The Checkup with Doctor Mike - Viral Plastic Surgeon Who Exposed The Health Insurance Industry

Episode Date: June 8, 2025

I'll teach you how to become the media's go-to expert in your field. Enroll in The Professional's Media Academy now: https://www.professionalsmediaacademy.com/Thanks to Dr. Potter for appearing on this episode.Follow her here:YouTube: https://www.youtube.com/@DrElisabethPotterMDWebsite: https://www.drpotter.com/IG: https://www.instagram.com/drelisabethpotter/?hl=enTikTok: https://www.tiktok.com/@drelisabethpotter?lang=en00:00 Intro2:37 Starting Her Own Practice13:20 Consolidation In Medicine27:37 Diep Flap Surgery / Advocacy with Coding50:50 Inspiration And Advice1:04:25 UnitedHealthcare Controversy1:33:23 Posting Their Letter1:37:00 Know Thy Self Help us continue the fight against medical misinformation and change the world through charity by becoming a Doctor Mike Resident on Patreon where every month I donate 100% of the proceeds to the charity, organization, or cause of your choice! Residents get access to bonus content, an exclusive discord community, and many other perks for just $10 a month. Become a Resident today:https://www.patreon.com/doctormikeLet’s connect:IG: https://go.doctormikemedia.com/instagram/DMinstagramTwitter: https://go.doctormikemedia.com/twitter/DMTwitterFB: https://go.doctormikemedia.com/facebook/DMFacebookTikTok: https://go.doctormikemedia.com/tiktok/DMTikTokReddit: https://go.doctormikemedia.com/reddit/DMRedditContact Email: [e-mail] Producer: Doctor MikeProduction Director and Editor: Dan OwensManaging Editor and Producer: Sam BowersEditor and Designer: Caroline WeigumEditor: Juan Carlos Zuniga* Select photos/videos provided by Getty Images *** The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional **

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19 and over, physically present in Ontario. Eligibility restrictions apply. See Golden Nuggett Casino.com for details. Please play responsibly. Oh, hi, buddy, who's the best? You are. I wish I could spend all day with you instead. Uh, Dave, you're off mute. Hey, happens to the best of us. Enjoy some goldfish cheddar crackers. Goldfish have short memories. Be like goldfish. Pumpkin is here at Starbucks, and we're making it just the way you like. Handcrafted with real ingredients like our real pumpkin

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to be quiet. I mean to the point where to the point where a president of the society showed up at my home. That's scary. Yeah. So, yep. Like, threatening?

No, in a very nice way. And how did that go? That went, well, yeah. I know bullying when I feel it. I literally was in the kitchen on purpose with the roof leaking into a bucket. And this man who walked in the door with a bottle of champagne. And I'm like, you don't know your audience. Like, I'm all in.

I've emptied my bank accounts, and you're bringing me a bottle of champagne telling me to be quiet? Like, this is not resonating. And that was one of those moments where am I someone who's going to just back down because I'm scared? Or, you know, am I that girl from Georgia who just goes, okay, well, I know what's right. I don't know what's true. So come at me. Dr. Elizabeth Potter is a board-certified plastic and reconstructive surgeon nationally recognized for her expertise in microsurgical natural tissue breast reconstruction. But her resume extends well beyond the OR. She's an outspoken patient rights advocate

who helped spearhead the push for a dedicated billing code. A billing or CPT code is like a barcode for a surgery. If that barcode exists, insurance can scan it and pay. Essentially, she ensured that women wouldn't lose access to this state-of-the-art procedure. You might also know Dr. Potter from the viral story earlier this year where United Healthcare allegedly called her while in the OR mid-surgery to grill her about a cancer patient's overnight's day. She stepped out of the operation to defend the patient's case, posted the story to her Instagram, and suddenly millions of people got a front row seat to the bureaucratic madness doctors wrestle with every day. So today we're going to dive into how a single billing code can decide whether a woman can access state-of-the-art treatment,

what happened in the aftermath of that now-famous United Healthcare call, and why it really matters for all of us, and the evolving ethics of profit versus patient care when scalpel meets the spreadsheet. Let's get started with a check-up podcast featuring Elizabeth Potter. Starting from the beginning of your career, how did you end up practicing where you are today? Okay, so in, I mean, in Austin, I always had my eye on Austin. I thought it would be a place where, like, as a woman, I would have independence. I don't know why I had that feeling, but growing up in Georgia, I identified Austin as a place

where I could be, like, I don't know, like open and in power. Okay. Was that movie influence, personal influence? How did that? No, actually, I remember, you know, honestly, I think it had a lot to do with sports. Interesting. And then also just learning about, like, the West. And I had this feeling about women in the West that they were strong and independent.

And that was probably, you know, like influenced by things like movies and stories. But I'd never been to Texas. But so, I mean, when I was in medical school, I saw a mastectomy. And I saw the reconstruction as they were finishing. And I fell in love with it. So I'd never seen that before. And if I'm a person that's never heard of the procedure, how would you describe it to me? Yeah.

So when a woman has breast cancer and has a mastectomy or has her breast removed, there are surgeries to reconstruct the breast. And those are actually covered by insurance under the Women's Health and Cancer Rights Act of 1998. And you can reconstruct that with an implant or with natural tissue. So I saw a surgery where they used a woman's own tissue to make her breast, like she went to sleep,

had mastectomies, woke up with a breast made out of her own, like, tummy tissue. And just a lot of things clicked for me, seeing that. being a woman um body image issues my grandfather had lost his legs like just like losing there was just a lot that just just really resonated and i leaned in and and went straight for breast reconstruction that's a a long journey that you were eyeing for yourself because that's not a quick path right no so i went um finished med school at emory and then four years four years then plastic surgery at southwestern and that was five years five years five years

Yeah. And then another year, a fellowship at M.D. Anderson. So let's see, Emory Med, then, yeah, it's a lot of years. Yeah. And the main passion for you from that case, what sticks out about that patient? Was it your conversations with the patient, just watching the surgery take place, like the skill set required to perform the procedure? What did you see that motivated you to connect so strongly with the field? I think it was, so I felt this feeling, in the operating room where it felt very controlled and like harmonious. It was like a zone. I felt as I felt that I was in the zone.

Yeah, it was in a flow state. Even as a medical student, something was like the bells were ringing and the birds were singing and I'm like, something is special here. But it was really rounding on that patient afterwards. She had traveled from the West Coast to Atlanta to have that surgery. And even back then,

I was very impressed by how hard it was for women. in to get health care and to get the kinds of health care that they wanted, like the surgery she chose and how much trust she placed in the surgeon performing that surgery. Why did you have to travel so far? Is it not uniformly available to? No, even back then it just wasn't very common. Still today it's not. Like there's not a lot of folks like me around. There's maybe like 200 microsurgeons in the country who do breaststroke instruction a lot. So it's not an easy surgery. Is it lack of training spots, interest? What is causing a limitation? That's a great question. I'd say it's a lot of different things.

Plastic surgery, the folks who go into plastic surgery, the majority of plastic surgeons do cosmetic surgery. Fair. Yeah. And there are many reasons why breast reconstruction isn't broadly available. One of them is reimbursement. And so any plastic surgeon has a skill set leaving training that they can make a lot of money with. Because they could monetize directly.

to the consumer and don't have to deal with any of the administrative burden of working with an insurance company, hospital administrators, et cetera. Is that a fair understanding? Yeah, and they can set their price. And the reimbursement for breastry construction is painfully low. And we've fought that. But I mean, I think that a lot of plastic surgeons just look at it and go, it's not worth my time. And I sort of set out from the beginning to create a case for breastry construction. Like before any of this happened, I said, I'm going to show that this is a viable career path so that other surgeons like me who love the work will follow through and do this with excellence, not just do it for one or two years as they're starting to build up their client base for their cosmetic practice. Right, right. Yeah, because I see a tremendous similarity in the through line of what you're describing with breast reconstruction and plastic surgery along with psychiatry and psychologists.

So when I'm trying to get mental health access for my patients, which is quite often being a primary care doctor, the people who are good or who are most experienced require cash payments up front, usually large some. And then the ones that do accept Medicare, Medicaid, some of the simpler insurers that have a tough time with reimbursements, they're not taking patients. Or there's a six-month wait, or they're falling in and out of plans. So I'm basically putting this impetus on my patient who is already in a dark mental place, lacking motivation, to say, hey, get motivated, call 10 places, get rejected from five of them. One will cancel on you. And the one that you do end up seeing, if you don't like them after the first visit, you have to do that process

all over again. Welcome to healthcare. Similar trajectory of the field moving away from what its intended path was to where the incentives led them. Absolutely. The financial incentives, if we're being honest about it. And also just the system. The way the system's built. I mean, it's gotten more and more cumbersome for doctors to practice within the insurance system,

even if they want to, even if the reimbursement's good. Yeah. You know, just the overhead of doing that and how hard it is to jump through hoops. And, yeah, so I think that there's a lot of similarities there. For me, it's, you know, a cancer patient who's already, I mean, they're so day. down and out. They have no extra energy to fight a fight to get breast reconstruction. If you put up

an obstacle in their path, they're probably just not going to get it. They're just going to have a mastectomy and, you know, fight that fight another day or maybe not have reconstruction. So I really, I really wanted to demonstrate that this could be done honorably and fairly and like with excellent outcomes. And I was on that path, like full steam ahead doing that. I even built my own surgery center where I like, I mean, took up personal loans, right, and built that myself to say, I can do this surgery in an outpatient setting and save money and have better outcomes and have a better experience for women affected by breast cancer. And it was like full steam doing that and trying to try and to negotiate with insurance companies to be in network with that. And then all of the

