somebody else to handle the business and administration part of it. I think part of what leads to that frustration is you get there and you realize that's not what's happening. You're not just able to focus on healthcare like you thought.
And so I think we will see the pendulum swing back in the other direction. The problem is those factors that drove consolidation or drove employment in the first place haven't really changed enough that a lot of physicians feel comfortable, and that, I think, tamps down your willingness to fight back to a degree, because you need to have an alternative in order to have leverage in order to drive change in a lot of situations.
And I think that's lacking right now in healthcare for physicians.
Speaking Up Risks
[[00:07:31] Stacey Richter: If there aren't alternative places to go work, then you could be up a creek without a paddle if your current employer starts having a problem with you.
[00:07:40] Stacey Richter: I wanted to know more about the risks internally to an overly loud doctor.
So I went back to Dr. Schwartz after this conversation and I asked him. He told me, he said, "I think there are different threat levels. Obviously, being fired is a big one, but probably that takes the form of not having your contract renewed.
Another possibility I think scares docs is the possibility of having privileges revoked or suspended or being subject to disciplinary action that could go on your permanent record. Basically, something you have to report every time you apply for privileges somewhere else.
It's a potential reputational hit, and that is something most doctors take very seriously, not just because it can impact your ability to get a job, but also because it feels like a commentary on your abilities as a physician.
Think of a professional athlete, musician, actor being labeled as difficult to work with, in essence these things may be more theoretical than common, but they can happen, and that threat is often enough.”]]
Noncompetes and Inertia
[00:08:40] Stacey Richter: You're talking about the structural constraints that you mentioned that holds back doctors, and some of these structural constraints that we have heard about in earlier shows are, for example, noncompetes, right?
Like, where are you gonna go?
[00:08:52] Ben Schwartz, MD: And it's not easy. You know, you spend at least two years, and sometimes longer, establishing a reputation. You go to a community, and you put a lot of time and effort into, you know, delivering great care in the community, gaining that reputation, establishing a referral base. And then to pick up and move and try to establish that somewhere else, that's a huge ask, and it's another part of the inertia.
Even if you can get out of a noncompete and you don't have to move, now you have to reestablish your practice. You have to kinda unwind yourself from the hospital. You probably can't solicit those patients. Maybe you have to join another group. Maybe there isn't another group in town, or maybe you have to start from scratch.
And how do you start from scratch to build a practice outside of that setting? If you've never been outside that setting, if you've always been employed, you know, it can be a scary leap to go in a totally different practice model.
So these are all the, kind of the structural things that, you know, make it a lot more complicated than it seems to just say, "Okay, I'm handing in my resignation, and I'm going over here. I'm just gonna hang out a shingle and be successful." Doesn't mean you can't do it or shouldn't try to do it.
[00:09:50] Stacey Richter: Yeah, and this also came up in the first episode with Yashaswini Singh [Episode 474] about private equity because the same thing happens there. Like, what are you gonna do? Like, leave the health system. If you go over to private equity who did a big roll-up and now they rolled up all the practices in the area, like, now you've gotta move your whole family 200 miles away or something.
[00:10:09] Ben Schwartz, MD: There's noncompetes, and there's a lot of risk involved, and we're generally risk-averse. And so, you know, sometimes you stick with the safest path, even though the devil you know is, is safer than the devil you don't know, and I think there's some inertia there to that, that safety even though you're not happy.
[00:10:24] Stacey Richter: Dr. Graham Walker wrote this the other day on LinkedIn. But it really layers onto Dr. Schwartz's point here into the why not just give administrators the what for, which actually was the original question.
So Dr. Walker wrote, he said, "Medicine has a strange culture around speaking out publicly. We spend years training physicians to exercise independent judgment, question assumptions, and speak up when something is wrong.
But when it comes to expressing judgments outside the hospital, we worry about ‘being unprofessional’ or ‘damaging our careers.’ Meanwhile, a 24-year-old tech founder in San Francisco who never spent a day in healthcare can announce plans to reinvent it, and investors celebrate the ambition."
Dr. Walker wrote, "Sometimes I wonder if medicine's deference and humility work against us."
You can definitely see how Dr. Walker's point of view and Dr. Schwartz's are certainly aligned.
