Baseball Arbitration, Benchmarking, and Physician Leverage with Dr. Adam Bruggeman: täielik transkriptsioon

they couldn't afford or uh were just unreasonable and felt like the insurance company should be stepping in to take care of it. 00:04:39.439 --> 00:04:47.439 And so at the end of the day, uh New York actually was probably the first one to really come up with what we would consider to be the modern system. 00:04:47.839 --> 00:04:53.519 They resolved it by creating what's called baseball style arbitration. 00:04:53.839 --> 00:04:55.439 Because here's what they did. 00:04:55.680 --> 00:05:00.160 First, they said, most importantly, let's get the patients out of the middle. 00:05:00.319 --> 00:05:03.199 Let's not have patients be responsible for these bills. 00:05:03.360 --> 00:05:09.839 Let's come up with a number that a patient's responsible for, and then let's deal with the insurance company and the doctor afterwards. 00:05:10.079 --> 00:05:18.879 So, primary importance, primary goal of the bill and the federal bill and every state bill that's ever been done, protect the patient. 00:05:19.279 --> 00:05:19.680 Right? 00:05:19.920 --> 00:05:26.639 Not protect the doctor, not protect the insurance company, not protect the employer, protect the patient. 00:05:27.279 --> 00:05:35.600 The the end result of that is we had to come up with a system for how we would deal with the doctor and the insurance company if they couldn't agree. 00:05:35.759 --> 00:05:38.959 So we give them some period of time to negotiate. 00:05:39.120 --> 00:05:49.680 If they can't agree on it, then we have to have a way of getting to a final number because we're gonna ban the doctors from going back to the patients and securing that dollar amount. 00:05:49.839 --> 00:05:52.879 That way we can, again, protect the patient. 00:05:53.360 --> 00:05:57.600 Baseball style arbitration, high-stakes arbitration. 00:05:57.680 --> 00:06:13.120 It's been called a bunch of different things, essentially where the arbitrator can only select one offer or the other offer, not do what they like to do in many cases, which is split the baby, so to speak, where they pick a number somewhere in between the two numbers. 00:06:13.360 --> 00:06:25.759 The goal of high-stakes arbitration is to force both sides to a negotiation because if you're really far apart, like we're seeing now in some negotiations, you have a lot to lose. 00:06:26.079 --> 00:06:29.759 You could be on the wrong side of a major decision. 00:06:30.079 --> 00:06:38.240 So it's to your advantage, unless you really know that you're right, to come to the negotiating table and figure it out before you get to arbitration. 00:06:38.560 --> 00:06:46.639 And at the end of the day, whatever the decision is made, uh the state government, New York said it's gonna have to be binding. 00:06:46.800 --> 00:06:56.079 We can't let this continue to go on forever and ever, dispute it in the courts, go get a second opinion, get a third opinion, appeal it, go to the Supreme Court, do whatever. 00:06:56.160 --> 00:06:57.199 It's gotta stop. 00:06:57.439 --> 00:06:59.680 Everybody's going to agree this is the end of it. 00:07:00.800 --> 00:07:04.480 New York's bill works fabulously. 00:07:04.720 --> 00:07:05.839 Everybody's happy. 00:07:06.079 --> 00:07:14.800 The insurers are happy, the employers are happy, the doctors are happy, the patients are happy, the insurance uh administration is happy. 00:07:14.959 --> 00:07:20.639 And there's a study done by Georgetown Health Policy that outlines all of this before it becomes a national bill. 00:07:20.959 --> 00:07:30.399 The state of Texas looks at what happened in New York and says, that's a really good idea, slight modifications, and ultimately implements essentially the same bill. 00:07:30.720 --> 00:07:35.759 We get to the federal government who says, gosh, we need to do something about this. 00:07:36.000 --> 00:07:36.560 Why? 00:07:36.879 --> 00:07:44.319 Because these states are coming up with plans and ideas on how to fix the problem, but they're limited in scope. 00:07:44.480 --> 00:07:47.040 They can only address certain plans. 00:07:47.360 --> 00:07:56.319 Those plans where your employer goes into the market, takes no risk, and buys a plan on behalf of their employees. 00:07:56.560 --> 00:08:12.480 But in cases where the employer is truly just using the insurance company as a third party, but is actually paying the bill and is fully self-insured, those claims are ultimately the jurisdiction of the federal government. 00:08:12.800 --> 00:08:15.120 So we needed a federal bill. 00:08:15.199 --> 00:08:17.279 And there were a lot of ideas on how to do that. 00:08:17.360 --> 00:08:19.120 I'm sure we can get into all that. 00:08:19.439 --> 00:08:37.759 At the end of the day, a large bipartisan agreement occurs where people who normally didn't agree on things agreed that the way to handle this was the way that New York, a blue state, and Texas, a red state, agreed on how to do things. 00:08:37.840 --> 00:08:40.159 And that was baseball style arbitration. 00:08:40.320 --> 00:08:45.120 So here we are today with a lot of issues that have come up now. 00:08:45.200 --> 00:08:49.600 Uh, but essentially the No Surprises Act was that bill. 00:08:49.840 --> 00:09:03.039 You mentioned another term, the IDR, the independent dispute resolution, is the name we give to the process we go through in the arbitration uh component of that disagreement. 00:09:03.200 --> 00:09:09.120 And the one thing I think gets lost in some of this is the percent that ends up in arbitration. 00:09:10.159 --> 00:09:35.600 So we know that 95% of all claims either A, the doctor accepts the initial payment from the insurance company, or B settles before we ever get to any sort of arbitration, meaning the two sides agreed on it, or the doctor just ultimately accepts the original payment. 00:09:35.919 --> 00:09:41.200 Only 5% end up in that last category that ultimately go to arbitration. 00:09:41.279 --> 00:09:42.240 It's actually 6%. 00:09:42.879 --> 00:09:46.399 Uh the insurers win about

one per one more percent. 00:09:46.559 --> 00:09:56.480 So if you add it all up, insurance companies are essentially paying what they believe to be their fair payment 95% of the time. 00:09:56.720 --> 00:10:02.240 Physicians are winning in arbitration 85% of the time, but that's on that last 6%. 00:10:02.799 --> 00:10:14.399 So in reality, in totality of all the claims that are out of network, doctors are only going and winning 5% of the time, and insurance companies are winning 95% of the time. 00:10:14.559 --> 00:10:19.200 The fight that we hear today, if you aren't aware of it, is about that last 5%. 00:10:20.480 --> 00:10:27.360 Insurance companies want to make that their dollar amount that they won the first 95% on. 00:10:27.519 --> 00:10:31.360 They do not want doctors to be able to get a number above that. 00:10:31.600 --> 00:10:35.840 Doctors are fighting and saying that's price fixing, that's unfair. 00:10:36.000 --> 00:10:49.120 I should be able to go in front of an arbitrator, put my data out there, and it's clear that when we do that and we have an independent arbitrator, somebody who has nothing to do with either party, they pick my data 85% of the time. 00:10:49.200 --> 00:10:55.759 It's clear that we need to allow me to go to arbitration when I don't get a fair number up front. 00:10:56.080 --> 00:10:58.399 So I'm gonna stop there because that was a lot of talking. 00:10:58.559 --> 00:11:02.240 But I think that gives a good baseline of where we are. 00:11:02.320 --> 00:11:09.840 Um and I'm happy to talk about any piece of it, what's gone wrong, the lawsuits, all the different things that have occurred to get us to this point. 00:11:10.639 --> 00:11:20.399 I think an important point to make, and I'd love to have you expand on it a bit, is if you don't have the IDR process as a backup, it's not just about that 6%, right? 00:11:20.559 --> 00:11:24.399 Because that affects the way the insurance companies can negotiate with you. 00:11:24.639 --> 00:11:36.799 And uh, we had Ed Gaines on on the show a while back, uh, who had an excellent example, and he talked about what happened in California, which took a different approach uh to IDR with more of a benchmarking approach. 00:11:36.960 --> 00:11:47.840 And that affected how independent doctors could then negotiate with insurance companies because if they can't hold out, uh then the insurance company has a lot more leverage on those negotiations. 00:11:48.000 --> 00:11:49.440 Can you go into that a little bit? 00:11:49.919 --> 00:11:53.600 Yeah, I mean, uh, you know, essentially that's the complaint today. 00:11:53.759 --> 00:11:56.320 The insurance companies are saying this is now unfair. 00:11:56.480 --> 00:12:04.080 You've priced, you've created a new price, and these doctors are winning at a higher price than what we pay, and that's not fair. 00:12:04.320 --> 00:12:24.240 But the opposite of that is where we've been, and California has been, which is that essentially the insurance companies, when setting a benchmark, then turn around and go to their own in-network groups and they say, hey, listen, um, this bill is passed, um, and it says that here is the benchmark. 00:12:24.399 --> 00:12:31.039 And we've previously contracted with you before all of this occurred at a number higher than this benchmark. 00:12:31.279 --> 00:12:33.039 So we don't like that. 00:12:33.200 --> 00:12:39.679 We know that we can get you down to the benchmark, and if you choose to not accept it, you're still just going to get the benchmark anyway. 00:12:39.840 --> 00:12:42.399 So we have unilateral control over pricing. 00:12:42.480 --> 00:12:49.279 And at this point in time, we believe that you either take our new contract or you go out of network and you are forced to take our contract. 00:12:49.440 --> 00:12:50.320 And we saw that. 00:12:50.399 --> 00:12:53.039 And you know where we saw that was Blue Cross Blue Shield. 00:12:53.200 --> 00:12:56.960 I don't know if this came up with Ed, Blue Cross Blue Shield of North Carolina. 00:12:57.200 --> 00:13:09.039 Immediately after the No Surprises Act was passed, but before it was implemented, in other words, before the rules were written by the Tri-Departments, labor, treasury, and health and human services. 00:13:09.600 --> 00:13:33.440 Blue Cross Blue Shield of North Carolina sent a letter to what they considered to be expensive doctors, meaning doctor groups that they had already contracted with and threatened to cancel their contracts because they explicitly stated that the No Surprises Act was going to bring down the contracting rate for them and that the doctors should either accept the new contracted rate or go out of network. 00:13:33.600 --> 00:13:49.919 So, in other words, insurance companies then use it as a weapon to force doctors out of network and or force them to the number that they feel is appropriate, which, frankly, is in many cases not has no relation to value, quality, outcomes. 00:13:50.159 --> 00:13:58.320 It's purely a budgetary number designed to improve revenue back to either the parent company or to the shareholders. 00:13:59.360 --> 00:14:04.720 So it would seem like if you set up these kind of caps on being out of network, right? 00:14:04.960 --> 00:14:18.720 Um which is the proposed solution to uh by many folks, that seems to hold that you will eventually drive down the uh the the rates that doctors can get, correct? 00:14:19.519 --> 00:14:20.320 That's exactly right. 00:14:23.039 --> 00:14:26.639 Is there uh data outside of anecdotes to kind of back? 00:14:27.039 --> 00:14:28.559 It seems like do we need data for that? 00:14:28.639 --> 00:14:40.000 I mean it's it seems so obvious that there is a if you if you cap outer network, if you cap they basically don't want to have a uh they don't want to deal with out of network uh out of network doctors, right? 00:14:40.080 --> 00:14:41.759 And so they they just want to have like some cap. 00:14:42.000 --> 00:14:47.840 Uh sorry,

