Healthcare’s Quiet Monopolies And The Cost Of Care

Full transcript

Hello, everyone. Welcome to another episode of the Anthony Eamon Show. I'm your host, Anthony Eamon. Today we got another great episode for all of you today. We're gonna deep dive into a topic that not many people want to even understand and two get confused all the time. So without further ado, welcome to the show. My brother, Dr. Eamon. Pleasure to have you on. And then welcome back, Tim. It's a pleasure to have you back on from Growth Pain Management. So let's do a quick little round of introductions. So, Chris.

Um, all right. So I'm Christopher A. Met. I'm a pain management physician. I work at uh Growth Pain and Spine with our wonderful CEO, Tim here. Um I did my residency training at Stonybrook. I did four years of sports medicine before going on to George Washington University for interventional spine for one year. Um and I started with the practice about two and a half years ago. Um you know, my biggest passion in medicine is you know treating patients in pain, sports-related injuries, spine, treat the whole body. So I take a holistic approach, um, multimodal pain control, and uh, we've really built a brand around that. And it's been it's been really it's been really great. Good, good ride. And Tim, quick little introduction.

Yeah, my name's Tim Growth. I'm the CEO of Growth, Pain and Spine. And uh my dad started it 15, 19 years ago. I started with him when it was 15 years old, and I've been working there for uh five, six years now, and um yeah, I'm happy to be here.

Yeah, so let's start with the million-dollar question. How do medical practices make the money? And how exactly does that look like from the business side of it to the patient side of it? So I'm gonna give a little what I feel like the average American understands about medicine. I pay for insurance, I then come to XYZ doctor. Let's say it's here, show up, get an appointment with the doctor, doctor does whatever they have to do for me based upon my needs. Uh, I go home. Sometimes maybe a pay copay, depending on the practice or depending on my insurance rates. And then if I have a deductible, I eat up a little bit of that sometimes. And then otherwise, the doctor just gets reimbursed for the insurance company and they make enough money just through that. Beyond that, I don't think anyone understands absolutely anything beyond that. Is that fair to say?

Yeah.

Yeah. So I want to talk about it from first the professional side of it. So what you guys specifically do. How does billing work from your office? So if I come see you and I'm trying I need a procedure done, or I'm just getting a consult. What happens on the back end after that?

So the doctor would see the patient, or the APP or provider would see the patient. They would do their note, they would sign their note, it would get closed, and then it would show up closed in a queue for billing to then go in and look at the note. So they would look over different things. I mean, most in in pain management and what we do, every every visit is typically an office visit or a consult. So it's considered an EM. So they would look at um, and practices do this different way. Sometimes the doctors do the coding or the EMR recommends the coding and then they follow it, or practices have coders or people trained on the AMA guidelines. So they would basically look at the note compared to the AMA guidelines, which basically are based on the severity of the case, and then they would decide whether or not what what level of service it um qualified for, and then they would assign the CPT code, which is the the code that's used for billing, and then they would do the ICD 10 code based on the note. So the note should be documented with a diagnosis like lumbar spondylothesis, and then they would know the ICD 10 code, which like lumbar ridiculous would be like M5416, right? And they would put that in the bill, it put the the EM in the bill, and then they would lock and sign off, and then it would get sent to a clearinghouse, and that clearinghouse is connected with all the different payers, and it would basically scrub that claim to make sure that there's no errors, like there's like billing is its own language, so there's modifiers and things that need to get put on based on what happened there, right? And so it would scrub the the payer rules against what was actually done in that situation, and then if nothing conflicted, it would pass it along to the payer, the payer would get it, and then they would take anywhere from two to four weeks to respond with either with an ERA or an EOB. ERA is electronic, EOB could be paper, and um that would come with either a pay payment or a denial or or patient responsibility, and then that would get posted to the patient's account, and then the patient would uh you know get get a bill, or we would have gotten fully paid by insurance.

And it's basically determined on complexity, I think is like a good simple way of thinking about it. Like an office visit has a certain reimbursable amount depending on the payer, and it's based on the complexity of the visit. Did you review imaging? Did you prescribe medications? And then each of those had different tiers of payment, and the billers determine based on that visit and what your note was how your note was written, what level that will be billed at. Um, and then from a procedural standpoint, there's certain guidelines set by payers on justification to bill a code and perform a procedure. So you have to check off certain boxes and make sure you're documenting the proper words in order to justify that claim and do that procedure. So, you know, one of the problems you run in with healthcare is you could do everything perfectly. You could do a procedure that is justified. But if you don't write the right words, if you're one day early from their guidelines, which are just their arbitrary guidelines that are loosely based on medical recommendation, they could deny a claim or take their money back depending on the payer.