[00:11:21] Ben Schwartz, MD: And I think that create, that worsens the burnout problem 'cause you, it sorta leads to that feeling of hopelessness of, "Yeah, well, this isn't great. I'm not super happy here, but I don't really have any, don't feel like I have any alternatives." And I think that's a really difficult feeling for a lot of physicians.
Lost Art of Independence
[00:11:35] Stacey Richter: If you're younger, earlier in your career and you're like, "Maybe I wanna go independent." In the past, there was kind of this apprenticeship, right?
Like, there's plenty of independent physician groups that you could go work for and then either work your way up within that group or you're like, "Okay, well, I learned how to do this and now I can go out on my own."
But if there's not very many independent physician groups out there, then how are you gonna learn kind of like the business of standing up a practice never having worked at an independent doctor's office before?
[00:12:04] Ben Schwartz, MD: Yeah, succession planning used to be a huge thing in private practice. You bring younger partners in, you teach them the business, you get them involved in the business, you give them literal and figurative ownership in that business.
And now, you know, when we have people retiring earlier and leaving earlier, or there's less traditional private practice out there, how do you bring the younger generation on board, keep them engaged, give them that literal and figurative ownership that's gonna allow them to sort of continue on versus say, "You know what? There's no future for me here. I'm just gonna go to the hospital and health system. It's a lot theoretically cleaner to be employed than it is to go into a practice where 70% of the people are looking to retire in the next three years and, and just kind of pass the business on to me and get out."
So I think it is becoming a lost art, which again, makes things more complicated.
You know, we can't just see the next generation as somebody to kind of pass the problems onto. We have to help set them up for success and not just see them as a means to facilitate my retirement, but see them as a means to continue and revitalize independent practice going forward.
[00:13:10] Stacey Richter: So I'm writing down some of the things that you are saying, Dr. Ben Schwartz, that are foreshadowing here.
[00:13:17] Ben Schwartz, MD: Hopefully not to hold them against me later. No.
[00:13:21] Stacey Richter: Well, they're the light at the end of the tunnel, right? So just in case anyone is becoming disheartened by some of the stuff that we're talking about, which is like the why for why this is hard, why this has happened.
This is also the reasons, honestly, why, like, let's just similarly to how we should not be finger-pointing employers, like it's so easy. It's not actually easy.
So we're kind of having a conversation about the reasons why this is actually harder than it may seem on paper, despite the impetus to try to fix the system and to be the giant and wake up and take back the ownership and power for what is going on in the healthcare system, which is clearly elsewhere at this moment in time.
Why Doctors Fragment
[00:14:01] Stacey Richter: But while we're on the why this is hard portion of this conversation, you know, also many people point actually to med school, where competitiveness is a thing. So you, you talk about leverage, you kinda have to collectively act at some level. Like, if you're just the one lunatic out there in the parking lot picketing all by yourself…
[00:14:25] Ben Schwartz, MD: I think we're, we're probably competitive by nature, just in being interested in medicine. Becoming a doctor, I think tends to attract a competitive sort of personality, and then from the get-go, in order to get into medical school, it's competitive, so you have to be competitive in college to get a position in medical school.
Then in medical school, you know, you're competitive on your clinical rotations to stand out and get a good grade, and then you're competitive to get residency spots.
And then you get into residency, and you're competing with one another, you know, to get fellowship positions and, you know, and then we start to kinda get siloed into our own specialties, and your specialty becomes your identity.
And so it's hard to get physicians, you know, rowing in the same direction from a kind of a broader perspective.
And physicians are a very heterogeneous group in terms of coming from all different walks of life and philosophies about, you know, politics and social issues and Medicare for all, and all this kind of stuff.
You know, we're not homogenized, and we shouldn't be. But how do we kind of put some of those differences apart and realize that we're all facing kind of high-level issues that affect all of us, right?
And some people, some physicians may be losing more or less than others, but we're all kinda losing, at the end of the day. And the system's also structurally set up to pitted against one another when you look at budget neutrality and say, "Hey, we have this one pool of money to pay physicians," that pool's not getting any bigger.
So yes, we wanna pay primary care doctors more, but in order to do that, somebody else has to lose 'cause it's a zero-sum game. And so structurally, we're pitted against one another when it comes to reimbursement, and so there's a lot of different factors that kinda keep us from pulling in the same direction.
