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  • Writer's pictureRebekah Bernard

The High Cost of Healthcare with Marion Mass MD - Part 1

We all know that the health care system in the United States is expensive, with the U.S. spending more than any other developed nation. Although it’s convenient to scapegoat doctors as the reason for high medical costs, the truth is that physician compensation makes up just 20% of total health spending. So, who is really responsible for the astronomical cost of health care today? To get some answers, we are joined by Dr. Marion Mass, a pediatrician and the co-founder of Practicing Physicians of America.

In part 1 of this series, Dr. Mass explains how Pharmacy Benefit Managers (PBMs) have benefited from safe harbor from anti-kickback statutes, allowing them to reap millions of dollars and increasing drug costs for Americans.

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Rebekah Bernard MD 0:07

Welcome to patients at risk, a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard. And I'm joined tonight by a special co-host, Dr. Roy Stoller. He is a fellow board member of physicians for Patient Protection and he is sitting in for Dr. Niran Al-Agba. We all know that the health care system in the United States is very expensive. And with the US spending more than other developed nations, why is that? It's convenient to scapegoat doctors, and that's what we always hear - doctors are just so expensive. But the truth is that physician spending only makes up 20% of all health care spending in the United States. So who is really responsible for the high cost of health care today? To get some answers. We are joined by an expert, Dr. Marian Mass. She's a pediatrician and the co-founder of practicing physicians of America. Dr. Mass Welcome to the show.

Marion Mass MD 2:05

Thank you for having me.

Rebekah Bernard MD 2:07

Dr. Mass, can you start us out by just talking a little bit about yourself and your background and how you got interested in health economics?

Marion Mass MD 2:14

I'm a pediatrician, I went to Duke medical school and I trained at Northwestern. Interestingly, I initially was going to be a researcher and I fell in love with clinical medicine. I really love taking care of people. And then when I had my children, we moved back here to where I grew up in Pennsylvania, they did a lot of hospital work at the time. And you know, when you're busy with a young family, you don't think about these things, you're burning the candle at all ends. And we have three and for years, and I sort of woke up, maybe when the youngest was out of diapers, and I said what happened in medicine? And it didn't take long for me to understand that like as physicians, we have lost all control. And it just didn't make sense to me. So I started unwinding. And I'm a pragmatic person, everything's about the money, right? So follow the money. And I started that. And then I sort of accelerated things, and the only child to there's four brothers that I have noticed very, very close to my mother, she did a lot of volunteer work, a lot of community work, she was just a very good salt of the earth person. And the medical system humiliated her when she was hospitalized. It was just, it was a comedy of errors. And it just felt like an abject humiliation and I'm not the kind of person to take things sitting down. And I knew how to play the game. And I was frankly shocked at a large accoladed hospital, this could happen. I almost looked upon it as a call to action for me. Because I thought to myself if this happens at an accoladed Hospital in the setting of good Medicare Advantage insurance, with an advocate for a daughter who's not going to take anything sitting down, what's happening in the middle of Detroit, to someone who doesn't know, who doesn't know how the system works, who doesn't have good access to begin with? And that's why I do what I do. So I started pushing even harder to uncover who's making all the money in medicine.

Rebekah Bernard MD 4:07

And I think we're gonna get down to a lot of the nitty-gritty of that tonight. And it's interesting you say, you know, if physicians don't understand it, how can patients understand it? And to be honest with you, this is something that we hear from a lot of our colleagues, you've been doing a lot of writing about pharmacy benefit managers, or PBMs. And they definitely seem to be involved in a lot of the cost of health care. But there are so many different middlemen and different sort of convoluted ways that they make money, that sometimes it gets a little overwhelming for us just to understand. So can you break it down and explain about PBMs: what they are, how they work, and why they're a problem?

