Full Transcript Podcast Introduction and Guest Background 0:06 Welcome to the Doctors Making a Difference podcast, where we help physicians to be empowered with the tools they need to successful in medicine, 0:13 in finance, and in life. 0:15 Join us as we highlight doctors and other professionals around the world who are making a difference. 0:26 I'm very pleased to welcome our guest today, Dr. 0:29 Josh Umber. 0:30 Joshua has the interesting story of not only being a board certified family doctor and going through the training and working in his home state of Kansas, 0:39 but he decided to take a little bit different path than most of us. 0:42 I am a family Doctor, Josh and I were talking before we hit record, I see the complexities of medicine from that side, kind of get a full spectrum perspective 0:50 of all the things that people deal with. 0:51 But Josh decided to do something very interesting called Direct Primary Care. 0:56 We'll talk about it in the episode. 0:57 I know probably a lot of listeners have heard of it, may not know the specific details, but I'm very excited to dive into this with Josh and talk a little 1:04 bit more about why primary care makes sense to direct primary as a primary-care doctor and how this can influence the system in United States and it can 1:14 also influence our individual patients one by one as we come across their stories. 1:19 Josh, would you mind introducing yourself to our audience? 1:22 Yeah, thank you for having me on. 1:24 Like you said, my name is Josh Umber, a family doc, born and raised in Alma, Kansas, then moved to Manhattan, KS for undergrad. 1:31 So go Wildcats. 1:32 We're a house divided though, because I then went to med school at the University of Kansas. 1:37 so we can cheer for K-State for football and KU for basketball. 1:42 But then, went into Wichita and trained in family medicine, finished my residency there and stayed and started our direct care practice right out of residency. 1:53 Well, tell me about that part, because it's quite a thing in, when you started this, I would say the majority of doctors finishing residency of all types, 2:02 maybe especially family medicine, were going into employed model sort of a practice. 2:07 And somewhere along the way, you had enough intelligence or bravery, or maybe your wife was brave enough to start her own business, 2:15 and not only that, but started in a different model than the most people do it. 2:19 So I'm kind of curious about how that story unfolded. 2:22 Yeah, you know, it's an interesting arc. 2:25 Growing up, my joke is my dad was a trash man and he was, but now he's a lawyer. 2:30 So we still tell people he is a trash man because it is less embarrassing. 2:34 And he has gone full circle. 2:36 He is our lawyer now. 2:38 It was honestly a blast. 2:40 We loved it. 2:41 and we worked on that truck for forever growing up. 2:44 Um, and it was great business model. 2:46 In hindsight, You paid once a month. 2:48 You picked up once week. 2:49 so I'd seen 20 years of a great, business being run. 2:52 And then in about 2000, as an undergrad, started working for a surgeon who was fresh out of fellowship and had no idea how to bill insurance, 3:01 right? 3:01 Brilliant cutter, absolutely amazing.
Why Josh Chose Direct Primary Care 3:04 And nowhere in all that training did anyone ever say, here's how you bill the insurance to get paid, not even well, just correctly, 3:11 I saw him just leave enormous amounts of money on the table because for him, billing insurance was a frustration, and not a requirement. 3:19 It kind of broke that. 3:22 idea you have growing up that if you work hard, the appropriate payment follows. 3:27 And so I could see that you could be an amazing skill person. 3:33 If you just didn't know how to play the game, you're going to lose. 3:37 we kind of in-person closed, I could point that out and say, this isn't how a good business is run. 3:42 And that started a career long journey of looking for doctors who did insurance free practices when that was concierge in 2000, 25,000 per person per year, 3:53 which the dirty little secret there was 98% of those practices failed. 3:56 25000 isn' even the one percenters, it's the 0.00 percenter. 4:04 So that was really hard for docs to find success in. 4:07 Others just doing an insurance free model, maybe more fee for service than membership. 4:13 And we watched that for the next 10 years, undergrad, med school, residency, and I just knew I wanted to run my own business. 4:20 I didn't want to do insurance. 4:22 Probably, as the Emperor's new close parable goes, the child who points it out is a wise fool. 4:29 I didn't know how hard it would be. 4:31 We have a banner in our office that says, we do this not because it's easy, but because we thought it'd be easy. 4:41 Just getting to residency and everything is hard and no one teaches you how to start a business. 4:46 And so we did all that, but it left all the room to make all of the mistakes and figure it out. 4:50 Once you carved out that okay, we're not doing insurance, it was freeing in a sense of great, you can do anything you want. 4:57 That worked out great. 