Welcome And Purpose Of The Show

Grantley Martelly 0:04

This is the Real Health Black Men Podcast, where we empower men to take control of your health. We provide vital information and build community support. So join us as we discuss everything from major health challenges to mental wellness and physical fitness. So if you're ready to level up your health and your life, you're in the right place. Let's get started. Welcome to the Real Health Black Men podcast. Today my guest is Dr. Tiffani Thomas. And we just returned from the podcast summit in Atlanta, Georgia, and I met her there. We had some interesting conversations, and I invited her to be my guest on the podcast there. Dr. Thomas is a board-certified family practice physician. She's also a businesswoman. She's a mom, and she started a new podcast. And we're going to talk about all of that, her personal experience, her professional experience as a doctor, her podcasting, and some of the challenges that she's helped us navigate with men and their health. So, Dr. Thomas, welcome to our podcast.

Dr. Tiffani Thomas 1:12

Thank you so much for having me. I am so glad to be here. I feel that this is an important cause and something that just doesn't get talked about enough.

Meet Dr. Tiffany Thomas

Grantley Martelly 1:22

Thank you very much. So let us begin by just grounding in. Tell us a little bit about yourself, where you grew up, your your training, and uh your family, anything that you think our listeners would be interested in knowing to get to know you better.

Dr. Tiffani Thomas 1:40

I am from the South. I was born in Mississippi, grew up in South Carolina. I went to undergrad in South Carolina. That's where I met my husband during undergrad. Went down to Charleston, South Carolina for medical school, and then I went to the University of Alabama for residency. I stayed there for a couple of years on faculty, and then eventually I moved back to South Carolina, right outside of my husband's hometown, to help start a residency program. I currently have four children. The youngest one is nine weeks old. So I am busy, busy, busy being a mom, also working full-time. And I made the transition from the clinic uh to working for an insurance company pretty much so I could be more present for my kids. I saw that there was a gap. And there was, there was more that I could do, I felt, by taking a working, a work from home position that I couldn't necessarily do in the clinic. And so that was one of the reasons also that made that transition.

Why Preventive Visits Get Skipped

Grantley Martelly 2:50

Thank you. That's going to be interesting to learn more about as we go. But let's begin with your experiences as a physician. You know, black men often struggle with taking the initiative to see their primary care physician, unless many times their jobs require them to do that. So in your experience, we had to live the experience and practical experience is why do you think that's such a struggle for us to take the initiative to make sure that we are living well, taking care of ourselves, taking care of our bodies?

Dr. Tiffani Thomas 3:22

So there are just a host of different things that black men have to deal with, have to take care of. And a lot of times when they when you feel fine, it's not necessarily a priority. There are so many weights that black men carry around. And if you're feeling fine, going to the doctor on all of the things on your to-do list, going to the doctor is not going to be very high up there. And also, there's well-known mistrust in the healthcare system. I cannot tell you how many times I walked into the exam room and you could just see the weight lifting off the patient's shoulders. They're like, You're Dr. Thomas. You were definitely not who I expected. And so there was just so much in that moment that they felt like they wouldn't have to explain, that they felt like I would just understand, just because I would have a similar lived history as them. And so I do think it's twofold. I think it just not being a priority and feeling fine because high blood pressure is one of the biggest issues. Um, and that is one of the most common causes of cardiovascular disease. And with high blood pressure, you feel fine. And so people don't necessarily feel like they need to go to the doctor because they don't feel the damage that's happening to their kidneys. They don't feel the damage that that's happening to their body. And so helping make it more of a priority is one of the ways that we definitely need to help solve it. But I think it just not feeling bad is probably one of the top reasons black men don't always make it a priority. But also there's that mistrust of the system.

Grantley Martelly 5:00

Yeah, that's an interesting, interesting concept because a lot of times we say, if I feel fine, everything's okay and we're not aware of stuff going on inside of us that could be changing as we're feeling fine until we're not fine anymore. So I think that's what you're getting at. So, what are some of the family and support structures that again, in your experience, you found that helps us overcome these challenges and these reservations?

Community Support That Gets Men Seen

Dr. Tiffani Thomas 5:30

I think taking things out of the clinic is one of the easiest ways to kind of help overcome that. And so here in the South, churches play a huge role. Um, having health fairs, just being able getting people and black men to check these things without having the stigma or the pressure of having to make an appointment, having to, having to get to the clinic, having to miss work, like trying to lower that bar. And so I think that's one of the the greatest ways communities can support. Also um as family members, because typically I always I asked almost every single, I was man, I was like, all right, why are you here? So, so who's the reason that you're here? Just to understand, like, okay, what person made you make this appointment? And it was almost always a daughter, a wife, um, or a mom that that made them come to the clinic. And I feel like understanding that a little bit more um can help understand like what can we do and how can we get men to have the initiative themselves? Um, but also just knowing that they have that support and like someone values them that much to be like, hey, I need you to get yourself to the clinic so you can be the best version of yourself because I value you and I need you of my life.

Grantley Martelly 6:52

Wives and daughters seem to come up a lot. Why why do you why do you think that uh spouses and daughters seem to have that significant effect over men, even though they may be reluctant in and of themselves, they seem to want to give in, especially if if it's a daughter.

