บทถอดความฉบับเต็มของ 25 - Dr. Shannon Fox-Levine: Always the Chief Resident, Payment Reform, and Pediatric Advocacy

Dr. Shannon Fox-Levine: No, as a teenager. That was my plan. And so then I was like, Well, I guess I am top of my class of high school. I probably should go to college. So I went to college. Chip Hart: Okay, so some parts I had that you didn't have Dr. Shannon Fox-Levine: Went to college as a criminology major, but that only that was very short lived. And then I was taking science classes because I love them. And so I was like, I should be a science teacher. So then I signed up to be in the education department, University of Maryland, go Terps. And my junior year I had to take a test to be like accepted into the education college. And it was like such an easy test and everybody was like stressed over this test. And I just thought like I'm getting straight A's in college. If this is like an easy test, is there something else I'm supposed to be doing here? And then the next semester, I took a histology class and it was one of the first classes that there were only twenty five people in the class and they were all pre-med, but me. And so, and I was finally like with my people, like we were talking the same language kind of thing. So then I was like, I guess I'm supposed to go to medical school. Why not? And so I took a gap year because I was late in the whole process and then went to the University of Maryland for medical school also in Baltimore. And my third year of clinical rotations back in those days, it was, you know, the first two years is very much like you're in a classroom, you know, big lecture hall. And then the next two years is your clinicals. And my first year of clinicals, I started with psychiatry, thought I wanted to be a psychiatrist. I'm still surprised to this day I didn't really stick with that. Because I do love that so much. But then every rotation I did, I just loved. I I'm that person. Like I'm that one that I love school. I loved every rotation I did except orthopedic surgery. That was barbaric. I don't know. I don't know how these those people do what they do. But then pediatrics was my last rotation. So I'm like, well, here I am. I've loved everything. I guess this is it. Chip Hart: They've been in a different order. You could be a radiologist right now. Dr. Shannon Fox-Levine: I could have been I don't think a radiologist. I like to deal with the people. The people. Yeah. So that's how I decided to be a pediatrician and went to NYU Bellevue Hospital for my residency where I met all those great people. That was the best time of my life. Chip Hart: First like up north. Yeah. You came back Dr. Shannon Fox-Levine: I came down but I've been around 'cause my dad was in the military. So I had lived in Florida anyway. So but I loved residency so much. so after the first few months really of residency, they were already starting to say, like, Well, we'll want you to stay for a chief resident year too. So I did actually four years instead of three, because I was a chief resident also. And I always say I'm a chief resident forever 'cause that's essentially Chip Hart: Everyone I know who did it is says that. Yeah, forever. I think there is a common thread that runs among camp counselors, chief residents, and lifeguards. Once you're a lifeguard, you're always a lifeguard. Dr. Shannon Fox-Levine: Just always looking out for everybody. Chip Hart: We talked about this event earlier. I remember when we were at Women in Pediatrics and we went on the sailing trip and I was standing up on top looking around and I don't who else it might been. Probably Andrew. All right. But I'm looking, I was Were you lifeguard? He's like, Yeah, and he's seven, seven. Like you you just count heads. It's in your you just constantly are looking. Today, go over at the beach club. There was a kid doing the dead man's float in the pool, and I had to wait for him to move his body before I kept going. It's not it's not heroic. You just it gets part of your routine and yeah. I see kids in a pool I I count. Dr. Shannon Fox-Levine: And as a chief resident in pediatrics, you fight for pediatricians for the rest of your career. And so that's basically what I do. I mean that's at the core of what I do every day is yes, I take care of kids. I take care of families. Right. That's where my my goal in my career is, my mission, what drives me is to make pediatricians be able to do what they do and be proud of what they do and you know, try to help with the moral injury that's constantly around us. especially in our state here in Florida, where, you know, it's it's so interesting how as pediatricians, we have to rise up to that plate to be at bat so often to like fight. And that is not our nature. Like our it's the antithesis of who we are. We're like lovers. Like we just want to hug everybody. But we're not, you know, like there are certain occupations that that train you for this, like being a lawyer. You fight every day, all day. Like Chip Hart: You look for chances. Yeah. Pediatricians. You're not confrontational. Dr. Shannon Fox-Levine: You wanna argue with everybody. So moral injury at I mean, you can't the the I don't think there's another career that really puts you in this situation. So how do we prevent that? How do we help our peers? How do we keep them going? And you know, my thing is always just like take one thing. Like don't feel like you have to solve, you know, the whole world's problems in pediatrics, you know. Don't, you know The smallest thing because that we're all in this together. So if we all have our little like lane that we're trying to do things, then in the end the total sum is the teamwork that goes into it. So Chip Hart: agree more. Well you're getting this is already philosophical. Usually like right now people people we're reminiscing totally over the first time we met. Like, well those are the those are the good old days. Remember that? Dr. Shannon Fox-Levine: Already got that question wrong though, so we I think we just had to move on. Chip Hart: I will say I will say when we

went to sushi tha I think that was the first time I was able to find out if I like I was able to find out if I would get along with you. Not that I'd expected not to, but like I don't Dr. Shannon Fox-Levine: You 'cause you had heard so much about me. I Chip Hart: I had heard Dr. Shannon Fox-Levine: remember you saying, Chip Hart: all your friends were pointing at you saying, You should talk to her, you should talk to her. And I'm She doesn't want to talk to me. And then you did. And so that was that. Also, I f I find it interesting when I asked the question, when did people learn they wanted to be a pediatrician? There's no pattern. I've gotten people who said I was born knowing that that's what I wanted to do, people who are like, it was in my rotations. It was I mean I've had some really funny answers and I have to admit that I expected more people to say to me, I kind of knew it when I was fifteen or something and that's not a common answer. Dr. Shannon Fox-Levine: It's interesting. Yeah, that is interesting. I mean, I think for me it was the teaching part. That is the commonality though. Like because we as pediatricians, we educate all day, every day, meet everyone where they're at, you know, to try to walk in a room and in two seconds be able to know your audience and how are you gonna sell what you need to sell. Chip Hart: I have so many people when I talk to them about being on podcasts, or when I say to them, you need to be in your local media. You need to call, become friends with your local news people. And they're like, I can't talk on TV. I'm like, you have no idea how good you are. You