SPEAKER_02 0:00

All right. The American healthcare system is effed. I think everyone can agree with that. Now, the problem is we all have our own opinions on what the primarily fault is, who's to blame, uh, and the reality is there's a lot to unpack. And so is the American healthcare system actually broken? And what is the honest take from myself and Dr. Lara on some of the current frustrations and holes that we've seen inside the medical system to give you a little bit more perspective on the current problems we have?

SPEAKER_03 0:43

I think this will just be nice to kind of bring up some of the issues that we face in healthcare on a day-to-day basis and how it makes healthcare difficult for patients.

SPEAKER_02 0:55

Yes, because if we just had a post go a little bit viral on TikTok where we I knew it was going to happen, we leaned in very heavy and we said doctors are not paid to prescribe medications. There's no kickbacks. There's no like if you hit certain benchmarks of prescribing medications, you get a freaking set of free golf clubs. None of that exists. It's not real. You do get sandwiches.

SPEAKER_03 1:22

And come to find out when you're But again, no, no, but the sandwiches, it doesn't matter if I prescribe them. I'm not getting correct it and then like having to prescribe it.

SPEAKER_02 1:33

But and that's very true. But it is so funny to me because like as we kind of unpack this episode and some of the the current issues we've seen, um, when that post went viral, everyone freaked out. Now there is this classic notion I looked into the the study on, which was over a 10-year time period,$12 billion was spent on quote unquote gifts and incentives to doctors. Okay. It was 800,000 doctors. 56% of these doctors were given some type of gift compensation structure, like it's all public knowledge. And so that so it makes that sound like it's a lot of money and doctors are getting paid off. But when you actually I did the numbers and you unpacked it, it was okay, 450,000 doctors. So out of 12 billion dollars over 10 years, 12, it's like 12.5. That's so be 1.2 billion dollars a year spent towards schmoozing doctors. Okay. Out of eight, 44% of all doctors never get a dollar. It was 56% of those doctors ever got something. So$1.2 billion over four over$450,000 doctors, that equates to about$2,600 a year divided by 52 weeks in a year. That's$51 a week per doctor that's getting some type of compensation, of which the average compensation is around$14 to$21, which we got to experience recently. Uh Lara, right before this episode started, found out that one of our lab reps came in with donuts. And she was like, yes. So she quickly scurried over to the kitchen and took a bite of a donut. So that was tracked. That's in her system. I don't know if it's under Dr. Jana or Dr. Lara, but that's all legally has to be compensated for.

SPEAKER_03 3:34

I don't know if that is the same for lab reps. I wonder how they're but I mean, this happens for pharmaceutical reps all the time. So it doesn't really matter. Um, but uh, I'm just letting people know that my uh prescribing pattern is not changed by the amount of donuts that I get.

SPEAKER_02 3:48

Because I'd also like to put it out there subpar donuts. Like we're not talking like Nantucket or some like super high-end quality donuts here. We're talking like mass-produced donuts. Which I mean, it was tasty. They're still good. But it's not gonna make you add extra zinc uh labs to some random patient because someone brought a donut.

unknown 4:10

No.

SPEAKER_02 4:10

It's not happening, people. I don't know why it keeps coming up. It's just funny to me.

SPEAKER_03 4:14

Well, and I feel like you're like teasing our next episode where we actually dive into pharmaceutical reps.

SPEAKER_02 4:20

Yes.

SPEAKER_03 4:21

So stay tuned, everybody. It's gonna be fun episode next.

SPEAKER_02 4:24

Me, Dr. Lara, Dr. Jana, next week are gonna be talking about our experiences over the last I mean, for me, it's been the last year or so of pharmaceutical reps. And for you guys, it's been almost 10 years in that game. So we're gonna have some fun stories, perspectives, and the whole process. We're gonna we're gonna pull back the veil, which is being schmoozed and kind of hassled and annoyed by big pharma reps.

SPEAKER_03 4:50

All right, stay tuned. Yes. Okay, where do you want to start now?

SPEAKER_02 4:53

I think the I think the number one that kind of leans in so much to this topic of a major flaw inside of the medical system today is primary care. And you're you were forced to make a change because the system doesn't compensate and value primary care. Do you want to kind of unpack that a bit?