Dr. Tiffani Thomas 7:12

Because they they want to, I mean, they want to please their little girls. Um I feel like they always want to please their little girls. I feel like with those spouses, they kind of like she she said to do it, so so I need to do it. Um but I do feel like men are like a lot of times go, yeah, my daughter, she really wants me to take care of them, take care of myself so I can be there for her. Because a lot of a lot of daughters, they like want their dad to walk them down the aisle. Or they like have these ideas and have these memories that they want to make with their dad. And if they're knowledgeable enough, especially if they work in healthcare, they know like these are the steps, like this is what could possibly prevent that. So let me make sure that you're taking all the steps to make it happen and to make sure that you are gonna be here to see your grandkids grow up or to walk me down the aisle or whatever it is. But I I do feel like men frequently they see their daughters as little princesses and they want to do whatever they can to keep them happy.

Grantley Martelly 8:09

That that is true. I've found I've also found that to be true. So we need support systems around us and community support systems around us. And in our communities, sometimes that could be a challenge for some men. Some people may be alone. If you have a spouse, that's good. If you have a daughter, that's good. But what about the guy who who just feels that he's alone and he may have been divorced or never married and he does maybe he doesn't even go to church, hasn't been to church in decades. What other kind of uh support structures that could be out there?

Dr. Tiffani Thomas 8:48

Of course, I think listening to podcasts, I feel like just being able to hear other men's stories. Um, so David Shand, so he is the person that puts on the podcast summit where we met. Um, in his most recent episode, he talks about his his doctor's visit. Like he just went to the doctor and got some lab results done and found out that he had a really low vitamin D. And he was like, I've been blaming being tired on my kids. It turns out that I actually have a low vitamin D. So I think just having a conversation about it and being around people who are talking about it to make it seem like, hey, I'm not alone. I'm not the only person that that's going through this. Like, let me understand other people's stories, let me understand like what um caused them to go. I do think that that David's co-host was part of the reason why he he ended up going to the doctor. Um, but but I do think that just making sure that you're putting yourself in that community, exposing yourself to different voices and hearing those different experiences, because I feel like it lowers the stigma, it um lowers the fear aspect of it and makes it seem like it's not like this event. It's like once you go, you're like, oh, that that really wasn't that bad. Like, yes, I was afraid of the getting some bad information, but it wasn't really all that hard. So I think just making sure that you're you're putting yourself in those communities and surrounding yourself with those voices.

Stigma And Fear Of Not Being Heard

Grantley Martelly 10:12

You you you mentioned the word stigma a couple of times. What what are some of the stigmas um that you have found in your practice that men associate with going to see their doctor?

Dr. Tiffani Thomas 10:24

That no one's gonna listen to them. Like that is that is the biggest one that that people are going to just force medicine on them and their voice isn't going to be heard. Um like whatever answers they get, it's not gonna fit into their lifestyle. So they aren't gonna do whatever the doctor tells them to do anyway. So like why go in the first place? Um just because they're like, hey, if if I tell them that I'm having issues with this, they're they're just gonna give me a medicine. They aren't gonna like try and do this, try and do anything with my lifestyle. They're gonna ask about my lifestyle. And so just making sure that they know that, hey, taking ownership of it and being like, hey, this is the issue I'm having. I need you to know that these, like, this is how I want this to fit into my lifestyle. Um, because doctors do have a reputation of not listening. Um, and so I don't feel like it is specifically black men that have that issue. Um, but it is something that I do feel like black men are afraid of and are more acutely aware of. And so that sometimes prevents them from getting to the doctor.

Grantley Martelly 11:58

So let's talk about uh heart disease and some other issues that are prevalent in the community. We know that,

Prostate Cancer Screening And PSA

Grantley Martelly 12:06

for instance, things like prostate cancer, heart disease, there are significant disparities in in the black community. What does this data show and why do you think, why do you think this is?

Dr. Tiffani Thomas 12:17

And so prostate cancer is something where black men are being diagnosed more frequently and they're also dying from it more frequently. And so early detection is the solution and probably the issue. Like you we aren't catching it early enough because if you catch prostate cancer early enough, the the studies show that there's pretty much a 100% survival rate. Um so if you catch it early, like no one's no one's going to pass away from from prostate cancer as long as it's caught early. But if you aren't going to the doctor until you have a problem, which means um either your your stream is weak or you're you're having to get up at night to go to the bathroom multiple times. Um it if that is if that is when you present, likely it's gonna be later when when you catch it. Um and so I think making sure that men are are getting to the doctor sooner, getting the test. And so typically for prostate cancer, um uh you can get a prostate exam, but a lot of times people are gonna track your PSA. And so your PSA is your prostate-specific antigen. And the issue with that test is the fact that it can go up and down for several reasons, not just prostate cancer. And testing it, um, so typically a normal PSA is from about one to four. So if you come into the doctor and they check your PSA and it's three, that doesn't give you as much information. Um, but if you came last year and they knew it was one last year and now this year it's three, it's like, okay, that's valuable information. Like, like, why is it it it more than double, it tripled? Like, why did it go up so high? Um, and so that's why getting it preventively and and getting it in series is really important. And I don't think people understand that about prostate cancer specifically. Um, just because it's not one of those tests where like you can do it and it tells you, like, you, yes, you have prostate cancer, or no, you don't have prostate cancer. Um, it's one of those tests that needs to be done in series. And I don't feel that people frequently know that. And that's one of the issues. Um, and then as far as cardiovascular disease, um, it is one of the leading um causes of death in African-American men. But it's a lot of times it's because your blood with your blood pressure, like I'm saying, you feel fine. Like you don't feel the effects of having um high blood pressure until maybe you have a stroke or um maybe something else happens. You have a heart attack. And so high blood pressure causes all of these downstream effects, but typically that's not where people, that's that's where people present and not where we want them to. Like we want to, we want you to go to that health fair um at your church and they'd be like, hey, your blood pressure is 150 over 90. You should go see your primary care doctor. And so that's what we want, but a lot of times it's people in the emergency room and they had a heart attack and they found out, hey, your kidneys aren't really working all that great either.