every pediatrician gives sound bites like a superhuman. And you do it in a calm, friendly, you know, understandable way. And you and because you've done it how many times? A hundred thousand? Dr. Shannon Fox-Levine: Yeah. Well, and you know, during the pandemic I was on the news a lot. Right. And that's what people would always say when they would say that they saw me on the news is they they like the way that I just identified also as a mother. You know, to say, Well, as a mother, this is I always think to myself, I don't want it to be my kid that doesn't get or that gets this illness because they didn't get the vaccine. Right. So, you know, that I just want to make sure I protect my children. And it really is. And I think as pediatricians that it tends to be like by nature, again, we're just real people. Also. I mean, all of the pediatricians I know are that way. That we just really kind of speak from the heart and, you know, we we will offer to say, Well, if it were my child, I would do this where But but I it's it you know, it's one of those things that if we offer, if it was my child, I would do I would go see this specialist where I have to ask doctors, like, well if it were you, what would you do here? And but we just offer that. Chip Hart: All right. Tell me what you're up to lately. So I when when I first met you, you were a partner in a practice. And then that practice has evolved substantially, but that is only part of what you do in your I don't know day to day week week to week. So tell me about your practice because people always want to understand like, what does it mean to be in practice in Florida? Tell me about your practice, but then I also want to hear about the Stuff you do with the academy and so forth. Dr. Shannon Fox-Levine: My practice was Palm Beach Pediatrics, 40 year old practice started by my partner who retired in 2014. We were were in Palm Beach County, three practice sites really since I started twenty-three years ago. We had the same general locations. We moved each office three times in the last twenty-three years, though, which was quite interesting. But believe me, it was worth it every time. And the three we have now are amazing sites and You know, we kind of branded them really nicely. And I'm very proud of the three locations that we have. So I was a partner for twenty I've been there for twenty-three years, partner for probably twenty-one years, I guess, two years after I started. I only had I had three partners initially, then one left shortly after I became a partner, and then the other two left only from retirement. And 20,000 patients-ish, at any point in time, 10 to 15 providers, a mental health program at one point that we really had up and running before the pandemic, and then started to kind of come off the wheels just because it was hard to get paid for the mental health staff that we had. So now we have a psychiatric nurse practitioner, which has been a huge win. Like we've had her now since 2021. She's amazing. She practices like I practice. So it's not like she's doing things that make us a little uncomfortable under our umbrella. I've always called us a buy the book practice. And the book to me is bright futures. So Chip Hart: You're making my Dr. Shannon Fox-Levine: I am a bright well, I'm a bright futures editor right now too, by the way. So that's one of the things we can l add to the list a little bit later. But I that's what we've said. I've said it, and then everybody has followed for many years. So if there is a bright futures recommendation, we do it. Patient Center Medical Home, when that started. We in Florida ten years ago, I was it'll be hard for me to kind of keep practice separate from all the other stuff I do. Chip Hart: That's okay. Dr. Shannon Fox-Levine: flow a little bit here. So ten years ago we had the Medicaid Medicare Parity lawsuit that we won. And so there was an the five year agreement where ACA, the state of Florida Medicaid, had to start paying pediatricians at the Medicare rates, which turned into like an incentive program. That's how we're paid the additional amount. But we needed a plan to do that. And so our pediatric council at the time, I was the chairperson, we developed a strategy for patient-centered medical homes to qualify. So we actually were getting something for all of us that had gone through

patient-centered medical home prior to that, something in return. Plus, it patient-centered medical home, we were actually showing, like we are doing all these things for patients as a medical home. In addition, the other qualities though that you could be able to get those incentives were, you know, there were certain HEDIS measures that they would go by as well, because not everybody was patient-centered medical home. For the Patient-centered medical home, you could qualify. And then these hedis measures because patient-centered medical home, we realized was expensive for small practices to try to figure out how to apply for. We were fortunate enough as a big practice to be able to pay somebody to help us. The Verdin Group helped us. They were amazing to get us recognized. And so that was one of those things that's like the buy the book concept that actually turned into. Money for us. You know, real money. It was real money. We were, you know, part of that whole rollout and Chip Hart: I remember when that happened and on one hand it was kind of unbelievable. You're like, wait a minute, they're gonna play pay parody in Florida? And then you do the math, and then everyone freaked out because no one wanted to do PCMH because it looked so hard. Right. It was annoying. And then I would say, look back at the money again. Yeah. And then look at it, like Dr. Shannon Fox-Levine: We did because we did get that as one of those requirements, we were able to get United Healthcare to give us a three hundred thousand dollar grant for pediatricians as a stipend to get so many hours with now Amanda Ross, who's the person for Florida first PCMH. So that was all during that time. And so again, that that was kind of like what our practice is based on, right? So that's why I'm telling you this story is that we have this foundation of patient center medical home, bright futures, again, integrative care, not the best. We don't have our own mental health, like licensed mental health team, but we have the medical part. Chip Hart: That's not easy. Everyone w everyone would if they could. Dr. Shannon Fox-Levine: And that's the thing is we have the we have the prescribing part. And what we've done in the last few years is I've partnered with a nonprofit, the Center for Child Counseling that is integrated in our EMR. So we can internally refer our patients to them through our EML. They have the chart. They can kind of see what we're talking about. They have all the demographics. They can put their notes in the chart. We can chat through our, you know, chat in our EMR. So we have something that works, but In the end, you know, it was really hard with mental health to be able to do that our all of ourselves. So all of that to be said, fast forward then to twenty twenty three when because of everything that we've done, our practice actually won an award, PCC award. Chip Hart: Not us. Dr. Shannon Fox-Levine: is short short for the primary care collaborative. Chip Hart: Yes. You guys won that award? Dr. Shannon Fox-Levine: Yes, we did. Okay. Yeah. I don't know. Chip Hart: We're we're like on we are we're one of their sponsors. We're like the only Yeah. all I've at one point, as far as I'm concerned, we were the only pediatric voice among their I don't even know what to call us, like their vendor sponsor. They would they would have all