Whose day? Is that the private or is that through Medicare Medicaid?

Oh, yeah. I mean, and we should we should talk a little bit about that. I mean, because people should understand like the level of scrutiny and the things that we have to go through in order to get paid and get paid without a takeback, right? So people think, oh, you get paid, you get paid a lot of money, doctors make all this money, it's great. People should know that, like, up until this year, where the big beautiful bill was passed, Medicare, especially in private practice, has cut every single year, year over year, how much we get reimbursed for different services. But beyond that, Medicare is really difficult because 90 something percent of what we do, and I think what mostly gets done in medicine, I think it's a little different at the hospitals depending on what procedures you do and whether or need not you need authorization. Medicare pays without ever seeing the note and without ever getting an authorization. And then what they do is they have up to seven years to go back and say, Hey, did you do this correctly? So I wound up in a situation, our practice wound up in a situation where we build something for two years, we thought we were doing it right, and then we paid all our doctors based on what they did, their productivity came out of our pocket, they left, some of them quit, some of them weren't with us anymore, whatever it was. I mean, we don't have high turnovers, thankfully they're all there, but I'm not gonna punish a doctor for something like this, right? And so they came back, they did an audit, they looked at everything, and they said, Oh man, we paid you $1.28 million dollars, and you shouldn't have gotten paid for that. So give it back. And then you have to go and fight them, and you have to hire lawyers that charge a fortune, and they and they even it's even set up even worse than that, because under Obamacare, one thing that happened that's absolutely outrageous, and there's two things that Medicare would often accuse practices of in the past. One was overpayment, and two was fraud. And under Obamacare, based on you know my conversations with our lawyers, is that if they accused you of fraud, they can now take expansive action against you in order to take back money or audit the practice. But if they only accused you of overpayment or overbilling, they weren't able to do that. So a lot of times these auditors would say, Oh, you know, your your billing practice fall outside the algorithm. We looked at five claims and we think you're committing fraud. So we're gonna suspend you from the Medicare program while you what we look at what you're doing, and then we may or may not find something wrong, and when we decide, adjudicate based on our process, we'll unsuspend you or we'll we'll revoke your license. And I've worked, I've worked with a guy recently who was revoked from Medicare for fraudulent billing, and you would think it's a fair process, and I think it's gotten a little bit better over time, but you know, in working with our lawyers on different, you know, things related to Medicare and other payers, we came across, you know, this story where this woman um you know got accused of fraud, was suspended from Medicare, and appealed multiple times, was found, they found against her, got in front of it, took four years to get in front of an ALJ, which is an administrative law judge. That's the final arbitrator of whether or not you did right or wrong. And she got in front of the judge four years later. Her practice, she already went out of business because she had been suspended for Medicare for four years. She lost her entire life's work. She gets in front of the judge, and the judge throws out the entire case. She did nothing wrong, but everything was gone. You know what the government says? Oopsie. Oopsie. Sorry, that's our process. And I just say, like, one other thing, like, and just so people understand like the level of scrutiny we're up against and like how ridiculous things can be sometimes. Last year we had an audit on back braces. We do DME as a part of the practice. We think it we found it to be extremely helpful to patients. And our doctors were writing the script for a back brace. It was called cryo lumbar brace. Uh uh, and it was like a G Force brace, that's where we were getting it from. And one of the words, like like it was like extend, was put into the quotation marks of like the exact like name of the brace, right? And the actual brace and its credentials for what it was approved for didn't include the word extend in it. And so Medicare initial findings throughout every single one of our braces saying that we gave a brace that doesn't exist that wasn't qualified. And so then we had to hire a lawyer to fight, and thankfully they overturned the under thing, the entire thing. Because how ridiculous is that? But I mean, it's just like things that people don't see.

So who sets the rates? Is it the insurance company set the rates for the reimbursement, or do you guys build the insurance companies based upon your risk, let's say, of what's gonna get hit back?

