Intro And The Reimbursement Puzzle

SPEAKER_01 0:00

My guest today is Dr. Erica Urquhart. She's an orthopedic surgeon and a partner at Urhhart Orthopedic Associates. She also holds an executive MBA, recently authored a book on her experience inside the business of medicine. She's also become one of the clearer voices on what physicians, patients, and policymakers actually see from the front lines of reimbursement. Erica calls her path to healthcare economics an on-the-job MBA, earned year by year as she grew in a private practice with her husband and started asking questions most physicians never get the time to ask. Something important to me in this conversation, we decode why the talent in medicine receives the smallest share of healthcare dollars, how algorithmic denials and delays quietly became a business strategy, and why prior authorization rules vary insurer to insurer for no defensible reason, and what patients and practices can do about it right now. So, Erica, tell me in the audience a little bit more about your journey.

SPEAKER_00 1:02

Well, it's a pleasure to be excited about this podcast interview. My name is Dr. Erica Rowe Urkhart. I'm an orthopedic surgeon and partner at Urkhart Orthopedic Associates. I got here because I'm inquisitive and I like to understand sort of the mechanics of what's happening around me. And I am one of those people that pays attention from A to Z. And as I started in private practice with my husband, my husband had started our orthopedic surgery practice when I was in residency and I chose to join him. When I started in practice, I began noticing lots of things that just didn't make sense to me on the business side of the practice. And I feel that I really earned like an on-the-job MBA before I finally decided to go to business school and obtain the executive MBA. As I began exploring all of the issues that continued to arise and became more and more frequent the longer we practiced, I became somewhat frustrated, as many physicians do, and really decided to pay close attention and begin to investigate some of the factors and then decided to speak out about it.

SPEAKER_01 2:24

That's sort of the physician's learning of the US reimbursement system and paperwork system, right?

SPEAKER_00 2:30

Absolutely. And this is not without the opportunity for education and information. As you know, we physicians, we do the four years of undergraduate, we do four years of medical school, then we do residency. So we're talking over a decade of education. And within that context, certainly after the number of years that we've been practicing modern medicine, we could educate physicians about the business of medicine. And that impacts academic physicians as well as those who are entrepreneurial and in private practice. So the opportunity is there, but the exposure, for whatever reason, is like a black box. And that is not, I think, without intention by stakeholder in this industry.

SPEAKER_01 3:29

So you said 10 years, but I want to step back a little bit because I I don't think what people appreciate an average physician that goes into a specialty by the time they start practicing and making more than minimum wage from their fellowship, they're generally

A Surgeon’s On The Job MBA

SPEAKER_01 3:45

what 35 to 40, depending on your specialty?

SPEAKER_00 3:49

Depending. I would say early 30s. Definitely on the primary care side, you could be 30-ish and in practice. So early 30s, but if a surgical specialist, mid to late 30s.

SPEAKER_01 4:02

Can you tell the audience a little bit about that?

SPEAKER_00 4:04

I love the way that you unfold that because one of the things I've gone through the process in the last year of writing a book about my experience. And one of the things that became apparent to me as I explored the writing process, talking to editors and agents and different players who have nothing to do with medicine. As we're talking about the core theme of what I'm writing, it became very apparent to me that there is this perception of physicians that is not necessarily the most positive out in society. When we're interacting with individual patients, generally speaking, I think we do feel appreciated by most people. We do feel that we're developing a rapport, we do feel a part of a community, but when we begin speaking about issues that are affecting us within the healthcare system, that's when again some of these ideas or even prejudices become manifest. And so it is important to understand that to get to the point of attending medical school, we had to work obviously really hard. There had to be a certain, I don't want to say giftedness, but there had to be a certain level of intellect to just be able to appreciate the volume of material that we're going to be receiving in medical school, especially during the first two years. And and then again, as you mentioned, the cost. And as you said, in our early 30s, we may be making money, but that money is going to pay back student loans if we didn't have the opportunity to pay for our education outright. And so to come into this industry, and it is an industry, and to have these ideals, these expectations that you know I've learned everything that I'm supposed to know about my specialty. I want to grow in my specialty, and now I want to apply it. I want to be able to help to care for my patients, and then to find that there's this barrier, you know, that is between ourselves and our patients. And it's really about how much is this going to cost? Are you trying to get more money out of me than you should? Or why do I have to pay for this? And then we're always the ones that are the bearers of the bad news if there's an issue with authorization or what the insurer will pay. When you know, we have nothing to do with that. So this on-the-job MBA, where we're learning along with the patients that we care for, about all of the ins and outs of the economics, and we're the ones who have to tell our patients healthcare is not free, that we can't work for free, that you know, there someone is going to have to pay, and if it's not the insurance company, it's you, and then having to look at how that impacts some of our patient populations, and they choose not to receive care that could be preventive and help them say five years from now or ten years from now, but they're making these financial decisions to basically put things off because they can't afford it. All of that is extremely heavy.