Marion Mass MD 4:45

Sure, it may take a little longer than a couple of sentences, pharmacy benefit managers -PBMs - they were initially created because you understand there's a lot of Americans that are on medications and they were meant to be able to administrate the prescription benefits for Americans. So you could think of them almost as the insurance companies for the prescription benefits very simplistically. And you know, when they were first formed, they were their own freestanding entities. And there's been a lot of consolidation and multiple ways over time.

Rebekah Bernard MD 5:21

So everybody that has health insurance, health insurance that pays for their doctor visits for their hospitalizations for their surgeries, and then they have a certain amount of coverage for medications. And then the idea is that these pharmacy benefit managers are the intermediary between the patient and the pharmacy for our patients to get their drugs, is that correct?

Marion Mass MD 5:44

That's a very good way of putting it. So you know, as I said, they almost become the insurance agent and the administrator for those medications. And you're right, the go-between the patient, the pharmacy in there, so on and so forth. But then, over time, what happened was insurance companies needed to decide just like they decide what doctors are we going to cover, you know, what doctors are going to be in our network? Well, what they call the network for, you know, Pharmacy Benefits is called the formulary. So in other words, most of us know, as physicians, like if I'm writing a medication for a patient because they have swimmers ear, I write the medication, but really the only medication that the patient's going to take is the one that is covered. And that is the one that is on the formulary, the list of drugs that the insurance company has approved. And it's the pharmacy benefit managers that are creating those formularies. And one of the things that I like to advocate about is that formularies are created by these pharmacy benefit managers, but in one of the most gigantic perverse incentives in all of healthcare, the pharmacy benefit managers are allowed to take monetary remuneration from the manufacturers.

Roy Stoller DO 6:58

So how did that happen, Marion, and if you're making on what I get from you is that this was supposed to help patients in a way? that was the intent is that - am I correct about that?

Marion Mass MD 7:07

I don't know. What about this would have helped patients because it's just such a gigantic conflict of interest. I don't know what anyone could have said that would have said, Oh, it's a good idea to have the pharmacy benefit managers be able to accept money from the manufacturers when they're the ones that are putting drugs on the formulary. Like, for instance, imagine if you, as a surgeon, were allowed to pay off the insurance company, and you could then be like, the only ENT on in the network in a certain given location. I mean, then you'd have all the patients right? Same thing is happening with the medications that are covered by Americans.

Rebekah Bernard MD 7:44

It would be like a monopoly- like patients wouldn't have any choice, they would only have to see Dr. Stoller. Now, granted, he's a very good ENT, but maybe they want to see somebody else. But I see what you're saying. So basically, they've been allowed to create this monopolistic system in which patients are only allowed to take the drugs that the pharmacy benefit managers have allowed on the formulary, and they are getting a lot of money back themselves. Can you tell us about how that works?

Marion Mass MD 8:11

Well, I do want to actually just rephrase something, they would say the patient is perfectly able to take medications, not on the formulary. However, with the costs being as they are, most patients are not going to choose to do that the pharmacy benefit managers are making an extraordinary amount of money. And I guess I want to backtrack and say, when you start trying to uncover costs in the healthcare system, what jumps out at you is there's a lot of costs that you can't see, you can't discover it. It's almost like you're, you're shooting in the dark. And you can only see a portion of the information here and a little portion there. For instance, you know, the pharmacy benefit managers must be making off like bandits, because if you look at a few examples of what we do know, there's been a lot of mergers between pharmacy benefit managers and insurance companies. So for instance, Cigna bought Express Scripts as one of the big pharmacy benefit managers, when Cigna bought Express Scripts, the revenues tripled. So you say to yourself, aha, these pharmacy benefit managers are obviously adept at making bank. But as I will explain in a few moments, you can't see the amounts of the bank that they're making in each of the little ways that they make bank. Another example just so that you don't think it's one on one but one of the other big three pharmacy benefit managers besides Express Scripts is CVS Caremark and they are of course owned by CBS. CBS also owns Aetna because they happen to have 16 billion-plus dollars lying around by Aetna, CVS. 60% of its revenue comes from its PBM as pharmacy benefits manager. So you say yourself, wait a second. This is a company that owns at now one of the biggest insurance companies in the world, but you just told me Dr. Marion mass that 60% of its revenues is coming from its benefit man. You're not it's an insurance company, not its brick and mortar stores from this benefit manager. So the next question that everyone should ask is, how do these pharmacy benefit managers make their money? Well, we already discussed the fact that they collect kickbacks from the manufacturers to make the formularies. Dr. staler, you asked how these companies got the right to receive money from the manufacturers, which is a kickback. And we know it's a kickback because it was created in 2003. As an exemption to the anti-kickback statute, you know, people in America aren't supposed to be able to receive kickbacks, it's illegal.