Grantley Martelly 15:26

Okay, so you you linked um heart disease to high blood pressure and kidney

How Blood Pressure Hurts Heart And Kidneys

Grantley Martelly 15:33

disease. Um, for many of our listeners, that there may not be a clarity on on that linkage. Could you sort of explain how the three of those are linked together more?

Dr. Tiffani Thomas 15:45

Yes. And so so heart disease basically is how well your heart is pumping. And so whenever you have heart, heart blood, whenever you have high blood pressure, basically that means your heart is having to work harder. And so your kidneys play a large part in controlling your blood pressure. And so a lot of the medications we use actually work on the kidneys. And so whenever you have high blood pressure, your heart's gonna be working overdrive and your kidneys are also gonna be working harder. And so, as your kidneys are working harder, they stop working as well. I feel like that's probably the kidney is one of the most complicated organs. Um, and so I feel like that is an easy way to think about it. Um, so, so if your blood pressure is high, your kidneys are are working overdrive, and your heart is working overdrive. Um, and so what can happen is sometimes the vessels in your heart can get what we call plaque around them. And so plaque is um from comes from your cholesterol. And so if your cholesterol is too high, you get plaque deposits in certain parts of your body, mainly in your heart. And so whenever you have a heart attack, basically that just means heart, blood isn't getting to a certain part of your heart. Um, so the so the vessels around your heart that are that help your heart pump. There's some area that's not getting blood supply, so your heart isn't able to pump as well. And so when you have high blood pressure, it's working overdrive. You may have that plaque around it. Um, and so so a lot of times there'll there'll be parts of your heart that that don't get enough blood supply. And if you have a heart attack, like a lot of times you can't get that function back. Like once it's gone, it's gone. Um, and so with your kidneys as well, a lot it's hard to reverse your kidney function once you lose kidney function. Once your kidneys stop filtering your blood as well, it's really hard to get that back. Um, sometimes you can, if it's in if it's a short-term injury, you see it improve. But a lot of times if it's something that's that's been going on for years, it's not something that's going to improve.

Grantley Martelly 18:03

I'm just trying to simplify it in my mind. So a lot of times when we as men talk about heart attacks, we're thinking about those symptoms, you know, that that pain in your chest, that pain going down your left arm, you know, that kind of stuff that says you need to go to the doctor. But you are saying that unless we're doing our regular checkups and getting information, our kidney function could be a precursor to a heart attack, or high blood pressure could be a precursor to a heart attack. But if we're not getting those things checked, we're waiting for the elephant sitting on the chest and the left arm pumping. This stuff's going on in our body, and those things may show up before the heart attack, right?

Dr. Tiffani Thomas 18:48

Definitely, definitely with your high blood pressure. Um, so high blood pressure are commonly linked to two acute events. And so when I say acute, that means that they happen quickly. Um, and so heart attacks and strokes are very commonly linked to high blood pressure. And so with a stroke, basically, it's it's pretty much a heart attack of the brain. And so there is an area of your brain that isn't getting blood supply. And so basically, with your blood pressure, your heart's squeezing really, really hard to get through those vessels. And the vessels, they are doing what they can. Um, but sometimes with all of the stress, sometimes the blood vessel can burst just because you're your your heart's pumping as hard as it can to get blood wherever it needs to go when there's just so much pressure. So sometimes you have um blood vessels in your brain that burst, and that's what causes uh strokes. Um, and then other times it's just like in the heart, you have that plaque, and then blood just can't get through, and there's a clot. And so those are those are the two common quick ways you find out that you have blood pressure. Either you have you have high blood pressure, either you have a stroke from it or you have a heart attack because of your high blood pressure.

Grantley Martelly 20:06

So, how does early detection play a role in preventing getting us this far, a

Early Detection Before Crisis Hits

Grantley Martelly 20:12

catastrophic event?

