What Your Healthcare Provider Assumes You Already Know

[0:00] So, welcome back everybody to the PTCH Podcast. First of all, I think it’s fair to say thank you everybody who has supported us. It’s been way better than we thought. Yeah, it’s really amazing. Glad that you’re getting value out of this. So, keep participating. Today we want to introduce a segment — a series that we should do every once in a while. We’re going to call this “Need to Know.” And it’s based on things that we as practitioners see that patients need to know, things that they just aren’t

[0:31] well understood and they can be important to your health. So today the thing that I think that you need to know is about your rights as a patient and the fascinating history of informed consent. I can’t wait to hear this. And I’ll be letting you know about all the little things you wondered about Medicare Advantage, Medicare supplements, why they’re good for you, why they’re bad for us. Ooh. And if you stick around until the end, you will get to see us play a game about some of the weirdest diagnoses known to man. What

[1:01] happens when a chiropractor and a physical therapist get together to make a health and wellness podcast? Chiropractors and physical therapists don’t like each other. Oh, think again. I’m Dr. Kathy Lynch, physical therapist who likes to help people move and get stronger. I’m Dr. Jason Young, an evidence-based chiropractor who uses humor just as much as adjustments to help people get better. Welcome to the PTCH Podcast. Remember, there’s no I in PTCH. All right, this — I think this episode is a true test because these are incredibly — like they could be very dry topics. Like I would not sign up for these topics if

[1:31] I was going to, like, continuing education. But if we can deliver this in a way that’s interesting and entertaining, then I think we’ve really done it. And if I say the word “interesting” more, then that makes it more interesting. Yeah. I’m glad you agree. See what I mean? Okay. Very interesting. There we go. The more you repeat a lie, it becomes the truth. Wow. Does that happen in the world today? Is there anywhere where we see that in public? Okay. No, you chose to talk about a topic that

[2:01] sounds painfully boring. Okay. Sounds like something that’s slightly less interesting than the tax code. Okay. What were you thinking? All right. So, I chose to talk about something called informed consent. And if you’re in healthcare, you know exactly what this is. And it’s just like — it’s not a very interesting topic, but if you’re not in healthcare, this is something that’s actually really critical to understand. So informed consent is basically the idea that as a patient, you have the right to know about the treatment that

[2:33] you’re going to receive. Isn’t that crazy? Yeah. Yeah. So, you have the right to know about the treatment that you’re going to receive, and you have the opportunity to ask questions, and you have the opportunity to say, “No, I don’t want to do that. I did not know that.” Yeah. Yeah. So, you know, it seems crazy to us here sitting in the 21st century in our 21st century podcast studio. Thank you, Cinematic Solutions. Oh, no —

[3:05] he’s going to turn off my video again. Oh, shoot. No. There it goes. And he’s gone. I’m in Cinematic Solutions jail. Okay. No, we love Cinematic Solutions. Better than anything. Yeah. So, yeah. So, here in the 21st century, we don’t really think about this because it’s just like, oh yeah, I have the right to do whatever I want. But not so long ago, people didn’t have this right. It wasn’t seen as a right. Yeah. So Kathy,

[3:36] I did not — would you like to know the history of this? I’ve been dying to hear about this. Oh, that’s good. So, have you ever heard of the Nuremberg trials? Yeah. Okay. So, World War II — the Nazis, have you heard of them? Yes. Okay. You’re not supposed to talk about Nazis, but they were bad people. We can talk about them in that context. Yeah. They did some really bad stuff and they got in trouble at the end of World War II, and there were these Nuremberg trials and everything like that. One of the things that came to light was that the Nazis were doing evil research — bad stuff. They

[4:08] were doing things where they were torturing people and they were trying to test the limits of human physiology, and it was horror-show-level stuff. Okay. And so then out of that we get something called the Nuremberg Code. Okay. Where basically there was some international agreement that for the purpose of research, you can’t do stuff that’s going to harm people, right? Seems like a good thing. It is. It is a good thing. It’s something that’s

[4:38] good that was born from something that was legitimately horrible, right? And then the other — another thing that’s kind of similar to that, another kind of landmark — I don’t want to say faux pas because that minimizes the atrocity of it — but have you heard of the Tuskegee studies? Yes. Okay. Yeah. So another example of something horrible. So, if you don’t know about it, the Tuskegee

[5:08] experiments were experiments that they did on 600 African-American men who had syphilis. Well, not all of them had syphilis. Some of them had syphilis, some of them didn’t, but nobody was told whether they had it, and they weren’t given proper treatment even though at that time penicillin was known to be a good treatment for syphilis. Almost like even a cure, right? Yeah. So

[5:40] this treatment was withheld from these people and they wanted to study what is the natural course of this disease. And it didn’t just affect the people who were in the study — it also affected their families, because some people ended up giving syphilis to their partners and it was passed on to children, and so it destroyed a lot of lives. It was evil stuff. Yeah. It’s pretty dangerous. And as a result of that, we got more rules in terms of what is and isn’t

[6:11] ethical in the world of research. So those are important things. Okay. So the other thing is the Belmont Report. This was a document in American bioethics that was written after the Tuskegee study. And the purpose of this was to guide ethical conduct of research involving human beings. And so there are three key principles that they focused on. One of those is respect for persons. Okay. Now, when

