093 A girl can dream, value-based and remove process driven work that is not evidence-based medicine and does not improve care from pediatrics

Dr. Sue Kressly is the mother of a blended family of three children and two grandchildren, a board-certified pediatrician, and a board-certified clinical informaticist. She was the founding partner of Kressly Pediatrics, an independent pediatric medical home in Bucks County, #PA. She served as the Medical Director for Office Practicum EHR and was the school physician for Central Bucks School District for over a decade. Sue is, first and foremost, a dedicated advocate for children and pediatricians and serves in many volunteer capacities at the American Academy of Pediatrics and national pediatric and health IT organizations. 

Dr. Kressly believes that all children deserve access to a well-coordinated patient-centered medical home neighborhood, and all pediatricians (including medical and surgical specialists) deserve the resources, payment, and support to meet the needs of the patients and families they serve.

 #wearepediatricians    #DocSue4President #valuebasedcare   #ehr    #medicaid  #podcast  @AAP  

Transcript

A girl can dream, value-based and remove process driven work that is not evidence-based medicine and does not improve care from pediatrics

[00:00:00] Dr. Bravo: Hi George, how are you? 

[00:00:02] Dr. Rogu: How are you doing Dr. Bravo? Today we have another one of those great, great, great physicians, Dr. Sue Kressley. Her topic is going to be a girl can dream, value based and removing process driven work that is not evidence based medicine and does not improve care from pediatrics.

[00:00:19] Dr. Bravo: Hi, so welcome back. It's a pleasure to have you and let's dig deep into some misnomers, such as value based care. 

[00:00:27] Dr. Kressly: Thanks so much for having me guys. And you know, this is 1 of my really top priorities. And I think that's very smart because talking about misnomer value based care. It is used by different stakeholders differently. What's value. Let's start there. 

[00:00:45] Dr. Bravo: Okay. So I'm going to level set a lot because you're incredibly intelligent, charismatic. And I'm always jealous that you're at the beach, but beyond that value based conversation started that I can remember with the [00:01:00] Obama Biden administration. As they were proposing the A. C. A. And as I understood what they were proposing is mega mergers of as many hospital system and physicians integration, the use of the M. R. for better communication with the not so openly stated aim of reducing the cost of the expenditure of Medicare in health care. Because in Medicare, they're spending 13, 000 a year per member and if a dual member, meaning Medicare, Medicaid, they're reaching 30, 000 a year in spend, and that's not sustainable for the federal government.

[00:01:45] So they were looking for ways to decrease the amount of money that we spend in chronic disease management. So instead of waiting for my heart condition to get so bad. That I'm in heart failure in the ICU, if [00:02:00] they can manage me as an outpatient with the scale and nurse visiting and save that hospital visit.

[00:02:06] Everybody benefits. 

[00:02:08] Dr. Kressly: So I'm going to push back here because I think that's when the word started being used. But the concept of improving quality and reducing cost has been at the core of insurance businesses forever for a lot of reasons. So I think that. The way you talk about a new frame, it is value based payment models may have started at that time, but it's, it's an old story and it's a business principle, right?

[00:02:38] How do you decrease your overall spend and increase what you're delivering? That's true of whether you own Grocery store or, you know, a hair cuttery or in medicine. So I don't think that it's a new principle. I think it's being applied. And just like anything, when you start to give it labels, people start to make [00:03:00] assumptions that they're talking about the same thing.

[00:03:02] And they're not. And absolutely we spend more money on healthcare in this country with worse outcomes than a lot of other developed nations. And that should give us all pause and we should all have responsibility in our contributions to that. But they're not bringing, printing more money to take care of people, right?

[00:03:20] Like, Costs are going up. People paying more for their insurance. Medicare is a problem and we're seeing it right now because I don't know if you saw the proposed cuts of 3. 3% for next year which is going to be problematic. But the reality is that when they made Medicare a federal government program, they talked about budget neutrality.

[00:03:41] It's one of the only reasons they could get it passed. But the reality is. You can't give more patients because now we have more aging Medicare population. I'm not quite there, but I'm close. And we have advances in medicine. How do you take care of more people doing more stuff with less money? It's [00:04:00] ridiculous. You can't. 

[00:04:01] At some point that's just cost cutting and budget neutrality. Let's talk about that value Word because many of the payers, the way they define value is quality over cost. Like I want high quality and I don't want to pay for it. Well, you can't have both. And are we talking about value , to the bean counters and the insurance company?

[00:04:24] Are we talking about value to the patient? Are we talking about value to the health care system? 

