Podcast #19: Dr. Evan Pollack: The Pie is Too Small—And Physicians Are Starving

Justin Nabity
This is the DocNation podcast. We are a movement founded by doctors for doctors dedicated to empowering medical professionals to reclaim control over healthcare decisions and advocating for their fair share of the industry’s resources. Please note the views expressed are those of DocNation and not necessarily those of our guest or reference health centers.

Reid Lancaster
First of all, Evan, thanks for being here. We appreciate you carving out some time in your day to join us now.

Dr. Evan Pollack
My pleasure.

Reid Lancaster
Yeah, we might as well just start now. Can we just start now? Yeah. Just a very, very casual conversation, a real conversation. As you see in politics, you know, just real, straightforward conversations are very, very effective on both sides. This is a nonpartisan comment, but yeah. Yeah, that’s the aim and that’s the goal for this podcast.

So thank you so much, Evan, for your time. DocNation exists to do two things. Number one is we help doctors on an individual level, and that level is just like a professional athlete has an agent. We are an agency for doctors. So we invite people to give us a call. Send us an email.

If you have questions about what those services look like. But it is the full gamut. It’s like, okay, but they can professionally. But it’s everything. We’ll help you buy a new car, help you sell a home. We’ll negotiate your contract. We’ll review your contract. We’ll help you find a new job. Matter of fact, we were speaking with someone late last night till almost 7:00.

And she’s looking to, this individual’s looking to move back to a different country because she’s not getting, she’s not being respected at all. And she comes to the meeting and she’s just the nicest human in the world. I mean, I was fired up last night. It was difficult for me to go jump back in with my family.

But I will say she’s been working there for eight years, and they’re making it very difficult for her to travel abroad to see her family. And Justin and I start licking our chops, and we said, this is exactly why you have us. We’re going to get you what you want, whether it’s finding a new job for you. She didn’t even consider that for some reason. But she was ready to put her two weeks in, and she was asking us, what’s the best way to put your two weeks in? And I’m just proud that we’re able to do so much more than help people put their two weeks in. So that was a fulfilling conversation last night.

And then the other aspect of DocNation is we exist to create a union. Healthcare is in shambles right now. And I’ll just, in my opinion, I’ll say why I think it’s in shambles. And we can get into that a little more later. But in my opinion, the star players have been relegated to the bench, and the people who need the star players, the fans who pay to watch the World Series have lost all respect in the physician because of the multiple middlemen like the insurance companies.
So, that was a little bit of a preamble. Without further ado, Evan, would you please tell us who you are and what brings you here today?

Dr. Evan Pollack
Well, I appreciate your baseball analogy. First off.

Reid Lancaster
Just helps people understand it a little bit better.

Dr. Evan Pollack
All right, I understand that just fine. So I’ve done a variety of things in healthcare. I practiced internal medicine for 20 years. I represented hospitals on their Medicare appeals, as well as their commercial denials. I actually contracted for a period of time with the Department of Justice doing fraud, waste, and abuse.

I actually led the fraud, waste, and abuse team for a period of time.

I’m very active with the American College of Physicians. I sit on, actually, their subcommittee for coding and policy, and I’m on the editorial board for ICD ten. So, I did a lot of stuff in.

Reid Lancaster
Sure have.

Justin Nabity
What triggered you to go from being in practice to then these other initiatives, these other aspects? What led to that?

Dr. Evan Pollack
You know, that’s a great question. And I really got to the point where I wasn’t enjoying being in practice anymore, and, you know, you practice because you love taking care of patients. And I wasn’t enjoying it. I decided to transition out.

Justin Nabity
Was that midway, or was it toward the tail end of, like, 20 years?

Dr. Evan Pollack
I practiced for 20 years.

And, you know, because I worked with a lot of physicians that transitioned, that I led, a lot of physician teams, you know, about 15, 20 years ago, I’m seeing that physicians are getting tired of it. You know, just for the reasons which you previously stated, and are looking for something else to do.

Dr. Anthony Giuffrida
What would you say is the biggest difference from when you started practicing 20 years ago to when you stopped practicing, in regards to patient care and how your interaction with the patients are?

Dr. Evan Pollack
So, you know, I actually started practicing when things were changing quite a bit. Hadn’t changed all the way. But, you know, certainly what you’re seeing now is more physicians being employed. They’re having their schedules actually made for them. So, you know, you come in, you’re expected to do so much, see X amount of patients, allot this amount of time per patient.

