This week on Inside Reproductive Health, Griffin gets to the root of the insurance debacle in the fertility industry with Holly Hutchison, managing partner of Reproductive Health Center in Tucson, Arizona. Are cash pay patients subsidizing insurance companies’ poor coverage? How can practice owners survive when insurance authorizations are exceedingly slow, reimbursements are laughable, time to pay is unpredictable, and patients don’t understand their own coverage- or lack thereof? Who is left holding the bag when insurance doesn’t cover what it claims to, and can anything be done about it?
Listen to hear:
The evolution of insurance in the fertility space: how it began, when it was successful for a hot second, and where it is today.
Griffin question which is more beneficial to the provider- employer benefit groups or insurance companies- and why.
Griffin question why fertility clinics haven’t cut out the insurance companies who are draining their bottom line.
Griffin discuss the cost-benefit analysis: (Reimbursement, time to authorization, time to payment, volume to practice, patient cost sharing) and how to bring more leverage back to the provider.
Sponsored be EngagedMD
Transcript
Griffin Jones 00:03
Miss Hudson Holly. Welcome back to Inside Reproductive Health.
Holly Hutchison 00:07
Thank you Griffin. It's great to be here. Again,
Griffin Jones 00:10
You were one of the earlier guests that we had on the show, it's good to have you back, I want to get into a topic today that I haven't really covered at all, which is about insurance, employer benefits, coverage and what's happening in the field, you're a good person to have on because you're the business side of of your practice, you co own your practice with your brother, Dr. Scott Hudson, who is the REI. And you. So you see a lot of what's happening from the billing side, firsthand. And I've just heard so many people talking about this more, one of the things that got me wanting to talk about what's happening is a client of mine sharing, you know, just like, it's like you can't make money on some of the services. And we can talk about examples later. But just before I guess I'm painting the picture, and I shouldn't be what happened and like what's happening, how it is with regards to insurance and reimbursements in the field, what like what was it like versus like 15 years ago, was it like five years ago? And then what's happening now?
Holly Hutchison 01:22
Okay, well, 15 years ago, it was pretty much cash pay, a lot of the insurance companies didn't recognise any treatment for infertility wasn't a very common thing. And then there started to be insurance coverage, as people started to realize, hey, we need high dollar employees that are likely to have postponed childbearing. And so to get those best engineers, as best doctors or best attorneys, were going to start offering coverage for some of these services. And then some of the bigger states like Massachusetts is the one that comes to mind mandated fertility coverage. So that started changing the whole landscape of fertility coverage in, you know, in the United States. And so that 15 years ago, we didn't really deal with insurance, it was really cash, you know, fee for service. And we had a lot of flexibility and how we could charge and what we could do. Five years ago, we started getting more infiltration of certain insurance companies and certain pharmacy benefit plans that got into this marketplace. And some of them are like secondary, second tier, and I don't even know how to put this, but they're, they're not exactly providing the care. They're just providing the network, and then administering things. So there's like different levels, like there's the payer, and then there's the people in between the middleman. And then this is the doctors. So there's, you know, different levels of all this stuff going on. So five years ago, I think we got more infiltrated. And now we're getting to a point where it used to be that I had 99% fee for service five years ago, it was probably 30% that was insurance coverage, that's that. And now we're looking at almost 5050. Now I'm an Arizona, we're not a mandated state, but it also means that we're taking there are certain patients of ours that are working for companies in mandated states in Arizona, so we have to take the reimbursement that Arizona offers. So it's the landscape of who's doing what has changed tremendously. And now we're almost I would say 60% insurance coverage. And we're also dealing with to give you an example, we've got payers that pay at an Arizona rate. And but the insurance is mandated out of Massachusetts, well, I'm not getting Massachusetts reimbursement. I'm getting some Arizona reimbursement based on Medicare, that doesn't cover the service that we provide. So we're with the insurance companies that come at a lot more cost for us to do business. Because I've got to have special people to do prior authorizations, it takes more time. And they don't always pay they're, you know, they're kind of squeezing because some of these parties and I think, you know, some, some of who they are, they're not the actual payers, but they're negotiating on behalf of the payer, and they make the money in the differential. So they're telling the payer, I can get you this service for $1,000 but then they come to the doctor and go hey, all we can pay you is Five, and they're making the differential on it. And they do a good job of administering those plans. They understand the fertility business. But it's not always for the patient's best interest. So the patient isn't getting insurance that isn't designed to make the patient get the best care and the best coverage. It's designed for all those other parties to make money along the way.
Griffin Jones 05:27
So 15 years ago it was almost entirely fee for service and started to get more insurance coverage. Five and 10 years ago, when that started, Holly, were how was the delta between what insurance was reimbursing and what you were charging for cash payments, once it started, like when insurance? Yeah, it gets a first started 10% or whatever?
