#299 - The Hidden Language of NICU Billing with Dr. Scott Duncan

In this episode of The Incubator, Ben and Daphna speak with Dr. Scott Duncan, Division Chief at the University of Louisville, about the critical importance of medical billing and coding in neonatology. The discussion explores how accurate documentation and thoughtful use of codes can impact everything from individual reimbursement to hospital funding and staffing. Dr. Duncan explains the key differences between critical care and intensive care coding, highlighting how misunderstanding these definitions can lead to missed opportunities for appropriate billing. The conversation also delves into the complexities of CPT and ICD-10 codes, bundled versus unbundled services, and how Diagnosis-Related Group (DRG) systems influence hospital revenue. They discuss how proper coding affects downstream resources, including staffing, and why the financial viability of neonatal units depends in part on getting this right. Dr. Duncan reflects on the need for better education in this area, particularly for trainees, and shares practical resources and upcoming initiatives aimed at helping clinicians build this essential skill set. This episode offers an eye-opening look at a topic often overlooked in medical training, but vital to the sustainability of neonatal care.

Transcript

[00:00:00.800] - Ben Courchia MD

Hello, everybody. Welcome back to the Incubator podcast. We are back with Daphna for a special interview that, to be perfectly transparent, we're recording at the CHNC symposium in Denver, Colorado. And today we have the pleasure of being joined by Dr. Scott Duncan. Scott, thank you so much for coming on the podcast and sharing. Sometime soon.

[00:00:23.420] - Scott Duncan MD

Sure. Thank you for having me.

[00:00:25.920] - Ben Courchia MD

For the people who don't know you, you are the division chief at the University of Louisville in Kentucky.

[00:00:32.900] - Scott Duncan MD

Yes.

[00:00:34.540] - Ben Courchia MD

Beautiful city. One of the. One of the few cities in the country that I had the pleasure of visiting. And this podcast recording was recommended to us to be done by our good friend Dr. Satyan Lakshminrusimha in California, who said that you were the person that we should be speaking to when it comes to medical coding and medical billing. Not that we're super excited about talking about billing, but that the gaps in knowledge between what we are currently utilizing, knowing, understanding, versus what we're actually practicing is where I really think there's going to be some interesting conversation. So I guess my first, my first question to you is, how did you get to become the coding guru?

[00:01:22.210] - Scott Duncan MD

You know, it was strictly coincidental. I spent the first third of my career in a private practice, and when the university called and said there was a spot there, my wife had the bags packed before I had the phone hung up because she was ready to come home and that was fine. But, you know, if I was going to go back into this, I was going to go back into it full force. So I worked for a couple of years, recognized I need another skill set, and went back and got a master's in healthcare administration through UNC Chapel Hill.

[00:01:51.570] - Ben Courchia MD

Interesting.

[00:01:52.080] - Scott Duncan MD

I will throw in a plug for them. That is a perennial top three school for that particular degree. And it was a wonderful experience and probably one of the smartest things I've ever done. But then, as coincidences go, there was an opening for the coding committee, which is a committee with the section of Neonatal Perinatal Medicine in my district. And David Adamkin, who was my division chief at the time, was and remains good friends with Gil Martin and recommended to Gil that I take that spot that was open. And then things have kind of snowballed since then that I eventually became chair of that committee.

[00:02:26.970] - Ben Courchia MD

What's interesting to me is that you, you start this process and you're not disgusted by it. You sort of embrace it. So what did you see? The, the potential to promote the work that was being done in neonatology? What was your, your perspective on, on.

[00:02:45.550] - Scott Duncan MD

You know, I Think the first thing was, is the years I spent in private practice. I started off as an old chief resident, so I always liked the business aspects of it. And then the years I was in private practice. First started off, started a nursery from scratch down in south central Mississippi, and once again was always fascinated by the business end of it. Coding and documentation and billing actually is a skill set you have to develop over time. Not too many people walk into it having a real good grasp of it. And, and so even members that we bring into the coding committee, we don't expect them to be a foremost expert in it. And we're there to help build them up and provide education not only for the members of the committee, but obviously for members of the section. And then it just started to snowball up from there, recognizing the aspects of this that is so important to our healthcare and our healthcare financing as well. During the degree program. The two areas that I really liked which were really, really nerdy is I loved accounting and finance and I love strategic planning.