other happened too. Well, I applaud you for doing that because most doctors, largely how complex the system is, are afraid for one reason or another to go and be that trailblazer. And without trailblazers like yourself, we won't see change happen. So I think that is one of the most important things that you're doing. And we actually have a similar relationship with a psychologist and psychiatry group that is trying to do the same in New York, where they're opening up a huge practice in order to accept patients who have lower forms of insurance. totally and use it as a viable path hopefully to motivate others and they reached out to us and ironically the person starting it was a med student that shadowed me when I was in my residency

program and he said can you recommend from like a financial standpoint what alternative monetization pathways can we create so that it sort of acts as a funding to actually take care of these patients because the insurers are not subsidizing and paying for the care that we're giving patients, we have to be unique or think outside of the box to actually turn a profit. And that's so ridiculous that that has to happen. What strategies did you use in order to fill that gap or subsidize the care so that everyone's getting good quality care, but you're still having a viable business plan? That's a great question. And it's one that I'm still working out. I think for the first many years of my practice, I just played the karma card. Okay. And I really just said. That if you do the right

thing he'll come back. Yeah. Fair. I did. We did the same thing on this channel, by the way. Okay. Right. Yeah. So, and I'm like, you know, I was in my late 30s, early 40s, and I'm like, I just know it's going to work out. And I've never met someone as, you know, committed to this as I am, and I'm just going to do the right thing. And the world is going to see that. And I would use the money that, you know, if a case paid me better, I would do the other case for free. And I never turned anyone away, you know, Medicaid, Medicare, try care, all of it. I never have.

And I tried to negotiate with insurance companies to get better payments, and that was just impossible. Was it you doing it as an individual, or did you have a group of local people that you were working with in the same specialty? I mean, I hired consultants and paid a lot of money to do that. And, you know, so frustrating, you know how this works, that in the same zip code, like I can find out what other doctors are paid for the same surgery that I'm doing and I'm underpaid in my zip code and they just don't they don't and is that because you're out of network or what's leading you to be paid less than them I'm in network for everything so then what is the reason for the disparity it's just they so there's no transparency so how are you able to find out their health talk of and when you're finding that out do you have a reason why they're

earning different sums for reimbursements no and that's still quite an important question that all doctors need to be asking, like, why is it that in the same zip code that a doctor, maybe even with less experience than I have, is paid 30% more than I am? Is it due to a bargaining power of a group that they're part of? It seems arbitrary, almost. But certainly what we're learning is that with more consolidation of groups, that those groups get better rates and the facilities and all of that. And that's part of the...

Well, that's why a lot of the solo practice offices are... closing left, right, and center, even in primary care. The idea of a family medicine doctor having their own practice doesn't really exist anymore. It's all group practices, largely because of the administrative burden required to do the negotiating, to do the arguing, the billing, the coding. And it takes the doctor's focus away from the art and science of practicing medicine and instead puts more emphasis on the art and science of making sure your notes are good and making sure you can negotiate and upcode liberally. Yeah.

I mean, gosh. So my dad was a doctor. He was an allergist in a small town. So I grew up around medicine. My mom was a nurse. And I really think that what you're describing is a phenomenon that's happened, you know, in the last 15 years. It's really been since the Affordable Care Act and the vertical integration and consolidation

in medicine. And before the affordable. Care Act, 75% of physicians were self-employed, and now 75% of physicians are employed by large entities. And I mean, that's, we're losing, we're losing that personal aspect. We're losing the, like, the magic of medicine where, um, no matter what decision I make, I'm always going to be, like, thinking about the best health of my patient, right? I don't have a fiducius. responsibility to shareholders in my practice to maximize the income from this encounter. But when you have huge companies now controlling the strings,

you know, we've seen this experiment for 15 years and we're living the result. And we actually, it doesn't just feel wrong. We now have data to say it doesn't work. Vertical integration isn't helping us take better care of patients. it's not making more equitable, you know, health policies. It's not even decreasing the price per capita. All the things that they said it would do, it's not doing. Right.

So it's increasing profits. Oh, it, oh, yes. And creating multi-billion dollar businesses. Right. And then these, you know, these huge industries that, you know, are paying themselves, right? So the whole, the whole fact that we should probably also jump in, because I know what you're talking about with, horizontal versus vertical integration. You have companies from a horizontal standpoint,

let's say one pharmacy is taking over a branch of other pharmacies. That's considered horizontal. But then you also have vertical consolidation where you have an insurer buying a pharmacy, buying a PBM, buying a medical practice, and then essentially doctors. And that vertical consolidation ends up becoming harmful largely because of the lack of competition. They essentially start squeezing out their competition through financial pressure, through poor agreements in bargaining. And it's a mess. And where I've seen it be the worst type of mess where it's so clear that it's unethical is in the PBM world, these pharmacy benefit managers, that were initially started as a way

to save us money. And that was the premise that was sold to us as the public. And we were like, cheers, yay, they're going to save us money per prescription. And then it started being a business where they said, okay, if we save you $2, we'll take a dollar. And then through vertical consolidation, they became part of the problem, essentially fake saving you money, but essentially making money from themselves, where they're now worth billions of dollars. Correct. To put an analogy that most people understand, the coupon company has become a billion dollar company. And that's not regulated.

No transparency. and none of the federal regulations that apply to the insurance company, the mother company, apply to that company. So, I mean, I think to add to that, there's also the sort of 8515 rule that was interjected with the ACA. Simply, an insurance company is supposed to spend 85% of premiums on health care and quality improvement. So, like, on taking care of you.

And that other 15% goes to wherever they want it to go, if it's to shareholders or CEOs or whatever. So one of the ways that vertical integration has been gamed is that they're now paying themselves, right? So to get into that 85%, they can say, okay, the cost of this drug is part of the cost of care for the patient. But they're actually just moving money from the right pocket to the left pocket. Yeah, exactly. Right? So it's cost, but they never left the bank.

Yeah. And all the while, if they can make the whole pizza bigger, the whole pie bigger, than that 50s. 15% on the top. That's how you get someone, you know, at United, who's making $64 million this year. Because if you can make the whole pie bigger, then that 15% is sweet. And the rest of us have to deal with the fact that we've just increased the cost of health care to make, to make them more money. Right. And that cost is sometimes hidden pretty well because they'll move it around from your monthly premium to your deductible to your co-pay. And you might say, oh, well, my annual amount that I'm spending on the monthly premium isn't that much

different. Yeah, but now you're paying double the amount when you go see the doctor. Now, when you have a major surgery, the cost that you have to incur on your own is much higher. And when they do that, they create really good press hits surrounding it, where they say, well, look, premiums didn't go up. Well, what about all the other things that you've packaged into it? Correct. And I see that not just as a physician, but probably I learned more about it running a small business in paying insurance for the employees of our company where I look at the cost.

I'm like, oh, my God, how do people afford this? The cost is become absolutely astronomical. And I'm curious how that plays into you running your business and how it changes the way you take care of your patients. Gosh, okay. So, I mean, at the heart of it, I always try to just do the right thing. I mean, I do.

And that's where I'm not trying to game the business and I'm not trying to make more and more money. Well, you're trying to do the right thing health-wise for your patients versus some of these private equity-owned industries are thinking about the profits and the doctors and the clinicians are thinking about the patients. Totally. And it creates this tension that even,

I don't know if you watch a show The Pit on HBO. You see that where, you know, he's saying we're taking care of patients, we're doing the best we can. You need to increase satisfaction. You need to increase the amount of patience scene per hour. And it's like, well, do you want us to deliver good care? Do you want us to see more patients? Listen, are we, do we want more money and higher throughput?

Or do we want quality? Right. And we just haven't decided as a country what we're going after. We spent the last 15 years going after, you know, money and numbers, right? How do we get more efficient? How do we see more patients? How do we do more cases in a day? And it's just demoralizing.

And that's where all of that, you know, that moral injury for a physician comes into play. Even talking with physicians who work as within insurance companies doing peer to peers. So I've had some private conversations with folks doing that. And they say that's exactly what it is. It's like, I have to do 20 of these a day. And I'm only judged on how quickly and, you know, how quickly I can get this off the plate. I don't have time to to dig in and look at the data, right? If I'm doing a peer-to-peer call and, say, a breast reconstruction case, like, I have, there's no way that I'm going to actually inform myself about that.

They just want me to deny it and move on. And if I, if I approve it, then someone leans on me. So, yeah, I mean, I just think across the board that we have, you know, like in, in chemistry where you have the equilibrium. Yep. No, Lechette Lechette principal, like where it's like the balance. That's like way back to a place where I don't want to go. I know, I know. But I feel like we have this equilibrium and we're supposed to have a good position where we have, you know, it's America.