SPEAKER_01 7:30

I think the message there is it's a barrier to your personal mission of helping patients. And I would also say the same thing for hospitals. I know when I was at Johnson Johnson, there were occasions where we were launching a new product that would cost more. And historically, most people would come back and do the reimbursement after. And on one of the products we were launching, we recognized that we were actually changing the entire profitability of a hospital if reimbursement wasn't yet made available. And that's a rarity behavior that a company would do that. You know, generally the process is a little backwards. So it's interesting to me. I interviewed a gentleman who has most of the infusion centers in the southeast, and they make their money on the buy side. So they don't even have a reimbursement code. So he buys it for a product for a dollar, he sells it for a dollar 25, that 25 cents funds his whole facility. Well, along comes a pharmacy benefit group, and they were doing what's called brown bagging. They were shipping it directly to the patient to bring it to the infusion center. And he was debating how long he can sustain that because he was going to have to shut down some of his more rural infusion centers if that model persisted, because he couldn't fund his employees and meet the state regulations. And so there's a lot of unattended consequences there because the business people on top are constantly monitoring flows of money and how to squeeze a penny out of something. Where the mission of hospitals and physicians are to take care of the population and be as efficient at it as they can. But if we don't fund them, it's a problem.

SPEAKER_00 9:15

It is a problem, and it's a fascinating one from the business perspective, because you can understand how private equity might back a startup that would do this brown bag. And it looks like a really great thing, right? An opportunity. There's an opportunity. But the downstream effects of that certainly, as you say, could rob rural patients of the infusion center for which the brown bag was created. And how do we have a prospectus on this? What are the mechanisms that we can use to protect health care in a free market economy? An economy where we can have these entrepreneurial ventures, where we can create opportunities for tech or direct to consumer access, expand the market per se, but still protect the patient and the centers. At the end of the day, the only obvious answer to me is regulation. The only obvious answer to me is having entities that are unbiased look at the, as you say, the end goal, right? The end goal is not to have a brown bag company that makes that is a unicorn that makes a billion dollars. That's not the end goal. The end goal is for the patient to get to the infusion center and to have their care, their infusion. So having unbiased entities that can evaluate and assess these opportunities and protect health care. But right now, I would challenge you, Jim, maybe you understand James better than I, but is there an entity, a truly unbiased entity, that is protecting care for patients?

SPEAKER_01 11:16

So I think you have some nonprofits trying to do that by disease specialty. My daughter was at a pediatric Medicaid organization in Boston, and during COVID, she was working at the house, and I was truly touched by the effort that she was doing to coordinate care both in and outside of the system. But arguably for that doctor's office, she was an expense. And so

When Money Blocks Patient Care

SPEAKER_01 11:45

they were doing it again for mission reasons. I think that one of the challenges, you know, we have these value-based programs. So in elderly care we have PACE, and I was talking to a uh ironically a venture-backed pediatric startup who's focused on rural areas and taking total I'll I'll bid the patient and I'll take care of the rest. Now that model works for them because they don't have events, right? They're covering the continuum of care. But for someone like an intervention cardiology, an orthopedic uh radiologist where we're handling the events, I don't know how that you know, shared risk getting more efficient sort of works. Do you have any idea of or No, it doesn't work.