Rebekah Bernard MD 10:37

Let me just stop you here. I'm just I'm really sorry. I don't mean to be ignorant. But what you're saying is, correct me if I'm wrong, that the drug company approaches the pharmacy benefit manager, and it says, Hey if you put my drug on your formulary, I'll give you money. Is that right?

Marion Mass MD 10:53

Well, I mean, I'm not present in the room at the time.

Rebekah Bernard MD 10:56

Is that the idea though? Like when you say -

Marion Mass MD 10:58

Yeah, exactly.

Rebekah Bernard MD 10:59

You mean, you guys, are there wheeling and dealing like, you give me this And I'll give you that, you add me onto your formulary, and I'll work some arrangement for you.

Marion Mass MD 11:08

Absolutely. So and actually, there are people that have sort of told some others how it works. And what they tell us is the pharmacy benefit managers contact them and say, you can tell us what percentage you want of the market share. So in other words, if if you have a drug that takes care of people's anaphylaxis, like injectable epinephrine, if you want your injectable epinephrine like maybe epi-pen to be almost all of the market share, you will pay something to have epi-pen be the brand name that's on the formulary. Shocking, right. Or like if there are eyedrops that you have for conjunctivitis, like a comment, like when children get that we'd be gunky, I that some bacteria in there. And they need eye drops for that. And you want your drug to be the one that's on the formulary that everyone is using, you can pay the pharmacy benefit manager, and then you what you're seeing is -

Rebekah Bernard MD 12:03

It's not a free market system, or it's not a system where like a contractor would bid a price, and then whoever gets the lowest bid would get a job. It's more of wheeling and dealing and negotiations where it's not about getting the best price necessarily. It's about making the best deal.

Marion Mass MD 12:20

Some people call it 'pay to play.' Worse yet, of course, like initially, when these kickbacks were allowed in 2003. By giving them an exemption to the anti-kickback statute, there was supposed to be a percentage of the cost of the drug. And they were supposed to be capped at 3% of the cost of the drug. So that of course, as you imagine, the higher the cost of the drug, the people choosing and making a formulary. Like if they pick an expensive drug to put on the formulary, they're gonna get a bigger kickback. So the people that are making the formulary are also perversely incentivized to pick a more expensive drug.

Rebekah Bernard MD 12:56

Wow. So what was the rationale behind allowing those kickbacks to be legal in this situation?

Marion Mass MD 13:03

I don't know. It makes absolutely no sense to me, we would have to go back and I believe the HHS Secretary at the time was Tommy Thompson, this is under George W. Bush. And he's now on the board of remarkably of Centene, which has part ownership in their own PBM. You know, it's remarkable how this all works.

Rebekah Bernard MD 13:23

So basically, it's like a political wheeling and dealing it sounds like to me and it doesn't sound like patients when, but it doesn't also sound like there's the political will to put a stop to this. I know you've been working on that. What are you hearing from politicians or different people that you're speaking with about the issue?