this stuff. There's Medicare based, Medicare based, Medicare based, and I would say that's all great. None of this affects the pediatricians. Right. Because you're pushing for all this legislation and unless it says and Medicaid or it talks about Medicare parity. It doesn't hit this huge batch of and yes, I know the primary care collective well because they share a acronym and we had to have a conversation about that. Dr. Shannon Fox-Levine: Great. I was gonna say it is always funny when you say PCC because to me there I have two distinct meanings for for that. So so we won that award in in tw 2023 because of all this that we had been doing and even the PCMH, because they're very much that's you know one of their primary focuses with NCQA. And so that I feel like kind of like put this huge bow on what we had been working so hard for so many years. at that point I had no partners. I own the practice myself for three years at that point. My my last partner, the pandemic started and he was like, Good luck. so I had to get through the pandemic on my own as a sole owner of, you know, kind of a a monster of a practice at that point, trying to navigate a pandemic, which we actually did very well because we had three offices. We were very creative. We had drive out yeah, we had one office was our sick, two were our well. And then we had it we had the very first COVID vaccine in the area from the health department to give to adults because it wasn't approved for the kids yet. And so that's when we created our outdoor parking lot drive through clinics. And that was a huge success. And then that turned into our flu clinics and because we're in Florida, so we could do it kind of all year if we need to. And so all that then Again, big bow. And then I started to get, you know, you're a sole owner. We would love to talk to you about selling your practice to us. And I never thought I would sell my practice. I mean, I I I think even you guys, when you visited us that one time, called me something independent, like like ferociously fiercely, fiercely independent, fiercely independent. I was always fiercely independent. I mean, it's just by nature who I am, fiercely independent. So I never thought I would entertain it, but I had a consultant who was helping me. And he was kind of saying, Well, you know, you have to look at the future here and what realistically is this future and is there something you can do? And so my whole mindset was, can I do something to make this even better than what it already is and not have the weight of it on my own? And I wanted to grow. I wanted to open new offices. I just

didn't have that in me. I honestly didn't. Many people do and you know, it's they're wonderful for doing that, but I didn't have it in me. Chip Hart: You didn't have partners. Dr. Shannon Fox-Levine: I didn't. I and I had the finances even. I could have done it financially, but I didn't even have that I didn't have the the I don't know, the mental energy to try to figure out how to do it. And I all I could think of is Sugar A. Leonard of all crazy things, you know, like how he was this amazing boxer. And I always remember my mom being so disappointed that he retired, but then he came back. To box and he lost a fight or something. And she was like, he should have never gone back in the ring. He was past his time, you know. So I kept thinking, Am I kind of at that point where I should say, all right, now it's time. I've got the big bow here. I've done all these things. How can I like just step into a different path? And so I can leave this how it was, like this amazing thing, and like just make it turn into something different at this point. Chip Hart: I have to say though, I wasn't expecting a sugar rayliner an analogy. Dr. Shannon Fox-Levine: I know, but I've now I go to like more Oprah. I feel more like Oprah now. That's that's my new that's my new Chip Hart: Well, I was Sugar Ray Leonard. Okay. Dr. Shannon Fox-Levine: Yeah. And again, it was because he, you know, like he maybe should have just stayed where he was, closed things down, stayed out of the game and just right. So like that stayed out of the game of trying to do anything, just and then let everything fizzle out eventually because I didn't have anybody that had any interest in taking the practice over and I'm not gonna do this forever. So So I met my future I mean, we courted is what we say. It's like we truly got married. my future partner who at the time there there was no existing Bluebird Kids Health. It was our CEO, Chris Johnson, who was being brought on by a firm that had the idea value-based care. And that was something else I forgot to mention along the way, we also really did very well with in our state. and that really because we are everything else, buy the book, patient center, medical home, you know, like we can do value based care very, very nicely to make it financially amazing for, you know, our practice. So which is pretty incredible how much money the plans make. That's what I learned from all of that. Like when you have a shared risk plan and you're getting half of it, I'm like, my gosh. Like this is what they all were just taking before. Chip Hart: Feeling guilty about the money you get, they're making so much more every time. Dr. Shannon Fox-Levine: And I never, and you had said that, but I never had really known that for sure until our shared risk plan. And then that was like, wow, this is now obvious. So again, to work with someone who had all of this by textbook knowledge, right? Like that's what they had developed this plan from is like we know how these plans work in Florida. And so we want to be able to work with a pro with a practice that already has some of this where we can help. capitalize on it, but really ultimately for the greater good, you know, for kids. And so I started talking to him. And yes, he finally convinced me that this was the way to Chip Hart: Or you know. Dr. Shannon Fox-Levine: he wore me down. And it really was because it's so unique. You know, it was not buying other practices. It wasn't us joining somebody. It was we are the foundation. So I felt like this is this is really what I wanted. It's just that I'm not going to have to do it. And that's essentially what it's been, you know, it's Our foundation, everyone new that comes to a brand new site. We've opened now two, three, four. And this next few months, we have another three. By January, we'll have another three. But everyone comes to us to train first. They learn from us, and then we take them to the new locations. And it's been really great to see, like again, our foundation. And I'll just say one quick story that really kind of Brought this now full circle to me. And I was like, yes, okay, this is exactly what I wanted. Was we, so we're in Palm Beach County. Broward County is south of us. Our latest office is in a place called Coconut Creek, which is just it's on the northern end of Broward County. So from our West Palm Beach office, it's probably maybe it's an hour, you know, with traffic and everything, maybe 45 minutes. And the first day it opened, I was seeing patients in the office. As a physician with a schedule, new patients coming in and a family of three. Two of the kids I was seeing in the morning, the third teenager I was seeing in the afternoon by herself 'cause she was a teenager. She wanted her own time. And I was seeing the two younger kids in the morning and and as a new office, we give us plenty of time because this is all everything's new. Everyone's new working there, first of all. And then all the patients are new. So you have all the new patient paperwork, which we're definitely perfecting also along the way, being a bigger team now to be able to do that. And so we have like a half an hour feed. So I was with this family for an hour, you know, just talking to them, getting to know them, doing as much documenting as I can do for, you know, past medical history, whatever. And as we're getting along in the visit, the mom, she says, I'm just so glad you're here now. And I said, well, you know, we're glad we're here too. I said, but you know, it it looks like your kids were getting great care here before. And she said, yes, they were. But I really, you know, wasn't ever so happy with it. It was just because that's all we had in this area. And, you know, they were down the street from us, but now you're down the street for us and we can come here instead. And so I'm kind of thinking like, she must like me. And that's kind of why she's so happy, you know, that she's they're here and we're here now

