Speaker 1:

Welcome to AACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com/podcasts. And now let's meet the endocrine experts who will be talking with us today.

Dr. Kevin McKinney

Welcome to another episode of the AACE Podcast. I am Dr. Kevin McKinney. I am an endocrinologist and I'm the chief of endocrinology at the University of Texas Medical Branch in Galveston. Today, we'll be discussing state and local advocacy and how you can best prepare yourself and be effective at that. Before we get started, I would like to thank our sponsors, Lilly, Boehringer Ingelheim, Abbott, and Insulet for supporting this engaging conversation. Joining with me today is Dr. Arvind Cavale. I've had the pleasure of knowing this gentleman for many, many, many years. He is an endocrinologist and heads the Diabetes and Endocrinology Consultants of Pennsylvania. And he has had the special role of going around Pennsylvania as president of the Pennsylvania Medical Society. And he has certainly learned a lot from that role and has shown its influence both locally and the state and in Washington DC. And so we'd like to get started with the conversation. So how are you doing today, Dr. Cavale?

Dr. Arvind Cavale

Hi, Kevin. Thanks for having me today, and thanks for AACE and its sponsors for this conversation.

Dr. Kevin McKinney

Good. So I guess we just have some free-flowing items that we have today. So first of all, tell me about how you got started in endocrinology and in private practice.

Dr. Arvind Cavale

So I was a small town internist in South Louisiana in the early 90s, and I am an international medical graduate. And that was my first position out of internal medicine residency in 1994. And I had to serve in an underserved rural area in order to apply for my citizenship. And as you know, even in those days, South Louisiana was a heavy diabetes belt. And in living in a town of maybe five or 6,000 people, I was the only internist that was handling the emergency room and the hospital and the clinic in that town. And that's where I found that all these people, especially people with type one diabetes coming in with diabetic ketoacidosis, and we would treat them and then they would go home and then come back every other week. We had no tools and the training was rather difficult or hard to manage. So I found myself with a lot of gaps in information, knowledge, experience. So after I finished my term in Louisiana, I went back to fellowship in 1997 and did endocrinology fellowship in New York. So that's how I ended up doing endocrinology fellowship. And after I finished my fellowship, I moved to the Philadelphia suburbs in 1999, and I've been there since then.

Dr. Kevin McKinney

Good. Good. Good. And since you've been in your private practice for the past 25 years, I'm sure you have found many things which have made issues which you have seen in your daily practice, which may have led you to want to get started in advocacy. So what were some of those things that were things which you wanted to make better about the practice of medicine?

Dr. Arvind Cavale

Yeah. So practice of endocrinology is what I found to be very satisfying, but very unrewarding as far as outcomes as well as income was concerned. And as you know, amongst specialties, even until today, we remain one of the lowest paid specialties. And so early in 2003, 2004, maybe 2005, those were the days when I was just building my practice. I had the fortune of working with a very seasoned nurse practitioner who was also a diabetes educator. And she taught me a lot of the things that were sort of outside of the office space, but into the space of the patient and how we could relate to the patients in a more personal manner and meet the patients where they were, so to speak.

And so the next eight years she worked with me before she retired, and we did a lot of work that we now can actually get paid to do. In those days, we didn't have continuous glucose monitors for everybody. So people would stick their fingers, bring their papers to the office, and we would review them every month, every two weeks. And all these things actually improved the outcomes for our patients, yet there were no codes to bill for any of these services. So the mindset for me was while we were doing right by our patients, the business of medicine was not doing right by us. And sort of I traced it back to where the policies were and most of the policies went back to Medicare and Medicaid and how the regulations were set up. And as endocrinologists, we had never advocated for anything that actually helped our patients or our practices. So that's how I got started with advocacy.

Dr. Kevin McKinney

Good. So it sounds like practice viability was the main thing that was the issue that–

Dr. Arvind Cavale

It was more like we should get rewarded for doing the right thing for our patients and we were not being. So because we have not a procedure oriented specialty, there was really no way we could actually collect for our cognitive services, our supportive services or patient education services, so on and so forth. These are the things that were helping patients, but were really not helping our practice in that way.