Adam, and I I may have missed it in in in the what what are they proposing that cap be? 00:14:48.720 --> 00:14:50.480 Yes, or some proposals. 00:14:50.879 --> 00:14:58.559 Yeah, there's a proposal, there's a bill that is out there recently introduced by the ranking member of Energy and Commerce, Frank Pallone from New Jersey. 00:14:58.799 --> 00:14:59.120 Right. 00:14:59.360 --> 00:15:10.799 Um, he has introduced a bill that uh does a handful of things, but most importantly ties what is paid out in the added network rate to what's called the QPA. 00:15:10.879 --> 00:15:12.399 That's not a term we've talked about yet. 00:15:12.639 --> 00:15:14.960 It's called the qualified and payment amount. 00:15:15.120 --> 00:15:24.080 It is the amount that the insurance company has uh calculated for the purposes of determining how much the patient owes, okay? 00:15:24.320 --> 00:15:30.159 And it is supposed to be calculated based on the average in-network contracted rate today. 00:15:30.480 --> 00:15:40.480 Um we know from the lawsuits that the Texas Medical Association took on that the QPA is clearly not accurate. 00:15:40.720 --> 00:15:51.759 And the very few audits that the federal government has done on the calculations of the QPA has has shown that the insurance companies have proven that it's not accurate. 00:15:52.000 --> 00:16:10.960 So, what we want to do now is benchmark to a number that is clearly not accurate and was really, again, designed to help figure out how much a patient is um is has to owe, because they have to owe, we have to figure out what's your copay deductible and coinsurance on this bill. 00:16:11.120 --> 00:16:15.600 We don't know how much it's gonna ultimately settle for, and we want to get the patient out of the middle. 00:16:15.759 --> 00:16:18.000 So we have to calculate that up front. 00:16:18.159 --> 00:16:30.399 Um, I think people get confused about the QPA and believe that that is the amount that they get paid initially as the initial payment in the IDR and the No Surprises Act process, and that is not accurate. 00:16:30.559 --> 00:16:33.759 The insurance company can pay any number that they feel fit. 00:16:34.000 --> 00:16:37.679 It can be substantially lower than the qualifying payment amount. 00:16:37.840 --> 00:16:39.600 They do not have to pay the QPA. 00:16:39.840 --> 00:16:47.360 So at this point, uh that is what Frank Pallone wants to base everything on. 00:16:47.600 --> 00:16:52.960 And interestingly, he also said that it cannot be challenged in the court of law. 00:16:53.120 --> 00:16:58.480 In other words, the TMA uh lawsuits would not be allowed under Pallone's rule. 00:16:58.639 --> 00:17:06.480 He wants the insurance companies to be able to calculate it and then not be held responsible for how they calculate it to anybody outside. 00:17:07.039 --> 00:17:07.759 So so, Dr. 00:17:08.000 --> 00:17:22.240 So the insurance um uh company lobbyist uh manifested in Congress, uh Frank Pallone, is is you know clearly um uh uh attached to QPA. 00:17:22.319 --> 00:17:23.920 And this is such an important point. 00:17:24.160 --> 00:17:26.720 I know it gets lost in NSA, IDR, QPA. 00:17:26.880 --> 00:17:34.880 QPA is simply the median uh uh uh you know in-network uh rate that is being paid. 00:17:34.960 --> 00:17:45.119 And the whole IDR fight is about whether or not this one insurer calculated number is a fair stand-in for what the market rate is. 00:17:45.359 --> 00:17:54.240 So the whole thing that you'll see uh that uh we're gonna talk about over and over again is is the fact that everyone uh the think tanks, right? 00:17:54.319 --> 00:18:09.359 The think tanks that again have they say they have the interests, the best interests of the of the patients at heart, maybe they do, but the whole thing is based on this idea that the QPA is the fair price, right? 00:18:09.599 --> 00:18:17.599 Like so the so the so the Paragon Um Health Institute um you know uh uh says it out front, right? 00:18:17.680 --> 00:18:22.079 They say, look, the problem with this is that the um where is it? 00:18:22.160 --> 00:18:23.279 Sorry, I'm reading here. 00:18:23.440 --> 00:18:26.960 Um the uh yeah, so here we go. 00:18:27.039 --> 00:18:32.799 Uh emergency medicine providers had a medium of median awards of 3.5 times the QPA. 00:18:32.960 --> 00:18:38.319 Neurologic surgery had median awards of 28 times QPA, physician assistants at 26 times the QPA. 00:18:38.480 --> 00:18:46.400 And these arbitration awards are much higher uh uh uh than that you know uh the median in-network rate. 00:18:46.480 --> 00:18:51.759 So it's about five and a half times the Medicare rate for the same uh uh uh services. 00:18:51.920 --> 00:18:58.480 Um and the median awards for all disputed line items, all these disputes, were about four times the QPA. 00:18:58.559 --> 00:19:03.920 So they're saying, uh Adam, that um that look, this is multiples of the QPA. 00:19:04.000 --> 00:19:14.400 And if you look at specific subtypes like neurosurgery and uh um and what else, uh physician assistants, um this is like 28 to 26 times the QPA. 00:19:14.480 --> 00:19:17.200 So Adam, how do you what what's what's the response there? 00:19:17.359 --> 00:19:21.440 Like are are are this is we're like massively overpaying uh compared to the QPA. 00:19:21.680 --> 00:19:23.119 That's why the QPA is so important, right? 00:19:23.200 --> 00:19:27.279 Because the QPA is being decided as hey, that is what that is that is what a physician has worked. 00:19:27.920 --> 00:19:31.119 Yeah, I think I mean a handful of things that just immediately come to mind. 00:19:31.279 --> 00:19:35.279 Number one, you know, uh Anish and I are in solo practice. 00:19:35.359 --> 00:19:40.400 So I this is not a good example, but Sonat and Anthony are not in solo practice, right? 00:19:40.480 --> 00:19:41.920 So you guys have partners. 00:19:42.079 --> 00:19:50.880 Um when you bring on a partner, uh, Anthony, how um and uh you've been, I'm sorry, you've been in

practice for how how many years now? 00:19:51.119 --> 00:19:53.119 Yeah, seven, eight-ish, something like that. 00:19:53.279 --> 00:19:53.359 Okay. 00:19:53.680 --> 00:19:54.160 Lost track. 00:19:54.400 --> 00:19:57.359 Um and and do you have any partners who have been in practice? 00:19:57.519 --> 00:20:01.440 So who how long is the longest person who's in your group been in practice for? 00:20:01.759 --> 00:20:04.640 Oh my gosh, it's gotta be 30 years. 00:20:04.960 --> 00:20:05.599 30 years. 00:20:05.839 --> 00:20:06.160 Okay. 00:20:06.799 --> 00:20:26.079 And let's just take let's just take whoever that person is and let's assume that uh, and you may have, that uh in July or August, you guys picked up a young just graduated uh somebody out of fellowship or out of residency uh who wanted to join your um your group. 00:20:26.240 --> 00:20:27.440 Did that happen at all? 00:20:27.599 --> 00:20:28.480 Do you know? 00:20:29.119 --> 00:20:31.119 Oh yeah, we got we got some youngins. 00:20:31.519 --> 00:20:32.799 Okay, perfect. 00:20:33.119 --> 00:20:49.599 What did the person who graduated from residency um on in let's call it uh that started with the practice on August 1st as their first day of first day ever in practice as a doctor get paid compared to what did the doctor with 30 years of practice get paid? 00:20:50.000 --> 00:20:52.559 There is a substantial differential between those two. 00:20:53.119 --> 00:20:54.400 But what did they get paid? 00:20:54.559 --> 00:20:58.720 What did what did UCSF get paid for the work that they did? 00:20:59.359 --> 00:21:01.920 Yeah, so UCSF gets paid probably the same. 00:21:02.079 --> 00:21:03.920 Uh details in the contract. 00:21:04.079 --> 00:21:06.079 But yeah, per RVU, they're getting the same. 00:21:06.480 --> 00:21:07.599 That's exactly right. 00:21:07.839 --> 00:21:38.319 So so we have a system within healthcare where we have agreed as physicians somewhere a long time ago that it doesn't matter whether you save the system money or don't save the money, whether you take the patient to the surgery center or take them to a hospital, whether you are employed or you're an independent practice, whether uh you've been practicing for 30 years or this is your first day in practice and you've never performed a procedure before, we pay everybody the same price. 00:21:38.559 --> 00:21:48.480 And the determination for how much we pay a group anywhere across the United States is based on the bargaining power of that of the entity that is negotiating. 00:21:48.640 --> 00:22:05.599 It is purely based on how big the entity is and how important that entity is to that market, not based on whether or not that entity provides any quality, whether it reduces costs, and whether or not The person, the individuals within that organization have more experience or less experience. 00:22:05.680 --> 00:22:08.240 And I cannot think of a service industry. 00:22:08.400 --> 00:22:12.880 You know, imagine if I went to my attorney and I