[6:41] you look at like, well, what is a person, right? And there was this idea that was born that people should be what’s called an autonomous agent. Okay. Do you have an autonomous agent? I think so. I think I met her last night. Okay. Yeah. So, no. But an autonomous agent is basically the idea that you can act on your own behalf. Yeah. But can everybody do that? No. No. So what are some examples of people that can’t act on their own behalf? People under the age

[7:11] of 18. Okay. Yeah. So children. Yes. Right. Yeah. Kids don’t always know what to do. No. Yeah. If you don’t believe me, just go out and make you one. No. I just bumped up the birth rate. Anyway, no. So yeah, kids are a great example. If you have somebody who has a disability, prisoners are another example because prisoners don’t get to choose where they are and what they’re doing. And so there’s the idea in this that these are people

[7:42] that deserve additional protections under the law. And so informed consent is a mechanism of just kind of respecting people’s autonomy, right? You’re a person. Yeah. You have rights and opinions and abilities to make your own choices. The next thing is something called beneficence. Oh, beneficence. Yes. And I practiced saying that. Yeah. I did a bad job on the other B-word, right? The name of this report, the Belmont Report. Yes. So, but

[8:14] beneficence. Oh, I’ve got that. So no, but the idea of beneficence is what we think that we’re getting from insurance companies — and we’re going to get to that — but it’s the idea that we want to maximize possible benefits to people while minimizing the possible harms, right? And that makes sense, like when you’re going for healthcare, you want to get the most out of it. Like we want doctors to be doing the best for us. And it kind of incorporates this idea, like the

[8:44] Hippocratic Oath. Yeah. Not be a hypocrite. Yeah. Right. So — oh no. It’s the oath of Hippocrates. Which I think is funny because there’s a lot of people who are like, whenever they see a doctor messing up or something like that, they’re like, “But you took the Hippocratic Oath, right? Oh, I did. I shouldn’t have done this.” Right? Or sometimes when people are like, “Oh, you’re a chiropractor. You didn’t take the Hippocratic Oath.” You know, and it’s like, okay, well, the thing that’s kind

[9:16] of interesting is a lot of doctors don’t take the Hippocratic Oath. And if you do take the Hippocratic Oath, great. And if you don’t, also great. But it’s an oath, right? Doesn’t stop people from being bad, but whatever. Can we go on a tangent here for a second? Yeah, let’s do it. I thought I was on it. If you — No, I got it. It relates to what you just said. Do you know what the acronym NARD is? No. Shout out to my friends Diane and Cat who taught me this acronym. What’s NARD?

[9:46] NARD is Not A Real Doctor. Oh my gosh. Yeah. Well, there’s a reason. So, we’re both NARDs. There’s a reason that I don’t know that acronym. Okay. Yeah. Yeah. If you don’t take the Hippocratic Oath, you’re a NARD. You’re a NARD. Okay. Yeah. All right. NARDs. Anyway, gosh, that reminds me. Should we rename the podcast? Yeah, the NARD Podcast. Hey, can we re-roll those credits? Yeah. So, all right. So, but the idea

[10:20] of beneficence is basically what people think they’re getting from the Hippocratic Oath. And part of the reason we don’t need that oath is because we have this Belmont Report. We have this idea of informed consent. So basically, if you become a healthcare provider, there’s this unspoken expectation that you are not going to try and harm your patient. No burpees. Oh, it’s a callback. We did a callback. Okay. Burpees. Nope. So that’s the second part of this. And then the third part of it is justice. And justice — I mean, it

[10:52] doesn’t seem like anything was left out of those first two pieces — but justice is the idea that there should be a fair distribution of benefits and risks. So if you come to see me for healthcare and somebody else comes to see me for healthcare, I should not expose you to more risk than some other person based on, you know, the amount of money that you have, the type of insurance coverage you have. We’re going to get to it. We’re getting

[11:22] there. Or any other thing. So we have the right to fair treatment and we have a responsibility not to give vulnerable populations unfair exposure. Right? So, like that Tuskegee study — those people were given unfair exposure, and in part it’s because they were minorities, they were poor, they were being paid to participate, but they weren’t being given informed consent, all the information they needed. So a lot of this comes

[11:54] from a research background, but what we want to look at is what does it mean in the world of healthcare today. So something that I have come across that is horrifying to me is, when I sit down with patients and I explain, okay, this is what you have going on, this is what a spine looks like, these are the things that we’re treating, and this is what you can expect in terms of — if you were to get this treated, if you were to do nothing — and here are your treatment options, here are the risks,

[12:24] these are things that could go wrong, these are things that could go really wrong, and then I give them an opportunity to ask questions — sometimes I have a patient who’s like, “Wow, I’ve never had anybody break it down to me like that.” Yeah. How do you feel about that, Kathy? Well, I hand him a piece of paper and just — you just sign it with like the 10 other pieces of paper on there. Okay. Yeah. But I mean, do you have those conversations with people? Yeah. About — yeah. And on that piece of paper, that information’s on there, right? Yeah. And it seems like it’s pretty basic, but one of the