SPEAKER_00 12:31

And you know, one of the reasons it doesn't work is because there's just not enough money there. So when you start looking at value and say bundling and all of these things, it doesn't factor in, as you were saying, it doesn't factor in the cost of the implants, the instrumentation, whatever that may be. And depending on the complexity of the case, it's very challenging if it's say, for example, a very complicated elderly person with, say, a revision total joint or a periprosthetic fracture that requires removal of the implant, which is a big procedure, then placement of another implant, which may be a very specific implant and somewhat complicated, and then if there's a fracture associated, the plate and screws and everything that goes with that treatment, what Medicare pays probably wouldn't cover all of what is required to get that patient walking again. If an actuary were to do the calculation, that number could be quite large. It reminds me of when my children were young and I tried to detail everything that I was doing with my kids, everything I was doing with work, and put it all on a calendar and say, okay, this is how I'm going to budget my time. It didn't fit. It did not fit, but somehow I got it all done. So if I tried to program it out and say, okay, for this 12-hour period when I'm awake and the kids are awake, this is how it's all going to come together. It just did not fit. And I think that's where we are in the event-specific parts of healthcare. Somehow, if we were to do it actually and try to make it prospectively planned out, we would find that there's just not enough money. And I do think that some institutions, that's why they close because they just aren't able to make those margins.

SPEAKER_01 14:40

Do you want to maybe explain in your practice what you see and the people you talk to, what they're missing?

SPEAKER_00 14:45

Yes, I think that this is a fascinating journey because we went through that process. When I first came to the practice, I began looking more closely at reports and my staff hated it. Okay, generate this, generate that. I wanted to see the details. And we did go through that evolution of understanding where we were underbilling or where there were certain additional codes that were missing, but the insurers have gotten smart. So I will say that what you're describing is probably most applicable to eight to ten years ago. And currently what we're finding is that, and again, I'm speaking about commercial pairs, and this is across the board, not any one specific pair, is that algorithms are being used, technology is being used to highlight those higher complexity codes and essentially to delay payment, either delay payment or deny payment. So reimbursement is actually, I won't say it's easier, but it's more predictable with the lower complexity codes. And once we enter into the higher complexity code region or the very infrequent code region, those claims are then either denied outright because there's a questioning of the code, and again, it's an algorithmic denial, or those codes then are delayed. And for our practice as a small individual practice, it could be delayed for a year or two. And what we find is that in order for us to get a fair hearing, we have to take the denial or you know, aggressively pursue either the denial or partial payment, and then engage a mediator, an attorney, someone who didn't actually do the work, who will take 25% of whatever we're able to recoup to then try to regain the reimbursement that you know was was due to us a year or two or three ago.

SPEAKER_01 17:02

So there was a uh this was about 12 years ago, there was a study saying if we had a flat tax, don't want to care if you own a house, don't want to care well. If you make a dollar, I get five cents, was I think the number at the time. And you'd be taking out every accountant and lawyer in the system. And there was a small movement to do it, and it got crushed. And the reality is for the average citizen, it would have been so simple, right? But this is why billionaires don't pay taxes, and you know, just and we but yet we complain because we have a certain tax code that makes us all pay different amounts too, right? So it's it seems to me that what's going on here is there's two slices to it. So the business that I was sharing with you was identifying the high-end code, and what you're bringing up is the second piece. So what? When I submit it, I ain't getting it. And I think that that's a very interesting thing. And so I owned a durable medical equipment business once in my life, and we had a Polish and a Spanish population, so I had actually reimbursement people that spoke both languages, and at the end of certain quarters, all of a sudden, all my reimbursement was getting denied. And what I learned after a number of years of looking into it is it was a cash flow management issue for the insurer.

SPEAKER_00 18:19

Yes.

SPEAKER_01 18:19

And so there's two things going on at that moment, right? So they're reserving their cash, I'm taking money out to fund my business, but at the same time, my reimbursement people aren't informed, and so they would run the risk of putting in new codes to seeing if it gets approved and then coming back and getting told it's fraud, right? So the system's a a little messed up that way. And I think in the news recently, there has been in the past couple years exposes on insurance companies that the denial and the delay is actually a business strategy.

SPEAKER_00 18:53

Yeah, yes.

Why Value Based Models Break

SPEAKER_01 18:55

Right. So that's probably part of the regulation issue. So in your advocacy, because this isn't how you make money, this is your passion. In your advocacy, what are you bringing forth on these issues and who are you pushing this issue to that can help you?