Holly Hutchison 05:51
Yeah, when it first started, there was a discount definitely given to the insurance company. So if we were charging to use round numbers, if we were charging $10,000 for an IVF cycle, the reimbursement would come in right around nine, maybe 9500, just depending on who it was. And there weren't a lot of x x accessory services that were provided, you know, back then we weren't doing Ixy all the time, we weren't doing PGT we weren't embryo biopsy, we weren't doing freezing necessarily long term storage, all those things which the insurers didn't pay for, they didn't understand. So that was a carve out cetera. Moving forward, they have gotten very, so there's a couple of things that happen, they either have negotiated way down. So if our $10,000 IVF cycle is now negotiated somewhere around 7500, right. And then the accessory services sometimes are covered, and sometimes aren't. So like PGT, for example, if it's covered, it's not me billing for it, it's the lab that's billing for it, but the biopsy, they will then discount out. So if my biopsy is $1,000 added on to my $10,000 IVF cycle. Now, I may only get reimbursed $500, for the time of my embryologist to do that biopsy, or they'll lump it all into the cost with PGT. So we're getting less reimbursement. And over time, the reimbursement is less to the point where oftentimes I feel like my cash pay patients are supplementing the cost of the insurance coverage covered patients. So if $10,000 is my cost of doing business with a reasonable return, and that's what my cash pay patients are paying, and I'm only getting $7,500 from it, then the people paying cash and now supplementing out. So if I have to raise it to cover my my, what I'm actually bringing in, it goes to the cash pay side, right? Because the insurance side is capped. And there's an Yeah, you can say well, you could just do more patients at a lower rate. But as we all know, then the kind of care that you can provide
Griffin Jones 08:21
with what embryologists like Yeah, yeah, exactly. With what are you guys, you know, that's part of the the debate that we had, or that that doctor or dunno Dr. Brower were having on the show a couple weeks ago, and when they talked about insurances, like Yeah, but how does that improve access to care if you don't actually have more providers, more staff, more embryos? Like if you don't have all of those things in place, then you're just adding to the waitlist? Exactly, exactly. Like Canadian waitlists are ridiculous. Um, and so but so But at what point though, does the like I'm trying to see when the teeter totter goes out, because what you said is what I'm hearing from clients and independent practice owners all over the country is that our cash pay patients are subsidizing the covered page covered patients and so at what point does like the teeter totter tip to where they can't do that anymore? Like there's not enough cash patients in order to to subsidize the
Holly Hutchison 09:33
well you know, this may be the you know, the self limiting thing if if more and more go to insurance coverage and are you guys can't make the money now I don't know about corporate practices where one doctor practice where a small practice I know how much it costs me to do things I'm not there's not this, you know, big corporation behind me funding into this thing, right? So I know what it costs me. At some point, if it's all insurance coverage, who would bother to work and do it? You know, it's gonna get to the point where it's not, it's maybe not even worth it, you can't do it or, or you have to really cut back on the service you provide for the patient.
Griffin Jones 10:23
So in turn, like, Can you give any examples of you being as specific or not as you're comfortable being but okay, of just like in terms of, of, of what some people are paying or offering to pay for different procedures and or different tests, etc?
Holly Hutchison 10:44
Am I allowed to tell the names of them?
Griffin Jones 10:48
That on my show, you're allowed to say whatever, but I don't know what your contract ramifications are. So if you're worried about your breaching something, then don't do that. It's okay. Like, you can say whatever the hell you want on my. But if you're worried if you're worried about saying something that might put you in an awkward position with, then don't, then I won't do it. Don't do it. Okay. Yeah,
Holly Hutchison 11:14
well, I will say okay, because I know they
Griffin Jones 11:16
but some numbers, but numbers that people have said and offered would would be helpful, and you don't have to, you don't have
Holly Hutchison 11:22
to like right now I'm, I'm dealing with a large theoretically not for profit insurance company that has blue in the name, that I can't even get a provider rep on the phone, I've been calling and calling and calling semen analysis, a covered service, it says it's covered, they have full health care coverage, blah, blah, blah, they pay $1.62 for a semen analysis. That's the reimbursement rate. And there is no way on God's green earth that I can provide that service. There's no machine that we put it in, there's actually somebody who goes and does that semen analysis, and it takes quite a while for them to do it. There's no way I can do that. So I mean, I have to pay the embryologist who goes to do that vastly more an hour than they could even do the number of semen analysis I couldn't, it's just doesn't work. So we've had to tell those patients, you know, if you want to take it up with your insurance company, if they want to sue us fine, but I will not do a semen analysis for you unless you pay cash. Because we can't, there's just no way and I can't get anybody on the phone. They don't, they don't care about any of it. So it's gotten to this point where there used to be somebody that you had a liaison with the bigger insurance companies. And maybe it's just because we're small. But the insurance company had a liaison, you had trouble, you were having problems, you needed to deal with something, you were getting too many denials, you had somebody that you could contact, and nowadays, there's no one there. Well go online and submit a form and then you hear nothing back from them. So the other thing that they do frequently is I provide the service, it's been prior to I know the patient has the coverage, we've checked everything. And then they deny the claim. And then we have to resubmit it. And then they say they've gotten the claim, and then they'll pay it. So by the time I actually get paid, I'm lucky, sometimes 90 days out on my service. There's no one that will do that 90 days payment, forget it. So they're getting it. I don't know if it's because I mean it our theory is that people are getting paid to deny so that they're not putting the money out there. So and that's how the insurance companies have all those glossy brochures and the gal who's the CEO of that company was paid out, this is in 2021, her bonus was $37.5 million. That's your money. Basically they just didn't provide services for that many people. So she gets this huge bonus. None of it makes any sense to me anymore.