said, I want to pay you at the paralegal rate. 00:22:13.039 --> 00:22:15.359 I'm not paying you at the senior partner rate. 00:22:15.759 --> 00:22:21.519 I don't care how many, you know, how much you want to charge me thousands of dollars an hour. 00:22:21.839 --> 00:22:25.920 I want the$200 an hour rate from the paralegal, right? 00:22:26.079 --> 00:22:31.359 That doesn't happen in the master plumber doesn't charge what a regular plumber charges. 00:22:31.519 --> 00:22:34.400 The master electrician doesn't charge what a regular electrician charges. 00:22:34.559 --> 00:22:39.119 And when it's a complex, complicated process, they charge more, right? 00:22:39.519 --> 00:22:42.240 And and in in healthcare, we just don't do that. 00:22:42.400 --> 00:22:48.640 It's like every spine fusion is the same, every dysquectomy is the same, every cardiac intervention is the same. 00:22:48.880 --> 00:22:52.000 Doesn't matter how sick the patient is, what I had to do to get there. 00:22:52.079 --> 00:22:54.960 It is paid the same, and it doesn't matter how much experience I have. 00:22:55.200 --> 00:23:00.400 So that just in and of itself helps to explain why the QPA is wrong. 00:23:00.559 --> 00:23:14.160 But I think there's a really good study that was out there that looked at the QPA and it compared it to the actual data that has been published by insurance companies to what the average in-network rates were. 00:23:14.240 --> 00:23:16.160 And it looked at the two, and you know what it found? 00:23:16.319 --> 00:23:28.880 It found that in many cases the QPA was a third, in other words, a third to a fourth that of the actual amount that the that that was being published as their average in-network rate. 00:23:29.119 --> 00:23:37.759 In other words, because the QPA is so artificially deflated, it's not uncommon for physicians to make three to four times that amount. 00:23:37.920 --> 00:23:43.839 And in particular, and I know none of us on this call are in anesthesia emergency medicine. 00:23:44.079 --> 00:23:58.640 In particular, in those two specialties, it is the common thing where doctors get paid three to four times the Medicare rate in their private practice, in their private insurance contracts compared to what they make on their Medicare patients. 00:23:58.720 --> 00:24:06.480 And QPA would not be unsuspecting to be one-third to one quarter the amount that they should be paying in those cases. 00:24:08.000 --> 00:24:09.119 I've got a question for you. 00:24:09.279 --> 00:24:11.759 Um and Adam, it's just great to finally chat face to face. 00:24:11.920 --> 00:24:12.000 Yeah. 00:24:12.480 --> 00:24:14.480 You've interacted uh indirectly. 00:24:14.799 --> 00:24:25.839 Uh can you can you uh um ascribe a cost to what this process is is what what the what is what's a tab on this? 00:24:26.160 --> 00:24:27.440 What's the tab on this? 00:24:27.839 --> 00:24:41.680 Um how much of that goes towards paying physicians, how much of that is administrative, and that's gonna lead to my uh second question, which is how much money are we spending to basically uh hinder price discovery in healthcare? 00:24:42.640 --> 00:24:43.200 All right. 00:24:43.519 --> 00:24:48.160 Uh so the question, uh the answer to number one is I don't think we know. 00:24:48.240 --> 00:24:49.440 And let me tell you why. 00:24:49.599 --> 00:24:55.039 Uh the number that's been published, New York Times and others have picked up on the number, is$22 billion since inception. 00:24:55.200 --> 00:24:55.440 Okay. 00:24:55.839 --> 00:25:02.000 But I can tell you because we did some investigating into this, um, we being sorry, we didn't talk about it. 00:25:02.079 --> 00:25:10.319 I I run a 501c4 called Indimed, which looks at um which is supporting independent physicians uh and and their issues. 00:25:10.480 --> 00:25:30.799 And we are look, we looked at the public use files, we found, just like several other people did, I think it's seven or eight different instances where it's probably a uh data entry problem where it listed that a an emergency medicine physician got paid in excess of$200 million in seven or eight different scenarios. 00:25:30.960 --> 00:25:35.680 Okay, we know they did not get paid$200 million on those claims. 00:25:35.839 --> 00:25:39.359 Uh it might have been$2,000, but it definitely wasn't$200 million. 00:25:39.759 --> 00:25:45.680 But those$200 million numbers continue to get included in the$22 billion number. 00:25:45.839 --> 00:26:01.119 In addition, we found ones where it was clearly they forgot to hit the decimal point, or they uh typed the same number too many times, or the number entered in was the same a number as the uh dispute number, which there's a dispute number that's assigned to every single one of them. 00:26:01.200 --> 00:26:08.079 And so it was this really large number that was exactly the same as the dispute number, which clearly somebody again typed the numbers in wrong. 00:26:08.319 --> 00:26:10.319 So I don't know the answer to your question. 00:26:10.480 --> 00:26:21.200 I would tell you about a third of that is probably coming from um the cost of administering the uh the process, and about two-thirds of it is probably going to physicians according to the data. 00:26:21.359 --> 00:26:25.119 So we need to take a look at all of that and confirm whether or not that's accurate. 00:26:25.359 --> 00:26:28.319 But uh that is that is the data that is out there. 00:26:28.880 --> 00:26:30.400 So where's that money coming from? 00:26:30.559 --> 00:26:38.079 I mean, who's actually besides uh besides the QPA piece, where's all the administrative and other um funds coming from? 00:26:38.160 --> 00:26:43.279 And and and how does that translate into premiums for the employers? 00:26:43.440 --> 00:26:48.640 Because the the there's there's there's one critical stakeholder that that that's never involved in these conversations. 00:26:48.799 --> 00:26:55.359 As we go to more employer-based contracts, the employer

doesn't have a say in any in any of what happens here, which is sort of fascinating. 00:26:56.160 --> 00:27:03.279 Yeah, so who's paying uh in in in ERISA claims, it's gonna be the employers directly paying, not the insurance company. 00:27:03.519 --> 00:27:10.000 In um in you know, in non-ARISA claims, it would be the insurance company's paying up. 00:27:10.640 --> 00:27:15.359 The the administrative fees are coming down because the federal government just reduced them dramatically. 00:27:15.440 --> 00:27:19.519 And so it'll be interesting to see how much that impacts that administrative cost. 00:27:19.680 --> 00:27:23.519 Uh, but the arbitrators still have a substantial piece in there, too. 00:27:23.680 --> 00:27:28.799 So we're we've reduced the cost per claim per disputed by$100. 00:27:29.519 --> 00:27:34.000 I think there were, you know, in the in the last quarter, there were like over a million claims. 00:27:34.079 --> 00:27:35.920 So a million claims times a hundred dollars. 00:27:36.000 --> 00:27:40.480 We're gonna save a hundred million dollars in the last quarter just in arbitration fees. 00:27:40.640 --> 00:27:48.319 The loser pays the arbitration fees, so um uh or pays the pays the arbitrator's fees. 00:27:48.480 --> 00:27:52.880 So uh the if if the doctor loses, then some of that money's coming out of the doctor's pocket. 00:27:53.039 --> 00:28:01.119 If the insurance company loses the 85% of the time, that's coming from the insurance company, which ultimately in many cases is coming from the employer. 00:28:01.279 --> 00:28:03.039 How does that impact um premiums? 00:28:03.200 --> 00:28:04.319 It's an interesting conversation. 00:28:04.480 --> 00:28:05.759 There's actually a study on it. 00:28:05.920 --> 00:28:08.720 Uh, British Medical Journal looked at this, and you know what they found? 00:28:08.960 --> 00:28:12.400 Found that patients out of pocket went down while premiums didn't change. 00:28:12.640 --> 00:28:20.559 And so it's it's really hard for us to get our hands around how it impacts premiums because I think we all know this. 00:28:20.720 --> 00:28:24.640 Premiums have been skyrocketing for the better part of 25 years. 00:28:24.799 --> 00:28:30.079 And we haven't really seen this like major change and uptick as a result of the No Surprises Act. 00:28:30.240 --> 00:28:39.039 So to say for when when these on these calls, when they're like, oh, our premiums are going up because of the No Surprises Act, and we determined it to be this percentage. 00:28:39.279 --> 00:28:47.359 I mean, I I kind of I think most of us in the physician community go, yeah, I mean, let's audit that like we audit a QPA and let's see what that really looks like. 00:28:47.519 --> 00:28:52.319 I mean, is that real or is that part of the uh message that's being put out there? 00:28:52.480 --> 00:29:01.119 I mean, I I think you can make the numbers in an insurance company look however you want them to look, to push whatever agenda you need to push to say

