Health Coach Insurance Reimbursement

Cheng-Huai Ruan, M.D.

Hi everyone, I have someone super special with me today, Ms. Margaret Moore. Thank you for coming. I appreciate you coming on.

Margaret Moore, MBA

Cheng, I can’t imagine a better place than being with you right now.

Cheng-Huai Ruan, M.D.

Aw, thanks so much. Thanks so much. So, for those of y’all who don’t know, Margaret Moore, she’s got an MBA, she’s an executive coach and founder of, and CEO of Wellcoaches Corporation. Basically it’s a coaching school for health professionals. And has trained and thousands and thousands of coaches. In multiple different countries, actually, right? Since the year 2000. She’s also the co-founder and chair of the Institute of Coaching at McLean Harvard Medical School Affiliate Program, and is the co-director of the Coaching in Leadership and Healthcare Conference and there’s this beautiful company called the National Board for Health & Wellness Coaching which has made a giant splash. 

And if you listen to the other sessions on this summit, I actually talk about the National Board for Health & Wellness coaches quite a bit. And what we are actually doing, and we’re going to be revealing some really cool things that have already been done and where we’re going forward in the future, myself included, with Margaret here. So the other really cool thing is that she’s the co-author of 20 peer-reviewed articles and seven book chapters on coaching, right? And there’s a lot of things that Margaret has done that’s been kind of blowing my mind. So we’re going to explore some of those things. So yeah, welcome to the show. So happy to have you on. Been looking forward to this.

Margaret Moore, MBA

Me too. Go for it. Although, that’s a little bit loaded. Me Too. So, sorry, I didn’t mean to take us off track.

Cheng-Huai Ruan, M.D.

That is totally cool. That is totally cool. And so-

Margaret Moore, MBA

There’s a good side of Me Too.

Cheng-Huai Ruan, M.D.

Absolutely. So you know, the first thing that I want to talk about is really kind of high level. Medicine has changed a lot over the last 18 months. You know, since the pandemic. But I think there’s more changes in the last 50 years of medicine than in the 200 years before that. That’s for sure. The way we practice medicine, the technology we have, is sort of completely different at this point. But I don’t think that medicine, and the training of medicine, especially me as an MD, going through medical school and residency, I don’t think the training has really changed in 200 years. Right? And so, just very high level, I just want to have you talk about, you know, what’s different now, and how should we pivot, and why the heck are so many doctors burnt out from this current process?

Margaret Moore, MBA

Oh gosh, yeah. Well, the first thing I would say, because I almost went to medical school, and I went left or right rather than the other direction and wanted to do international business and biotech. And so I understand, you know, I think I understand the mind of a doctor. So you have someone that’s really smart, that understands the demands of, too many understands. Understands just how hard it is to grasp the complexity of human biology. And actually having the confidence to say, okay, I’m going to step into this space and I’m going to work with this very complex set of physiological systems, much of which we don’t understand. You know, we know more than we did even five years ago. Because I want to make a difference. I want to help people. 

So there’s this heart. I mean, I know not everybody has a good heart that goes into medicine, but there’s this smarts. Smarts and heart. And then we’ve created a healthcare system that has reduced doctors to widgets. So we take all these really, really, really smart people with big hearts, and then we put all these layers of bureaucracy and technology and finance and policy, ridiculously complex. I mean, healthcare as a bureaucracy is choked. I mean, you know the breakdown. 35 percent of healthcare dollars go to health plans who have nothing to do with the delivery of care. And then another 35 percent goes to drugs. And I think arguably that, there’s a lot of innovation. 

I was in the biotech industry. I was part of that. And look at vaccines. I mean, you’ve got to say thank you to the innovators of drugs and vaccines, etc. And then you have the people actually delivering the care. Underneath the bureaucracy that’s supporting it, or, you know. And so, here you have these smart people and they’re just getting squished by all this. And all their smartness is just being, you know, filling out reports and electronic health records. So it is one of the most colossal wastes of human potential today. And on top of that, if you look at all the other industries, as I can tell you, in the leadership realm, most industries that are especially cutting-edge in terms of demanding high intellect and skill, have a lot of investment in development. Leadership development, you know, social intelligence. All that stuff. And that, there’s no money for that. So doctors have stunted growth, because they haven’t had the support, and they’re being squashed. So it’s like, it is just a disaster for all this brilliance, to be honest.

Cheng-Huai Ruan, M.D.

But I mean, how did we get here? I mean, how did that even happen? It wasn’t always like this. You know, how did we get here to where we are now?

Margaret Moore, MBA

Well, you know, I’m a Canadian so I wasn’t here when a lot of this was happening. And in Canada, they’ve got their own problems. But you know, I’ve been here 20 years, which is not a lifetime, by any means. You know, I think it’s like, and this is a metaphor, who knows if it’s actually science, but it’s almost like it just kept happening and happening and happening, and nobody stood up, and the doctors were just like, trying to do the right thing, and trying to get their work done, and trying to serve people. So it’s just, you know. There’s a wonderful book, I think I was telling you, called Humanocracy, which is a complete takedown of bureaucracy. 

Which had its place, because you used to have these despotic, capricious leaders in the 1800s. And so bureaucracy sort of professionalized things. But at this point, all of that, and I have an MBA, can be taught to people really quickly. Everybody can have all of the bureaucracy skills and knowledge, which, I know what you’re trying to do in this program. If you’re smart, you can learn it really quickly. But now we had all these layers and layers that we built over years, and I think with healthcare, we kept building more and more bureaucracy instead of reducing it. Whereas other industries are trying to distribute leadership and distribute autonomy and empowerment. So it’s a bit like a snowball, it just kept going and going and going without stopping.

Cheng-Huai Ruan, M.D.

Yeah, and I think, you know, we’re in the pandemic era and the pandemic era really allowed us to reveal that side of bureaucracy. Because there’s not a time that I can remember where a lot of physicians got together, really, in the pandemic era, and started forming these groups and coalitions, looking at, hey, why don’t we have PPEs?