Griffin Jones 14:15
This is part of my ignorance of how insurance works. But let's say Insurance Company A is only going to pay $1.62 for something like semen analysis. Are you able to say what you accept from insurance company A or do you have to either accept insurance company across the board or not? In other words, can you say we do take insurance company A for Fe T's and retrievals but we don't take them for testing or ultrasound? Is it? Is it categorical?
Holly Hutchison 14:46
No, it's not. And that's why it used to be you had to provide a rent at least in Arizona we had a provider rep and so if we were starting to see a drift in reimbursement or something was costing us a lot more, we could go to them and negotiate ate, what we were going to, you know what we were going to be paid. And you could go with your top codes and say, Hey, these are the top codes that we bill that we commonly bill, this is the reimbursement that we need from these codes. And so we can negotiate it for the last, I would say four years, it is like pulling teeth. Now there are some of the companies like progeny care at some of those people that they are negotiating. And they're also trying to get the best price that they can for their payer, because they're not a payer. But at least they have somebody there who you can negotiate with, and you can explain to them what you're doing. But with the bigger insurance companies United Healthcare, Blue Cross Blue Shield, Aetna, the it's like it's silence out there radio silence. Now if I were a 20, doctor, practice, maybe I'd have more clout to go in there and do something. But I think they're even doing it to the three four Doctor practices. Maybe if it's Corporation, like if you're a spy or something, you go in, and you go, Hey, this is what we're going to do. This is all we're going to take or we're not going to cover you guys. That may be happening. I've got some insurance companies now that I'm definitely considering that we just will not take. So
Griffin Jones 16:21
I definitely want to talk about that about like where insurance companies start to get cut off and and then where that channel leverage falls. But with one thing that you said about having more doctors for that type of have you leverage of what they pay as well, so you're getting just skimped on that dollar 62 Holly because one person who owns a large practice group in a major city told me that they got offered $10 per seat.
Holly Hutchison 16:54
So I'll see there's a major major city just think about
Griffin Jones 16:57
how much money you could be raking in if if you were if you had some more Doc's, and we're in a bigger city. So obviously, it does depend a little bit on city side, but even larger groups with, with more doctors still getting this kind of squeeze. And then I talked to this, this doctor more and said, Well, you know, like, Where does, we're talking about leverage. And we were talking about how like Richard Groberg was on the show, and he said that that networks have failed to provide the discounts it's given, they failed to provide that scaling, that ostensibly should be why someone signs up for a network. It's right, right, they can better negotiate with these insurance companies, then then I can and this doctor thought that the reason why that hadn't happened is because it really you really only have the leverage at the market level, meaning that particular city. So let's, let's pretend, Oh, who's kind of a midsize? Yeah, like Austin or Charlotte or something like that, that. Atlanta some place like that, let's let's pick one of those places and say that it makes more sense to try to consolidate with the docks there than it does to be a part of a national network. Because if you let's pretend there's 20 docks in Atlanta, and you have 18 of them under one roof, then you have the leverage to
Holly Hutchison 18:29
negotiate to control the market. Yeah.
Griffin Jones 18:32
What do you think? Do you think that that makes sense? Or would I think that they don't sell enough?
Holly Hutchison 18:37
I think that makes sense. And I still think that the insurance companies, you know, let's face it, they get how they make money is through premium dollars, right? That's the service they sell premium dollars coming in, theoretically, the money's invested are held, earning interest. So that when, and you're looking at a broad swath of people, so I'm going to insure 30,000 people, and only 800 of them are going to need fertility coverage, or in some cases now that's like the old the old school version of it, like if you are BlueCross BlueShield, right? So it's an economy of scale. I'm going to collect this money for those people. And I'm only going to be paying out on 800 of my 30,000 And so there's going to be money in reserve to pay other things as they come in. Well, I think what's happening is they're keeping a lot of the money and I N. The other thing is that fertility has become its own separate carve out. So like if you're a large employer, and you've got 15,000 employees and you want a fertility plan. What's happening now in the in the industry is you're they're saying okay, well how many women do you have fertility age in your company, or how many couples do you have that might be trying to conceive, and then we're going to charge you $1 amount on top of their insurance to put the fertility piece in place. And when they're no longer trying to have children, we're going to take it away, so that we're not paying that for everybody. So it's not, it's not the cost of the fertility care is not spread out over all 15,000 of your employees, it's clustered into a smaller group of them, that then you're paying an additional premium on top of, to cover fertility services, right. So those groups that do that, they're really motivated to make the cost of it as, as cheap as they can. So that they can make the differential between what they're paying us and what their be what they're charging the larger group. So when you start following the money, you know, it's not beneficial to the patient ever. And there's other things that they're throwing into these, the mix of this stuff, like one of our larger employers just went with a coverage plan, where they've got on to say, a cap of $25,000 on their, their programme, right, so you get $25,000 worth of fertility services, they put them in to get access to the fertility coverage, you have to be in a high deductible HSA plan. And the HSA plans are great, but the insured the the employers and employees don't understand how it works. And what they don't realize is that HSA qualified plan usually has a very high deductible that goes with it. And what I've been seeing is that deductible is up to $6,000. Now, so your cost sharing into it as the patient is that I have to pay the first $6,000 of my coverage in order to tap into my $25,000 benefit. So how many people do you know that are in the ages of 25 to 35, that have $6,000 saved to use to do that, or in their HSA, because what happens is they get this HSA and they don't even know that they're supposed to fund it, they're supposed to put money into it.