[00:03:46.180] - Scott Duncan MD

I thought those are two of the most fascinating areas within the master's work.

[00:03:51.160] - Ben Courchia MD

And so one of the things that's interesting to me in this conversation is the one that as neonatologists, we tend to agree with whatever we decide to call ourselves or whatever we decide to call the care we deliver. We are neonatologists, we are neonatal care physician, we are neonatal intensive care. We're a neonatal critical care physician. We just don't make any distinction, however, when it comes to coding. The, the, the, the distinction between intensive care and critical care is one that is very important, kind of crucial, and that not many people are aware of, because to them they might say, isn't it the same thing?

[00:04:26.210] - Scott Duncan MD

Well, the distinction between critical care and intensive care is, is very important. One thing to note is, is that you don't have to be a neonatologist to use those codes and you don't have to be in a NICU necessarily to use those codes. But a critical care code basically says that this child's illness is so severe that if you remove therapy that you're looking at imminent demise. Now, there's not any real good definition as to what imminent demise is. And the other half of that definition goes along with the idea that it requires a fair amount of critical thinking and thought process in order to determine what you're going to do.

[00:05:03.220] - Ben Courchia MD

And that's critical care.

[00:05:04.260] - Scott Duncan MD

That's critical care. Intensive care basically says that you need to do frequent vital signs, continuous monitoring. And we think of those as our babies who Are growing and feeding and having apnea spells periodically that don't require a lot of intervention, that type of a thing.

[00:05:18.810] - Daphna Yasova Barbeau MD

And I think some people, there are some definitions for what qualifies critical versus intensive care. And I actually think people are using the codes, but some people maybe not to their fullest degree. Can you talk about some of those thresholds?

[00:05:33.730] - Scott Duncan MD

You know, I think the not using them to the fullest degree, a lot of physicians don't really want to fool with it. And it becomes important from a lot of different areas. Of course you want to get paid, right? That's the first thing that you have to recognize. But in critical care, most of our kids that we think about that would be critical would be those kids who are ventilated, those kids requiring CPAP, those kids who are on prostaglandins, those types of things. If you remove the therapy, once again, you're looking at imminent demise. The thing is, our critical care codes are global bundled codes with a few exceptions. And the delivery room is a perfect example of a few exceptions. So a delivery room, when you attend a delivery, there's no time frame to it. So if you go in, you actively participate in a delivery, you can charge for attending that delivery. If you do nothing more than CPAP, then you charge the attendant delivery. If you provide positive pressure chest compressions, then you can charge the tenant delivery and resuscitation. If you have to extend beyond that, then you can add the things that you had to do, Things like intubation, putting lines in chest tubes, that sort of a thing.

[00:06:46.990] - Scott Duncan MD

Once the resuscitation is over and you're into the unit, most of that is bundled into that single global code with a few exceptions. A great example of an exception would be something like a chest tube. A chest tube you can bill for independently. So I think a lot of times we see errors in the proper coding for the resuscitation and failure to code for things that aren't bundled together. And through there. The other thing that I think that we see, that I see even with my own group a lot of times is not using the proper ICD10 code. This committee has traditionally, in years gone by, focused primarily on the CPT codes. And we've really extended out into the ICD10 codes and the proper documentation as well. The wrong ICD10 code will get your claim denied. Put in an O code, which is maternal based codes on a baby's chart, they're going to kick that right out.

[00:07:38.740] - Ben Courchia MD

The one that I've seen the most is Perinatal Depression, which, like sometimes mood disorder, which is a mood disorder. And the. But they're like, no, but the baby was depressed. And it's like, no, but that's not what you're coding for, right?

[00:07:50.750] - Scott Duncan MD

Yeah, that's exactly right. Well, that's a great example, though. So if you look at something like hypoxic ischemic encephalopathy, there's about four different codes for that, and one of them is a nonspecific code, and then it's graded by severity. So this gets a lot deeper. It really revolves away from the question you asked me, but it's really important. So you have to understand facility payment as well. Right. So there's two major ways facilities get paid, particularly with the Medicaid population. Half the states use an APR drg, half the states are a little bit less, uses what's called an MS-DRG. That's what CMS uses. It's a simple method. There's only about six different levels of that, but the payment goes up pretty dramatically from something like $9,000 for a hospital stay to nearly $40,000 for a hospital stay. And if you put the HIE code in there, you're going to get the cheaper, the cheaper reimbursement.