4:59 We knew this was what we wanted for forever because it just made sense. 5:04 Kind of going back to my personal statement for getting into med school. 5:08 I had this fantastic, eccentric neighbor, Trottel, a German immigrant, and I watched her go through a broken healthcare system and the eccentric, 5:18 crazy, fun, interesting, unique person that I knew, the system made her into a bad patient. 5:29 She didn't show up on time. 5:30 she asked too many questions. 5:32 The system didn t give her any reason to trust it either, and they treated her like a number. 5:39 I wanted to be in medicine, but not that kind of medicine. 5:41 And I think that carried us through a lot of this kind, you know, figure it out. 5:48 Like you said, You wanted treat your patients like an individual, not like a number. 5:53 and you wanted be able to say, I want to offer the care that they need, Not the insurance or somebody else dictating that to me, 5:59 But rather giving it to the person in the way that the need it. 6:02 Maybe I had to back up one step and just have you define, again, most people on this are going to hear direct primary care and they're going have an inkling 6:09 of what that means. 6:11 And you mentioned concierge medicine. 6:12 I think a lot of people kind of have this idea of, hey, we're gonna pay $25,000 a year to have direct access to some primary-care doctor or somebody to 6:20 come to my home. 6:21 But would you mind kind walking through the model? 6:23 What is direct-primary care? 6:25 Help define that briefly for folks who may not really be intimately familiar with it. 6:29 Yeah, on some level, primary care is what I think is going to fix the healthcare system because it gets back to kind of first principles, 6:38 a smarter way of providing the service. 6:41 We're using insurance wrong. 6:42 A wrench makes a decent hammer, and a hammer makes horrible wrench. 6:46 So we need a better model for primary In this sense, it is an insurance-free model that charges patients a monthly membership, 6:54 like a gym or like Netflix or Amazon Prime, for a broad range of access and is based on age only. 7:02 So for our patients, that's $10 a month for children, 50, 75, or $100 a months for adults, just based their age ranges. 7:11 And those are the prices we started out with 2010. And we've been able to hold on to those, right? 7:16 What insurance company has been, you know, been ever to go a year without raising their prices. 7:20 But we knew in exchange for that, we wanted to offer as much value as we could. 7:26 So the membership provides unlimited home visits, work visits office visits phone calls, text messages, emails, video chat. 7:36 but also we been to eliminate copays. 7:39 Copays are a speed bump. 7:41 that the insurance requires so that patients have to spend a little bit of their own money before they spend the lot of the insurer's company's money. 7:50 We don't need it as a business model, right? 7:54 And no more than a gym needs a copay to try to keep people from coming into the door.
How the Direct Primary Care Model Works 7:59 And so we love that aspect of it because it hits those quadruple aims, more care, faster, easier, etc. 8:07 But then continue to add that value. 8:10 Any procedure we can do in the office is free. 8:13 Stitches, biopsies, joint injections, ultrasound, although we're not as good at it as we Could be. 8:19 I see the residents coming out of training. 8:21 They are so much more used to that than how we trained. 8:25 We have a DEXA for bone density screening, body composition, et cetera, full term monitor. 8:32 And because, you know, those procedures are all essentially extremely low cost and EKG costs me 40 cents. 8:42 The coffee in the waiting room costs 80 cents a cup. 8:44 So if I don't bill your insurance for one, why am I doing it for the other? 8:48 I just don t need to anymore. 8:50 And I'd rather not have the frustration than the revenue. 8:53 But it keeps going. 8:55 I feel like that's the beauty of the direct care model is it tries to touch more than people expect primary care to do. 9:02 We can do wholesale meds and wholesale labs. 9:04 Or about 80% cheaper than Amazon, 70% than GoodRx, and about 40% cheap than Mark Cuban. 9:10 There's not a billionaire alive who can get med's cheaper then a direct-care doctor. 9:14 And if you go direct with the labs, CBC is two bucks, TSH 250, A1C 3, Lipid 350, right? 9:22 The goal of direct care is to make most healthcare too cheap to ensure. 9:26 And be able to get all that for 50 bucks a month is a huge step in the right direction for putting patients first in order to fix healthcare. 9:36 Yeah. 9:36 So I want to clarify that a little bit because it sounds kind of astonishing in some ways, because I think like you said, 9:43 $10 for a child per month. 