SPEAKER_03 5:17

Well, it's just very interesting that primary care is essentially the base of our healthcare system. We can't do what we do in healthcare without primary care because it our healthcare is so referral-based. And so, unless you have a primary care referring you to a specialist, a lot of times you can't get there. And primary care offices, uh, they are uh, or primary care clinicians are consistently, and this is not a complaint, I'm not complaining about this, people out there, but primary care physicians are traditionally and consistently the low one some of the lowest paid physicians in healthcare. Um, and this is because the payment structures by insurance companies tend to reward procedures, tend to reward in hospital care, and they don't really value these like cognitive, team-based, whole person approaches to medicine, which is a lot of primary care. Um, there's also a lot of that in rheumatology, is another one, that they don't do a lot of procedures. It's a lot of cognitive work. And so the the whole structure of payment is what has led to this. Which I'm not complaining about the pay that I'm getting. It's just an interesting way that the whole healthcare system has been uh modeled.

SPEAKER_02 6:30

Well, because the dynamic shift forces what you had to deal with before, which was if you want to get compensated to a certain level based upon your degree and stature, guess what? You had to see more patients.

SPEAKER_03 6:44

Yeah.

SPEAKER_02 6:44

And the volume had to go up.

SPEAKER_03 6:46

That's the only way you can get more in primary care, is to see more.

SPEAKER_02 6:50

Yeah. And so that's why you're rocking out two to three thousand patients and you were seeing how many patients a day?

SPEAKER_03 6:56

I mean like 20.

SPEAKER_02 6:58

Yeah, 20 patients a day with 15-minute-ish on average, like set. Like, so you can't, there's there's no depth of being able to really work with a patient in a way, not because you don't want to, not because you're not knowledgeable of helping a patient, you're pigeonholed by insurance compensation that if you want to be able to get paid a uh a realistic wage for how much debt you have, for how much everything, that's your only option.

SPEAKER_03 7:30

And interestingly enough, um, the hospital systems, they uh they want primary care, even though primary care consistently operates in a direct financial loss to a healthcare system, which is so interesting. Um, but research shows that primary care has these huge and enormous downstream revenue effects for a healthcare system by referrals and getting people to specialists. So the I would not say that I felt like I was ever pressured to refer more, but just the whole setup of the rushed visits made it so referrals happen more regularly, I think, in the in the system because you didn't have time to address a lot of these things. So you just had to refer out half the time. At least that's how I felt.

SPEAKER_02 8:12

Well, because I'm sure you had enough lag time between appointments where it's like, I probably can refer this out to almost have it done more efficiently than me spending another 15 minutes.

SPEAKER_03 8:22

I'm like, I don't have time to talk about that problem. Um, do you want a referral?

SPEAKER_02 8:25

Yeah.

SPEAKER_03 8:26

And that's how it was sometimes. I did something. I know.

SPEAKER_02 8:37

Yeah. And that still comes back to fundamentally how insurance has compensated certain practices. Um and it's super interesting because dad dad's talked about this multiple times where he thought the momentum shift would happen, which is uh short small procedure-based things get compensated better. Interventional cardiology, doing a a lot of uh uh work in the cath lab. That's what that was. And so that's how that kind of was structured and happened. And so, but dad knew like he used to be an internist before that, and he thought insurance would pull back and and see the problems they were creating, but they didn't.

SPEAKER_03 9:19

Well, and you hear all the time how important primary care is. You I hear this in the news, and it's like we gotta fix the the lack of primary care doctors in this, in this, uh, in the country. And you always hear that, and no one's doing anything to make it more in an incentive for med students to decide to go into primary care. It's like why would they want to do that? I hear from specialists all the time. They're like, oh, you're a primary care doctor. They're like, good for you. I could never do that. It sounds awful. Like they they know that it's a lot of work and it it doesn't, there's not a lot of value or that it seems like people don't put a lot of value into, even though they talk about the fact that it's valuable.

SPEAKER_02 10:04

I can believe that. Um, I mean that that's that's obviously a a breaking point number one, and that's where like some of the the the things getting around it, it's like, all right, if insurance isn't gonna change their patterns, that's where concierge, direct primary care has come along to try to move the needle. Now, I always I almost want to know this is just off the rip. Yeah, does insurance like that? And they're like, sweet, we don't have to pay for it. Uh-huh. And if these people are gonna do direct primary care membership models, that's 60 to 110 bucks a month, or concierge at 250 bucks a month, and they're gonna pay it out of pocket, so we don't have to do it. Sweet. So I'm I'm very intrigued if cut if insurance is actually happy with kind of this moment.

SPEAKER_03 10:51

Like, ooh, we actually want it to go this direction.

SPEAKER_02 10:53

Because like that's less that they have to pay back.

SPEAKER_03 10:57

I mean, people do tend or a lot of I think people going into a direct pay model of primary care are going to start choosing lower-tiered insurance models so that they have smaller premiums and their whole they don't need them as much or to use the healthcare system as much. Um and so I don't know how much that impacts the insurance companies and how much that's real, I don't know.