Griffin Jones 22:29
That's also it's also a bad way to use an HSA is to take money out of it exactly if you have. So this, maybe this is a little side tip, maybe I'm gonna go on a little bit of tangent, but everybody knows, everybody who knows me knows I love talking about this about HSAs. Because a lot of people don't know HSA is the best retirement account that there is absolutely the 401k match, the first thing that you should do if your employer is matching your 401k is to go up to that match. But then you max out the HSA before the rest of the 401k. Because HSA is the only triple tax advantage account, meaning you deduct it from your taxes, you can put it in a really tax inefficient account like dividend accounts or dividends. Let that grow tax free on the tax deferred. And then you can withdraw it tax free as long as you save all of your receipts. So if you had to use that $6,000 For your fertility treatments, you would want to save those receipts from 2022. And then when you retire and 2052 or whatever, you are reimbursing your 2022 self with money with money then from that had no taxes that has just been growing. Yes, yes. That's a little tip. But that would be but no.
Holly Hutchison 23:54
I mean, if you think about it, if everybody in the United States had a high deductible HSA plan, there was a government back plan. I'm talking about Medicare for All Ooh, scary. If you had that, and you were required to have it by the time you were 21. And you put the full amount you could put in the HSA, by the time you would never need the health care system. You would self fund your own health care. Now there would be people of course, that are going to end up with a catastrophic cancer or something that they have to have more care, but that's what that whole Medicare plan would then cover but most of the people in the United States would be able to self fund everything we did. That's the aside. So anyway, but here's what happens to my patients, okay, so they have $6,000 that they have to pay upfront. Okay. This just happened to a patient of mine. So she says well, we've got this you know, plan and where you got $25,000 coverage and it covers my it covers the medication So I'm like, Cool. Well, who do you have to get your medication through, I have to get it through CVS Specialty Pharmacy, great, I'll call and I'll get the prior authorization, call and get the prior authorization for it, send it in, send in the prescriptions. Everything's cool. So I'd say to her, make sure that you ask them how much they're going to charge you before you allow them to send the medication, that you know what your co pays are going to be. Do you want to know what her copay was for medication I could have bought at the regular Specialty Pharmacy, the cash pay Specialty Pharmacy, her quote on her medication was $1,800. Okay, $1,800 Caremark CVS Specialty Pharmacy told her her medication costs were $6,000. Guess what that was? That was her deductible. So she was going to be paying $6,000, the deductible amount to wet vastly overpay three times over pay the cost of what her medication workouts. So that's another,
Griffin Jones 26:09
That's another point. But that's what I was talking from, with someone from a discount pharmaceutical programme, let's say, and that's what they were saying. It's happening all over the place that it's like, okay, so you could have used that you could have used, whatever part of that benefit is towards your clinical care, but you maxed it out, and then you had to end up paying money for clinical care, because you overpaid for the meds that you could have gotten for exactly for 25 or 30%. of the price. Right. Right. So that's to say that you're not the first person to say that, and if the people that did talked about that to me want to come in and talk about that in more detail. They can okay, so the payer is sometimes getting screwed on, especially when it comes to meds like that the insurance company, the employer benefits, bro, courier company, like you said, their job is to win the differential. And so when did they start getting pretty emboldened about winning that differential, like starting to offer pretty, you know, it's like, Wait, we can't even make money on that.
Holly Hutchison 27:25
About two years ago. So the first year with those Employee Benefit groups was great. You know, they just come in, they understand the fertility piece. They're slick, they know it all. It's all done. It's easy to get prior authorization. You know, everything's wonderful. I'm thinking, Man, this is excellent. If this is where insurance is gonna go, sign me up. Because this is so much easier on my staff, everything's great. And then the next year came and they were paying basically what we asked for. And we're, we're very reasonable, by the way, just want to put that out there. We're not the $25,000 IVF cycle place. We're really reasonable. So they, I think they thought, wow, this is great. You're way less than some of my other people have gotten in other markets. And then the next year, it's a 30% haircut that they wanted. So I had to go to the mat with them, and then kind of finagle some things because they weren't willing to change some things, but I was able to get some things altered. So the end result was I was almost up to the reimbursement that we had had the year before. And now I'm looking to see what happens in the next year. I don't know what's gonna happen. But if
Griffin Jones 28:48
that was that 30% Cut, was it across the board? Was it for retrievals or transfers? Yeah. It was
Holly Hutchison 28:56
across the board. Pretty much across the board. Yeah. Okay. Yeah.