[00:04:30] In kids, which is the reason we are all struggling and George you know, elevated 20 points in a recent conversation because. There is no way to squeeze more money and juice out of reducing cost in care for kids.

[00:04:49] The value is because kids are infrastructure. And when you invest in the infrastructure, you build long term value. But these guys who are making these decisions [00:05:00] are in their seats for maybe 18 months and they're told they have. 12 to 18 months to reduce spend by 3% across whatever. And that's all they're looking at that. If you're going to look at value in that narrow cost cutting window, all you're going to do is trim the fat off of everything. And there ain't no fat left in pediatrics. 

[00:05:19] Dr. Bravo: You're incredibly smart and you know, this numbers inside out, but I'm afraid many , on our audience don't know it when I told my level set, go.

[00:05:29] When I told my dad, who's a lawyer and is 85 years old, that 50% of U. S. children are covered under Medicaid, he said I was nuts. 

[00:05:40] Dr. Kressly: It's Medicaid or CHIP, but you're correct, under a governmental program, right at the end of the public health emergency, more than 50% of kids are covered by Medicaid and CHIP. Let that stand for a second.

[00:05:55] Because that equates to the number of Children in this country that are living [00:06:00] near around the poverty line. Medicare was started because so many seniors were in the poverty sector of the economy. Now, half of kids live there. Let that sit with you for a second. 

[00:06:16] Dr. Bravo: And then I'm going to level set a little bit more because we come from Colombia.

[00:06:20] And in Colombia, 50% of the population really lives in poverty, poverty, meaning they live in a shack. Lucky if they have a toilet. And they cook by burning wood. Okay. No air conditioning, no refrigerator poverty. Okay. He, he couldn't believe it. He couldn't believe it. He's like, this is the us How can 50% of the kids live in poverty?

[00:06:47] How can they qualify? I'm, I don't know, dad, but they do. Okay, now let's use some of New York numbers. New York spends 2, 418 per [00:07:00] child that they provide or finance health care for in New York State through their Medicaid program. That's less than 200 a month per kid. And the average family in the U.

[00:07:15] S. spends 220 a month on, not counting Netflix, Having TV and internet in their house. So the state of New York in half their children, things that they're worth less than your cable subscription. Swallow that. 

[00:07:38] Dr. Kressly: There's where you get to value. Okay. 

[00:07:40] Dr. Bravo: We do not value children. Let me level set a little more. Let me level set a little more.

[00:07:47] Because once we talk about the numbers, it's disgusting. Okay. New York Medicaid spends the majority of, so New York Medicaid spends 4, [00:08:00] 600 per adult that can work, that is poor, that enrolls in Medicaid, twice as much as they do in the kid. The kid can't work. I'm not talking disabled. I'm not talking elderly poor.

[00:08:15] I'm talking adult that is enrolled in Medicaid in New York. The total spend and physicians are. Labs and x rays in New York state for Medicaid services is 300 million a year out of three billion dollars that they spend on Medicaid. So it's not even, it's not, it's nothing compared to what they're spending.

[00:08:41] And because it's a two to one ratio, They're not even spending 100 million a year in care for Children. 

[00:08:48] Dr. Kressly: I have a question. Is that the actual dollars that go to care? Or are we now carving out an administrative crazy overhead on top of that? Some of that spend that's not [00:09:00] actually going to care. 

[00:09:01] Dr. Bravo: That's it.

[00:09:01] They don't carve it out on what, not health care is. Making off of that and you know, they're just that's what they're spending 

[00:09:11] Dr. Rogu: the insurance companies Managed care medic case they don't care about pediatrics. I'll give you an example I had a discussion, I organized for our clinically integrated network, I had people, we got technology to do value based contracting, and dashboards, and everything that you need.

[00:09:25] People, networks, technology, to reduce care. Got to the table with some bean counters, and he says, You know what? Do you know what pediatric spend is in the overall healthcare budget? Budget dust. 2%. But you guys, I was with my vice president, Dr. Espinoza, but you guys seem to be like nice guys wanting to do the right thing.

[00:09:47] I'm gonna humor you and give you a value-based contract. They gave it to us, which was fine. Then 2020 came, all of a sudden things happened. We did whatever we did. It was bring, we brought in kids during the pandemic. [00:10:00] We did have shared savings. So the insurance company made money. The organization made money.

[00:10:06] The doctors made money. Life was good. Right? Fast forward 2021. Repeat the same people, same technology, same everything. Because people started going back because it was a lot of spend with these silly, rapid viral panels that cost 1, 500 and they pay out that. People online. The budget was out of control.

