Venkatesh Ramnath
Appearances
Behind the Bastards
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I could take a stab at it. I'm not a health policy wonk, but I am a physician that has to deal with Medicare all the time. So Medicare, in sort of general terms, is a type of health insurance that is provided by the federal government. It is almost exclusively for individuals above the age of 65, as it dates back to the 1960s with Lyndon Johnson's Great Society program.
Behind the Bastards
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coverage for any individuals above that age such that all their medical services or products you know whatever they need for their health care is actually covered by the government this is the federal government now the interesting thing about medicare is that there are different parts to it there's part a which is primarily for some essential services and includes hospital care but
Behind the Bastards
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There's Part B, which includes whatever physicians' fees go into that health care. And then there's Part D, which relates to pharmaceutical prices, so your drug costs. It's not comprehensive in the sense that there's always something more that individuals need, but Medicare... for all intents and purposes, is the sort of standard, and it should cover most of an individual's needs.
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Now, that said, the commercial payers, that is the other insurance companies that are not federally government-sponsored, take their lead from Medicare. So a lot of the different payment rates
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or coverages and services, they all look to what the centers of Medicare and Medicaid services dictate as far as what is an acceptable reimbursement rate, what are the rules around what should be covered and what should not. So that's why Medicare is such an important entity for the United States.
Behind the Bastards
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Let me add to that. So, you know, telemedicine has been around for a very long time, at least technically speaking, right? I mean, you can go back to the 1970s, even when you talk about the intensive care unit, which is where the sickest people in the hospital are. There are studies that come out of the 1970s.
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However, ever since people have had iPhones and been on Airbnb and everything else since 2007, that inflection point actually had a wave of opportunity that washed right into medicine. And as Kaveh is saying, we have such a fragmented healthcare system
Behind the Bastards
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that has folks living in rural areas, suburban areas, and urban areas, all of whom are at the mercy of what specialists may be there contracted at any given time for any given specialty. Now, telemedicine, as it's gotten more and more popular, has kind of leveled the playing field. I mean, you can be in...
Behind the Bastards
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rural place like where I'm sitting right now on the U.S.-Mexico border, or you can be in New York City, one of the densest populations, but you might not have access to specialty expertise without telemedicine. With telemedicine, you can now have access. And I've seen patients love it. You can deal with the sickest of the sick, like I said, intensive care units.
Behind the Bastards
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But you can also have outpatient experiences. And we've seen a number of different commercial opportunities that have leveraged that. But the point is that as we're hearing on this, it's become sort of a standard operating procedure for how we deliver health care. And if you just pull the rug out from that, there can be some unintended consequences to that that are not insignificant.
Behind the Bastards
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Yeah. So basically, the sort of this convoluted way that we pay for services is it looks to one standard, even though some may argue, how did that standard come about? But regardless of that, Medicare is the central authority that basically tells everyone this is what we should be doing and this is how much we should be paying for it.
Behind the Bastards
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Now, the commercial insurers can decide to exceed that if they wish. If they, say, have an employer whose employees they want to have a special contract with, that's fine. That's not restricted. But the bottom of what is considered a reimbursable amount is really set by Medicare. And so they move the bottom. And so if you drop the bottom,
Behind the Bastards
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you can pretty much well assured in this, you know, in a capitalist, you know, sort of mentality that the costs should go down, right? I mean, why should you pay more for something that you don't need to, right? And we see that every year, okay? Every year there's new technology, but the slightly older technology, which is, again, covered by Medicare, they move those reimbursements down.
Behind the Bastards
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So whether it's a sleep study, you know, for someone with obstructive sleep apnea or difficulty sleeping at night, or it's some ophthalmology technology, or it's some ultrasound machine, it doesn't really matter what it is. Medicare is always trying to minimize costs, which is understandable. They want to make it cost effective, but they are setting the lead. So everyone will follow what they do.
Behind the Bastards
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That's kind of the way that our system is sort of set up.