whatever cost is driving whatever cost you want to make it. 00:29:01.279 --> 00:29:07.359 The reality of it is physician dollars account for about 7% of 7 to 8% of the entire spend in healthcare. 00:29:07.519 --> 00:29:14.799 So I assure you that small percentage increases in physician spending is not dramatically driving the ultimate healthcare cost. 00:29:14.960 --> 00:29:21.599 I would tell you, as I think Anthony and all of us on this call have said many times, the number one driver right now is still hospitals. 00:29:21.920 --> 00:29:22.240 Yeah. 00:29:22.559 --> 00:29:24.000 And there's there's plenty of good evidence. 00:29:24.079 --> 00:29:34.880 You know, uh Vivian Ho and uh Zach Cooper both published numerous studies that show that that almost parallel increase between hospital spend and insurance premiums. 00:29:34.960 --> 00:29:37.519 So I think that that's definitely a point worth bringing up. 00:29:37.680 --> 00:29:43.119 Uh do you have any any sense why uh everyone was so happy with this in New York? 00:29:43.279 --> 00:29:47.599 And then when it becomes national, now all of a sudden it's not okay. 00:29:47.759 --> 00:29:50.000 I mean, what's the what's the rationale there? 00:29:50.720 --> 00:29:55.200 I, you know, I've I've wondered that myself because and and listen, it's out there, right? 00:29:55.279 --> 00:30:02.720 The Georgetown Health Policy Group put out the original paper on it and they interviewed everybody, and it was like, this was a resounding success. 00:30:02.799 --> 00:30:03.839 This is great. 00:30:04.160 --> 00:30:08.240 Um uh maybe maybe more knowledge of it. 00:30:08.319 --> 00:30:13.200 I think I think there's also a fear that what would happen if every doctor went out of network tomorrow, right? 00:30:13.279 --> 00:30:14.319 Like, what would that mean? 00:30:14.480 --> 00:30:15.920 And I think that's the fear tactics. 00:30:16.000 --> 00:30:26.640 And I've heard that those types of numbers thrown out there like, well, if every doctor did this, if every doctor canceled their contract, if everybody did it all at once, here's what that would look like, and that's why this is crazy. 00:30:26.799 --> 00:30:32.480 But I mean, every doctor's not, and ever and it's and you know, that's a part of the way that this works. 00:30:32.559 --> 00:30:34.640 It's been consistent over all of the data. 00:30:34.799 --> 00:30:38.079 It's about 6% of claims that go to the arbitration process. 00:30:38.160 --> 00:30:41.839 It's it's 6%, you know, 6% of the eligible claims. 00:30:41.920 --> 00:30:42.720 It's not moving. 00:30:42.880 --> 00:30:46.240 So I don't know what is creating the problem. 00:30:46.400 --> 00:30:52.480 I don't know uh why we are seeing such a um vocal change on it. 00:30:52.720 --> 00:31:00.640 Um, you know, people talk about the number of estimated claims that we're going to go through this as being somewhere around 17,000. 00:31:00.880 --> 00:31:08.079 I I just wish that uh truth and advertising that every

everybody knows the answer to this question who's in the health policy arena. 00:31:08.240 --> 00:31:12.559 And the answer is they based it on New York, and New York excluded emergency medicine. 00:31:12.720 --> 00:31:12.960 Okay. 00:31:13.200 --> 00:31:16.799 Emergency medicine is the number one submitter of arbitration claims. 00:31:16.960 --> 00:31:26.960 Had they based the national amount on the already existing Texas experience, they would have gotten the nut, they would have overestimated the number of claims that came in. 00:31:27.039 --> 00:31:33.119 So if we based it on Texas and then extrapolated to the United States, they would have guessed too many claims coming in. 00:31:33.200 --> 00:31:40.240 They would have guessed almost two million claims coming in, which are one and a half million claims coming in, which would have way overestimated the first year's claims. 00:31:40.559 --> 00:31:43.359 They guessed based on New York, which was a faulty number. 00:31:43.440 --> 00:31:46.480 And I, you know, whoever made that decision made that decision, they just missed. 00:31:46.559 --> 00:31:47.279 It is what it is. 00:31:47.359 --> 00:31:48.480 It was a bad estimate. 00:31:48.640 --> 00:31:56.079 But let's stop using that to say that doctors are abusing the system when we just made a really bad estimate to start with. 00:31:56.160 --> 00:32:03.039 And frankly, everybody who uses that estimate and uses that argument knows how wrong that original estimate was. 00:32:03.200 --> 00:32:05.519 It's just convenient to use the argument. 00:32:07.039 --> 00:32:09.119 Can we take take that uh a step further? 00:32:09.279 --> 00:32:12.079 This idea that what if every doctor goes out of network tomorrow? 00:32:12.160 --> 00:32:18.480 I mean, with you know, let's steel man it a little bit, with this process in place, why don't more doctors go out of network? 00:32:18.559 --> 00:32:22.160 And are there some places that do use this as a revenue strategy? 00:32:22.319 --> 00:32:26.960 I mean, I've heard stories that seem kind of weird and can only really fit with this process in place. 00:32:27.039 --> 00:32:33.279 Like, for example, uh physician being in network but then making his PA out of network so he can get IDR claims for that. 00:32:33.359 --> 00:32:34.960 I mean, is there some gameship? 00:32:35.039 --> 00:32:36.640 Is there some abuse of the system going on? 00:32:36.799 --> 00:32:42.480 And and again, to this point, like why don't more doctors just go out of network if this does prove to be so lucrative? 00:32:43.599 --> 00:32:53.200 Well, I think I think we all, I think many doctors still uh A are underneath some form of employment or someone else who's making those decisions. 00:32:53.359 --> 00:33:06.880 And I think that those um, you know, if I'm working for a healthcare system that a hospital, I'm making tremendous amounts of money on taking those cases and bringing them into my hospital and on the facility side. 00:33:07.039 --> 00:33:16.799 And so, you know, and on the ancillary revenue, when they when the doctor refers out their imaging, their physical therapy, and all the other ancillary pieces, and then they keep that referral within our system. 00:33:16.880 --> 00:33:25.279 And so when they need an endocrinologist or a hospitalist or whatever, that's all staying in our system, and we're making money two, three, four times on that same patient. 00:33:25.519 --> 00:33:30.720 So um, I think a big piece of it is who runs and controls the practice. 00:33:30.960 --> 00:33:33.359 Um, that probably drives why it is. 00:33:33.440 --> 00:33:49.759 I, you know, the physician assistant you just mentioned, um, I would tell you from every physician I speak with who's in in the space and I and all the data we've ever looked at, you know, remember that physician assistants make 85% of what a physician would make if they assisted in a in a case. 00:33:50.000 --> 00:34:02.799 And honestly, arbitrarily without any real good data, um, the federal government set up that physicians, when they assist in the operating room, get paid 16% of what of what surgeon of what the primary surgeon gets paid. 00:34:02.880 --> 00:34:04.640 So it's 85% of 16%. 00:34:05.359 --> 00:34:17.119 At the end of the day, when you take that and you consider that, for instance, the federal government's looking at paying under$1,000 in physician fees for a doctor to do a total knee or total hip replacement in in next year. 00:34:17.280 --> 00:34:25.440 And then you say, okay, then I'm gonna take roughly 14% of that number and I'm gonna apply that and make that what the PA is going to make. 00:34:25.519 --> 00:34:30.719 And you know, that PA's got to be in the OR and that means they're not in clinic or they're not doing something else. 00:34:30.800 --> 00:34:41.119 And you think about that, I mean, 14% of eight,$850, that PA would have made more money seeing the first patient in clinic than they ever made working in the operating room. 00:34:41.360 --> 00:34:58.239 And so I think we're hitting a point where surgeons need the PAs in clinic in order to be efficient, but but but insurance companies consistently devalue the work that's being done there and are wanting to push that to hospitals or other people to have to pay that incremental amount. 00:34:58.400 --> 00:35:04.159 And surgeons are just taking it into their own hands and saying, listen, I'm gonna get paid this extra amount for my PA. 00:35:04.320 --> 00:35:09.519 Um, and I mean, frankly, PAs are probably underpaid for the amount of work that they're doing in these claims. 00:35:09.840 --> 00:35:13.519 Is it the hospital or the insurance companies that are undervaluing us or is it Medicare? 00:35:13.599 --> 00:35:18.480 I mean, it really all like you, like you mentioned, it's Medicare that made the rule about 16, 85% of 16%. 00:35:18.880 --> 00:35:22.719 It's Medicare that's devalued our RVU conversion factor year over year. 00:35:22.800 --> 00:35:25.440

It's Medicare that's added all this administrative burden, right? 00:35:25.519 --> 00:35:36.320 I I mean I hate insurance companies as much as anybody, but it really seems to me like it's Medicare the one that's been really ratcheting us down so that we don't even have Medicare as leverage for the insurance companies. 00:35:36.400 --> 00:35:49.360 In the UCR days, you know, you could at least fall back on Medicare with your UCR and say, I can be, you know, hold out a little more with the insurance companies, but with Medicare ratcheting everything down, it's you know, you need private insurance to supplement Medicare, not the other way around. 00:35:49.679 --> 00:35:59.679 Yeah, but what happens when private insurance contracts are below Medicare rates, which is happening all over the country for the largest insurers, which in most cities, in most states, I mean, I'm not calling anybody out. 00:35:59.760 --> 00:36:06.719 I'm just the the reality of it is in most states, Blue Cross Blue Shield is the dominant player, whether whatever their name happens to be in that market. 00:36:06.960 --> 00:36:12.800 Um, and can I mean uh the American Medical Association did a great study on the concentration of insurance markets. 00:36:12.880 --> 00:36:29.039 And I, you know, not to try and really dive out of this, but if you look at the data and and why um, you know, think tanks are going to push for benchmarking, because when insurance companies hold all of the chips in a market, they have price control. 00:36:29.119 --> 00:36:35.119 And when they have price control, that that that is proven in many studies to drive down the cost of care in a market. 00:36:35.280 --> 00:36:40.239 But the problem is that there is no bottom to how far they're willing to drive down the cost of care. 00:36:40.480 --> 00:36:50.400 And because of that, you end up with what has happened now, which is doctors leaving independent practice, driving into consolidation, becoming employed by largely healthcare systems. 00:36:50.559 --> 00:37:01.119 And when they become employed by a healthcare system, that drives the cost back up again because there is no, because the healthcare systems learned what the insurance companies were doing, they consolidated at the same time. 00:37:01.280 --> 00:37:03.039 And now you've got these behemoths. 00:37:03.199 --> 00:37:09.199 I say, you know, it's like King Kong fighting Godzilla in the center of every city across the world or across the United States. 00:37:09.360 --> 00:37:12.960 And ultimately, those two, neither one can truly win. 00:37:13.039 --> 00:37:15.440 And so they beat each other up and everybody else loses. 00:37:15.599 --> 00:37:21.119 And so the idea behind insurance consolidation is it will drive down cost. 00:37:21.280 --> 00:37:22.159 I agree with you. 00:37:22.320 --> 00:37:24.480 The problem is they will drive down cost too far. 00:37:24.559 --> 00:37:30.239 And I would tell you, I know many people in my own market whose insurance contracts are below Medicare rates today. 00:37:30.320 --> 00:37:33.840 And if we think Medicare is too low, insurance companies are paying way too low. 00:37:34.000 --> 00:37:56.800 And I, you know, I will say like the worst thing I have heard, and I won't say who has said it, but the worst thing I've heard in all of my meetings, and I try and meet with all the stakeholders in the No Surprises Act business, is when I've been told now, basically, hey, we understand that you guys are winning all this time in the No Surprises Act, and we agree that you deserve to get paid more. 00:37:56.960 --> 00:38:00.559 Um, help us fix this No Surprises Act and we'll pay you more. 00:38:00.800 --> 00:38:03.119 It's like, why does it take the No Surprise? 00:38:03.519 --> 00:38:12.559 What about the No Surprises Act makes these people in the private sector say, now we need to pay you guys more money and we're willing to do it? 00:38:12.639 --> 00:38:15.360 Like, why did it take the No Surprises Act to get to that? 00:38:15.440 --> 00:38:31.440 Why was that not something where when you see every one of my spine surgeon colleagues in this market driving up to the hospitals and becoming employed, why did anybody pick up the phone and call them and say, hey, before you take that contract, before you sign that contract, we're willing to sign a better contract. 00:38:31.599 --> 00:38:38.800 We're willing to make the economics, you know, better for you, but at the end of the day, a savings for us compared to you becoming employed. 00:38:38.880 --> 00:38:41.840 And I think that is where the entire healthcare system has fallen apart. 00:38:41.920 --> 00:38:45.199 The employers have largely given everything up to the insurance companies. 00:38:45.280 --> 00:38:49.679 The insurance companies have done everything they can to scrape every dollar out of the system. 00:38:49.840 --> 00:39:00.320 And now you you just don't have enough doctors who are willing to take anything and ultimately drive ourselves into these higher cost centers that ultimately drive the healthcare cost up, not down. 00:39:00.719 --> 00:39:12.159 Well, I guess the issue is that they didn't really care if that were to happen because yes, the the cost of uh uh joining uh these you know consolidation was high. 00:39:12.559 --> 00:39:25.440 Um, but now they're they're you know now an outer network person is getting uh is potentially getting rates that are even higher than what the contracted rate they have that they're paying to the hospital system, right? 00:39:25.760 --> 00:39:28.559 Because yeah, I I I would just caution when we do that. 00:39:29.199 --> 00:39:30.320 Here's what I would caution. 00:39:30.480 --> 00:39:30.800 Yeah. 00:39:32.159 --> 00:39:34.880 We can't assume a world like that. 00:39:35.039 --> 00:39:43.599 I think what we have to do if we're gonna have this as a as a true um kind of thought process, what we have to do is we have to create two worlds. 00:39:43.920 -->