[12:56] reasons we do that is because we’re good healthcare providers and we want to give people good healthcare. The other reason we do it is because, well, it’s the freaking law. Yeah. Right. You’re required to get informed consent. Yes. So I’m shocked to find the number of people who don’t think that they have a choice. They aren’t told about any sort of alternatives. Right? So, a great example is when people come in and they’re like, “I have to get surgery.” Right. My doctor told me, “I have to

[13:26] get surgery and that’s the only thing that’s going to help me.” And you’ve heard this, too. Oh, yeah. Is that typically the truth when people are like, I have to get surgery? No. No. Absolutely not. Is surgery an option? Absolutely. Definitely right. But what they don’t even know is that before they have to — before they’re supposed to go get this surgery — a lot of times that protocol is to try conservative care, like four to six weeks of conservative care. So they’re going to go see a physical therapist. They’re going to go see a chiropractor. But it’s

[13:57] presented to them in that — the end result of this is going to be surgery. Correct. That’s not really fair. No. Because you’re not treating people like an autonomous agent, right? Correct. And so that is a very, very important thing to understand. And so I could go through all the basics of this is what has to be in the informed consent, right? But if you’re just the average person listening to this, you don’t need all those, right? Here’s what you need. You just need that feeling in your heart. Right?

[14:28] So, here’s what I mean by that. You need to feel like when you’re sitting down with your healthcare provider that you have options, right? That it isn’t just, “Okay, this is what you have going on and this is the only thing that’s going to help you.” Chiropractors are guilty of this. Physical therapists are guilty of this, right? Surgeons are guilty of this. And I don’t think that it’s just because there’s bad doctors or bad providers. I think that there’s people

[14:59] who are overwhelmed, overworked, and they just — it’s like, we’ve got somebody waiting in the next room, and so we got to wrap this up. We gotta wrap this up. And that’s what people are thinking when they’re like, “Man, the informed consent part of this sucks. Like, why am I still —” Nobody’s listening. No. So I can say whatever I want, right? But it’s such an important thing. So when I say the feeling in your heart, I mean it. So if you’re sitting there and you’re talking with a doctor, provider, or anything like that and you feel like what they’re presenting to you is your only option,

[15:30] you can do a few things. Number one, you can ask, “What are my options?” That’s probably the first best question. That is a great question. And you might notice a look of surprise. “What are your options?” And if they tell you that your options are just to like be in pain and die, then the next question you ask is, “Do you think I should get a second opinion?” Where’s the exit? Yeah. Exactly. Right. And if it’s a good provider, they’ll

[16:01] be open to the idea because good providers, they want to participate with other healthcare providers, right? Yep. And so I’ve had people ask me that and I refer them to you. Yeah. But I’m only kind of kidding. Yeah, I do, because there’s people who are like, “I don’t want to get an adjustment,” or, “I don’t believe in chiropractors,” or whatever it is, and they’re like, “Well, do you think I should get a second opinion?” I say, “Yeah, I think that’s a great idea,” because I’m not worried about that. I feel solid about my diagnosis or

[16:31] whatever. So yeah, go talk to somebody else. Yeah. And if that’s a better thing for you, then do that, right? Yeah. And then the other thing too is you should have the opportunity to ask questions. And one of those questions that you should always be asking, even if you feel like you have a good understanding of what you’re going to be doing and why, is what are the risks? You know, what could go wrong? What are the side effects? And if they say there’s no side effects, that’s not true. No. Right. There’s side

[17:01] effects to everything. Yeah. Again, ask for the exit. Yeah. And that’s not to tell you that every single treatment that you want to do is dangerous or difficult, or like there’s nine or ten really terrible things that could happen. Some treatments are extremely safe, right? Like, I feel like what we do is very safe, right? But I still tell people, like, if you get an adjustment, you might get sore afterwards. You could get a headache, right? There’s a very, very small risk that you can have a fracture or dislocation or something

[17:31] like that. But your doctor, your provider should be talking to you about those things. So they should be giving you a diagnosis, or at least a — “This is what I think is going on.” They should be telling you, “These are the things that I think that you should do.” Here’s the risks. Here’s the advantages. Here’s what happens if you do nothing. And they should give you an opportunity to ask questions. And then at the end of all that, they shouldn’t just jab you with the needle or shove exercises in your hands. They should ask you, “Would you like to

[18:01] do this?” or “Can we proceed?” Some people do this. Some people just do like a blanket, “Hey, we’re going to have you sign this whenever you are doing your initial paperwork,” and everything like that, and that checks the legal box off. But anytime somebody is going to have a change in their treatment plan — like, “Hey, we’re going to start using this therapy,” or “You’re going to start using this medication,” or taking this supplement — we need to go through that process of gaining informed consent. And that protects patients. And it protects

[18:34] them not by avoiding problems, because the risks are the risks whether you know about them or not, but it protects patients from being abused. Right? You’re not in that Tuskegee experiment. You’re not in a concentration camp. You are an autonomous agent. And that’s all I have to say. Well, I think also in our culture, doctors are seen as an authority, right? We’re not really supposed to question authority and we’re supposed to take what they say as the gospel. Doctor