Behind the Bastards
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I do want to add something here, and I do want to be careful about the term, because telemedicine and telehealth are not only sort of a catch-all, but they're sort of used interchangeably, right? And just like anything, you have to be specific about the term. So I think what we're talking about on this podcast is telemedicine in terms of a two-way audiovisual technology.
Behind the Bastards
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interface where you can have a direct face-to-face consultation or interaction with a practicing practitioner. Usually that's going to be a physician, but it may be a nurse practitioner or other physician extender, we call them. But just to be clear, telemedicine also extends to
Behind the Bastards
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other types of devices like wearables, those things that they're either, you know, trackers that you can wear as your Fitbit or a sleep device, you know, that you can wear around. Those kinds of things are kind of put into the telemedicine bucket and And it's not clear to me, at least, how that is going to change.
Behind the Bastards
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I think April 1st is when the face-to-face coverage from a professional fee standpoint, that is slated to end because they did liberalize it during the COVID pandemic. And it's been extended, I think, another year around that. And that will definitely change the dynamic here. But it's not clear how much of it extends to other types of remote physiologic monitoring services and products.
Behind the Bastards
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Yeah, it's a tough time, certainly. And coming out of the pandemic, this is not what really anybody expected. But the stresses have been mounting for quite a while, right? Healthcare professionals are seeing and feeling more stress at work, whether it's the demands of the job, meaning that there are fewer resources to spend on a heightened number of patients with increasingly complex diseases.
Behind the Bastards
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Mm-hmm. Or even just the questions that we are getting from patients. A lot of patients now are asking me really financial questions. I mean, literally the other day, I had a woman who was unfortunately having septic shock and was faced with having to amputate her leg. And I was speaking with her husband because she was becoming more and more delirious.
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He was just asking me about, well, I'm going to have to sell my house in order to fund what might come down the pike as far as being at home with services. I was trying to get an understanding of how he viewed his wife actually going through the thing that we're watching in the moment.
Behind the Bastards
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But it's a preoccupation that has taken up a lot of space in the room, and it's now coming on to physicians to sort of navigate at least some questions and answer those questions around it. So that's a long way of saying that physicians and nurses and other healthcare professionals are feeling more and more stress in a system that's just buckling, right?
Behind the Bastards
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And the last thing anybody needs is to be having to do more without really a clear... understanding of the purpose around it, right? And we are all for cost effectiveness. We want that to work. We also want to provide care irrespective of someone's religious, political, or other beliefs. And yet, you know, we have to work within a system that we kind of
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are not really understanding how they're approaching this issue. Are they with us or against us or somewhere in between? It's sort of a moving target. And so I think that's what's kind of sandwiched a lot of healthcare professionals. And we don't really know where to turn for some of the answers that we ourselves are looking for.
Behind the Bastards
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It's sort of a vexing question because I think some of this is... Let's be clear. Some of this is on our messaging. As healthcare professionals, I mean, there are more and more articles. In fact, there was a Wall Street Journal piece a couple weeks ago that was saying how patients are increasingly not trusting their doctors. And there are data to say that we don't communicate very well, right?
Behind the Bastards
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So there is that, and that's on us. Mm-hmm. And, you know, another op-ed piece in the Boston Globe by Ashish Jha, you know, did a mea culpa around some of the things that public health, we did wrong. We got it wrong in COVID where we didn't, you know, deal with some of the doubts and lack of evidentiary base for masking and some of these other things that basically hurt us in the end.
Behind the Bastards
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So there's definitely that. However, you know, restoring the trust in healthcare professionals is, is sort of like a basic step to anyone getting their health care. I mean, I think people still go to their doctors. Most people still trust their doctor to some degree. And I think that that's at least a bright spot in where we are. Because when we've lost that...
Behind the Bastards
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I think we're we're really in trouble. I mean, it's slipping, but I think that there is a way to to restore that trust. But it starts so that it just starts with a conversation. You know, if someone has a vaccine hesitancy or they don't understand what's going on, that's the opportunity to open the doors to a dialogue conversation.
Behind the Bastards
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And I think maybe that's, you know, maybe that's the starting point for any of this. We all want cost effectiveness. We all want, you know, transparency. We also want to have choices that make sense to us, but let's not make it an adversarial confrontation. And I think that that goes for both sides.