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

Or what’s going on with these reimbursements, and stuff like that. And all of a sudden, you know, when the pandemic hit, you’re like, okay, well, you want medical students to go into New York and volunteer, who are nowhere near trained in any sort of anything at that point. And wanting to volunteer to be in the front lines and stuff like that. And then there’s sort of this idea that because you’re either about to get an MD or you have an MD, or you’ve been an MD, that you’re supposed to be able to do everything. And I think that’s a mentality that a lot of doctors have coming out of medical school. 

That, oh, I’m an MD, I went through residency, finished residency, coming out, I’ve got some debt in my pocket. But I’ll just figure it out. Right? I’ll go into practice, work a little bit, open my own practice, and I’ll figure it out and I’ll kind of go from there. And that is a nice fairy tale story that almost never happens, unless there’s some loss associated with it. And because, you know, about half the country’s doctors are burnt out on a daily basis, and about 80, just a little under 80 percent are burnt out in one of the five days of work, right? It’s weird that they never question about the weekends. 

Doctors work Monday through Sunday, so it’s just very interesting, they never question about weekends. So I think that we’re in this time where the coronavirus has really kind of opened its doors and say, hey, what’s the limiting factor here for all these aspects? And then, CMS and Medicare and Medicaid services all of a sudden had, hey, let’s reexamine our reimbursement structure. And emergently start paying the doctors to do telemedicine, and to do this. And you know what, we’re actually going to decrease the time the doctors get paid to about 48 hrs rather than six weeks. Right? 

I’m like, well where the heck was this before the coronavirus? Right? And why is that that all of a sudden these things are actually possible? It took a pandemic for people to really understand and realize that there’s bureaucracy that was limiting these factors. And now all these things are being done, and we’re really kind of fast forwarded 10 years on where we’re trying to go as physicians. So you’re right. You know, doctors became widgets. And that’s what this summit’s all about, is like, no, we’re not widgets. We would love to know more about what’s going on, but there’s no official education to know more about it, and the bureaucracy, like you said, layer and layer and layer. And we’re just kind of drowning underneath there.

Margaret Moore, MBA

Yeah. We’re killing the spirit of physicians.

Cheng-Huai Ruan, M.D.

So. Speaking of the spirit of physicians, you know, I think that the people who will be watching this summit are the type of people who have a spirit and that’s ready to be kind of released and launched. And I think that we have to kind of design that for the future. So now that we know that we’re under these layers of bureaucracies above my head, where do you think we should go, as a country, in the healthcare side, in the next five years? Where do you think we should go?

Margaret Moore, MBA

Well, I’m just going off the top.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

You know, I think the health insurance structure, business structure, I pray for blockchain to take it over.

Cheng-Huai Ruan, M.D.

Hmm.

Margaret Moore, MBA

To use systems. Because we get, you know, just all this paperwork. There’s got to be a way of simplifying all this. You know, I know insurance was easier. And I don’t have the answer to that. But we’re at a place where, you know, the computational power and networking, there’s got to be a way to reduce that 30 … So in Canada, where I come from, the administrative costs of running healthcare, and I’m not bragging about Canada’s healthcare, because I know a lot of Canadians come south for better healthcare. It’s not a perfect system at all. But the administrative costs are like 11 percent. Not 35 percent. And that 25 percent would actually take care of, you know, proper reimbursement. So what we need to do is we need to shift the financial model so more money goes to the people who are actually carrying the whole frigging system.

Cheng-Huai Ruan, M.D.

So yeah, I think-

Margaret Moore, MBA

And so the first place to go-

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

I’m not so, the drugs and, I mean, I come from that area, that is like, look at, without vaccines today, you know. I mean, I think there’s ways to improve that. But you know, that innovation is so critical. I think we need to take the bureaucracy, both in healthcare and in health insurance, and squish it down to, you know, you’ve got to get it down to 10 percent. Like, you just say, okay, this is all we can afford. Because doctors aren’t making enough money. They’re making, you know, my doctor friends are making less than most executives today. After all their education and all of that. I mean, I know there’s people that are, so, and I know people don’t like to see doctors getting rich. But I don’t think that’s happening anymore. It’s a lot of work for, like, if you’re in primary care, you know. You are just working for every dollar. So we have to change the system so that we squash the bureaucracy so we can actually pay clinicians to spend time with patients to make a difference.

Cheng-Huai Ruan, M.D.

Yeah. So speaking of doing that, you know, I’ve always envisioned, and I got into integrative medicine a few years ago, and I always envisioned that there should be some other entity or body that deals with more of the conversations and communications with patients and preventative care, right? Because right now, with primary care going the way that it is, the average primary care doc sees a patient for seven and a half minutes.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

They’re not going to know very much about the patient. Right? And I think when I discovered health coaching, which is only very recently, only in the last four years, when I discovered health coaching, I realized that this could be the entity that is responsible for the social determinants of health. For not what medicine people get prescribed, but where do they live, how much money do they have, do they have access to transportation to see the doctor? Right? And if you prescribe them a drug, who’s going to make sure they actually take it? Right? And so I think that the, you know, and I hate to use the word compliance, because I just think that’s very dictatorship-

Margaret Moore, MBA

Engagement.

Cheng-Huai Ruan, M.D.

Yeah. I think patient engagement, you know, with their health, and patient empowerment required its own specialty. And I think that’s where kind of the health coaching fit. And so I think that on the first segment of this summit, with Sandy, we actually talked about the definition of health coaches and training and stuff like that. So for you, I really want to focus on execution. How do we get health coaches into practices. What does that look like, and what does reimbursement look like. So lets touch on that a little bit.

Margaret Moore, MBA

Yeah, so I think we’re, yeah, so that we’re agreed, and when I started 20 years ago, after my biotech career, and I started from scratch in coaching, because I believed there needed to be a professional that knew how to help people engage fully in taking care of themselves. That all the drugs and procedures in the world were only going to go so far if people weren’t investing in their own health and making it a project. And so that’s still to be realized, to have a workforce of coaches that are skilled at that. It’s a new skillset. Like, sitting down with people and getting them to think deeply about why health matters at a level they’ve not thought before. To really reflect on, you know, where is the starting point. Is it their emotional state, is it their, you know, it’s not a small, it’s the toughest conversation. 