We have the business of medicine and we have health care, like the providers. And we want the patients to be somewhere on this balance where they're getting great care. And also, you know, the industry is healthy and the workforce is healthy. and they're well paid and all of that. But we're so far away from giving good care and so heavily towards making money for insurance companies that we've lost it. Like we have to reset in a different place

and that is going to be so painful for the industry. Yeah, very painful. And they're smart in the sense of they're doing it in a way where most people don't see it. They'll create these roadblocks that seem really reasonable. Oh, we're preventing fraud, abuse of the system. And that's reasonable. do that. That's good. Let's not have fraud and abuse of the system. We've seen issues with huge

cases of people abusing Medicare, Medicaid, millions of dollars, fraudulent screening programs that end up getting people procedures they don't need. But when they're creating these roadblocks, they're creating them to decrease spending, not to eliminate abuse. Because if you see who is getting rejected, for every one abuse case, I mean, there's got to be hundreds, if not thousands of cases that are rejected simply as a cost-saving measure. And I remember this from a TV show I used to watch on Showtime, House of Lies, where they were marketers. And they said, oh, hey, we'll get this promotion that will give people a rebate off of your product. And people will be so happy. But by the way, we know that most people won't go through the hoops required to do it.

And then we'll deny the first set of them. And then the second set, only 1% will end up converting. So you're going to save a whole ton of money. Oh, my gosh. There's so much to say. There's like, right, it's the fact that only 1% of denials are appealed. Yep. So, so say you want to decrease fraud and abuse. Well, they're not just decreasing fraud and abuse. They're denying everything. Yeah.

The good stuff and the bad stuff. And even when the things are appealed, over 50% are denied. Again. So that's baked in to, to the business plan. Yeah. Right? I've seen some stats from the Kaiser Foundation where like 18, 19% of, in-network, insurers are denying cases, claims, et cetera.

And then out of network, it gets up to double, even more than double, 37, 38%. Think about the number of that. It's over three out of 10 claims are being denied. And while certain insurers say, well, it's better for us, ours are lower. I don't see that happening as a person who deals with it holistically on a large scale. I don't know if you do. Just back it up and think about this. Like, we have people paying their hard.

earned money for premiums because they expect that their risk is being reduced in some way. They're being taken care of in some way. And 20% of the time, they're being denied. And what is the reason for denial? It's usually administrative or other. It's not medical necessity. It's not there's, it's administrative or other. It's a technicality. Yeah. And they thrive on that technicality. Right. And I think it also, when you think about businesses that are this large, if they can dial up and down the expenditure, right, if they can deny enough where they know what the inputs and outputs are, right, that's helpful to them. It doesn't, it's more predictable as a company. It's also like, you know, the accounting in these companies,

you just have to wonder, like, they're just moving money around with all the different vertically integrated components and in an insurance company you have to have reserves too so you take out of the reserves and i mean it's very complicated it's not resulted in better care for americans in the last 15 years and and we were we were sold that right there was a a big study in 2008 that looked at it was called like the triple aim in health care and it was this revolutionary idea that okay now to have good health care to have a good health industry we're going to have to address um you know these three components, and they were like, let's see, cost per capita, the patient experience and patient experience of care.

We'll fill it in. Okay, sorry. So basically, it led to us doing vertical integration, right? It was like, this is the reason why we need to do this. Yeah. Okay, so come 2022, and they're like, oh, darn, that actually didn't work at all. And now they've added in, you know, we actually need to look at health equity. and we need to look at the workforce health

because we didn't think about that before and we've set ourselves on a course that we're crashing. And then in 2022, Congress asked for the RAND Corporation to look really hard at that and they did this study that's so dry and so boring to read but so eye-opening because it's like, oh, let's look and see. Did insurance company consolidation help

health outcomes? Looks like it didn't. Okay, let's look at, you know, physician ownership by insurance companies. Did that help lower costs? Looks like it didn't. And they just go dispassionate through all these things. And it actually hasn't helped. So can we just, can we just admit it that this whole creating monopolies of insurance companies has not helped us? And we need to, we need reform. And I think we need competition and transparency. Bank more on course when you switch to a Scotia Bank banking package. Learn more at scotia bank.com slash banking packages. Conditions apply. Scotia Bank. You're richer than you think. Yeah, all important factors. And I want to get back to your story. So you wanted to open up

this practice that was doing things the right way. Yeah. Working with all insurers, perhaps pro bono at times. What was the journey like starting it? Troubles, issues, hurdles that you faced along the... Yeah, I mean, I think, you know, just the funding for it, that was hard. It's hard to start a practice, a solo practice. But I think when you take excellent care of patients, the money was coming in, you know, and I do a lot of volume, because I take care about 40% of the women in Central Texas with breast cancer. I mean, it's just, I do 20 cases a week, see in a normal week, just me in clinic, I'll see 60 patients. And that's on two days. I do about 500 cases a year. So like just in volume, it did a couple things. It made me excellent.

So by there are, there are great things about doing a lot of work. It made, it made me take deep flap surgery from a surgery that took me 12 hours to taking me four. Right. So like, I love that. And I'm all about efficiency and safety for patients. And that improved safety because last time under anesthesia is a thousand percent, yeah. And I would never have been able to do that if I had been cherry picking only the cases that paid me a lot. So by taking care of so many people, I was able to get better at this. So it seemed okay. It was okay for the first five years.

And then reimbursements just started to go down and down and down. And then there was a big reimbursement change where. They made the code the same. Yeah, they made the code the same. And that's when I first stepped into kind of advocacy and wound up in D.C., just saying this is ridiculous. That's also when I first felt like, are you guys kidding me? I'm a doctor. What did it shift to and from?

And how did that impact percentage-wise your practice? Okay, so the reimbursement cut was like over 50%. And the danger was that it would be cut to 10%. percent. So by 90 percent. Wow. Yeah. And we know that. And what was the initial code coding for that then looped in your new code as well or your previously new code? So it was a CPT code 19364 and that code says breast reconstruction and it includes any free flap and that could be a surgery that takes all of a woman's muscle or one that's super elegant and leaves her able to use her muscle, right? It just didn't recognize the difference between those things.

And then the other code was an S-COD, S-2068, and that was the code for the very elegant surgery. So when the societies decided to combine those codes together, and they actually put under the descriptor for 19364, they included like all of the elegant things and the garbage things. And the reimbursement stayed at the garbage rate. Right. Right. And I was just, I'm like, why are you doing this? What was the major organization's reasoning for making the change?

You would have to ask. Do they put out any statements about it? You know, I would say that that was a very difficult couple of years. And there were some meetings that were very difficult. And I think that today that the American Society of Plastic Surgeons has evolved from the place where they were when they agreed to that coding change with the AMA. but I still have a lot of strong feelings about the fact that it ever happened. And they never allowed the code to be,

like they still haven't recommended that the code be rewritten. They've just allowed for the existence of an option. That world is very dark. The world of the CPT code and the AMA is very dark. And I mean, by the way, the coding book is, you know, it's published by United. It's Optum and the AMA.

And the AMA makes, what, $200 or $300 million a year on that? There's a vested interest in continuing that status quo there. So, I mean, we could have a conversation about RVUs and how doctors are not. I mean, that, it's broken, but people are heavily invested in the status quo. From a lobbying perspective. Lobbying, but also just the existence. of, I mean, we're locked into a system currently with RVUs that doesn't value physician work. Like, all it values is, for me as a surgeon, like the time in the operating room, like the malpractice and the overhead.

It doesn't reward me for doing surgeries that have better patient outcomes. Like, the patient is even factored in. It's that system. And for folks who don't do procedures. Yeah. For us in primary care, it's strictly numbers. It's a quota game, basically. It's ridiculous. I mean, for my dad was an allergist. It's like, really, you know, you guys, you're thinking about really complicated things. You're spending a lot of time meeting with people who have a lot of complicated intersecting systems at once. This is why concierge medicine happened. Of course. Right? And that makes complete sense to me. Because we have, you get what you value. We set a system in place that doesn't value that physician work. And so, everybody's played the game. All of us, right? We're trying not to, and I mean, physicians everywhere are fighting it, and we're trying to still provide care, but you can't not pay physicians and expect that patients are going to get great care. Like, it just doesn't work that way. Well, once the

incentives change, you're just pushing people away from performing good work. Or being doctors at all. And now we're going to have a shortage. I mean, you know, let's just play it out, right? We will we will learn a lesson. Will we learn from the lesson? I don't know. But I think we're all in the middle of learning a lesson about health care in the U.S.

It's ugly. Yeah. So you were saying that it's not just the lobbying efforts to RVUs. You were saying that there's more involved on the back end from the CPT codes

and the AMA's role in this. Yeah. I mean, I just think that, you know, I'm not a conspiracy theorist, but having spent a year and a half of my life advocating for a coding change, I spent a lot of time in D.C.

and heard a lot of stories and saw, I wanted the right thing for patients. It was clear that we needed to reimburse appropriately for surgeries that helped patients. And we're talking about women with breast cancer. People on both sides of the aisle agreed. And it always came down to money in the codes. Always.

The government was like, we won't price fix. We won't price set. I'm like, what are you talking about? Like, you guys do that all the time. You put a number on it. Say what's too little to pay and what's too much to pay. They don't overpay, but don't underpay. Right.