Behind the Bastards
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That's a hard question to answer. I would say, let me back up. You know, I think that the COVID pandemic Yes, there are a lot of things that went well. The vaccine development was phenomenal. I mean, revolutionary. Who would have expected that to happen?
Behind the Bastards
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However, it also just revealed how shattered our public health system really is in terms of messaging, even detection, spreading information, even the vaccine distribution. was completely chaotic, right? So I don't want to say that, you know, the public health response during COVID was some sort of paragon to be emulated or replicated, right? So that said, though, absolutely.
Behind the Bastards
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I mean, you know, how are we going to handle a new era of this what-if scenario where we don't know what virus is coming next. I mean, I'm seeing these days, I'm even seeing viruses that never caused the kind of respiratory failure in the past. They're doing it now, whether it's RSV, the respiratory syncytial virus,
Behind the Bastards
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or even non-COVID coronavirus, which should just give you a cold, the sniffles, and yet it's causing devastating, you know, pneumonias. So we're in a new era and, you know, antibiotic resistance is not getting any less, you know, problematic. So what do we do in this era? Well, I think awareness is the first thing. OK, awareness around. Yes.
Behind the Bastards
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I mean, these diseases are transmitted from person to person. You know, we all know somebody who doesn't want to take a vaccine. I mean, I don't think that's a surprise to say we know of somebody or directly or maybe one degree of separation. Right. And I think you need to have those community conversations. You need to have one on one conversations.
Behind the Bastards
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Yes, it's going to be uncomfortable, but we got to talk about it and talk to your health care provider about it. I mean, yes, you can look up stuff on TikTok. Yes, you can look up stuff on Google or you name your online resource, but you want to have a person that can actually understand from years of living and breathing this stuff
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and also who listens to you as a human being in the same community or somewhere nearabouts, right? To put together what the science says in some sort of meaningful way to you and not some anonymous, you know, resource that may or may not have all the, you know, all the data at their fingertips, you know? So, so I guess it still goes back to how does anyone find reliable information and
Behind the Bastards
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Where do you go when you've got questions? Most people want a human being who's lived and breathed this with experience to help them navigate. I certainly see that not just as a doctor, but as a friend, as a family member. I mean, I constantly, you know, they're asking me these things.
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And I would suggest that, you know, your audience may have connections both personally, but also professionally to those folks that can help them navigate.
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if I could just follow up with that. I think part of what will help with the support for some of these programs is to take a few minutes to think about what the other side is worried about, right? I mean, we all know about
Behind the Bastards
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The excesses of certain online bad actors who are telemedicine, they use telemedicine to promote, you know, ADHD medications or other types of psychotropic medications, which was not it was not supported and it actually caused harm. Right. So so there are things out there that are excesses. and somewhat harmful.
Behind the Bastards
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And if we could, as a community, sort of help frame the approach to dealing with some of those things and preventing some of those problems, then I think some of the support will kind of sort of show itself. I think the worry is if you open up the floodgates too wide, human nature being what it is, it's going to encourage bad behavior.
Behind the Bastards
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Not that anybody wants that, but there is something to be said about some scrutiny, right? So if we're the ones, and I completely support the use of telemedicine, but I also want to be careful about how to promote its thoughtful and safe use and wed that in the proposal and not just leave it for others to figure out. That I think would potentially...
Behind the Bastards
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change the conversation around, well, you just want this and we're not going to give it to you. Like the standoff will subside when you try to work a partnership out as opposed to a give it to me or else kind of scenario.
Behind the Bastards
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Okay. Well, thanks, James. I have a sub stack. It's called Be a Health Architect. You can look me up at Be a Health Architect. And I have a conversation there around an issue that certainly affects me and those around me, which is physician burnout. But in the larger sphere of healthcare professionals, it really touches everybody in healthcare. So that's where I'm posting actively.
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I'm also sharing that through various other avenues, such as X and Blue Sky and other places. You can find me there. I look forward to seeing you there.