Value-Based Care and the Changing Healthcare Landscape

January 18, 2023 | Podcast: Future-Ready Business

Following the pandemic, many industries have experienced major shifts in the way that they do business. In the forefront is the healthcare industry, which was forced by the pandemic to consider the benefits of value-based healthcare, as opposed to more traditional fee-for-service models, when the world shut down. On this episode of FRB, we discuss with family medicine physician Dr. Lane Aiena what exactly value-based care is and how the business landscape in the healthcare industry is changing.

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Our Hosts:
Erin Camp

Erin Camp
Associate, San Antonio
Twitter: @BusinessLawyerE
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Art Cavazos

Art Cavazos
Partner, San Antonio
Twitter: @FinanceLawyer
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Episode Guest:
Dr. Lane Aiena
Family Medicine Physician
Host of Doc To The Future Podcast
Twitter: @DrLaneAiena

Episode Transcription

Erin Camp: Hi, I’m Erin Camp, a corporate finance lawyer with Jackson Walker.

Art Cavazos: And I’m Art Cavazos, a corporate and finance lawyer with Jackson Walker. And this is Future-Ready Business.

Erin Camp: As always, we’d like to remind our listeners that the opinions expressed today are ours and those of our guests, and do not necessarily reflect the views of Jackson Walker, its clients or any of their respective affiliates.

Art Cavazos: This podcast is for informational and entertainment purposes only and does not constitute legal advice. We’ve got a great show lined up free today with our guest Dr. Lane Aiena. So, Lane, do you mind telling us a little bit about yourself?

Dr. Lane Aiena: Sure. First and foremost, thank y’all for having me. So excited to be on the show and get to talk to you guys about this topic. I’m Lane Aiena. I’m a family medicine physician in Huntsville, Texas, which is just north… well, I say just northbound, about an hour north of Houston, depending on how fast you drive.

Art Cavazos: With Houston sprawl. That’s considered just north.

Dr. Lane Aiena: Exactly, in Texas. If it’s an hour or less, that’s essentially neighbors, right? So, we’re a small private practice. We have six family medicine physicians and our practice, we serve a pretty rural population overall, we do all kinds of things, we do procedures, if our patients need them, we obviously don’t have a whole lot of specialists. So, we work up quite a bit. And I really enjoy it. We’ve got a great patient population. I couldn’t imagine being anywhere else.

Art Cavazos: And you also have your own podcast, right? Doc To The Future.

Dr. Lane Aiena: I do. Doc To The Future, your podcast place for pertinent picks of what’s coming to affect you in the future of medicine. Yeah, I’ve practice that a few times.

Art Cavazos: You can’t tell.

Erin Camp: You want to tell us a little bit about the general subject matter?

Dr. Lane Aiena: Sure. I was at a meeting with the Texas Academy of Family Physicians, and we were talking about the transition from fee-for-service to value-based care. There was a gentleman from Blue Cross Blue Shield that came in to talk to us about it and when we got done, I went to Tom Banting, who was the CEO of the TFP, and I told Tom, “Tom, I’m scared to death of what he said, but I don’t know a word of what he said. And I didn’t understand any of it.” So, we had a good chuckle and we kind of realized that, especially as more rural physicians, we just haven’t really been exposed to this. So, we started brainstorming on how can we educate our membership, especially those in the more rural areas about value-based care and these alternative payment models. What’s a good way for them to consume this? I had mentioned how about a podcast.

I actually have a radio show here locally. I’m in that studio as we speak. It’s called Thursday Morning House Call. It’s a little five-minute thing we do every week. It’s about topics – today was about chest pain – and that gives me a little bit of the background, fortunately, to be familiar with what equipment I need. I’ve got a great guy who helps me to produce it: Glen Edwards, a radio personality. He’s been just instrumental in teaching me how to sound good and taught me how to use the editing software. Anytime I’ve got questions, I can just bounce them off him. He’s been fantastic.

At the time of the recording, we’ve released three episodes and an intro. I plan on releasing our fourth episode very soon, kids willing and allowing me that time. We’ll see how it goes. But we’re very excited that at our most recent convention, the podcast was very well received. Everyone’s excited to hear a little bit more about it. We’re opening with a value-based care mini-series, and then we’re going to grow from there.