00:39:51.519 The first world is where we never pass the No Surprises Act, and these out of network doctors go through the old process that they went through, right? 00:39:51.840 --> 00:39:57.199 Which it I'm gonna tell you right now, there are many plans that had statements that said they paid 80% of bill charges. 00:39:57.360 --> 00:39:58.880 That was in planned documents. 00:39:58.960 --> 00:40:01.760 They had to pay those amounts when the doctor was out of network. 00:40:01.840 --> 00:40:02.159 Okay. 00:40:02.400 --> 00:40:07.039 And it wasn't confined to whether it was done in an operating room or in a clinic or somewhere else. 00:40:07.119 --> 00:40:08.719 That was the plan document. 00:40:09.119 --> 00:40:11.360 Um, so you had you had that world. 00:40:11.519 --> 00:40:13.599 And then you have this world with the no surprises act. 00:40:13.679 --> 00:40:19.440 And I think if we're going to be truthful and honest about comparing it, we can't compare to what the in-network rate is. 00:40:19.519 --> 00:40:24.400 We have to compare to what it would be out of network if it weren't for the No Surprises Act, right? 00:40:25.119 --> 00:40:27.760 Because that's the reality of what has happened. 00:40:27.920 --> 00:40:32.880 We so the total reimbursement is what the reimbursement would be, what the cost sharing would be for the patient. 00:40:33.199 --> 00:40:47.920 Total cost of care for the entire United States, if if that same five or six percent of the United States of the United States doctors went into an out of network process and settled versus went through this process that they're going through now, what would that cost? 00:40:48.079 --> 00:40:51.679 And we know what that cost is, and I can tell you right now, it's a cost savings. 00:40:51.760 --> 00:40:59.679 And there are other, there are groups who have already done these analyses and they're showing that pre-NSA, we paid more for emergency care than we paid post-NSA. 00:41:00.239 --> 00:41:02.320 The difference is, here's the difference. 00:41:02.559 --> 00:41:08.639 The difference is that we now have a federal government who is counting every dollar. 00:41:08.800 --> 00:41:14.719 Previously, employers and insurance companies were not really paying attention and calculating every dollar. 00:41:14.800 --> 00:41:18.719 And so they didn't know how much they were truly spending out of network or it wasn't being disclosed. 00:41:18.880 --> 00:41:21.519 Now that it's being disclosed, they're like, oh my gosh, we paid it all. 00:41:21.599 --> 00:41:22.639 But what are they basing it on? 00:41:22.800 --> 00:41:23.920 A baseline of zero dollars. 00:41:24.000 --> 00:41:26.719 They're saying we spent$22 billion on out-of-network care. 00:41:26.800 --> 00:41:28.159 That's crazy, right? 00:41:28.400 --> 00:41:44.079 But they're not basing it on what is true, what truly would have happened with all of those claims had they gone through the old out-of-network process and what they would have settled for, which most of them would have settled for substantially more than what the first 95% are settling for, which is the QPA. 00:41:44.960 --> 00:41:56.000 But in the past you had you had you I mean in the past you you patients were being s stuck with some portion of that, correct? 00:41:56.320 --> 00:41:58.239 And so the pa and so no? 00:41:58.880 --> 00:41:59.440 Not always. 00:41:59.599 --> 00:42:16.960 So I would tell you in the majority of those out of network discussions, what would happen in the in the um in the negotiation between the physician and the insurance company, if they came to an agreement, um they would typically say, and as part of this agreement, we're we're holding the patient harmless for any further cost. 00:42:17.280 --> 00:42:25.360 Now, in in some cases, particularly in emergency medicine, um, they were not coming to agreements, and there were honestly some bad actors, right? 00:42:25.440 --> 00:42:29.119 And they were ultimately billing patients for substantially more money. 00:42:29.280 --> 00:42:38.320 They were making probably as much as they're making under the No Surprises Act, and we're still charging additional amounts above and beyond that into um to the patients. 00:42:38.400 --> 00:42:42.239 And so I I think I think there was a mix of that all going on. 00:42:42.400 --> 00:42:51.519 Uh, but I would tell you that in a lot of scenarios, the negotiation at the end of the negotiation between the insurance company and the doctor, they both agreed to hold the patient harmless. 00:42:52.079 --> 00:42:58.719 So I I think one of the one of the look, I I'm of course, uh as an independent physician. 00:42:58.880 --> 00:43:02.239 The problem with independent physicians is that we have zero negotiating leverage, right? 00:43:02.320 --> 00:43:09.039 I I I I mean, you just if if you're in network with Aetna, you're in network with uh uh United, uh you know, Blue Cross. 00:43:09.199 --> 00:43:11.760 I mean, what negotiation can I do with them? 00:43:12.079 --> 00:43:14.480 I just take whatever rate it is they give me, right? 00:43:14.559 --> 00:43:22.480 So, and and I'm not allowed to um talk to 12 other cardiologists in Philadelphia, right? 00:43:22.559 --> 00:43:28.079 Uh and organize and say, hey, you know, let's all go and form an organization and do this because why? 00:43:28.239 --> 00:43:29.280 Because price fixing, right? 00:43:29.360 --> 00:43:33.440 The the Sherman uh uh the Sherman uh Act that prevents uh price fixing. 00:43:33.599 --> 00:43:45.440 Now, the Sherman Act was specifically geared towards consumers who were shopping at like grocery stores and a bunch of grocery stores getting together, right, and and raising the price of bananas, okay? 00:43:45.679 --> 00:43:54.239 Because the idea was that the that the power um that this was this was unfair and uh you know, unfair uh um on the part of the suppliers. 00:43:54.480 --> 00:43:59.760 You wanted uh suppliers to be competing on uh producers and suppliers to