And then, you know, the CPT system, that editorial panel and the whole, the way it works is just so broken. I mean, sending out a survey to 40 surgeons in the United States asking, do you perform deep flaps, just like randomly to plastic surgeons and how much times does it take you? This is not science. This is not the way that you come up with a system that rewards. or that guides reimbursement. So the differences between the codes as how they used to exist. If you could lay that out in a simple way for me, this code represented this type of procedure,

this code represented a higher level of procedure. Why was that considered higher level? What benefit did it give to patient? And what has now been taken away by grouping the two codes? Okay. So simply put, S2068, for you. deep flap. That describes a code, a surgery that is far better for patients, doesn't leave them like disabled, basically, by removing their entire rectus muscle and is better in the health care

system, right? So we have patients who are using less opiates, less pain, less pain issues with surgery. They're not staying in the ICU for multiple days. Their length of stay is, you know, not five days. It's maybe one or two or three. and they're able to thrive, right? They leave this experience of having had breast cancer and reconstruction, and they're able to go and live their life and run a marathon and do what they want to do with their bodies, right? They're not just disabled from the reconstruction.

So that surgery, I think the national average reimbursement, I would have to look back at this. I don't want to miss say it. I think it was around $20,000 for a deep around that. And it might have been, it might have been like 15 to 20. the reimbursement rate for $19364, $2,700. Okay? So that reimbursement is, honestly, I'd say, if you're taking a woman's muscle and you're doing sort of this barbaric surgery, like, I understand not paying a lot for that.

I get it. Now, forgive me for my ignorance on this. Why are people even performing the worst surgery? It sounds in every aspect worse. It's easier. The difference is that that surgery is easier on the surgeon and harder on the patient. It's not elegant at all. It's not, there's basically, the hardest part of a deep flap surgery is me saving the muscle.

Right. It's really hard and delicate. And I'm getting right up against these blood vessels and I'm protecting them so that I can save the muscle. And the other surgery, they just cut the muscle out and they never, and the vessels inside it. So, yeah. Is the field in general moving away from that older procedure? That's hard to say. Yeah, that's hard to say.

Is that a push that's being made? We've made that push. And I think in our efforts with coding for that year and a half, we made that case very strongly with the American Society of Plastic Surgeons. And now I think it would be much more common for people to acknowledge the difference between the two. but our specialty has a long way to go. It's incredible that in a day and age where we have just a superior treatment available, and yet we're saying, well, the other one's cheaper,

so we're just going to do that one when it has worse outcomes, and it seems like every sense of the idea of giving someone a medical care. Exactly, and that's why I was like, this can't be. If I could just make you understand, then we would change it. And so the win that we got at the end of that year and a half was that they kept the existence of the S code. So CMS agreed. The CMS said...

So it's like a modifier? No. So the S206-8 exists now. So CMS said, it's a very long and complicated story, but the government got it. And they said the only thing we can do here is... Mandate the existence of the code. That's the only one we have control over.

The CPT codes, that's up to your... society and the American Medical Association, and we do whatever they tell us to do. That's just how it's always worked. So those two organizations would have to agree that they didn't, that all of these surgeries weren't the same. So it's very, very telling that the AMA and the American Society plastic surgeons wouldn't do that. And so still today in 2025, 19364 describes all of those surgeries.

They didn't do what they could. The government did what they could. CMS said, we'll keep this code. Because I made the case to them. We made the case. We just need this option. The AMA and the ASPS aren't moving. We don't know why.

It doesn't make sense. So when you write them or have meetings with them, what happens? For the first year and a half, when I first did this, like the first phone call I made to the ASPS, they didn't even know what was going on. Like I sent an email to one of the presidents, and he was like, I'm not aware of this issue. I mean, this is a cosmetic, a cosmetic surgery society.

They just, they didn't know what they were doing. And then I had a lot of meetings and got, you know, I hired lobbyists myself and I got surgeons from around the country to call the ASPS and other societies to weigh in and make the case for patients. And we got patients involved. And they started to evolve under pressure, right? But that was not comfortable for me at all. I mean, they, there was, there may have been a video that circulated of me that was

circulated by the ASPS that was labeled disparagement. Then it was me talking about this issue on social media where I said that they should do better. And, um, and they circulated it in what way? Via email. Saying what? Saying that I was disparaging the American Society of Plastic Surgeons. Hmm. Because they were offended.

Mm-hmm. Okay. Yeah, they didn't agree. So I'm just saying, like, if today, they would say we support deep flaps and we support microsurgery that doesn't hurt a woman's muscle, I will tell you that in 2022 through 23, they leaned very hard on me to be quiet. I mean, to the point where, to the point where a president of the society shows, up at my home.

That's scary. Yeah. So, yep. Like threatening? No, in a very nice way. And how did that go? That went, well, yeah.

I know bullying when I feel it. And so I stood in my kitchen and my husband was there. And one of my dear friends who was also an Olympic athlete. and I just wanted witnesses. And she watched. It was me standing my ground for patients. And I made the case. And I just said I'm not stopping.

Like here I am in my house. Like I literally was in the kitchen on purpose with the roof leaking into a bucket. And this man who walked in the door with a bottle of champagne. And I'm like, you don't know your audience. Like I'm all in. I've emptied my bank accounts

and you're bringing me a bottle of champagne. campaign telling me to be quiet? Like, this is not resonating. And the hope was that you'd stay quiet and they would continue doing these codes? Yeah, it just, they, they were meetings where they said, it just, we have looked into this and it's not in the interest of our members. This is not in the best interest of our members. And so what they mean is cosmetic surgery, right? They looked at the number of microsurgeons, the number of folks doing breast reconstruction, and we're such a minority in the whole society, right? There's 8,000 members and there's just a couple hundred of us. But my point to them was, but there are patience. If you are going to be my society, then you have to care about

this, right? And so there was a Zoom call where a lot of folks chimed in and weighed in, and they laid out their case for why they didn't want to change this code. And it included things like they didn't want to, quote, open up the codes, which means they don't want anyone else. I don't want any other codes to be looked at. So they were protecting all the other codes in plastic surgery. Like they didn't want to put a precedent in that these codes are. Right. They said, open to modification. Yeah, they said, oh, whenever they look, if they open up this box of worms, they're going to decrease reimbursement for everybody, not just for you guys. Right? And I was like, I... But why would they decrease reimbursement? Well, their case was that the government does

that. That when they opened, that historically, but I mean, I think this sounds just like a threat. This just sounds like gaslighting, right? Yeah, it sounds like the, the opposite of what would happen. Correct. And that's the opposite of what actually did happen because I didn't shut up. And I just went another direction.

I went straight to CMS and the lobbyists did their job and lots of law, lots of members of Congress weighed in and were supportive. But no, the society, they just, they had their reasons.

And the first time I saw them really come around was when we had our meeting with CMS. And they sat there. I think they saw, the fact that I got a meeting with CMS, right? And we had literally thousands of people writing letters and we formed a coalition of nonprofits. They had to show up with a different statement.

And there's no sub-organization that works specifically with breast reconstruction. No, there's the reconstructive, like in the Microsurgery Society. It's really small. And around breast reconstruction, they kind of seem to do what the ASPS told them. Specifically with regard to that surgery, the person who was the president of the society

or the former president of the Reconstructive Society was still performing that surgery, the one that removed muscle. Right. And like advertising it. I mean, that's how much they cared about this issue. It was like, okay, if you're not performing the better surgery.

Don't speak for them because we won't say who that individual is. But if I ask them, why are you still performing the surgery where there's a better one available? What would be their response? That's the one I know to do. Even though it's significantly more harmful for your patient. I think so. It's so much harder.

It's very hard to do perforator flap surgery. I mean, the focus it takes, but I would say it's better to do nothing than to do a surgery that removes a patient's rectus muscle. It's better to just send them to someone who knows how to do a better surgery. And I'm surprised that organizations that perhaps are not focused on the reconstructive side of things, Coleman, some other breast cancer organizations,

they weren't participating in advocacy alongside you? They were. Oh, they were. They got on the coalition. That's how this changed. Got it. Yeah, I was talking with the American Cancer Society, Comen, like we had a huge coalition of nonprofits.

We had patient advocacy. That's social media. That's why this changed. Got it. Because I got nowhere with the traditional paths. Nowhere. Nowhere with my society. Instead, I, you know, paid for lobbyists and I went to D.C.

And how did you, you said social media? How did you use social media to make this happen? We just had Instagram lives and we talked about the issue and introduced it to patients and just said, write your Congress people. And then we had, we made that easy for them. I went to the hill with patients. It was a huge movement. I went to, there were probably, I don't know if it was,

I don't remember the exact number of patients that signed on the letter. But in the breast cancer community, people know that that happened nationally. They were a huge force for change. And that taught me about, you know, the power of the patient and the power of social media. I have to ask, how does one hire a lobbyist? Well, I just called them up. And they were, it was, they were, um, one 800 lobbyists. Where do you find a lobbyist? You know, no. So, I mean, I asked, um, some friends and a friend who was familiar with the issue said, you should call this person. And I called. And that lobbyist, they were great. And they saw, they saw the issue for what

it was. And like everybody, they had an experience with breast cancer and their family. And, um, yeah, they, they went to the mat for us. So they basically get you connections with people who are in charge of making these decisions, the committees, congresspeople, senators. Is that how it works generally? Yeah. Well, they got connections with the offices and asked for meetings. And then I would show up to D.C. and go have 20 minute meetings. And you're not getting compensated for I want people to realize that. Oh, no, I'm paying for the privilege. Yeah.

Right. Yeah. I'm paying a lot of money a month for this. It was actually $10,000 a month. Wow. Yeah. And you had this success. You got CMS to hear you out to make the change.