Art Cavazos: That’s fantastic. And I’m going to go out on a limb and say are you, like, a millennial?

Dr. Lane Aiena: Yes. Technically, yes. I think I’m right on the edge of it. I’m 35. So, born in 1987. I believe that gets me right in there.

Erin Camp: You’re smack in the middle of it, Lane.

Dr. Lane Aiena: Oh, am I? See, I don’t know anything about it. Not the startup versus non-startup. And I’m like, man, they’re speaking to me here. I get it. So, yes, I am a millennial.

Art Cavazos: Yeah. I only ask that because it strikes me as interesting that, you know, you confronted something that you weren’t sure about, you didn’t know much about, and kind of your first reaction was, “Let’s start a podcast about it.” Because I actually had a similar reason for wanting to do this podcast—and, Erin, you can share your own reasons—but as corporate attorneys are dealing with businesses day-in and day-out that are confronting challenges in the business world and I was seeing a lot of change with technology, things like AI, automation, machine learning, Blockchain, VR, AR, the metaverse, Web3, you name it, there was a point I think, you know, this podcast is helping me, but there was a point where I didn’t know what any of that meant. I saw this as a really great way to bring folks on and have these conversations and learn about all of these different things. So, I just thought that was really neat that you kind of had a similar idea.

Dr. Lane Aiena: I think that it helps the listeners quite a bit coming from the position of genuinely not knowing. I think a lot of podcasts have experts to host the podcast, which make it more difficult for them to think of the questions that your average listener would have want to hear. I think coming from the position of “Tom, I don’t know what value-based care is. I don’t know what any of the alternative payment models are,” one of the pieces of feedback I got was, “Man, those are some good questions you come up with. Like, those are genuine questions. Those are things I want to know about.” And I think with you guys, it’s the same way. When you’re coming from a genuine place and it’s something you want to learn about, that comes off in the podcast and I think listeners really appreciate it.

Art Cavazos: Agreed.

Erin Camp: Totally. Another thing we talk about a lot is millennials bringing sort of a social aspects, like a social responsibility aspect, into – or they tend to – into the companies that they create. It sounds like maybe your practice and how involved you are with the community and how much you seem to really care about your community, do you think this plays into how you feel personally about value-based medicine? Or do you think that’s an accurate representation about how you feel about your own practice?

Dr. Lane Aiena: Sure. I think that several different communities that are interwoven throughout it. I think that the physician community needed a way to consume this. You know, PowerPoint is boring, no one’s going to open a PowerPoint in their email. No one reads spam emails. Who has the time to click on a link and read it? If people were willing to do that and had the spare time, they’d have done it by now.

I think that the desire to outreach to the community of physicians, it made podcasts a pretty easy choice. This is the probably the No. 1 way people consume things and learn things right now. If not No. 1, it’s certainly up there. With the community, you know, I always try to remember that medicine doesn’t end at your four walls. One of the big drivers of a switch to something like value-based care is trying to take into account the social determinants of health. There’s a new phrase that I believe is non-medical drivers of health.

I’ve got a great episode—I’m sorry to pitch my own podcast, but I’m really excited—I got a great episode with Dr. Sherri Onyiego coming up. We had a great talk and its very eye-opening. What we talked about is what I do in my office only affects about 20% of the patient’s health; the other 80% is where you live and what you live around and all of those other things that play into it that I’m not directly touching as a physician. So, how can we incorporate that and change that to bring down the cost of medicine, but bring up the value? Knowing that someone’s not taking their insulin is one thing; knowing they’re not taking their insulin because they don’t have a fridge to store it in – one fridge is a lot cheaper than multiple emergency room visits and multiple hospital visits, so it would be cheaper overall, but we’re not taught to think that way as physicians. So, this is a new paradigm that we’re approaching here. It’s an exciting time to be able to educate people and, honest to God, kind of like you said, Art, to learn myself, that part of this podcast is self-serving so I don’t come off as the Dollard in all of our meetings. So, it’s been really exciting. I’ve enjoyed the podcast, I’ve enjoyed my guests. I think that the podcast is gone as well as it has 100% because of my guests. We’ve been very fortunate that way. And I hope that that continues.

Erin Camp: Yeah. I hope it does for you, too. In like super layman’s terms, could you explain what value-based care is and how it compares to sort of the more standard fee-for-service payment model?