[19:05] knows best. Absolutely. I think they call that patriarchal healthcare, right? Oh, yeah. That sounds about right. Down with the patriarchy. Up with the matriarchy. Yeah. Whatever female doctors say, just listen to them. Just do it. Don’t even listen. Just do what they say. Don’t question that. You don’t need informed consent. No, no, no, no. But okay, I learned something there. I feel better. Do you? I feel better. Yes. Thank you for letting me get that

[19:35] off my chest. I feel like that’s something that people need to — I think I really do feel like that’s an important thing for people when they walk into a doctor’s office to know that, you know, they’re in charge. Yes. You know, the doctor’s there to give them advice. You’re asking their advice. You can take their advice. You don’t have to take their advice. So, and no doctor should pressure you into doing something that is good for you. Now, I think that if you have a good relationship with your doctor and your doctor is really kind of

[20:06] stressing a point, you should listen to that if you have a good relationship with them. Right. Right. And they’re like, you know, I really think that this is a good idea. It’s because they care about you. And you are asking for their educated advice. Yeah. Oh, what’s the worst though? You know the worst, right? Is when somebody’s like, “Oh, really? You think that? Well, I saw online — Google said.” Google said. Yeah. Well, I don’t know. I found some exercises on YouTube. Don’t

[20:36] trust anything that you see on YouTube. Yeah. We’re not telling you to disrespect your physician. I think we’re on YouTube. Oh, we’re on the YouTubes. Yeah. Okay. Well, the example that I give is, you know, when people are like, “I heard that if I have a headache that medicine is good for a headache, and so I’ve been taking medicine and now I have breast tenderness.” What’s the medicine I’m taking? Birth control pills, right? And it’s like, just because it’s medicine doesn’t mean

[21:06] that it’s good, right? And it’s the same with any treatment, right? Oh, I had back pain, so I decided to do exercise. So, what exercise are you doing? Well, this is why you need a professional, right? Is to help you kind of zero in on what’s the right thing. Mhm. Yeah. Now, to kind of segue to what you’re talking about, one of the frustrations that I have in the world is that informed consent doesn’t really mean anything if you’re working with an insurance company, because your

[21:38] doctor can have a great treatment plan. They can explain it to you, you know, the risks and everything like that. And then when you go to execute that treatment plan, if your insurance company is involved in the payment of it, the insurance company could say, “It’s gonna cost us a little too much, and so we want you to — you should mess around some.” Yeah. Oh, you could have side effects. Yeah. But this is spendy, so let’s just do some side effects. Okay. You could just do this at home. Yeah. Exactly. And so insurance

[22:10] companies, they like to step in the way of that doctor-patient relationship sometimes. Insurance companies are not all bad. No, but they are. And — No. Okay. They’re not. Health insurance is a good thing. They pay us barely, but they pay us. Yeah. But basically, a lot of people don’t realize that in our country, health insurance companies practice more healthcare than doctors. And they’re not even licensed. They’re not — last time I checked. No, they try to get around it with those guys on the phone that are peer reviewers. Peer

[22:41] reviews. And you know, I know some people who have been peer reviewers. And I’ll tell you, they don’t last long. Yeah. You won’t find somebody who’s like, “Well, I’ve been a peer reviewer for 25 years. Best job ever.” Yeah. It’s — Yeah. It’s like, “I feel like I was really helping people.” No, they don’t feel like they’re helping people because they’re kind of given a script on what to do. Quota. There’s quotas out there. So, tell us about insurance. Well, what I wanted to

[23:11] talk about specifically today is Medicare, and I want to explain the difference between Medicare Advantage and Medicare Supplement. So, let’s start with what you know — Medicare has different parts. So Medicare Part A, it covers all of your hospital stays, inpatient, those kind of things. So what we’re going to talk about, what I’m going to talk about is mostly Medicare Part B, which covers all of your

[23:41] outpatient visits. So the visit to your doctor, blood draw, those kind of things. That’s Medicare Part B. And Medicare Part C, quote unquote, is Medicare Advantage. And then of course — am I confusing you yet? No, I’m good. Well, but you should tell people who gets Medicare. Oh, people 65 years and older. But there’s other cases where you can get Medicare if you’re younger and have a disability like ALS. If you have ALS,

[24:11] they’re going to put you on Medicare. Yep. Yeah. I mean, you got to fight tooth and nail to get it, but you’ll eventually get it. Can I just point something out? Now, this is not a political podcast, but I want to point out that you have already said more than certain people who have been appointed to very high-ranking government health positions know about Medicare. Yeah. And yours is 100% accurate. And it’s appalling to see that somebody else’s — not going to be named, but you can Google it — was 100% not.