What did that victory feel like for you? That felt like, I, I breathed a huge sigh of relief because I was afraid that my career. that my career and the practice of breast reconstruction for all of these patients was going to come to an end. I really felt like that's where we were going if we couldn't honor patients in this way. If we couldn't take care of women, just this very simple argument, if that wasn't understood at the national level, I thought we were headed for disaster. So I just felt relief. But yeah, I mean, I'm not someone who celebrates well.

Like, I'm not, I always, like, I'm on to the next. But since that time, I know that that's changed women's lives around the country. And they've told me that. And I've heard from patience and I'm proud of it. I wouldn't change it. I wouldn't change it for the world. It definitely got me ready for United. Because literally, like,

I'm not scared. Yeah. That was like a warm-up. Yeah. And when United reached out and I felt those feelings in the moment, yeah, I had all the feelings.

But I also had an experience to draw on where I was like, ah, I've been up against somebody before. I've overcome before. Yeah. And I know who I am. and I'll take it back. I'll take it back. I was scared. I was scared. But I know how to do this. Well, if you weren't scared, something was wrong. Right. But yeah. And it's also like, so I'm glad. And like so many things in life, I'm really glad for the experience that I had advocating and dealing with societies and people who bullied me. Right. I'm glad for that experience. It made me stronger. And,

It made me ready. When I found out my friend got a great deal on a wool coat from winners, I started wondering. Is every fabulous item I see from winners? Like that woman over there with the designer jeans. Are those from winners? Ooh, are those beautiful gold earrings? Did she pay full price?

Or that leather tote? Or that cashmere sweater? Or those knee-high boots? That dress, that jacket, those shoes. Is anyone paying full price for anything? Stop wondering. Start winning. Winners, find fabulous for less. This is missing in society quite often.

Purpose. But you're like exponentially elevating that purpose. You're showing up for your patients as best as you can to accept all insurers. You're performing procedures pro bono. You're being the best doctor that you can by minimizing time that the surgery needs, how much time the patient's under anesthesia. And then you're like, well, I'm not doing enough. And you're like, I'm going to put my own money in to lobby to get this foundation,

foundational change to happen. How do you drive yourself to do all this? What's your motivating principle there? When you say it, it sounds much more impressive than it feels on the inside. But I think it's just... Well, I think this is, you should feel it. This is, it's bigger than I'm even saying. it's um i feel my i feel my sense of purpose deeply and this is like this kind of conversation is like

where i'm this is where my superpowers are right because there is something deep inside me that just says do the right thing and i like the hard thing right i like finding out who i am i like the experience of of getting uncomfortable and going like recognizing that that's an opportunity um and i also know that that that's not something that everybody's willing to do and so that makes it feel like it's a place to make change right because if i'm not willing to do it who else will be i just it's hard to explain but how do you develop that moral compass? I think that goes back a long way, probably.

I think that I listen to patients and I'm listening to what they need and they don't just need a good surgery. They need for me to care about their whole path, right? And I do. And so for me to care about patients with breast cancer, I have to care about doing a surgery that's healthier for them. I have to care about insurance too. I have to care about their financial health. I have to care about how, you know, the hormone blockers make them feel. Like, sure, I'm a plastic surgeon, but I'm also just a human trying to lean in as best I can

where I've got influence. And that feels good to me. So like I learned somewhere along the way how to like, in a very meta way, kind of cheer for myself. I didn't do that when I was a kid. I was always motivated to work really hard, but I wasn't, like, internally proud of myself. I can now look at myself and go, I'm glad you're doing that. I know it's hard. And that sounds really weird, but it's motivating. Like, even in the hard moment, I can, I know who I want to be. And I'm proud of myself for doing the hard things.

If you had to give advice to someone that was listening, right now that wants to develop that. Is there any tips you can give them? Gosh, yeah. Get to know yourself. Really get to know what drives you. And don't judge it. Like, just figure it out.

When do you feel good? When do you feel like you're in your zone? You know, for me, like there are specific things that I do every day that get me ready. And figure those things out. I think, um, accepting discomfort, being willing to be in those moments, and looking for opportunity. There's so much of this is about perspective, right? You don't have to go out and seek some experience to do this.

Like, just live your life. And in those moments where you feel like there's a challenge, just say to yourself in that moment, what's the opportunity here? Why does the universe keep presenting me with this challenge? What have I not learned yet? how can I get better? How can I make other people better? How do I change the temperature of this room?

Right? What's the legacy I want to leave? I mean, I literally think about these things all the time. And I'm open with my friends about it and my family. I think maybe even just... How do they react to it? They love and respect me now. But I mean, to the point where...

I mean, I hope they love and respect it, do people. No, they do. But I just mean, I think it's... um what i value right like when i you know spent my savings on on lobbying and all of that or even going up against united um you know having conversations or i would say you know i'm not going to leave you an inheritance but i'm going to leave you a legacy and that sounds like a like a line but i mean it like i'm not i don't have kids i don't want to leave here with a bunch of money, I want breast reconstruction to be different because I was here.

Now I want health care to be different because I was here. I want the way that Americans interact with insurance companies to be different because I was here. So, yeah, there were those times when, you know, the nieces or nephews were like, you're never around, you know? And, yeah, that's a sacrifice. And, you know, I do need balance just like everybody. but I know that my family is proud of me. Yeah, and that, that means a lot.

I mean, I'm just a kid from Georgia, you know, like my family was very humble. And I've always known what it's, yeah, my family means a lot and where I came from means a lot. So, yeah. It's hard because. you look at yourself as a kid from Georgia, but you're much more than that. And you're much more than that to not just your patients, but to people you've never met that you're having an impact on.

Have you heard from individuals who've had their lives changed by the procedure that you advocated for? I have. And that's so heady. Yeah. Right? And I would love some advice on how to process that from someone who has this impact around the globe.

you know but I'm just so thankful for that and it's reinforcement it helps me know I'm in the right place and I like receive that and every individual matters and that just it's like why be on social media why even do this well you can you can affect more people they're people who need to know there yeah I think it affects me I hear from people all the time

and it's almost like unbelievable all I can do is I kind of put that to the side and just keep moving forward trying to do the next right thing right right because I feel intensely

that I'm in I'm in a zone I'm in my purpose I'm on the right path and and it's like all those times when I told people, you know, where it's uncomfortable, there's an opportunity. I'm like, oh, my God. I need to stop saying that.

There must be so much opportunity. Like, this is so uncomfortable. Right. It's so uncomfortable. But, yeah. Do you ever feel like you're in a video game and the stamina bar keeps dropping? But then every time you get one of those letters or statements from a patient, it kind of refills it, like a little booster? Even just last night, like on the plane, you know, lately, like sometimes I get a little, I say,

again, me saying I'm not scared is not accurate. I am scared. I have moments that are more scary than others, and I've had some of those recently. And I worry about, you know, the pressures being applied to me. And I saw some comments that were posted on a video that I did. I don't know, like a month ago. Okay.

And it was like, keep doing what you're doing. You know, it might be scary, but you're changing the world for the better. Like those kinds of things or, you know, just last night reading those things made me less nervous. That, that's real. I'm actually really thankful for the community that has rallied on social media. I'm not just giving. I'm definitely receiving. Yeah.

That's powerful. For me, I've gotten hardened in my year. of being on social media in that I've grown accustomed to thinking that a lot of the negativity or positivity could be fake. Bots, people who are unwell, people from other countries trying to distort communication in the states. There's so many weird scenarios that I've seen play out over a decade being on social media that I think, unless you know, like you get an email from someone, you can

pretty quickly realize where this is a person who's reasonable, who actually had something happened and is being grateful versus comments on social media. I think it's much harder to gauge it to authenticity. So for me, I've actually, to protect myself, have disconnected even from the positive comments on social media for fear that I'm being driven by the comments, whether they're positive or negative. That's so good. Well, it's good, but it's also can be problematic because as you were talking about that equilibrium in our MCAT studying, that equilibrium exists in that mass communication space as well, where if you disconnect too much from both positive and negative, you end up with PTSD. PTSD, patients who suffer with PTSD, a lot of

times will try and pull back their emotions so hard to not have one of those outbursts or negativity spells that they actually don't get enjoyment either. So you have to be very careful of don't let it impact you, but let it impact you sometimes and try and strive to seek some sort of balance there. And it's very messy because we're humans after all. I'm just taking this all in. I'm trying to like press record in my brain because I mean, I have so much to learn about this. And I feel like I know when things feel healthy and when they don't.

And there are times when I just have to put my phone down. Yeah. Are you good at that? Because I'm bad at that. I'm bad at it. I'm bad at it. And I'm always like, is there something that I need to be, like, addressing or, yeah, I'm going to think on that. I think that I tend to be someone who's detached.

Like, that's been my coping mechanism my whole life. You know, I've been able to just, like, cut the emotion off and do the work. Right. And so. Which is what health care training basically inspired us to do. Oh, God. So much wrong. There's so much pathology.

Yeah. Um, so, you know, I mean, I've been on social media a little bit of time, but I haven't had a lot of attention until really this year. Um, so in that period of time, I've actually felt like an emotional engagement, like for me or like I felt safer to like be emotionally involved in the work that I'm doing. Um, I don't know if that makes sense. it does but um yeah i because you struck a nerve right maybe it just resonated so deeply where i was like i needed that encouragement um i try not to i try to have enough purpose for it not to matter how it lands right even i don't want to be scared of the reaction right i just want to be so sure about the message and the truth of it that i'm good and that's like that's the power right and that's the thing like with my patients who have cancer and I'm like oh but you're you get to control the response like as long as I'm good there I'm good

but there are moments when like last night when a comment maybe it's from a bot but maybe the universe sent me a bot you know to make me feel good and I'll take it because it felt better you know well that my fear is will i feel badly when i see the opposite oh no don't what if you see the opposite well no i'm not i'm just saying in a hypothetical i know but i'm just saying from me to you like i just want you know if this isn't like my gift to you it's like just hear my voice going like no no just put that one to the side and i'll delete them like oh i'll block somebody okay i'll block somebody if they come to my space and insult somebody there i mean no no thank you No room for that.

