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Becker’s Healthcare Podcast
Dr. Elisabeth Potter on Breast Reconstruction, Insurance Challenges, and Fighting for Patient Access
00:17:45
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- [00:00]
Scott Becker
This is Scott Becker with the Becker's Healthcare podcast. We're thrilled today to be visiting with a brilliant surgeon. We're visiting with Dr. Elizabeth Potter. Dr. Potter's got a practice in Austin, Texas. She's going to talk to us about sort of the good, the bad, the ugly challenges of managed care and a lot more. Dr. Potter, can you tell us a bit about yourself and your practice?
- [00:22]
Dr. Elizabeth Potter
Sure. I'm so glad to be here. Thanks for having me. I am a reconstructive microsurgeon. I. I live and practice in Austin, Texas, and I care for about 40% of the women in Central Texas affected by breast cancer. So super high volume. I've always, you know, been in network with insurance and tried to do the right thing by patients, and it's been an interesting year.
- [00:43]
Scott Becker
And talk to us a little about that first. Talk about, I, I know you're an Emory graduate. Talk a little bit about your background, how you ended up in the specialty. Talk about that first, because you've got an inspirational story for a lot of people, including a daughter of ours who's in medical school. Tell us a little bit about how you ended up in. And reconstructive surgery and more.
- [01:01]
Dr. Elizabeth Potter
Lovely. I grew up in Georgia. My father was a doctor. My mom's a nurse. Grandmother was a nurse, anesthetist, went to Princeton University, and then I went to medical school at Emory, where I really fell in love with reconstructive surgery. I'd never seen a reconstruction before. I saw a woman have a mastectomy and was invited to stay to watch the reconstruction, and everything clicked for me. So I learned how to do these surgeries where you use your own tissue. It's a natural reconstruction, and, and move, you know, a part of someone's body to reconstruct their breast. I went to University of Texas Southwestern, which was the top plastics program in the country, completed that residency, and then went on to MD Anderson to do my microsurgery fellowship and then set up my own practice in Austin, Texas, with the goal of bringing, you know, excellent care into communities. So trying to get microsurgery out of the academic center only and bringing it into the communities where patients needed it in.
- [02:03]
Scott Becker
How much of the practice is traditional plastics or cosmetics versus reconstructive? Do you break it down like that? And how have you built your practice?
- [02:12]
Dr. Elizabeth Potter
Absolutely. So my practice is about 90% reconstruction. And I mean, I do love doing cosmetic surgeries, and I think of them more as restorative surgeries. That's the, that's the perspective I take to any surgery that I do, whether it's reconstructive or, quote, cosmetic. It's about being more comfortable in your skin, regardless of, you know, what the circumstances are. But because there are so few of me nationally, I am overwhelmed with work. So, you know, I did 500 surgeries last year. I do just, you know, every week, just a lot of surgery to treat the overwhelming number of women in the United States that don't have access to all of the options available in breast reconstruction. So Even today, only 40% of women know about their options and understand that these surgeries are covered by insurance under the Women's Health and Cancer Rights Act. So there's still a huge number of women out there who don't have access to someone like me who, who can do not just implant reconstruction, but also the, really the gold standard of reconstruction, using your own tissue that lasts a lifetime and is really, you know, an elegant solution to a really terrible problem.
- [03:31]
Scott Becker
That's amazing. And what an Inspiration you are, Dr. Potter. And talk a little bit about insurance, dealing with insurance day, and what does that look like and how challenging is that today?
- [03:43]
Dr. Elizabeth Potter
So in order to care for women affected by breast cancer, I have to care about insurance. And I learned that as a resident and as a fellow, and I took that into my business model when I started my own practice. My goal was to be able to offer breast reconstruction in communities through insurance in network. And it's a simple goal, and it has proven to be unbelievably challenging and complex. So, you know, when someone has a diagnosis of cancer, it's financially devastating. But treating breast cancer is, is one of the biggest costs for employers of women in, in that working age range of 40 to 60. So we're spending a lot of money as a nation each year treating breast cancer and, and performing breast reconstruction. And my goal was really to, to make a, you know, a double case for breast reconstruction, to, to be the best surgeon I could possibly be with great clinical outcomes, but also mindful of the fact that if I was really going to get this into the hands of patients, I needed it to be affordable. I needed it to make sense for hospitals and insurers and employers. What I found over time is not what I expected to find. I set out to prove a case. I set out to prove the case that a great surgeon with a good heart and, you know, willing to put my own money into my practice and years of work, wanting not, not to get rich, but just to be able to make a living, pay my bills and stay out of debt, doing breast reconstruction at the highest level. I set out to prove that that was. Was a viable career. And I never expected that the story I would be telling is that it's not, and that that's because insurance doesn't want to participate with surgeons like me in providing the best care for their patients. It's. It's shocking to me. I truly thought that my story was going to be the story of creating a pathway for other surgeons to do what I've so passionately done. And instead, my story is taking a different turn, and it's more of a cautionary tale about the state of insurance and how difficult it is for doctors just to do the right thing and to operate within the system. So what I mean is I set out to operate specifically within the system, to be in network, to do all the things that my patients needed. Right. And what I found is it's not doable. It's not doable. And the reimbursements are. Are so low. And the structure is set up with all the vertical integration on the insurance side to crush the independent practitioner. The system is rigged against doctors who want to maintain their voice in private practice and financial stability in their own practices. So I guess I'm sounding the alarm that if someone like me can't succeed in just the market of health care currently, then we are on the precipice of a real health care disaster.