Dr. Lane Aiena: Yes. Just last night, I was in a meeting where we realized we still don’t have an elevator speech to describe value-based care, right? You’ll hear other phrases like alternative payment models. The current model we’re in is fee-for-service, and that means – as you guys know – you come to me, I do something, you pay me. That is how we’ve done it for a long time.

One of the problems with fee-for-service is that it rewards doing more. In medicine, that doesn’t always mean better outcomes, right? I could get a colonoscopy on you every single week, you’d never get colon cancer, but you’d spend a fortune, you’d be horribly uncomfortable, and there’d be a huge risk of procedure complications, but I get paid each time I did that colonoscopy. So, it’s kind of a perverse carrot at the end of that stick. Most doctors, I like to think, can see past that, but it certainly creeps in even if you’re not noticing it, right?

Fee-for-service brings up the question of how can we increase the value of this care while decreasing the spend? So, not necessarily pay me every time I do something, but pay me based on how are my patients doing. They measure certain outcomes of quality – and there’s so many of those we could reference. Just to name a few would be: Am I getting the mammograms for my patients that they need? How is the blood sugar control for my patients overall? How’s the blood pressure control for my patients overall? They measure these things, and there’s different ways – some of its full reward, some of it’s a mixture of the carrot and the stick, as I like to say, and some of it, when you say full capitation, means you’re taking on all of that risk. We can get into those a little bit as we go, but that’s kind of the shortest version I can give you as far as fee-for-service versus our transition to value-based care. Because, frankly, fee-for-service isn’t sustainable. It’s one-third of the economy, the price is continuing to go up, and there’s just going to come a point where that system is going to just not work anymore.

Erin Camp: Maybe this is a good time to talk about sort of what your practice is like, because now I want to ask: Do you feel the way you feel about value-based medicine because of the type of medicine you practice? Or do you think that, you know, generally, even if you were more of a surgeon type where it really, all your practice is is this very active doing things on a case-by-case basis? Do you think that influences sort of how you feel about value-based medicine? So, I guess maybe the first thing to do is just – do you want to tell us a little bit about your practice before we get into that? Because I don’t know if the listeners really understand what you do.

Dr. Lane Aiena: So, it’s a private practice, which means we’re not, you’re not going to see—called Huntsville Family Medicine—you’re not going to see Methodist Huntsville Family Medicine or Tri-St. Luke’s Huntsville Family Medicine. We are six equal partners in the practice that share ownership. So, all the decisions go through those six physicians that work there. I love it. That’s what I was going to—what I’ve wanted to look for ever since I started. There’s nothing between me and my patient now. There’s drawbacks, too. I’m certainly not saying private practice is certainly the way to go for everybody. That’s my personal preference, that’s the way I went.

Now, in a small town, mostly rural private practice, we are absolutely fee-for-service, very traditional, as far as how we bill, what we bill, etc. To the point of, like I said, up to a year or so ago, I’d never heard of this. I mean, I’ve heard of it. But you hear so many – I’m sure lawyers are the same way – you hear so many buzzwords that go across your email that come and go and live and die that I’m not committing them to memory until one of them tends to stick for a little while.

So, I think one of the big things that started to change my mind and change other’s minds about the fee-for-service model was COVID. That’s when it kind of hit us all personally. The issue with COVID was I wanted to keep my patients home, because bringing them in exposed them to unnecessary risk, especially early on when we didn’t really know what the exposure was going to be like, what the early symptoms looked like, how long before it are you contagious. So, we ended up doing a lot of medicine through messages and a lot of messages over the phone. Here’s the problem: Doctors aren’t paid for that. There was no payment structure in place for that. So, you had at one point, I think, I’d read 2% of private practices in Texas had closed several months after COVID had started, which doesn’t sound like a lot, but imagine if in the next three months, 2% of the McDonald’s in Texas had closed. That’d be national news, right? So, this was a big deal and we needed to start exploring other models. How can we pay physicians not just based on how many surgeries they did, which again, surgeries were cut for a while, right? All non-elective surgeries went out the window; all non-elective procedures were closed off. Those surgeons were hurting, too. How can we pay our physicians not based on every time you do something, but maybe based on each life you take care of and the quality of care you’re giving for that life.