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We should give listeners some context. 2025 has been a unique year for you, to say the least. Tell us what happened, how this year got started in such a media, social media frenzy that it was? I made a post like other posts I've made in the past, but it resonated pretty broadly. So I was operating and got a call from an insurance company, United Healthcare. And they were asking for just like basic information about my patient who was actually having surgery. And it was just so absurd that they needed her diagnosis and wanted a justification for her overnight stay, like in the middle of operating. They reached me in the operating room.

It just, the absurdity of it made me post. And I just said, this is what happened today. And you obviously said it not expecting some sort of heavy response. If I had known. Well, I don't know. Would you have done it differently, maybe? That is a good question. I think legally I wouldn't have said the name United

because then I wouldn't have had the pain. Right. But also my life's trajectory has changed because I said United. And so I'm okay with that. Maybe TBD on whether or not you change it. Also, I mean, I was like I learned a lot from that. Well, let's keep going with the story because this is interesting for folks. Okay, so I posted, and that post went viral.

And the post, you told the story. That was it. I just said, basically, like, here's my day. Here's insurance. I can't, I don't have words for this. How did they get me in the OR? This is ridiculous. And that post went viral.

And then, um, and describe to folks, because viral could take so many forms. Like, I have YouTube videos that get a million views regularly. To some people, a million views is viral. But your story went viral, viral, viral. Well, I mean, I haven't tallied up the views, but someone has told me it was like 14 million across. I think it's much higher than that. Okay, I don't know.

I haven't looked. Seriously, you wouldn't, I don't even know how to look. Well, it's hard because you have to compile all the social media platforms. And when someone makes a post on X and doesn't look at it. Oh, yeah, there were so many. Yeah. So it got around. Tens of millions.

Okay. I'm going to trust you on that. It was a lot. It was to the point where people were calling me from around the world. like asking for my story and what happened. News agencies calling you, I presume. Totally, yeah.

And they're calling you direct or how were they reaching you? Yeah, because I mean, I'm just a person. They were emailing my practice or sending me a message or calling my,

the phone at the practice. How did you realize, like what was the moment that you realized it was getting so much attention? The day after I posted it, I walked into the hospital and an orthopedic surgeon

walked up behind me and pad me on the back and was like, thank you for saying that. And I was like, what? So you weren't aware yet? No. wow okay no um because i was going in to do more deep flaps yeah like it was like a regular day totally yeah um and did you then grab your phone yeah let me had noticed that like my phone

was kind of beeping a lot and then had to turn off notifications on it but i don't at that point i wasn't like checking um and uh yeah so that was just strange but also it's like this is actually really interesting and i'm glad that that this is getting some attention because it needs it because we've gotten out of control. And the initial attention, was it people asking questions, thanking you, angry with you, all the above? Most of them were, oh, yeah, think back. Most were positive.

There were some negative, for sure. There were some negative from plastic surgeons. There were some negative from surgeons saying, like, why did you take the phone call? And I had to explain. So, like, yeah, I'm in the operating room. Why would I take a phone call? That sounds like really irresponsible. and I went through the process of, oh, gosh, now I have to explain to social media why I took the phone call.

Okay, so I have a partner in the room. There was a doctor in the room. Right. Still operating. Also, I was afraid they were going to charge her for the surgery. So I'm thinking about her, you know, financial health and all of that. I mean, it's. And usually they're not reaching out to mid-operation.

I mean, they literally sent a message into the operating room. And there was a post-it note, United, the patient's name, you know, call them back. Like, they're asking to talk. right now, it seems urgent. Like the nurse manager, it went through multiple levels to get to me in the operating room. And then I had a two-minute phone conversation with them. And what did the conversation? What was it like in general referencing? The patients, whether or not they should be getting the surgery? Literally, it was just the most mundane details. What's her diagnosis? Why does she need to stay overnight? So it was about to stay. Yeah. Which should be figured out after

totally there's no reason today why this needs to happen and why am i having to think about this but that's what doctors around the country are experiencing why and i'm assuming correct me if i'm wrong that you don't think that this is happening where insurers are constantly calling people in the operating room but you're pointing to the bigger picture here where these insurance companies in their denials are being so aggressive that it's even reaching you in the operating Correct. And the feeling that I had for, you know, more than a year before that with insurance, you know, this whole coding thing led up to it, right? Like, the feeling that I had was if an insurance company tells me to jump, I say how high. That's what it feels like for me to do breast reconstruction, because they could just not pay or charge the patient. I mean, the stories I heard and dealt with prior to this call led me to this feeling of if, I don't address this, something bad is going to happen to this patient. So, yeah, it wasn't, no, I don't think that people are being called out of the operating

room routinely, although I've heard from surgeons who've said, I've gotten a call on the way to the OR, very similar things. Sure. But it's just in general that we have to deal with insurance companies in the middle of the day, certainly interrupting care. I mean, I've heard that. I mean, I do that all the time. Right, peer to peer.

Prior authorizations. Yeah, it's all day. I've had prior authorizations for the most basic antibiotics because I prescribe capsules, not tablets on the electronic health therapy. I mean, why? Well, because they didn't do a great job negotiating capsules and they did tablets, but it's America, did you know this? It's just ridiculous.

Like, let's just stop it. Let's stop it. I mean, because think about that delay in treatment, so you have a delay in giving an antibiotic, right? That has a medical outcome. And at some point And how do you quantify that? Yeah.

And at some point, that feels like you're making a medical decision. Now, I know that's, you know, a broad leap, but like when an insurance company tells me you can't operate for another two months just because on a patient with cancer, that feels like they're making a medical decision for that patient. They're overruling me when I say I want to do, it's time for surgery. Or, you know, when they deny whatever. Like when they make those denials, what are they basing the denial of? I mean, which one?

Well, like in your mind, the hypothetical you're going with, you're saying the patient needs this now, and they say two months. Yeah. What's their logic behind? They said that that was, that they had literature to support that. To support that they should wait? Yeah, so this was a woman who had a unilateral mastectomy, she was in her 30s, she had one breast remorse for breast cancer. And that was like a year and a half ago. The night before that surgery, so we planned to remove both breasts.

The night before that surgery, her insurance company denied the contralateral mastectomy. they said we're not going to pay for removing the breast that doesn't have cancer. Okay. So the morning of surgery, the patient was informed that the insurance company had said that by the breast surgeon. And they were like, this is so stressful. Let's just do, let's wait. And when you're having reconstruction eventually, let's do the other mastectomy. So you're going to have another surgery in the future.

Let's just do your other mastectomy later. So she was like, okay. So basically the patient agreed on the morning of surgery to only have one breast removed, not both. and the reasoning by your calculation to remove both was what? Well, the patient's, so high risk, family history, she was 36, she had an advanced disease, she was counseled about her risk, and that was a choice that she made with her breast surgeon. So I'm their reconstructive surgeon. Then there's the breast surgeon who does the cancer part of the surgery, and they had made that decision with her.

So that's the part that got denied. So first, that was denied. Got it. So then fast forward a year, and this woman who's had the breast on for a year because it wasn't removed at the first surgery, and this completed chemotherapy in radiation and then waited four months because I, as a microsurgeon, know that four months after the end of radiation,

I have a 99.7% success rate at doing a deep flap. So four months is good. And there's no literature that supports longer. And I have lots and lots of data because I track everything I do, like times and all of it. I have lots and lots of data to say that that's the right time for me to do that surgery for her. So I submitted to the insurance company

and I said, I'd like to do her deep flap reconstruction, and also it's time to do the mastectomy on the other side. So we're going to do both sides. And the rigmarole that they sent us through was ridiculous. They said, no, four months doesn't sound right. Let's wait another two months. And I'm like, why? I'm the doctor. I'm the one. Well, we have some data that says that six months is recommended. I'm like, that data doesn't exist. There's no guideline that says that. Right? But I had to go through multiple calls, finally get on the phone with an oncologist. Finally, I got an oncologist and explained to the folks that I could do this at this time. And they also, at that time, we're saying we're not going to

cover the other mastectomy still. So they revisited that again. And I had to explain, no, she has one chance for me to do deep flap surgery. And if I don't do both breasts now, I can't come back can do it later. And she has chosen to have her breast removed. And by the way, these are her risk factors. And this is why. It was just, I mean, that's just a couple of months ago. All of this extra time with an insurance company turning the screws and practicing medicine, I would say, but also delaying a mastectomy. Like, delay, I've had patients before who, you know, them restectomy has been delayed and we found more cancer than we thought we were going to find. There's a health implication to delay and companies that practice in health care and insurance really need

to be aware of that. I'm sure they are. We just have to point it out. Do you think the delay is truly in the patient's best interest from these companies or is it usually a way to wait for the patient to fall off the plan, a way for someone else to take responsibility from a financial standpoint, like they're swapping and let's say they're 65 years of age now, or are they thinking about the patient? I just, there's, I can't imagine how they're making that decision by thinking about the patient. I was the doctor. I had all of the data to support it. It just seemed financial. And it happens over and over and over again where I feel like the delay is part of them controlling cost. It's a dial they can turn.