Dr. Kevin McKinney

Good. Good. Good. Where did you first get started with your advocacy career? Did you do it through organizations? Did you go directly to the states or–

Dr. Arvind Cavale

Yeah. By 2005, 2006, we had now established a very steady working relationship between my staff and me and my patients. And we accumulated a lot of data showing that our process was actually very effective for our patients. So in end of 2006, the American College of Physicians started a program under a funding that they had received called Center for Practice Innovation, and they picked 34 practices across the country and ours was one of them, and we were the only endocrine practice that they picked. And so for two years, we did the project with them to show them how, and it was very well documented as how we were able to convert a very episodic process into a more continuous process of managing diabetes and chronic disease. And this was 2007, and then in 2008, they published the documentation, and I had actually done a little interview for AACE. There used to be a newsletter that AACE used to participate in called the Patient-Centered Endocrinology Project or something similar. Patient-Centered Endocrinology. And we had documented on how a continuous process would actually be beneficial for the patients, but the billing and the coding were not conducive to that kind of a process.

And so that was 2007, 2008. And we continued to do what we had to do, but for the next, I would say, 10 or 11 years, we were basically doing it on our own dime. We really weren't getting paid for any of those things. But it turned out that it was a good marketing tool for us because patients loved it. And so we became a very strong referral center for word of mouth referrals, and turned out to be that was the most critical move for our practice, because as you know, over the period of the last 16 to 18 years, there has been a lot of consolidation of primary care practices. So most of the practices have been acquired by hospital systems. And as a consequence of that, independent specialty practices are relegated to tier three referrals as far as endocrinology referrals are concerned. So our primary care referral sources pretty much dried up after, I would say, 2013, 2014. But our referrals continued very strongly because patients used to refer their family members, their coworkers, their friends, even people who they met at the bar or whatever. 90% of our referrals over the last, I would say, 12 to 14 years have been word of mouth referrals, which are the best way to get patients because they really want to see us for what we do.

Dr. Kevin McKinney

So you did some work with, sounds like with ACP and then with AACE. Did you work any collective way with ACP to try to help them achieve their priorities or did you do it more with AACE at the time?

Dr. Arvind Cavale

So unfortunately that project did its job, submitted its documentation, and I disappeared. I think the people who were leading the project also left the organization. It was on their website for a few years, maybe five or six years, and then I don't know what happened. But interestingly, an anecdotal story, which I think you will enjoy, is in 2016, we had a major issue, but also turned out to be a turning point in what would happen in the future, which is the first of our baby boom patients with type one diabetes who had been on an insulin pump and a sensor for at least a decade turned 65 in 2016. And when he entered Medicare, essentially Medicare didn't have any policy to cover his continuous glucose monitor. And so he just got lost, he got dropped, but his wife was very insistent and came to us to say, "What can we do about it?" So we got together and we hired a local patient advocate who helped us build a good portfolio of supporting documents. And there was another endocrinologist from Maryland who was doing the same thing at the same time, and we shared documentation, and we actually took legal action against CMS in an ALJ court in the fall of 2016.

And based on the submission and the deposition we gave to the judge, the judge ruled in the favor of the patient and issued an order for CMS for Medicare to cover for his continuous glucose monitor. That was probably one of the first cases in the country that went through this way. As time went by in the next six months, in 2017, we were confronted with the same problem for the same patient because the temporary order expired. And so now we had the playbook, and so we went with the same advocate, with the same documentation, went to court again in early 2017, and we won again on behalf of the patient. And this time there were six other endocrinologists across the country who had won their cases. So now we had a very strong set of precedents that were set. And so by middle of 2017, as you know, CMS finally made it official that coverage of continuous glucose monitors were now available for people with type one diabetes. So that changed the whole narrative in a lot of ways.

Dr. Kevin McKinney

Good. That's an excellent example of where advocacy and legal action will provide positive outcomes for your patients. Just to clarify some things for the people that are listening, I think Dr. Cavale mentioned ALJ. I think that stands for administrative law judge. This was a federal court or was this a state court in which you worked through?

Dr. Arvind Cavale

I think it's a special court there. I think it's maybe under the federal jurisdiction, but even in those days, the judges held their hearing by phone, by conference call. So we would get sworn in and depose in front of a judge. We would submit documents ahead of time and he or she would review the documents and come prepared for the case. It was a very formal process.