9:46 That means they're going to pay $120 per year. 9:48 And I know when we bill just a well child visit one time, the insurance pays probably over $200 for that. 9:55 Well, Chad, but that has to also pay for the insurance that I have to, you know, for malpractice insurance has, to pay the receptionist and a nurse and 10:04 the biller, not to mention the brick and mortar space that we're seeing the patient. 10:08 And then we have, also, pay an expensive electronic medical record system. 10:12 All those costs kind of get fed in and then also the doctor is supposed to get paid. 10:16 And so I think people listening to this are going to say, how could I possibly stay in business if I'm charging $120 a year for unlimited access? 10:24 Or if an adult patient on this more expensive end of spectrum, $70, you're still paying less than $1,000 a continuous access to your doctor. 10:33 And goodness, I just think about how much the list price is for the services we offer for patients. 10:39 But we also have this big complicated system that has to be built around what the insurance will pay, not necessarily what this service actually costs 10:47 to provide. 10:47 So walk us through that. 10:48 How do you stay in business? 10:50 Yeah, it's funny, I had a patient use our online scheduling option recently and he came in, we did our appointment and at the end he's like, 10:58 can I just ask like is this working? 11:02 I'm like yeah, why do you ask? 11:03 We've been here 15 years. 11:04 He's, like there are so many open spots on the calendar for self scheduling. 11:09 I just didn't know if you didn' have any patience. 11:11 And so we had a good chat, you know, and then last like, no, this is how it's designed, right? 11:15 Most of what we do doesn't have to be done in the office. 11:19 It sure can be, but meeting people where they're at, calling, texting, emailing, video chats, pink eye, may get them right away. 11:28 First thing where the guy want to. 11:29 No, just shoot me a picture of your eye. 11:31 now and every hour until we're kind of comfortable with how this is progressing, because that's so much better care. 11:39 It drops into EMR, it takes a short amount of time to evaluate, etc. 11:44 But when you're limited to that you only get paid when they come through the door, that changes everything. 11:51 We have one staff member for two physicians, basically. 11:55 At least that's what we recommend. 11:57 We're busy with a lot of irons in the fire, so sometimes we staff up. 12:01 But that is the general math for the business. 12:04 So you're talking about one nurse for every one to two doctors and 1,200 patients. 12:09 It shouldn't work. 12:10 They should sound too good to be true. 12:12 You should call the BS flag. 12:15 We were participating with a documentary recently and the theme of the documentary was, why are health care prices so high? 12:22 I said, oh, they're not. 12:25 The cost of healthcare is quite low. 12:27 EKGs, meds, labs, I can buy a thousand amlodipine for eight bucks. 12:32 It is literally under a penny a pill. 12:35 And that's not because we're good, that just the wholesale cost, right? 12:38 That's for a regular family doctor. 12:43 We keep making healthcare expenses and then trying to use insurance to cover everything. 12:49 There's an economics book, Predictably Irrational. 12:52 We would never buy car insurance if it was sold to us like health insurance. 12:56 Why do we keep buying health insurances in this broken way? 12:59 We're working with an employer group tomorrow. 13:02 Their health-insurance premiums are going up 27%. unsustainable. 13:07 And they're saying this wiped out their last three years of raises. 13:10 There has to be a better way. 13:12 So yeah, the cost of a well child check or any visit in an insurance model looks inflated, but it is because you have so many more hands in that pot. 13:23 But when, I joke, there's no profit in direct care practices. 13:28 Functionally, you has overhead, nurses, rent, EMR, malpractice, et cetera, and then whatever's left over goes to the doc. 13:35 So it's an extremely lean, but extremely efficient and kind of just intelligent business model. 13:41 So I like to reference these two stories. 13:43 One is Christopher Columbus's egg. 13:44 And the short version is they say, well, you're not that smart for discovering the new world. 13:50 We all thought it was round. 13:52 He takes an egg, he challenges all the king's horses and all of the King's men to make the egg stand up. 13:57 Of course, an egg won't stand up. 13:59 And so they say it's impossible. 14:00 So you all agree, it is impossible, takes the egg, smashes it, egg stands up, right? 14:06 The idea is he made what everybody agreed was impossible i.e. 14:09 fixing healthcare with a simple trick, made it so benignly simple anyone could do it. 14:15 Right? 14:15 That's what direct care is. 14:17 Or Napoleon's aluminum. 14:18 When he wanted to impress dignitaries, generals ate it off silver, Napoleon ate off gold, and dignitaries ate of aluminum, 14:26 Fast forward, you introduce a new technology and now we have aluminum foil we throw away. 14:33 Good business, capitalism brings the comfort of kings to commoners. 