Dr. Tiffani Thomas 20:15

Yeah, so just making sure you're checking your blood pressure regularly, you don't it you don't have all of that stress. Like your heart isn't pumping so hard. Um, it decreases the amount of stress that's on those blood vessels. So um a lot of times the the way I explain it is so if your blood vessel is really, really tight. And so when you have high blood pressure, your blood pressure is your vessels are are tight and constricted. And a lot of the medicines, they work to either relax the blood vessel so there isn't as much pressure and your heart doesn't have to work it hard, or they work as a diuretic. And so a diuretic, all that is is um it helps get rid of the fluid. And so it it just puts more, it puts less things in the vessel, so there isn't as much pressure. So there's kind of like two ways to kind of work at it. And so whenever you do that, you're like, okay, if the if the vessel's wall doesn't have as much pressure, then it doesn't have to work as hard, it doesn't have to work as hard, and your heart doesn't have to work as hard either. So there's less stress, less potential for a vessel to burst, um, and less potential for for a heart attack or or a stroke or those things.

Grantley Martelly 21:31

Thanks for the clarification. Help helped me to understand it a little bit better as well. Let's talk about the other side of your practice. You said in your introduction that

Why A Doctor Moves Into Insurance

Grantley Martelly 21:44

you went from family practice to the insurance industry, and you had personal reasons for doing that. If you want to go into that more, you can. But I want to spend some time trying to understand the insurance industry, maybe even a high-level overview of the insurance industry, because to many people, the insurance industry is like a necessary evil, right? It's like we don't we have to do it, we don't like to do it. They're so stressful, you you you can't get true to them. When you do, there's always the stress about whether they're gonna pay or they're not gonna pay. So we're gonna get into some of those things. But so let's begin with um, do you want to talk a little bit about why you made that switch or Do you just want to get into it?

Dr. Tiffani Thomas 22:30

I can talk about why I made the switch. And so, um, so even with physicians, um, whenever you talk about going to work for an insurance company frequently, they're like, oh, you're going to the dark side. Um, so it's not just with patients, it's like that's how physicians talk about it as well, how doctors talk about it one to the other. Um, but so I was working as a residency program director. So not only was I seeing patients in the clinic, but I was helping train residents to become to be attending to see their own patients. And so initially I went into family medicine because I wanted to take care of everyone. So during medical still, medical school, whenever I do my rotations, a lot of them, internal medicine, they'd be like, okay, we see everyone except pregnant women and children. And then for OBGYN, oh, well, we see all women, but we don't see any men. And I really wanted to be able to take care of everyone. And I felt like family medicine was the only area that I could do that. And so that's why I went into family medicine. I did my residency there. Um, and I noticed in the clinic that a lot of times moms were making sure everyone else got to the doctor, but they weren't taking care of themselves. And so as a family medicine doctor, I felt like I still wasn't able to take care of everyone. And people weren't taking care of moms. And if I could take care of mom, the mom was then gonna make sure the kids got to the doctor, the husband got to the doctor, everyone else got to the doctor, but someone had to take care of her. And yes, she'd go to the OBDYN, but a lot of times I'd ask moms, hey, what do you do for yourself? And she would just stare at me. And so whenever I decide to make the switch to working from an insurance company, I saw it as that would be my way to eventually start my company and grow my company because I was not going to be able to do it in the clinic. If I was seeing patients every single day, I was pouring out to them, like my tank normally would be empty. And I would not be able to come home and then work on a side project or work on growing the business that that I felt like I needed to grow. And so a lot of times that's why I moved to insurance. It was a lot of flexibility for me. Um and so it's I also spent time working at a free clinic. And so it's not that I'm completely removed, um, but uh, but I don't see patients the way I used to. And so so now I I have that ability to still take care of moms, um, just in a different way.

Grantley Martelly 26:24

So let's talk about a uh overview of the insurance industry. Um, what do what do patients need to know? Family needs to know is about things like prior authorizations and what your doctor does versus what you need to do. How does the industry work from a perspective that we can understand a little bit better?

Dr. Tiffani Thomas 26:45

Yeah, so prior authorizations are a necessary part. Um, so one of the medical directors that that I work with, she says that if everyone