Dr. Kevin McKinney

You also mentioned some ideas around insurance being a big issue for you. And many people do not understand that insurance is not really a federal issue. That's really a state issue. Every state has its own insurance rules. And so even though there are federal programs that are set up with CMS, with Medicare being the rare exception, many of the insurance decisions are made at the state and local level. And I know Dr. Cavale has had some unique approaches to insurance in his practice. Can you describe what you do with your insurance and then how have you advocated for insurance at the state level?

Dr. Arvind Cavale

Yeah. So this has evolved over time. Initially, my personal philosophy with insurance in my practice has been that basically it's two rules for my practice. One is if I need an attorney to interpret an insurance contract, then I don't accept that contract because I think I can read plain English and I don't need an attorney to do that. And the second thing that I keep in mind is if an insurance company does not have a local or regional medical liaison or a medical director that is assigned to our practice, I don't accept that contract. Those are the only two criteria, hard criteria that I use. And so over the years I have essentially trickled my insurance contracts to just two insurance contracts plus Medicare. And that's basically what I've done for the past 18 years now. And in some ways it simplifies a lot of processes in our practice so that the staff is not bogged down by trying to understand five different requirements from five different companies or six or seven or eight or whatever.

And that's something that is very unique to small practices. We don't have the wherewithal nor the bandwidth to really hire enough people to understand what a Cigna contract differs from an Aetna contract and so on and so forth. So my focus, and we've always focused on this, is anything that takes us away from focusing on the patient outcomes is a distraction and we would rather not have that distraction. We've been fortunate that we've been able to do that for such a long time. And for a while I was not even accepting new Medicare patients, but then the last seven or eight years I've been, because I think Medicare in general, when you take the bigger picture, has evolved into a more friendlier program as opposed to some of the private insurances. Having said that, as a president of the Pennsylvania Medical Society, I've also had opportunities to write letters to different regional insurance companies about certain rules that they have instituted lately the last year or two. And of course with the federal, with the 2027 physician fee schedule with its own requirements, I've also had to write a letter to support or oppose certain things that they have suggested. So things have evolved over time. Yeah.

Dr. Kevin McKinney

So that gets us to a transition to another subject, which is your involvement in the Pennsylvania Medical Society. So tell me what level of the PMS that you first started getting involved in, then tell me about how you ascended throughout your career then to eventually become president of the PMS.

Dr. Arvind Cavale

Yeah. So my process was very atypical and most people will go through the county medical societies or sections and then get to the board and so on and so forth. I really didn't do any of those things. I was involved in my county society. I was mainly involved in the international medical graduate section where I was a delegate to the house for a few years. Over the years, some of the leaders at the medical society recognized the depth of knowledge that I had with regard to advocacy and policy, as well as my ability to create bridges between different factions or different groups of disagreements. In 2023 is when I won election for vice president of the Pennsylvania Medical Society. And if you had asked me six months before that, I had no idea that I was going to be a candidate for that position. But there were several past presidents who convinced me that the time was right and I was probably the best candidate at that time. And so they nominated me and I guess I won an election at that point, and so here I am.

Dr. Kevin McKinney

What have been the major issues that you've probably had to go to Harrisburg to testify on?

Dr. Arvind Cavale

I haven't actually testified a whole lot. Mostly I've gone to Harrisburg to support some of the actions taken by the board of the Pennsylvania Medical Society. We are actually going to be in Harrisburg on the 28th and 29th of this month, that's next week. And we are going to have formal meetings with the state legislative, both Senate and the House branches. There have been several issues at the local level that we have tried to tackle. They've tackled some of the PBM issues. We had a bill that passed that reduced the non-compete clauses for employed physicians to one year. And we did have a couple of unsuccessful attempts as well. We were not able to get some relief. There is something called venue shopping that is very unique to Pennsylvania that is people trying to bring their liability medical malpractice cases to Philadelphia or Pittsburgh even though these alleged actions happened in some other counties.