The transition to that model if we had had that during COVID – now, of course, hindsight is 2020 – but it would have been seamless. I’m not taking care of you because I’m seeing you face-to-face; I’m taking care of you as a person wanting you to be healthy. Even though I’m not getting paid per phone message, I’m getting paid for you in one way or another. Now that’s – we’re getting more into the capitation model, I want to be as specific as I can, that would be more of a capitation model – but that’s when I really started to think about, “Yeah, this ain’t gonna fly.” Now, we were very fortunate our clinic stayed open during COVID, we had a great patient base, and we were able to keep our heads above water. I wanted to say I’m very grateful for that. I’m very grateful for our staff. But a lot of physicians’ offices weren’t as lucky. So, when you have something like that start to hit a lot of physicians personally, a lot of us start thinking we’re paying a third of the economy for this and it’s not working? There’s gotta be something else.

Art Cavazos: You see, you mentioned a buzzword there, capitation. For listeners who don’t know what capitation is, could you explain what that is?

Dr. Lane Aiena: Certainly. Capitation means I would get paid X amount of dollars per patient that I take care of, period. I don’t get paid any extra when they show up. I don’t get paid any extra when they don’t show up. All of the tests I ordered, be it imaging tests, the lab tests, would come out of that payment that I was given for that patient. Every time they saw a specialist, it would come out of that payment that I was given for the patient, and then every time they were hospitalized, it comes out of the payment. Now, that would be considered like a full-risk model. And that’s, you can imagine a lot of physicians are very wary to adopt a full-risk model, because we all think about those patients that we have that oftentimes to no fault of their own are very expensive when it comes to medical care. There are answers for that getting in big organizations, accountable care organizations that would, when you get a whole lot of physicians that would dilute those out, we could have a whole episode about those. But the short answer is that’s what a capitation model would look like.

Art Cavazos: And is that essentially one type of value-based care?

Dr. Lane Aiena: It’s one of the ways that you could look at paying for it, yes. And, again, these are big, big phrases that mean a lot of different things. Value-based care may not even be the phrase we end up sticking with by the time this comes out, months down the road, as someone may be listening to it. Or just like the social determinants of health is outdated. Now it’s medical drivers of health, non-medical drivers of health. These phrases are apt to change. But in a broad sense, yes, that is one of the ways that you could look at value-based care.

Art Cavazos: You also mentioned being a rural practice, private practice. Is this rolling out kind of the same for every type of practice would? Would a kind of large Metroplex practice move towards value-based care faster or slower? How is the rollout happening?

Dr. Lane Aiena: The big places are definitely moving towards it faster. Part of the reason for that is because they have such big patient populations. With these patient populations, for example, if you take on risk, it’s getting diluted out amongst everyone, right? The other reason is part of the value that would come from this, from tracking all this, is data. Data is a valuable thing. Be it for Medicare, Medicaid, private insurance, seeing trends, seeing data, being able to track that being able to study that, that’s pretty valuable, and they want to take you on if you can offer them a lot of data. I have six doctors in my practice. We can’t offer a lot of data compared to, you know, Tri-St. Luke’s. It’s making it a lot easier for them to jump in. They can pay entire teams to look into this and see what would fit best for them. When you’re in a more rural private practice, it’s just, kind of, you keep your head down and you work and you talk to your patients and you work with your patients and each day is another day. It just doesn’t roll out to us as quickly. It takes a few people in a big system to notice this, to bring it up to the board, and start the ball rolling. It just really hadn’t gotten to us yet.

The problem with small practices is it’s gonna get harder and harder to be a small practice when this model comes up. So, you’re looking at different things you can do. Selling your practice is an option, which some people will be all for. They’ll certainly like the check they get, right, at the beginning. I, personally, it’s not really what I’m leaning towards right now. Another is to join ACOs, like we’ve referenced earlier, that kind of help get a whole bunch of these different practices together to work under an umbrella. There’s several of those that like to focus on rural communities that you can look into. And then those are the two of the big ways. There’s other ways to approach this that you guys, probably a little beyond the scope of this episode. But those are two of the first ways that come to mind that a small clinic would be able to eventually try to catch up with and keep up with these bigger entities.