Prior Authorizations And Your Options

Dr. Tiffani Thomas 26:56

got everything approved, no one could afford the premiums. And so that's kind of one of my guiding lights whenever I'm at work or if I have to deny something, it's like, okay, I'm denying this because it doesn't meet the standard. Um, and it's not that I am saying no, I'm not clinically practicing medicine. So basically, with the prior authorization, it is a doctor saying that, hey, I think my patient needs this, and I think you should cover it. And so when we go through our process and we're looking at the different, um, the different cases or or surgeries or imaging, we're saying, are we going to cover this? It's it's not an answer of, are we, is this something the patient needs? Is this something the patient would benefit from? It's are we going to cover it? Are we going to pay for it? And so that is not us saying that the patient doesn't need it. A lot of times with prior authorizations, they don't necessarily meet because everything hasn't been done. And so a lot of times, physical therapy, especially with muscle skeletal injuries, um needing back surgery or something like that, they need the physical therapy first. That's a key portion. Um, and a lot of things will be fixed or will be made significantly better with just physical therapy. And so with prior authorizations, we're just going through the steps like, hey, have you all done all of these things prior to asking for this? So that's a prior authorization. And so there's approvals and denials. Approvals just means that, hey, we are going to cover, we're, we are okay with you having this, and we will cover whatever portion was agreed to. And of course, there are deductibles and all that stuff, but we we won't get into all of that. Um, but it's kind of the insurance company says, okay, we are we are okay with this. Um, and so with with those, one thing that I want patients to know is that you can, if you, if the insurance company says no, a lot of times you can request for your doctor to do a peer-to-peer. And so that is like, hey, can you call their insurance company and tell them why you think I need this? And so if if there's a case that I review and either I say I say no to, um, a lot of times there will be doctors that call and we have a conversation about it. We're like, hey, have you done this? And sometimes it's just like, hey, you've done it. Can you just send me that piece of paper that the patient had physical therapy? And so there's that. And then you can also request a peer-to-peer. Um, or you can request an appeal if you really don't think that that was the correct answer. You can just be like, hey, I want you to make them look at this again. And so that the processes do vary from state to state and by insurance companies, but for the most part, a lot of a lot of times you have the right to an appeal. And so the appeal can go several different levels up. Um, but the the most important thing that I don't think patients know about is the fact that we call them grievances, um, but pretty much there are they're they're basically complaints, but I don't I don't want you to, they aren't negative. Um we don't view them in a negative light. Um, so if you feel that someone did something wrong to you, like you can have your insurance company look into it. And I don't feel that patients, especially African-American patients, black patients, use that enough. Because while yes, you are one, if your insurance company agrees with you, like they have significant power to start making changes. So I feel like if enough people were like, hey, this is what happened to me, and especially if your insurance company is able to establish a trend, they're able to kind of decide, like, hey, this might not be a company that we want to work with anymore, or or this might not be uh an imaging provider that we want to continue using. You can ask your doctor to do a peer-to-peer, and so that's when that's when you get a denial. You can ask your doctor to do an appeal. Um, that that's like making them look at it again, and then you can go ahead and file a grievance and say, hey, this is what happened to me. This is my story. I don't think it was right. Can you all look into it?

Grantley Martelly 31:40

That's a great introduction and understanding those those different processes, prioritization, grievances, appeals, denials, and approvals. But people say, you know, why should I have to go through all of that? If my doctor says I need it, you should pay for it because he's he or she's the one who is seeing me, and you're talking over a phone or over an email and you don't know what's going on with me.

Dr. Tiffani Thomas 32:08

Yeah, so so there's a couple ways I look at this. And so um, in clinic, I made sure that I stayed up with all of the most up-to-date information. And so the recommendations change frequently. A lot of times, if you are in one state and your doctor primarily operates in that state, but your insurance company for whatever reason is in another state, a lot of times that can become an issue. Um, and so for me, for instance, um, my insurance provider is from the state of North Carolina, um, but I get most of my care in South Carolina. So sometimes it is just a state-to-state difference and like how they do things in that state varies. And so I don't think patients always realize that, hey, it's basically just a state difference. It's based on the location. The other thing is that that doctors have relationships with certain insurances, insurance companies. If you go to a doctor that doesn't have a relationship with your insurance company, then that is something that the insurance company is like, hey, like we, these are the doctors we have relationship with. Like that doctor isn't one that we have a relationship with. And so that also presents as a problem frequently because if they're out of work, out of network doctor, then um then they're like, no, we're we're not going to approve it. Like a lot of times it's like, hey, just go to one of the doctors that we are okay with, that we have created this previous relationship with. And that sometimes can solve a lot of the issues.

Grantley Martelly 33:45

So, but how are patients supposed to know all of this? Are aren't the doctors and the insurance companies supposed to know that? And then if the insurance company chooses to provide services in multiple states, aren't they the ones who are supposed to be up to date on what's going on in that state? So that if I am in in Washington and my insurance company is in Georgia, then and they choose to s to work with doctors in Washington State, isn't their responsibility to know what the differences are so that I don't have to go through all that hassle?

Dr. Tiffani Thomas 34:21

Yeah, it's it it gets to be really, it gets to be really complicated. And I I recently had a baby, and so um I got exposed to it firsthand, and I was like, wow, this is this is actually really complicated. Like I see why patients have such an issue with it, because not only that, because my insurance company's in North Carolina, I'm in South Carolina, my I have my baby in Georgia. And so just like going through all of all of those different steps, like I I do understand it um very acutely from a patient perspective. And so a lot of times what the insurance companies do is they have like these are our approved providers, and they make you get a referral first. And so with that referral, that allows you to make sure that you're going to a doctor that's in network. And so most that's one of the ways insurance companies kind of make sure you're going to someone in network by by providing a referral. And so once that referral comes through, it's like, hey, we can have a conversation, like, hey, the person you were referred to actually wasn't in network. Um, these, these are the doctors that are in the network, like, like choose one of them. Um, I see where patients will pick like a system. They're like, hey, we're going to use this system of doctors. And then all of a sudden they're like, oh, well, I changed my mind. I want to go to this other doctor. It's like, well, you picked that system. And so helping patients understand it, that that's where it is, it is very complicated. I do think insurance companies could do a better job at making sure patients understood what they were signing up for. Um, of course, they do provide all of the information in this very long uh packet to whenever they send it that no one ever reads. So, like, they're like, hey, we gave you the information, but it wasn't in a digestible format. Um, and so I do think they're taking the steps, but not enough.