[24:42] Yeah. Jeez Louise. Yeah. So, yes. Okay. So let’s just recap. So Medicare Part A — that is hospital stay. Hospital stay. Yeah. Medicare Part B is outpatient. Outpatient — when you go to see your doctor, when you get blood draws, if you have other services, dialysis, those kind of things, where it’s a day trip in and out basically. That’s me overgeneralizing. Medicare Part C is Medicare Advantage. That sounds like the deluxe stuff. Yeah, it does, doesn’t it? Like if

[25:12] I’m over 65 and I want, you know, breast augmentation or something like that, I need Medicare Advantage, right? I want to get that LASIK surgery, right? I want to get the hair replacement. I think this is where Medicare got marketers involved. Are you telling me that’s not in Medicare Advantage? That part is not in Medicare Advantage. And then what’s this Medicare Supplement? Yes. It’s for when you need to get some vitamin D or magnesium. Yeah, you need some Metamucil

[25:43] fiber in your diet because you’re over 65 and a half or something. Does sound like it to me. So, Medicare Supplements — actually, you can only — so that is not true. Okay. So I just busted that myth. This is why you’re talking about this part and I’m not. So, you have to choose — you can choose between Medicare Advantage coverage and Medicare Supplement coverage. And so I’m going to just list some of the things. I’m going to go down a list of what Medicare

[26:14] Jason: Medicare Advantage covers — and then I’m going to contrast that with what Medicare supplement does. So when you turn 65, you know, you get all these marketing newsletters, phone calls — like, what are you going to pick?

Kathy: Yeah. You don’t have to wait till 65. I’m already getting —

Jason: 40? Hey, I’m not even 48 years old yet. I get like three or four calls from like New York and Mumbai every single week. “Oh, hello, Mr. Young.”

Kathy: Yeah. Which one do you —

Jason: And I say I’m 47 years old. “Oh, we’re very

[26:44] sorry.” Okay. We’re very sorry. All right. So, Medicare Advantage. Yes. Okay. Medicare Advantage replaces original Medicare. That’s not relevant at this moment, but it replaces original Medicare and often includes Part D prescription coverage.

Kathy: Yes, prescription coverage. Everybody loves it. Very confusing, right?

Jason: Mm-hmm. Yeah. A, B, C, and D.

Kathy: That’s right.

Jason: So, if you get a Medicare supplement plan, it does not include Medicare Part D, but

[27:16] it supplements original Medicare. Okay. See where we’re going with that?

Kathy: Yeah. So, is it — is a Medicare supplement kind of like privatized Medicare? And so is Medicare Advantage

Jason: as well — they’re both offered by private companies. So, like Blue Cross Blue Shield, Pacific Source. Mm-hmm. Yeah. United Health.

Kathy: Oh, you said it now.

Jason: I did. You didn’t make me say it. Yeah. Sorry. Regence.

[27:46] Okay. So Medicare Advantage is more of a managed network. Okay? So it typically uses a network of doctors and hospitals, and if you go outside of that network, you have to pay a little bit more. Medicare supplement generally has no network restrictions. You can see any doctor that takes Medicare, for that matter. Here’s where we get into the cost. Medicare Advantage — usually their premiums are very, very, very low.

Kathy: Yeah. And this is where they get you.

Jason: Yeah,

[28:16] and that’s how they get you — you might have a copay, coinsurance, and deductibles for services. Medicare supplement typically has a higher monthly premium, so you kind of pay more upfront, but you usually have less out-of-pocket costs when using the services, right? Like I said before, Medicare Advantage usually includes prescription drugs — that’s Medicare Part D. If you have a Medicare supplement,

[28:46] you have to purchase a separate Part D prescription program. Okay.

Kathy: You keeping that straight?

Jason: I got it. Yeah. By the time I’m 65, I’ll forget it. But they’ll probably change it — or Medicare might not be available.

Kathy: Mumbai, though — she’ll fill me in.

Jason: So Medicare Advantage — they will offer additional benefits: vision, dental, those kinds of things, all under their one plan. Supplement does not cover that. You usually have to find another company where you can get vision and dental. Okay. So,

[29:19] and the reason these exist is to give people options, right?

Kathy: Yes. So it’s like, if you’ve got a little extra money

Jason: yeah,

Kathy: in your retirement and you want to make sure that you’re very well taken care of, then you can crank up the health insurance.

Jason: Exactly. There’s some Medicare Advantage — and I think supplement — that actually will cover chiropractic too, right?

Kathy: Mm-hmm. Sure. Let’s not share that though.

Jason: Okay. No, I’m just kidding. Yeah.

Kathy: Yeah,

[29:49] it does. Yeah, it definitely does. Yep. And I know of some that actually had visits for acupuncture as well.

Jason: Yeah. Well, and I think that the thing that’s kind of cool about this is that, you know, if you want more, you can get more with one. And if maybe you can’t afford more, you’re still taken care of, right? Which is good, because everybody pays into Medicare. If you were working, you pay into Medicare. And so it’s like later on in life, you’re taking that benefit out, right? So

[30:19] that’s good. So let’s get into the nitty-gritty here. Okay. So how do you choose, and why would you choose one over the other?

Kathy: Right.

Jason: How do Medicare Advantage — how do those insurance companies make money with Medicare Advantage?

Kathy: Well, sometimes I think they’re the only people making money.

Jason: They are the only ones. I’m not. No. Here’s how. Exactly. And here’s the point about that. What Medicare Advantage companies do — so, let’s say Regence, right? They will bid to

[30:50] Medicare and they will say, “Hey, I think it’s going to cost us $12,000 to care for Jason this year.” And so Medicare pays them $12,000 for your care. And so they are now incentivized to pay out as little as possible

Kathy: yes,

Jason: for your care. And so how do they do that? It’s this thing called prior authorizations.