And so that has increased in the past three or four years. And we tried to bring some sanity to that to say, you really can take legal action only in the county where you were provided care for, but we haven't been able to make that move. So that's been a little bit of a difficult hill to climb. We are trying to help physicians who are employed by hospital systems. So there has been a movement in many states to unionize some of these physicians. And the medical society in Pennsylvania has actually assigned a task force for the last year and a half that has actually delved very deeply into this. And we will potentially issue a request for proposals in the coming year to see if any of the national or regional unions are interested in joining or partnering with the Pennsylvania Medical Society to actually create a type of a physician union. We don't know yet how far we have gone, but we have gone into the depth as to learning about how these ... Whether it's the teacher's union or the AFL CIO or the SEIU. So there are several national and regional unions that we have interviewed and the task force is working on it.

The other part we have done is to help with our independent practices. We had a fairly well attended the independent practice summit in Harrisburg in June where we introduced concepts of direct contracting with employer groups, with business groups. We introduced the concepts of direct practice, reference-based pricing, dealing with self-insured entities, so on and so forth. So that's another project we are just beginning. And there are several agencies that are working with us to help us educate our physicians how to reorder some of the business aspects for independent practice so that they're not so dependent on the large insurers for their survival.

Dr. Kevin McKinney

That's actually quite a bit on over there. I'd like to take time just to explore some of the things which Dr. Cavale had mentioned, particularly in the area of medical liability reform. Really, most medical liability reform takes place at the state level. And Dr. Cavale is right. It does take a long sustained level of advocacy to try to get an outcome that you are desiring. I can give an example like in Texas where we have the Texas Medical Association about 25, 30 years ago, there were people that were doing a lot of venue shopping, which he was describing. People would frequently send their cases down into what's called the Rio Grande Valley of Texas because that was where they found more friendlier juries. So the TMA and his physician members frequently went to the state capitol to advocate for one, cap on economic damages so that they could stop the jackpot justice and just really cover the true damages that someone gets from a medical liability issue. And number one, and number two, just ensure that the rules are compliance consistently around the state so that if you apply the rules consistently, then you indirectly get rid of the venue shopping for medical liability. I can tell you that it probably took about eight to 10 years for a TMA to get the final rules there and people are trying to attack it at every legislative session. And so in Texas, they happen every two years, so they're always trying to fight those off. What he's mentioning there is that it's important to not just give up a fight if you just have an issue and can't get through the state legislator that one time. You have to keep up the sustained level of advocacy and develop relationships and networking with your legislators regardless of what party they're in so that you can make sure that you can get the outcome that you need. So that's some great discussions that you have there. You talked a little bit about direct primary care, and I think you have a direct specialty care practice, which does sound like it's completely since you said you take two insurances plus Medicare, but basically you have direct care practice. How has that helped your practice being in that type of role here?

Dr. Arvind Cavale

Yes. So geographically, I'm basically surrounded. My practice is surrounded by three large hospital systems. Each of them is a very massive system. And as I said, our philosophy is essentially to be patient-centric. No matter what, we want to be patient-centric. And so holding that philosophy in mind, we essentially decided to move away from any entity or any contract that potentially pulls us away from that responsibility. So in some ways the decision was not as difficult as it sounds, but what we also decided was to understand what our community needs and what our patients can afford. And so even if those who see us out of network, pay us a cash price, our cash prices are very nominal. We keep it just enough so that people can afford it. We do not want them to lose care. So this actually started during the recession of 2008, 2009.

That's where I learned my lesson because there were a lot of people who lost their insurances during that time because they lost their jobs and many of them required a lot of our help. So what we did was we decided we are going to create very affordable cash prices for these people. And we went and canvassed on their behalf. We went to certain national laboratories and we said, "Can we negotiate prices on behalf of our patients?" And so we were able to get a national lab to give us almost 90% off of their retail price. So for example, a test that was $90, they would give it to us for about 13 or $14. So if we had to get a metabolic panel and an A1C and a TSH, it would not cost more than $50 for the patient. And that contract we have still maintained now till today, it's almost now 19 years or 18 years that we had that.

And between our cash prices and the cash prices of the lab, and then we contacted some of our radiology groups in the area and asked them if they could give us good cash prices for ultrasounds or CT scans, and we got good cash prices for them too.

So essentially what we made sure is that these folks did not lose their continuity of care. And with whatever they needed, we were able to get them with a reasonable cash price, under a reasonable cash arrangement. And many of them obviously went back to work and regained their insurances and so on and so forth, but they still maintained our contact with us in our care in our practice. So in a lot of ways, we figured out the long way that just taking care of the patients is good business strategy and it's good marketing strategy and it's good survival strategy. So that's really how we've essentially thrived over the years.