Grantley Martelly 36:21

So I I understand the outer network, but what what happens when people get uh denials that are within that work? Is that a different sort of denial? Does this interest does the industry see that differently? Because I hear

Denials, Evidence, And The Idea Of Harm

Grantley Martelly 36:37

frequently from people who are working with a physician and a referral that's in that work, but yet they're still dealing with challenges to get things approved.

Dr. Tiffani Thomas 36:47

Yes. And so that that is a different, a different system. And so one thing that with every denial, there comes a there comes a letter, and there are specific reasons as to why. An example, um, I feel that's fairly uh it's probably not fairly simple, but um, so trigger point injections um is an example. So typically if you have a place on your shoulder or somewhere where you're having a lot of pain, sometimes doctors will do trigger point injections. Um, and so they are something that patients can benefit from, but we have to be careful because just because a patient benefits from them doesn't mean it's also not doing them harm. And so it's like, hey, that made me feel good, but it only lasted a month. Okay, I want to get one every single month. And so from the patient's perspective, they're like, my doctor says I can do it. I want to do it, so like why isn't my insurance company covering it? But like if you look at the evidence, you look at the research, the research says that that these things shouldn't be done more than every three months. So then there's this gap. There's this gap between what the patient wants, what the doctor is okay doing, versus what the medical literature says. And so the insurance company is most likely going to rely on what the research says in the medical community, and they're gonna be like, okay, every three months. So then what do you do in those those two months when you want it, your doctor is okay with it, but your insurance company is saying no? And so that's kind of one reason why things are getting denied because it's not necessarily that the it's not necessarily that um it is harming you, but there isn't evidence to support that it is the correct and it is the most beneficial thing to do. And so trigger point injections are something that are very common. Um, and it's something that um not every insurance company reviews. And so it's something that the insurance company that I work for, we do review. And so it's a it's been a recent source of confusion because the patients are like, hey, I want this. My doctor says it's okay, why aren't you covering it?

Grantley Martelly 39:10

So harm, you mentioned harm. Um that's the first time that I've heard that insurance companies are concerned about preventing harm to patients. Typically, people associate that with their doctors. So that that's a new a new thing. Do you do you have a standard definition of harm, or or is that where the conflict comes between what the insurance company thinks is harmful or beneficial versus what a doctor thinks is harmful or beneficial?

Dr. Tiffani Thomas 39:37

I do not have a standard definition of harm. And I do feel like it's probably in uh a grayer area um where doctors probably would be like, hey, this is something that I know is beneficial benefiting my patient in the short term. But it's like, hey, what is it doing in the long term? And so I think viewing it, viewing it through the lens of what is what is best um right now for the patient versus what's best in the long term probably is something that differs from the physician perspective versus the insurer's perspective. But insurance, insurance companies definitely are concerned with harm um and they don't want to do any harm to patients. Um and that's one of the things that I did not realize until I started working for an insurance company, um, is that they review cases in which harm, they think that there possibly was harm cause to patients. Um, and they review them in detail. And so I I didn't realize that like there were people in the background. Like even if something happens to you and you didn't bring it up to anyone's attention, like there are people in the background just like, hey, was this right? But I do think defining harm is something that is it's a gray area. It really depends on who's looking at it. Because I I know the patients sitting there like, hey, this would help me right now. It is doing me harm not to get it, versus the insurance company being like, hey, no, if you get too many of these, it could potentially harm you in a year or two. And so I I definitely see where that could be a point of contention um in and people just viewing it differently.

Grantley Martelly 41:25

So what happens to that information when the insurance company reviews that and finds that there, in their opinion, there was potential harm to the patient. Does that just go into notes for the future, or does that go somewhere to to help the patient, or does the patient even find out that that analysis was done?

Dr. Tiffani Thomas 41:46

I am sure it differs between different insurance companies, but there's a letter that goes to the doctor or to the facility. And so sometimes it's like say it is a skilled nursing facility where a patient was getting care, and it may not have been one person, it may have been several. So, like a letter goes to the skilled nursing facility, and a lot of times it'll be like, hey, this was an event that happened. And so sometimes they are just tracked and trended. And so if you start to see a trend, it's like, hey, maybe that insurance company would be like, hey, we will no longer allow our members to come to your facility. Is there different actions that the insurance company can take? I am not sure. I do believe if the patient initiates it, then they definitely get a letter. But I don't know if they get a letter if it is something that the insurance company initiates.

Grantley Martelly 42:35

Don't you think this patient should know that?

Dr. Tiffani Thomas 42:39

I I do think the patient should know it, but I'm not that is not part of my process. Um that is a question that that that I I I'll ask when I get back to work. Um that's not uh that's not just part of the process that I'm a part of.

Grantley Martelly 42:57

Why is it so expensive?

Dr. Tiffani Thomas 43:03

Healthcare, insurance is expensive because healthcare is expensive. I would say insurance isn't the issue. It's a system, it's a system issue. Um because even when, and like sometimes I just don't understand, like it's like we agreed to pay this much of the bill.