be competing on price. 00:44:00.320 --> 00:44:07.599 And if you organize against a single consumer, that was going a single consumer walking and trying to buy bananas, that was unfair. 00:44:07.760 --> 00:44:10.880 And and you can, I can see that, you can understand that, right? 00:44:11.119 --> 00:44:41.199 Of course, I think wrongly, I mean, I'm not a lawyer, but wrongly, I think physicians somehow have been handcuffed with doing with with with with doing this because of this market power asymmetry thing, even though the person that we're negotiating with is not, you know, Joe the plumber or Joe the investment banker, it's freaking United Health, which, you know, last I checked at$4 billion in in profit last quarter, right? 00:44:41.360 --> 00:45:08.159 And so it's like so what are so you know, when people talk about, oh, the unfairness of these No Surprises Act and oh these rates and oh these physicians, you know, it's fundamentally what it what it comes down to is that for the first time in forever, maybe, you have independent physicians that have some leverage in negotiating prices with with um uh uh with insurance companies. 00:45:08.320 --> 00:45:10.559 We've never we've never had leverage otherwise, right? 00:45:10.800 --> 00:45:16.320 Um uh I in leverage that specifically keeps the patients out of it, right? 00:45:16.480 --> 00:45:17.840 Mandated the patients are out of it. 00:45:17.920 --> 00:45:22.719 So now it really is insurance versus uh, you know, and us. 00:45:22.880 --> 00:45:25.599 And and yes, market prices have come up. 00:45:25.760 --> 00:45:40.159 Market prices have come up in large part because market because the market has been massively depressed by all these different things, by legislation, by federal government legislation that has suppressed uh uh the price of services to physicians, right? 00:45:40.400 --> 00:45:57.119 The legislation has not been geared to suppress healthcare costs because the moment anyone in the federal government talks about fixing healthcare costs or nationalizing healthcare, right, you know, now all of a sudden it's the coalition of us and the insurers together saying, okay, that's a very bad idea. 00:45:57.280 --> 00:45:59.519 We don't want uh prices to be fixed. 00:45:59.840 --> 00:46:10.480 But the the the federal government, that the legislation, that whole the sausage as it's being made, is being made to essentially control the costs that physicians can get. 00:46:10.639 --> 00:46:12.800 So they want to keep us at this percent. 00:46:13.280 --> 00:46:16.159 And by the way, we are the ones that provide all the services. 00:46:16.239 --> 00:46:30.320 We are the ones that should have all the leverage, which is why we're the most dangerous, and which is why I think there's you know, billions of dollars that are going not billions, uh maybe millions and hundreds of millions of dollars that are being are going into lobbying to kind of control that. 00:46:30.480 --> 00:46:39.760 So it's a very long monologue to say that, look, I I I get that you know, I'm fully if you're not unless you unless you make some radical changes. 00:46:39.840 --> 00:46:52.639 I'm talking about, you know, the Supreme Court reversing the uh um uh the uh uh ban on physicians organizing, but uh right, but uh and again, the only way physicians can organize is basically get under one NPI number. 00:46:52.800 --> 00:47:01.440 In order to get under one NPI number, now all of a sudden, you know, Adam, oh, that's a nice help, that's a nice EMR system that's nicely uh optimized for you. 00:47:01.519 --> 00:47:03.119 Oh, nope, you gotta you gotta change that. 00:47:03.280 --> 00:47:08.880 Oh, you you need a bank account, you need you need, you know, uh significant clinical and financial integration. 00:47:09.039 --> 00:47:14.880 I mean, basically strips your autonomy to join some larger group, pay them a management fee. 00:47:15.039 --> 00:47:16.320 Uh, you know, anyway. 00:47:16.400 --> 00:47:19.199 Uh so look, I I I I get I get that piece. 00:47:19.519 --> 00:47:34.079 But on the other side, um it seems, you know, I think the the the issue is is that people see this as this was supposed to uh uh you know address a narrow issue. 00:47:34.239 --> 00:47:40.079 It was not supposed to address the issue of physicians being unable to negotiate, right? 00:47:40.559 --> 00:48:02.079 Um and so I think part of the reason why there's all this bruh about this is that you know it was supposed to address a narrow problem and it's now being used by physicians, I think rightfully so, to correct to correct uh to correct kind of a larger problem. 00:48:02.400 --> 00:48:13.440 But if you really zoom out and go even more meta than than than this, um most of these are elective services uh that that that this is happening to, right? 00:48:13.920 --> 00:48:25.840 So uh you know from a from a principal standpoint, why is it that like should should we have knee replacements that are covered by third-party insurers? 00:48:26.000 --> 00:48:31.119 Why is it not something that is just between patients and orthopedic surgeons? 00:48:31.280 --> 00:48:42.960 Meaning go, you know, Oklahoma style, um, you know, and and say, hey, you know, Adam Adam Brugeman has a price list, you know, these I don't take insurance at all, and I just negotiate with the patients. 00:48:43.119 --> 00:49:00.400 You know, so some people will say that, you know, this is just another play by the COCAs and the Brugemans of the world to get a piece of that insurance pie when actually, if you want to be pure first principles about this, you you unplug, don't take any insurance again, don't do NSA. 00:49:00.639 --> 00:49:04.719 You just provide it, provide, provide us a uh, you say that, hey, I'm gonna do your knee replacement. 00:49:04.800 --> 00:49:05.840 This is my price. 00:49:06.000 --> 00:49:08.320 You know, if you want to pay it, go ahead and pay it. 00:49:08.880 --> 00:49:10.960 Yeah, there are people who do that, right?

00:49:11.039 --> 00:49:13.360 Uh the problem is that's gonna be market by market. 00:49:13.440 --> 00:49:18.719 If I'm in San Francisco, I probably have a lot more people who are willing to pay a cash price or Philadelphia or New York. 00:49:18.800 --> 00:49:23.760 Uh probably not as many in South Texas that are willing to pay a cash price to have their total knee replacement. 00:49:23.920 --> 00:49:40.159 And listen, I've got, um, to my knowledge, uh two colleagues in this community who are completely opted out of Medicare who do cash pay-only total joints, and um they seem to be pretty happy with what they're getting, and and it seems to be working for them. 00:49:40.239 --> 00:49:46.719 My question is, what if I mean, again, getting back to the same statement, could every doctor go do that in San Antonio? 00:49:46.880 --> 00:49:50.320 Would every doctor in this market be able to go to a cash pay market plan? 00:49:50.559 --> 00:49:54.400 And would A that limit access inappropriately to patients? 00:49:54.480 --> 00:49:59.519 And B, would that lead to, I mean, how many people could afford to ultimately do that? 00:49:59.599 --> 00:50:00.639 What would that look like? 00:50:00.880 --> 00:50:04.719 And I think that's the ultimate problem in some of these episodic care. 00:50:05.280 --> 00:50:10.400 Um I mean, why why why are any primary care doctors taking health insurance today? 00:50:10.480 --> 00:50:12.000 Why aren't they all direct primary care? 00:50:12.159 --> 00:50:25.280 When there's a much more clear model for them than there is for episodic care, like what all of us on this um, well, you know, Anish, you you you do provide some less than episodic care, but we, you know, really from a surgical speciality, we provide episodic care. 00:50:25.360 --> 00:50:26.880 How do you how do you price that? 00:50:27.039 --> 00:50:34.880 Um, but yeah, I mean, not everybody's in DPC because not everybody can afford it, but I I I do I think we have to, I think a couple of things. 00:50:35.039 --> 00:50:36.880 One, we have to work within the system we have today. 00:50:36.960 --> 00:50:40.800 And so as physicians, we, you know, the dominant system is an insurance system. 00:50:40.880 --> 00:50:51.599 It doesn't mean we're not working towards something else, uh, but you've still got to keep the lights on, as as they said when I was in health administration school, you know, no margin, no mission, right? 00:50:51.760 --> 00:50:56.800 So if you may have the best mission in the world, but if you have no margins, it really doesn't matter whatsoever. 00:50:56.960 --> 00:51:00.960 So physicians have to do what they need to do within the fee-for-service system. 00:51:01.119 --> 00:51:06.320 Um, but that doesn't mean we can't be arguing for continued change to other systems. 00:51:06.639 --> 00:51:18.880 What that may be, and I think all of everyone on this call has has come up with some great ideas about how to fully reform the healthcare system into a better system that can align cost, quality, and value. 00:51:19.199 --> 00:51:20.800 I I I do find it amusing. 00:51:20.880 --> 00:51:25.360 That's very well said, you know, uh we have to work within the system we have, right? 00:51:25.440 --> 00:51:33.440 I mean, you have and and what we have is a tremendous number of people that are paying insurance premiums for to get their knee replaced if they were to get their knee replaced, right? 00:51:33.679 --> 00:51:38.800 Um so yeah, you know, uh and I think we I think we can do both, right, uh Adam. 00:51:38.880 --> 00:51:48.159 I I mean uh my my concern is that you know, as much as physician prices are depressed for um uh in in many ways, right? 00:51:48.400 --> 00:51:59.039 But there's also, of course, inflation of physician service physician value as well because of the third party system. 00:51:59.199 --> 00:52:16.880 Right, if you if you didn't have a third party system that existed at all for elective services, like some of our some of us some of us would think would be the cleanest model for elective stuff, um then it's probably the case that many of us would make less than we make now. 00:52:18.320 --> 00:52:24.960 Um, I mean obviously if if you didn't have Medicare that paid for nuclear stress tests, right? 00:52:25.280 --> 00:52:27.360 There'd be a lot fewer nuclear stress tests done. 00:52:27.679 --> 00:52:29.199 That revenue stream would go down. 00:52:29.280 --> 00:52:35.119 So the the value of a general non-invasive cardiologist uh you know would be would be reduced. 00:52:35.199 --> 00:52:38.960 And so there is this it's this interesting problem here. 00:52:39.039 --> 00:52:54.960 There's there's no question, you know, it's insanity what a spine, you know, you guys are you know insanely uh uh talented individuals who do extreme you know stuff that you know whatever a few hundred people or s can do in the in the United States. 00:52:55.199 --> 00:53:08.880 Um and you compare that to, you know, the average, say, lawyer, not average lawyer, but you compare that to a lawyer, you know, of any any type of similar thing, and and and and the dollars per hour are just insanely different. 00:53:09.360 --> 00:53:19.360 And you know, I'd argue that of course you guys are you know getting, you know, what is the value of getting somebody who can't who who's who has pain every time they take a step and making them pain free, right? 00:53:19.599 --> 00:53:22.480 So I I I I I totally get it. 00:53:22.559 --> 00:53:44.800 And I think I think you know, there's certainly value that is there there's certainly do you see what I'm uh you know, I struggle a little bit with the fact that in our massively third-party funded system, there's probably a large share of us who are, as physicians, who are, you know, kind of benefiting from that. 00:53:44.880 --> 00:53:50.800 And if we were out on the open market, it may be a lot harder for us to kind of, you know, get paid. 00:53:51.280 --> 00:54:06.159 I I would tell you