14:37 Doctors have this fear of being involved in business. 14:40 To me, family medicine and business is a love story. 14:45 I love being a family doctor.I love using business to help complement being family doctors. 14:51 that it's not personal, it is just business. 14:54 There's nothing more personal than this business, you are feeding my family in exchange, I'm caring for the health and well-being of your family. 15:03 It's extremely personal. 15:04 So not having insurance involved, not have a red tape and bureaucracy, finding solutions to meds and labs to make all of this affordable I tell my med 15:15 students all the time, if we take our own seriously and do no harm, that has to mean, do you know financial harm? 15:21 It begs us to strengthen our business skill so that we can continue to solve the problem of healthcare affordability. 15:30 Then, yeah, there's no reason these things have to cost that much. 15:34 They're just, they do because we have a broken, bloated system that were not trying to fix the right way. 15:40 Thank you for answering. 15:41 Another question I have is, so I told you before we hit record, I work in a rural area. 15:46 And I think half the town probably has my cell phone anyway, and they come at all hours, day and night, in text, nights, 15:52 weekends, holidays. 15:54 It's the life I've chosen in rural setting. 15:56 But I thing a lot of doctors are saying, hey, kind of like having to be able to turn off the phone and I like to not have to called in all the hours of 16:03 the day. 16:04 And when they hear direct primary care, they say, but that would mean I would have to be on the call 24-7-365. 16:11 And so, you know, kind of walk us through that. 16:14 How does that work with your life? 16:15 I definitely feel like the work-life balance is better in direct-primary care than it was even in residency. 16:24 When we were starting our internship here, the graduating residents were heading out to the workforce. 16:30 Three years later, by the time I'm graduating, half of those residents are leaving medicine because of burnout. 16:37 We talk about burnout in all these funny ways, but I don't think we actually address it. 16:41 You're burnt out because you're playing an unwinnable game. 16:44 There is no way to win in an insurance model. 16:47 They're always going to leverage bureaucracy against you. 16:50 It's a cold war, you know, to the point that we don't even include the review of systems meant something. 16:55 Now it's so meaningless, it is not required in insurance, Billy, or so my medicine is telling me.
Practice Economics and Patient Access 17:00 because we've just abused that fact. 17:02 We keep playing this game of who can chart more, who to bill more who, can beat the insurance games. 17:07 They'll win all the times. 17:09 The frustration comes from playing that and then the game is the paperwork, not the patient. 17:16 When we were med students, we're all Bernie, right? 17:19 We're wet behind the ears and newbies, but we loved patients, We loved songs, loved all of that. 17:26 And that gets beaten out of us through a complex system. 17:29 When you get to sit with a patient for an hour and get know them and know their family and like you do, I think one that brings a lot of that spark and 17:37 love of medicine again. 17:39 The American Academy of Family Practice has a report out, says 92% of direct care doctors are happy with their career choice and 54% insurance-based doctors. 17:51 So we're doing something right. 17:53 I say, yeah, I'm available 24 seven. 17:55 I may not reply 24 7. You have patients who text late at night for refills or early in the morning, you know, about pink eye. 18:02 They don't really expect you. 18:04 they know you sleep. 18:05 And I think even that's fun because I was out of town Friday, Saturday, Sunday with my wife and we went to learn how to fly fish. 18:13 Right? 18:13 Everything relates to direct care in my world. 18:16 I had no idea what fly fishing really was. 18:19 And the needles are insanely small. 18:21 Ridiculously small because they don't want to hurt the fish. 18:24 Sure. 18:25 Less is more. 18:26 Designed by subtraction. 18:28 So I have this whole article I want right in the head of even in fly-fishing. 18:33 The rule is do no harm. 18:35 You focus on this one process and you get in flow state. 18:38 Doctors can't get into flowstate because they're being interrupted every seven minutes. 18:43 We want to be with patients, not with paperwork. 18:46 Building a model that allows you to do that, you know, 600 patients is what we consult with doctors and recommend. 18:52 That seems to the right size. 18:54 So on any given day, I'll probably see three or four patients in the office for 30 to 60 minute appointments. 19:01 extremely manageable. 19:02 And then a handful of call, texts, email, things that come through. 19:06 So when someone does need you at night, we're on the weekend. 19:09 I had a patient send to the ER, I have your doctor's history, so I want to say I'm special. 