We determine the coding on whether or not, like, for instance, the EM Dr. Amen was talking about earlier, like the complete level of complexity, but Medicare sets the rates, which is set by the government, which ties back to the budget, right? And then most of the payers, aside from workers' comp and no fault, which have their own fee schedule in New York, I think it's different in other states. So workers comp and no fault pay the same. And then most of the other payers pay a percentage of Medicare. And that could vary from 50 to 60 percent of Medicare or Medicaid, which is even less, all the way to, you know, hundreds of percent of Medicare. And uh, you know, if you're a private practice, you're usually not getting much more than Medicare.

So think about it this way you have a private practice, you're a small group, you're trying to you have a lot of overhead, you only have one, you know, working physician who's bringing in money to the company, you have to hire all this back-end staff, and they're gonna determine we're only gonna pay you 80% of Medicare. Well, how do you get to determine that? They get to pick. Now you take a large health system like Northwell, they can charge two, three, four, five times Medicare rates because they have the power and the patient population. When quite frankly, it should probably be reverse. Why would a healthcare company want to pay these big, expensive healthcare companies and then screw the little guy and not let them grow? You're essentially you're encouraging monopolization, and that's just kind of how the system is set up.

They just wind up with such big bargaining power when you're a huge health system, and then the cycle self-perpetuates, right? When you're NYU, which purple, I was just having a conversation today. There's purple everywhere. Actually, uh Metro PT just cut a deal with NYU. They are now affiliated with NYU, they're doing a joint venture, Metro PT, all over Long Island, and they're getting NYU's rates. And you know what? I would guess that their profit bottom line, no expenses changing, is going up 3x just because now they're getting NYU's rates. And so, you know, NYU has all this bargaining power because they can't afford to not have them in network. Because if they're not in network, they're gonna get bludgeoned at a network with added network rates, and all these all these employees of other of other employers are gonna complain, oh, I can't go to NYU, I can't go to these hospitals. Like, how are you a legit insurance company? So they get backed the insurance companies get backed into the corner, have to agree to exorbitant in-network contracts with these big hospital systems, and then these big hospital systems come look at these other practices and say, Oh, well, you're five X more valuable to me than you are to you. So I'll just suck you right up. And then everybody winds up employed by the big system, and then everybody's a cog and a wheel and miserable.

That's so interesting when you look at it and you kind of see. I mean, everyone knew healthcare was screwed up, right? The whole system is bad. Wax. And I think COVID shed a real big light in the healthcare system as a whole, especially exposing certain parts of it. And I guess the specific point is you look at let's take the COVID vaccine, something super controversial back at the time, right? It was uncovered that not that doctors were getting paid to push the COVID vaccine, but insurance would reimburse based upon the percentage of their population that did get it. And you see this, I saw this on the prediatrician level level, talking to some pediatrician doctors. Like they would deny people who didn't want to get the COVID vaccine because it would drop the compliance rate, which would then get them dropped from specific insurance companies.

Why? I've heard the term used that it's a bit of a mafia. You know, it's a large group that has an agenda and they have what they believe to be the proper motive and the proper way to treat patients, and then they make incentives and they make reimbursement trends and they cut reimbursements in places they don't want it, and you kind of herd the sheep in the direction that they they want healthcare to go. I think it's also a simple way of describing it.

It's crony capitalism, also, right? Because you have big government in bed and reliant based on their policy with big pharma. And like it kind of goes back to like the big banking, too, right? Like just too big to fail, right? So here it is where politics comes in and the government comes in and they tell big pharma, you gotta do this, mass produce it. Like, and they require them to do it. And then on the other end of that is like everybody's gonna have to get it, you know, because otherwise, where does where does it end up, right? And so uh we wound up in that situation. And obviously the vaccine was not very uh well, I don't know, obviously.

I I don't think it was very effective, but it just kind of I think it shined a light to a lot of people about what goes on, and then it opens up the doors to seeing how screwed up everything is now. I mean, you mentioned let's take Northwell, for example. I for those that don't live in the area, that's the biggest hospital system. If you live in Long Island and you don't know Northware is even down to Florida, they've expanded everywhere. Northwell's huge. Absolutely insane. It's mind-boggling that someone like that is getting three to four times a differential on insurance paid through to them. And let's take it to the the other example. Let's talk from the consumer standpoint, right? So if I'm not lucky enough to get a really good health insurance through my employer and I have to go to the marketplace or find a private, it's gonna cost me as an individual here in the state of New York 1,100 bucks for disaster insurance a month with a deductible that's $10,000. So now I'm getting screwed as a consumer, and now you're telling me that I'm getting screwed paying all this money, but if I want to come see you, you're gonna get screwed seeing me, where I'm better off going to the bigger guy now because they'll get at least some money out of me while you're not gonna get any money. We're both double dipping into a system.