Marion Mass MD 13:42

Well, I think the pharmacy benefit managers, and we'll talk in a moment about all the other ways they make money because none of it looks really very good. It doesn't pass what you know, people call the sniff test the whiff test, right? It just doesn't smell good. What's going on there when we talk about kickbacks, essentially, for a long time to get their drug on to the preferred list. And then they had a monopoly. And there's lots and lots of monopolies across America, we have a series of monopolies it's, it's called them enough money, the whole system. So the big pharmaceutical companies are winning, of course, you know, the PBMs themselves are winning. And now that there's been all this consolidation with insurance companies buying the PBMs, then they're winning too. So no one wants to change the system. So the politicians will be like hemming and hawing. And they'll say, but now that the insurance companies own the PBM, they have us over a barrel because they'll make the premiums go up. If we take away their kickbacks, they'll just like they'll undercut us in another spot. So we can't do that because they'll make us suffer. They'll make us look bad. Of course, I'm like, dude, you're all bad. You're terrible if you don't get rid of these kickbacks.

Roy Stoller DO 14:52

You know, Dr. Mass, what's incredible in your articles, you talk about vertical integration, and I am absolutely I'm amazed that now they're hiring practitioners and not even physicians who are now employed by the sister companies of these PBMs. And the whole thing just is crazy how all the money is exchanging hands from practitioner to PBM, to insurance company. Is this why you think health care costs are so out of control?

Marion Mass MD 15:21

Oh, well. So with the vertical integration, you have a whole welter of conflicts of interest. So it's not just the kickback in the formulary, but the pharmacy benefit manager makes a little cut of each prescription, you know, so they also take their fees. And remember how I told you, you couldn't see how much the kickback was? Well, you can't see the fees either. So the pharmacy benefit manager pulls away their amount from the insurance company who now owns them in many cases, right? Because Cigna owns Express Scripts. And we know that united owns optum. And we know that CVS owns CVS Caremark and Blue Cross forever has had its own PBM, that longer than everyone else. It's called prime therapeutics. So there's that vertical integration of insurance companies owning the PBM. But now as well, what they've discovered is they have a revenue source by having a brick and mortar place where they can start doing clinical things. So the prime example I like to use is CVS because they have you know, how many 1000s of little CVS drugstores with the heart on it make it look like they're the like, you know, greatest little people out there. And these CBS minute clinics, as they call them. They announced early on when they were expanding the minute clinics, they had no intentions of hiring physicians. So the standard of care for medicine, according to CVS, who owns you know, an insurance company and owns a pharmacy benefit manager who gets to collect kickbacks is don't use the physician. So they can take a practitioner and they tend to use nurse practitioners in the minute clinics when they can, and they can put the nurse practitioner in the minute clinic. But I mean, I kind of think to myself, when I look through the studies, it seems to me that nurse practitioners in many studies tend to prescribe more, I mean, I'll let you expand on that. And then we'll get back to where the conflicts are.

Rebekah Bernard MD 17:16

We've definitely seen studies showing that nurse practitioners and physician assistants are more likely to prescribe more medications in general, they have higher rates of opioid prescribing higher rates of inappropriate antibiotic prescribing. So like, you know, antibiotics for viral infections, for example, more antipsychotics more steroids. I mean, the list just goes on and on. And it's really interesting because we've explored a little bit the Robert Wood Johnson Foundation, and that Johnson and Johnson is the manufacturer of many different drugs. And then they also have been encouraging nurse practitioner expansion. So then these nurse practitioners are prescribing more possibly of their medications. And it's sort of a big, like you said, it is that vertical integration because the nurse practitioner prescribes the medicine, the medicine is made by Johnson and Johnson or Janssen or one of those subsidiaries, they then fill that prescription at the CVS, the pharmacy benefit manager takes a share of the money. I mean, basically, it's just money just going through that whole chain.