19:13 But being available is the special part. 19:16 She started off with what looked like Venus lakes in her lips, but she doesn't have those. 19:20 Between 9.30 and 10 o'clock, more bruises show up. 19:24 It's got to be a sulfur allergy. 19:29 It's that, you know, this isn't going to be good. 19:31 Ended up being ITP, but she needed to go and nobody wants to in the ER, it's, 10 o'clock at night. 19:36 No, This is real. 19:37 You gotta go. 19:38 To the point that it, I'm not special. 19:41 It just that we have time. 19:43 I post funded a group yesterday on Twitter because they published a study that Stoffer, more time with Medicare patients improves outcomes. 19:54 We had to study this. 19:55 Like we went so far. 19:56 It's like, well, seven minutes. 19:57 Can we do six? 19:58 Can do five? 19:58 Why? 19:59 It seems like outcomes get worse. 20:01 What if we just gave them more time? 20:03 Like, I don't know. 20:04 Seems like what if use toilet paper? 20:06 Uh, it's such an obvious thing. 20:08 And then we studied it and we're proud to publish this, we reinvented more tolerance patients. 20:13 We've come full circle through the uncertainty. 20:16 And I know that's a long answer to a short question, but no, this is a very sustainable work-life balance. 20:22 I like working, so some people might be 500, I can flex up to 700 patients easy, along with running the other stuff. 20:29 So the beauty of having continuity with patients and flexibility, you're working for the patient, and you are not fighting insurance. 20:37 The care itself is drastically easier, let alone the others pieces. 20:43 And Josh, it does sound too good to be true. 20:45 A patient panel of, again, primary care doctor often has 2000, 3000 patients in their panel and you're seeing 20 to 25 patients a day. 20:55 You're saying a patient of 500 to 600, three to four visits per day, you are available, but it's not like the numbers are so overwhelming. 21:03 And you probably know most of those people because you sat down with them for 30 to 60 minutes a couple of times a year and they don't get penalized for 21:10 coming in more than once if they need to. 21:12 And so, again, it almost sounds too good to be true. 21:15 And I guess that's one of the things on direct primary care. 21:18 I wondered how has the insurance industry responded to direct-primary care? 21:23 As you've rolled this out and patients have adopted this in various locations around the United States, what's been the response to that when patients 21:31 do that and they don't have necessarily traditional insurance paying for their primary-care? 21:36 I mean, it is interesting. 21:38 Big insurance never paid too much attention to it. 21:41 I think, understandably, they were too busy doing their own thing. 21:45 So with smaller groups, we always worked with Allied National out of Kansas City. 21:50 And you could go in and say, look, the pitch was spend $50 with direct care to save $500 under insurance. 21:57 And the smaller insurance companies were fine with that because they just wanted, they had to fight for the business and be creative like that. 22:04 But it also gave them an edge when they could offer insurance that was 30 to 60% cheaper than a standard plan that wasn't trying to innovate. 22:13 I think the big insurance could go the way of Kodak is not because their bad at it per se, The game they're playing is unwinnable too, 22:23 because the government structure rules around how insurance companies have to spend the money, essentially have a perverse disincentive for them to make 22:33 anything cheaper. 22:34 Technically, they'd get punished if they saved too much money. 22:37 The Affordable Care Act is currently written. 22:39 So discouraged innovation in such a large way in an insurance model. 22:43 That being said, now that it's to the point of breaking, Even the insurance isn't happy. 22:48 They know this isn' working. 22:49 A 27% premium increase, they're going to have people just not take that insurance. 22:55 Agents are getting less commission. 22:56 It's harder to get and keep business. 22:58 So you're seeing that squeeze kind of come at it from all directions and make everyone more pliable to find solutions. 23:05 Doctors are frustrated, but they're very risky. 23:08 15 years ago, they didn't think this would work at all. 23:11 Now, we had our largest national conference ever this summer with the AAFP, and it got oversold twice. 23:18 And then some residents just crashed it. 23:21 Who crashes a CME event? 23:25 It wasn't standing remotely, it was sitting remotely. 23:27 The doctor was so ready. 23:28 He said, okay, I've seen this work in my town. 23:30 I hear it more and more. 23:32 My frustration with the insurance model is higher every year and my comfort with a direct care model being functional improves every years. 23:39 So that delta makes it easy to change. 23:42 I think this will be the only way to practice primary care, really any outpatient care five, 10 years, because we can't afford to insure it anymore. 23:52 It was never logical to affordable things, but we kept doing it. 23:55 So you don't beat the system, you let it kind of punch itself out. 23:59 And now you're seeing a lot more insurance innovation, especially post the big, beautiful bill passing to clarify direct care and HSAs are legal. 24:08 In my opinion, have always been legal that allows employer groups. 24:12 A lot of flexibility now that they were kind of standing on the sidelines for. 24:16 So yeah, I think DPC will grow faster now than it ever has.