- [07:26]
Scott Becker
And we really are on that precipice, if not already there. I mean, we talked recently to a neurologist in central Texas, and he's one neurologist in a population of about 500,000 people. There's so many places where on the precipice of disaster, you're trying to do a complex procedure, but a great procedure, and you can't get paid for it as you get paid for it. Or you get sort of great difficulties with insurers. Hey, is it denials or pre authorizations or they just won't authorize this type of procedure? What do you get from the insurance companies?
- [08:01]
Dr. Elizabeth Potter
Well, I'd say as a private practitioner, I get no insight, no lens into what they're paying doctors in larger corporations. Right. And larger groups. So I get taken advantage of. And I can see that. I can see that when I go to Fair Health and I. And I look at reimbursements even in my zip code. So I see that. So what I would say is reimbursement drives access. And although there is a federal act which guarantees coverage of breaststroke instruction, it does nothing for reimbursement. And when reimbursement is poor, then we're unable to deliver that care to patients because we can't keep our doors open. So one specific example I would give is, so I read the writing on the wall. I'm more than a decade into my practice, and I saw that reimbursements were going down and that it was going to be really hard to keep my doors open. And I. And I heard insurance companies saying, you know, wow, look at what we're doing with total joints. We're moving those into the ambulatory surgery setting. And it's saving money for our, you know, our members, and it's better for patients. We have better outcomes and all this. And I said, okay, that sounds great. I can do that in breast reconstruction because I've taken a surgery that, you know, takes some folks 10, 12 hours to do, and I can do that in three to four hours. I can do that in an ambulatory setting. Let me invest my own money in building a surgery center where I can do these surgeries in outpatient setting. Insurance companies are doing it with orthopedic surgeons. They say they love this. Like no one else has done this. Let me do this. I'm going to do it. So I take out loans personally, guarantee loans. I build the surgery center. Mind you, when you're a doctor, you don't get a guarantee from an insurance company that they're going to contract with you. You have to trust them. I can't. I can't contract until my, my surgery center is built and certified and functioning and doing in cases. And then I can ask the insurance company. But I've always been a network with all the major insurers. I would have no reason to, to believe that I wouldn't be allowed to be a network. Not only that, I can look on the Texas Department of Insurance and see that insurance companies are applying for waivers in my zip code saying that there are not enough surgery centers like the one I'm building for them to offer adequate access to surgery centers in my zip code. So they're telling the state of Texas, we, we don't have enough surgery centers. So I'm looking at that going, okay, well, they don't have enough. And they say they want, they want more things like this. I'm going to build it, and then that's going to provide the income that will guarantee that I can continue to do this work long term. So I'll make, I'll make not just the surgeon fee, but the facility fee, and that will. That will help fill the gaps so that I can make payroll and pay the bills. So I build it. And then the insurance companies don't contract with me for no good reason. They just don't.
- [11:02]
Scott Becker
Do they say anything or what do they say? I mean, no.
- [11:05]
Dr. Elizabeth Potter
So specifically what United said was the network's closed. And they said the network was closed while they were applying for waivers with the state of Texas, saying that they didn't have enough surgery centers in my zip code. It's insane. This is how rigged the system is. I personally took out $5 million in loans in debt. I built a surgery center as one of the best microsurgeons in the country, well known for my outcomes and patient advocacy. I built it. I did everything that they say they want. Even in a recent press release regarding prior authorization reform, all of the insurance companies together lauded how they're taking big, big surgeries and sending them into outpatient settings. They're. They're saying they're doing this, but they're not really.