And, as the technology in healthcare has increased, you know, now you’ve got your preauthorizations, you’ve got more expensive testing that you would like to be able to use, but you’re limited to use. You’re definitely spending more time fighting payers to get things done.

And, as you said, patients’ only interaction is with the physician, and they tend to take it out on the physician because that’s the only person that they see.

Reid Lancaster:
You know, because they’re in the process, they’re going through the process. It’s a miserable process for them. And but they don’t understand that their physician, who they’re talking to, is being handcuffed in so many different ways.

Dr. Anthony Giuffrida:
Yeah, yeah. Also, I realized the physician doesn’t really have all those answers either. I mean, the, the goalpost shifts so much I can’t keep up with what codes to use and what insurance is cover what I we wouldn’t learn that in med school. We learned how to take care of patients and how to treat diseases. And unfortunately, I feel like we’re getting pulled in 18 different directions.

And I think that’s leading to that burnout you’re talking about.

Dr. Evan Pollack:
Yeah, absolutely. And a lot of physicians are leaving practice either to do administrative type work or just get out of health care altogether.

Dr. Anthony Giuffrida:
One of the best lines my partner said is, “Medicine’s the hardest thing I ever worked at to get into, and now it’s the hardest thing I’m working at to get out of.”

Reid Lancaster:
Wow.

Dr. Evan Pollack:
Yeah.

Dr. Anthony Giuffrida:
Yeah. Which is sad to see because we want our best and brightest in medicine and to stay there.

Dr. Evan Pollack:
And that’s an excellent point you raised. In the past, the best and the brightest did go into healthcare, and I’m not sure that’s the case anymore.

Justin Nabity:
Well, the best and brightest see the writing on the wall. And they are smart and they’re looking at things and they’re making a judgment call on how to set themselves up. They’re not ignorant to the situation of what’s happening. You quoted in a previous article how 77% of physicians have gone from being in an environment that was autonomous to now being told what to do, told what to think.

I really think we’re in a situation where they want doctors to function like factory workers instead of thinkers. What do you think has led to, if you had to summarize, like pinpoint what the cause of that switch of 77% leaving being in charge of their own life and charge of how they see patients? What’s led to that?

Dr. Evan Pollack:
So, you know, that’s an excellent point. And it’s a complex issue. I don’t think that physicians necessarily want to sell their practice and become employed. Although really, if you look at physicians coming out of training right now, most of them prefer to be employed.

But to run a practice is incredibly expensive, particularly a primary care practice where you’re, you know, office-based. The overhead is tremendous.

A lot of practices being sold to insurance companies, hospitals, or private equity, it’s not necessarily because that’s what they want to do. It’s because that’s what they have to do, or they’re going to have to close their doors.

I think the big issue is: whatever entity buys a practice—whether insurance, hospital, or private equity—is their major goal to keep the practice going and provide good health care, or to make a profit? If it’s to make a profit, then that’s where physicians really suffer because they move in, get rid of personnel, cut costs, trying to turn it over and sell it.

Whereas there are instances where physicians are employed, like Kaiser, Mayo, Cleveland Clinic, where the goal is to provide good health care. And there are some physicians pretty happy in that situation.

Dr. Anthony Giuffrida:
Yeah, they’re marketing it as good health care. So that’s what matters for those companies. But I agree, it’s hard to see, you know, people still have to stay on for five years and you lose half your staff. And the reason for that is there’s no extra money coming in from CMS. The cuts come every year.

Dr. Evan Pollack:
Just got approved. Another cut to physician salary. Not only is it being cut, but it’s not been increased commensurate with the cost of living. So it only looks like a 2.5% cut, but it’s something like 20% when you factor in the cost of living.

Justin Nabity:
Earlier this year, there was a letter issued with like 200-plus members of Congress talking about supporting no more cuts. It was bipartisan. To read what you mentioned earlier about us existing for a union, us existing for advocacy. People get afraid of the word union, or they get afraid of striking, or these different terms.

They feel like most doctors aren’t aggressive by nature. They’re very much patient-first, wanting to connect with people and help them. Very servant-minded. And we’re in a situation where we can no longer have things go as they are, and there is support. There’s lots of support on Capitol Hill in DC to do this.

Dr. Evan Pollack:
Yeah, it’s a good point. I mean, physicians in general don’t want to get involved in big organizations or advocacy. But my recommendation, personally, is I got involved with the AMA. You could say what you want about the AMA, but they’re the largest lobbying group of physicians in the country.