the people who are who have opted out have told me that they make more money in the the cash paying uh surgeons that I know um in the total joint space make more money than they did when they were accepting health insurance or Medicare. 00:54:06.639 --> 00:54:09.840 Again, the question is, is that truly scalable? 00:54:10.320 --> 00:54:11.440 Could everybody go there? 00:54:11.599 --> 00:54:16.239 Just like the, you know, the primary care is the easiest one because they're so much farther ahead of everybody else. 00:54:16.480 --> 00:54:19.760 Could every doctor in your market go to direct primary care? 00:54:19.840 --> 00:54:22.320 And would there be enough patients who are willing to pay? 00:54:22.480 --> 00:54:27.840 And I don't know what the going rate is right now for DPC, but are there enough people who are willing to pay that rate? 00:54:28.000 --> 00:54:29.519 Could could everybody become like Dr. 00:54:29.599 --> 00:54:33.440 Kaufman, all the emergency medicine physicians and open their own urgent cares? 00:54:33.599 --> 00:54:35.360 Is there enough need for that sort of thing? 00:54:35.599 --> 00:54:40.400 So those are the questions like the you know, the insurance market works for everybody. 00:54:40.559 --> 00:54:45.519 Um, some of these other ideas maybe don't work at scale for everybody. 00:54:45.679 --> 00:54:52.320 And um that's you know, how do you maintain access while at the same time, same time working on these changes? 00:54:52.719 --> 00:54:53.199 Excellent point. 00:54:53.360 --> 00:54:59.840 Um because obviously no nobody's gonna be happy if they if you suddenly, you know, uh 20% of the population can't can't afford a knee replacement, right? 00:54:59.920 --> 00:55:02.400 Um, so getting to that model is different. 00:55:02.800 --> 00:55:11.360 Uh we didn't talk uh uh perhaps we're remiss to not talk a little bit about um the IDR process in terms of the arbitrators, because the arbitrators have been in the news as well. 00:55:11.599 --> 00:55:19.840 Um you know, the the the put the pushback would be that um the arbitration pro arbitration process in terms of deciding what is an appropriate fee is incorrect. 00:55:20.000 --> 00:55:30.559 One of my big uh pet peeves whenever we talk when whenever um some think tank person talks about uh the arbitration process and and you know these uh, you know, oh my God, they they got this super high number. 00:55:30.639 --> 00:55:39.360 And it's like, okay, if they got the super high number, I I I what I need to know, what I need to know is what were the two offers, right? 00:55:39.440 --> 00:55:50.880 Yeah so because if the offer was a dollar for some some some knee replacement, uh, or the offer was$100, then maybe this is incompetence on the part of the insurance company because what do you want the arbitrator to do? 00:55:51.119 --> 00:55:55.440 Now, Adam, I would say on the flip side, I mean, and that data should be out there, right? 00:55:55.519 --> 00:55:57.039 Adam, why is that data

not out there? 00:55:57.119 --> 00:55:58.559 What is what are the offers? 00:55:58.719 --> 00:56:02.880 Are these are these awards that are say 26 times the QPA? 00:56:03.119 --> 00:56:23.199 Um, and again, I not not I'm not saying that the QPA is necessarily the be all and end all, but but some of these awards that are that seem outsized relative to uh you know that shock the conscience or whatever, uh are those awards bad arbitration or are they because of bad offers? 00:56:24.400 --> 00:56:29.920 I mean, listen, I I think the hard part is that none of us are arbitrators, and I think that's the question that we've always asked. 00:56:30.000 --> 00:56:53.599 I they what I honestly what I really hate about it is that what's happened is that people have said this theory if arbitrators only get arbitrations when there's a dispute between a doctor and an insurance company and they always side on behalf of the insurance company, then they would cut off their own supply of revenue. 00:56:53.840 --> 00:57:02.960 And therefore, all arbitrators are biased to select physician numbers in order to keep the money train coming. 00:57:05.119 --> 00:57:06.639 That is the argument, right? 00:57:06.800 --> 00:57:07.679 Now think about that. 00:57:07.760 --> 00:57:10.960 I mean, I I don't know how many, I I I've never looked into the data. 00:57:11.199 --> 00:57:16.079 How many arbitrators are there, many of which are contract, outsourced, and contracted, right? 00:57:16.239 --> 00:57:19.280 How many arbitrators are there in any one given company? 00:57:19.920 --> 00:57:32.960 That you would have to have a company that would have some sort of company policy that instructs every single arbitrator to find in this way, or that they lose business or they're no longer selected as an arbitrator, right? 00:57:33.119 --> 00:57:38.960 You would have to find company policies that support that to show that that's actually the case. 00:57:39.119 --> 00:57:47.280 And they have interviewed, they just I saw a recent article where they interviewed IDRE, former employees, people who've worked there before, been previous arbitrators. 00:57:47.440 --> 00:57:52.559 Not a single one of them said they didn't follow the law or they didn't follow the way the law was written. 00:57:52.719 --> 00:57:58.000 All of them said they followed the way the law was written, um, and then talked about how the process works. 00:57:58.159 --> 00:58:02.800 So I think I think the arbitrators are doing what they can do. 00:58:02.960 --> 00:58:04.639 I think this is based on offers. 00:58:04.719 --> 00:58:09.360 And listen, they're humans, they're gonna look at two offers and they're gonna pick the best offer. 00:58:09.519 --> 00:58:23.760 I I I, you know, if you're a high offer and your other other side of that is a very low number, and you've got to pay arbitration fees when you lose, which may completely wipe out whatever dollar amount you got paid, so that you get paid essentially zero dollars. 00:58:24.000 --> 00:58:29.840 You gotta like, you know, you would really strongly think about whether or not you want to put that number forward if you think it's fair or not fair. 00:58:30.000 --> 00:58:36.400 So it's clear to me that when the physicians are going to arbitration, they feel confident that their number is accurate and fair. 00:58:36.639 --> 00:58:39.360 And it's clear to me that the arbitrators are agreeing. 00:58:39.519 --> 00:58:51.679 I I don't know that we can get into the mind of the arbitrators to say why that is, but if you also need to know that like almost half of all arbitrations are being won on defaults, which means that the insurance company didn't even show up. 00:58:52.000 --> 00:58:55.599 So it's hard to parse all that out. 00:58:55.679 --> 00:59:01.039 And like just getting to your PA example, I can't remember what it is, the Paragon Institute said 25 times or something like that. 00:59:01.199 --> 00:59:03.519 Remember, the PA is probably only getting paid$100. 00:59:04.159 --> 00:59:13.199 So when we say 25 times, like I think sometimes we imagine these massive numbers means that the PA probably got got paid in some of these claims$2,000. 00:59:13.519 --> 00:59:15.119 Now, is that a high number for a PA? 00:59:15.280 --> 00:59:25.360 It's a higher number for a PA, but it's also not like some number that people are going, oh my gosh, they got paid$250,000 for this, and that was 25 times the normal rate. 00:59:25.599 --> 00:59:38.320 And um the other really interesting thing is is that when when uh the um there was an orthopedic study that was done, and I need to find out, uh, I need to look and see who did it because I can't remember off the top of my head. 00:59:38.480 --> 00:59:42.239 But they asked patients, how much do you think your doctor got paid for this? 00:59:42.480 --> 00:59:46.800 And what do you think was a fair amount that the doctor should have gotten paid for it? 00:59:47.039 --> 00:59:52.400 And the answer to the fair amount that the doctor should have gotten paid was over 10 times what Medicare pays. 00:59:52.559 --> 01:00:00.880 So when we ask, when we ask the people receiving the care what they think the value of the care is, it's over 10x what Medicare pays on average. 01:00:01.039 --> 01:00:01.199 Yeah. 01:00:01.360 --> 01:00:23.039 Um, and that part is really hard for the insurers to get their head around because they believe that the number they put out there is the fair amount because what they think is, as you said, that that was a fair negotiation between a doctor and an insurance company when in many cases it was a very lopsided, one-sided David versus Goliath, not a fair at-arm's length transaction. 01:00:24.079 --> 01:00:30.079 Yeah, and you know, the one thing is that this is from the uh I uh from the Paragon Institute's own uh data. 01:00:30.320 --> 01:00:34.159 I mean, most IDR awards actually fall within five times the QPA. 01:00:34.320 --> 01:00:36.239 Like the vast majority

cluster there, right? 01:00:36.400 --> 01:00:42.000 So, you know, it's it is really frustrating to see, and that's an important uh uh point. 01:00:42.159 --> 01:00:50.159 I mean, one, the QPA is probably depressed, suppressed, but the vast majority cluster uh within five times the QPA. 01:00:50.320 --> 01:00:56.880 It is the rare outliers that cluster at significant numbers, uh uh, you know, uh significant multiples beyond that. 01:00:57.119 --> 01:01:08.880 And so, you know, of course, the solution that's proffered by by a number of think tanks is just get rid of the whole IDR process or get rid of the IDR process for the elect for elective stuff only. 01:01:09.039 --> 01:01:21.119 When, okay, but what is your evidence that this is working so so badly if the vast majority, just by your own data that you put out, suggests that the vast majority cluster within uh uh you know five times the QPA. 01:01:21.199 --> 01:01:25.840 So and just don't forget, this is an outlier of an outlier, okay? 01:01:26.000 --> 01:01:26.239 Right. 01:01:26.400 --> 01:01:29.599 When we do statistical tests, 5% is the outlier. 01:01:29.760 --> 01:01:32.480 The 5% is the amount that's going to the arbitration. 01:01:32.559 --> 01:01:35.519 They're not arguing that they're winning 95% of the time. 01:01:35.679 --> 01:01:41.199 What they're arguing about is we're losing five percent of the time, and we can't stand to lose any of the time. 01:01:41.519 --> 01:01:47.519 We believe that our original rate that we pay 95% of the time is the rate that should be the payment for all 100%. 01:01:48.000 --> 01:01:48.400 Why? 01:01:48.639 --> 01:01:49.519 Because we said so. 01:01:49.760 --> 01:01:51.440 It just not because there's data. 01:01:51.760 --> 01:01:55.760 It goes to show you how much better they are on the business front than we are. 01:01:55.920 --> 01:01:57.039 I'm telling you, it's insane. 01:01:57.199 --> 01:02:00.719 Like, you know, you and you and I both run these independent practices, right? 01:02:00.880 --> 01:02:07.599 Like, if we told some MBA about how it is we do collections, like meaning, I mean, it'd be insane, right? 01:02:07.760 --> 01:02:13.119 I mean, that the amount of money that that you know I write off every month in collections, right? 01:02:13.199 --> 01:02:15.119 Uh, because I'm I'm, you know, whatever. 01:02:15.280 --> 01:02:17.599 Um, but you know, to them, that'd be like, what? 01:02:17.679 --> 01:02:18.880 You're a stupid, you're stupid. 01:02:18.960 --> 01:02:25.599 Like, why aren't you turning this over to some collections agency that then ends up in some, you know, that you know, that threatens lawsuits and all that stuff. 01:02:25.920 --> 01:02:39.679 But but just it goes to show you that even if I'm making the point that even though this this deals with 5% of all the of all these cases, that is a expense fund that is potentially growing, and they're gonna come after that. 01:02:39.760 --> 01:02:42.719 And they're not gonna come after that