Work-Life Balance and Burnout Relief 24:21 Yeah. 24:22 I want to clarify that for those who didn't know that direct primary care previously was excluded. 24:27 If I've got this right, Josh, excluded for paying for direct, primary-care fees. 24:31 But with these clarifications this last year, they are included. 24:35 So folks can use their, can they use flexible spending count of dollars to pay for it? 24:40 So my little bugaboo about it was it never illegal. 24:44 The IRS was just quiet on it. 24:46 And by all definitions of IRS document 213D and 502C, the legal definition of a medical service was any legal payment to a physician, 24:56 surgeon, dentist, chiropractor, et cetera, right? 24:59 It's a document written in 2003. It doesn't even mention nurse practitioners or physician assistants anywhere as a qualified medical expense. 25:10 But it's a living document. 25:12 It's meant to be implied that any specialty, any trainee, physical therapy, speech therapy et cetera is a legal medical expense. 25:23 So we always did it. 25:25 We operated with thousands of doctors for the last 15 years doing HSA. 25:31 But for bigger employers, they were more afraid of the IRS than they are of their potential savings. 25:39 Now that it's confirmed legal, it makes the larger employer groups much more comfortable. 25:45 So it was always being done. 25:46 It's just now we know it. 25:48 We got that checkmarked. 25:50 Well, and so for folks who are listening, who may have been nervous about doing this before, or if like I'm thinking about some of my family members that 25:57 take advantage of having a drug primary care doctor as their doctor, there's always this question, can we use flexible spending account money? 26:04 Can I use my health savings account associated with the high deductible insurance? 26:09 That's been legitimized 100% now. 26:12 And I guess another question related to that is, You know, of course it's a good idea to have insurance cover those big catastrophic items. 26:19 And I agree with you, why are we insuring something that's affordable? 26:22 Like that makes total sense. 26:23 Why do we have to insurance to pay for something? 26:25 That shouldn't cost that much. 26:27 In context of that, how, what percentage of your patients over these last 15 years, would you say do carry some sort of high deductible or catastrophic 26:36 type insurance? 26:36 So if they are hospitalized or experienced cancer or something like that. 26:41 We actually have a pretty high uninsured rate and it's kind of gone up over the years. 26:44 Most direct care docs will tell you, you know, 75% have insurance. 26:49 So that's 25 to 30% who don't. 26:52 Whether that just can't afford it at all, employer doesn't offer it, they don' meet subsidies, They feel healthy enough to keep their premiums because 27:01 they need it for something else. 27:03 And putting the car before the horse, I think we've always done that wrong that you need insurers to get care, right? 27:09 You need to pay $1,500 a month premium to Get Metformin that costs two cents a pill. 27:15 Right? 27:15 I mean, not even I can buy a thousand metformins for $13. Like, what are we doing here? 27:21 Right. 27:21 Your A1C is 250. Let's just. 27:25 Which is funny because then I asked doctors, I think we're well trained on the pathology of sight, not the application of it. 27:31 And the applications of good psychology is getting patients to understand that if their meds and their lab tests are more affordable, 27:39 then it's easier to invest in their long-term preventative health. 27:42 If it is not transparent, if it s difficult, it it expensive, they're going to push those things back later into the future and that will create problems. 27:54 The business model, combining with the psychology of how to change patient behavior. 28:00 The lower the price, the more compliant they are, and the better the outcomes we get. 28:04 Yeah. 28:05 Well, those are some big principles could be applied to the whole system. 28:08 Like you say, why pay a really expensive premium to insure something which, you know, 95% of your care really probably could done at your primary care 28:16 doctor's office. 28:17 If you don't have to ensure that because it's not so expensive, you know, maybe we don't have to have insurance be this thing that's supposed to catch everything. 28:24 And then you don' t maybe leave quite so many people out on the back end. 28:27 Because I wish everybody had access to some sort of catastrophic insurance. 