SPEAKER_02 11:19

Well, it's like that kind of unpacks the the transition point, which is insurance, uh-huh, which is an absolute dumpster fire.

unknown 11:26

Yeah.

SPEAKER_02 11:27

And as somebody who leans conservative in nature and don't believe that the government and and just taxes fixes all problems. Because from my point of view, uh, as we kind of see some of the flaws in the current healthcare model right now, uh that'll kind of lean into it more. Health insurance, I was on like the silver plan for priority for for freaking six, seven years, which is like middle of the road, all fine. And I watched my premiums, like my premiums almost didn't move for like five, six years, and the last three to four just jumped. Um, a lot of it has to do with uh Obamacare subsidies and also like more and more people, unhealthy people on the medical system, pulling it down, more people on medications, pulling like making the prices go up. Like there is that reality to the whole mix. And I mean, I've looked for the idea of finding a freaking, all right, create me a a health insurance plan where none of my medications are paid. Like, I don't I'm not on many medications, so it's like I don't care about any of that stuff. I just want something if I get cancer or a car accident, I get compensated, I get paid back for. And other than that, I don't care. So I dropped to like the lowest tier uh insurance, and then for example, you went a whole different route. What like funny enough, as a physician, you don't even have health insurance, right?

SPEAKER_03 12:54

I do not. Yeah. I use one of these health share type plans where you still you pay an annu or you pay a monthly fee to this company, but then depending on how many members within the company request funds for, say, an injury or an ER visit or something, um, depending on that, you pay more or less each month, but there is a cap to it. And so you know you're not gonna go over a certain number. This is at least how mine works. Um, but you're gonna get billed kind of your standard beginning of the month kind of base pay. And then depending on how many people request money throughout the month, you get a second bill later in the month. And it's worked good for me.

SPEAKER_02 13:36

It's so funny. Like, uh, as Lara and I figure out getting married and how we want to deal with that.

SPEAKER_00 13:43

Yeah.

SPEAKER_02 13:44

Yeah, she has more cojones than me. I'm just sitting there going, but that's not insurance. And I'm like, what?

SPEAKER_03 13:50

But if all you want is catastrophic, that's really what it's for.

SPEAKER_02 13:54

True. But the problem is is technically it's not considered her insurance. It's it's it's health share. So they don't legally have to like, at least with insurance, they legally are obligated to back at a certain level all of your bills where these things, again, they may be so much better in the long run. It's just unknown. And so what is your what is your okay?

SPEAKER_03 14:16

I am not a conspiracy theorist in any way. And so I'm like, this is great. All these people want to help each other. And they do. You get a you get a monthly newsletter and they tell you about how people are helping each other. It's great. Very positive.

SPEAKER_02 14:27

Again, I like it's it's one of these things where it's like, you're just you're you're more confident in it than I am. Like, I mean, it's probably gonna be I also just don't think I'm gonna need anything. Well, that's the whole point. It's like outside of a car accident or something major, I'm not really concerned. And so you you wonder how health, but I wanna I wanna kind of unpack that side of things more on like people understanding where some of these healthcare costs come from and how just convoluted and jacked up the scenarios are. Um, would you like to go into your current patient uh blood uh having a zinc blood test done? Like, guys, I don't think people understand insurance companies, medical systems, no one knows what they're paying, why they're paying, and who's paying. It's so big and convoluted and all jacked up because of um there's a lot of uh uh there's a lot of lack of competitive nature in the healthcare space now because of lack of competition, because for my argument, in uh the government doesn't allow competition. We've had episodes with John Runquist on some of that kind of stuff. Um, but like, okay, walk me through that because that blows my mind.

SPEAKER_03 15:41

So I ordered a zinc level for a lady. I don't remember why, and it we built it through her insurance, and then it got denied through her insurance. So the insurance was then going to charge her or make her pay, it was around$230 for this one lab test. When if someone walked into our office and paid cash, our cash price for a zinc level, it was about six bucks.

SPEAKER_02 16:08

So cash pay was like six bucks for a zinc blood test. But when it was gonna be filed through insurance with an insurance denial, it was 200 plus dollars for the exact same test.

SPEAKER_03 16:23

And I have I don't know why and how it works this way. I don't, I have no idea. It does not make sense, and I don't know how they do it that way, but uh we now um have all of our patients that they want to zinc level pay cash.