Well, I don't know that you're better off going to the bigger guy.

I mean, you're you're just in such a better guy, the bigger guy's better off that I go to them.

Oh, yeah.

Right? Because they're gonna make more, but I'm also getting screwed up as a consumer.

Yeah, yeah, because you're gonna pay a coinsurance or have a deductible and it's gonna be that much higher because their rates are that much higher. And right, so you're you you get you get the brunt of that, right? You're gonna pay the 20% coinsurance or the deductible, and it's gonna be at a much higher rate. You have a thousand dollar deductible or five thousand dollar deductible, or your ten thousand dollar deductible, and you go to NYU, and NYU gets six hundred dollars for an office visit, and we get $150. Well, if your deductible's ten thousand, you're paying six hundred dollars if you go to NYU, you're getting paying $150 if you come to us, right? So, but that's that's what happens. Everybody that that that becomes the options that that's out there.

So it's just and just access to healthcare in general, you know, they have control over what a physician can do and what algorithm you can treat, right? So if I say to my patient, listen, you had three back surgeries, you've had epidurals, you've had a nerve ablation, you're on opioid pain medications, you're 45 years old. We're not going to do this for 55 more years of your life just taking opioids three times a day, right? We need something more durable. Well, what do we have left? There's not a lot of options, right? So we have spinal cord stimulation, neuromodulation. This is a very well-established treatment. It's basically a pacemaker for your back that blocks pain signaling to the brain. And for a lot of patients, it's life-changing. It doesn't work for everybody, but there's a trial period. You try it out for a week, you see how beneficial it is, and you offer it to them. So that trial period not guarantees, but drastically increases the rate of success when you do this permanent implant for these patients who have no other options. But now each individual health payer can determine what rules they want in order for a patient to have access to this treatment because it's so expensive for them. So, for example, we we know that certain health insurances we're gonna get an approval for. Oh, they're great, they'll cover that treatment, no problem. And then I'll have a patient come in and I'm like, you know, damn, I know this is a great option for you, but I can't even offer it to you. They're like, well, why not? I'll put the request in, but you know, it's United Healthcare. I know they're gonna give me a hard time. We have a very low success rate with Fidelist or United Healthcare, right? Put the request in, they deny it. They say, This is the reason we denied it. There's no blood work. We get denials for we don't have a platelet count. Where'd you even come up with that rule? Like, where in medicine do I need a CBC in order to do a spinal cord stimulator? So then you get the blood work, you submit it, they deny it again. This time it's something different. I had a denial from Fidelis once that said, no evidence of another spine bone pain problem. I don't even know what that means. That's not even a medical term, spine bone pain.

Well, that's because they don't have doctors reviewing reviewing it.

So then you're like, well, yes, I know that there are other things that hurt, but the main issue is what I want to treat with the spinal cord stimulator. Okay, you have to do a peer-to-peer. Well, what's a peer-to-peer? Peer-to-peer is a process that is a mirage that your physician has the opportunity to get something approved. However, having done many, many, many peer-to-peers, I'll tell you how most of them go. You get on the phone with someone who's not in pain management, who's a physician, who works for the healthcare company, usually someone retired or general practitioner or an OBGYN, and you've printed up all of these research papers and you've been reading them all day. You blocked 45 minutes in your schedule where you're not going to make money, just so you can get this patient approved for this stimulator. And you go through your whole spiel and they go, you know, I know what you're saying, and I agree with you. Medically, that makes sense. Unfortunately, due to this piece of paper that the insurance company gave me that said that this is not an approved treatment, I can't agree with you. And I said, Well, and I've tested this, I've said this to these physicians. And I say, if you were me, do you think that this is a good treatment? And they always say, Well, you know, it makes sense, and and I get why you think it could help. And yeah, this is, you know, I've seen it done in other places, and I'll give examples of patients who have been successfully treated with it. But unfortunately, I can't approve it through a peer-to-peer.

So then what is the point of a peer-to-peer? Well, how do they get incentivized? How is that doctor by the insurance company getting incentivized?