If this was easy … So this is a very skilled profession. It’s harder to do, I mean, clearly going to medical school is hard. But if you want to engage people and get them to change themselves, this is a very sophisticated skillset. So I set out all those years ago to do that. And then starting up now three organizations, all with different parts of the puzzle. So that’s, I believe that the future of primary care is that coaching is at the front of the practice. Having warm, thoughtful, and tough conversations with people. And you can’t have a medical assistant or someone junior. You’re dealing with people. Like, you have to sit with them and you have to look them in the eyes and you have to get them to see what they’re not seeing, without pushing, without getting their resistance. 

It’s a really great skill. And I love it because it’s hard. And it’s rewarding. Because when that conversation is done well, which good coaches can do consistently, people move. So what does that mean? So one of the reasons nobody talks about that burnout is so bad, that isn’t, I don’t know why it gets missed in the assessments, is because the patients aren’t doing well. And here you are, you’ve got all this training, all these years, and you can’t get your patients to take care of themselves. You can’t get them to, you know. So it feels hopeless, right? Like, darn. Like, you’ve got all these skills. 

So the first thing that happens, especially, you know, I think the best burnout intervention is for physicians to go through a few days of coach training and actually, even if they don’t want to be coaches, just to start to have more powerful conversations. So as soon as you start having more powerful conversations with people that become the medicine themselves, the coaching is the medicine, then the doctor, you know that, you’re living it. You’re happier because you see, my god, these people are energized, they’re moving. The coach is happy. And they’re not, it’s not like a reality TV show, where they lose 100 pounds in two weeks. That’s not real life. You know, you’ve heard me say, probably, that what I learned from Alvaro Pascual-Leone at Beth Israel, neurologist, expert in neuroplasticity, is that you can only grow one millimeter of neural network a day. 

So you can’t change your life in a week or a month or, you know, I think a year, you start to get there. If you’ve got 100 pounds to lose, it’s probably more like two or three years. So when you have those skills to help people change, it changes your view of what’s possible. Because if you layer in there all the really excellent intuitive analytical diagnosis, now the patient feels as though, wow, there’s uplift here. Like, I actually can go somewhere. And so I think it’s the most, it gives lift, not drag, to healthcare. And I also think, though, you know, here we are, you and I know, we’re like shoehorning the cost of the coach into this, you know, huge expenses. And so, we’re fighting … Fighting is not a coaching word. 

But we’re up against the health plans pressing, you can’t invest in this because it costs too much, and you have to show us ROI. Because there’s like this much left to spend on wellbeing, right? Like, after everything else. So we’re like trying to wedge this incredibly important skillset into this, you know, like it’s an archeological dig, if you go through the layers and layers of costs. So I think the whole point, as I mentioned, of Humanocracy is to go back to serving humans, not serving institutions, and go back to what works, and how can we compress the bureaucracy into the absolutely minimum, so we can enable the work to get done, to help people get well.

Cheng-Huai Ruan, M.D.

Right. And I think the question on everyone’s mind is, like, whose pocket is this going to come out of? Right? And that’s a really hard one to answer.

Margaret Moore, MBA

Yeah. Yeah.

Cheng-Huai Ruan, M.D.

And so-

Margaret Moore, MBA

Yeah, because there’s a lot of people who’s jobs, millions and millions of jobs, are based on bureaucracy. And you don’t want to kill your own job, right? So yeah. But at some point, you have to do the right thing. You just have to. Like, at some point you just, look at the health of the American population. I mean, the mental heath, obesity. Like, this is a population that is not doing well.

Cheng-Huai Ruan, M.D.

Right.

Margaret Moore, MBA

And more technology and more blah-blah-blah-blah-blah, you know, it has to, and it comes from human conversations. And love. And tough love.

Cheng-Huai Ruan, M.D.

Absolutely. So I think let’s break out into some psychology for a second. Because most people, most of my friends, went into medicine for very specific reasons, and that was not delivered after finishing, right? They went into medicine because they like to connect. And connection is almost a bad word in primary care practice. You spend seven and a half minutes with a patient with a patient on average, right? They went into medicine to feel significant. I mean, the last thing that you feel significant is if you can’t get your patients to change, or the insurance doesn’t reimburse you for, you know, for X amount of time-

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

for whatever you’re doing.

Margaret Moore, MBA

Yeah. Soul destroying.

Cheng-Huai Ruan, M.D.

Yeah. And they go into medicine, I shouldn’t say they. We went into medicine, also, for a sense of contribution and a sense of growth. And I think though neither a sense of contribution or growth is really met by a lot of people, after training. And it is because of this. And it’s because the way we’re trained is that, and I’m trained in the academic institution, and within schools, and within residency programs and fellowships, we’re trained that the value that a doctor can provide a patient is through knowledge, right? And that knowledge is based on your training, so if you have more degrees, if you go to more conferences, you’re able to deliver more value for the patients. 

Now, on the patient side, most of the time they don’t really care about your knowledge per se, but they just care about the fact that you care. And so that’s not really taught. So the value that’s taught within school systems to provide to the public and to the patient is not necessarily what we went into medicine for. And that’s what’s creating a massive amount of burnout. So enter health coaches. So we started having health coaches four years, oh more than four years ago now, in my facility. And what the coaches did was something that was very unexpected. And it just happens naturally to the dynamic of a practice. And what the coaches did is that all of a sudden we were getting, we had these coaches, they were seeing patients and working through tough times and SDOHs, social determinants of health.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

All of a sudden, I start noticing that we started getting five to six times more Google reviews, and they’re all five stars. Right? With the practice. And it’s all about the health coaching. It’s like, “Wow, this is great. They care.” You know, it’s not like, oh the health care coach cares about me. No, they as an institution, they as a practice, care about me. And when we have that on a feedback, you know, I’m just blown away by how much significance and validation I felt because of what the coaches actually delivered to the practice. So that was the first thing that happened. The second thing that happened is this tremendous sense of growth. Like, man. 