SPEAKER_02 16:38

Well, and that's the whole that that's the angle of of part of this problem right now is there's so much of this game inside of the major healthcare systems, uh, all playing, playing chicken with health with health insurance, that okay, they know if they charge, if they if they need$40, they can't charge insurance$40. They have to charge them$80 because insurance is gonna say, we'll pay you half, or whatever that's gonna be. And so right now we're creating this bigger and bigger gap between the reality of the cost of something and playing chicken with insurance and these other uh areas of like trying to make sure they can get the money they need. And so the reason why I'm not a fan of a national healthcare system as it currently sits is because this game of chicken has not been figured out yet. So your big healthcare systems are jacking up prices to the two in insurers and all this kind of stuff to buffer in the in between while they're all playing chicken with one another. And so if you just make the government pay these bills, where's the auditing to know are these effective prices? Who's doing that? And it gets so big and so ridiculous that you don't actually fix the problem because you're just throwing it into a bigger trough. And then obviously, from my point of view, and the the the taxpayers end up fronting the bill, and then someone who's it's basically why we get in the student loan crisis we're in, is because the government decided to guarantee student loan debt and the colleges were able to keep inflating the price of education. Oh, David's going off on the phone. And I guess it's the same thing again and again and again. It's just it's a definition, it's always very well-meaning, well-meaninged people that lean the Democrat side, they mean well, but then they don't realize that very money-happy people can take advantage of the systems and make a lot of money off the government.

SPEAKER_03 18:36

It's just why I mean, I love that in our concierge practice, we have the time to like actually figure these things out. Because if a patient in my, when I was working for the healthcare system, if they were like, I got charged whatever, you know,$230 for this lab test and they were all mad about it, I'd be like, Yeah, sorry. But because I have the time and we have the time to work with our lab companies and uh make sure patients aren't getting overcharged, we can actually figure these things out, which is great. I don't fully understand it, why it's charged that way still, but we can at least make it as little as least expensive as we can.

SPEAKER_02 19:12

Yeah. And that's where like the insurance side of things, it's a dumpster fire. There's a lot to unpack, but just know from people listening right now, physicians are just as drained and unknown with how the system works as everybody else.

SPEAKER_03 19:29

And we don't have the answers. I have people ask me things about their insurance, not in infrequently. And I'm like, I don't know. Like, first of all, like what what insurance do you have? And then which plan within that insurance do you have? And I don't know, you have to go talk to your insurance company, which nobody wants to go do. I understand that, but it is true, I do not know the answer to your insurance questions typically because it kind of goes aligned with that.

SPEAKER_02 19:57

But one of the things that you've been currently dealing with uh from another patient standpoint that you finally got concluded, which is like another big issue within the health in healthcare problem right now, prior authorizations from insurance. Can you unpack that whole process?

SPEAKER_03 20:15

Well, I have multiple stories on that because it happens all the time.

SPEAKER_02 20:18

Yep.

SPEAKER_03 20:19

But um, for people that don't know, um, a prior auth is a process by which uh healthcare insurance companies they require clinicians, physicians, PAs, whatever, to obtain approval for a medical service, for imaging, for a medication, be a procedure before it will be covered. And so this was originally done to help reduce unnecessary spending in healthcare. But really, uh I think the research shows that it overwhelmingly just makes more administrative burden for offices for healthcare systems. And it is a huge frustration on a day-to-day basis in healthcare uh offices. So um, so every time we order something.

SPEAKER_02 21:01

So uh actually keep you can keep explaining it if you want.

SPEAKER_03 21:03

No, I think that was, I mean, that was the main thing. But um the typical problem, I'd say I'll start with this story that most recently happened. But a patient came to me with a finding on some imaging that uh was what we call incidental. So she was not looking to find this problem, but because she had the imaging done, we saw it. And so it was like, okay, we have to deal with this now. Um, so I went into the guidelines to see, okay, with this specific finding, what do we need to do about it? And there, there was multiple guidelines from Canada, the US, you know, different groups all recommending the same follow-up CT scan. Okay. I'm like, well, that makes it really easy. We'll do this CT scan. Uh, it'll help us determine whether this is something to be worried about, uh, such as cancer or just something totally benign. And the insurance company denied it. Well, that's weird. Maybe they just didn't have all the information, right? I don't know. Um, so all insurance companies are different with what you do now uh once they deny it. So sometimes you send stuff in, sometimes you call them, sometimes um you can't do anything. Like it's just fascinating to me. So uh for this per particular patient, I sent in a letter explaining like these are all the guidelines we have that say this scan is needed. And I got it another denial back saying, Nope. And it said, this case is closed, you can no longer appeal this further. That was it. And so that's it. Like there is a finding that we're supposed to have a follow-up on that insurance is telling me, her physician, that the patient shouldn't get.

SPEAKER_02 22:48

And that's uh some of the prior off game right now is insurance is starting to play a very dangerous game of are you acting as a physician by controlling uh medical processes and systems?