Kathy: Yes. Yes.

Jason: And prior authorizations basically — your

[31:20] doctor has to beg and grovel for permission to run a test that he thinks — or she thinks — is medically necessary. And so the doctor will send in, “Hey, I think this person needs an MRI because they can’t move their arm.” “No, no, no, no, no. I think they need 6 to 8 weeks of physical therapy before we give them that MRI.”

Kathy: Well, because how expensive is an MRI?

Jason: Not that expensive. Yeah. Well, compared to physical therapy.

Kathy: Yes.

[31:50] Right. So physical therapy might be a bit of a cost savings, but sometimes they’re like, “We don’t want to do both. Surely they don’t need

Jason: yeah,

Kathy: both.” Right. Let’s not do both there. Yeah. So Medicare Advantage — they are incentivized not to. And so, for example, I had a patient who had a total knee replacement, which is pretty laborious rehab. And she got 12 visits

Jason: mm-hmm,

Kathy: for a

[32:21] post-op, which is probably like eight more visits than you need, right?

Jason: Oh my god.

Kathy: Anybody out there that’s had a knee replaced —

Jason: yeah,

Kathy: I mean, you need ongoing care for 3 months. Yeah. And 12 visits is going to get us through about 6 weeks.

Jason: Yeah, because you have to get them — you have to be in there early moving that knee.

Kathy: Yeah, and getting them strong. And so 6 weeks is not going to get it done. Well, and I’ve never had a knee replacement, and I don’t have a lot of experience — like, I have patients who have had them, I have friends who have had them. But if I was thinking about getting my knee replaced,

[32:53] just outside of the whole idea of, you know, let’s get strong and everything like that — what does a normal thing look like? Like, that’s scary. Like, so I’m just mostly going to be sitting there on my own just trying to figure out how to get my knee better?

Jason: Guess what people are doing? Sitting there on their own trying to get their knee better and googling.

Kathy: Yeah. See, and I know stuff.

Jason: Yeah. Right. But I would still be very uncomfortable with that. Like, I want to make sure that there’s some sort of professional helping me through that process and, you know, looking at me

[33:24] trying to move my my bionic knee, trying to attach to the Bluetooth in it with my phone. Right. It’s like — so I can see if the battery needs to be changed, or I don’t know how that works. Here’s a hint. There’s no Bluetooth. So there’s a problem. That’s why — why do I want that knee then? I want a better one. That’s why we — why can’t we just have people do their own rehab from — see, now this was part — this is not part of the informed consent. I want — I specifically wanted the one with Bluetooth. But no, actually, like when I think about that, and I haven’t given this much thought

[33:54] before, but that’s terrifying. It is terrifying. And this poor patient. So I had to go back and tried to grovel. Can I at least get six more? Like half? Yeah, more. No, she can be doing these exercises at home is basically what they told us. So this poor, you know, woman is — and I am — we are communicating. Yeah. Outside the lines. Yes. Trying to help her. But yeah. Well, and here’s — here’s the terrifying thing. Yeah. For providers is, let’s say that you

[34:27] decide, you know what, I just really want to help this person out, and so I’m just going to — I’m just going to do it for free. I’m just — I’m just going to do it for free. What can happen to you? Go to jail. Yeah. You can literally go to jail. Yes. For giving people free care because you don’t feel like they’re getting enough. That’s right. That’s stupid. It’s not right. Yeah. You can go to jail for giving free stuff to people who we should be charging Medicare. And most people don’t know this, right? When I found out, I was like, “Pump the

[34:58] brakes.” Doctor, what is it? Too late for me to get like a job in front of me or something like this, cuz — yeah. And it’s why a lot of providers don’t want to work with Medicare. Yep. But what’s the fastest growing segment of our population? People over 65. Yeah, that’s right. So, let’s transition to Medicare supplement, which I find less evil. Okay. So, the costs are higher out of pocket. Yes. In the beginning your premiums are

[35:30] higher. Yes. You don’t really — but you don’t pay a lot of co-pays usually, co-insurance, things like that. And how do they make money? They make money with their premiums. Yes. Right. So they are incentivized to make your care less costly, but at the same time there’s usually little to no prior authorization. Yes. Because they’re making money off of selling their plan. Yes. Yeah. And so there’s, you know, you have to look at both sides

[36:01] of how you want your healthcare to look. Do you want it micromanaged? Not just managed, but micromanaged. Do you want your healthcare provider to be able to make a decision? Exactly. Do you want your healthcare provider to be able to make the right decisions with you, or do you want that, you know, Seth down in Ohio making that decision with you? Yeah. Drinking a Coke. Exactly. Not a diet Coke even. He’s sitting there drinking Coca-Cola. Right. He probably graduated from Ohio State.