You don’t like what the AMA does? Join them and change it. Because that’s your voice. You can’t sit on the sidelines and say, “Well, I don’t like what they do.”

Then there are specialty societies, like the American College of Physicians, where I’ve gotten very involved with their advocacy. I’ve gone to their leadership day many times. But you need to get out there and get involved.

The AMA, they’ll tell you, “You don’t even have to show up for me—give us your money and let us advocate for you.” And they do a lot of advocacy.

Dr. Anthony Giuffrida:
Yeah, and I think the younger group of physicians coming out is really soured by the AMA. That’s the word on the street. It’s going to be a problem because either we need the AMA to change, or someone else needs to step up and come in to advocate more.

Dr. Evan Pollack:
That’s why DocNation exists—to help support the AMA in any fashion or to become a similar governing body. We want to support, we want to help. Maybe this is the bridge for a meeting at some point with whoever we need to meet with at the end.

Dr. Evan Pollack:
With the AMA, you know, to say, “Hey, we’re physicians, we want to get things done.” You know, I’ll throw this out there—the membership of the AMA is pretty expensive for a physician. The AMA does not make its money off its membership fees. It makes millions and millions of dollars off the CPT codes. So, make the membership free!

Dr. Anthony Giuffrida
Yeah.

Reid Lancaster
How much is the membership?

Dr. Anthony Giuffrida
Especially the young guys with $300,000 in loans.

Dr. Evan Pollack
Right.

Dr. Anthony Giuffrida
They don’t have… I mean, it’s sad to say, but physicians these days don’t have that money to throw around.

Dr. Evan Pollack
No! I think it’s like about $800 or something like that. Make it for free. The AMA does not need physicians’ dues to run because they charge a fortune for CPT and they own CPT.

Dr. Anthony Giuffrida
They need that. They need the numbers. I agree with that. That’s a great idea, at least for maybe your first ten years of practice. It’s free.

Dr. Evan Pollack
Yeah!

Dr. Anthony Giuffrida
And then, yeah, I agree with that. That would be a great idea.

Reid Lancaster
Justin, this segment was started by your question about what would you do, Evan? And I’d like to just share a story from less than 12 hours ago, a meeting, the same meeting we had last night. And this physician said… she’s the first of all, she’s the least combative human I’ve ever met in my life. The nicest human.

Dr. Anthony Giuffrida
That’s most physicians. We’re not…

Reid Lancaster
The nicest, sweetest, most hardworking. What she had to do just to get to the States to become a… I mean, she’s just one of the most amazing people I’ve ever met. And, she said, I don’t want to sound like I’m pointing fingers or anything, but really, what’s difficult right now is our nurses are underperforming, and they know they can underperform and they’re not showing up as much as they should.

And the administration won’t discipline them, let alone fire them, because they have a union because there’s strength in numbers. And she said she ended it with, it’s easier to fire one of us, one of the physicians and just replace us. And that broke my heart last night. It was like…

Justin Nabity
How is that even possible? How did I get to the point where it’s that bad?

Reid Lancaster
And this is, and I’m not disrespecting nurses, but just level-wise, it’s like saying, okay, Shohei Ohtani, the best player in Major League Baseball, okay. Yeah, we don’t like we’re going to fire you instead of the third-string guy.

Dr. Anthony Giuffrida
And some of that boy.

Reid Lancaster
Why? What doesn’t that even register? That shouldn’t even make sense. But why? Because administration speaks the same language that now the nurses do: power. Okay, where there’s going to be a legal issue, there’s going to be a big fight. We don’t want to fight that. What’s the group that we as physicians?

Dr. Evan Pollack
I’ll tell you a quick story about my experience in the AMA. I served as a delegate to the AMA for eight years. And, one of the meetings was interrupted by a group of medical students who actually forged the ID and barged into the delegate hall, and what they were doing was they wanted public health care policy, right?

Justin Nabity
Yeah.

Dr. Evan Pollack
And the perception was that, you know, the AMA is against this, however, that actually came up for a vote with the AMA, and it was so close, whether or not they supported or not. It was so close that they had to do a ballot in order to do it, it was just a few votes, and I couldn’t help but think that instead of barging in and banging on a bunch of pots and pans, they could’ve joined the AMA and gone in there and voted. It would have passed.

Justin Nabity
When was this?

Dr. Anthony Giuffrida
Here’s a question.

Dr. Evan Pollack
From years ago.