SPEAKER_00 19:12

This is a fascinating issue, and we're just continuing to evolve as we are discovering what this industry looks like from the financial perspective and where every dollar is going. On the patient side, we're advocating to our patients and our practice, and when we're encountering patients who have had issues, try to be proactive on the front end. That's our best advice. To look at your insurance policy and to request, especially this time of year in January, early in the calendar year, the insurance summary plan benefits. A lot of patients don't even know that it's their right to know what their insurance will or will not cover. And if, say, for example, you have arthritis, or if you're looking at it for your elderly parent and you're just curious about what is accessible to them, you can request in advance to know how many sessions of physical therapy am I covered for? What will be my copay? Does a deductible come into play there? For example, if an elderly patient in our practice has a managed Medicare plan, they very well may have a limitation on the number of physical therapy sessions that they can have as an outpatient. And even though they're elderly, they may have a copay of, say, $25 per physical therapy session. So for someone who's on a fixed income, if that's $75 a week times four, that could be quite significant for them. And it could be a barrier to recovery from that fracture. So requesting the insurance summary of plan benefits, knowing what is the insurance company paying for, what am I expected to pay for, paying attention to whether a doctor is in network or out of network, depending on the plan that one has, that may or may not dictate who is your provider, who cares for you. But on the back end, look at what is called the explanation of benefits or the EOB that comes to you from the insurer, and just peruse it to see did they pay your in-network doctor in network or your out-of-network doctor in network? That happened to me recently. I had you know routine care, my physician was out of network, the surgery center was in network, but when I looked at the explanation of benefits, the out of network doctor was played in network. But I have benefits for out of network. Why did you pay my doctor in network? So those types of things are things that patients can do. Follow the money, just look at what your premiums are covering. From a provider standpoint, I have discovered in our practice, again, I don't know this for a fact, but I have found that when we allow errors to continue, say for example, we bill for something and we find that at 90 days that claim hasn't been processed or that claim was processed incorrectly. If we let that slide, if we're not on time with looking at that and following up, we will see more and more errors coming through from any specific insurer. So from a provider standpoint, it's really important to unfortunately have the staff, which means you have to pay more people, to pursue those claims, to look at those claims routinely and regularly, and to flag errors on reimbursement. And I wish I could say that errors in reimbursement were infrequent and almost never happened, but it's exactly the opposite. There are almost always errors in reimbursement, and it's our job to make sure that the doctors are paid appropriately for the work that they do. So on the provider standpoint, billing correctly, reassessing those claims, following up on reimbursement, really following the billing and collection side of things. From a societal standpoint, I think it's really important for us to recognize that only certain entities are really benefiting from the for-profit nature of our healthcare system. We have winners and we have laggers, and the winners tend not to be reimbursement dependent. I think that's the societal question that we're going to have to come to a reckoning with sooner rather than later.

SPEAKER_01 23:56

So, what do you advise for people that reach out to you when they're practice to take for steps?

SPEAKER_00 24:05

On the practice side, it really is what I mentioned before. Pursue doggedly the money that you are owed. Don't take no for an answer. And even if it means paying an attorney 25% of your reimbursement, don't let that go. Don't take it lying down because you're doing the work. It's fascinating that we have this system where you have these experts who are the ones who are actually doing the health care, right? Be it the physician, the nurse, the assistant, they're actually doing the work. But when you look at the healthcare dollars, they're getting the smallest fraction of the healthcare dollars. And so we can question whether this system is actually working or if it's fair. But from a practice standpoint, it is very important to follow the dollar. But it's tenuous because you're reimbursement dependent and the entities that are paying are much larger. Even if you are managing a healthcare system. For example, my alma mater, Johns Hopkins, they couldn't find an agreement with United Healthcare for reimbursement. And these episodes had popped up earlier in 2025. It happened to Stanford, it happened to Mount Sinai, but Hopkins was the one where they literally could not come to an agreement. United Healthcare had other facilities that they

Algorithmic Denials And Delayed Payment

SPEAKER_00 25:35

could work with, and 60,000 patients found themselves without their healthcare at Hopkins and had to find other healthcare providers. So it, you know, the insurer as an entity has the leverage of network, has the leverage of number of subscribers to call the shots. So that is a challenge. And certainly, as you mentioned, the actuarial complexities of providing insurance are realities. However, I think the counterpoint to that is that most of these companies still remain profitable, and that many of these companies where 20 years ago you didn't see health insurers in the Fortune 100, let alone Fortune 500, United Healthcare as the largest, is a Fortune 100 company. We have to ask ourselves a question: should an insurer be in the Fortune 100 from a philosophical standpoint? What does that represent? I think we're looking at what it represents in terms of patients and the issues that they're having to get the healthcare that their premiums are paying for. But this is what the end game looks like when those that control the money control the industry.