28:30 Yeah. 28:31 You get a car wreck, you get cancer, or you some horrible diagnosis. 28:35 If you're going to be in the hospital, it's going cost more money. 28:38 But like you say, why do you have spend so much money just for access, to take care of your basic metabolic syndrome diseases? 28:45 A lot of the medications, especially the ones that have been around for a while, they aren't very expensive. 28:49 And the tests get marked up a lot in the labs, but truly don't cost that much for a lab to actually run the test. 28:54 I think often we get sort of typecast or pigeonholed as anti-insurance because we don t take insurance here. 29:01 But we're really just more pro-efficiency. 29:04 Like having life insurance, car insurance homeowners insurance. 29:07 They're affordable enough and I almost never use them. 29:11 If I do, my premiums go up. 29:12 We can get to a point where. 29:16 You make 80 to 90% of care, 80-90% cheaper. 29:19 Now, the question of ensuring everybody gets so much easier because I don't really care who pays on some level. 29:27 Could the government pay?
Insurance, HSAs, and Employer Adoption 29:28 Yeah, absolutely. 29:29 Charity pay, sure. 29:31 Should they pay $100 for a CBC when we can get for two? 29:34 Absolutely not. 29:36 So it makes the purchasing power of the money we put into healthcare 10x better, but it also means we can cover more people less often. 29:45 And I kind of had this bug about how doctors are trained to solve problems. 29:49 We tend to do it in a very sort of multiple choice way. 29:55 rule followers and rote thinkers and stuff like that. 29:58 Because we're not trained to, of course, not going to be good at this, but taking a problem and saying, well, why do we keep trying to insure everything? 30:08 Somebody asked, how do you fix health care? 30:09 Give everybody insurance. 30:11 No, you can't just keep spending money indefinitely on it. 30:14 That's not the answer. 30:15 The answer is often behind us. 30:17 If we studied how other things get discovered or innovated, it's usually going in a completely different direction than the rest of the group is. 30:26 And so the problem to solve is that we want people to use lesson shifts. 30:33 The general way we thought for forever is more insurance is better. 30:39 If I could just get that poor person insured, then I can get them everything they need. 30:43 That's true on some level, but then higher taxes, that's harder on small businesses. 30:49 Then people have to stay in jobs. 30:51 We have the dog that doesn't bark type things where we don't appreciate that there's a significant financial harm to patients and their families and lives 31:02 if we keep trying to just use this tool of insurance for everything. 31:07 Where, and yet sounds a little too good to be true, we want our cake and eat it too. 31:12 We want more care, more often, cheaper, better, faster, easier. 31:16 But I mean, I've got a supercomputer on my wrist that has more computing power than went to the moon when it's because of good innovation, 31:23 right? 31:23 So we shouldn't be so afraid to say that can't-be-done. 31:26 we should say, how could it be done? 31:29 And explore that. 31:30 And now if you can get the women for them, then you don't care who pays. 31:34 The church could pay, the government could, pay their family could. 31:37 But it's 98% less than if we insure. 31:40 We keep problem solving like that and I think we just got to be better about that because Insurance isn't the best way families can spend their money, 31:49 right? 31:50 If they're in debt, they could get out of debt. 31:53 They could start a business. 31:54 they can invest in their future. 31:55 There's a lot that can happen if we lower the cost of health insurance premiums. 32:00 We're not really trained to think in that way. 32:02 It seems counterintuitive, but like buying the fake diamond for your engagement feels wrong to say you have less insurance. 32:08 we want you to have the right size of insurance, Liberty car insurance pay for what you need. 32:14 You see these kind of ideas everywhere else, but not healthcare. 32:18 If we decrease the cost of healthcare by 80%, we can insure everybody for a fraction of the price that we're doing now. 32:24 And then we could do all kinds of good with the money left over. 32:27 On a $4 trillion system, the math works out pretty well, and I know it's shocking, But we should probably say $2 trillion out of health care system. 32:35 Economist Sean Flynn in a book, The Cure That Works, written about this. 32:39 Another MIT economist, MacArthur Genius Grant award-winning economist has a books, Risky Business, How Insurance Companies Fail. 32:47 They see how much waste there is in the system. 32:50 Everybody agrees the healthcare is broken. 32:52 When you say, but I can get that medicine 99% less. 32:54 Seizure Medicine at Walgreens, $108 cash price out the door. 32:56 Our cash is $1.32 to the patient. 33:03 make it make sense, right? 33:05 And then people say we can't fix healthcare. 