Dr. Anthony Giuffrida
I have a question that I think a lot of people want to know, and I don’t know if you have the answer, do you think the AMA does enough and/or can they even do enough to fight the CMS cuts? I think that’s what I’m fighting.

Dr. Evan Pollack
They are presently fighting.

Dr. Anthony Giuffrida
Why does it keep happening? What are we doing that the cuts are almost a yearly thing? I mean, it’s almost like your Christmas present here is your 2.5% cut.

Dr. Evan Pollack
So one of them. Yeah. One of the things I think people don’t really realize with health care is that health care is a pie, right? And if one entity grabs a bigger piece of pie, someone has to get less. So that same money’s being divided into dessert for physicians, for hospitals, for pharmacy, for payers with the Medicare rates, it all has to be split.

Dr. Evan Pollack
And if you pay somebody more, somebody gets less. And clearly more money needs to be put into health care. And, you know, I think that’s… make it a bigger pie! That’s the only way you’re going to get a bigger piece.

Dr. Anthony Giuffrida
Okay. Who’s getting the added percentages when physicians are getting the cut?

Dr. Evan Pollack
Well, there were some areas that got like, I think the rehab facilities got to increase and there were some increases in coding that, you know, if you’re doing a more complex patient that you can add on to your fee a little bit didn’t help all physicians, but it might help some.

Dr. Evan Pollack
But, you know, certainly it wasn’t a whole lot, but this is a huge issue with the AMA. I get their newsletter on a regular basis. They are fighting it. I don’t think most people know it. And it’s not like I’m a big AMA fan. I appreciate other doctor organizations as well, which go out there and fight, and what I would like to see is I would like to see these groups in the AMA delegation meetings with a voice there because, you know, all doctors should fight together as one voice.

Dr. Evan Pollack
The AMA, if I was going to give, you know, other than their dues, one of my criticisms is that they keep people out of their meetings and they should not be doing that.

Justin Nabity
Maybe that’s something we can help out with. Maybe we help them get more outreach, more participation. Among the members, we rally the medical students as the next generation to get more plugged in. I love the visual. What you’re talking about with the pie. If the pie’s like this and we need it to turn into this, well, people are going to complain. There’s so much money spent on health care. We spend double or triple or whatever other country spent on health care, blah, blah, blah. Well, maybe there’s money being wasted in other ways in our government that we do a little bit better job of managing the money there to then put some more money into the pie. That should be for health care that affects everyone.

Justin Nabity
I think about this all the time. What am I getting for the tens of thousands of dollars that I spend on taxes every year? What do I get? Do I get really anything? It’s the connection between value and… so health care affects everybody. It’s so critical that we receive quality and we have more money spent on health care. We have access to more information, we have more research, we have more technology, we have more of everything we’ve ever had in society. And yet the quality of our health care, you look at the average person, we’re in the worst shape ever as a society. And maybe…

Dr. Evan Pollack
That’s exactly right.

Justin Nabity
Maybe that’s because the pie that you said is not big enough, and the slicing of the pie isn’t to the right people.

Dr. Anthony Giuffrida
Right? And Doctor Pollack, I’d love to hear what you think about this. To me, the pie is an interesting take, because the pie that we’re talking about is the money from the government.

Dr. Evan Pollack
Right.

Dr. Anthony Giuffrida
I think a lot of money gets lost in health care to private insurance. The profit that is made and the overhead that is there, and private insurance is enough to fund.

Dr. Evan Pollack
So here here’s the thing about private insurance. And you know, I’m reluctant to ever adopt a stance where one entity is a bad guy.

Dr. Anthony Giuffrida
And I’m not saying they’re bad. I just think there’s…

Dr. Evan Pollack
Yeah. So here’s the thing. Let’s take like United Health Care, which is the largest, and they’re, you know, attempting to monopolize health care in a way. But they do not make the majority of their profit off of their health insurance plan. The profit margin last I heard was something about like 5%, which if you compare it to like a tech company, which is 20%, they’re not making a huge amount. They make a lot of their money off of OptumRx.

Dr. Anthony Giuffrida
Hold on, hold on, the tech company has a product,

Dr. Evan Pollack
Right?

Dr. Anthony Giuffrida
What does United Health Care have other than sick people?

Dr. Evan Pollack
Well right, but the majority of their profit comes from Optum, not from the health insurance company.

Dr. Anthony Giuffrida
Fair enough, yeah.