SPEAKER_01 26:57

And and it's it's a bit of controlling the patient too, right? I think of this is a really weird example, but I I think it's not terribly dissimilar. Um, if you look at the average uh HVAC person that comes to your house, if you go back 20 years ago, it was mostly a private person who got paid and you know made their own decisions. There's an entire intermediary industry that's come in that gathers things on the internet, deploys them out to this person, they're making less. And at the same time, these guys are making money and your prices are going up. So the question is these intermediaries are are making money. And I think this is with AI and everything going on, this is going to be a very interesting challenge across all of our economy. How do you keep current on all these issues?

SPEAKER_00 27:49

I read the newspaper, I talk to people, I read books, going through the process of writing my own book certainly allowed me to review some historical data. I'm very dependent on journalists, investigative journalists. And I have noticed, especially in 2025 when there was more litigation surrounding uh healthcare stories, that journalists generally are more cautious in terms of what they're reporting. And I think part of that, again, has to do with the size of these institutions, these insurance institutions, and their ability to pursue litigation and to withstand the scrutiny. Yes, and we do have that. I personally can't look at it every day because I find it somewhat depressing. We do within our practice have staff that are monitoring those. And one of the big things that has come out for orthopedics this year is that Medicare has been transparent about the use of algorithms to review a small subset of orthopedic codes. And what I noticed when I reviewed those codes was that they were primarily areas where Medicare would extend a denial. So, say for example, most Medicare patients have some degree of arthritis. So if it were a knee arthroscopy or partial menasectomy that was indicated for a Medicare age patient, that was on the list. Other treatments that generally have been in the literature shown to be slightly better than placebo or no better than placebo, those are the ones that I saw on Medicare's list that would be reviewed by algorithm or by AI rather than by a specific entity.

SPEAKER_01 29:48

How many referral patterns do you have to your orthopedic practice? I mean, there has to be dozens, right?

SPEAKER_00 29:54

Yes, there are lots of referral patterns. But just to get back to your point, I would like to propose that this is an ideal opportunity for technology. That I make the argument that we should have standards. As you say, these criteria are, I would say they're sometimes hybrid. If we're looking for prior authorization for an MRI, the requirements at Cygna are different from the requirements at United Healthcare that are different from the requirements at Aetna. If I'm looking for an MRI of the lumbar spine, I have a CPT code, I have an ICD code, and this is what I'm looking for for a specific patient, then why can't across the industry we have a set of criteria that must be met? Why are they different from entity to entity? Standards could certainly reduce some of the waste, some of the variability, and create an ease of submission of claims and then also review of claims. And why we aren't leveraging technology to do things like that, to create those standards, I certainly wonder why. Yes. As a specialist, we do have multiple streams of how patients come in. Patients could just know about us because their cousin was treated in our practice. They could come by recommendation of their primary care doctor or their rheumatologist. When I first started in the practice, we participated in a Medicaid HMO plan that was across the state. And we would have patients literally coming from across the state because most orthopedic surgeons were done with that Medicaid managed HMO, managed Medicaid HMO, and basically said we're not participating. And it took a very you know critical experience for us in our practice where we too had to say we're no longer going to participate. We found

Patient And Practice Survival Playbook

SPEAKER_00 31:55

that the patients that we were treating they needed us, that it was a beneficial experience both for us and for the patients, that you know, this was something that we were willing to do, almost in a philanthropic kind of way. But ultimately, the red tape and the lack of services for the patients and the conflicts of getting authorization, in addition to the fact that they only wanted to pay for office visits and would give us a very tough time when we did surgery on our patients, all of those reasons forced us to leave that plan. But there's certainly the opportunity through the creation of standards and the utilization of technology to create uh decreased waste and an opportunity for transparency both for patients and for physicians.