Griffin Jones 29:00
And did that happen at a certain time? Like, did they get over a certain threshold of patients that you were seeing, or did they land a couple more employers in the marketplace?
Holly Hutchison 29:10
So they landed some big employer groups in our market?
Griffin Jones 29:15
So yeah, so so at that point, that's when they started to feel like they had that leverage?
Holly Hutchison 29:23
Yeah, because there were more covered lives where, you know, initially, I would have like, four of there's a year maybe, and now it was more like one to two per cycle per month. Okay, that we had. Yeah, so they, yeah.
Griffin Jones 29:41
So, so like, so going up to, you know, so they probably quintupled their number of that they were that they were sending you in a year and they're like, all right, right. Now's a good time for us to give you a haircut to try to win that differential which makes sense. But if we're thinking of it from the providers point of view, and I understand that everybody has a point of view of if employer benefits want to come on the show or insurance, you guys are welcome on the show too. But I'm, my job right here is to look out for the providers in this case, and patients in another show, etc. But just right now, I'm trying to think of, I'm trying to help the providers negotiate and I'm punching above my paygrade. Here how
Holly Hutchison 30:31
I do that a lot. I worry about it, it's how you
Griffin Jones 30:33
grow. I'm trying to think of like, well, now seems like a good time to try to push back because volumes are like people are pushed to six 810 week waitlist. So why don't you give your waitlist a haircut before you give coverage a haircut, you could actually probably afford to reduce the number of people that could potentially be because you're already pushing them back from time you're already right. Access to Care. So if we have, you know, we've got united at Blue Cross, and then we're on the employer benefit side, we've got Carrot Progeny Kind Body. And, and, and those aren't all of them. But like, those are just six people right there. And I'm not saying who's who, but it's now not the time to say, okay, all right, I've just recorded these six, or eight or 10, or however many there are. And I'm doing a kind of x y access of where reimbursement and volume to my practice meet. And then I'm chopping off the lowest one, like is now not the time to do it. Because let's that's for the insurance company three, they are, they're the lowest on the on the access of reimbursement there. And then they're second lowest on volume to my practice, and therefore their net lowest and therefore, salary patients, we no longer accept except that we no longer accept insurance company three is not what's the reason not to do that?
Holly Hutchison 32:17
Well, that's and that's exactly what I've been looking at doing is, you know, where do you want to? Where should we cut the we, I mean, one of them, we're gonna cut because it's just, they're impossible to deal with, and then they don't reimburse. So there's no point in continuing with that for me, because and they're maybe they're probably one every other month that's got coverage. And, you know, one of the other things that's happening with them not, and some of them now the, the carrots kind bodies and, and progenies, they do a really good job at prior authorization. So it's very easy to get those patients into a cycle round, right. But when I'm dealing with an Aetna Blue Cross Blue Shield, Cigna, you know one of those UnitedHealthcare, it can take an entire month to actually get the prior on. So the patient could have been in and done with their cycle in the time that it takes for us to just get the prior off for them. And so you start looking at some of those, and then the reimbursement rate, it's like why why bother, this is not a benefit to my, to my patient, really, it creates more anxiety, they're waiting stuff gets, they're constantly getting screwed up. And at that point, it's not it's just not worth taking it. And I've had patients that in the past that, you know, they they go where their insurance covers it, like a couple of the old school providers, we've quit, we, you know, we cut out a couple of them a long time ago. And so patients, we ended up getting the patient's back anyway, because they will go to another provider, they weren't happy. And then the insurance really didn't provide as much as they thought it was going to provide. So it's a problem for the providers. It's also a problem for the patients because it's really limiting their access to care in a timely manner as well. So it's not fair to anybody.