[00:10:26] We had two or three kids that had devastating illnesses, some cancers, a liver cancer, a brain tumor. We had 100% quality metrics, but we missed the shared savings, so... It's all gone. So, we're trying to make a case that pediatrics is different, you have to do it on quality, less on shared savings, because all we can prevent is ER visits , and admissions.

[00:10:49] That's all we can prevent. And hospitalizations. Yeah. Yeah, they had kids that had 500, 000 in medication bills. Then the guy had the nerve to tell me, well, doc, back in 2020, you guys sat [00:11:00] down and did nothing and collected all that money while that was not nice of him. I let him have it. Cause we were there every single day.

[00:11:07] I take COVID very personally. I was on the front line in my office, seeing all this patients that were all the other people closed down and we saw them and they didn't go to the ER yet. Our organization got zero. 

[00:11:21] Dr. Bravo: George. I feel you. You're absolutely right. In a way, people need to hear the story, Herb.

[00:11:26] You're absolutely right, but you're barking up the wrong tree. I know the problem is the legislature's in Washington because it's a very well informed people tell me 50% of the budget for Medicaid comes from the feds and CMS has. A big, big, big hammer that makes you do what they want you to do at the state level with Medicaid, because otherwise you don't get the money.

[00:11:56] And so that's how it works. So don't tell me that this is [00:12:00] a state issue, because as we say in Colombia, you're peeing out of the can. This is a federal and a state issue. But the problem is that... 

[00:12:10] Dr. Kressly: The cultural issue. It's, it's a cultural and a business issue to the 

[00:12:14] Dr. Bravo: New York, the New York legislature is decided that they're only going to pay 200 per member per month on Children on Medicaid that are not disabled and are not in a nursing home.

[00:12:27] And the managed care program says. Shoot. They went to the E. R. The visit was 1200. The multiviral panel is test was 1200. We can't negotiate that because there's an emergency. We spent the 2400. We're out of pocket. Where do you want me to come up with the money? Yeah, 

[00:12:47] Dr. Kressly: problem. No. Well, you have to 

[00:12:50] Dr. Bravo: advocate to the legislator.

[00:12:51] So there is the money. But it's our 

[00:12:54] Dr. Rogu: problem advocate 

[00:12:55] Dr. Bravo: who's going to advocate you and me, brother, because there's no one else to do it. 

[00:12:59] Dr. Kressly: [00:13:00] No, wait a second, gentlemen. So, first of all, the whole business of medicine has changed enormously over the last 10 to 20 years, and it used to be that people making decisions. of insurance companies ha actually happens when you and there were medical di companies who worked coll bean counters to decide w thing to do for all stake and those of us who are p care to them. We have abso That changed that and the bean counters drive everything and that doctor or that person you were having a conversation with George has no idea what it actually looked like to be in your office during the pandemic trying to hold down and keep people safe.

[00:13:46] There's a couple of things here. The story has to be told and people have to understand. They're not printing more money. We have to look at this differently and totally change the way we approach this in pediatrics. And we have to shift [00:14:00] this, and we're going to have to figure out those of us who want to change the system, what messages resonate with the people we're talking to.

[00:14:08] We are not good social scientists about messaging, and we have some work to do to figure out what those messages look like. And we have to start looking at long term investment and what matters. And kids don't matter in this country, the crumbs on the couch are budget dust.

[00:14:24] There's a lot we can do with a little bit more and we just need to do it now. We're going to have to take from somewhere. They're not going to print more money. So, and we're going to have to sit down and have some hard conversations and people are going to talk about death panels. And, you know, look, I've told you before I lost my parents when they were 53 and 59.

[00:14:44] But you can choose where you spend that money wisely. That's where the value comes in. To me, if you took many people in their, my mother in law recently passed. If you said to her, Honey, we can put you on [00:15:00] dialysis. We can add all these medicines. We can put the ICU, you're still going to die in the next 2 weeks and you'll probably die in the hospital or we can take that money and keep you comfortable at home and invest that.

[00:15:13] So that 10 families of three Children each have their investment in themselves to be the best healthiest from mental and physical and well being. Can we take that money and use it to them? She would have said. Absolutely. But nobody's willing to have those hard conversations. I think the tide is changing as our generation ages, there is more of a movement to to get rid of futile care at the end of life.

[00:15:41] And we have to work on getting that conversation and reinvesting those that those dollars where they matter, which is in investing in the future. 