down the street. Right. And I was like, that's so good to hear. She was like, because I bring my 18 year old to you. And I was like, You do, your eighteen year old? 'Cause the the one in the afternoon's thirteen. So I'm thinking eighteen year old. She said, Yeah, I have a fourth child. He's eighteen, but he has special needs. So I take him to Palm Beach Pediatrics in West Palm Beach. And the other three kids are healthy. So I just take care of them here. And so I never had the a pediatrician locally that I really wanted to see. But that special needs kid, I had to drive him up and see Dr. Kuiper's at your West Palm Beach office. And I was like, okay, this is what we're doing. Cause this is the exact mission of what I wanted to do is take our care coordinate coordinator model, which is also what won us the word at PCC, because our care coordinators are kind of like our hub. And we do complex care very well. And she, this mom was the perfect example of that. That she not only wanted to make sure that her 18 year old could still, you know, go up to that office and see Dr. Kuiper's, which I said, of course. But she wanted to make sure that Carol, Holly, and Lisa, the care coordinators and the triage nurse at Palm Beach Pediatrics of old were still going to be able to help her. And I was like, of course, we're all just one team. I said, it's just that we have a local office now that you can bring the other kids to. So that was like, again, a another bow, you know, the cherry on top type of thing that it made me feel like, okay, this is exactly what we wanted. So It is our model. It's our we have a an admin office that we've had for a long time, a call center, that has had our care coordinators, our triage nurses, any management that was in that location. Now it's exploded. It's twice the size. It's still the hub for Florida, even though we have Jacksonville offices and Broward and Orlando to open the start of the year, end of this year, start of next year. And so that's gonna be our our main admin office and that's where that care coordination happens, which to me, you know, the calls are the most important thing. Coming in, going out, all of that, you know, warm handoffs to whatever we need to do. So so that's kind of the story of where I am now. I'm the medical director for South Florida, but I I feel like it's gonna get too big too fast. And I I'm the type of person I don't like to do things unless I feel like I can really dedicate time and do them well. So I think I'm gonna pair back to Palm Beach County again, which are As I say, it's the OGs. The OGs. I mean, it's all a know, I've worked with people. We have a a nurse who's been with us for 30 years, who's still with us. We didn't get rid of any staff. The staff that are have left have left on their own, but that took a while. Like some after two years are like, I'm gonna go do something different now. I have a nurse practitioner who I work with on a daily basis. She's been with us for twenty five years. You know, the docs I work with in my location twenty years. 19 years. So we've all worked together for so long. So I think because of all the other hats I wear in my in my advocacy world, that I feel like I just it's time for me now to kind of step back and just focus on my local, but then be able to do more of the all the other stuff that I do. And the other stuff is. For the Florida chapter, I'm on the board of directors. So I'm a regional representative for our state. But also I do other things. You know, I just gave a lecture about autism screening and testing. So how we started a pilot program a year and a half ago on how to actually diagnose autism in the primary care setting and how to so my three things, of course, because of my payment background were how how to do it in a timely fashion because we know time is money, how to bill for it correctly to get paid for it. So how are we going to watch those claims and make sure we get paid appropriately? So what codes are we using? This was all new language to me that we had to learn because there was a code that we've never I didn't know existed that I had to know about. 96112, it's called it's it's the testing code for up to 60 minutes. So that's your the two tests that we use for autism. and then lastly, is everyone gonna like respect what we've just done? And it's not all for naught that we just diagnosed this kid with autism. The family went through these two 30 minute visits, which is all it takes, and we've given them a diagnosis, but now they take their little paper to the ABA company who like laughs them out of the place because you know, they don't they don't respect what we've done. So we proved it all. We did it. So again, that was the Florida chapter of the AAP. We have an autism task force, so I'm part of that task force. And so this was my kind of like contribution. to a task force that's mostly the developmental behavioral pediatricians, child psychiatrists is on there. The ABA specialist, like their organization is on there. But my contribution was like, okay, but in primary care, how can we get these kids? 18 months to 36 months. We're not talking 10 year olds here. We're talking just those obvious walk-in-the-room. We know it, the mom knows it. We just need something. Chip Hart: Yeah. Now you you just did say something subtly that you blew by. when you said, Well, with my payment background, you have y explain your payment background. Dr. Shannon Fox-Levine: So payment background is starting pediatric council in the state of Florida, or I was starting with that. It had already existed in the past. I revitalized it. That was with the Medicaid, Medicare parity lawsuit transition. So that was, you know, I was the chair of that at the time, which was a really cool days where the plans would come and meet with us too. It was a lot of fun. I was just telling the local sunshine health, which is one of our Medicaid plans about that. And she was like, we would do that. I'm