Griffin Jones 34:23
I promised I will figure out this sponsorship scheme for inside reproductive health so that we can get people on advertising, sharing their content, without it being an endorsement for me, because there are so few companies, there might be one or two other companies that I would give an endorsement to. But so far it has just been engaged MD and the reason is, I'm just not qualified to be able to talk about a certain company's performance, it would have to be so disproportionately positive. And that for me has been engaged MD, I have more than half of my clients that have used, engaged MD, every single one of them loves it, many of them have started after we begin working with them. And they and every other person that I've ever spoken to that is a user of engaged MD talks about how much time and grief, it saves their nurses and their staff, that they don't have to do the same things over and over again, they have a much more scalable and efficient platform for educating patients building that rapport. So then when the nurse or the clinician talks to the patient, they're able to tailor that conversation to what the patient actually needs. And that repeating the same things to someone that's a deer in headlights, I keep hearing how much time engaged MD is saving fertility staff keep hearing how much stress it's saving them at a time, when burnout is still crazy, people are still leaving positions left and right, when in my view, they shouldn't be we still lack a lot of technical, logical solutions that I hope we have in the next 510 years, but engaged in the is one that is here now, and more than half of the practices in North America are using engaged MD. So I hope that you are in that group. But if you're not, if you're still in the now on the laggard side of the bell curve, then I hope that you go to engage md.com/griffin. And they're going to give you a free workflow assessment, you're going to be able to see what other clinics, you're gonna get some insights from how other clinics have things structured. And you're gonna see a couple major areas that you can prove to keep your team from burning out to keep them who says that's free, as long as you mentioned, my name and the podcast. And I ask that you share that with them anyway, because it's one of the things that helps give free content to you and to all of the listeners, but the real beneficiary is your team and your patients, because patients have a much better experience when they can be better educated when they can do things on their time. And then they can have what needs to be tailored fit to them. Truly personalized care. And so the real beneficiaries, our staff, and patients do it for them, not me. But it's nice to help other podcasts and get yourself a free workflow assessment by going to engage md.com/griffin. And now back to the show. My primary care provider just dropped me because they, they got rid of their nurse, they kind of forced the nurse practitioner into retirement, they decided they weren't going to seems counterintuitive, because it seems like they if they aren't getting reimbursed last they it seems like they would want to advance. But for whatever reason, they, they they didn't I think they'd probably just looked at like, Okay, what's the total capacity that we can do and, and it makes sense. For, for what we have, and then when so when, when she left, they didn't replace the advanced providers and they did not absorb the patient load of the advanced provider. This is a primary care providers, the as I did, my grandparents went here, my parents go here, and it was just like, whoo, whoo, you got it. And so I do, like it does hurt the patient. And I worry about that happening in fertility and you'd said like, okay, you know, we'll start with this one company that isn't reimbursing, and they have such low volumes. Why haven't you done it yet?
Holly Hutchison 38:53
Because I haven't finished doing all the analysis of like, cost benefit analysis of it. Because some of these plans have in the last year changed their structure of reimbursement. So not just the structure, but like the way the plan operates. So like, again, high deductible HSA plans were the cost sharing part. So like, there's one, there's one group that has a high deductible HSA plan, this is their fertility benefit. I love this high deductible HSA. So your deductible is, I think, in this particular case, it's $5,500. And then once you meet your $5,500 threshold, and medication by the way, is not included for this particular plan. Once you meet your threshold, they cover at 50% of the discounted build rate. So if I build them $5,000 They're discounting it by half To like $2,500, and then the patient owes 50% of that. So, in those particular cases, and this was one that's just newly happened, and we hadn't really gotten a lot we hadn't because they delayed payment for 90 days, we didn't know where we were coming out in the whole scheme of things. Because we're at first I'm thinking, well, patients can pay 50%. But then their discount rate was just was really high, suddenly really high. And so now I'm looking at what are we actually? What are we getting out of it? And what is the patient getting out of it, and it's not looking like it's going to be a win win at all. So that one's going to be the first one to be chopped out.
Griffin Jones 40:40
Okay, so let's, let's see if we can make that this cost benefit analysis a bit more formulaic? Because I Okay, it appears that I'm missing something. So I just had x and y, which was like, reimbursement and volume in practice. So but it sounds like there's at least a couple other things that should go in the cost benefit analysis. One was the, I guess, the way they charge patients or, or cover patients, what else needs to go into this cost benefit analysis before people start chopping people left?
Holly Hutchison 41:17
One of the things is like time to payment. So if I've got a, you know, insurance company that doesn't reimburse in a timely manner, that just cost me a lot because, you know, time value of money, I haven't had my money, I've provided the service I haven't I have my money, I've had to pay all my employees, and, you know, keep the lights on in the building. So there's that? How long does it take my employees to get the prior authorizations and get things set up so that we can submit a claim claim to these people that they will pay on in a timely manner? So those are, those are important things to because if it takes like Joan in my office 25 hours to finally lock this whole whole thing down? Is it worth it for me to have her spend the time on the prior authorization, submit the claim and then have to dog the claim afterwards? I mean, it's inefficient becomes really inefficient, and it's really expensive to the office. So that really eats into your profitability if they're not paying on time. And then I gotta pay Joan, to go dog the claim later.
Griffin Jones 42:31
So reimbursement, time to payment time, to payment and volume to practice, what would you call like the? Like? How would you categorize or describe what you were talking about? Have they make the patient pay for 50%? Or they make the patient go through a pharmacy and use up? Yeah, what would we call? Whatever that whole phenomenon?