Dr. Kevin McKinney

Do you think that most private practitioners are trying to move towards direct type of practice or do you find still that insurance getting involved with insurance is really the way to go? Or you just going to find a pluralistic system where some people feel comfortable in one way, other people feel comfortable in other ways?

Dr. Arvind Cavale

I think the last part is probably how it's going to go. I think most of the specialists are still doing the conventional form of practice. A lot of the younger family medicine, internal medicine, primary care, pediatrics are moving into direct care models because I think they were the most affected by the lack of or declining fee schedules over the years. My model, actually ... I have two different models. I have a conventional model that I use in my practice, and I've also developed a bundled diabetes program for the last eight or nine years that I offer to employers who are willing to purchase a diabetes plan for their employees. So it's an annual bundle and we offer them certain targets, both metabolic and self-management targets at the end of 12 months. And so they recognize that when we do that, and this is even before all these things started with the GLPs and so on and so forth, we would always market that as a complete package for cardiometabolic health and weight management if necessary and risk reductions for the renal and liver disease and so on and so forth. So it really covers the gamut and it's a high value proposition for employers who are willing to cover 100% of costs for their employees.

Dr. Kevin McKinney

So how do you handle the drug pricing in your type of practice? So that still is mostly insurance?

Dr. Arvind Cavale

Yes. That is the hard part. So some of the things as You've heard from your own fellow Texan, Mark Cuban has a very good plan called cost plus drugs, and that has now become my go-to source for most of the drugs. In fact, generic liraglutide is now available for under $100 a month through cost plus drugs. Generic Farxiga is now available for 20 some dollars a month or something like that, very affordable, $50 for 90 days of Farxiga. So little by little, I think the market is slowly moving towards taking care of the customers, as patients or in pharmaceutical terms for their customers. So we try to educate some of the employers on hiring what they call as a fiduciary PBMs where the discounts from the manufacturers is directly passed on to the patient. And that is really the key in reducing prices is if you have a PBM that negotiates a significant discount on a brand medication, I would say 90% of the discount should go back to the patient.

Right now with the larger PBMs, that's not happening, and that's why they end up with very high costs. But the smaller PBMs that define themselves as fiduciary, they really work on a fee basis where they collect a fee, but they don't keep the rebates that the manufacturers offer. So there are many such smaller PBMs now. So it's an educational process for the purchasers as well. And that's one of the focus of my advocacy efforts is to bring purchasers of care and physicians into the same room and say, "What are your pain points? What are your pain points? And how can we meet in the middle and work out a deal that favors the patient?" Because ultimately what happens with these direct relationships is employees that are patients get care at very low out-of-pocket costs or no out-of-pocket costs because the employers realize that direct contracting saves them at least 20% to 30% top dollar compared to conventional plans.

Dr. Kevin McKinney

So let's shift a little bit here. So another thing that is controlled a lot on the state's levels is how technology gets implemented into a physician practice. I know you have some strong thoughts on technology. Do you think that we have an adequate amount of regulation for the tools that we have to use such as the Medtronic medical record and the implementation of AI? What do you think are things which we need to really address there to make sure that the physician is protected in those types of things?

Dr. Arvind Cavale

Yes. So I think we should have learned a lesson from the electronic health record implementation over the last 15 to 20 years. And what I have learned is we didn't lead that effort. We were led by others in that effort. And so we got caught between trying to do the right thing for the patients clinically and trying to do the right thing electronically in the record. And there's a lot of conflict in that. So with AI, I'm hoping, and I'm preaching to everybody that will listen to me is to say, let's get on the leading edge of the implementation as physicians and let's decide what is important to protect, what are the things that we can allow AI to do, what are the things that we need to ... So what are the questions we are not asking right now? And so towards that goal, this October at the House of Delegates of the Pennsylvania Medical Society, I have invited our friend Graham McMahon, who is an endocrinologist and president of the Accreditation Council for Continuing Medical Education, ACCME, to be our keynote speaker. And he's going to discuss where medical education, where medical practice and professionalism fall or lie with respect to AI and AI-driven world of healthcare. So we will have a nice discussion on October 24th.