[36:35] Oh my gosh. Yeah. Yeah. Don’t get me started. So, that’s my rant on Medicare Advantage and Medicare supplement. Well, and here’s a — and here’s a crossover here, right? Cuz part of this whole Belmont report — you have these three things, right? You have — what were they? Respect for persons, beneficence, and justice. What you just talked about doesn’t sound like justice. And the issue is if you

[37:05] have Medicare Advantage because you can’t afford a supplement because maybe you had a job where you didn’t put away stuff for retirement, or whatever — that’s not justice. Like, you have to choose to have somebody try and do your care on the cheap. Even though you’re getting some help, right? And the thing that’s crazy with it, and this is part of why our healthcare system is such a train wreck, is if you have more

[37:36] money or less money — who’s a bigger burden on the healthcare system, and I don’t like that word, right, that it’s a bigger burden — who uses it more? It’s people who don’t have money, right? They can’t take care of themselves and they have less access to care, and that whole problem just gets bigger and bigger, snowballs. Yeah, it does. They can’t get preventative care. So, if everybody would just go get their spines adjusted. That’s what I heard very, very often. No,

[38:07] I’m just kidding. No. Well, and it hits us too because — I mean, it’s — we’re really fortunate that chiropractic is included in Medicare. We fought for years to be included. Here’s the crazy thing. According to Medicare, there’s only three possible problems that a person can have. That’s joint dysfunction of the cervical spine, thoracic spine, or the lumbar spine. Those are the only three diagnosis codes that we can bill to Medicare, and there’s only one service that’s covered, and that is a chiropractic adjustment.

[38:37] Wow. Yeah. So, there’s been a lot of fight to change that, and hopefully it improves, but then the reimbursement for it is incredibly low. It’s the lowest — it’s the lowest paying insurance out there, and you’re required to bill it. Yep. Or you’ll go to jail. You’ll go to jail. Yeah. And we’re not joking about that, people. It’s like — it’s literally — people go to jail. And is that what we want to be doing, is throwing healthcare providers in jail?

[39:07] I guess so. And as small business owners, it’s hard to explain sometimes to the patients, you know, why we’re discontinuing taking their insurance. Like, we literally take a loss on your visit. Yeah. We love you. Yeah. But we also got to pay the rent. It’s so hard. Yeah. You know, and so don’t be mad at us. Please be mad at Medicare. Yeah. Well, and we look greedy. Yeah. We do look greedy, cuz I drive a really nice 2008 Honda Ridgeline with a busted passenger — what happened. Yeah.

[39:37] Someone saw that. Yeah. Somebody busted my window when I was up at this like Oregon Chiropractic Association convention. Yeah. In Portland. Yeah. Some dude — some criminal mastermind busted my window and tried to buy a carton of cigarettes. Okay. On his electric scooter. Oh, he got — well, no, he didn’t get it. Oh, he did. Yeah. He got denied and I called up the place and they knew who he was, which is funny. Yeah. He’s not smart. Anyway, okay. If you’re out there listening to this, I won’t say your name cuz court case pending. This

[40:08] just turned into a crime episode. Yeah, it did. To catch a predator. No. But yeah. And so here’s the other irony of Medicare is if you and I were both in the same profession — let’s say we’re both physical therapists because I want to feel good about myself for a minute. And I was like, “Hey Kathy, how much are you charging for, you know, therapeutic exercise?” And you’re like, “I’m charging this amount.” I was like, “Oh, okay. We can go to jail.” Yeah, we could go to jail. Yeah,

[40:38] That’s illegal. It’s called collusion. It’s price fixing. We cannot do that. However, it’s exactly what Medicare is — 100% — because when you look at how insurance companies reimburse, they do it based off of a percentage. It’s called a relative value unit. There’s even an official name — an RVU, like an abbreviation for it — and everything. And all healthcare costs are based off of some derivative of what

[41:08] Medicare reimburses. And so if you’re wondering why healthcare is so expensive, it is not because of greedy doctors. No. It is because Medicare says this is how much this is worth. And then insurance companies say this is the percentage of that that we’re going to pay. And then at a greater level, 60% of the cost of healthcare is hospital administration, healthcare administration trying to figure out how you can squeeze as much as possible out of those insurance companies. Mhm. And

[41:40] meanwhile, like if we were doing prehistoric healthcare, you know, a hundred physical therapy sessions might be worth like three pretty shells and a chiropractic adjustment might be worth like half of a rock or something like that. So what we see with healthcare is we’re not seeing the real price and value of services. We are seeing what Medicare has set up as essentially price fixing. And this is my last episode. The government’s coming.

[42:10] They’re going to throw me in jail for this.

Kathy: Yeah.

Jason: But I love you all, and I thank you for having joined us for — all — what is this, seven episodes?

Kathy: Yeah.

Jason: And it’s infuriating and I don’t know what to do to fix it, but these are things that we think that you need to know. These are definitely the things you need to know.

Kathy: Mhm.

Jason: Yeah. So maybe one of you is smart enough to fix it. So Kathy, I think we said at the beginning we’re like, this is going to be a short episode.

Kathy: Yeah. We’re — oh, like we don’t have much to say.

Jason: But I think now that everybody’s

[42:41] gone to bed, maybe we should play a little game.

Kathy: Oh, man.

Jason: All right, let me see. Okay, here we go. So I actually did a pump fake on you, because in the outline I put like a different title for this game, but it’s a completely different game. All right, so this is a game called Name That Code. Now, one of the —

Kathy: Yes.