[00:16:00] Stacey Richter: It's also, how do you work as a team? I don't think there's very, very many, like, management training classes in any given med school. There was just an episode with Dr. Rebecca Andrews [Episode 536] about team-based care, and it's definitely, it's not just like throw a bunch of people in a room and hope that it goes well.
It's a thing to be able to work collaboratively, not only across doctors, but also with everybody else in the organization.
[00:16:25] Ben Schwartz, MD: There's a lot of things that we could change about medical training in medical school and in residency.
I don't think we do a great job of sort of preparing doctors to actually go out and practice medicine, not just from the clinical standpoint, but also what is it like to exist within the healthcare system? What's going on in the healthcare system? How do you understand the business of medicine? How do you understand, you know, what's changing and how to adapt to those changes?
We tend to be kind of tunnel vision on take care of the patient, which is what it should be ideally, but that's not the reality that we live in. And to our detriment, I think it's kind of cost us the seat at the table.
I was just at a conference, the American College of Surgeons Clinical Congress conference on a panel and one of the docs came up to me, he's interested in this stuff.
He's at an academic medical center, and he's like, "Well, I'm interested in it, but I can't get any of my partners interested in it. They're totally oblivious to this stuff. They have zero level of interest in it. How do I, you know, get them to understand that?"
And I think that's something that we can do better, you know, to educate other doctors on, "Hey, this is what's going on around us," and, you have to understand it, you know, get involved a little bit to support the people that are doing this work to advocate and to drive change.
But we all can't be oblivious. We have to understand that this is going on and it's slow and it's death by a thousand cuts, and I think that's why it happens and we've been oblivious to it, and why we kind of wake up 20 years later and realize how much autonomy has been eroded, how much reimbursement's been eroded, how many of us are now employed.
[00:17:50] Stacey Richter: I'm gonna oversimplify because I think you said this very well. Currently in physician training and maybe the way that a lot of physicians think about it, they think about the one patient in front of them, and how do I best take care of the one patient in front of them, or how do I take care of my patient panel?
And we have very few, listen to the first show [EP404] with Dr. Suhas Gondi about how many physicians are actually on the boards of hospitals, right? It's a shockingly small number. And if there's not doctors up at that leadership level, it all sort of trickles down in a kind of suboptimal way at the bedside.
[00:18:25] Ben Schwartz, MD: Yeah, I think it's at the leadership level, and, and there's certainly doctors at the leadership level in different, you know, payers, health systems, what have you. I think the question is, and another kind of area of friction and where we don't get along is oftentimes once you cross that chasm, you know, the MD suddenly means something different, and you're not seen as, you know, a colleague anymore. You're just kind of seen as the enemy. And in some cases, maybe that's fair. In some cases, it's not fair necessarily.
But if we're gonna put physicians in leadership positions, congress, you know, payers, health systems, whatever it is, you know, how do we maintain that connection with sort of the broader medical community and not label that person as the enemy?
And how can that person keep in contact with the rest of the medical community and sort of, you know, be seen as somebody that can bridge that gap between those two worlds rather than as somebody that sort of left that behind and is now, has a different set of incentives that are not aligned with their physician colleagues?
Dyad Leadership Done Right
[00:19:24] Stacey Richter: I feel like we, we've pivoted, thank goodness, from the doom scroll portion of this conversation to the, "All right, now how do we fix this?" portion of the conversation.
So our, our first kind of piece of advice here is how do you do dyad leadership, let's just call it that, in a way such that the clinical leaders who are upstairs have that connectivity with the bedside.
You said something the last time [Episode 481] which really stuck with me, that there's a very, very... it's a very different view one foot from the bedside than 10,000 feet from the bedside.
How do we ensure that they don't wind up just kind of getting sucked into those palatial C-suites and then wind up kind of losing the role that they were supposed to have?
[00:20:10] Ben Schwartz, MD: Yeah, and it's not easy. It's not easy to bridge those two worlds because they each have their kind of, you know, challenges and they each have their expectations, and they're both valid, right?
And if you have somebody that's trying to, you know, bridge both of those gaps and understand both of those things, you know, hopefully having lived it on the clinical side and bringing some of that to the administrative side.
But at the same time, you do have different incentives and you do have different pressures, and it's hard to walk that line and not have one side feel like you're favoring the other side. It's not an easy thing.