[00:08:44.090] - Ben Courchia MD

And so I think that's what we should focus on. I think I've spoken to many people about this just because I'm curious, and I've spoken to people abroad as well because I'm curious about how they deal with coding and so on in the U.S. many people will say, oh, I didn't go into this for the money. So I don't, I don't know, it doesn't matter to me. Like, I get paid the same at the end of the month, so why should I try to spend, waste my time doing this? And I think we don't really understand the ramification of how the hospital on a larger scale sees the revenue generated by the different units and how that eventually downstream, does impact our field as a whole.

[00:09:21.420] - Scott Duncan MD

Yes, it does. And what it does is it creates resources. So if your downstream revenue is, is down for whatever reason, you're not going to get the resources you need. How many, how many folks. I know that everybody in the US is looking for nurse practitioners now, Right. Because residency hours are going to be cut back. And so we all need additional. Satyan wrote a paper on that just recently. And so that does affect your downstream revenue and it affects your ability to drive revenue sources.

[00:09:49.510] - Ben Courchia MD

And, and what you were referring to earlier with the DRGs is that there was a. I'm not exactly sure when that happened, but there was a shift in the way medical billing and coding took place in the nicu where in the past you could have build. Build individually for every single thing you did in the nicu. And then it transitioned to a bundle where basically babies are categorized based on just the severity and the acuity of their illness. And they just fall into one of these select few codes that are available in terms of the care they're receiving in the nicu. Can you tell us a little bit when that happened and how has that affected.

[00:10:28.760] - Scott Duncan MD

It happened before my time.

[00:10:30.490] - Ben Courchia MD

Really?

[00:10:31.400] - Scott Duncan MD

Yes, a lot of that happened before my time. There's, you know, I've been in healthcare Since I was 17, I got 47 years in healthcare. And the only constant is it's always changed. Right. Even our codes, our physician code provider codes have changed across the years. And now you have managed care organizations that are working within the Medicaid population as well. So a lot of the states will work on those DRG basis for those. There are still some places that do a per diem basis. There's not a whole lot of them, but there's a few of them that do. And then the private insurers may pay differently still. And of course there's also additional funds that flow based on whether you're an academic center, whether you're training residents or fellows, and there are other modifiers that goes along with that.

[00:11:16.060] - Ben Courchia MD

Yeah. And it removed basically the opportunity to exploit the system. I thought I was talking to one of the older attendings in my, in my training who said that you could potentially, some people, some people could have gotten away with coding for a cardiac catheterization for an arterial line. And that was, that was that paid more, apparently. And I think you hear all these stories and you're like, oh my God. So I think on the one hand it does help rein in a little bit some of these practices, but it does make. Create a situation in which there's less room for error when it comes to the clinicians today and how they, they code for each of these of these patients.

[00:11:53.550] - Daphna Yasova Barbeau MD

And how do you think neonatology specifically impacted by that? Because see, the bundled disease code is the same for the 26 weeker and the 22 weeker. Potentially, though the 22 week may have much higher acuity, may stay much longer in the nicu.

[00:12:12.570] - Scott Duncan MD

Yeah. And part of that's impacted by which DRG system to use. So the, the simple DRG system that CMS uses, the MS-DRG, that doesn't allow as much flexibility. The APR or the three MS-DRG systems will allow for more flexibility because it does severity of illness. And looks at. There is a mechanism looking for extended length of stay and when your cost exceed the DRG by X percentage, since you can just get additional fund flow then.

[00:12:40.220] - Daphna Yasova Barbeau MD

But I think there's still a lot of people who, if you're not familiar with those things, you're. You're not billing and coding for those things.

[00:12:47.740] - Scott Duncan MD

That's correct.

[00:12:48.290] - Daphna Yasova Barbeau MD

That's so interesting.

[00:12:49.010] - Scott Duncan MD

I think there's a lot of folks who still work under RVUs as well. And so that's a whole different issue when you think about it.

[00:12:56.540] - Ben Courchia MD

Yeah.