SPEAKER_03 23:04

It's just fascinating. I mean, I'm like, I don't understand this. I, from my knowledge and my training and reading the guidelines, know that this is the right test for this person, person, and I can't do anything about it unless you want to pay thousands of dollars to have it done by cash pay. But I mean like this is ridiculous. I don't get it. And the fact that I can't do any further appeals just boggles my mind.

SPEAKER_02 23:26

Wow. All right, you got any more?

SPEAKER_03 23:28

Well, so this is like this is not typically how this happens, but this is just another frustration of all the steps that you have to do with um with insurance. That I ordered a MRI of a man's knee for his chronic knee pain, and that got denied. So uh I called the insurance company and I said, Well, how can I have like additional information? I want to explain why this is important for this person. And they said, Well, do you have an account on our website? And I was like, No, I don't have this account with their uh with their insurance company. And so they were like, Well, you have to get an account. Okay, we worked on getting an account for four months. So I ordered this MRI in December, and we finally got approval for this account in April. And he got his MRI. So it was a win, but it took four months, and all it was is because their process is you have to have an online portal. And that was the only there was no way around this.

SPEAKER_02 24:31

Yeah, and you're sitting there going, like, well, here's my medical license, here's this, here's this, set up my account. What what are we talking about here?

SPEAKER_03 24:37

It was insane. So these are just uh these are the kind of frustrations that an office is dealing with, but at like, you know, think of multiple providers in a practice, think of how many patients they're seeing in a day, how many times they're dealing with this.

SPEAKER_02 24:50

I know, and it's totally fine because it's not a big deal. Amanda. Yes. Prior authorizations is the bane of her existence.

SPEAKER_03 24:57

And anybody that that's their job, they hate it. I don't think anyone enjoys prior authorization.

SPEAKER_02 25:05

Just to explain something, just to have somebody read a chart that says, No. Okay, well, I want to talk to your superior. Okay. Then you get to their superior and then you say the same thing and they go, okay. I know.

SPEAKER_03 25:19

It is so crazy. I mean, a typical way that you have to do prior authors as well is if it gets denied, you call, you have to do something called a peer-to-peer. If you people have heard of that, where you, as a physician, have to talk to the physician that works for the insurance company. And you essentially argue back and forth about why this is needed. And if you're good at arguing and providing the right data, you might get a yes. But that's also another way to do it. So this is like the process.

SPEAKER_02 25:46

It's not uncommon. I've heard this from multiple different physicians where the person you're talking to is not even a peer, in the sense that like you're a cardiologist and you're speaking to an ophthalmologist.

SPEAKER_00 25:57

Yeah.

SPEAKER_02 25:57

And it's like you're not even trained in this. And I have to, as a cardiologist, explain to you, as an ophthalmologist, why what I'm doing is clinically necessary.

SPEAKER_01 26:09

And it's so crazy.

SPEAKER_02 26:11

How it turns into an absolute dumpster fire. Now, again, checks and balances are important, and there there is a level of like uh whether you like it or not, I I've heard conversations from my dad all the time in the cardiology space where um there was a period of time there were a certain group of cardiologists that love to basically calf everybody because it made them more money. They would say, guess what? Well, I'm doing it because I'm trying to make sure this patient doesn't it has the best opportunity to get to see if there's a blockage and X, Y, and Z. And dad's sitting there going, like, no, you're you're you're barreling your stats trying to make more money. And so it does exist.

SPEAKER_03 26:52

And you understand why there needs to be checks and balances on this process, but but it's like it's almost like every medication that you prescribe that's not like a statin or a blood pressure medication that's standard. Like practically, I feel like every med that we prescribe comes back with prior authorization needed. And you know, like no one, no one was check looking at this to see if this is important medication. It's like they just automatically send it and make you do more work.

SPEAKER_02 27:22

Yeah. But it's see, and this is where I do want to play devil's advocate here, because I like the one, the classic one to me, and contrary to probably a belief, outside of a couple of insurance companies from my knowledge base, most of them don't make much money. They're so upside down because of everything going on, because primarily, like, there's so many Americans on multiple pharmaceutical medications because their lifestyles are poor. They are doing everything not ideal. Like the easiest one to me to unpack with this all is okay, say someone's premium monthly payment for their personal insurance is$500 a month. So$500 a month is going to the coffers. If half of America gets put on a GLP one and is at top dose, which is like$399 a month.$449 is$449 a month, that means they're basically the health insurance is upside down. If they're spending all their money on one drug. And it you can't do it.

SPEAKER_03 28:22

And so just making the physician's offices work harder is not fixing that problem.