Holly Hutchison 42:58
patient's skin in the game? I don't know. I think that there's a name for it. They call it like, what is it? It's like the cost sharing is basically it's a cost. Okay, yeah. All right, let's write let's call it that for now sharing, okay,
Griffin Jones 43:14
like patient costs sharing. So but it seems to me like as long as those things are true, that the leverage then starts to tilt back into the provider side of the channel, and then it forces more competition on the coverage side of the channel. Because a if we, we've gotten cut from these five centers in town, and we're and, and this company's HR department is hearing about it, but we don't really have fertility benefit, because nobody here in town, nobody take it. And that puts more pressure on the the, the covering group, whether it's an insurance or an employer benefit group to, to say like, well, we're gonna we're gonna go with this group instead, because they actually do. The clinics actually do take them. So it's, well, there's
Holly Hutchison 44:11
one fine point in there. And that when you talk about like in a market, where there's five providers, if all of them decide to leave, you know, XYZ insurance company out because they're not paying, it's great, but what tends to happen is so there's language in the contracts that we have, that you're not allowed, that the reimbursement rate is proprietary, so you're really not allowed to share it. You can kind of hint to it with other providers, you know, with other providers that you know, but you're not allowed to by contract, you shouldn't be talking about what your reimbursement rate is, right. So, there has to be some kind of cohesive force within the market that you have. Because if one person cuts out And there's four other providers that are still taking it because they haven't paid enough attention to see what those people are reimbursing yet, then it's it's not going to affect that the one man out is not going to have a better bargaining position. Now he is going to have more time to see more patients in the top tiers, right. So that's good. But it's not really going to punish the actions of the way the the insurance companies are reimbursing until you get a broad range. And this is why I think were one advantage of being, you know, like a provider group or a corporate group, is that you have more power in the marketplace. Whereas somebody like me, I quit taking them, I can just count on the fact that I'm not well, maybe,
Griffin Jones 45:47
well, maybe there's lots of markets out there that have 25 3040 RBIs in the market. But you know, they might belong to a network group, network group. Yeah. And they belong to a network group. But in that market, they only have three of the REI. So they really don't have they don't have that leverage. Yeah, leverage. Yeah, or necessarily anyway, and thank you for clarifying that. Because what I think the reason why people should do it is for the reason of being able to see more of their patients to have their cash pay patients reimbursing, etc. But that's the reason why they should do it. And and I'm not even talking about like, talking with other providers about reimbursement rates, because there's, there's those contractors and there's there's price fixing things you'd want to actually I don't mean that but I just mean, if once you cut if other people cut to it, and it happens to be the same person, the same group craps, yeah, that puts more pressure on puts more pressure on Yeah, the company.
Holly Hutchison 46:51
The other thing that's happening with all of this, too, is that people are not educated about insurance, nor do they know what it covers how much it covers. And this includes doctors in my practice that have coverage, have no idea what the insurance does or doesn't do, they just look at, like when they go to their open enrollment. They look at the different plans, and it's like, Oh, this one provides coverage for IVF. Well, we're having you know, we've been having trouble, I may need this. So I'm going to, I'm going to sign up for that plan, which may be a little bit more, you know, it's probably a little more expensive. But then until they really, they don't bother to read any of the information to find out what it actually covers and what it doesn't cover. So they're completely ignorant. And this is where the surprises come in. It's like you signed up for a plan that has IVF as a benefit, but now your deductible went from $2,500 to $6,000. And that's your cost share of the cycle is $6,000. And they don't have the money saved, and they can't come up with it. And then you get the provider who then they're like, Okay, well bill for our services, we bill for the services, and then we find out they got a $6,000 deductible, and they have this big payout that they have to Oh, well can. I didn't know we were gonna have to pay that. We didn't we didn't understand even though our people say you've got a $6,000 deductible. I know, I know, you're going to bill insurance first, right? Yeah, well, they think what some miracle is going to happen, that they're not going to owe that money. And now I've got an accounts receivable on my books for a long period of time because they don't have the cash to pay for it. And they didn't put money into the HSA. And part of that's because we're in a market where the per capita, our per capita salaries are lower than other parts of the country. So people don't sometimes have money saved. But it's really difficult when the patient isn't school. They don't tell them and the benefits peep managers at these bigger companies aren't they don't inform them of what's going on either. So they just think, well, I've got this thing and IVs gonna be free for me. And it's not. There's cost sharing, there's, you know, sometimes it's not the best shake for you know, to be able to do that with the have a plant you'd be better off with the less cost on your, your co pays and deductibles and all that kind of stuff than with a plan that covers IVF that has a really high deductible.
Griffin Jones 49:29
Generally speaking, what are the differences that you see between employer benefits groups and traditional insurance companies?
Holly Hutchison 49:39
Those come the employer benefit companies. They really understand the fertility market. They understand what they're doing. They understand the language of fertility, and the coding system that they use is more direct. So you're not billing for each individual service you're billing on a lump global Code typically, that includes X and such stuff. And they're very clear about what is included and what is not included, what the patient is going to be have to pay out of pocket. They have patient coordinators, so the patient going into it, they may not understand all the everything that they've got. But they are as schooled as they can be going into it, knowing what the coverages, whereas with the traditional insurance companies, then the patients have very, very little understanding of what the benefit actually is, and what it pays. And they don't know their limitations to coverage. And they don't aren't told about what their co pays and the deductibles and the they're not told about it. And they don't bother to go look, they don't bother to read the booklet, you know, most of them are and I'm not slamming on millennials, but most of them take any written work, and it's gone because it's not on their phone, so they can't read it. And if you go to the websites are fairly cumbersome. And when was the last time you looked at an explanation of benefits? Do you have any clue what it says? It's telling you?