[00:12:57.010] - Scott Duncan MD

And for an individual. You never want an individual neonatologist to work under an RVU system because, well, for example, we've got about six nocturnists. Well, they're not going to get any RVUs at all. The only thing that gets admission codes at night. Whereas somebody like myself, he said quietly, who's working only day shifts, I'm going to get all the daytime charges. So if you're going to be into a DRG system, you want to make sure that that applies for the department, the division, the practice, whatever it is, as a group, and not the individual. And the other thing is, and I think Mark Mercurio wrote about this, we're working ourselves to death.

[00:13:31.940] - Daphna Yasova Barbeau MD

Yep.

[00:13:32.610] - Scott Duncan MD

So we push more RVUs per FTE than any other subset. The race to the bottom.

[00:13:37.550] - Ben Courchia MD

The race to the bottom is.

[00:13:39.140] - Scott Duncan MD

That's correct. That's correct. If you haven't read that, you should.

[00:13:42.270] - Ben Courchia MD

Yeah, it's. It's a great paper.

[00:13:43.400] - Scott Duncan MD

It's a great paper. It is. You understand, we also support a lot of the other practices that don't make a lot of money. When you think about pediatric infectious disease. Dr. Satyan actually was in Louisville last week. He delivered the Billy Andrews lecture. That's why I kind of trusted. When you mentioned Dr. Satyan. Yes, I saw him last week.

[00:14:02.160] - Ben Courchia MD

Yeah, we. We saw him a couple. I mean, he's, he's. Dr. Satyan is everywhere, all the time. Yes. And he probably showed. I mean, I'm. The way you're talking about his talk. I know exactly which slide you're referencing to where he shows about the. The RV is generated by the different specialties and how much neonatology does generate in relation to other specialties and how. We are one of the most productive specialty across the board, adult and pediatrics.

[00:14:26.560] - Scott Duncan MD

Yes.

[00:14:26.930] - Ben Courchia MD

And yet our revenues are nowhere near commensurate to the amount of RVUs we generate for the hospital. And, and his, his, at least when he spoke to us, his call to action was really to say, we need to do something about this because we're being shortchanged in what we can do, resources that can be allocated to our patients and our services and our staff. But just before we get into this, I mean, we talked about some of these, these MSDRGs, which by the way, these are Medicare severity diagnosis related groups. But these groups of code does tie in with rvus. And so as units are looked at, maybe not like you said, not on an individual basis, but as a group, as a physician group covering a NICU, and you're looking at number of RVUs being produced, how you've coded during a given year will directly correlate with how many RVUs are being produced. These are not independent metrics. They are very much tied to one another, tied together. And I think some people need to know that because I don't think everybody realizes that these are, these are very much connected.

[00:15:28.610] - Scott Duncan MD

Each of the CPT codes has their own RVU assigned to it. And the RVU is based upon physician work practice expense and malpractice liability. And then there's a geographic adjustment that's put on it as well. It obviously costs board of practice in Los Angeles than it does in Louisville. So they may get a higher payment based on a little bit higher RVU on the same code. So the RV used for the physician workforce is really based on that CPT code. The payments back to the hospital is more based on that DRG system.

[00:16:02.850] - Ben Courchia MD

Very interesting. One of the things that's frustrating to me is that this is very much an important part of the sustainability aspect of our specialty. And yet, at least I'm going to speak for myself. But I'm pretty sure everybody's in the same boat. Nobody talks to us about this throughout training from, from medical school all the way to the end of fellowship, and it's 10, 15, 14 years sometimes. And how come no one tells us about this? So my question to you is, do you think that there's, there needs to be a movement to make our trainees more knowledgeable, at least about medical billing, medical coding? And then my second part to my question is if you didn't have the privilege of having any form of introduction to it, what are your, what is your advice for people to want to say, okay, here's where you go to learn about this without following unfortunately in your path, Having to go through a master's degree where it's a bit more.

[00:16:56.160] - Scott Duncan MD

Intensive, You Kind of handed that to me on a platter, didn't you? So, yes, absolutely. We've actually proposed the idea of having some business aspects of neonatology as part of the fellowship training. Right. And I certainly. I know for those of us who do it, like on the coding committee, I always do at least one lecture a year for our trainees on how to do this and do this correctly. Now, your coding committee under the section also is engaged in education. Right. So we provide the coding workshop at Scottsdale. We provide a deep dive in the afternoon, and then we also do at least one other lecture on business aspects of neonatal practice. During that particular workshop, we've tried to pair with TECAN and MIDCAN to also do webinars, perhaps a little more basic for the TeCaN, since that's training in early career, a little more complex for the midcan. We're getting ready for Scottsdale this year. I'm going to meet with the coding committee next month, actually, and we'll probably. We're going to talk about restructuring how we do the coding workshop a little bit so that the first portion of it is more basics, and then the second portion of it, it's a little more complex.