SPEAKER_02 28:28

No, but my whole thing is I want to at least play devil's advocate on insurance side because so many people want to just sit here and gripe on what insurance is or isn't doing. Simultaneously, this is my argument from someone who's been down 200 pounds for over a decade, who was pre-diabetic by the time he was 15, massive high blood pressure. I was not doing myself any service on, I was on Lysinepro by the time I was 15. I was on metformin by the time I was 15. I was on multiple medications, all these specialty visits. Whose fault was it? I. And there's this massive uh, at least from my point of view, everyone who loves to blame insurance and large medicine for all the problems inside of healthcare. One of the big ones people do not want to talk about because it sounds like patient blaming and victim blaming, is the average American is not even doing the basics for their general health. And doctors and insurance companies are forced to pick up the slack for average American drinking too much alcohol, sitting too much, eating too much hyperprocessed foods, not eating enough whole foods, not doing the basics, so they're overweight and leading to all these problems that forces the hand of insurance to pay more for it.

SPEAKER_03 29:49

The question I think is, and this could be a whole nother topic in and of itself, is why are so many Americans so unhealthy? Is it because they're all not trying hard enough? Because that's not probably the answer.

SPEAKER_02 30:03

Well, okay, uh it's multifactorial because you go into Europe and you go into these other countries, they have way more walkable cities, which plays into it.

SPEAKER_03 30:11

Well, there's so many things that play into it. And that's where I think it's so challenging to it's that's why it's so challenging to fix the problem that Americans are so unhealthy. Because there are so many factors that go into it. And there uh there in all areas of life, there are factor, like so many areas contribute to this.

SPEAKER_02 30:31

Well, and that's where vitals and values and what we speak about is so important. It's all about the context and nuance. It's never just insurance is the problem or healthcare systems are the problem or doctors are the problem. It's so much more complex. And it's if you it's like anti-diet die club in the documentary. If you don't explain all the context and nuances of why someone's over overweight and obese from uh potentially childhood trauma leading to emotional deficits and how you uh how that emotionally affects you to socioeconomic and what is your access to quality food sources and uh what is your career path that leads you to stress problems that leads you to all this kind of stuff. Exactly. So there's so many pieces. It all plays a role, um, and that's how you actually create incremental change. And it's always this dance between trying to make a difference by pointing at problems, but also don't fall for what most people do, which is just point a finger in one direction and say it's their fault. It's like it's just not realistic. It's the current health care health system problem is you have uh you have too much big money inside of especially like corporate healthcare systems. They're very top heavy with C-suite executives that take a lot of money off the top. That's an issue. You have insurance problems and sometimes how they're prof like they're trying to create their granular ways to make profit. And dad's made that argument all the time. Like, yes, a business healthcare is just is a business. It has to be, in the sense that it's gotta break even. It's it has to. Because you like this contrary to popular belief, if if it's always losing money, it'll eventually implode. Like, period. Like, and there is merit in business type people going, okay, you have 17 types of gauzes. That's a lot of money with a lot of skews. Wait, wait, wait. Is there a way to drink it to the water?

SPEAKER_03 32:36

Wait, wait, wait. Are they the ones dressing the wounds? I know, but simultaneously. Go talk to Amien about how many gauzes they're needed. She is our wound care expert expert at the soft. But going to the original point, yes, there's still too many PAs because I don't think they should send one for every single med that you prescribe. That's on top.

SPEAKER_02 33:05

There's too many what?

SPEAKER_03 33:06

PAs. Prior OS.

SPEAKER_02 33:07

Oh, prior offs. Yeah. I was thinking physicians assistant.

SPEAKER_03 33:10

No, that's fine. We can have those. Um the prior os. Um if every time you prescribe a medication, you have to then go back and defend it. That becomes very taxi on healthcare workers.

SPEAKER_02 33:26

And it's like that's your time, and that time is money.

SPEAKER_03 33:28

Yeah.

SPEAKER_02 33:29

Um, but also crazy enough, too, the whole idea of where some of this comes into play too is health insurance or uh uh malpractice insurance. We've gotten to such a place inside of that world, inside the big healthcare systems. Malpractice insurance is such a massive cost inside of your big healthcare systems because everyone is just look at the majority of billboards you see on on the roads today. They're primarily lawsuit-driven legal companies, Morgan and Morgan's and stuff. The reason why they can do that is because they're making so much flippin' money suing big systems for billions of dollars, which then jacks up insurance premiums, which creates the big circle siphon siphon there again and again and again. So it's like America's costs are big in a way, too, because we love to sue everyone. It's a very high lawsuit-driven country, which then jacks the price of everything.

SPEAKER_03 34:27

You're just hitting all the problems.

SPEAKER_02 34:29

We're just hammering it. I'm just that wasn't even on the list. I just started ripping at it.