I think it's about garnering trust with the clinicians because you have that experience, you can speak that language, and you can have their best interest in mind.
But at the same time, you know, doc just blanket agree to everything that they say and automatically assume they're always right because you came from that world. But help them understand, yes, I understand this doesn't make sense from the clinical perspective, but here's why we have to think this way from maybe more administrative perspective.
We say that in value-based care too, right? Of, you know, yes, in some ways this feels like, you know, driving clinical decisions from a nonclinical standpoint. But at the same time, there's a good reason behind it. And be able to justify that and be able to, you know, bring evidence and data, be able to speak the language and say, "This is why we're doing it the way that we are."
It's not driving a clinical decision, it's just trying to do what's best for the patient in the, in the best way, the most cost-effective way.
[00:21:29] Stacey Richter: So let's consider that our first piece of advice. Let's be deliberate about how we are leading, making sure that there are physicians in leadership roles doing the dyad leadership and doing it correctly.
Physician Led MSOs
[00:21:40] Stacey Richter: The second thing is, and you had alluded to this earlier, this is what I wrote down, figure out how to come up with new models that are possible even in the healthcare industry that we currently have.
[00:21:53] Ben Schwartz, MD: Yeah. There's a lot of attention now on corporate practice of medicine, so I think a lot of people feel that the next version of independent healthcare is probably not going to be smaller practices.
[[00:22:06] Stacey Richter: Do listen to episode 529 with Dr. Eric Bricker, where we talk about how much more consolidated health systems can manage to get paid for the same services as independent practice. Also, here is a recent post by Christopher Habig on this exact point.]]
[00:22:26] Ben Schwartz, MD: It's hard to remain independent and be successful.
And so there's this idea of you know, strength in numbers, economies of scale, which I think are beneficial if implemented properly with physician leadership.
So MSOs kind of are controversial in terms of this management structure and can you aggregate doctors together in numbers to get the benefits of an MSO structure without some of the sort of extractive things that we've seen in some of the, you know, investor-backed MSOs.
And I think the answer to that is yes, it's challenging to do it because you have to get, again, physicians rowing the same direction. There's governance issues in bringing doctors under one roof. But I think these newer models sort of walk that fine line of independence, but also kind of consolidating physicians together, but maintain that physician governance and leadership and not have somebody else with an ulterior motive kind of running it.
[00:23:20] Stacey Richter: So MSO, managed services organizations, and what we've got going on there is that somebody is managing the services, not necessarily like within the physician group. And there's two ways that... There's two structures there. One of them is that it is owned by private equity owns that managed services organization, and then the other one is that it is a physician-led organization.
[00:23:44] Ben Schwartz, MD: The concept itself is neither positive or negative. It's really in the implementation of it. And so if you have somebody that's giving those management services, they're taking a management fee and they're providing capital, but they're also, you know, they have equity and they're looking for an exit over a timeline, you know, then it tends to be less successful or then kind of the structure is a bit different as opposed to, look, there's physicians leading it, there's physicians owning it.
They're not looking to sell this to somebody else. They're not on some timeline. They're just looking to develop, stand up something that takes some of that business pressure off of the physicians, allows them to practice medicine the way that they wanna focus on practicing medicine, but take some of that administrative burden, that business management burden off of them, but in a sort of a non-extractive way or in a way that's not looking to eventually sell you to somebody else.
[00:24:36] Stacey Richter: Andrew Tsang said this very crisply [Episode 521]. How you get paid fairly in this current healthcare industry is you have to have leverage. And how you have leverage is you have numbers. You have bigger numbers negotiating on your side of the table. And so you can really see that there's definitely a structural impetus to gang up, but there's two different ways that you can gang up.
One is with an MSO. That is all the things that you just said. It's probably physician-led. The goal is to support the physicians that are part of that MSO.
And then there's this other model, which is pretty extractive. If you go online, you can listen to a lot of very sad stories of doctors who sold their practices, you know, being promised a second bite of the apple, right, and then never got it, and it's just not good.
So there's sharks that are swimming in these waters. Just if you're gonna do the MSO route, just make sure you thoroughly investigate from what I'm hearing.
[00:25:32] Ben Schwartz, MD: Yeah. Like I said, I mean, I think the concept has merit. It's really in the implementation of the concept.