[00:18:09.150] - Scott Duncan MD

The resources that you have through the academy are pretty extensive and runs from anything from the coding newsletter to coding for pediatrics. Of course, you can get references from the AMA. The AMA owns CPT. I use Optum as another place that I use for ICD10 coding because of some of the resources they have there. It becomes expensive to do that over time. At one time, we had written the Quick Reference Guide for Neonatal Coding and Documentation and really have not been able to gain traction to publish a third edition of it, although we would. We would like to do that. I think the thing that we need to think of now is how do we put this electronically, how do we put this into an app and that sort of a thing.

[00:18:55.210] - Daphna Yasova Barbeau MD

We're talking with journal barrier. Just that it's changing so often or what are some of the.

[00:18:59.820] - Scott Duncan MD

I think it is. I think anytime that you think about how medical education in general has. Has evolved over the years and how learning has evolved over the years, I think this is an area that we need to think about how we can do it a little bit differently. We're going to look at writing a series of articles on coding and documentation similar to. There was a series of articles on quality improvement that was published in Journal of Perinatology. I've been in contact with Dr. Gallagher, who's agreed. Yes. And I think we're going to put out a series of about six articles. Oh, that's. We just need to finish it and formalize it in order to get it going. And hopefully by 2025 or 2026, we'll see all those in print.

[00:19:39.570] - Daphna Yasova Barbeau MD

Perfect, perfect. We spent a lot of time talking about kind of the daily codes, but you also had an article just this year, the 20th of May of this year, about neonatology consultation coding. I'm hoping you can talk a little bit for yourself.

[00:19:53.750] - Scott Duncan MD

A little bit, yeah. Which one was that really about?

[00:19:58.250] - Ben Courchia MD

It was a correspondence in the Journal of Perinatology.

[00:20:00.650] - Daphna Yasova Barbeau MD

Some of the things that neonatologists doing that are not part of the daily code or for example, we have colleagues who are consulting in the cardiac icu. I have a special interest in palliative care. The pre clause, the er. Yeah, the newborn nursery, you know, are we using the right code?

[00:20:17.800] - Scott Duncan MD

So there's, there's a different approaches to that. Let's use the cardiac ICU for one. If you're called and asked to do a consultation in a cardiac ICU and it's a critical care scenario, in that instance, you would not use the global code. The primary physician would do the global code, but you can use a time based code. The example I can give you, perhaps you're called to help with ventilation in a baby. And you go up and you look at the ventilator, you make adjustments, you write out a consultation note along with an assessment and a plan. You document the time that you put in on it. Perhaps you stop and intubate. Re. Intubate the kid for one reason or another. Well, you can use a time based code. You have to take out the time you spent intubation. And since you used a time based critical care code, you can charge separately for that procedure because the time based codes aren't bundled. So that's one method. In a critical care type of scenario and other scenarios, there certainly there's a series of outpatient codes that you could use if you're doing prenatal work in the office, for example.

[00:21:21.600] - Scott Duncan MD

Or what I think commonly happens to us is we get called for the mother who has come in and she's 23 weeks and ruptured and you want to be consulted on that. Well, there's a series of codes that can either be based on medical decision making or time. You have to hit that threshold of time in order to bill for that initial consultation. I'm not thinking of it off the top of my head. I think it's 9, 9, 252234 to 255. There's a time threshold you have to hit for those. So you document your time, you spend in preparation, you spent doing the actual face to face work, you spend doing your follow up work communicating with the other physicians. Now two weeks later they call you back and they say now she is 25 weeks and they, they've got some questions they want to ask you about there. You don't use hospitalization code or the, the consultation codes because you've already done it. You only get one of those for admissions. So now you use subsequent hospital day codes on those. So those, I mean that's kind of a quick background how you do that.