SPEAKER_03 34:32

I'll say, what else is on your list? Was there anything else we covered?

SPEAKER_02 34:36

Uh health insurance machine. We kind of went into that. Um drug. I mean, we can go into drug prices a little bit. Like they're expensive. Yeah. I mean, one of the things that's so interesting is if you look at the world, American pay America's play massively disproportionate of the profit of the rest of the world's pharmaceutical drug costs. Because that's the benefit of large national systems where Great Britain can come in and say, we will not pay more than$9 for this drug. However, you need to do it, we don't care. We're not going to use it unless it's this price. So then what happens is since America doesn't have that competitive leverage, we can't do that, which then what pharmaceutical companies do is they jack the prices up in America because we'll pay them and we don't have the leverage to keep it down. That is an issue that we're facing.

SPEAKER_03 35:28

I mean, I believe there's also higher utilization of these meds in our country. Yeah. So that's going to play a role as well.

SPEAKER_02 35:37

Yeah, because our general health is uh as but again, every co contrary to probably belief, most modern countries are all doing this with all chronic diseases, too. Like we're ahead. But just because we've been the most affluent and the most like kind of that whatever whatever the main mechanisms behind like that whole world, the hyperprocessed food choice and sedentary lifestyle and all that kind of thing, because I mean, I mean, Americans, what is it? In America, the average family has like two and a half cars per family. It's something like that. And it's like you go to Europe, you go to Asia, it's like 0.7. And so because people bike and walk to places more, and we just sit so friggin' much. We're also a massive sized country where biking isn't really realistic.

SPEAKER_03 36:28

Well, yeah.

SPEAKER_02 36:29

Or people wouldn't do it anyway.

SPEAKER_03 36:31

Um I mean, another big part of the medication cost issues are these pharmacy benefit managers or PBMs, which I think we should have our own separate episode on this. But those third-party uh intermediary negotiators uh play a big role into why our meds cost more.

SPEAKER_02 36:50

Yeah, and they take a piece at the top. Yeah.

SPEAKER_03 36:52

Like we need to find somebody that's an expert in this.

SPEAKER_02 36:54

Yeah, we gotta definitely have someone that's that's a that'd be a fascinating topic.

SPEAKER_03 36:58

But yes, I think that's a good one.

SPEAKER_02 36:59

Maybe we could get uh talking to Todd.

SPEAKER_03 37:03

Yes.

SPEAKER_02 37:03

Maybe we can get um uh Mark Cuban on, because Mark Cuban's definitely gonna know everything about PBMs.

SPEAKER_03 37:09

We can get Mark Cuban on here.

SPEAKER_02 37:11

I mean, Todd got him on a documentary, so maybe we're I don't know that we're at the same level. I'm gonna have Todd text Mark Cuban and be like, yo, there's this Vitals and Values. It's a really cool concierge medical practice podcast.

SPEAKER_03 37:25

You should be on it.

SPEAKER_02 37:26

And you would you would love to talk to Dr. Lara and David on PBMs because he's passionate about it with one of his new companies he's got and the current problems.

SPEAKER_03 37:38

I'm sure we're gonna be top of his list to talk to.

SPEAKER_02 37:41

I mean, we're kind of big deals. We're considered the number one concierge medical practice or medical uh podcast in the country.

SPEAKER_03 37:48

Great. We have a huge um competitive here.

SPEAKER_02 37:52

We're still a big deal.

SPEAKER_03 37:53

We are a big deal.

SPEAKER_02 37:54

We got new ones.

SPEAKER_03 37:55

All right, get Mark get Mark Cuban. Let's talk to him.

SPEAKER_02 37:57

We're working on it.

SPEAKER_03 37:59

All right, anything else that you want to make sure you covered?

SPEAKER_02 38:01

Um, I mean, gosh, there's so many things we can go into.

SPEAKER_03 38:04

I think we should do the we could do like a second, we can make this again.

SPEAKER_02 38:09

Like, I mean, I'm looking through the drug price problem. We kind of looked into that.

SPEAKER_03 38:13

Um I think it's like helpful when I because I think there's so many things that I see day to day that are a frustration for patients that I think they're important topics to continue to address.

SPEAKER_02 38:24

And it changes. And like that's that's the reality of this whole process is like um we fix one problem not knowing it's gonna create these three problems.

SPEAKER_00 38:33

Yeah.

SPEAKER_02 38:33

It's like, oh I go back to student loans and this whole meta, oh, uh accessibility to college is unfair. Cool. Let's make the access easier and allow more people to create student loan debt to move the needle. That sounds great. That fixes the problem. Yay! And then 15, 20 years of unfettered, uncontrolled decision making on that standpoint helped create our student loan bubble. And it's like you do something thinking it's going to fix a problem, not knowing the secondary, tertiary, and quartary issues.