I mean, if I feel that the coaches are doing well for the patients, and the patients are valuing what we’re doing because of the coaches, then we need to double down. So my growth mindset came in, to say, hey, lets, instead of having the health coaches be an adjunct or add-on to a practice, why don’t we centralize the communication between the health coach and the patient, and then the physicians are the ones that are supporting the health coaches. Which is our current practice right now. When that happened, a massive explosion of just love and connection and support came from our patients, came from the public. And then we had to stop taking new patients for a while. Honestly. Because there were just so many referrals coming in.

Margaret Moore, MBA

Wow. That’s beautiful.

Cheng-Huai Ruan, M.D.

Like grenades, you know? So, it was a good grenade, I would say.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

And so what happened is that health coaches turned a system that’s very bureaucratic and, you know, we take health insurance. We’re not a concierge practice. We take Medicare and stuff like that. We’re a very traditionally oriented, fee-based structure. So we took a very complicated system, put some humanity, sprinkled some humanity into it, and all of a sudden it’s like you’re going from black and white to color. Or you know, like a Claritin commercial

Margaret Moore, MBA

Yeah. Yeah.

Cheng-Huai Ruan, M.D.

or something like that. And so I think that was the value of the health coaches I didn’t necessarily, you know, expect at the time. But now, like, none of the providers within my facility, we can’t imagine practicing medicine without health coaches. Like, it doesn’t exist, you know?

Margaret Moore, MBA

No, I know. We so much need to clone what you’re doing. Because it’s, yeah, so it’s leading with heart, right? Because when people are suffering with medical issues, they’re worried, they’re scared. And sadly, we have to do research to show the value of empathy and connection and compassion. I mean, it’s where we’re at, right? You know. Somehow, the doctor looking at the computer screen doesn’t, you know, we have to actually do studies to show that that, it’s really, we’ve lost our way, really, in terms of understanding what improves health. And you know, if you were a physician a hundred years ago, when you didn’t have a bag full of tricks and drugs, all you had was putting your hand on your patient’s arm and just saying, you know, I care, and I’m here, and it’s okay. So. And the other part of coaching, though, is the growth part. 

And so the thing about humans is that we want to grow. We actually, we want not to stay stuck in our current muck. We want to grow. And the coach is using the compassion as the starting point, to build safety and psychological connection. And then from there, we say, oh, well what would it look like if you did that? What would it look like if you did that? You know. And they kind of get, they feel the caring and they start to see the possibility. They’re not resisting any longer. Like, “I don’t have time for this, I can’t do this.” And then they come to you and you can, like, just do your thing, because they’re already warmed up. 

They’re connected. And then your intuition is probably, when you say that your skills are at a higher level, because you feel the patient’s with you, and you then, you’re awakened to your full intuitive power. Because it’s not just, I mean, yeah, the data’s there and the, but you need to read what’s needed. And you need to work on, you know. And when the patient’s relaxed and feels safe with you, you probably do better work too. So it’s upping the game for everybody. Everybody. What is coaching? Just helping people be at their fullest potential. It sounds so trite. But none of us are operating at our full potential.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

That’s why there’s room for, we’re not, we’re blocked by all kinds of stresses and strains. And the coach’s job is to see that and help people move past it. Yeah. So it’s like, you turn whole primary care into this house of growth and wellbeing. It’s like it’s a cultural shift that is what’s needed.

Cheng-Huai Ruan, M.D.

Yeah, absolutely. And I think even beyond primary care, I think coaches in surgical specialties are really missing out on an opportunity. Because there’s nothing better than pre-op communication and care.

Margaret Moore, MBA

I know. Yeah.

Cheng-Huai Ruan, M.D.

Post-op.

Margaret Moore, MBA

yeah.

Cheng-Huai Ruan, M.D.

Right? Pain management. It’s such a beautiful thing to see. Because, so most of our surgeons that we refer to obviously don’t have coaches. So we actually have them have sessions with the coaches, pre-op with our coaches, and then post-op, work with pain, and all the stuff like that. And check-in visits and stuff like that.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

And so, that puts, actually, value back to the physician who we refer to. So a lot of surgeons like getting patients from us, because we know we have an emotional and coaching support system.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

That kind of-

Margaret Moore, MBA

There’s some nice data on that. I was reading about it because we were looking at, and are looking at an opportunity, pre-hab and post-hab. And I think what surgeons and the financial people don’t get is people are scared, going into surgery. And you know, and they can’t necessarily share their fears with their family, and they certainly don’t want to share it work. Because both are dangerous. You know, you don’t want your family to be overly stressed and you don’t want your work to know that you’re vulnerable. So you carry this vulnerability. And the coach just gives you a space to just, like, oh yeah, I’m really scared. 

Like, I mean, who isn’t scared going into, have you ever been to an OR? Like, it’s not, it’s a very scary place. Even if you’re a doctor, I think. So yeah. So I think, and I read a review article on pre-hab and the main thing the reviewers concluded was that what people need to deal with is their emotional fears. The exercising, the eating better, and sleeping better, you know, we want that for sure. But mostly, they just want, they want to have a place to just share their worries and recognize it’s normal and they need to get strength as they move into this.

Cheng-Huai Ruan, M.D.

Yeah, absolutely. And as you’re saying that, it reminds me of a current structure that’s already almost perfect. And that’s hospice. So-

Margaret Moore, MBA

Oh.

Cheng-Huai Ruan, M.D.

Let’s think about it for a second, right? So hospice care. The physician, by the way, so hospice doctors are like the happiest doctors I have ever met. I know because I used to be one.

Margaret Moore, MBA

I know. Even though they’re end of life. Yeah. I know.

Cheng-Huai Ruan, M.D.

And all they do is to give certainty and connection to the patients and the patients’ families, right? And so the discussion of end of life, they will take them from grief to celebration. And-

Margaret Moore, MBA

Wow.

Cheng-Huai Ruan, M.D.

I really enjoyed being a hospice, I used to be a hospice director. I really, really enjoyed being a hospice director. It was like my cooldown for the day. Because I was in-patient, ICU, out-patient. When I did my hospice was my favorite rounds. And it’s because it’s all about, like, the communication that’s behind it, right? And then when–

Margaret Moore, MBA

How do you end life well. Yeah.

Cheng-Huai Ruan, M.D.