Dr. Kevin McKinney

Oh, wow. Looking forward to that. I think you'll find that many of your state societies are having discussions with regards to how AI is implemented within their state. The legislatures are going to take up AI sooner than the federal government will. I think it's no secret that there's a lot of dysfunction at the federal level. And so the states are not going to wait for regulations to come from the federal level. They will just start deciding themselves. So if you as a physician want to address how AI is implemented in medicine in general in your practice specifically, it is important for you to engage with your legislator on a personal level to ensure that the rules are written in a way that will benefit you. So keep in mind that if you can't do it by yourself, at least get it done through your state County Medical Society or your state society and join with them so that you can have a bunch of physician voices on the ground speaking to those issues. It's always important to speak with a collective voice instead of by yourself because sometimes people try to pit one person against each other. So it's important to speak in that collective voice.

Dr. Arvind Cavale

Yeah, couldn't have said that better. Yeah. So do your homework, learn. So one of the advantages I have is my son is a machine learning AI engineer, and so I try to educate myself. I ask silly questions off of him and gain some knowledge from the technology standpoint as to what the capabilities are, what the pitfalls, where are the weaknesses, how much can we trust a certain source, et cetera, et cetera. And being an AI engineer, he's a skeptical AI engineer. So it gives me that voice in my head, which I think every doctor should do due diligence to understand what this technology is, how it fits, especially in endocrinology since we are speaking to the endocrinology world here. There is so much opportunity just from an AI technology standpoint, but there are also a lot of minds along the way and we have to be very ... If we can learn and go ahead of the curve, we can lead the implementation of guardrails and so on and so forth.

Dr. Kevin McKinney

So I don't know if you spend a lot of time, I suspect you do, but certainly in Texas we have a lot of concern about access to care. And so people have different ideas on how to expand access to care. And one of the things which we talk about is team-based care. And team-based care is a hot subject and involves who's leading the team, it involves scope of practice expansion and things like that. What has been your approach in Pennsylvania to handle these types of issues?

Dr. Arvind Cavale

Yes. So this is a little bit, if you can look at it's a clash. There's been a lot of talk about overexpansion of the scope of practice. At the same time, there's a talk about team-based care. And similar to the national associations in Pennsylvania, we have taken the approach that physician-led, patient-centric team-based care would probably afford the best access or best method to access care for patients. And I'm sure the Texas Medical Association is thinking and acting along the same lines.

Dr. Kevin McKinney

Yes, we are. And we always emphasize that we are trying to not necessarily limit someone on their ability to work in the state. But just keep in mind that physicians are the ones that have had the most training and the most practical experience in handling conditions. And especially in our specialized endocrine world where things are really complex, it's important to emphasize that a physician is probably best to lead that certain team to make sure that good outcomes are held for patients overall.

Dr. Arvind Cavale

Yeah. No, not to say that physicians should be putting their hands into every pot. So we must learn to lead and delegate and respect the decisions of some of our delegations, and that's important. So in my practice, even though we are a small practice, we have a very useful team delegation process. And so I have a clinical manager who also does my clinical research. She's my research coordinator, and I have a medical assistant, and I have a dietician who is an independent practitioner, but she operates out of my office once a week. And so we have our clear delegations of who does what and up to what level. And we have 100% trust in what each of us does. And our dietician also does our pump training, so she does a lot of our pumps. We have about, I would say about 500 or so pump users in our practice. And even today where I had to leave a little early to come to this conference, my dietician was still there doing pump management with one of my patients.

So I pretty much trust what she decides and she will email me and say, "Okay, I made these changes to the pump setting or so on and so forth." And that works beautifully because we all understand my manager's been working with me for 22 years. My dietician and I have been working together for 26 years. So we pretty much embedded in each other's minds as far as how we think. And that's really the key in terms of creating empowered teams. And they're not going to be afraid that I'm going to second guess their actions, and that's what's important.

Dr. Kevin McKinney

I totally agree with that. I currently supervise, as director of my division, I have a faculty member and I have five advanced practice clinicians. And the key is to build trust, but also if they don't understand something, please feel free to ask their physician colleagues so that you can help point them in the right direction. So the team building goes in both directions.