Art Cavazos: You mentioned another word – data – that we talked about a lot on this podcast, and you know data analytics and that sort of thing. So, to my understanding, another big aspect of value-based care is using that data to kind of grade or rank physicians and specialties and things like that. How do you see that playing out? Is that going to drive referrals going forward? Are kind of the highest ranked and graded physicians going to get the most referrals, or how’s that going to work?

Erin Camp: Or even like, well, they get paid more?

Dr. Lane Aiena: Right. Y’all touched on a few big topics there. One of them is the data and the grading. It’s funny you bring that up, because it’s something to think about in that doctors by nature are competitive. It’s just one of those things. We physicians don’t like to be told you’re the worst at something, right? Even if you order the most CAT scans of the pelvis, well I don’t want to order the most if it’s unnecessary. So, a lot of this grading is – now they’re not going to show me the other names, but they would show you where you rank with everyone else – to try to increase the value of the care you give. That’s what a lot of these ACOs will do is they’ll sit you down and they’ll say, “Okay, you know, Dr. Aiena, you’re doing great with your mammograms. You’re in the top percentile for that. You’re ordering all those. But, man, you order way more CT abdomens than your colleagues that take care of a similar patient population. So, you may want to start reining that in a little bit.” It could be just based on me recognizing that I’m an outlier, or it could be that, again, with the value-based care model, they tie some of my pay to that through the incentive or they decrease the end-of-the-year pay a bit. Again, there’s different models that not one model has kind of come out as the top model to use there.

The other thing you touched on is specialists. That is a huge topic in this right now in where do specialists fit into this? Because fever service in surgery, I mean, you see a patient may ideally once, right? You see them, you do the surgery, and they’re good. Obviously, there’s pre-op and post-op follow-ups, don’t get me wrong, but where does that fit in? One of the things you mentioned is who’s going to make more money, who’s going to get the most referrals? Let’s call back to the capitation model for a minute. Let’s say I’m in a full capitation model. I know cardiologist A down the street orders a loop recorder and a heart cath and strips the veins of every patient that walks through the door, right? Let’s, whatever, I’m just – those are three things that just popped into my head – whatever tests, you want to say. I know cardiologist B takes some more thorough history, orders more based on best practices and studies, and tends to deliver more value-based care in that model. Their patients do just as well, they don’t have as many procedures, they’re introduced to less risk, and they spend less money. I’m naturally going to shift towards B. I think a lot of that happens already. I think a lot of the time primary care tends to send to the specialist that orders more that is, you know, maybe I got to just say more consistent with their style of medicine. But you’re going to see a lot more of that, of the specialists who deliver more high-value care, getting more referrals from the primary care. Now, how they tie that together is kind of to be seen, but that’s going to be a big part of it.

Erin Camp: This all seems like all very positive. You can get like good referral sources, because you’ll have that ranking. And that’s how everything’s going to be calculated. But what happens to that person on the bottom? Like, what happens to that person doing the worst or providing the worst value? Or what if someone just has a negative outcome, and maybe it wasn’t the fault of theirs? I mean, will they be penalized?

Dr. Lane Aiena: Sure. With the first question, the goal is to hopefully get the other physicians through the carrot or the stick to bring up the value of their practice, right? So, that’s the whole idea of the model. We’ve yet to see what’s going to happen. You got to remember, in medicine, the money’s a pie, right? I mean, this is a finite source of money. Somebody’s getting more money, because someone’s getting less money. That’s one of the fears of this value-based care is this redistribution of where those funds are going. When there’s not a lot of food at the table, table manners tend to disappear, right? So, if someone starts to see less and less money, we don’t know how that’s going to go.

To the second one, that’s been a big counterpoint to value-based care. I have a handful of patients that are just sick and there’s no other way to put it. They’re just sick people. They’re wonderful folks, this is of no fault of their own, but it just costs a lot of money to take care of those patients. Will value-based care encourage physicians to not see patients like that? And that is a huge fear in this. That’s a question that I’ve yet to see answered sufficiently. I think that in big organizations – this is the answer you’ll commonly get – big organizations will dilute that out, which will still encourage you to see those patients. I’m hoping that that will be the case. I don’t think anybody has just patient after patient after patient that costs a fortune to take care of. But one that I saw very recently – one of the nicest guys I know, I love seeing him, I look forward to it when he’s on my schedule – I have to see him frequently, he sees several different specialists, he does every word of everything you tell him like its gospel, he’s just got a lot going on. So, you hope genuinely that people like that aren’t punished as we shift to this new model.