Jason: Okay. So one of the things that’s interesting about healthcare and health

[43:11] insurance is when somebody has a diagnosis, there is a code that is attached to that diagnosis, and these codes are agreed upon across all healthcare. So Kathy uses the same codes that I do, and we use the same codes as a hospital down the road and everything. And so it just standardizes things. Now, this latest set of codes that came out is extremely detailed and there are codes for like every freaking thing. Okay.

Kathy: ICD-10.

Jason: ICD-10. Yeah. And so in this game, I’m going to read an ICD-10

[43:42] code — and don’t worry, I’m also going to give you a clue. Okay.

Kathy: All right.

Jason: And you’re going to try and guess the diagnosis. We’re going to see how close you can get. Okay. So it doesn’t have to be word for word, but I’ll give you an example. I’m just going to give you it for round one. Okay. So the ICD code is W61.62XA. Okay. And the clue is: you went to feed the ducks and you left with trauma. Okay. And the answer is: struck by a

[44:12] duck, initial encounter. There is an ICD code for getting hit by a duck.

Kathy: Yes. Literally, there literally is.

Jason: All right. So, you ready to play?

Kathy: Let’s give it a shot.

Jason: So I’ve got nine of these and we’ll see how you do. Okay, so we’re just going to run through these real quick. All right, ICD code V — as in Victor — 95.43XA. You probably already know this one. Clue: when a Tesla isn’t enough and you need intergalactic collision insurance.

Kathy: Struck by a meteor.

Jason: Oh, pretty close. Spacecraft collision, initial

[44:43] encounter.

Kathy: All right.

Jason: Next one. ICD code Y — as in Yankee — 92.241. It was all going fine until the chandelier fell off during Figaro.

Kathy: Swinging from a chandelier. Oh, that would be a good one.

Jason: But it’s actually: hurt at the opera.

Kathy: Oh, yeah.

Jason: Okay. Next one. The code is W22.02XA. Clue: this is why we don’t text and walk.

[45:16] Kathy: Karen — let me think about that one. Can you repeat the — this is why —

Jason: Oh, you wanted the code. I know. This is why we don’t text and walk.

Kathy: Oh. Tripping over a fire hydrant.

Jason: Oh, very close. Walked into a lamp post, initial encounter. All right. W55.21XA. The cow says moo. And then the cow says yum.

[45:46] Kathy: Knocked over by a cow.

Jason: Oh, so close. Bitten by a cow.

Kathy: Oh, yep. Yes.

Jason: Next one. V — as in Victor — 97.33XD. You survived the jet engine and came back for more.

Kathy: Sucked in by a jet engine.

Jason: Let’s go. Subsequent encounter. Yes. That’s what the D means.

Kathy: Yes. Exactly.

Jason: All right. Z63.1. This is an amazing one. Okay. Sometimes the biggest health threat is

[46:18] Sunday dinner.

Kathy: Dinner with your in-laws.

Jason: Oh my gosh, you guys. Are you serious? Problems with in-laws. Yeah.

Kathy: Woo!

Jason: Okay, man. That’s a win right there. Okay, here we go. Bonus round. R46.1. Clue: there’s no dress code for the ER, but maybe there should be.

Kathy: Strangled by a belt. I think I’ve actually been diagnosed with this.

Jason: It is bizarre personal

[46:48] appearance. Can you believe that?

Kathy: All right.

Jason: Two more. T63.443A. Spider attack. Possibly an accident. Possibly an assassination attempt.

Kathy: Spider attack. Charlotte’s Web.

Jason: This is toxic effect of venom of spider. Okay, here’s the best part. Undetermined intent.

Kathy: Undeter —

[47:21] Undetermined. Undetermined intent. We don’t know why the spider did it. We don’t know why the spider was trying to poison you.

Jason: Yeah. Spider’s been taken for interrogation.

Kathy: Okay, one more.

Jason: All right. You’re already a winner. So, okay, here we go. This is Z — as in zebra — 99.89. You’re addicted to your iPad. You’re just device dependent.

Kathy: Dizziness and silliness due to over-iPad

[47:52] use.

Jason: Sorry, that wasn’t even close. Here we go. Dependence on enabling machines and devices not elsewhere classified.

Kathy: Oh, so yeah.

Jason: All right. Hey, but very good. The ones that you nailed — like the in-laws one — that was epic.

Kathy: Oh jeez, that is a win just based on that.

Jason: Okay. Woo. All right, that is enough. This is now officially our longest episode ever. How did we do this? Going to be the shortest.

Kathy: Yeah. It’s probably also the best episode for insomnia.

Jason: Yes. So yeah, I know. I’m going to be using this heavily. Heavily. Anything about Medicare. All right.

[48:23] Well, thank you, Kathy, for all of your research and insight. I know I learned some things about Medicare supplements and everything. If you have things that you want to know about, leave it in the comments of one of these episodes, wherever you happen to stumble across this podcast. And there’s probably an ICD code for tripped over the PTCH Podcast. Yeah. Is there an ICD code for can’t speak English as a first language? Okay. But yeah, so if you

[48:54] have things that you want to know about, leave it in the comments. We’re happy to talk about it. Thank you so much for all the support that you’ve given. And anything that you want to say in closing as we sign off? One last thing. What is it? There’s no “I” in PTCH. Okay, good. Oh, yeah.

[49:24]