Dr. Evan Pollack
They have OptumRx, they have Optum 360. They have all the practices they’ve purchased. This is where they are making the majority of their money.

And if you look at a lot of other health insurance companies, it’s the same thing. And unfortunately, you know, you talk about the health care, why it’s so bad. We have all the technology in the world, but only a small sector of the population gets to take advantage of that technology.

There are a lot of people that do not. And what really this country needs is some type of a national health plan that people would buy into if they need to, and offer it as an option. And if anything, it’ll keep the insurance companies honest as well.

Dr. Anthony Giuffrida
I’ve always said that at least a tiered system would work very well here, I think.

Dr. Evan Pollack
Yeah, yeah. No, I completely agree. It’s crazy that we don’t have it because almost every other nation in the world has some type of government health plan.

Dr. Anthony Giuffrida
I don’t think we can go fully to a government plan. It really hurt the doctors over there. And they’re all looking to come here. But I agree, you can’t have physicians being upset and patients not getting good health care at the same time.

Reid Lancaster
Right. That doesn’t exist. We were getting great health care, but we can’t have both.

Yeah. I don’t know how much I like that idea. I’ll give you two examples from two different clients. One of them is U.S-born and married to his wife, who is Russian. When they met, she said, “I’m not sure I want to be poor my whole life.” In Russia, physicians don’t make any money.

Justin Nabity
It’s like a few hundred dollars a month.

Reid Lancaster
Right. And so fast forward to the conversation we had last night. If our client decides to go back home to move back to Argentina… she will go from making 250 to what was it? 35 grand.

Justin Nabity
We said 55, but she’s like, “Yeah, probably less than 55.”

Reid Lancaster
Right, less than that. So I’m just giving a ballpark estimate. But she said it would be difficult for me to afford a place to live.

Dr. Evan Pollack
Here’s another thing I’ll throw out that hasn’t been spoken yet, but I think it’s an important issue. U.S. physicians do get paid more than physicians in other countries. However, U.S. physicians spend a fortune for their education. Most U.S. physicians are coming out close to $500,000 in debt. So that’s going to take years and years to pay off.

Dr. Anthony Giuffrida
So we also come out older. That’s two to four years of earning power gone. Other than that…

Reid Lancaster
Evan, is that the average? Is that a stat we can lean on, 500K?

Dr. Evan Pollack
The average is like 350,000. But to me, that’s a little bit low.

Justin Nabity
Think about when we started our other team, Reid, back in the day 15-plus years ago. I remember going in and lecturing at universities. I was talking about 170, 190, 15 years ago. Think about what’s changed with inflation and everything else. The cost of education is rising rapidly—6% per year is the typical percentage.

Reid Lancaster
Anthony, I’d like to end this podcast with final words from Evan. But before we do that, can you give me that one liner you spat out about 15 minutes ago? What was that?

Dr. Anthony Giuffrida
About?

Reid Lancaster
“I’ve never worked so hard to get into something.”

Dr. Anthony Giuffrida
Yeah.

Reid Lancaster
I’ve never worked so hard as I did to get into medicine. And now I’m working just as hard to get out of medicine. And the thing we were talking about is side gigs—like what we’re doing on the side, trying to get patents, doing other things. And you think about it. An NFL quarterback might have some advertising deals, but they’re not trying to get out of football. They’re trying to play as long as they can.

When was the last time you saw a professional athlete who was happy to retire? Look at these guys—they’re getting celebrated for an entire year. Look at Derek Jeter. His last year was literally a retirement at every stadium he played. Why do I bring up professional athletes?

Because there’s a reverence for them. There’s a respect for them. But why are we respecting people who throw a ball so much more than people who save a life? I’m not expecting doctors to make $60 million a year. I wish they would, like a top-tier quarterback. But they ought to be able to pay back their debt in a few years—not 12, not 10 years, which is what we’re seeing with all of our clients.

Dr. Evan Pollack
Well, if you circle back, I don’t think there should be only one option in this country, and that’s a government health plan. But I think it should be there as an option for people who can’t afford private insurance. I still think that for people that can afford it, they would get some type of private insurance.

There has to be some type of regulation on pricing, and it should be price transparency. And there should be oversight into private entities purchasing health care practices—whether or not they want to do it just for profit, or whether or not they’re really actually interested in maintaining good health care.

Reid Lancaster
Evan, thanks so much for your time today. We appreciate you.

Justin Nabity
Thank you.

Dr. Anthony Giuffrida
Thank you very much. This was great.

Justin Nabity
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