Erin Camp: Yeah. I mean, this is making me think about oncologists, too, you know? Like, someone that does see patient after patient that is very, very sick, and oftentimes, maybe a majority of their outcomes are negative, sadly, due to the disease that they’re a specialist in.

Dr. Lane Aiena: It is, and again, you hit the nail on the head with where specialists fit into this. Part of the model is certainly to reward early detection, so you think breast cancer, you think colon cancer, getting their screenings, catching it early. I just had a gentleman today that decided to do what’s called a Cologuard. I’ll do a quick pitch for Cologuard – I don’t know if we can mention brand names on here – but it did get colon cancer early, and he detected his colon cancer early, and it literally saved his life. That would be one of the things they track. But what about pancreatic cancer? What about uterine cancer, where there is no early detection? Right? Well, I don’t know the answer to that. That’s going to be an expensive case, and we’ve got to figure out how that fits into the model.

Art Cavazos: And no problem mentioned anything. We probably should just say we’re not sponsored by anybody or endorsing anybody.

Dr. Lane Aiena: Yep. And this is not medical advice, either. I should probably throw that out there. Don’t take medical advice from someone on a podcast.

Art Cavazos: Another thing we’d like to talk about on this podcast is, you know, you mentioned COVID and the pandemic. A thesis we have, or a premise we have, is that we are kind of in the middle of this big transition across the economy right now. I think you’ve definitely talked about it already in the healthcare space, and we’re seeing it really in every industry. Part of its technology-driven, part of it, you know, is the pandemic was just a big, punctuated point for everyone and just changed the way that business was done probably forever in a lot of different ways. Part of it is also demographic. You know, we were kind of joking earlier about millennials, but millennials are turning 40 this year, so there is kind of a generational shift occurring, as well. So, all of that kind of comes together.

I guess, really two questions: The first one is you’ve been talking about, you know, that we haven’t seen a lot of this yet. A lot of this is kind of still to come. When exactly is value-based care going to roll out, and when do you think it’s going to really be kind of the new norm? And then the second part is, how do you see that changing health care overall, kind of the business of healthcare?

Dr. Lane Aiena: The rollout is happening as we speak. It’s starting more at the bigger places and kind of creeping outwards. Medicare, then you’ll see through Medicare managed plans, is starting to transition. Places like Blue Cross Blue Shield through their managed plans are starting to, where they’re tracking more value in trying to manage in some way somewhat related to value-based care. We are seeing that shift as it is, because as I’d mentioned earlier, fee-for-service is just not something we can keep doing and expected to keep working. As far as when the shift is going to happen. It’s really tough to say, I’m thinking in the next five to 10 years is going to be the prominent model. But that’s a big crystal ball question right there. I hate to speculate. My guess has been for a while here five to 10 years. As far as how will it change medicine? It’s going to be sink or swim. Get on board, or go into what we call direct primary care, where you just take cash pay and you don’t involve Medicare or insurance, that’s going to be kind of it.

Once you have all of the parties that control the purse strings have decided to switch to this, well then, it’s done. You know, we’ve transitioned. I didn’t get a vote. So, it’s part of the reason why we’re trying to educate our members on it now through the Texas Academy of Family Physicians and also through the Texas Medical Association. We just had our first meeting on alternative payment models last night. We’re really trying to roll out the education now that our membership can be ready, because you want to start getting into this now. You want to join an ACO now. You want to sell now. The way I told that to my partners was, “Look, right now, we’re the prettiest girl without a date. Pretty soon, we’re going to be the only girl without a date. We’d rather ask for a date right now than do it later on.”

Art Cavazos: Or guy.

Dr. Lane Aiena: Or guy. Usually, when I was the guy without a date, that just meant I didn’t get a date.

Erin Camp: In regard to, like, uninsured people, because one of the big issues we have is just like payment of health care, what happens to that uninsured person that goes in that might have to pay a cash price? Is there still going to be a cash price for services when we’re no longer fee-for-service?

Dr. Lane Aiena: It’s a tough question to answer, because I don’t think anybody really knows.