And it's if we deny this, if we delay this, then, you know. Profits will be X. Yeah. And I do think that a lot of insurance companies got dinged for denying things after the fact. So I've felt a move towards like slowing down ever getting. to the OR. Like that's another way, rather than doing the surgery and then them saying, we're not going to pay.

Yeah. We felt, oh, we won't, we won't do the surgery yet, or we're going to make this process drag out for another two months. And I've certainly had the, you know, aging into the Medicare population. And all with the same notion as the marketing principles from that show of, oh, there's going to be attrition. Of course. But again, like, these are companies who have.

have a fiduciary responsibility to maximize profits for their shareholders. And we're practicing medicine. And we have a responsibility to do the right thing for our patients. We have to meet in the middle somewhere. I mean, it's ugly. And there is a balance to be had there. But the balance is just so off. If you had to say, let's say the balance, perfect balance is at 50.

And then other side is 100, all business or zero is all patient. where do you think that balance is now? I think we're like, I think we're like 80% towards all money. Yeah, I do. I think that's a fair number to be. Yeah. And I know that we can improve it just by bringing awareness. I mean, I know that's people just say that all the time.

But if we don't know it, if we can't explain it, if we haven't made it understandable for the average American, then, okay, they're just going to keep doing what they're doing. Well, that's why people love to dunk on social media as being problematic, negative, and there are definite drawbacks to social media. But one of the huge undervalued impacts of social media is the success you had by adding that code or returning the code. The conversation we're having here to potentially put pressure on insurance companies to make a swap or the government to force insurance companies to make the swap.

Because odds are they're not going to self-regulate to turn a smaller profit. So I think this is a great avenue for it. I think it's the avenue for it. I mean, this is, you know, the most democratic thing around lately, you know, all voices being heard. And it's, it's, there's good and bad. But let's get the information out there. Well, that's a quote that you said earlier that if people just knew, they'd make the change because it's just so logical. They're just not aware of it.

Yeah. Well, social media will kind of evens that playing field and allows us to tell people. I love that. And I think the business of insurance is so convoluted that the more I understood about it, the more I felt like, wait a minute, that can't be real. I want the public to know about the 8515 rule. And I want the public to know about vertical integration and what that means so that we can all pressure, apply pressure for better. And even, I'm not saying, I'm not saying I know the solution, but let's talk about it, right? Is it, there's a lot of other options out there. And there are insurance companies who are trying to do better. Yeah. Yeah. Orthopedic surgeon claps you on the back, says, great job.

Oh, yeah. You're getting all this feedback. That's wonderful. Some negative that you feel you ought to correct. What happens then? um then i i think really the next big thing that happened was that united sent me a threatening letter so there was quite a response um on social media and they basically sent a letter that was six pages of you know saying that i had lied and that that never happened um saying that

I was allowing violent, um, communication to exist on the internet with references to the murder of their CEO within some of the responses. Um, you know, just, it was just a whole litany of like, of things we think you've done wrong here. Um, it was, it was just gaslighting gone wild, right? How'd you feel when you get that? I got in the middle of the night and I was scared but also my heart was racing and I'm like what is going on you know I read it read it through and through and um did you agree with any of their criticisms no I truly didn't and I knew that what I said was true and honestly like you know the talking about um the murder of their their CEO like there were comments left that seemed to be supportive of Luigi Mangione

right? And that's something that I've seen pop up. And at that time, I mean, I was, I was just doing my work and I wasn't spending my whole day going through the comments, deleting things that sounded negative. I didn't even know how to filter out comments at that point. And especially the volume of comments coming in during that time. I mean, you know, since then, if I, if I see something that's like really blatant, I'll just delete it. I don't, I don't, I don't, they're acting like you're a corporate entity with a giant social media team monitoring comments. I'm just a lady. Yeah. I'm a surgeon. And I'm still operating and I'm doing my best. But also I do think that. And that's not your responsibility either. It's a police speech.

Like if you do it, cool or good on you. If I need to. Yeah. But that's not a mandate. No. And also, I mean, I felt the sense of this need for the public to speak. I felt that after Mr. Thompson murdered and the response was, was so complex, right? I felt like people are getting something off their chest. And is it very tragic that someone lost their life? Absolutely. Is it very tragic that people are having to navigate the healthcare system that leaves them feeling like they've been harmed in such a, such a deep way that they have to lash out here? Yeah, you're not equating them. You're just pointing out to tragedies happen. It's just, I'm just saying, and I actually think there's something healthy about that communication existing in the world. Right. So,

so when I, like, when I meet a patient who has breast cancer, it's not my job to tell them how to respond to that. Like, they have your feelings. Be angry. Be sad. I mean, I'm not here to tell you what to feel. And I felt the same about people's responses in a way. Like, I'm not, I'm not telling you that you shouldn't feel that way. Actually, the more I listened, the more I saw, really deep problems that were, you know, not just in my world of breast reconstruction, that were so much broader. And I felt the need to lean into that. Yeah, but that letter was, that was scary. And again, here I am saying. I was good. Yeah. Well, it's okay to be scared. Yeah. Yeah. I mean, that morning I went out to my car and I called.

I texted my sister and told her, and she said, we're house girls. That's my maiden name. She's like, we're house girls. Just give them hell. And I contacted an attorney who was amazing. And then we went from there. Now, in taking on United in this battle, because it's become a battle of sorts, had they reached out to you and said

we want to make sure this never happens again we feel like some miscommunication happened but we want to do better by our patients and we want to include you in that revolution how would you felt if they've done that? I would have loved it. I would have loved it and I would have been like oh my gosh, when and where let's go

I'm going to go to Minnesota, right? Like I'm in that, let me tell you what I've learned. Why do you think they chose not to go down that, haven't you? I honestly don't think that they, for whatever reason, were really engaged with who I was or what I was doing or who my patients were. Like, I don't even think they realized that I'd been advocating for access to breast reconstruction through insurance. Like, I'm on your side. I've actually been going to the map so that patients don't have to go out of network and cash pay, right? I probably do 1% of the breast reconstruction for United.

Like when you, back of the number, back in the napkin calculations, like I do a lot of breast reconstruction for them nationally. So I just don't think that they knew that I was not a bad actor. And they thought I was some one that they could bully. And they probably, honestly, I think they thought, what's the quickest way to make this go away? Because it's been a rough couple months for us and we don't need this publicity. But, you know, I,

I had a different kind of reckoning in that moment. Yes, I care a lot about insurance and I care a lot about my patients and I care a lot about advocating for access to reconstruction. But there's some moments where, you know, I just feel like I'm being asked who I am. And that was one of those moments where am I someone who's going to just back down because I'm scared. Or, you know, am I that girl from Georgia who just goes, okay, well, I know it's, I know it's right. I don't know what's true. So come at me, you know? Yeah, and I also don't even understand what the ideal outcome is for them. I really think it was for me to be quiet.

You know, I think they send these letters out. Maybe it's that they see what I see now, which is that. And you made the letter public. Well, that was, that was a great advice. And I think sometimes just letting someone's words, you know, speak for themselves. Like if you're in a meeting and someone says something really nasty, just pausing and letting it echo in the room for a moment, that's kind of what this was. It was like, okay, let's just let you, everybody read it and see how United talks to a woman who's devoted her life to taking care of women with breast cancer through insurance. Let's just let that hang out there.

And it felt wrong. And people felt that with me. It feels like zooming out from this example that crisis PR folks are not great at their jobs. Who was advising them? Because it just, it almost would have been a good story. Oh my gosh. And still, here's the thing.

It still can be, guys. Yeah, like, it still can be. you agree that there's something wrong. You're passionate about patient care. They describe themselves as passionate about patient care. Why not come together and do something meaningful? Even if it's not 100% of what you hope to achieve, there's got to be some middle ground of making progress

in at least a positive direction. Like as bad as it's become, right? Yeah. So I don't know why that approach was taken. That's very interesting. I read, I'm a Reddit person. I like reading negative comments on Reddit as my hobby to make myself feel bad at nights, I don't sleep.

But I was reading a few comments of people pointing out that the insurer likely called you because of some rule that exists in Texas about inpatient versus outpatient stays and how inpatient observation is different than inpatient based on the number of nights. Was that the reason why this whole mixup happened or is it deeper than that? I think it's deeper than that. I mean, I just don't, I don't buy that. Yeah, this just happens so often. I remember this is probably this week or last week that I was seeing a patient who on

ultrasound had a one and a half centimeter mass in their liver that they said better examined through MRI recommend for their imaging. And I order the MRI, it gets denied because my interpretation of the interpretation by the radiographer wasn't in my note. But the note is connected to the report. And I don't know what. And again, all of that is just another hiccup where they're like, oh, it's a hiccup that will get solved.