Why Healthcare Costs So Much

Dr. Tiffani Thomas 43:16

I'm like, well, why don't we charge that? Why why was the doctor charging that much in the first place? It is a system that just does not make sense. It doesn't make sense why the premiums are so high, it doesn't make sense why the cost is so high. Um, and and so it's like they just keep going up because it's like, hey, well, we know that the insurance company is only gonna pay a percentage, so let's charge more. And that eventually gets trickled down to the member. Um just this like like whoever hatched the idea, made the plan, it does not make sense to me. Um, and so I feel like I've learned so much from it, like just being on this side of it. And it's still like I've learned so much, but it's still like who created this system. Like I feel the whole system needs to change. Um, I don't know who's going to change it, but I feel like it's a system issue. As so part of the reason why the the prices are so high, and the band-aid solutions are not as helpful. It's like, oh, let's cap the amount of money that this medication can cause to cost. And yes, that is helping in the short term, but it is an entire system issue. Um, and so we have to figure out how we can fix the entire system. I don't think insurance is the solution everyone thought it was gonna be. Um, and so of course, we know other countries like Canada, they have a universal health care. And so within that system, there are still people who look and say, hey, can this get approved? Um, even though no one is necessarily paying for premiums like they do in the United States, but there's still a time issue in someone reviewing those things. And so even though it is a possible solution, um, there are still benefits and um and issues with with that as well.

Grantley Martelly 45:13

Yes. There there's so many questions that we can get into here on this topic and compare systems and stuff like that. Because I'm not I'm I'm also not convinced that a system like in Canada and England is really the solution as well, because they have their share problems that we hear about, you know, people waiting years to get care or also have issues with denials and priority. And all of those things as well. So I'm I'm not sure that is the question. One more question here before we move on. And and you don't have to answer this if you don't want to. But we hear of insurance companies making hundreds of million dollars. And even recently on 60 Minutes, there was one insurance company who was making billions of profit a year. People were saying how can they be making billions of profit a year and still denying care for people? So how do we help the lay person understand the difference between that? Because to many people, that doesn't seem right.

Dr. Tiffani Thomas 46:29

I agree with you. Um and I do not know that I can help. So I specifically work for a not-for-profit insurance company. So my insurance company is they do not, they do not have shareholders, like they they do not answer to people trying to make money. And so we frequently have meetings and there are several initiatives that just went through to try and decrease the amount of money it costs to run the insurance company so members can get access to more. And so I specifically work for a company that is not for profit. Um, and so that is how I can sleep at night. Um, I would not be able to work for the one of those companies that are denying things yet making millions, billions of dollars. And so I know that that is not the company, the the company that I work for, like we are constantly trying to decrease our overhead. And the CEO of our company is very aware of they're like, hey, this is where we are at. These are um the measures that we're we're taking. Um, so for example, one of the things that they changed, they actually changed our PTO policy. Um, and so typically with paid time off, whenever you retire, they pay that out at the end of the year. Um, so they just got rid of it. And so so now they're like, this should save us millions of dollars in the future because we don't have to pay for your time off once you retire. And so the company that I work for is actively trying to find ways to decrease the amount that they're having to pay their employees so they can give that back to their members. That is not every insurance company, but that is the one that I work for. And that is the only reason that I'm able to work for them because they are not for-profit.

Grantley Martelly 48:14

But thank you for that. I probably need to have two or three episodes that are completely dedicated to insurance. And but I I I appreciate you you giving us that broad overview, helping us understand some of the things and some of the terminology that we we sometimes take for granted, but everybody's puzzled with. Let's switch now to your podcast. You made this switch because you wanted to start a business and do something else. And you started a podcast called Moms of Margin. Tell us about that. What's the focus about that?

Dr. Tiffani Thomas 48:49

So Moms of

Her New Podcast For Overachiever Moms

Dr. Tiffani Thomas 48:50

Margin is my company's name. Um, and so the the name of the podcast, we've we've gone through different names, um, but the current name is the Overachiever Moms Podcast. And so basically, the heart behind it is those moms who do everything for everybody else, but nothing for themselves. They are they have a space to come to get permission to say no, permission to do less, and and permission, permission to not carry the weight of everyone else around them. And so that is the heart behind it. And so I'm launching it uh July 13th was when the first episode will drop. And so it's just for those moms who are constantly putting themselves on the back burner. They don't do any hobbies for themselves, they really don't exercise. They're busy making everyone else's appointments, but not one for themselves. And so it's to have to for those moms to have a self, a safe place for some encouragement and just permission that they also need to prioritize themselves.

Grantley Martelly 49:50

Okay, so so the company is called Moms of Margin, the umbrella, but the podcast is the overachiever moms podcast. How'd you come up with that name?

Dr. Tiffani Thomas 50:01

So basically, I am an overachiever, and I feel like a lot of moms relate to that. They're they just think they can do it all. They think that they can just add on thing after thing, um, especially working moms. They're like, hey, I'm gonna have a kid, and then I'm going to be able to continue all of my old responsibilities, and I'm going to be able to do all these new responsibilities. And so they are for the most part able to do it because they stopped doing things for themselves. And so I'm like, hey, the the word that kind of describes that pretty much is just an overachiever. Like you were trying to meet everyone's needs. And so if moms can relate to that, um then pretty much they can relate to the podcast and what we talk about in the podcast.

Grantley Martelly 50:45

But don't you think that there's some mental and emotional challenges with feeling as though I have to do all of these things. And then when they're not doing them anymore, could there be sort of like a deficit that I'm not being a good mom because my checklist, my daily checklist just went from 25 items to 15?