Yeah, exactly. And I think you, you know, with hospice I used to joke with people that in hospice medicine, we skip over the BS and we get to the very end and all people care about at the end of life is not that they worked too little or anything like that, but all they want is, like, I wish I had a better relationship with X person, right? And so, I see the, you know, when I started Texas Center for Lifestyle Medicine, hospice was actually my inspiration. And I wanted to develop a hospice-like atmosphere, but not with dying people, right? But with the general public. And everything that was good about hospice, the relationships and stuff like that, we put into practice. 

And that’s eventually what came of our facility. And so. But this all is well and nice. But we’ve got to get paid for it, right? You know, I’m in, this is private practice. I started this with my own money in my own pocket. And it’s got to make some financial sense too. And the first couple years took big hits and big risks seeing if this stuff works. But I think we’re at a point, we’re at a point in time where we’re staring to see some movement. So why don’t you start talking about what’s been done in terms of insurance reimbursement, working with CMS, and we’ll go from there?

Margaret Moore, MBA

Yeah. So I think the bigger picture is to appreciate that of the hundred, the full healthcare dollar that pays for those layers and layers and layers of things that we need to make room for maybe five percent of it to be spent on the connection conversation, the human relationship, which is what really makes people thrive. You know. I mean, plus, I’m a great believer in, I mean, I’m a fully bionic woman, with all those, you know. So I get all of the science, and I think it’s wonderful. But we have to really pay for that relationship. So we have to save somewhere else. We have to be, like, because what happens is we try to say, okay, let’s have five percent of, so what are your revenues, just call it, you know, couple million, three million in revenues, a primary care doctor. So let’s just spend $150,000, like five percent. So then we have to figure out, like, so if you actually got to manage the whole $3,000,000 and all the medical, everything, could you find five, if somebody gave you control over all that, you could figure out how to fit in the investment in the wellbeing. Instead, we’re trying to like shove it into this bloated system. 

So we have to be way more thoughtful about, what are we investing in and why, and not try to compare. This comparative effectiveness is, everything’s, it’s actually overanalyzed and it’s missing the point. It’s like everybody’s looking at the wrong thing. So I think first thing is, we all have to agree we need to invest in that relationship. Both the doctor’s time and the coach’s time. And we have to pay for it within that several million dollars. Which means we have to actually, like a business would do, you know, you’d figure out, okay, like … But it has to be system-wide. Everybody has to join in and say let’s, how can we save five percent to put it towards this kind of investment, which is what people need. 

So I think we have to engage in a larger conversation. And everybody has to help figure out how do we create … Because if we just try to hammer on the health insurance and Medicare, like adding another dollar, and then you just go through, you know, we’ll get there, I’m pretty sure we’ll get there because we’re doing the right things but we have to have a mental shift, a sort of whole consciousness shift, as to, like, we have to invest in relationships in healthcare. And we have to pay for that. And what can we do. So just take cancer. You know, if you get cancer treatment, what’s your treatment cost? What? $100,000, $300,000, $400,000? There’s no money. There’s like, all we need is like $4,000 for a coach for several years. Take end of life for a cancer survivor, because I’ve coached people in Stage 4. And I’ve worked with somebody. And we were going to start a nonprofit to provide coaching for Stage 4 cancer survivors. Because they often live for several years, and they get dropped off at the side of the road after spending a gazillion dollars on their treatment, and nobody is there to help them. 

Nobody. They don’t know … It’s devastating. So what if you got the whole oncology industry and said, okay we just need to create, you know, five percent, three percent, of the cost, needs to go to help the patient after their bodies have been ravaged by cancer therapy. They are literally, like, they’re bag of bones. Exhausted, sick. You know. And we don’t give them anything. Nothing. And that’s, like, that’s just got to stop. It’s just got to stop. So we’ve just got all messed up in terms of how we spend money. And we really need, so I think we, you know, I don’t know how to start this conversation at a higher level, but this is a higher level conversation about values. And principles. And we need need pilots. And we’ll, you’ve already shown, you invest in the relationship, you get the return. And so, yeah. So it’s a big deal, this endeavor. And it can change everything.

Cheng-Huai Ruan, M.D.

Yeah. You know, that shift in mindset is necessary from every aspect. So when I started a practice, I didn’t really know how much to allocate for it, but I just know that was necessary, to get conversations and health coaching within the practice, because I don’t necessarily want a repeat of what I’ve had before, what I experienced in residency, what I experienced as a medical student. Because, you know, I’ll give you an example. Right now my sister is in medical school. And she’s an ivy leaguer. She’s in a great school. But it’s not necessarily great by her definition. Because she, like today she was very upset about, like, there’s no one advocating for the relationship between the nurse and the patient. And the nurse is just being absolutely blasted by, you know, the charge nurses and stuff like that. And she just, she sees the relationships aspect of it, which is exactly like me. 

I see the relationship aspect of it. And I see that, okay, well, in a traditional primary care practice, the medical assistants can make or break a physician’s reputation, right? But the medical assistant has a million jobs. Has a lot of different jobs. And the medical assistants can get burnt out if they’re trying to deal with patients and relationship and discussion from there. So there’s not a lot of time allocated to training that medical assistant. And even if they did, the more the physicians are burnt out, the more the medical assistants are burnt out. You know, just from a leadership standpoint. Now, if you enter a coach then, what if we take a lot of the responsibility of what the medical assistants do, and then put that towards the coach. Now that medical assistant just increased his or her productivity. 

We actually measured this, okay? How much stuff you get done. And it’s very simple. One of the KPIs, the Key Performance Indexes that we have is how many insurance insurance preverifications we go through on a day prior to people seeing us, right? And honestly, when we started having coaches, it went from this medical assistant doing 54 insurance preverifications to over 200 per day. That dramatically decreased our fixed costs, and then, now we up that level and say, hey, you know, why do we have to have a person in-house do it? Let’s have a virtual assistant, for example, which is a fraction of the cost, do this. And now the person in-house, all they do is cater towards the patient that’s physically there. And so now you have the medical assistant is being, every second that they’re there, they’re dedicating a lot of their time to the patient, and engagement, and training them in engagement. And all of a sudden you have this a-ha moment when the patient walks through the door to the front receptionist. 