Marion Mass MD 18:23

Absolutely. And then to make you know, the integration like the horizontal integration, even worse, there's records, you can read articles where the pharmacy benefit manager is choosing how much that they're paying the pharmacy right. Now, the independent pharmacists will say it seems as though we're making less than other places, and we have no control over it. So they just have to take what they're given, right. And so then they're getting less and less all the time, and then along comes CVS and then offers to buy them. So then now you have in addition to the vertical integration, you have more horizontal integration going on. So now they've bought up a pharmacy, and then they have more opportunity to perform all that same welter of conflict of interest. And in a moment if you want to we can or we don't have to talk about the specialty pharmacy angle of this as well. This is another interesting, you know, tell us about that. Yeah, so a specialty pharmacy is simply a pharmacy that ships out medications that need to be sent out and kept under controlled conditions. So for instance, you know, insulin really can't be kept at room temperature or patients that have cystic fibrosis, they have to take enzymes, so that they digest their food appropriately so that they maintain their weight and so the specialty pharmacies are supposed to send these things out under very good conditions. However, there's been some post - I'll, I'll think of the article to add to your podcast, but there was an Express Scripts, not keeping their medications temperature-controlled, and there was a mother of a little girl with cystic fibrosis. And she started having gi problems and losing weight. And the mother questioned and said, these enzymes are coming in, they're coming warm, and they're not under the right temperature controlled. And she, she got all the way up to some administrative person at CVS who said, You're not a pharmacist, ma'am. You know, it's a little upsetting. But so the specialty pharmacies, they're doing the same sorts of things. They're like a big conglomerate, and they're sending the medications out. But the bigger places are not seeming to do the same careful job that an independent pharmacist is willing to do an independent pharmacist could easily serve as a specialty pharmacy. But what will happen is this that if you have that vertical integration if you are at now you can say, Nope, only CVS Caremark is going to their specialty pharmacy is going to be the only one I allowed you to use. If you have Cigna, nope, only the one associated with Express Scripts, that's going to be the only one you're allowed to use. So each of these pbms also has an associated specialty pharmacy. And they're making money too. So they're, it's like, they've created all these clever little ways with their vertical integration and their conflicts of interest to make money and, you know, if we let them keep on going, they'll simply take over the subsection of primary care that and even some specialty care that we all know,

Rebekah Bernard MD 21:35

That made me think of a post that you wrote, where you talked about, you're working in an urgent care, and you saw a patient that was really quite sick. And you were able to recognize that because you're a physician, you're a pediatrician. And your point was, if the dad had taken this kid that was really ill, to a CVS MinuteClinic, or maybe seen a nurse practitioner that went to an online NP training program that never even worked as a nurse before, would that diagnosis have been made. And I think that's a really good point. And patients are being encouraged to utilize these places, not only for urgent care issues but for their primary care. And they're really losing access to physician-led care, because their insurance company is incentivizing them to use these sort of facilities really as a way for them to make more money.

Marion Mass MD 22:22

Sure, imagine if you own an insurance company. So they're CVS and if you're an Aetna patient, they may say to you, okay, they can incentivize you like easily if they want with a copay maneuver. Zero copay if you go to the CVS MinuteClinic first, and you know, x copay if you're going to go to your primary care practitioner. So where are most people going to choose to go? And then once they have you into the CVS MinuteClinic? Well, yes, I think you need this prescription. And while you're here at CVS, go take a look at aisle two, and four and seven and get these items. And I think you better make sure that you get this particular brace that we have on aisle 16. So you can work it so that you're training your employees to make more money for you after you pull people in with the use of the Copays. And if I mean I paid attention, but uh, about, I think it was 2018 they changed what we call e&m coding management coding that we use. Physicians recognize there are usually five levels almost no one ever built one, it's like a very, very simple level, numbers two and three, got a bump up in their payments. And then numbers four and five got a slight bump down.

Rebekah Bernard MD 23:37

Yeah, and just to clarify twos and threes are considered like two would be like a cold that you don't even do anything for a three would be a very basic problem like controlled high blood pressure. And then the more complex problems are your level fours and fives. So a person with 2, 3, 4 problems or they're getting really sick would be a level four or five.