Dr. Tiffani Thomas 51:08

Yes, yes, definitely. And because moms, a lot of times they believe that if they don't do it, then no one else will. And it has to get done. And so it's so a lot of it is just permission to say, hey, thank you, but no, thank you. Like I I have a full plate, and if I pick that up, something is gonna get dropped. And so having changing mom's viewpoint of their yeses and their no's. So whenever you say yes to something, you're actually saying no to something else. And so if you say yes, like yes, I can work late, then you're saying, no, I won't be home for dinner. And so if you can change your viewpoint, change your perspective on a lot of those things, yes, you'll still have some of the mom guilt. Yes, you'll feel bad for not doing everything, not being everywhere. But if you can change your viewpoint to what your priorities are and view it through the lens of your priorities, then a lot of times you'll feel better about those decisions. And you won't feel that you're necessarily dropping the ball or not meeting everyone's needs. You're just meeting the needs of those who are most important to you.

Grantley Martelly 52:23

So it's okay to say no, and it's okay to accept that some things that you were doing before may not get done.

Dr. Tiffani Thomas 52:33

Yes. And it's but mostly it's also important to accept help. Like there's no one gets a badge for doing it all by themselves, and and no one gets a badge for not asking for help. And so a lot of times, like there is a village around you and they will help you. But if you operate as if you don't need any help, um, then they aren't necessarily gonna offer it. But if you're like, hey, can you pick up Susie from Ballet? Um, a lot of times, especially grandmas, they would they would jump at the idea to go pick up one of their grandbabies. Um but if you just pretend like you have it all together all the time, then they might not uh know to offer the help.

Grantley Martelly 53:15

Yeah, that that's true. One of the things we talked about was you you spend some time on meal preparation and stuff like that. One of the things that takes up a lot of time that you're you're trying to help develop some tools to help mom simplify that in our closing moments. To talk a little bit about that aspect of it and and why you chose to focus on that aspect as well.

Dr. Tiffani Thomas 53:39

Yes. So one of the things that I find that I talked about a lot in my clinic was food. And food can be the answer to a lot of people's problems, especially even men who are dealing with high blood pressure, um, if they can decrease their salt intake, decrease the amount of red meat that they're eating. And a lot of effort goes into meal prep. Cooking the food, shopping for the food, chopping the vegetables, a lot of effort and time goes into that. And everybody's got to eat. And so if I could help moms spend less time in the kitchen cooking meals, then they could be, they could use that mental space and they could use that time for doing something more. And so if we can in chat, instead of you spending 30 minutes every single day in the kitchen, and we could spend one hour on Sunday and then maybe only need to spend 10 minutes in the kitchen, like that that time save that you could do, you could exercise. Uh maybe you go for a walk with your husband who has high blood pressure and he needs to exercise more. And so just creating that space and helping moms understand that if there's anything that you do every single day, a lot of times you can batch that into one day. And so allowing them to batch that meal prepping into one day allows them to to free up time, space for themselves, for those that they love, um, just so they can do it better and more effectively.

Grantley Martelly 55:08

So that's really interesting. So tell us, tell our listeners where you can find your podcast and how to get in touch with you.

Dr. Tiffani Thomas 55:17

So you can send me an email at momsofmargin at gmail.com, or you can follow me on Instagram at the Overachiever Mamas Podcast. And then my podcast is gonna be on Apple Podcasts as well as Spotify.

Grantley Martelly 55:33

Okay, we will we will also put that in the show notes. So as we wrap up here, what are three things that you want our listeners to take away from this discussion this morning?

Dr. Tiffani Thomas 55:43

So the first thing is that you can advocate for yourself. You can ask your doctor to, hey, if you get a denial from your insurance company, you can ask for a peer-to-peer. You can ask for an appeal. Like there are steps that you can take. Also, if you feel that, so that's the first thing. The second thing is if you feel that something was wrong, you can tell your insurance company about it and get them to look into it. It's not something you have to go through by yourself. It's not something that you have to think that you are all alone dealing with. You can ask your insurance, your insurance company to look into it. And the third thing is just figure out who in your community that you can partner with. Um, and so if it's just listening to a podcast to kind of decrease that stigma, um, get yourself more interested and decrease the amount of fear that you have about going to the doctor. And so we want to make sure that you are going to your primary care doctor, getting the preventative care, um, and knowing what all your options are, what your numbers are, and making sure that you're getting your lab work done.

Grantley Martelly 56:51

Thank you very much, Dr. Thomas, for joining us today. It's a very interesting discussion. I'm glad we met. And I look forward to our continuing discussion. Um, maybe we can exchange the favor with each other sometime in the future. But I wish you the best of luck in your business, mom's a margin, in your podcast, and also as you raise your family, because you're living the things that you're talking about. You're a mom of four and a business owner and an entrepreneur and a real estate investor and a wife, all of these things you're you're doing. So you're you're not talking from theory, you're actually living it. So thank you very much.

Dr. Tiffani Thomas 57:29

Thank you. Thank you so much for having me.

Grantley Martelly 57:33

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Grantley Martelly 57:50

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