like, okay, well, next year we're gonna try to do that again. So Pediatric Council that then morphed into payer advocacy advisory committee for the AAP. And I'm the chairperson for that. I've been on that for now two or three years. And it's all things payment basically in pediatric. Chip Hart: Lot of our friends. Dr. Shannon Fox-Levine: It is. Yeah. It is. And it's SOPA and PAC are kind of like married, you know, like Chip Hart: Well we should not on the other. Dr. Shannon Fox-Levine: Yeah, exactly. We go back and forth and we, you know, those of us on PAC are on soap looking at stuff on soap all the time and seeing what we need to help our colleagues on soap with because ultimately we are the ones that meet with the payers. Yep. So we meet quarterly with the payers, all of them really. There's some that are a little bit different kind of meetings, where just more f you know, more informal, but with the big payers, Aetna. Blue Cross is only one we struggle with, but we ha it's elevants. Elevance is like kind of all of that, right? So we do have Elevance. Cygna and United Healthcare we meet with Centine and Melina. And then Tricare, we have the connection, Christoph Diassio. He's yeah, he's on my I have a team of superheroes actually, to be honest, on the pack committee right now. So it's pretty amazing group of people. Chip Hart: We just did the Academy just asked us to do some analysis of down coding claims. Yeah. And it's a fascinating thing to see. One of the things we discovered was that some of the payers with a consistent pattern are not coding those electronic ERAs properly and they're dropping in a field that is supposed to be for the adjudicated code. They're dropping in other information and technically. That's a HIPAA violation. And so even though it's not in some places it's affecting things a lot, but when you you go in, it's like doing an MRI of someone looking for X and finding a tumor. Like we were going in to look f for this down coding and we see this huge problem over here. And it was Nita Mohanti who's like, we're gonna come back to that. And so I was like, We're right here and we just we just sent them a few hundred thousand lines of payment data. That's a n to say like, Hey, you you know you can Kung Fu this any way you want and figure out which payers are causing the problems, who's reporting it properly. Because one of the things we found was in the down coding. I'm like, I'm not here to defend the payers as you know well, but it looks like when they said very few people will be affected by when they made those national announcements. It's true. Very few people were affected. And overwhelmingly, not exclusively, the people who are affected were people who are using the lower resolution. ICD 10 code. So if you just put OTUS, you're getting zapped. So it was largely, I'm like, I can't argue with them too much about that. But, but a lot of them weren't indicating that they were down coding with cart codes. There are other ways to do it too, but a cart code would appear right there in front of you as a biller. You if it said this code was adjudicated and said you have to look at the original claim and then what they're paying. And I'm like, that's a real problem. They're trying to sneak it by you. Dr. Shannon Fox-Levine: Nina Mahanti has been an amazing Chip Hart: Amazing. Yeah, li I like working with her and everyone I talk to at the Academy is like, my god, we've needed her all this time. Dr. Shannon Fox-Levine: She's amazing. She really is. I mean, every I feel like everything is coming together at the right time. And she's a huge part of that. Eric Lenzo also, who you know, works closely with her. Megan Roop, who is my the staff person for our committee, they're just yeah, they're amazing. And you know, when when people say, Well, we pay this dues to the AAP, what do we get from this? I'll say this is what you get is you get people who are truly advocating who are and not us, like we're volunteers, you know, we're just kind of like, you know, that we're the eye candy, you know, like the the smart people behind it all are like the ones that are really running the show here. But it's that what you get is well, you get the transparency data. Right. I mean, how else are you gonna get that? Like And if you don't use it, that's on you. And if you don't like it, well, tell us because we are constantly working on that and trying to help pediatricians navigate it so that if there's codes on there, you know, that they feel like aren't, you know, really representative of what they do, then let us know. Chip Hart: I after years of being off of it, I went back to Reddit because I was just reading things and I I had never back when I would re read it, I never looked at the pediatrics channel. And I s I one day I flipped in there and there was something about private practice. And I'm like, Well, I know the answer to this question and then just and I started answering stuff. And at some point someone said, Are you chip heart? and I was like, no, it's that obvious just because I was referring to data that it that had was out. It would be obvious there. But last week, two weeks ago, there was someone had posted, The AAP hasn't done anything for me for years. And I was like, Well, I understand. Like I'm not I I'm not an AAP member. I can't be. I'm a I'm like all of us at PCC. We're all outside of it. So we have a different perspective. And you know, I can tell you as someone who was somewhat actively separated from the AEP for a long time. Like they We weren't really welcome, our perspective, the perspective that PAC is really starting to understand. And I said, The AAP today is not the AAP from twenty years ago. And hey, if you want a list of the things that the AAP has done for you lately, look here, here, here, here, here, and here. I can point at the revenue per visit and in particular, I can point at the RVUs per visit of a pediatric practice over time and I can point at

the year. The Im's admins got picked up because it made a huge difference. I mean, literally, I'm saying this off the top of my head, but I think the average RVUs per visit over the last 20 years in pediatrics have doubled. And RVUs are not something that are inflation affected. All right, because it's all relative and it's an all-zero sum game. Okay. It's not like It's not like they've doubled the RVUs because inflation has doubled. That's not how it works. And so you can look at it and I'm like, that is a direct result of a massive amount of work by people at the academy. And everyone and in I was like, look, and in 2001, when the ENMs went up by 25%. All right. That was a very specific intent. Or the the intent was specifically from the Fed was to move that money from the specialties and the proceduralists to primary care. Like that's a massive in improvement. When the the IMS the new IMS admins without admin, like that stuff, the Academy would have never promoted something like that. Dr. Shannon Fox-Levine: And even the G twenty two eleven we've had it push and push and another letter to payers that we just had come out, you know, it's like we're not giving up, we're hanging in there and maybe it'll evolve for twenty twenty seven, but for right now we're in twenty twenty six and we need to keep doing what Chip Hart: And doing. And so many of the people who are saying, What has the Academy done for lately? They're not building the G2211. When their only job when that code came out was to build that code. That's your only job. Maybe get some money from it, but create a united front for all pediatricians to say to the payers real code, real our views, real money. And let's recognize what the G two two one explains. It's better to see your primary care physician who has a holistic narrative view. of your of your history than to go for to this minute clinic, to this minute clinic, to this minute clinic and end up in the ER. Right. And and what's a G2211? Fifteen bucks? That's what we're arguing about. Yeah. And where and so in that first year or last year, whatever it was, when Medicare spent four hundred million dollars on that couped, who got the money? Mostly specialists. And you're like, and at the Academy, well, I the Academy has imperfections and Any organization of that size and breadth of opinion is going to have problems. But I'm one of the people, because I'm on the outside of the academy, who appreciates the fact that the academy still puts the kids first. I understand the interest that many pediatricians have in an organization