[00:15:50] Dr. Bravo: Absolutely true. And I will tell you personally, it wasn't about the dollars or leaving it to anyone. When COVID started, I saw what was happening with people in the ICU with COVID.[00:16:00] 

[00:16:00] I made sure that my directive said do not intubate me if I get COVID. I've lived a very, I wouldn't say privileged, blessed life. a very happy life. I've been extremely fortunate, not at least to be living in this country. And I did not want to be intubated for six weeks to then go at a nursing home at the age of 53.

[00:16:24] I didn't, I rather, I rather go. Now that they're not intubating you, they give you a high flow oxygen and I've been vaccinated and there's medicines. My thinking has changed. It wasn't about the dollars. I just don't think that's how I want to live. But anyhow, I've gotten away from the conversation here to your point.

[00:16:43] The whole, I'm just going to use the ACA as a reference point because it's not too far , in the past. The whole idea there is what you're saying is, are there opportunities to provide great care and minimize the expense? Yes, they [00:17:00] are. If you, Thank you. The example you gave if you're if you're on dialysis and nothing's going to change, maybe it's time to find a transition you just like the hematologist will talk about this is his or her cancer isn't going to get better.

[00:17:16] What can we do to help them in the last days of their journey, and they don't make apologies for it. That's part of how they see their job. If you have congestive heart failure and we could put a scale on your home and send a nurse aid to make sure you're moving around and you're not getting 15.

[00:17:35] Great. Awesome. You know, that because if you land in the hospital, it's a 30, 000, 50, 000 spend if we can spend 1, 000 a year doing that. And you're better off and you don't land in the hospital, we all win, 

[00:17:52] Dr. Kressly: but there's, we all win. That's the value piece. When we look at value, it has to be value to everyone.

[00:17:59] It has to be [00:18:00] value to the patient, the family, the health system. And society hospitals making, well, they're not making enough money Medicare. They're all dying too, because the profit margin at some point we have now gotten this profit margin to such a low place that you, and especially when you're talking about engaging and talking about health equity in this conversation, right? Equity doesn't mean equal. Not everybody needs the same thing to be able to achieve health, optimal health. And if we're going to really work hard at getting some of our vulnerable families involved in preventative care and early diagnosis and treatment, first of all, it takes more money.

[00:18:41] And effort and resources to get them and show them a value, engage them. And then we've just increased our total spend because that population just didn't cost us anything for the last five years because they weren't going to the doctor at all. And that's what happened to George. People weren't going to the doctor.

[00:18:59] Now, all of a [00:19:00] sudden there's this pent up need and demand and like. In what universe did that payer think that the spend wasn't going up? We have a new problem with new illnesses and deferred care. Hello? That doesn't take rocket science. Great. 

[00:19:18] Dr. Bravo: I'm going to be very sarcastic, so please, everybody, excuse me.

[00:19:23] But if you want to, if you want to save money, quote unquote. In pediatrics, don't pay for well, child, it seems anymore run the pediatricians out of town. The pharmacist. We'll give the shots without any screening at all. And because most pharmacies in our huge, like CVS. They can get great value on those immunizations they buy, and the ones that can go to the cvs can go to the health department.

[00:19:51] Dr. Kressly: Yep. And then how long do you think it is before society pays the cost of not investing in the children health [00:20:00] and wellbeing 

[00:20:01] Dr. Bravo: upfront? I, I, I just being very sarcastic, 

[00:20:03] Dr. Kressly: right? The, the, the mental health system. We're going to talk about people in the ER with an untreated and undiagnosed things whether it's diabetes or chronic disease or asthma.

[00:20:14] So, so yes. So 

[00:20:16] Dr. Bravo: that's being really,

[00:20:18] that's being really stupid, but you, you could pad your numbers for United by doing that. Okay. And you would get a great parachute. Golden parachute out you go with the use of a private jet and five million a year for the rest of your life. 

[00:20:37] Dr. Kressly: Which is one of the reasons when you design value based payment models for kids.

[00:20:42] The cost of anything preventative has to be carved out of total cost of care. That is, we should be incentivizing investment. There's a practice friends of mine in Pittsburgh who rocked HPV vaccination rates. So let's talk [00:21:00] about the spend down the, down the way for procedures and treatment for cancers with they prevented cancers.

[00:21:09] Well, guess what? HPV. HPV vaccine is a little expensive. 

[00:21:13] Dr. Rogu: Yeah, 30 years from now, nobody cares. 

[00:21:15] Dr. Kressly: Yeah, that's the problem. Okay. We are not taking the long... 

[00:21:19] Dr. Bravo: We could also, save money. This is gonna hurt. I'm probably gonna be canceled. But, don't do any more mammograms. They're expensive. That people get breast cancer.

[00:21:30] Yeah, but that's... I mean, that's just, that's just a whole, wrong thinking about this. 