They're paid by insurance companies. I don't know what their contracts say where they have to deny a certain number of claims. I don't know if that's true. Maybe that's true. But I'll tell you one thing the mindset of the insurance company is let's just blindly deny a hundred requests. You know, doctors are way too busy. They're not doing these reviews, they're not doing the appeal process. So 40% of them are not going to appeal. We just save 40% of the money and we'll approve the other 60%. And for a lot of things that are too expensive, they're just going to deny it forever as long because there's no incentive for them to approve it. You know, and as physicians, we can't give recommendations on insurance companies to our patients. We don't do that. But, you know, it's frustrating because I I know I have to treat my patients differently depending on which insurance they have.

So you're a patient coming in, and there's two different sides of this angle, right? I'm coming to see you as my doctor, right? You have four other patients waiting within that same hour block because you're trying to get a bunch of people in the door, right? And then you're seeing that you and I are talking 10 minutes. That's a good visit, the 10 minutes for some people. Maybe 20 minutes is a long freaking time sitting there talking. So, how do you get a complete medical profile of someone to be able to treat them the right way when? You're short for time. But then the argument on your side would be well, I'm gonna get denied XYZ claims from this person, or it's disapproval is gonna kick back seven years. I have risk, I have crazy risk. I'm waiting weeks to get paid if I get paid, which then they can look back seven years. Oh, take it a step further. What about my practice? Now I'm worried about getting sued. So I have to risk have a risk profile for that. So how is it beneficial for a consumer to live in a world where you're seeing hundreds of patients in an eight-hour shift and you're trying to make money as a business because you have to, right? It's not you can't do this for free. But then I'm getting the shit under the sick as a consumer and I may not kick that done. What's the solution for this?

It's a delicate balance, and I'd love to hear the business out of this. But from the clinical side, we we leverage a lot of employees or non-physicians to assist with that intake process. So, like I have a scribe who does a whole 35-minute intake, gets a full history, and then presents it to me so that when I go in the room, I can go, okay, is this this? Oh, let's talk about this bleeding disorder. You have this, this, and it's a much quicker encounter, so you can get through a lot of information fast. Um, so that's one way to leverage it. I don't know from a administrative side what you mean.

The way I look at it, and sadly, in my own experience, I think it comes down to this, right? It's in in a lot of medicine, it's one size fits all. It's extremely niche, and you're gonna come in and you're gonna fit into an algorithm, or your problem's probably not gonna get solved.

You're gonna I don't I think for 20% of the population, and maybe that's a little bit of an exaggeration, but there's a lot of people, they never get their problems fixed.

I think you're right. That's I think that's amazing, amazing point. I think you're a hundred percent right of that. They don't fit the algorithm, they don't get fixed, they get kicked around from specialist to specialist to specialist because they don't know what to do or they don't want to treat it, or they don't want to get that involved. Dr. Amen's actually fantastic about this because you know, I know you're describing visits that take 10 or 20 minutes, but Dr. Amen will spend, you know, as much time as needed solving the patient's problem and even helping them on beyond the scope of you know what would be typically pain management to point them in the right direction to who they should go see. So I do think there are doctors out there that that care and deliver exceptional experience and acumen and and can help people who otherwise don't get results. And so I think it's the the problem is that it's the diamond in the rough and it should be the opposite.

Yeah, it it can be very cookie-cutter with some experiences where you go to an office and it's like, all right, I'm a rheumatologist, I'm gonna do blood work for these 11 things. And if it's not that, sorry, I can't help you. But like, I think what makes a good physician is when a young girl who sit is a real story, a young girl comes in and she's got numerous fractures throughout her life, and someone goes, You're 17, you shouldn't fracture your wrist throwing a bowling ball, right? You must have some sort of bone density problem. Let's look into that. So you send them to the primary care. Primary care doesn't help solve the problem. So I find myself ordering blood work I don't typically order and ordering bone density scans on a 17-year-old, which got denied, by the way, because she wasn't of the right age to have a bone density scan. But we did eventually get that approved, thank God. Um, but you know, it's just a it's a it's very hard to practice good medicine when Medicare cuts are three, four percent every single year, and there's not more physicians because people don't want to go into medicine because reimburs reimbursements are cutting, patient populations are getting older and sicker, especially in pain management, and you have less time to spend with patients, and the access to care is so complicated for both the clinician and the businessman who's like, I want to offer these patients these treatments, and I'm not allowed because we're losing money. Like, there are literally procedures that I love that we can't do because we lose money if we do it. That's crazy, you know? So it's it's like science is way up here, medicine is 10 to 15 years behind, you know? And it's it's really caused by the this complex system that isn't a hundred percent accounting for what's take a silly example because I love that.