ASCs and Site Neutrality
[00:25:38] Stacey Richter: Another thing that has come up is ASCs, ambulatory surgical centers.
What's your... You know a lot about this one.
[00:25:46] Ben Schwartz, MD: Yeah, for sure in orthopedics it seems to be working, I mean, for hip and knee replacement surgeons because of the cuts that we're facing. I think most people feel at this point that if you wanna have any hope of maintaining independence, that you have to have some ownership in a surgery center that's doing some of these higher acuity cases and getting a distribution from that center for, to offset some of the declining reimbursement.
More and more care is shifting to the ASC setting. The regulations are supporting that. CMS is getting rid of the inpatient-only list. They're adding more procedures to the ASC appropriateness list. They're really putting it on physicians to determine who's appropriate for the ASC and who's not appropriate for the ASC.
And so I think that is becoming a means of maintaining independence, and it's not just for orthopedic surgeons or total joint surgeons, it's for other specialists that can do procedures in an ASC outpatient setting, and that's becoming a larger and larger number of procedures.
And it's good for the system. I think they're lower costs, sites of service. The studies show they deliver equal outcomes, safe care.
Direct Contracting Frontier
[00:26:51] Stacey Richter: Talk to me about direct contracting, which just continuing my track record, my streak of making sure direct contracting comes up in every single Relentless Health Value episode. As a way forward here, what do you think about direct contracting between the two sleeping giants?
Right? Like, you've got the employers on the one side who are waking up, two awake giants maybe, and then physicians who are like, "Wait a second, the middle is so messy that if I just contract directly with the employers, we can work together.”
[00:27:23] Ben Schwartz, MD: Yeah. The middle is messy, it's expensive, it's complicated, it adds that administrative burden.
So I think everyone that is interested in this type of thing, and I'm sure most of the people that listen to this podcast, are bullish on direct contracting.
And we talk about it a lot, and I think it's been successful in pockets because it does remove that middle layer. It allows for that direct relationship between the person delivering the care and more or less the person receiving the care, or at least somebody that has the incentives that are, should be aligned with the person receiving the care.
And so I think there's a lot of potential there. I think it will be, in a lot of ways, the next frontier for independent practices as a way to kind of stave off some of the administrative complexity and declining reimbursement that we're seeing in the traditional system. To go direct to employer, you know, negotiate fairly for the cost of, or the value of what you're doing, and do it in a way that's, that the contracting is, can be more straightforward.
I think that the key is to build up the supply side and the demand side and to make sure that the volumes are there to support it, to make it something that realizes that potential.
[00:28:27] Stacey Richter: Yeah. And that's a big... We had Dr. Steve Schutzer on the podcast [Episode 294] He's an orthopedic surgeon. He spent all this time and effort standing up a rather large practice that could take direct contracts, could not get any employers to buy it.
[00:28:42] Ben Schwartz, MD: Yeah. That's a common, common thing. You know, I spent some time working on that in you know, a prior position as well and you know, we loved those patients. I think the patients loved us, too. I think the employers loved us. But it's complicated. Employers are fragmented. You might have 100 employees here, 100 employees there.
And how you bring those things together to make it worthwhile for everybody and have those conversations, I think we're still trying to figure out.
[00:29:06] Stacey Richter: I said something the other day about just how there's a lot more resources that are available to help self-insured employers do direct contracting. Dean Jargo made a funny comment about this on LinkedIn. He, like, underlined it and he said, "Yes, there are.”
Whenever you have a two-sided market, it's always this, like, someone's always ahead of the other in any given... And it's also local. It's very local.
[00:29:28] Ben Schwartz, MD: Yeah. Necessity is the mother of invention, and obviously we know that healthcare costs, insurance costs for employers have, you know, again, for the fifth, tenth, whatever consecutive years, reached a breaking point. But it does feel like it truly has become the breaking point.
And same thing on the, you know, the supplier side for physicians of, okay, there doesn't seem to be a viable path forward anytime soon for me to really reverse the declining reimbursement. But here is a pathway where I could probably negotiate with somebody, because you really don't negotiate with CMS, and it's very hard to negotiate with a commercial insurance company. Easier, in theory, to negotiate with employer who's motivated.
And I can say from the physician standpoint, used to go to orthopedic meetings even three or four years ago, and this wasn't on anybody's radar screen. Now you go to meetings and there's at least several sessions on it, and there are people that are doing it well and have set it up well and put the time and effort in and have success doing it.