[00:21:36] Dr. Kressly: Okay, that's what happens when you get bean counters who don't really look at the long view and you're giving them a directive to reduce spend, which is why we have to influence that value is not just reducing spend.

[00:21:52] It is investing in the health. Of the community and and we, so the next time George somebody [00:22:00] says you spend more, the answer would be, what did you do to invest in the health of the community? In two, five and 10 years. Tell me what efforts you put to investing in the long run, or are you going to be not in your job anymore? And it's somebody else's 

[00:22:19] Dr. Bravo: so you when you're talking to bean counters, you got to talk like a bean counter. Okay. And even though they only care about this quarter, because they don't intend to be in the company next quarter, they're going to hop to another job. That's like HPV. HPV costs, I think, 250 a dose.

[00:22:35] You need two doses, 500. One's with an exam, so now we're up to 600. The other one is just a shot, so you get 20. So what are we, 700 in spending over six months? 

[00:22:48] Dr. Kressly: Every year. Well, no. Once 

[00:22:50] Dr. Bravo: for this person, right? Yep. 

[00:22:52] Dr. Kressly: Max. Most people don't get paid that much for a well visit. Every 

[00:22:56] Dr. Bravo: year. Every year, in America, [00:23:00] 2, 000, no, 4, 000 women die from cervical cancer.

[00:23:06] They spend 300, 000 taking care of their cancer. We spend 2. 2 billion taking care of cervical cancer. That doesn't count. And I'm not a woman, so I can't tell you if this is true or not. But that doesn't count the discomfort of a vaginal exam, a pap smear, which I've never heard anybody say it's something they look forward. It's like, I've never heard a guy say, Oh, it's time for my prostate exam. I'm so lucky. 

[00:23:41] Dr. Kressly: That's only part of the spend, Herb. That doesn't count, 

[00:23:44] Dr. Bravo: but I'm, I'm, I just tell, that doesn't count the women that need colostomy, because it was expensive, and have 

[00:23:51] Dr. Kressly: pregnancy losses, and have supplies, and have preemies, and then we have preemies, yes.

[00:23:58] And 

[00:23:58] Dr. Bravo: I'm not counting [00:24:00] those 4, 000 women that died in their 30s, the cost to their children. Their husbands, their mothers, their brothers, the cost of society because this young person is not going to work for 30 years, pay taxes, raise a family, buy a home, use a car, buy groceries at Wegmans. So, 

[00:24:22] Dr. Kressly: and then let's add, let's add female and male head and neck cancers, which are huge and yes, HPV derived.

[00:24:28] Okay. Anyway, we all agree. No, we don't short sight. We agree. We don't have us. Yes, it is short sighted when you only look at reduction of cost as your value and let it define value. And I think we need to hold the feet to the fire of the bean counters who keep trying to insist that's the value based program.

[00:24:51] No, that is not. That is cost reduction. Call it what it is. And let's define value together from all stakeholders, but [00:25:00] with the patient and the family at the center of the conversation. This has to be a social discussion on everybody's Thanksgiving table. Not one that happens with the bean counters and George getting frustrated.

[00:25:13] Yeah, that's 

[00:25:13] Dr. Bravo: on. 

[00:25:14] Dr. Rogu: I asked you, Sue, has any person. organization, institution put this case forward and wrote about this, talked about this with the HBS after other, other than the Merck 

[00:25:29] Dr. Bravo: companies, you guys are going to be shocked. There's an AAP. It's not a policy. I think it's a commentary issue. And I think Sue Berman and Sandy Chung are part of that committee.

[00:25:43] And they talk about The idea of net present value, net present value is an economic term that doesn't just measure that spend. For example, I buy my house, it's 600, 000. That's not [00:26:00] the net present value of someone buying a house because I'm going to need curtains. I'm going to need furniture. I'm going to need this.

[00:26:09] I'm going to pay property taxes. I am going to do landscaping. I am going to do so many things because I bought that house helps my little county be well. 

[00:26:22] Dr. Kressly: You support the economy of your community because you are investing in buying a house. That's right. Investing in the kids is the same concept.

[00:26:34] Dr. Bravo: Exactly. And there is for my Republican friends, which I love you dearly. Before you go off the rails, there's good debt and there's bad debt. Bad debt is when I can't afford the Range Rover and I go borrow money to pay 1, 800 a month to lease a Range Rover. I am stupid for doing that, but good debt is when I invest in my business, [00:27:00] which has a seven fold return on my community, or when I borrow money to buy my house. and I pay my mortgage and I don't flip houses. I don't refinance. I buy the house. I enjoyed. I live in it till I can't pay the mortgage. Okay. And the old fashioned way on it for 30 years and retired to stand about right, but that is good. That is good that that is lifting up everybody and investing in Children. Even if we have to borrow the money to do it now will give us the healthy young workforce that this country needs to maintain its democracy and its constitution and not doing so now is no longer an option.