Marion Mass MD 23:55

So now, just like the pharmacy benefit managers have done where they say, well, you make your choice as to where you're going. They can say to your patient, nope, is zero copay. If you go to the CVS MinuteClinic. First, they show up the CVS MinuteClinic, they can probably with most twos and threes, the patients may tend to be okay, they're going to collect more of that money for the simple visit, right. And then even if they see, or two or three, they'll still collect their money. If the patient is a complex patient, you know, four or five, they may simply say, Well, this is too much for me to handle. So I'm sending you to your primary and they'll bill at a very low rate for that visit because they didn't do much centered on the primary who's now going to collect less than they had been because the fours and the fives are collecting less. So like you can sort of see it's going to be a spiral for the primary care practitioner. That's part of the system as it were right? If this is allowed to go on as it is where minute clinics and I call it drive by minute clinics, quite frankly, because that's what They feel like to me, but yes doc in the box was not even a doc. I think that we're going to lose primary care.

Rebekah Bernard MD 25:08

Well, it is a big concern. And we know that primary care Docs are among the lower paid physicians - not that we're not well compensated and I'm not saying that at all. But when you compare our salaries to CEO salaries, which is something you've been blowing the whistle on, especially the growth of CEO salaries just in the year 2020. During our pandemic, when payment was being cut, doctors and nurses were being furloughed CEOs made more than ever and you posted this and this was shared in one of the articles that you wrote, for example, David Cordani, the CEO of Cigna, made 491% more money in the year between 2019 and 20. Sam Hazen, the CEO of HCA healthcare made 330% more money. And I think it's so interesting. I'll just use HCA healthcare as an example, because that's one of the largest for-profit healthcare systems in the United States. And what's so interesting about it is this company has been in trouble with the government so many times back in the 1990s, they got more than $2 billion in federal fines. And that was when our current senator and former Governor Rick Scott was in charge of HCA. Then they were accused of engaging in questionable Medicare billing practices, keeping separate books, they, I mean, so many scandals, they actually paid another $2 billion in criminal fines, pled guilty to 14 felonies, they had an insider trading suit in 2005. And now most recently, I just read, it's in the news like two days ago, they're acquiring these trauma centers. And they're doing this trauma activation. So like they gave an example of this guy who fell off a ladder, he was okay, he just needed some stitches. And they called a trauma on it. Because if it's a trauma activation, they can bill up to $50,000 because they activated the team. So they're activating the team on like, all these different things that aren't like, like real trauma would be like a major car accident or, you know, serious things where you have to call in surgeons and do all these things. So they're like, calling it on everything, really just to make money. And that's what's happening in this corporate healthcare system.

Marion Mass MD 27:25

Yeah, it's really pretty shocking. You know, if you think about it, it's it's almost, doesn't it feel like a game? Like it's like their little game? Okay, what can I use in my game to make money? Well, you know, here, we're going to keep some of this money instead of giving it to the pharmacy, and we're going to, we're going to take more money and give it to CBS and less to the independent, we're going to buy up more of these pharmacies, we're going to like, put people in our little pharmacies, and now we're going to get them to prescribe more, we're going to drive people to there because it's all these little games of how can we make money, it just doesn't feel right to us as physicians,

Rebekah Bernard MD 28:00

And I love how you call them out. So there's a Twitter post that you made that I just love because first of all, good old Dan O'Neill started everything up. I don't know - he's a healthcare executive. And I'll let you tell more about him. But I just want to give some background. So physician assistants talked about me changing their name to Physician Associate. So some different organizations like the American Osteopathic Association put out statements saying we don't think this is a good idea. We think it'll be confusing to patients. So Dan O'Neill posted a tweet that he has since removed, but we have screenshots and he said, criticizing physicians, he said, 'I will never understand how such a high income, high-status profession can be this insecure and this self-absorbed, do other professions spend this much energy on unscientific, unhelpful assertions of primacy over their highly trained colleagues.' So he wrote that critical remark, and Marian just started nailing him with all the different -all the hypocrisy. So number one, she said she says in her post, 'I have questions. Number one, I hope you don't mind being transparent because your extensive work in the IT healthcare field is affecting billions of Americans.' And then you revealed a lot of information. Do you remember all the things that you exposed about Dan O'Neill?