SPEAKER_03 39:09

Aaron Powell, or we would have to do an episode on student loans. And we're not doing that. Rip out we're not doing it, David.

SPEAKER_02 39:17

Come on. It's like basically the same. I could I could use the explanation of the student loan bubble to almost explain two other major problems in America today because it's the same rhythmic pattern again and again and again.

SPEAKER_03 39:29

I mean, physicians do have a lot of student loans.

SPEAKER_02 39:32

Yes, you do. And the fact that your stud your student loan uh interest payment is 6.5% is lunacy. When we were talking about like when we were going through everything and working through like fine the financial side of things, when you when I when we were talking about the student loan debt and you had 6.5% interest, I'm like, see, this is the problem with Republicans. They just want to burn the system, which is annoying too.

SPEAKER_03 39:59

I don't think ever anyone ever feels sorry for those us people with student loans. They're all just mad that we weren't forced to pay them because of I don't know why. Now we are. They're coming back, people.

SPEAKER_02 40:12

They're coming back.

SPEAKER_03 40:13

Payments are coming.

SPEAKER_02 40:14

Yeah. But then pausing the system for the last five years doesn't fix the problem either.

SPEAKER_03 40:19

No, but it's really helpful for me. Paying those things off. I guess it is more relevant than I thought, but we're still not going to talk about it right now.

SPEAKER_02 40:27

Yeah. Because it also, don't kid yourself, that plays into your whole situation medically. You it's harder for doctors to take risk in trying new things outside the medical system because they're like, I gotta pay a quarter million dollars in student loan debt back, and I need this job just as much as anybody. So yeah, I hate how health hospitals do X, Y, and Z. I hate how insurance does X, Y, and Z. I can't take the risk of doing starting up a direct primary care system. Uh I can't take the risk of starting a concierge medical practice because I'm in so much financial stress myself. Uh woe's me to fix that problem.

SPEAKER_03 41:09

That sounds about right.

SPEAKER_02 41:10

So, contrary to popular belief, most of the time your doctor is just trying to make it by as much as anybody else.

SPEAKER_03 41:19

There's a lot of truth to that. So, but nobody seems to ever feel sorry for us. No. Which I'm not asking for sympathy. All right.

SPEAKER_02 41:27

Um I think this hit a lot of main talking points. That was this was this was a fun conversation. Cool. I'm looking forward to the conversation next week with Jana as well, talking about really diving into pharmaceutical reps, the relationships there.

SPEAKER_00 41:41

People are gonna be mad.

SPEAKER_02 41:43

Oh, these clips, there's gonna be a bunch of people losing their friggin' minds over sandwiches.

SPEAKER_03 41:49

Over sandwiches. If people literally work in the healthcare field and they've seen shady dealings, let us know. But most of these people I did get one.

SPEAKER_02 41:58

I know you did. I got a comment on one of those videos. And I wanted more, but I need more details. I know, because anyone could say anything on the internet. Um, but it was like this person said they worked as a front desk or whatever for some doctor in California.

SPEAKER_03 42:12

I want to know what kind of doctor.

SPEAKER_02 42:14

Two-hour lunch breaks with pharma reps, and then occasionally they said they would have pharma reps bring a limo to their practice, pick them up and do massages throughout the day. And I'm sitting there going, what doctor has time for that?

SPEAKER_03 42:27

Yeah, I'm that's what I'm like, what specialty was this person in? My guess plastic surgery.

SPEAKER_01 42:34

I was saying the same thing. I was like, if anyone can get away with that, it's plastic surgery.

SPEAKER_03 42:38

I feel like that's a whole nother field all in and of itself. I think we should the same way. When we get to this conversation, be like, this is for like the general, like primary cares and cardiology and like these type socialists or these type physicians. But stay tuned, everybody. It's gonna be a good topic.

SPEAKER_02 42:55

Well, if you guys have any other uh ideas and thought processes of podcast episodes, we'd love to hear them. If you uh we'd greatly appreciate five-star rating and reviewing the podcast on whatever audio platform you're listening to.

SPEAKER_03 43:06

Absolutely.

SPEAKER_02 43:07

Uh, and if you uh find this valuable to friends that believe in conspiracy theories around medicine um and blaming primarily doctors, which is crazy to me, um, please send them this because I think that gives them a lot of perspective.

SPEAKER_03 43:20

Yeah, let us know what you like, what you don't like. Let us know that you're out there listening. Thank you.

SPEAKER_02 43:25

Have a phenomenal day, and we'll talk to you all later.

SPEAKER_03 43:27

Aye.