[00:27:52] They're sick. The kids are sick. They are obese. One in five is depressed. It's [00:28:00] a suicide or death by suicide. It's among the top causes of death in the American young young. They are hurting. It is time to stop. 

[00:28:12] Dr. Kressly: No, it's not only time to stop. It's time to start investing in fixing the problem early. If you have any for the, for the listeners who don't know about the Heckman curve.

[00:28:26] I encourage you to learn about it. The dollar spent in the first three years of life pays society for decades beyond that in healthier children in less spend, but not just in the health care sector in other parts of the economy. In the workforce sector in the juvenile justice sector in the educational sector.

[00:28:50] If the public health emergency didn't tell us anything, it's that we are not investing enough in keeping people healthy. [00:29:00] Let's start with the word health, right? Our health care system is about putting band aids and treating chronic diseases. It is not about promoting, preventing and maintaining health and well being.

[00:29:14] It is time to really look at that and who is. the expert in the room about investing in prevention, early diagnosis and treatment, well being, and the long purview. It is pediatricians. 

[00:29:31] We should be, you know how now websites are mobile first, you have to design everything on your phone so it'll scale to your computer. How about we start designing the healthcare system, the well being system, Child first, because if we refocus it on that, we create long term value and everybody, but we got to figure out how to deliver that message to the stakeholders who make the decisions that make all of this [00:30:00] 

[00:30:00] Dr. Bravo: without mothers, teachers, without pediatricians, we don't have. A free society. We need those three pillars to grow healthy children that buy into our constitution and keep us at peace and prosperity. And the time to do that is now. 

[00:30:24] Dr. Kressly: No, it's yesterday now, but the next week, the best time to build a tree is yes or to plant a tree is yesterday. The 2nd, best time is today.

[00:30:33] But here's something that I don't know if you've heard if you look a couple of decades ago, kids. We're 33 ish percent of the total American population, right? We're now about 23 to 24%. So we are taking up less room and in the space of the conversations about where to put spend, the population is aging.

[00:30:58] Look at some of the European [00:31:00] countries where all of the kids are leaving and they have no idea how they're going to sustain their economy. Because there's not enough healthy young people to sustain, sustain middle and later in life. We are getting close to that. This is the right opportunity to instill and invest in the infrastructure of children.

[00:31:23] So that we can have a vibrant society and economy for generations to come. The bean counters who are making some of those decisions based on just. decreasing this quarter's cost. We have to hold their feet to the fire and hold them accountable when we are in a sicker world in five years and it's their fault.

[00:31:44] Dr. Bravo: Yeah. And so I'm just going to go off topic for two seconds. In Italy, I keep getting advertisement, come to this little town in Italy. We'll give you a beautiful house plus 2, 000 a month to live. For 5 years, but you have to [00:32:00] stay in the house for the 5 years and promise to bring your whole family. That's what happens when you don't have young people in society. 

[00:32:08] Dr. Kressly: That's that's the investment. And that's where the economic investment and bought and having living in a house and all that extra net value. They're that that's the net value that Sandy and Suzanne have been talking about as far as the net value of investing in pediatric 

[00:32:25] care.

[00:32:25] Dr. Bravo: Correct. I am going to go. I'm going to move on to another topic that just bugs. It gets right under my foot. It's like a little pebble. I can't walk. Okay. Oh, oh, yes. Why do we need unfunded mandates that do not improve care? Take me away from the exam room. What are they producing for society? 

[00:32:48] Dr. Kressly: They're producing their own value. This is a, this is a game and, and let's just talk about it because everybody's got their special little project and whether it's DEA, eight hours of training, [00:33:00] and then they want to make us pay for it to begin with, right? We. Everybody thinks their addition of their little thing is something that physicians and pediatricians can just do.

[00:33:14] The problem is we are dying from not even a thousand, now a million paper cuts that are stacked up against us. And what they have to understand is It is taking us away from our commitment to serve our patients every time they ask you to do an eight hour CME, that's eight hours times three or four kids an hour. that are not getting access to care. So the value there of administrative hassles to serve a single narrow goal. Is it worth the cost of Children not having access to appropriate medical care? And the answer is no. [00:34:00] So how do we figure out What this is goes back to the Cressley question. What problem are they trying to solve?