Marion Mass MD 29:18

I can't say I'll remember them. I'm glad you have it in front of you.

Rebekah Bernard MD 29:21

But I do because it was crazy. Because you basically you found his resume. So you posted like, here's his resume. First of all, he's a US Senate Health Policy fellow through the Robert Wood Johnson Foundation. And then he became Senior Vice President of change healthcare Incorporated, a $350 million business line. He was the vice president of Practice Fusion, which is a cloud-based electronic health record that sold for $250 million, even though they were supposedly worth $1.5 billion. So you were asking all these questions like wait a minute, if it's worth 1.5 billion, how did you sell it for only $100 million, where's all the missing money? So it's like you said, look for the money, where is it going into whose pocket?

Marion Mass MD 30:06

Sure. I think like what I found fascinating. And I started with Mr. O'Neal by pointing out that, you know, should he show up in the hospital, after a motor vehicle accident or with a sick child or with a ruptured appy, we will take care of them. And that's what we do. You know, like, I think, I've never actually met any physician that would refuse to take care of patient. I mean, I certainly hope we don't get to that point. But while throwing shade on our professionals for being very wealthy, and I can't see his money trail, but it's on his own website, all of these positions that he held. So I just asked the questions, I guess, like, I can't assume that he made millions of dollars while being at practice using a company that was worth 1.5 billion. And by the way, PracticeFusion got nailed for taking illegal kickbacks - that's in the press, too. So that may have been under his watch. In fact, I think it was.

Rebekah Bernard MD 31:02

So yeah, hypocritical that, you know, this is a guy that's contributed to the burnout rate of physicians with these electronic health records and profited mightily off of it, I would assume, criticizing physicians just for standing up for their profession.

Marion Mass MD 31:16

Yeah, you know, and doesn't it feel strange to all of us, and you can comment on this. But I always say it's like, you know, the suits versus the scrubs. And we do need some suits in the healthcare arena. But I think the suits have been in control for a long time, or at least they've been asserting control. I really do believe that physicians there should we choose to say, Nope, you're done here. And nothing really happens medically, without the stroke of a scalpel, or the signature of a pen or the click of a mouse nowadays, whatever you would say, right, it can't happen without the training that we have behind us. And in a way, you know, this issue that you all have taken on, too, is a delicate issue to handle, because it's hard as physicians, people can throw shade on us and tell us that we're being elitist for attacking another profession. I never make it about attacking the profession. What I'm trying to point out is that it's really a lot of corporate people like Mr. O'Neill or others that would like to be able to utilize a more inexpensive brand of practitioner, if they can make it so that that practitioners are allowed to do what we're allowed to do. I think, actually, in a way, I feel very sorry. And you wrote a wonderful article A while back, I believe in Kevin, MD that the nurse practitioners ought to be as a guest. And this whole situation is as we are back in the day nurse practitioners were, you know, very experienced nurses. And now there's a different model that's certainly sprung up. And I sort of feel that the corporates, they're using them, but they're gaslighting us.

Roy Stoller DO 32:59

They're also intimidating. doctors know we can speak up, we risk our jobs.

Rebekah Bernard MD 33:04

I wish that we had more time to discuss this, but unfortunately, we're out of time. I want to thank my co-host, Dr. Roy Stoller. And I want to thank Dr. Marion mass for joining us and we'd love to have you back another time to elaborate more on these important issues. If you'd like to learn more about this, we encourage you to get the book patients at risk, the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and at Barnes and Noble. And if you're a physician and you'd like to join us, please look into our organization physicians for patient protection. Our website physicians for patient Please listen and subscribe to our podcast and our YouTube channel. It's called patients at risk. Thanks so much and we'll see you on the next podcast.

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