[00:22:26.980] - Ben Courchia MD

Even if. What about if. I'm sorry, this is like very. Now I'm geeking out over this. But what if the, the, the parent has been discharged and is now back? I was thinking are you allowed then to reconsult? Is it a reconsult? Well that's a good question. I stopped the expert.

[00:22:42.310] - Scott Duncan MD

No, there's.

[00:22:43.020] - Daphna Yasova Barbeau MD

Because this happens a lot to us.

[00:22:44.650] - Scott Duncan MD

Yeah. There's a time frame that's associated with it and I'd have to go out, look it up to be honest, in order to give you the right answer. But there's a timeframe associated with when was the last time you provided services to em And I don't remember it off the top of my head.

[00:22:57.000] - Ben Courchia MD

No problem.

[00:22:57.750] - Daphna Yasova Barbeau MD

Then I have a separate consultation question. So so many people are sub, sub specializing. Right. You've got the person in your unit you call for neuro and HIE babies or the hemodynamics teams now or again palliative care. Is there a way for a neonatologist to code for consults that are. Since they're not the primary team for that day.

[00:23:22.400] - Scott Duncan MD

Not if they're the same tax ID and the same practice. Right. All that's going to get gobbled up in your global codes. We've addressed this as a committee a time or two and we're asked to create codes or at least consider creating codes for different scenarios. And most of those you really can't do.

[00:23:38.230] - Ben Courchia MD

Interesting, interesting.

[00:23:40.420] - Scott Duncan MD

Unfortunate though.

[00:23:41.800] - Daphna Yasova Barbeau MD

Yeah, it's a lot of extra time and expertise sometimes.

[00:23:46.200] - Scott Duncan MD

Absolutely.

[00:23:47.070] - Ben Courchia MD

Yeah. And the incentivizes the, the people who we could leverage for the care of our babies because just there's no, there's no incentive there.

[00:23:56.950] - Scott Duncan MD

It has to do with the taxonomy codes and whether you're the same tax ID and whether you're the same practice and that sort of thing. We've got, we've got a group of neonatologists who do neonatal follow up. Will they come in and do a consultation with the families before discharge, which.

[00:24:12.390] - Daphna Yasova Barbeau MD

Is so valuable for the family.

[00:24:14.180] - Scott Duncan MD

Yeah, but enough. And I know you can't see it on a podcast, but it's a big zero.

[00:24:20.710] - Daphna Yasova Barbeau MD

Right?

[00:24:21.430] - Scott Duncan MD

Right.

[00:24:21.810] - Daphna Yasova Barbeau MD

Yeah. And then. Right. So then some hospital systems will say, well, we can do without that, but it's really so critical to that transition of care for that family.

[00:24:31.700] - Scott Duncan MD

Yes. You know, and that goes back. You can make the argument it goes back to the value equation. The value equation was originally Michael Porter, who was a Harvard business guy who wrote pretty prolifically in the medical literature. Go ahead. Is value, and then we've added a lot to the top of that equation. But cost isn't always the only answer to it, right?

[00:25:00.010] - Daphna Yasova Barbeau MD

I have some questions about business of medicine, but did you have more coding-related questions?

[00:25:04.640] - Benjamin Courchia MD

No. I just wanted to mention something that, to me, is important because I think some people in the US may say, Oh, this is typically US problem, but that's not true. When you talk to people around the world, I've spoken to colleagues in Canada and to other colleagues around the world, coding is the lifeline of their practice, and they are actively being coached on how to code appropriately for their patients because the sustainability The community of their departments is directly tied to their ability to code effectively. It goes from a variety of different things. I've seen places where they have little workshops for new hires. I've seen units where there's the one guy who's going to basically tutor everybody else into how to code. But it is not a US-centric problem. It's something that everybody is doing as medicine globally is turning from a charitable endeavor to more of a business.

[00:25:58.310] - Scott Duncan MD

I think that's That's a great point. I think it's easy to look at our healthcare system and say we could do better. I think any healthcare system could obviously do better, and we could do more for less, and so on and so forth. But I really think we have an outstanding healthcare system if you compare apples to apples. That's the big issue is comparing apples to apples. We probably need to provide some basic services that aren't necessarily paid for. We've grown up in a system that pays for illness rather than pays for wellness. Absolutely. That's a huge issue. I I wish I had. If I had a good solution to that, I'd be a rich guy lying on the beach.