[00:34:06] They're trying to solve the problem that they want physicians to stay up on education. And I applaud that because it's really easy to fall behind. But how do we weave that into the daily work where you get. You know, and, and, and, and think to it, guys, the guys in up to date got really smart about this, right?

[00:34:27] Like, I want to learn how to treat Rocky Mountain spotted fever. It's been a long time since I did it. Let me click on something and get contextual knowledge that I apply to patient care, and it doesn't take me out of patient care. We have to figure out how to and there are. Somebody who's smart technology guys, figure this out, figure out in our workflow how we, we learn while we deliver care.

[00:34:53] Don't separate the two. They're making us learn here stuff that we'll never see and [00:35:00] take away from care. It should be contextual learning. We learn this as adult learners. When you teach adult learners, they're contextual learner while we're doing the job. Get rid of all the rest of the hoops and embed them in the day to day work that we already do.

[00:35:16] Dr. Bravo: Three points on that. I'll tell everybody, Google it. And NBPAS. Won't say any more about it. Okay. Already a member. Number two. Did I say that? You're already a member? Good for you. I'd like you even more. Number two. In the old days when I was a nut. Well, I'm still a nut. I was crazier because I was younger.

[00:35:38] When I had a paper chart and I saw an interesting case, there's something I didn't know really about it. I go down to the medical library. I search it out in some journal. I would photocopy it and I would put it on the chart. So all of the other doctors in my practice, when they opened that [00:36:00] chart, that article was at the very top of it.

[00:36:03] And there's a review article. And they went like, Oh, this kid has X. Oh, here's the review article. Oh, wow. How interesting. And then we learned. 

[00:36:14] Dr. Kressly: Presentations when we learned from each other? When we sat around and talked about interesting cases? And what would you do? As an intern, 

[00:36:21] Dr. Bravo: I did journal club with my attendings in their houses with beer and cheese.

[00:36:26] Okay. And it was every month event. It's all gone. I will say there's the one kind thing I have to say about ECW. I found out that I can go to up to date or I can go to Mayo Clinic. It's tracking your time and I can do that. No, I can. Put the hyperlink in there. So I saw a kid in the clinic the other day that had been anemic, like hemoglobin 9 for several years.

[00:36:52] And they're from Afghanistan or Pakistan. And I said, this doesn't make any sense. And, you know, they treat him with, with with [00:37:00] iron. Doesn't it really cool? I said, maybe he has one of these. He's a genetic, or something like that. Nobody's bothered to do a hemoglobin electrophoresis on him. And so I sent out the whole workup.

[00:37:12] I looked it up actually from the Academy of Family Practice. And then I hyperlinked the article for the order of the practice on my note. So when she sees that patient in the follow up, she can click on it. I think is it? Oh, wow. This is what hurt was thinking. That's the thing. Those are the things we need.

[00:37:29] Dr. Kressly: We learn from each other and we learn while we're doing. And then it's not memorization of useless stuff and taking a test reinforcement learning along the way. And let's get rid of the stupid administration that adds add no value to care and let's use that same effort because it's really the same effort to strengthen our care, not take away from our care.

[00:37:54] It's just, you have to do it like daily dusting. instead of like go sit somewhere for a [00:38:00] day and listen to garbage that you're not absorbing half of because you're also, you know, finishing your charts. I agree. 

[00:38:07] Dr. Bravo: And so then one, one more, there's, there's, I call it the evil empire. I find it unconscionable, and this is just a legislative fix that managed care medicates in any given state will vary on their rate of reimbursement to pediatricians.

[00:38:25] Dr. Kressly: Payment I'm going to get you on that 1 1 payment 

[00:38:29] Dr. Bravo: rate of payment. 1 will pay 40 for a physical while the other 1 can afford to pay 85 for the physical. So, it's not that that stays not giving him enough money. You don't have carriages values having margins more than. Oh, I said the word I wasn't supposed to say the word then then someone else that needs to be stopped at the legislative and you cannot contract with the state and not give what the state has decided is a fair [00:39:00] reimbursement for, excuse me, payment for that CPT code and the discussion. And if you can't, 

[00:39:06] Dr. Kressly: it has to be a floor and it has to be at least Medicare, but probably more because we have more than 1 patient.

[00:39:13] When we take care of kids, we take care of a family. 

[00:39:17] Dr. Bravo: All right. So now I've complained, I've complained all day because before you, we had great guests, Dr. Dean on moral injury and just phenomenal guests. You got to read that book. And what do we do? How do we solve this? 

[00:39:34] Dr. Kressly: Well, I think that we have to, we have to sit down.