Erin Camp: And if you can’t answer, it’s okay. But I mean—

Dr. Lane Aiena: It’s okay. I’d be happy to talk about it. If you don’t mind me kind of launching into the land of speculation here.

Erin Camp: Please do.

Dr. Lane Aiena: I would imagine it’s going to be similar to what we’re doing now in that, like at my clinic, we can’t always accept the cash pay, right? It’s a private practice; we’re not getting government funding for that. I’ve got to pay my staff. This is the part of medicine people get uncomfortable talking about is pay and why we charge. I tell patients I’m not just paying me, right? I’m paying to rent this place, I’m paying for licenses for this technology, I’m paying my nursing staff, I’m turning the lights on. It costs a fortune to run one of these places. We operate with pretty thin margins, as I’m sure you guys know. So, the cash pay, generally speaking, you can accept X amount of cash pay and just kind of eat the cost. And that’s just what you do. The other thing is government subsidies for the uninsured patients. Federally qualified health centers, for example, get paid a subsidy to help with the uninsured population. I’m part of the board for the Walker County Hospital District. We make sure there’s funding for the indigent care in our area every year. So, there’s different pools that that comes from. This may be naive of me, but off the top of my head, I don’t see how that changes. I think that that still is the model that’s going to have to go with.

Erin Camp: It’s interesting. Yeah, I don’t really see anything differently. I don’t really know any other option either. I mean, there still has to be some sort of like cost directly tied to that service, too.

Dr. Lane Aiena: Right.

Art Cavazos: Yeah, I mean, there’s definitely a lot of challenges left.  I think the question about, you know, what are we going to do with chronically ill patients that, you know, the value-based care system seems to kind of incentivize practices to stay away from – those types of patients, because they want to keep their numbers up, right? They want to keep their outcomes positive and high. So, it’s kind of like lawyers who, you know, only one represent innocent clients, right? Doctors who only want to treat well patients. There’s definitely, I think, a lot of challenges left. But like you said, it sounds like it’s going to be several years coming. Still, this is kind of a process that’s going to play out over time. So, we’ll hopefully have you back and get an update.

Dr. Lane Aiena: I’d be happy to come back, and I’ve really enjoyed the episode. Thank you all for having me.

Erin Camp: Thank you.

Art Cavazos: And thank you, everyone, for joining us on this episode of Future-Ready Business. We touched on a lot of things today regarding the changing business landscape for doctors in the healthcare industry in general. In the meantime, Dr. Aiena, where can folks find you?

Dr. Lane Aiena: So you can find me on Twitter, but I don’t remember my handle because I don’t use it. So, let’s just ignore that part.

Erin Camp: We can include it in the text.

Dr. Lane Aiena: We’ll put it in the show notes. And I can dust off my Twitter.

Art Cavazos: And you’ve got your podcast where can folks find your podcast?

Dr. Lane Aiena: Right. That’s what I was going to lead into. So, if they want to take a listen, I invite everybody to listen to Doc To The Future. It comes up easier if you search my name, Dr. Lane Aiena, A I E N A. So, search for Doctor the Future on our podcast. We’d love to get the word out a lot of what we talked about today. We really take much deeper dives into on the podcast. So, if you are interested in this episode, I think you’ll really enjoy some of the episodes that we did over there.

Art Cavazos: Yep. I agree. I’ve listened to all of your episodes so far, and a lot of lot of really interesting tidbits.

Dr. Lane Aiena: Well, thank you. I appreciate that.

Art Cavazos: If you’d like the show, please rate and review us wherever you listen to your favorite podcasts. And please share Future-Ready Business with your friends and colleagues.

Erin Camp: Thank you to our producer, Greg, on the ones and twos. You can find us on Instagram at @futurereadybusiness. And you can find me on Twitter at @BusinessLawyerE. E for Erin.

Art Cavazos: And you can find me on Twitter at @FinanceLawyer. As mentioned at the top of the show. The opinions expressed today are ours and those of our guests they do not necessarily reflect the views of Jackson Walker, its clients or any of their respective affiliates.

Erin Camp: This podcast is for informational and entertainment purposes only and does not constitute legal advice. We hope you enjoyed it. Thanks for listening.

Art Cavazos: Goodbye, everybody.

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