The front receptionist is not on the phone, because someone else is on the phone, either in the back or a virtual assistant, dealing with the patient side. You have a greeting, right, and then you have smiles, and then we have an IV infusion center, so on the IV side it’s sort of the exact same setup. No one’s really doing a million different things at once. Unless we’re with someone that was sick. And the coaches actually were able to not only allow us physicians and practitioners to operate at a higher level, they dramatically improve the operations of the medical assistants at a level that supersedes any other position within the practice. And so, we went back to the drawing board at the very beginning of the pandemic. 

And we’re like, okay, we’re going from five percent telemedicine to 86 percent telemedicine in two weeks. Right? Because the country’s shut down. So we tripled down on our virtual assistants and all the stuff like that, decreased our fixed costs. And so we kind of made it through the pandemic by decreasing costs. And now we’re on the other end of it, and we had three locations, by the way, and we shut down two, now we have one. But we kept our telemedicine model, so all those things were able to happen once you have this re-shift in focus of, why does healthcare cost so much in the first place, back in 2019, for our facility, whereas now we’re running leaner, but we’re running better.

Margaret Moore, MBA

Wow yeah.

Cheng-Huai Ruan, M.D.

But all that couldn’t have happened without the health coaches allowing the other players to operate at a much higher level. So I think what you’re saying about the five percent allocation is valuable, but people don’t understand, that five percent is just the beginning, because your return on investment is dramatically higher.

Margaret Moore, MBA

Yeah. No, I get that. I’m just saying.

Cheng-Huai Ruan, M.D.

Yeah. Dramatically higher.

Margaret Moore, MBA

I know. The point is, like, you just make space for it. Because now–

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

The connection is there. Yeah. Yeah. Well you are, I mean, you’re brilliant in terms of, like, watching those details and having the bandwidth to see what to do better and to leverage these human relationships. And you know, I just pray to god that whatever you’re doing, it gets out there on billboards in healthcare. Because you know, I think we’re on the same page. We’re not going to stop until this is done. I mean, this is not, we’re not playing around here.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

This is not, we are not going to let a million clinicians, healthcare nurses, doctors, get squashed like this. It’s just not right. It’s just not right.

Cheng-Huai Ruan, M.D.

Yeah. It’s not.

Margaret Moore, MBA

It has to stop. And you know, we’re not done until it’s better. And everybody else that has some other interest, you know, counting whatever they’re counting, checking boxes, building software that draws the bejesus out of human beings, all that’s just got to stop. It’s abuse. I mean, it’s just really bad. It’s just, it’s like, I can say this because as a coach, I work in other industries. And there’s nothing, I mean, there’s definitely, I mean, there’s other industries that are not treating their people well. But this is among the worst. And it got here in an insidious way. And it’s going to take a bunch of us, you know, holding hands and just not giving up until we get something that’s sane and productive and really helping everybody thrive. If the healthcare workforce doesn’t thrive, how the heck is everybody else going to thrive?

Cheng-Huai Ruan, M.D.

Yeah. Absolutely.

Margaret Moore, MBA

It’s just not going to happen.

Cheng-Huai Ruan, M.D.

And the healthcare workforce, especially nowadays, if you look at social media, there’s just so much distrust going around, right? And so, all of a sudden, the physician is at the crossroads of, you can no longer be in the middle. You’re either left or right. So if you say something, oh you’re left. If you say something else, oh you’re right. Right? The middle ground no longer exists. And that’s a very dangerous place. And it’s really hard to be careful. And so what happens is that there’s just sort of this retraction that happens. Especially with censorship and stuff like that that’s been going on. And I think that, and as that happens more and more, there’s sort of this sense of loss, and it’s this sense of helplessness that really exists amongst the healthcare practitioners. And that is something that is not just common, but it’s almost expected amongst most of my physician friends. It’s like, oh well, you know, we’re dealing with this again, okay. You know. And–

Margaret Moore, MBA

well you know, there’s this wonderful, he writes in a stealth mode, Hanzi, a book called The Listening Society. There’s a philosophy called metamodernism. So modernism is capitalism, postmodernism is liberalism, and metamodernism is the integration of the both. And the theme, really what’s really important from the three core psychological needs is that the right is about self-determination, which is, I get to, you know, free to be who I am. Which is the number one human need. It’s not going to go away, even if you try to squash it from the left. The left is about caring for folks. Which people also need. So you have to have both. We cannot as humans, it’s a polarization. Like, taking care of myself, taking care of everybody else. You have to have both. So it’s crazy that we’re fighting over this. Because humans need both. 

We actually need to get above it and integrate the two, not, we have to integrate polarity, not foster it. And as long as you have these arguments, and people just, you know, readiness to change? First thing that happens when somebody wants you to change, what do you do? You resist. And if they really press you, and they really tell you how awful you are, they resist even further. So all we’ve done is create more and more and more polarity. And we’ve lost our humanness. We’ve lost our ability to be listeners, you know, we’ve just lost a lot. But you’ve got to, everybody needs to know there’s another level of consciousness here. Which is to integrate both. Not one winning over the other. Ultimately, it’s the integration. And unless you get to that place, you’re going to have people fighting for their side of that polarity.

Cheng-Huai Ruan, M.D.

Yeah. No, absolutely. And I mean, just scroll through Twitter and Instagram right now. You can witness it within a few finger swipes, right?