Dr. Arvind Cavale

Yeah. In fact, one of the things that I learned most was from my former nurse practitioner. She taught me a lot of techniques of getting people to do what they don't want to do in a lot of ways.

Dr. Kevin McKinney

I know exactly what you mean.

Dr. Arvind Cavale

She retired in 2012 and I still ... I still keep her notes. I still keep her little bits of information stored in my computer files as to what she was saying. So I appreciate her even after 14 years of her retiring.

Dr. Kevin McKinney

One final state issue I'd like to discuss is with regards to state issues. This has to do with telemedicine. A lot of those rules are implemented on the state level too. Yes, there are rules that are implemented nationally too, but how things get paid happens on the state level with telemedicine. What has been your approach to telehealth and maybe Pennsylvania has an approach to telehealth also?

Dr. Arvind Cavale

Yeah. I don't know of any specific policy yet in Pennsylvania, but some of the things as an endocrinologist ... So I'm going to deviate a little bit because this is a good example of how to do certain things. There is a chain of direct primary care practices called Atlas MD, their national chain of direct primary care practices. And I belong to their specialty consult called Atlas Consult. So if any of their primary care docs has an endocrine issue that they need a consult with me, doesn't matter which state they're in, they will send me a note and say, "We need your opinion about these things." And they'll send me some documents through a secure channel that I can review. And if they need me on the virtual, I'll be on the virtual if necessary, or I'll just give them my comments and say, "These are the suggestions I have." And they will usually implement that and either tell me it worked or it didn't work or whatever else they need to do.

It's a good model to implement within the state as well. So as you know that the funds from the Rural Health Transformation Grant are beginning to trickle into states as of now and into January. So I have volunteered the medical society's help to the state administration to see if physicians in rural areas need help from specialists in urban or suburban areas through virtual consultation. That's one of my pet projects actually, because I think that will save a lot of dollars. It will save a lot of access problems, reduce access problems. It'll empower many of the clinicians in small towns and rural areas to actually access higher level care for their patients. So that's how where we are starting. We are beginning to talk with the State Department of Health to see if there's any opportunity for Pennsylvania Medical Society physicians to operate under those areas in the Rural Health Transformation Fund project.

Dr. Kevin McKinney

Excellent discussion. There are a lot of federal things which get passed down to the state to implement. And obviously the one we know about mostly is Medicaid, which is a federal program that the states implement. And I think different states have implemented Medicaid very differently and some adhering to the Affordable Care Act and others opting out like my state Texas has. So those are all things which are decided at the state level. So if you think that something needs to be done differently with regards to Medicaid, advocate at the state level for it too. I think I've reached the end of my particular questions. Is there anything that you think I missed, Dr. Cavale?

Dr. Arvind Cavale

So the only thing I suggest to people who are listening is engage yourself in educating students and residents and fellows. Over the last decade or so, I've been pretty successful even in my small effort. Over the years, I've helped graduate two endocrinologists who used to be my residents in internal medicine, and I've graduated three classes of medical students now in the last three years. And I believe maybe one of them might be going into endocrinology in the next two years. So we'll see. I think that really is essentially what we are doing right now. I mean, whether you or me, it really is not going to affect our practices one way or the other. It really will change the landscape for people who will start practice in the next five to 10 years. And I think that's where the focus of current advocacy should go is how to change the landscape for the next generation.

Dr. Kevin McKinney

I certainly agree with that, Dr. Cavale, and thank you very much for all the discussion we've had today, and it was very engaging. And I think that you, the listeners, should learn a few things about how you can engage locally and a statewide level to try to affect the things that physicians are engaged in and to improve the practice of medicine, improve your health and your viability. So I think we'll go ahead and end there. Put a plug in there to look at the AACE Advocacy Committee website. I think if you go in the AACE website and go for healthcare professionals and you press the about button there, you'll see the advocacy tab there. You click on there and you'll see all the things that we are discussing in the advocacy committee. And I'd like to go ahead and just give a final word again for our sponsors, Lilly, Boehringer Ingelheim, Abbott and Insulet for supporting the Advocacy Podcast. And we'll talk to you later. Bye-bye.

Dr. Arvind Cavale

Bye-bye.

Speaker 1:

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