It's here and here. This is your differential, right? Where science is to where medicine is. Here's the silly example I say in the show all the time, and I always use physicians as a silly example. I go into the doctor's office, they're measuring my height and weight, and they're telling me my BMI. Why are we still using BMI as a metric? Probably because the way insurance companies want to get reimbursed off is my guess. But BMI for an individual has no, doesn't really matter. There's no that sticks out as a BMI, like I'm considered overweight, I don't look overweight, right? So why haven't we progressed even to a body fat scan that we can now get done with bioelectrical impedance in 15 seconds?

It's very simple. It's too expensive and it takes too much time. And the truth is, while there's not a 100% correlation with BMI and there are outliers that aren't going to fit in certain trends, you can get a good estimate of the general population and make some good recommendations based on on BMI, understanding that if a big jacked guy comes in, you're probably, you know, I'm not becoming digging jacked, thank you.

But but I think, you know, tying back to the earlier conversation, I mean it it's not easy for anybody in the system, right? And I agree. At the end of the day, you know, people don't like to hear this, but there is not unlimited resources, right? Like there just isn't. And I think like the most unfortunate part about society is that people are taking a third of their paycheck or more and for health insurance, and they can't afford their housing and they can't afford to put food on the table, and they struggle to be healthy because of the stress and the things that are happening here, and that costs them a part of their life, right? It it definitely reduces life expectancy, would be that stress to not have nutrition, to not have access to the gym and whatnot. And so I I think what you know, what I think would be a reasonable solution is to understand and realize that most money gets spent in the last couple years of life on health care. So why can't people opt into a program or opt out of end-of-life care for terminal illnesses, to die with dignity, to have euthanasia, to have these things where they could say, man, I might live five years longer if a third of my pay wasn't going to health insurance? I might live five years longer if I had more time at the gym because I wasn't worried about expending all these hours of work to pay for health insurance that sucks anyway, so that when I am dying, I can get radiation or chemotherapy. Why not make it so that that isn't that isn't the case? You know, sure. I mean, like, end of life stinks. I'm sure it sucks to suffer. I'm sure it sucks to die. But at the end of the day, like, why are we forced into that situation versus being able to say, you know what, I want a better life now, I want a better life for the foreseeable future when I'm over 70 years old and I have liver cancer and you know I have a year to live. Not gonna spend three million dollars of society's money on expending my life six months. I don't know.

Here's a crazy phenomenon personal experience for me. I tore my chest a couple months ago, right? I got my medical bills, I did the math. I was better off paying out of pocket for the rate my insurance company was charged for the surgery, for my doctor's visits, than I was paying for my health insurance. Think of that. Yeah, it was cheaper on an annual basis for me to go through the surgery, pay the hospital out of my pocket, than it was to have the health insurance, which by the way, took seven months to get because I had a huge legal issue with it. But like, what that's backwards.

The short answer is not everybody's gonna save money having health insurance. And the truth is, because of how expensive end-of-life care is, and one percent of the population is using 99% of health care costs, is that you are paying for that 1% that's using it, so that with the thought that one day they're gonna pay for you. But if every healthy person didn't have health insurance, those sick people would be paying five, six times in health insurance to cover that same cost. So it's almost like I look at it as you're you're paying it forward to it being you one day. But I understand your your uh it should be an option, dislike of that.

It should be an option to choose what benefits you want.

Because then you get screwed. Now you're stuck in a sick care system, and that's what everyone's going to. Which they just keep getting sicker and sicker and sicker because no one's looked at the entire picture. Because you're stressed seeing hundreds of patients, you're stressed dealing with insurance companies fighting all the time. People are stressed because they're paying a lot of money out of pocket for health insurance and not getting the exact things they need, and everybody's losing.

I think the short answer is we're not allowing competition because we're allowing large health systems to get paid so much more than small companies. So there's there's there's a monopoly. I mean, that's true, but it's a mafioso monopoly in the clinical side, and then on the insurance side, it's a business which is you know democracy, but it's hard to have healthcare make sense financially when somebody's taking some of that money and putting it in their pocket. The people have to lose in order for a healthcare insurance company to make money. So everybody has this impression that doctors are the reason that that healthcare is so expensive. I mean, if we collect 31% of what we bill, we're chest bumping in the hallway out of excitement, you know? It's it's not. It's it's the fact that there's a lot of money being taken out of the pot and put into the pockets before it's even offered to hospitals and small medical companies.