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

And so I think that in practicing medicine, in building Texas Center for Lifestyle Medicine, you know, my main lesson that I learned is that, do not compromise human connection, no matter what. And sometimes, and I’ve been guilty of this, and I acted because of a fight or flight fear that, oh, I’m losing too much money here, and how am I going to make payroll, and all of a sudden you look for other different things. And then you become polarized, and then you just kind of blind yourself. And so that’s not what I want any of my colleagues to go through. But for me, it was kind of a necessary evil, to kind of challenge my–

Margaret Moore, MBA

Yeah, to go to the, yeah, to go to the analytical side.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

And then when I started to say, hey, let’s just step back for a second, what do I value in the practice? Well, I value the way we communicate with patients. Well, how do we communicate with patients? Well, let’s do x, y, and z. We train the staff, and then we have health coaches actually come out and train the staff. And a health coach is actually formally trained in communication, which is perfect. And now with our coaches sort of at the helm of that education piece of communication, and then we start seeing case studies of how we turn, like, really, patients who we labeled as very out there, right, and all of a sudden they’re like our biggest fans. You know. And then now, all of us are at a point where there’s no such thing as a crazy patient.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

It’s just that they’re not heard. And so we take it, put it as a challenge for ourselves. Well, let’s turn this patient. Let’s just talk to them. And I mean, we do it very quickly. And so, I was never taught that in medicine. And I was taught in medicine that there are patients that you should stay away from so you don’t get sued.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

Right? And the reality situation is, if you try to push someone away that’s, quote, unquote, toxic for you, they’ll most likely come and sue you. But if you try to help patients, and talk to them, and even if you can’t help them in the traditional sense, in prescribing a medicine or a narcotic or something like that, and you’re just like, hey, you know what, I see your pain. And I want you to do well, because my intention is good. But I don’t necessarily have the tools. And all of a sudden, even though we’re telling patients that we can’t do certain things, we get five star reviews. 

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

From that conversation.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

And–

Margaret Moore, MBA

Because they appreciate the honesty, yeah.

Cheng-Huai Ruan, M.D.

Yeah. And so when I looked at that, I went back to the drawing board. I was like, okay, all right, let’s educate myself on the things I really need to understand, which is CPT codes, right? Procedural codes and reimbursable codes. Let’s see what we got. So in 2019, you have a brand new set of codes that came out for communication. 2020, even more came out. 2021 it just exploded, of how there are so many reimbursable events for communication between the patient and the physician, the patient, even the clinical staff and the patient and health coaches, that I’m like, well no one’s really kind of figured this out yet, because there was not a necessity to focus on the communication. 

But what if we obsess about patient communication? What algorithm then do we have for the patient communication? And if you guys wants to know what the algorithm is, it’s a one-sheeter. It’s actually in the description of this video. Some of you already have it because if you signed up for the summit, that was my free gift to you. So we have this little sort of algorithm. And our health coaches are at the center of that algorithm of providing this, you know, pulling this lever here, communicating. And then we can design a communication system that’s digital as well as in-person, as well as on the phone, and our health coaches actually manage all that, which is wonderful. And then I heard about you being involved in health coaching CPT codes. So the temporary CPT codes that were developed. So can you just kind of touch on that just a little bit, we don’t want to get too much into it, and where that’s going?

Margaret Moore, MBA

Yeah, so, I mean, the arc of the story is that when I set out in 2000 to create a workforce, you know, we had to build protocols. We had to generate evidence, we had to train lots of people, and we had to gather the outcomes, the data. We had to start with science as well. And then we had to, at 10 years in, we started to have an industry. I was alone for the first five years. With a school and a textbook. And then we started to have a gang of us. And we all agreed that we weren’t going to have a workforce without standardization and a national test. And we spent five years negotiating that. And then we were ready to build an exam. And my friend David Eisenberg at Harvard School of Public Health now was consulting for the National Board of Medical Examiners and he heard them talk about health coaching, and he says, you’ve really got to talk to this group. 

And they were about to compete with us. And so David put them in touch and then I spent three years shaping an entrepreneurial deal to value our input and their input, and they invested multiple millions of dollars. We built a national exam, and the standards. And that all came out, you know, probably five years ago. And then we started then on the policy side. So we began talking to CMS about existing codes. You know, you’ve seen the document, that took a couple years and multiple conversations. And then the VA drove, initially with our help, the application for health coaching codes. Because they wanted to, they had trained a lot of people and they wanted to track it. So a lot of things happened to get those codes. And we are actually back to the panel again in September. 

We’re on our fourth round. You know, it’s an areas that’s, we’re breaking new ground. But we’re going to get there. So we’ve got codes. We’ve got the literature. We have to track the use of the codes. We’ve just got to do what you need to do to get to Category 1. We’ve made a really good impression on the panel. Because we’ve worked particularly hard to bring all the players together at the meetings and make a good impression. We’re doing all the right things. And so at some point, I’m actually not worried about the codes. I think the bigger issue is what we’ve been talking about, is how to wedge in, in this economic, you know, multilayer cake, in ways that … In my early 30s I was a global marketing manager and had a huge success launching Haemophilus influenza vaccine in Germany, of all things. 

We saved lives. It was, as you know, Haemophilus influenza causes bacterial meningitis that kills kids. So I know I saved lives back then and I gathered together all the epidemiologists in 10 countries in, it’s a long story, but it was sort of a marketing accomplishment. And so that’s the way I think about this. How do we pull the forces together to make something happen. And we haven’t quite got that yet. You know, it’s sort of like working up the ground. So I don’t know exactly how, but I’m pretty confident that we’re going to, just our conversation and the people that are in our gang, we’ve got to take the, we have to find the key to get the conversation to shift where everybody says yeah, like, this is what we need. And we can’t just be, you know, we can’t talk to 100 payers in 50 states. 

We can’t get there that way. We have to find a faster path where everybody says, okay, this is where we’re going. So that’s where we are right now. So I think, you know, we need the bigger picture thinking, the more strategic thinking, understanding the shape of healthcare. And I think the biggest reason to bring in health coaches is to save primary care, and make it meaningful. I think that’s the, I think that comes back to physicians and burnout. I think coaches can actually really be the missing piece, as you’ve just been saying. So I don’t quite know exactly how it’s going to happen, and I think these things are emergent, but we’re ready for the conversations, we’re ready for the moves. 

We just have to keep plugging away. We’re on the right path. This is where the world needs to go, this is where healthcare needs to go, this is where physicians need to go. And we just keep going and, you know, like The Beatles playing for, how many, 11 years and then finally they’re, you know, we’re a bit like that. We’re not The Beatles. We’re our own version of that. But that’s what we’re doing. We’re just building the ground. We’ve done everything right. We’ve got all the moving parts, and now we need to make some bigger moves that change the game.

Cheng-Huai Ruan, M.D.

Absolutely. And so, I think the takeaway here is that there’s, you’ve created a standard at the National Board of Health and Wellness Coaches, right? And there’s a Board certification that’s there. So it’s not like, you know, anyone can call themselves a coach and .