SPEAKER_01 32:46

Well, I think uh two stories I want to share. I shared with you previously that I was running some of the master's programs at CMU for a number of years, no longer doing it. But when I first started in 2007, I was shocked how a CMU masters of healthcare policy and management what they were making. And I remember talking to a physician friend and said, okay, I came from Jane J. and McKesson and Boston Scientific and all these other places where these salaries were competitive around the country because they were trying to draw the best and the brightest. And that was not the case at the time. Now, I will say today that number is totally competitive. So I think we're starting to get some more administrative talent, some better education in there. But we also need the tools, and I'm not sure if you're familiar with the company Argmetics, it's a spinal. So this is a little dated, so they're doing well and they're still crushing it. But basically, what they would do is they would do a 3D-based anatomy scan of your spine, and it shows you how do you how do you orthopedic people have such results without these tools? 20 years ago, I just have no idea. But you put the spine on the table, you're doing your thing, right? And you have your map, but you move the patient by two millimeters, now your screws are off, right? Just for the audience to sort of understand mechanically how amazing orthopedics are in terms of the results they've gotten. And so this did require a CT scan. And their biggest market adoption issue several years ago was if there were CT scans inside the hospital, meaning it was a fixed cost and they would get reimbursed on a different sort of code, no problem getting that done. But if the hospital didn't have it and they had to send it out and pay retail prices, the CFO was blocking it. Now, having said that, some of their not only were their results amazing, but they could actually have visuals of patients who went home and did the wrong things that they weren't supposed to do. Now they had actual evidence, right? So, in the absence of having evidence, these procedures, different classes and codes are guaranteed for a certain period of time. Doctor has to do it and the hospital has to do it free again, right? For a revision. It's amazing when you looked at the absolute outcomes results of this technology and that some hospitals weren't adopting it because they didn't want a CT scan. And so it's a pennywise and pound foolish thing. And I think the issue is that our measurement systems that exist today are so young and naive that they don't really have a sense of root cause and overall outcomes impact.

SPEAKER_00 35:18

I think it's really important to make to connect those dots and to make the argument that there should be standards. We deal with the similar thing with the knee and the hip. We're not dealing with experimental technology, so the patient's insurance is responsible for the cost of the CT scan prior to the knee or the hip replacement. As you say, the outcomes are significantly better when robotics is employed to do these total hips and total knees, but some insurers will not pay for that CT scan to allow the patient to have the robotic procedure, which has better outcomes. And how we deal with that obviously becomes an administrative burden because we want to do the best for our patients. We want to make sure that they have the opportunity for the best possible outcomes. And that's where that healthcare waste dollar comes in because of that administrative burden. But if there were standards, national standards, and we could talk about international healthcare systems, but and I'm not saying that we want to live in China, but having internet, you know, having these standards, having the just prescriptive uh instruction for those things that are known. Hip replacement, knee replacement, that's not new. No, you know, for those things that are known, having those standards could be quite beneficial to the industry.

SPEAKER_01 36:49

Yeah. And then there are pockets of incredible creativity going on in this country. I will occasionally do strategic sessions with boards of directors, with providers, and there was this nonprofit in Idaho. And because they were a nonprofit, they really took the time to measure things and think about things, which is a little different from for-profits sometimes. They don't have the time. But what they had done is they had actually figured out a way when their rural patients had cancer to send them to the mayo clinic. They had someone that set up the housing because these are old people that are nervous, and in some cases, these were farmers that never traveled out of the area. They take care of the transportation, they'd take care of everything, they get them treated, set them in a hotel, and bring them back home. And it was actually more cost-effective. So there's creative things that you can do, but unfortunately, that

Standards Tech And Better Outcomes

SPEAKER_01 37:40

structure was outside of a traditional reimbursement system, those extras, right? So these guys were self-insured because they were a nonprofit and they could do it their way. But those are the kinds of things. And I think Kaiser is an interesting example. And we were talking earlier, your husband was part of UPMC, which I know here in Pittsburgh. And so I often say if I were trying to get normal disease done Kaiser is a place I'd go. If I'm trying to get some extraordinary care for something cutting edge, I would go to UPMC. And the challenge that we have is how do you get both of those standards together, right? It's a really interesting challenge. What else would you like to share with the audience?