I want to just bring up one last point where I see medicines going to maybe you've been aware of this, maybe you're not, but I've interviewed a lot of people and they're all kind of getting on board, especially in the Midwest, I've noticed, which is really interesting. Private practices like this are moving more to a concierge service, meaning um, I come in, I say, I want to sign up for you guys. What's your monthly rate? I pay a flat monthly rate, just to you specifically, and I get a server, just like joining a gym and my gym memberships I get with it. And I can sign up for any tier I want, and everything's taken care of and paid for it. I don't have to worry about it. Do you think that's the future of medicine and that's the only way it's gonna head? Or are that is that 10 years out and we're nowhere near that, and we gotta rock bottom out first? Because it's gonna burn him out, right? And it's gonna burn you out, and everyone's just gonna keep getting sicker, like you've seen the average lifespan's going down, which is wild. So where's it gonna go?

I think it's gonna trend in that direction, and I think there's always gonna be a little bit of a middle ground, right? Like, I think you'll see that more and more and more and more as insurance be can continues to get more and more unaffordable, and every single year rates go, you know, insurance premiums go up 15% and whatnot. But once again, like when the government forces employers to offer health insurance and forces people to have health insurance, and that's the system they're in, there's always going to be that that system. People are gonna be going with health insurance to the doctor because a third of their paycheck has to go to health insurance, right? And and that's just the reality of it. I mean, concierge medicine will continue to trend in that direction for the wealthy people, for the people who can afford the doctors who will think outside the box, for the doctors who want to be entrepreneurial and help people more than you know the broken system allows them to. And so I do think that will continue to grow and make a difference. The other hard part about it though is you're you're not really able to offer both, I don't think, very easily, because you know, when you accept insurance companies, you can't have really different rates for cash pay than you charge insurance, so you're locked into this compliance aspect of the state.

Well, it wouldn't be cash pay because it'd be membership or recurring service, yeah. So it would just be all inclusive in a recurring bundle.

Yeah, yeah. So you could charge 500 bucks a month and you get any pain management service you need under a certain obviously limit because the surgery centers couldn't be included. Things like things like that. But yeah, I mean, I think that's a great idea.

Do you have anything to add from the uh clinician side of it?

I think, like he was saying, the white glove service is probably going to be in our current model reserved for like the top one percent of income population, but it wouldn't work for a large-scale population when you're talking about how many people are in the United States of America. Um, and I think certain specialties will definitely be able to do that much better, like primary care, cardiology.

So then what happens to practices as a whole? Because you see you say rates are dropping every year, right?

They consolidate. Every year they drop. They're going to hit a bottom. No, they join NYU.

Yeah, that's what I'm saying. They're they're herding the sheep. Back to the herding the sheep. They're herding the sheep to these large healthcare systems because that's what they want because they have the most control.

The hard part about that model and pain management specifically, though, great model for a lot of specialties. But I mean, pain management is so technical, right? Like you say, oh, it's 500 bucks a month, you get unlimited services. Well, what if Dr. Amen is like, oh man, you shouldn't have more cortisone? But the patient's like, well, I'm paying for it. Yeah, I'm $500 a month. Right. So you're good, like pain management is just tough from that perspective because then it's like, you know, well, where do we go from here? But um, I think cardiology, you're seeing that, like other other primary care, you'll see that, other specialties, you'll see that. But yeah, I mean, you you make a great point. Where where does it go?

Where does it end? Small groups are gonna have to join a multi-system group or MSO where you know they have one central billing agency that's able to consolidate costs and you can practice, have numerous clinical entities practicing under it. Um, that's how you can survive outside of a big healthcare system. It's kind of become a little big system. Um, or you continue to struggle to keep your head above water, you have to constantly add new revenue generating arms of income to your company. You know, get in. You can't, you the truth is you can't just come in and see 20 patients and go home. Not a single type of practice anywhere in the US can survive doing that. You can't. Not if you're collecting insurance rates. You have to offer procedures, you have to have multiple avenues of offerings, you have to be multi-specialty and offer psychology and chiropractic and acupuncture. You know, otherwise you can't survive. That's the truth of it. But I think it is good also because from a clinical perspective, you're more complete. You should offer more, you should be able to offer access to all of these different things for patients. So you either do that or you're not going to survive and you'd have to join an MSL.