that puts the pediatricians first. I do believe in a the ness the necessity of a pediatric union, let's just call it broadly. But a an organization that puts the kids first, especially in twenty twenty six, I think that's that's the different that's why I like working with pediatricians. Because we can all say, Hey, look, we might differ here, but this vaccine in front of me, this child in front of me, that's more important. And Dr. Shannon Fox-Levine: And that's the other thing, you know, that I feel like the AAP has really changed over the years because we're like again, the first at the plate with the bat right going after these issues, these big issues. And then we're getting the others to come along with us. And so, you know, the lawsuit against the C D C that's a great example. It's like, you know, we so many people out there like we're gonna sue this the government. Chip Hart: So many people said, Why are we suing the C D C this is a waste of time? I'm like, are you not the same people who complain that the AP doesn't do something? This is exactly what they should be. If who who should be suing them first? Dr. Shannon Fox-Levine: The AP. And again, this is them standing up for us as I going back to what I was talking about earlier with moral injury. Like that's, you know, vaccines are our core. Right. They're our core. And I'm not going to say they're they're our core beliefs, because belief to me is like a, you know, like a religion or, you know, it's our core base of data and science and research to be able to keep kids healthy. Right. And we're being attacked. at our core with these vaccines. And so the AAP stood up to that on our behalf. Like we didn't have to all be do Chip Hart: I would say your core belief is that certain diseases are preventable. That's your core belief. And that preventing those diseases is your obligation. If someone came along, this isn't gonna happen, but if if RFK came along and actually showed that vitamin A can prevent measles, if the science showed vitamin A prevent measles, we'd all say, like, awesome. Like, don't wing take drop one of the M's from the MMR. We know that's not gonna happen, but it's you don't care about the MMR. You care about not getting measles. And that's something that people don't understand. Right. Like you would stop giving vaccines in a heartbeat if those if we could actually eradicate polio, you would never give a polio shot again. Dr. Shannon Fox-Levine: I I say it every day that I say to families, it's kind of crazy that I went into a career that I make babies cry every day. Like I make them cry. They're laying here crying and it and I actually feel good about it because I know I'm keeping them healthy. but we that's what we do around here is we make everybody cry. But in the end, it's because of that fact that this is for the greater good. Like they they're we're gonna keep Chip Hart: I realized I think I was talking to Christoph when I said this. One of the differences a pediatrician faces other the relative to other specialties is if when you're an orthopedic surgeon, you know exactly who you're helping and who you're saving. When you're a radiologist, you know exactly who you're helping and who you're saving. Endocrine, whatever. When you're a pediatrician, you don't know who you're helping. Yes, the child in front of you. But when you give that vaccine to that child, you don't

know how many other children you're helping. You don't know how many grandparents you're helping. And the the impact of that is it's different. And the fa the fact that you are willing to do it on the promise of preventing problems, as opposed to the other specialties who get immediate gratification and consider themselves heroic for it. When you're like, Well, actually, the science also says keeping a million people from dying every year from preventable diseases or this particular disease, that that's It's a different beast and that's right. Dr. Shannon Fox-Levine: Well, and the the hardest part of that is we aren't dealing with the patient themselves for that consent. We have to go through some other people to get that ability. Crazy. And well and and that's the thing. And well, you know, crazy but also just misguided. You know, now in in our state and and locally, we have patients who are not getting the PKU, like the newborn screening test. So that we now we have vitamin K, the newborn screening test, and the hepatitis B that they they don't want. And we're like, why would you not get the the blood test? I don't understand why you don't want a blood test. Chip Hart: Not heard the PKU one. Dr. Shannon Fox-Levine: No, these are and again, these are things because people are being misguided. Social media, they're on, you know, TikTok, they're watching things on TikTok and they're coming to us and it's really changed the way we practice because they're coming to us with information about things that we don't really No, but we also don't know how to counter, you know, because we're not sure what they're looking at. So I I will say to them, well, can you show me, you know, I had a teenager the other day who was talking to me about some type of testosterone injections. And I'm like, what are you doing? I mean, he was like, no, because I had it on this TikTok. I was like, my gosh, can you show me what you're looking at? Chip Hart: And can you tell your parents to take your phone away from you? Dr. Shannon Fox-Levine: Yeah, but or the parents can't shouldn't have their own phones because they're the ones looking at all this stuff and then making these decisions for their children that it's it's so misguided. And, you know, I my hope is always that they build trust in us and they eventually listen to us. But we don't accept anyone in our practice practice that comes in and says we're not doing any vaccines. we just don't wanna really put the risk of our other patients. In our waiting rooms, you know, there that because of these people don't want vaccines, but also it's again the moral injury c concept, right? If they're not gonna listen to us about what we think is the most critical thing for their child, what else what else what are they gonna listen to? What are they gonna listen to? What are they gonna even do that? Chip Hart: gonna not if they don't trust you, that's not a relationship. Yeah, I I used to feel I used to feel like I I'm because I like to convince people, or it's just my nature. And I always thought, like, if I were a pediatrician, I would I would take nonvaxxers because I would wear them down. But when that Bob Sears outbreak happened and two of the kids who got measles were in the waiting room for their one year visit, I was like it's not about that kid who isn't getting the vaccine. It's about the kids who haven't gotten the vaccine or who can't. I have a friend who I grew up on with we did swim team together and he was famous ten years ago, because I looked it up the other day. He got famous ten years ago because he sued the California state system because his son with leukemia or something couldn't go to school. And he's like, I I believe that we should not allow these unvaccinated kids into the classroom because it's dangerous for my why does my kid have to suffer because you don't you don't want to vaccinate? And I'm like, that's a really hard question for people to answer. And he that was in twenty fifteen. And I'm like those lawsuits have to come back. Dr. Shannon Fox-Levine: I mean, and it's so hard because there's so many correlations with other things. You can't drive drunk. I don't care if you drive drunk and hurt yourself. But Chip Hart: So Dr. Shannon Fox-Levine: but y it's against the law because you could h hurt other