It's like, but the more hiccups you have, it's like the same way when you're trying to create a good user interface. Like the electronic health records, we all agree is crap. But for example, Apple has done a great job with cell phones, right? That's why people love Apple. So the more clicks it takes to get to, something, the less you want to use it. Totally. So here,

instead of more clicks, they just have more steps. And they call them hiccups or administrative blunders or what have you. And don't you know that they know that that's slowing it down? Of course. Right. But it's, again, I can't

prove that. Yeah. That's my assumption. And or maybe they are saying, well, we're trying to do it for reasons X, Y, and Z. But there is just this added benefit that is being neglected. So to me, if I'm running an organization and I'm being, this is me running my own, let's say, organization that's doing insurance, someone accuses me of that and I am firm in that profits aren't the reason why I'm doing it. I will then say all the profits that

are gotten from surgeries that didn't happen, procedures that didn't happen, will go to serve X causes because we want to make sure that it's clear that we're not doing this for the financials. We're taking all of our incentive away from it, but that's not happening. Again, though, I mean, I love that you're framing it in this way because I do feel the opportunity and the discomfort. And there's still time, right? I mean, United specifically has had a leadership change. Their CEO's step down. There's, you know, one of the board, the board chairman came back.

Like, I know they're looking hard. at their company. I know they are. Well, it's a shitty position for whoever is in charge because you are not someone running a nonprofit. You're running industry that is facing a reckoning. And are you going to be the person that does the right thing and cuts your business? Or are you going to be the person that drags it along until the next person works so you can get your bonuses and payouts, etc. Again, they're not a non-profit company. I know.

How do we expect them to just have an internal reckoning to make a big change? Well, if they're not going to do it right for patients, they shouldn't be in the business of health care. I agree. It is the business of health care. But yeah. I mean, I would say it would be a good investment to make a pivotal change right now. It's kind of like, you know, private equity versus like long-term

investing. Like when you're thinking about private equity, it's like, I've got to turn this around and get out of it in five or seven years. You do different things. Why don't you just recognize that this is a long play, right? Do what's right for the next 20 years. And I'll help. I mean, I'll help. Lots of us will help. But we can't keep doing more of the same. Yeah, it's hard to get doctors in your corner to cheer you on when the business is functioning as is. Yeah. No. And I think we need competition. And competition brings out the best in everybody. And it's, you know, we need something in the market other than what we have now.

And incentive change from government could also be a role here. Totally. But I think that also with the ACA that, you know, physicians get known hospitals. I think we're introducing that. I think that creating space for the direct care model, which is, you know, like concierge care, but different. I think that making a space for that with employers would provide a lot of competition. that would be very healthy. Yeah, I have no idea where this is headed.

But after you were in your car and you talked to your sister about taking on the challenge, what came next? So we posted the letter that they had sent to me. There was a week of me, there was a week of me weighing that. Like, is this, my attorney told me, this may be difficult for you. Are you sure you want to do this? And I decided, yes, we're going to do this. And then the response was really overwhelmingly positive and supportive towards me and appalled at the insurance company treating a doctor and patients in that way.

You know, I just think it was like people get little looks at an insurance company from different scenarios. And I think they've just had a lot of glances from different perspectives. perspectives lately. And this was another one that added up to something is a miss. What about press? Yeah, so people called. That was, I'm not used to that. But there were a lot of, you know, folks from around the country and even other countries calling, asking for my perspective. I learned, you know, quickly about how to speak with reporters and what background is and, you know, And how did all that go?

Like, do they invite you on morning talk shows? Are they inviting you for quotes and subtext in New York Times piece? No, no. I mean, there hasn't been, I would say there were, like, The Guardian, there was like Bloomberg News, there were some online news things. There were, yeah, it wasn't as big as people reached out and then didn't publish things, too. and I don't know how that all works. Interesting.

And then there was like a separate thing where like a prominent investor weighed in and that created a different vibe, a different tone to the inquiries I was getting. Right. So where do you see the conversation existing today? Today, I'd say that it's taken off from that point. And now what we're interested in is talking about the truth of health care in the U.S. And exposing and shedding light on what's really happening for patients and providers. and creating a space where it's not just complaining,

but, you know, an opportunity for listening to multiple viewpoints and making change. Like, yeah, I feel like I personally have found something that I'm supposed to be doing, and I'm glad to have that. It's a privilege for anyone to care what you think about something. And I take that responsibility really seriously. And if I'm going to speak about it, I need to do my homework and be adding. So I think the conversation is, I don't know where it's going to end up yet. Well, I guess it leaves open a part two.

Yes, it does. For a conversation to see where it went and how change actually happened. At least I hope happened. Yeah, that's awesome. What's the takeaway from the journey thus for? far if you had to tell yourself 20 years ago. Hey, be prepared for X. For me, the takeaway is know yourself and get in that zone and know what it feels like

to be in your purpose. Yeah. Yeah. The takeaway for me is like, you're okay. Just keep going. It's funny you say know yourself. I have one tattoo, and it's know thyself. Oh my God, but that's like, I only get this one so far as I know, body and life.

And like I'm going for the resonance. Like I want that frequency where it feels like I'm at my best and I'm having the most impact. Like both things are true. And then I want to exist in that space. Fair. Yeah. Practical tips for providers and patients dealing with insurance blunders. Anything you've learned along the way?

Get on social media. Okay. Yeah. Seriously. Loud speaker? Yeah. Get on social media. The truth is an absolute defense to liable.

Don't elaborate. Don't embellish. Just speak the truth. Let people know. And I think that it has real power. And don't accept a, don't accept a, denial at face value, appeal. Yeah.

Yeah. With, I believe the last number I saw was $220 billion in medical debt in the United States, which is these numbers are over six percent owe over $1,000 in medical debt. I mean, the numbers are staggering. It's staggering. And those numbers don't accept. Do not accept. Don't just write the check for the bill that comes in the mail.

Yeah, fight it. Negotiate it down. There are companies to help with that. I think there's even apps out there. that help with that? Like, look for help. Prescription drug companies, Mark Cuban's company.

Yeah. Good RX is one. Blink Health. There's so many that are trying. Again, that's why social media is great because it's just some people aren't aware. I mean, the crazy part of me being a primary care doctor is it's not enough for me to know the condition,

have a good line of communication with the patient, explain their treatment for them, the treatment options, what to do if it doesn't work. but then also printing out the good RX coupon for them because they don't have a printer. So, like, all of these things are part of health care now. Yeah. And a lot of people say, oh, AI is taking care over health care.

I'm like, oh, maybe it's a tool that we could use it somewhere. Let's use it where it's actually beneficial to all of us. Yeah. If we're going to use it in primary care, let's use it so that I can spend more time face-to-face with my patient, not with the computer. Right. If we're using it in insurance companies, let's use it to, decreased the amount of denials from administrative bullshit, where it can identify administrative

bullshit and not issue the denial. If we're going to use it in imaging, let's make sure that it's imaging that is checked by a human as well, so it's not increasing rates unnecessarily of procedures, of diagnoses, et cetera. So we just need to be careful and make sure that we're not villainizing tools. We're not villainizing industries either, because this conversation, where I hope it doesn't land for people, all insurers are bad or insurance industry is evil. it needs to be a tool that is used appropriately and imbalanced, as you said, with the chemical equation that I no longer remember. I love that.

And insurance is really important. I mean, as someone who practices breast reconstruction, I rely on the Women's Health and Cancer Rights Act, which says that the surgeries I do are covered by insurance. I mean, insurance is so important. I just want it to work well for patients and providers. It's not that we want to throw it out, right? yeah yeah at the end of this i want to just give you credit that you could have had an incredibly successful career charging cash for your procedures for which i'm sure you're outstanding at

and you chose to go about it in the most problematic difficult hurdle like way and instead of running the marathon straight you're skipping it you're jumping it you're swimming it you're crawling it and applauds, applause to you because that's not an easy journey. And I know it's tough, especially for someone who's experienced what it feels like to have social media just to send upon you. Oh my God. That's awesome. You're the best. Thanks for this. Well, thank you for your honesty. Where can people follow along the journey and support you in your future endeavors? So I'm mostly on Instagram and TikTok. I've got to get on YouTube. What's your handle? Dr. Elizabeth Potter. Dr. Elizabeth Potter.

And is there a book somewhere on the horizon? Actually, I, yes. I think that there is. Okay, good. Because I hear that's a must. Okay. Which hopefully then becomes a movie, or at least a limited series. Thanks so much.

That's amazing. That's so funny that you said that because, yeah, that's been, I've talked with some folks about that. So we'll see. Well, what's the title as brainstorming the title? Okay. I don't know. I don't know.

Well, I like this. We could do a live brainstorming session. I like live brainstorming. Okay, so when friend becomes foe. Ooh. Too dark, perhaps, too metaphorical. Scrubbed out, plugged in. Oh, my God.

You're good at this. I love this stuff. Scrubed out plugged in, that's good. That's not bad, right? Because then you want social media. That's really good, actually. And it's also like, I want to talk. to get on social media.

Like, we need good doctors on social media with good information. We'll leave that as I'm working for this. That was a good one. That's awesome. All right. Well, thank you so much for your time. Appreciate you. Huge shout out to Dr. Potter for flying in from Texas for this interview.

She's staring down some pretty scary stuff with this insurance industry situation. And I have a ton of respect for her for fighting the good fight and doing everything she can to advocate for her patients. If you like this conversation, I recommend scrolling on back to listen to at my discussion with Sophie Grace Holmes, a professional athlete who ran 36 marathons in 36 days despite living with cystic fibrosis. It's one of my favorite conversations.

Speaking of conversations, if you enjoyed this one, please leave us a comment and a five-star review as it helps us find new viewers every time you do so. And as always, stay happy and healthy.