Griffin Jones 51:08
Only when I get billed for something? Yeah, but
Holly Hutchison 51:11
you, but even so it's like, Wait, my doctor bill X and such, then what does this mean? What does this mean? What does this mean? What does this mean? There's all these lines, and then this is what I'm going to pay. They don't always understand it. They also don't understand that there are some things that like, for example, I went and had a colonoscopy, I went to a qualified center that takes my insurance, I made sure I had the prior art, everything was there, blah, blah, blah, the anesthesiologist on that particular day was not in network. And so my anesthesia was not covered. And, you know, I'm assuming I'm at the place that I have I have the prior auth. Everything else should be fine. Right? You don't get a pre authorization for the anesthesia. So there's all these little tricks along the way that the insurance companies play. And, you know, patients just don't they don't get it. They don't understand it. Most of the time, most of my patients are healthy young people. They have not used their their health care much at all, if at all, and don't understand how it works. And no one teaches you that stuff in school. Right.
Griffin Jones 52:31
Between the employer benefits companies and the insurance, traditional insurance companies, does one class tend to be quicker at authorization quicker at reimbursement.
Holly Hutchison 52:43
Yeah, the Employee Benefits company's hands down.
Griffin Jones 52:48
So I'm, this is speculation, but And again, it could be just what I don't know. But it seems to me like united as loot, maybe it's just such a tiny piece of what they do. But like United at Blue Cross, they're losing. They're losing at least books of business parts of business to to these new companies. And it just seems to me like, I don't know why
Holly Hutchison 53:16
they aren't getting better at it. They're not getting better at it. Yeah, I think, you know, I think it's hard for them to hire good people. It's, their systems are incredibly cumbersome, and have so many layers and levels to them. And honest to God, one of the things I tell all my patients is, when you call your insurance company, to talk about your benefits plan and what you have and what you don't and your explanation of benefits, always get the name, the time and the date of who who you were talking to, I've had patients call in to find out about their benefit. And somebody's told them that they have benefit for IVF when they don't. And they've the all those calls are recorded. And so they complained to the Arizona department of insurance when their IVF cycle was not covered. And the person told them you don't need any prior if nothing, just go ahead and have a good day. And so they went back to those phone calls. And sure enough, they had to honor what they told her. So you know, they're so confused. Even the people who are telling you what your benefit is, or the people you call to find out often do not understand at all, what they're telling you, particularly in the world of fertility.
Griffin Jones 54:38
I think it for as much as this is important for patients. Now, I think it's really important that younger doctors know this too. Absolutely. It is really going to impact the way that you do business what you decide to do in practice. And I think as, as younger doctors think about do I want to be part of a network? Do I want to go in academics do I want to open In a private practice, I think this idea of maybe I want to form with people in a marketplace could be more important than just do I want to be part of a nationwide company. And yeah, I don't know what your plans are, how there might be private equity people listening might be hospital systems listening, I'm not talking about what you want to do in the future. I'm saying if I were a young doc, your practice is the prototype of what I'm what I'm interested in. If I'm a young, like, if I'm a young Doc, I am I'm buying into your practice. I'm having an agreement with you and, and your brother, Dr. Scott Hutchison, and I then am using that time to recruit other people we're coming into a market that is growing but is not overburdened right now with like, with like, like in LA or like it now in Austin, or a Denver market that has way too, a big way to go up. That is a great place to live. And, and then and while I'm making your brother in you and your team work with me for another however many years I'm bringing in a couple more Doc's and then now we have this much of the marketplace. Oh, and by the way, I've also increased, the EBIT de this thing's going to be worth because I brought in these other people. If I'm a young guy like you, your Pratt Reproductive Health Centre in Tucson is what I'm, I'm going to combine like if you're thinking about where you want to live to sounds pretty damn cool. It's pretty, pretty good opportunity.
Holly Hutchison 56:44
I don't know that I call it cool right now. But hey, St. Louis was heat index was 112. The other day it was only 98. It's not really that bad. But no, I mean, we have, that's one of the things I I'm very proud of is the fact that we have been able to provide great care in our industry in this city, and have a lot of fun at it have a great work life balance. And now we've brought other young people into our we don't have a young Rei yet, but all of our staff is all young people that are really stoked on what they're doing and what's going on and would love to be able to provide that assistance and help to a young, thriving, you know, just turn it into our art city is getting younger. And it's a lot. There's a lot of fertility care that needs to be done here. And the powers that be right now are old, and they're old, old men, so to speak, who are going to be leaving this area. And so having some new blood and young a young doc in this town would be that's exactly who people want to, to be able to go see. So
Griffin Jones 58:01
you've also given younger Doc's a lot to be educated about with regard to insurance and coverage and reimbursements. And so if there are younger Doc's listening that are like, oh, I want to learn more about that. Can they contact you? Can
Holly Hutchison 58:15
we absolutely, yeah.
Griffin Jones 58:16
Do you want to give your email address here?
Holly Hutchison 58:18
Yeah, it's Holly super easy Holly like Christmas, holly@ at IVF tucson.com will also be easy.
Griffin Jones 58:26
We'll also include that in the show notes for for those of you Doc's that are wondering like, well, what's this going to be like with insurance? Holly is a great resource, as has been proven for the last hour. Holly Hutchison from Reproductive Health Center in Tucson. Thanks so much for coming. Thanks,
Holly Hutchison 58:42
Greg is great to be with you. Appreciate it.
58:46
You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice drives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health