people. Right. Right. So like that's the concept is like this is community. We live in community. We don't live out in the middle of nowhere in, you know, North Dakota all Chip Hart: Your actions have consequences, and that's the issue. All right. New set of questions. as a pediatrician, what's keeping you up at night? Dr. Shannon Fox-Levine: fact that our payment for what we do is the least of any specialty, but yet the the work that we put into what we do is I would argue more than many of the specialties. And I just feel like it's it's unfair. I'm just I worry that people aren't gonna want to go into pediatrics because this is the buzz. It's been the buzz for a while. And yes, none of us go into this for the money, by the way. That's just not our nature. Chip Hart: Absolutely. But you need you you the people coming into it need to be able to pay their school loans. Dr. Shannon Fox-Levine: And it's just unfair, period. I mean, why why does this happen? And why it happens is because we have these separate systems of Medicare, Medicaid. Medicare is very different, you know, and and I think if there's some way and you know, the hope is that there is some way to make this just a better system for kids. And for ultimately pediatricians, you know. That Chip Hart: I think if kids voted, the Medicaid problem would get fixed and then and then a lot of this would go away. A lot of p I would say the overwhelming majority of pediatricians, if Medicaid paid Medicare rates, they wouldn't know what to do with all the money. And and people in our world understand when I say do with all the money, it means like they just now would it would be approaching

fair. I'm not saying pediatricians get rich. It's they don't I don't think civilians understand how little money there is That goes to the doctors. Dr. Shannon Fox-Levine: Exactly. Exactly. And and we're doing that work every day. And, you know, the the summers get harder and harder for us because of this is no longer you know, we we've we've got all these amazing vaccines for all the illness out there. So we see very little true like sickness. And so our I I call them our well sick, you know, like we see our We fill in our sick visits with our well kids that have chronic conditions. And it's all behaviour and so even those checkups are all behavioral health. Chip Hart: Behavioral health is sticky work that does you don't get the same satisf you don't get the same immediate satisfaction. You can't fix it. You don't come you you don't have a kid walk out of a room saying, All right, I don't have to worry about him. 'Cause it just doesn't happen on that behavioral health. Dr. Shannon Fox-Levine: And it's time consuming. Chip Hart: Right. And heavy. Right. It's not like it's not like popping a kid's elbow 'cause that's that's like a magic trick. Right. And but you can't pop a kid's brain and Maybe someday. Maybe someday. But that's that's hard. The behavioral health stuff is hard and heavy and Dr. Shannon Fox-Levine: And it's commonplace now. it's you know, and and yes, it is because we're asking, but we need to be asking and we probably should have always been asking. So it was probably always there. We just didn't know because, you know, I didn't fill out a Ph Q when I was a kid. Chip Hart: It was it was always there. It's definitely worse. I think I don't know. I I you know, I grew up in the seventies, like you, and the strong ones lived. That's what happened. Resilient Resilient. Dr. Shannon Fox-Levine: Yeah. Chip Hart: And you didn't think you didn't Yeah. Kids kids are shockingly resilient and pliable, but right now they worry because we worry. That's why I'm that's my extension. So as a pediatrician though, what are you looking forward to? What excites you? What's gonna make you work for another twenty years? Dr. Shannon Fox-Levine: I I think a and this again goes back to like that wanting to fight for pediatricians. So every time we make just one little step forward in anything that we're doing in an advocacy effort, it gives me more energy to keep going. Okay. So I'm one of those people that, you know, I can have all these ideas, but if just one of them actually pans out for the good. And then I'm like, okay, well, I'm good for five years now. Like like we can work on these other things now. So and I have to say the transparency data for me, that was one of the biggest in my career. At 'cause I just never thought, I mean, I always talk about that Hamilton musical, you know, in the room when it happened, the the song. I play it in my head all the time, thinking about that, that I was sitting at that table having that discussion, thinking there's no way the AAP is ever gonna go for this. Working with a private vendor, like this is not gonna Chip Hart: Paul Paul has crazy ideas three, four times a year. And he says the same thing, you know. And this is this is Katrina Skinner, lesson 101. You have not because you asked not. And Paul asks and asks. And when it started looked like it was happening, I like, I can't believe that. Dr. Shannon Fox-Levine: doing I was amazed. I mean, I was, you know, it was Christoph who mentioned it just because we had the resolution that we were discussing that had passed. And I was like, well, sure, I can ask him. Let's see. And then that connected him with Nita. And then Nita made it happen, really. Right. And so I mean, that is the AAP. Nita, I'm not the AP. She's the AP making it happen. And so that was a big thing for and that'll get me keep me going for a while because again it it just shows that all right there is that potential that we can make a difference. Chip Hart: It is the single biggest obstacle to pediatricians negotiating plans. You have no context for your numbers. Dr. Shannon Fox-Levine: This was such a nightmare for all my whole career to sit at these tables with the payers and say, Well, I really think that we would do all these things, so we should be paid this amount and you know, it's all based on Medicare rates, right? And they would say, no, you're already paid at the Can't Chip Hart: Always lying. Always lying. Dr. Shannon Fox-Levine: compare because you can't talk about your rates. So I was always like, Well, well, that's not fair. Like Keith, they could tell me anything. They so now Chip Hart: Remember years ago, like twenty-five years ago, 30 years ago, I went to San Antonio, Texas, and I I visited like six or eight practices. And were they all PCC clients? Maybe one or two of them weren't, but I had I had all their I could get their data. I was looking at the numbers and what had happened is UHC had come into town a few years before, did a very classic thing. They came into town and and offered better rates than everyone. Come in. Give you great rates. Everyone signs up. Three years goes by and now you get the your update and they've cut everyone's fees by twenty, thirty percent. And it was just i I happen to be there as that was happening. And the first practice I go into, the doctor's like, Hey, can you look at my new fee schedule? And I look and I'm like, they're cutting you a lot. He said, I know, but the the rep told me not to tell anyone, but he's giving me the best rate in town. I'm like, okay. I go to the next practice. Don't The rep told me, don't tell anyone, but he's giving me the best rate in town. And I looking at all the rate cards or, you know, these these spreadsheets I made. And I was like, Well, he's clearly lying to s five of you. Okay. Cause one of you has better rates than the others. And but they're all bad. You know, they're all bad. And I had a meeting, I remember because of this place that's a