Margaret Moore, MBA

No. I mean, the number of years it took to get to that. Like, it’s not a small thing, what happened to get there.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

And I know, just pulling everybody together, getting, like, look at the fitness industry. They can’t agree on a national, a lot of professions have not been able to do that. We’re there. We’re going to get there. We are going to get there. There is no doubt about that.

Cheng-Huai Ruan, M.D.

Yeah. Well, great. So if a doctor listening to this wants to find a health coach to find solutions for their practice, where should they look?

Margaret Moore, MBA

Well, the National Board of Health and Wellness Coaching has a site with a listing. But my school, Wellcoaches, which, you know, we have a 95 percent pass rate on the exam. So we’re baked in to the standard. Our coaches are great. You know, they’re really great. So you know, you can look at Wellcoaches or the National Board. There’s other schools that are good too, but shop carefully. Because it’s a, there is a standard but it’s not, there’s lots of variation in that, how it’s delivered.

Cheng-Huai Ruan, M.D.

Great. And also, for those of you who don’t know, in April 2021, there’s a new taxonomy code that’s for health coaches.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

Which kind of validates, when that taxonomy code came out, it really validates what I’ve been trying to do for the last four years, and I felt good about it. But that taxonomy–

Margaret Moore, MBA

That’s probably the easiest thing we did. All we had to do is fill out the form.

Cheng-Huai Ruan, M.D.

That’s good.

Margaret Moore, MBA

But we had done a lot to get up to that point.

Cheng-Huai Ruan, M.D.

Yeah, but with the taxonomy code you have a definition now of what health coaches are, so I think this is the board on which we spring–

Margaret Moore, MBA

Yes. 

Cheng-Huai Ruan, M.D.

To figure out, let’s define this. And instead of putting a wedge of the health coaches into a system that’s already defunct, we have to think about how it’s going to be engineered. And I think it really starts with people experiencing health coaches within a practice, and how they actually interact and communicate. And I think once they, there’s an a-ha moment a couple months in where you’re like, wow, people are actually smiling in the waiting room. That’s really good, right? And people need to experience that a-ha moment. And that’s a feel-good. But then when you put that into a business case, like I did, then it feels really good because not only is it sustainable, it is an absolute integral and necessary part with the practice, which I think is fabulous. And so, I’m just going to close it out real quick with one kind of a difficult question for most people, is, knowing what you know now, what is one thing that you know now that you wish you knew four years ago?

Margaret Moore, MBA

You know, I would say that, and I don’t know if this is, and the women who are listening might be able to relate to this, I think that what holds us back, I mean, there’s two syndromes in the world. Overconfidence and underconfidence. And you know, I would say that my, what I struggle most with is doubt. I mean, you’ve heard me be very confident and very sure-footed, and I am. And there’s definitely, parts of me are that way. I have to stop doubting.

Cheng-Huai Ruan, M.D.

Stop doubting. Yeah.

Margaret Moore, MBA

Doubting, yeah.

Cheng-Huai Ruan, M.D.

I think that’s a-

Margaret Moore, MBA

That’s probably the thing I have to learn every day. Don’t doubt myself. Don’t doubt the possibility. Don’t doubt the opportunity. Because I am very confident, but then I don’t sleep, you know. You stress out because you’re projecting. In coaching we call that the leadership shadow. The more you take on as a leader, and you’re taking on a lot, the more you take on, you’re going to have vulnerability travel with it because you have to step up and project confidence, but it’s not all built yet, right? So then you’ve got–

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

Then you live with a, you know, middle of the night, you know, the bad dreams, whatever. And so yeah. The thing that I am gradually overcoming is doubt.

Cheng-Huai Ruan, M.D.

Yeah. No, that’s great. Me too, actually. I think there’s another segment that we have on some people talking about doubt as a woman, as a minority, as an immigrant. So I think that we all have that sort of mentality. And there’s always something that’s driving us to do better. And that’s what puts us and connects us together. But that doubt, which creates that sort of imposter syndrome, is something that I think everyone should be feeling. If you’re not feeling it, something’s not right.

Margaret Moore, MBA

Yeah, you’re not humble enough. Yeah, you’re overdoing it.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

But it is what, it’s processing. So as coaches, that’s the growth edge. So you process the doubt, because that’s what makes you stronger. What matters most is that you’re aligned, you know, there’s some sort of, like, we’re in a, you know, if you use physics as the metaphor, this is a very big ecosystem, right, of forces. And the positive attractor in human society right now, and you saw it with the pandemic, is more humanity. We’re moving to more human, humans first. I mean, it sounds ridiculous that we wouldn’t be humans first, but institutions somehow got to be first. Money started to be first.

Cheng-Huai Ruan, M.D.

Yeah.

Margaret Moore, MBA

And so the attractor that we’re on is really putting humans first. And that is where the universe is going. It might be 100 years, it might be, but when you know you are, your compass is set on where the highest expression of humanity is, you don’t need doubt. You might go up and down, and it may not go well in your lifetime, or tomorrow, or whatever. But you know you’re on the right path. And that’s like all you can ask. Is that you’re on the right path. And you find other people who are on that path with you. And when you’ve got that, you know, we aren’t going to fail. But if you don’t have doubt, you’re not looking for all the obstacles. And you know, you have to. It’s a balance. But you also don’t want it to, we have to live a long time, so we don’t want the strain of this to drain us and to age us. We have to keep ourselves youthful, which means we have to find a way to do this with the least amount of strain. And that’s what I really mean, is that I stressed. My problem is just adding, it’s the stress of it. And every day I get better at stressing less and moving forward.

Cheng-Huai Ruan, M.D.

We’re all in it together. That’s the best part.

Margaret Moore, MBA

Yeah.

Cheng-Huai Ruan, M.D.

So, well thanks for coming on. I really appreciate your time. And if you guys are interested in getting a health coach, go ahead and click on the link that’s with this video in the description, which takes you to the National Board of Health of Wellness Coaches, and as well as Wellcoaches as well. So thanks everyone, for listening. Have a good one.

Margaret Moore, MBA

Thank you, Cheng.