- [12:02]
Scott Becker
Right. They all talk a good game. But we also sort of know this concept of pre authorization. It's all political in exchange for some of the. The stress they've been getting from the government and so forth, but not really. It's a very, very cozy relationship between the government and the insurance companies. So not really changing things. It doesn't feel like.
- [12:20]
Dr. Elizabeth Potter
Correct, correct. No, that's. And that whole statement was just. It was a lot of theater. That was a lot of theater.
- [12:26]
Scott Becker
Yes, we totally agree. So where do you go from here? Can you survive in practice? Can you live in practice, but just can't make money from the surgery center? And now you got to pay all this debt down from the surgery center, you know, and you can't really sell it, so you're sort of stuck with that until you sort of just grind through the practice, right?
- [12:45]
Dr. Elizabeth Potter
No, no, I'm going to pivot. I know. I'm, I'm. I mean, back me into a corner, and I will show you what I'm made of. And I predict that insurance companies are going to come around and say, we, you know, the good ones will say, we definitely want you in our network. We want you. Do. We want to contract with you. But I'm also going to show that there's another way of delivering care. I mean, I'm looking at all the models. If, if it's. I need to tell the United States public about, you know, the direct care model and show how that can work in breast cancer, then so be it. But I refuse to Go down behind insurance, that is not happening.
- [13:25]
Scott Becker
And there was a lot of shortages in a lot of specialties. And so we see more and more, I see it a lot in spine orthopedics, people going to direct pay model. Obviously in the primary care area there is just a huge shortage of primary care physicians. And so many, many markets we've got. Concierge is the only way to get to a primary care physician. So I mean, and one of the things we see surgeons do sometimes when the payer won't allow them to use the surgery center, they bring cases back to the hospital, which can be very expensive for the insurer. And sometimes we see physicians at groups work that angle as well till the insurance companies become clear, oh yeah, it is better to do it in the surgery center. So you've got concierge or direct patient care options. And for sure we see this in spine significantly, lots of people doing direct care. And you're figuring out those pivots that.
- [14:17]
Dr. Elizabeth Potter
You'Re going to make, oh, a thousand percent. And I mean, we're not going under this way. And I think part of my new goal is to shed light on how unfair the system is. I don't think Americans like businesses that are unfair. I don't think they like paying premiums into systems that aren't actually doing the right thing with their money. So, so yeah, I, I, we are figuring this out and it's amazing to see the number of people that have come have approached me and said let's think about it in this other way. I'm, I'm, I'm excited about that for the future. I'm sorry for traditional insurance because I think that, that they're going to have to rethink their model. And I, I know that sounds very bold for one woman in Texas to be saying that, but I truly believe it. It's not working for Americans and it's not working for, for providers. I also think that the number of medical students and residents and fellows who are reaching out to me saying we will not practice in an environment like the one that you have been forced to practice in. We must have change. That tells me that, you know, medicine may be the new place for, place for activists. And I don't think that insurance companies want that, but that's what they're getting because, you know, medicine has turned into not the best economic decision for the young professional right now. If they go into it, they're going into it to make a difference and to change the system. And I'm all for it.
- [15:50]
Scott Becker
100%. And you're absolutely right. I mean the insurance companies at one time sort of managed risk and did a lot. They're just a pass through and just an extra system feels like often.
- [16:03]
Dr. Elizabeth Potter
Oh, absolutely. I mean, these days insurance is actually practicing medicine, no doubt about it. So the, the function, I mean, I think insurance is really important. I'm super thankful that we have the Women's Health and Cancer Rights Act. I would love for insurance to be functioning in a way where they were facilitating care, facilitating those interactions between providers and patients. But, but that has, that relationship has mutated into something that is really not helping patients or the practice of medicine. We're all starting to see that. We've all, we all see that pretty clearly. The, you know, the anger from Americans is palpable around insurance. So, you know, I think don't let a crisis go to waste and let's use this energy to reform how we deliver health care. And I'm hopeful that there are good actors on the insurance side. I know that there are and I'm interested in drawing attention to the good actors. You know, that's how we'll get better behavior. But I think the bad actors are, you know, they're going to have to change or get out.
- [17:13]
Scott Becker
Right. The bad actors are numerous and powerful. Dr. Potter, what a great pleasure to speak to you. I know it's a daunting challenge, but you're inspiring nevertheless. What a grinder and what a warrior and what a brilliant surgeon. And just a brilliant backstory as well. Father's a surgeon, mom's a CRNA from Georgia. Now one of the great micro surgeons in the country. Dr. Potter, thank you so much for joining us today on the Beckers Healthcare podcast. What a pleasure to visit with you.
- [17:42]
Dr. Elizabeth Potter
Thanks so much.