and just write polite little emails. 01:02:42.880 --> 01:02:47.360 No, they're gonna they're gonna send they're gonna send all this stuff to the New York Times, right? 01:02:47.440 --> 01:02:48.239 With the outliers. 01:02:48.400 --> 01:02:52.239 They're gonna send it, you know, they're gonna you know feed whoever in the ecosystem. 01:02:52.320 --> 01:02:59.840 And that ecosystem is gonna blare these outlier cases uh uh as if that is the norm, and this is what's raising healthcare prices. 01:03:00.079 --> 01:03:00.639 Yeah, Brookings. 01:03:00.960 --> 01:03:01.519 Meanwhile. 01:03:01.760 --> 01:03:01.920 Yeah. 01:03:02.159 --> 01:03:18.719 Meanwhile, you know, what's raising healthcare prices as everyone, I mean, apparently Zeke Zeke Manuel, Brian Blaise, Ashis Shah, Anthony DeGiorgio, all all the great minds together can can acknowledge that, my God, this is actually, can we talk about hospital consolidation? 01:03:18.960 --> 01:03:24.159 Um, though it is fascinating to me that, I mean, again, these are maybe, I don't know. 01:03:24.320 --> 01:03:29.199 I I I I also think that as smart as they are, they don't necessarily play the long game, right? 01:03:29.440 --> 01:03:42.159 Like I still go back to this insane conversation I had with a healthcare executive on some panel I was doing, and I was asking, like, don't you want multiple different providers and multiple different regional health systems that are doing the same thing so you can negotiate, negotiate? 01:03:42.320 --> 01:03:47.599 And and he literally looked at me blankly and said, No, we just want one health system to do everything. 01:03:47.760 --> 01:03:49.920 I'm like, well, then they have complete price control. 01:03:50.079 --> 01:03:50.719 Is that not true? 01:03:50.800 --> 01:03:55.440 I'm like, and then he just shrugged his shoulders, like, well, then they would be providing high quality because they're high volume. 01:03:55.679 --> 01:03:57.360 Yeah, they're also not for profit. 01:03:57.599 --> 01:03:58.719 Yeah, right, right, right, yeah. 01:03:58.880 --> 01:04:05.119 Anyhow, it it's a perplexing thing, but but I think it I do think it goes to show how much they care. 01:04:05.199 --> 01:04:12.960 And also that a very important point that this represents an off-ramp for a lot of people that are in that work that are stuck taking these in-network rates. 01:04:13.119 --> 01:04:19.840 And I mean, if you're a solo hand surgeon in New York, right, um now you have now you've got leverage. 01:04:19.920 --> 01:04:22.559 Now you can say, you know what, I don't have to work for the health system. 01:04:22.719 --> 01:04:27.280 I can go out and I can negotiate these, I I can I can have negotiating power. 01:04:27.360 --> 01:04:30.079 Uh, and and I don't think insurance companies like that. 01:04:30.239 --> 01:04:36.719 They want everything, they want all different levers to be fixed because that they need the house to always win. 01:04:36.800 --> 01:04:38.480 And that is, and that, and that's what happens. 01:04:38.800 --> 01:04:42.000 So all right, sorry I monopolized a lot of that. 01:04:42.079 --> 01:04:47.519 Umath, any any any other questions, issues you think of here? 01:04:48.000 --> 01:04:52.719 I think it's really funny that they're so I saw that 22 billion figure. 01:04:53.519 --> 01:05:02.000 I I'm I'm just shaking my head, laughing, going they're that last five percent, they're they're fighting tooth and nail for it. 01:05:02.320 --> 01:05:07.679 I I and I'm just it's just it's just nine the 95% is isn't uh isn't enough. 01:05:07.920 --> 01:05:08.800 You know, what are you gonna do? 01:05:08.960 --> 01:05:12.800 And so I mean the the the question I was gonna ask you, you sort of answer this. 01:05:13.039 --> 01:05:20.719 Um is the problem that we're overpricing the problem that they're under pain. 01:05:21.119 --> 01:05:21.760 I think we know these. 01:05:22.239 --> 01:05:23.119 They've already admitted it, right? 01:05:23.199 --> 01:05:28.559 They've already they've already told us in meetings that they're under pain and they know they're under pain, and how do we make this go away? 01:05:28.639 --> 01:05:34.159 Because we're we don't want these big numbers, we don't want to pay these larger amounts out, but we know we're under pain. 01:05:34.239 --> 01:05:35.280 So how do we get there? 01:05:35.599 --> 01:05:37.840 Yeah, so I mean who's gonna do a Medicare knee? 01:05:37.920 --> 01:05:45.119 I'm in an orthopedic practice, and when I talk to my orthopedic partners about that, like Medicare pays us a thousand dollars for a total knee. 01:05:45.280 --> 01:05:47.360 Who's gonna do a total knee for$500? 01:05:49.119 --> 01:05:51.039 No one's gonna do a total knee for$500. 01:05:51.840 --> 01:05:53.679 The hospital employee doctor, why? 01:05:53.760 --> 01:06:03.519 Because$500 is a drop in the bucket compared to the you know forty, fifty thousand dollars they've negotiated at the facility side and and their and their margins on that. 01:06:03.599 --> 01:06:09.280 Um they they they don't care about the whether the doctor makes$500 or$1,000. 01:06:09.519 --> 01:06:12.239 It just is not material to their take-home. 01:06:12.800 --> 01:06:18.719 And the downstream revenue they get from the PT and the brace and the MRI and the yeah, all that. 01:06:19.199 --> 01:06:30.000 You know, if you just if you could publish a price and set it up with the patient, say this is what you pay for a total me, we're spending a lot of money to make sure people don't know what the what their health care costs. 01:06:30.400 --> 01:06:50.559 I I uh and I'll I'll try uh not to close on a really down point, but like what I what I said in one of my most recent talks is do we need are are we okay with or do we understand that many people are now seeing the physician fee schedule as a loss leader in order to make other revenue? 01:06:50.880 --> 01:06:57.360 Because that is how we all make our money, but that is not how anybody else in healthcare

makes their money. 01:06:57.519 --> 01:07:01.760 We are just purely a loss leader to get someone in the door to get something done. 01:07:01.920 --> 01:07:07.760 And that is a scary, scary statement, in my opinion, but it is the reality of where I see the economics currently. 01:07:08.079 --> 01:07:11.440 Well, that's 150% true if you are taking Medicare, right? 01:07:11.599 --> 01:07:25.280 It's like you know, Medicare Medicare reimbursement for those who have been asleep, Medicare reimbursement has gone down 33% uh, you know, uh if you adjust for inflation over the last, you know, whatever, 30 years, uh, compared to facility fees, which are just zooming up. 01:07:25.360 --> 01:07:27.760 So total Medicare cost is massively up. 01:07:27.920 --> 01:07:31.760 Uh physician fees are are down for Medicare. 01:07:31.840 --> 01:07:35.039 So Medicare for the large health systems, 100%. 01:07:35.599 --> 01:07:37.599 You are a lost leader if you're doing that, right? 01:07:37.679 --> 01:07:38.480 So all right. 01:07:38.559 --> 01:07:39.440 Well, uh, Dr. 01:07:39.519 --> 01:07:42.239 Giorgio has pumpkins to car with with with the kiddos. 01:07:42.480 --> 01:07:43.519 Uh very exciting. 01:07:43.679 --> 01:07:47.360 Um, so uh, but and this has been a fantastic uh hour-long discussion. 01:07:47.519 --> 01:07:51.280 I really hope folks listen and tune in, listen again on Spotify. 01:07:51.360 --> 01:07:59.039 Like the your value as a physician is completely dependent on the discussions that uh uh and and the advocacy that Dr. 01:07:59.119 --> 01:08:02.239 Brugman is uh is kind of is talking about. 01:08:02.400 --> 01:08:07.360 Um uh, you know, you're not you're not naturally worth anything, right? 01:08:07.679 --> 01:08:19.439 The system has to be set up to make you work something in healthcare in terms of how it's set up uh uh uh today, because most of it is in the insurance market, most of it is Medicare, most of it is Medicaid. 01:08:19.520 --> 01:08:24.399 And so what you're worth has everything it has everything to do with this conversation, right? 01:08:24.560 --> 01:08:27.920 I mean, you you can see, I mean, the the Paragon Institute actually says it. 01:08:28.000 --> 01:08:37.119 The Paragon Institute says that one of the problems here is that you know, with more and more of these out-of-network uh rates being being higher, then in-network rates are gonna rise. 01:08:37.279 --> 01:08:46.720 Oh no, physician, god forbid, god forbid, like you know, uh your in-network rates will go up, uh, you know, dragged up by anything. 01:08:46.880 --> 01:08:48.800 So super important, you know. 01:08:48.880 --> 01:08:56.640 I don't care what your politics are, right, left, you know, green, uh, you know, uh, I don't care what your position is on Israel, Palestine, or Iran. 01:08:56.800 --> 01:09:05.279 Um, if you're a physician in the United States, you we should all be uh uh on one boat, uh uh hopefully not sinking. 01:09:06.960 --> 01:09:07.920 All right, folks. 01:09:08.079 --> 01:09:08.800 Thanks so much. 01:09:08.880 --> 01:09:09.760 Uh we Dr. 01:09:09.840 --> 01:09:14.640 Burguin, we we have to have you on, you know, we should just schedule you for uh every four week uh episode. 01:09:15.600 --> 01:09:16.319 Thank you so much. 01:09:16.479 --> 01:09:17.119 I appreciate it. 01:09:17.359 --> 01:09:18.239 Thanks so much for coming on.