[00:26:35.920] - Benjamin Courchia MD

Yeah, absolutely.

[00:26:36.850] - Daphna Yasova Barbeau MD

Well, I mean, to that point, you went out, you got the extra training. I feel like at some point in time, in Many decades ago, physicians were much more ingrained in how hospitals ran, how their own practices ran, how their outpatient clinics have run. But there's now this dichotomy where we have administrators, and then we have people providing the health care, which is good and bad. But I guess my question to you is, what responsibility do we have as physicians, neonatal health care professionals, to remain aware of the business of medicine? I feel like we've gotten so far away from it that we no longer have any control over how some decisions are made about our practice.

[00:27:23.360] - Scott Duncan MD

I think that's where you have to educate your administrators as much as anything else. They're not on the front lines. There was a paper written recently, and I think either the Association of Academic Division Directors or one of the other groups have had some brief touches on this called Administrative Harm. That's decisions that were made With that realization the downstream effects on your patient population or on your workforce for that matter as well. From my standpoint, in order to provide good care, there are times where we need to educate the administrators as well. Instead of saying, You can do more for less, we need to say, Here's what we need in order to do more.

[00:28:05.750] - Daphna Yasova Barbeau MD

Any tips on addressing the C-suite? What's the best way to bring this to their attention? What data are they looking for?

[00:28:14.250] - Scott Duncan MD

Oh, that's a way too broader question. You always have to narrow it down to about a 10-minute conversation or less. If you wanted to put me to sleep, put me in a room, start showing me slides. In about 10 minutes, I'll be gone. I think even When you're thinking about education things, if you really wanted to lose folks, and in today's world, start with an hour lecture, and by 10 minutes, they've wandered off, and they're texting on their telephones, and even the 10-minute lectures, they wandered off. It started daft. You got to get it down to short bits You have to make it things that they recognize, that the administrators understand. I'd like to think that we overall have really good relationships with our administrators. We've integrated healthcare systems. You University of Louisville, you asked my clinical workers to Norton Children's Medical Group. It's a great health care system, and it's doing a really nice job. I'm able to meet with them and work with them on a regular basis, meet with a hospital administrator, at least every other month, meet with the chief medical officer at the same time frame, executive vice president for pediatric service line along that same time frame, even my department chairman on a regular basis.

[00:29:25.280] - Scott Duncan MD

All of those are good to be able to sit and just go over issues and how do we address the issue? Sure.

[00:29:32.830] - Daphna Yasova Barbeau MD

I like that. Are there tips for educational resources for people who are interested in learning more about the business of medicine?

[00:29:41.470] - Scott Duncan MD

Well, the academy has a bunch of resources, obviously. There are degree programs. I'm sure there are certificate programs. I know Harvard's got certificate programs. Even our school started another master's in healthcare administration at Louisville. The other route to go actually is through public health. We talked quite a bit about the concept of business in medicine, but I think public health is something that really we need to focus on as well. When you're thinking about diversity and equity, inclusion and inequity in the care we provide, I think that's another route to really look at with a critical eye and consider advanced degree work in. We're able to at least offer our fellows certificates in certain areas. Health profession's education would be one, but some of our fellows, since they put a little skin in the game, I have one fellow who we're going to hire who's getting a master's at School of Public Health.

[00:30:38.660] - Daphna Yasova Barbeau MD

It's like separate tracks.

[00:30:40.220] - Benjamin Courchia MD

Sometimes it starts with these little certificates where you get a little certificate and you're like, I want a bigger certificate.

[00:30:46.550] - Scott Duncan MD

Absolutely. It also makes you marketable. That's right.

[00:30:50.270] - Daphna Yasova Barbeau MD

Absolutely. Specific expertise. Yes.

[00:30:52.030] - Scott Duncan MD

Absolutely. Absolutely.

[00:30:54.240] - Benjamin Courchia MD

Scott, thank you so much for taking the time to spend these 30 minutes to speak to us about this. This was very enlightening, and I hope that it's going to make people reflect and think a little bit harder about the health of their departments and of their institutions and try to take steps that will bring more longevity to their respective units. So thank you. Thank you for staying. Sure.

[00:31:18.990] - Scott Duncan MD

That's great. Thank you for having me.

[00:31:20.320] - Benjamin Courchia MD

Of course. Thank you very much. Thanks.