chain down there called Papa Deuce. I had this meeting and I got all fired up and I said, I got home, I told my wife, I said, I'm gonna go around the country and do all of this. I'm gonna, I'm gonna get everyone to I this I almost said the word. I'm gonna get all the doctors together. We're gonna price bite. And she had me talk to one of her attorney partners and she was like, So I need to introduce you to the FTC. What you're describing is totally illegal. I'm like, Why how can this be illegal? We open up the rule and we look at the law for it. And the it was like I read this stuff. I was like, did the insurance companies write this? Because it's so crazy how anti-physician. The laws are relating to sharing prices and price fixing. Yeah. I asked about the history of it, and it made sense a hundred years ago before insurance companies. You know, if you're the the mayor of New York, you can't afford to have all the doctors suddenly raise their prices and keep your citizens out. But that's not what happens. That's not what happens anymore. The doctors raising their prices is irrelevant. Right. I'm preaching to the choir. But it's like I know. It I just remember when that f that time I was so confused by how is how do people not realize how dumb and broken this is? I know. And then Dr. Shannon Fox-Levine: And fresh and frustrating on our end because you can't even have a conversation about that then. It's kind of like, All right, then it's over because you just told me I'm already paid the most. Chip Hart: But then I realized people do know exactly how broken it is and they they they depend on it for their business. Yeah. All right. So now I've I have three more questions, two of which are new. I have asked people these questions, but never in the podcast. The first one is is I suppose more philosophical. So if you could go back to yourself at the beginning of your career and give yourself advice, what would it be? Dr. Shannon Fox-Levine: Beginning of my career and giving myself advice, what would it be? Probably to not be so hard on myself about having work life balance, but realizing that it was one and the same. You know, we were always you know, this was part of the whole my generation of, you know, medicine and burnout and you need to do more things for yourself so you can have work life balance. But in the end, you know, I own my business. My family was fully involved in it. We would have our annual employee appreciation picnic. Me and my boys would go to Costco with the the cart, load stuff up, you know, cook the burgers for everybody. You know, like this was a family business. Chip Hart: Right. Dr. Shannon Fox-Levine: And so Chip Hart: If you don't have a restaurant a family restaurant or whatever. Yeah. What's your what's work life balance when it's when everyone's doing it? Dr. Shannon Fox-Levine: But in my head, I because I'm such a rule follower and wanna, you know, be by the book all the time, I'm like, but I have to have work-life balance. And so I actually had stress about having work-life balance. Chip Hart: Wasn't it? Dr. Shannon Fox-Levine: You doing it right. No, it wasn't. And now that I've let that go, and I'm now it helps now because my boys are older. But now that I've kind of let that go and I'm like, you know what? It's fine. If I wanna do my charts at 10 o'clock at night because I need to for tomorrow to make it a better day. It's it's fine. It's just fine. Instead of this whole pressure all the time of not having pajama time either, because that's not good work life balance, you know. And I so much pressure through my career of like on myself because being hard on myself about not taking enough time for myself. Where I think I did. I think we did a great job raising our kids in spite of it all. I Chip Hart: That is doing this work I wasn't jobs. You weren't doing it for s the man. Right. You were doing Dr. Shannon Fox-Levine: Or just to put food on the table. Right. That was never the intention. Chip Hart: You're doing it because that you had a bigger cause. I also think there's something to be said about I don't mean to get too serious, but there's something to be said about you as a mom modeling I'll call it CEO behavior to two boys. I think there's value in that that has to do with work. So you showing them what your capacity was and what your values are and how important it is to do some of these things for other people. That has that was part of your life balance. Dr. Shannon Fox-Levine: And work the work ethic, all of that. And and I'll tell you, Sue Cresley is my mentor and she was the one that told me this. And I it had never dawned on me until she said that to me. And that was probably, I don't know, two or three years ago when she asked me to be part of the the payer advocacy advisory committee. Cause I was like, I just need to have better li work life balance though. I know Let me tell you about that. You know? So but she was right that she was right. Right. And that was her point, is that what does that really mean if you really love what you do? Chip Hart: Yeah, that's a that's a great point. I like that one. All right, so you're ready? You're gonna laugh don't laugh because of what I'm saying, I'm going somewhere with this. It's the zombie apocalypse. Okay. And the zombies are coming. And the don't worry about the premise. This is just what what we're trying to focus on is the question. And I'm gonna ask you two questions. There's no wrong answer. It's just enlightening. Zombie apocalypse. The zombies are coming. You're going to be eaten in an hour. Okay, or whatever. What is your last drink? Dr. Shannon Fox-Levine: We kinda have the zombie apocalypse here in Florida, you know, because we do have government officials that we feel like are zombies coming after us all the time. So I do feel like I experience this a little bit. And my last drink would likely be it would likely be a glass of white wine. Because that's usually my favorite Pinot Grigio. Chip Hart: Okay. Any particular brand? Dr. Shannon Fox-Levine: Rafino. Chip Hart: Okay, because we're looking for sponsors. We've heard everything from Yuho to Fanta to Jesse Hackle named like some very specific Scotch. I can't remember. Like it the range is the range is substantial. I will say I will say that someone, I'm not gonna name her, who was once AAP president, immediately went to like propofol and something else, like so fast, and we were all stunned at the table. Dr. Shannon Fox-Levine: Well that's smart then. We were with Chip Hart: We're all shocked by it for about three seconds, then we said, And that's why you are A P present. Dr. Shannon Fox-Levine: Brilliant. Brilliant. Chip Hart: As you're s as you're drinking your glass of white wine, you've got a you've got a Sony Walkman with one song, a battery that has enough battery to listen to one song. What is the song that you listen to as you go out? Dr. Shannon Fox-Levine: Justin Timberlake, the dance song. Just dance, dance, dance. From the tr the trolls movie. Yeah. Chip Hart: I needed to ask these questions from the first time I started doing these these podcasts. I've just asked this question once when we all went out, and then I've amended it over time. And the answers we get, some people take 20 minutes to answer a question. You just took 10 seconds both times. We've had Elvis. We've had, I'm trying to think of some great ones. what did we get the other night? Instantly, I'll think of it in one second. But we had in one second. Bittersweet symphony. Yeah. Yeah. And So people just have their people have their thing. Dr. Shannon Fox-Levine: my go to. Yeah. Can't stop this feeling. That's the name of it. And just that just dance, dance, dance. So I'd be going out thinking, just dance it out. Dance it out. Perfect.