[00:39:38] We know the problem we're trying to solve. But we're not using the right levers with the right messaging. And so I think that we have to sit down with some social scientists who understand the power of quick words and phrases and framing the conversation from a different viewpoint in so to, we can resonate it.

[00:39:58] And then we have to make this [00:40:00] not about somebody else's problem. This is every person, every patient's problem and understand. each of our parts in solving the problem together. We can't do this alone. This can't come from mandates. But it's going to have to come with collaboration, lots of listening and figuring out the messages that resonate that we can move the needle.

[00:40:22] Listen our kids are depending on us and I know that George had a bad week and, but he's going to come out fighting anyway. Because he knows every day when he sees so much need in the patients that we all serve some of our moral, I would say a lot of our moral injury is becoming us because we see the need and there are others who are giving who are saying, you can't have the resources to meet him.

[00:40:44] We're going to make you do this other meaningless stuff again instead. and you can't have enough money and resources to be able to serve the patients and give them what they deserve. And so we go home every day feeling like we failed. And that's not us. That doesn't take more yoga [00:41:00] and more walks on the beach in Sanibel. That takes healthcare system redesign and it's time to relook at the whole 

[00:41:08] Dr. Bravo: thing. All right. So I'm going to do lightning round with you. One, should we be investing more than 200 a month in our children? Yes,

[00:41:18] we need a new guide, right? A net value ruler or when we're spending, not just all the physical cost of 100. 

[00:41:30] Dr. Kressly: It's not spent. It's fun. It's net value of infrastructure investment. We have to change that conversation. 

[00:41:37] Dr. Bravo: Every pediatrician that has access to their in New York is called delegate. Here we have a legislature and a Senate that has the opportunity to talk right to their representative at the state level and their senators should do it today.

[00:41:53] Dr. Kressly: But we now give me a week. We need to give them the right talking points in a language that's going to [00:42:00] resonate. So it just doesn't end up in the circular file soon. Be ready. Know who your people are. Come send me your talking points. Let's figure out which resonates the best and what has the most impact. And then let's talk, but figure out who your people are. 

[00:42:16] Dr. Bravo: Okay. We need to ask our mothers to write to their representatives. Tell 'em what difference, and I'm gonna be very self-centered. I did for them. And I'm gonna tell you a short story. Yesterday when we, when you texted me, I was at a fundraiser.

[00:42:37] Fundraiser for juvenile diabetes. I was there, and remember I'd been at hospitalist. An ER doc, an urgent care doc, and I never did the journey that you or George did where I put up a practice and it was that practice for 30 years.

[00:42:57] The mother of the [00:43:00] patient that brought this little kid since he was in diapers as a newborn to the urgent care called me one day. And said, I won't say his name on the air, but Johnny, he's peeing a lot and losing weight. I need to see you today. I said, come in. She came in, the glucometer wouldn't read because it was so high.

[00:43:23] And she said to me, it's diabetes, isn't it? I said, yes, you're right. It is. Let me call the endocrinologist. At the Children's Hospital and see how we can get you admitted. That was more than 10 years ago. He's now a thriving adolescent doing the call circuit as he applies for colleges. I have taken care of him, his brother, his mother, his grandfather, and his uncle over pictures.

[00:43:57] When she brought him to the urgent [00:44:00] care, that night I cried with my bourbon. Because I knew how long that journey was going to be for that family. I am so blessed that they invite me to these things. And when she introduces me. He introduces me as my friend, Herb, and right away, her girlfriends say, that's not your friend.

[00:44:23] That's Dr. Bravo. We all know, because you don't do anything without talking to her, anything that's medical, and anyone in your family, he has to figure out whether they're telling you the right thing or the wrong thing. And that. You cannot buy with money. 

[00:44:40] Dr. Kressly: Let me just say it is that human relationship in the humanity that you cannot, the bean counters, they discount that.

[00:44:52] Ask them, George, how many lives did you save this month? How many lives did you save this month? We all have those stories and that's what fills our [00:45:00] heart. And I'm going to leave you with this last thing. Every day we wake up and understand why we went into this. God forsaken, beautiful profession called pediatrics.

[00:45:13] It's because our patients matter, their families matter, and every day they give us hope of a better world. So let's partner with our kids and families that we're privileged to serve and dare to hope that we can make a difference and make a better world. We can do it. But we have to do it together.

[00:45:35] That's 

[00:45:36] Dr. Bravo: right. Thank you, 

[00:45:37] Dr. Kressly: Sue. Thank you. Always a pleasure guys. Bye. Bye. 

[00:45:42] Dr. Bravo: Bye.