Going back to the competitiveness and the FOMO of hey, somebody's doing this, they're successful, and they can present that, then it gets me thinking, "Well, why am I not doing that?" Same thing, same pressure that makes you go start doing robotic surgery is going to make you more open to, you know, direct contracting and working with employers and not just dismissing it as something that's not worthwhile because it's a tiny book of business, but you put the effort in to, to make it a, a bigger book of business.
[00:30:48] Stacey Richter: I never thought I would hear FOMO and direct contracting in the same sentence, but welcome to Relentless Health Value.
Collective Action Options
[00:30:55] Stacey Richter: So the last maybe way forward here, and I'm gonna say this carefully, is collective action with physicians. Maybe think about how you're gonna work together, band together, and gain leverage within the existing model.
And there's been a lot of talk about unionization. I think there was, for the very first time in the Twin Cities, there was a doctor walkout, which was a big deal. But as you contemplate what the potential is or the not maybe, or the watch outs for collective action amongst physicians, what are you thinking?
[00:31:31] Ben Schwartz, MD: Yeah. I think it's about, again, trying to put aside your differences as much as you can to realize that we're all facing the same structural issues to some degree. Maybe different degrees and maybe in different ways, but we have sort of this overarching, you know, lack of autonomy, declining reimbursement, increasing administrative burden, you know, feeling of burnout like that affects all of us.
And coming together, however you wanna define it, I think we have to do that. If we don't do that, we're gonna continue to stay fragmented. It's gonna be very easy to, you know, continue to push us to the margins or to not give us a seat at the table, because at the end of the day, it comes down to leverage and strength in numbers.
So maybe it's unions, maybe it's some sort of organization that physicians can actually get behind and support and put aside their differences enough to realize, again, we don't have to agree on everything, and we all have our own challenges, but we also all have challenges that are common to all of us that would be beneficial for us to be able to figure out a way to work together on those things.
Knowledge Is Power Close
[00:32:32] Stacey Richter: I am encouraged to hear what the ways forward are. There was a bunch that you listed.
[00:32:39] Ben Schwartz, MD: It's, you gotta start kinda nudging the giant, and I think from the physician standpoint, that is the simplest thing is just educate yourself, understand what's going on, take an interest in it and that's how you start.
And then you go from there. Not everybody, you know, needs to go to DC and lobby, and not everybody needs to get an MBA and try to, you know, become an MD MBA administrator. But I think just educating yourself on what's going on around you is the first step. And, you know, sharing podcasts like Relentless Health Value or, you know, keeping your ear to the ground is the first step. Knowledge is power.
[00:33:14] Stacey Richter: I love how you said that. It's knowledge is power. Awareness is power. Trying to figure out how to work together and advance toward a better future.
[00:33:25] Ben Schwartz, MD: Unfortunately, it's the reality is it's not enough anymore to just think that being a doctor is head down practicing clinical medicine. It's also being aware of what's going on around you and getting involved in some degree, or at least being educated in some degree.
[00:33:40] Stacey Richter: As Dr. Bricker said, relative to employers, no one is coming to save us. Like, no one is coming to save us. So if anything's gonna happen here, it needs to be the individuals who desire change picking up a torch
[00:33:53] Ben Schwartz, MD: We've proven in other areas of our lives that when we put our minds to it, you know, we can do difficult things. We just need to put our mind to doing this difficult thing.
Where to Find Ben
[00:34:02] Stacey Richter: Is there anything I neglected to ask you that you would like to mention here, Dr. Ben Schwartz?
[00:34:06] Ben Schwartz, MD: I feel like our conversations are always stream of consciousness, which is great because I think there's always, you know, more questions than answers.
But thinking about these things I think is important. And so I don't think you always have to have the answers, but I think you do have to think about them.
[00:34:21] Stacey Richter: If someone is interested in learning more about either your work or your excellent Substack or your posts on LinkedIn, where can they find you?
[00:34:31] Ben Schwartz, MD: Yeah. Come to LinkedIn or The Surgeon's Record is the name of the Substack.
[00:34:36] Stacey Richter: Thank you so much for being on Relentless Health Value today.
[00:34:39] Ben Schwartz, MD: My pleasure once again.