SPEAKER_00 38:20

Oh, that's a fascinating question. Because I'm still trying to figure it out. What do listeners of this podcast or people who are interested in healthcare, how much do they want to know? What do they want to do? How far do they want to go? I guess the one thing that I would mention that we haven't touched upon, we've spoken about the industry as if it exists outside of a context. We did speak a little bit about government-backed insurance, but there are elected officials that are supposed to be overseeing all the things that we're speaking about. And if your audience, your listeners, have concerns about healthcare, have concerns about, say, prior authorizations or practices that exist within healthcare that could be benefited by technology, write your legislature. Let them know that you are interested in healthcare and you are interested in legislation that could make healthcare more affordable, more accessible, and more up to date with the advances in technology that we're seeing in other sectors. Don't be quiet. Write to your legislators, let them know what you're thinking with regard to your healthcare and what's accessible to you.

SPEAKER_01 39:42

I met a fascinating woman on one of my podcasts whose side hustle is she's created in Massachusetts an advocacy group to get healthcare wisdom people into politics. And I think the challenge is our current healthcare system, you know, it started. I remember when I was a kid, my grandmother lived with us, Dr. Wally would come to the house.

SPEAKER_00 40:09

Yes.

SPEAKER_01 40:10

So these were independent practices, and then hospitals looked at physicians as a kind of sales rep. When your family couldn't take care of you, they advised you, right? And so physicians became a hospital's revenue source. And over the years, it's just morphed, and we've got this fragmented system that uh needs attention, and it's so much bigger than any and any one person can put their wrap their brains around. And I think that calls for what that woman was doing with advocacy so that people can can understand it. I think that's one of our major challenges is it just doesn't uh you know make sense to people. The first one got denied. We looked up the patent reviewer, and this person was an you know computer science AI expert. And what it dawned on me was that the data sources that we were bringing together because of HIPAA and privacy and all that, there were gray areas in the market that if you were a consumer, you know, you were an Amazon customer, we'd know everything about you all the way through. We'd know your finances, we know everything. And so it ended up educating that person, and it took a long time to educate that person that I called these black holes in the market, and that we were with AI being able to fill those black holes with information and yet keep privacy. And that person had no idea. So I think part of the problem with our people that are well-intended with this is they just don't know it. And I've been in this business for 30 years and I still don't know.

SPEAKER_00 41:44

And I would join that bandwagon. I think we all have those facets if you're in the industry. You have the facets that you know very well, and there are other facets that you probably don't understand quite as well because, as you say, it's so fragmented.

SPEAKER_01 42:00

So if someone wanted to try to replicate your journey,

Follow The Money And Write Lawmakers

SPEAKER_01 42:05

what would be the easier way or what pathway would you provide them?

SPEAKER_00 42:09

For someone who wants to understand, this is something I learned in business school, and I think it goes across time period, across cultures, always follow the money. Look at the business side. If you want to understand healthcare, look at those winners in the healthcare markets, those companies that are profitable, those parts of the sector that are profitable. Then look at the losers, look at the ones that are struggling. I do think you can very readily divide them into those two groups, those that are reimbursement dependent and those that are not. But I think to get the overall view, if I had done that 20 years ago, I would understand. But it took the personal experience of going through all of that. So once you've got a handle on the business side, then begin exploring the technology, the advancements, what technological innovations are targeted toward efficiency, are targeted toward streamlining processes. And then lastly, looking at that doctor-patient relationship and thinking about, if you're thinking about solutions, thinking about ways to use those first two categories to bolster that relationship and to solidify that relationship. Because at the end of the day, we practice medicine because we care about patients and we want to have those relationships. We want to help to make people's lives better by helping them to have better health. And so it always has to come back to the patient. It always has to come back to how is this going to make me someone who can provide health care better?

SPEAKER_01 43:55

I would also say that particularly for the physician office space, it Material cost in a hospital is in the 40 to 50 percent of a code, whereas in a physician office, it's generally under 25 percent. And so what's interesting is the McKess and the Cardinal, the Henry Shines, these sales reps, value to their physicians are generally helping them get efficient in their practice and do other things. So I would also say that they're a source of information that's very unique because for them to add value, it's not about how good our material is and what it does in a procedure. It's more to do with how can I help you improve your practice, make your patients happier and all that. So I think that's another source. Well, I want to thank you for joining us today.

SPEAKER_00 44:44

It was been a great chat.

SPEAKER_01 44:48

I'm gonna shut this off. I wanted to just show you something.