You have you have to have understand the economics too behind it. Like, one of, you know, my dad's philosophy on medicine was always the best business model is great medicine. And then we kind of expanded on that and thought, like, okay, well, you know, if it doesn't hurt the patient and could potentially help the patient and is good for the practice, well, we need to take advantage of that so that we have the resources to do other things that we might lose money on that are beneficial to patients so that we can practice good medicine. So, you know, there's a lot of things that are screwed up. And I think the government tries, like with DME, they've gone through a competitive bidding process in a lot of areas, and you know, the obviously Aspen and those companies will argue against it and say it's terrible because people have more back surgeries, wind up in the hospital, and maybe that's all true or not. But what what seems to not make sense, you know, on a big a bigger picture is that a back brace, for instance, from Medicare will reimburse $750. But you could do an intercept procedure, which includes banging into the spine, burning nerves, 45 minute surgery in a surgery center under anesthesia, and you could get paid the same 750 bucks.

And there's only a very small percentage of people to do that procedure.

And by the way, that back brace I'm talking about is an off-the-shelf brace. You don't need an orthodist, the doctor doesn't need to fit the patient, right?

And so when Which is wild that they're building $750 for a brace that you can go buy online for $100.

Well, it's not prescribed by a doctor.

Wild.

But the fact of the matter, and those those things are inefficiencies in the system and should get better. But the reality is something like a spinal surgery, right? You talk to guys who do ACLs. It's like Medicare pays them $1,200 to do an ACL. How did how do you survive with the malpractice that's a hundred grand and college debt, medical school debt to do it to do an ACL that's twelve hundred dollars? Like it's not like everybody's running around tearing their ACL. We gotta do a hundred ACLs a week. Like, I mean, where does that come from? And so it's just it it just becomes very difficult, and you have to understand the economics of of of medicine so that you can provide good medicine because those other things that are kind of disproportionate pay for our ability to provide scribes and other resources to the doctor so that they can do a better job. But if you're not thinking about that like a private practice and you're just thinking about, you know, medicine, you're gonna go out of business.

And there's a huge misconception that when they see these bills from the hospital for their, you know, knee surgery or their spine surgery, and it's fifty thousand dollars, they're like, Oh my gosh, the doctor just made so much money. The doctor probably got 600 bucks for that. You know, the this the anesthesia group, the hospital gets by far the most money. They have they have facility fees.

That's a whole nother podcast.

Like, for example, a very like one of the most complex procedures we do is putting a wire next to someone's spinal cord, and you thread it through this couple millimeter space and guide it all the way up their spine. There are very few people in the world that can do that. And we do that in the hospital. We have to make incisions and suture and implant a battery and guide these leads into the skin. We get 400, 500 bucks to do that three-hour surgery while the hospital probably got 50s 20 grand. And the reps. The reps who oversee the procedures that I do oftentimes are making more money than I am on a procedure.

Oh, I love that. At the hospital, doctor opens the door and they get billed. It's like, what do you mean?

I didn't even want you to come. So you're being forced as a provider. Like, I would love to spend an hour and a half with every patient. I'd be the best doctor. I'm positive of that, but I can't because it's volume-based. You go out of business if you're not able to both be effective and efficient. And that is something that I struggle with. I mean, it's a conversation we have all the time. It's like, I spend a lot of time with my patients. I do give them the time, and I'm always behind because of it. But it's like this delicate balance between being an amazing provider, which I do think that I am, um, and being able to have the volume to then be able to stay afloat and not be part of Northwell. So it's very difficult.

I think this was eye-opening for a lot of people. I hope that everyone watching has an understanding of the complexity behind what actually goes on. And when you're watching TV or watching Congress or talking to your doctor and being like, I don't understand this person makes this much money. It does far beyond, and the system needs to be structurally destroyed to be rebuilt in a proper way because I don't think there's any fixing what we're currently at. It needs to be demolished and redone. That's my personal take. If you guys have any of the questions on it, please comment below. Happy to do a follow up episode on this. But thank you so much to my brother, Dr. Eamon. Yes, thank you. Thank you so much, Tim, for coming on, and we'll see you guys next week. Don't forget to like, subscribe, and share. Until next time.