33:06 It's just, yeah, the numbers are too big. 33:08 I'm often told if you just lowered the price 30%, more people would believe you and more would probably try to buy it. 33:14 And ironic, but probably true. 33:19 No, thank you for your reflections. 33:20 I mean, I think these kinds of conversations need to happen nationwide at the grassroots level. 33:25 And then our lawmakers need look at it as well, because there's so many third-party people with their fingers in the pie, 33:32 so to speak. 33:33 The insurance companies have a lot of incentives, and the pharmaceutical industry does, the hospital associations, everybody that has anything to do with 33:41 our current model, has a reason where the inertia says don't change it because we're profiting from this or it's working. 33:47 If it ain't broke, don' t fix it, that kind of thing. 33:49 But I think you're arguing, hey, it is broken. 33:51 It does need to be fixed so that this is sustainable for our kids, for the next generation. 33:55 We talked about on this podcast quite a bit, leaving medicine better than we found it. 33:59 And what you' re talking about, Josh, is a way that that could possibly happen, where we say we make primary care really the home for, 34:05 the majority of your health care, 80 to 90% of you needs are going to happen there. 34:10 And you can go, like you said, more often to longer visits, whatever you need without this big disincentive to go get care. 34:17 I think it could make a huge difference if this was implemented at a larger scale for other people. 34:22 The sad part is kind of our self-limiting lack of imagination that we can fix this. 34:30 We have a private space race across multiple billionaires. 34:37 We now have reusable rockets. 34:39 We have more satellites, self-driving cars before we got affordable healthcare. 34:43 It's so wild, but that's what they chose to fix.
Scaling Direct Care and Closing Thoughts 34:48 Because healthcare is weird and broken, they believe we can get to Mars. 34:53 What kind of healthcare are they going to get on Mars? 34:54 Are they gonna find the Blue Cross network? 34:57 No, they're going to have a paid doctor communicating with them, et cetera. 35:02 And what do rich people do? 35:03 What do athletes do, you think they wait in line for insurance? 35:06 No. 35:07 They just pay a lot for it. 35:08 Satellite phones used to be expensive too. 35:11 Now my watch has a phone. 35:13 These things get much cheaper. 35:15 We just have to the imagination to think that it can be done. 35:19 Yet we can leave healthcare better than we found it, and I think we could empower family medicine. 35:27 unlimited visits, telemedicine, procedures, medicines, labs, terrible medical equipment, cash price radiology, normally 80% less. 35:37 We do doctor-to-doctor telespecialty consults. 35:43 So I can call up a dermatologist, talk doctor to doctor. 35:45 35 bucks, I get a Dermatology opinion in one to two days, right? 35:51 It costs me more in staff time to have my nurses fucks with the local dermatologists who won't see them for six months. 35:58 Right? 35:59 So skip it. 36:00 Play a different game. 36:00 Invent a solution. 36:02 We have the bet. 36:02 Yeah, there's a great book. 36:03 Everybody's probably familiar with Simon Sinek, Start with Why. 36:06 I tell my med students, we have best why in the world. 36:09 We have patient care. 36:10 Anything we do drastically improves their lives. 36:13 And anything that we can recreate, we share with other clinics, other direct care practices, direct special care, and pass along best practices. 36:21 We are truly only limited by our imagination. 36:25 In our system, We Have nearly 2,000 doctors. 36:28 we offer them a free radiologist, cardiologist pharmacist and lawyer, right? 36:34 Because the cost of fractional ownership of a cardiologist to read x-rays across 2000 doctors is minimal. 36:44 And now any one of those doctors, if they're not sure about EKG, they don't have to put their patients out to the system and wait and get billed a lot more. 36:52 They just call up the cardiologists that they have on speed dial and getting an opinion on an EKGs. 36:59 It seems so silly that that's all it costs to fix this. 37:03 hire a doc to help docs, we couldn't have done that 15, 20 years ago. 37:07 We are limited by our imagination, not by the government or what insurance, if we play that a different game. 37:14 If you're trying to get insurance to pay for it, whoever pays the piper picks the two. 37:18 So it's just vital that we show, especially our med students, how to use that skill, flex that muscle, look for solutions. 37:25 Man, Josh, thanks for sharing. 37:27 It's pretty exciting. 37:28 What you're doing is amazing. 37:29 And it's not just an idea. 37:30 You've done it for 15 years. 37:32 I want to give you a chance to just kind of plug some of the stuff you've been doing as far as promoting this. 37:48 Yeah, our main website, atlas.md is for our software for direct care practice and EMR. 37:54 And then you can reach everybody there live chat. 37:57 Hello at atlast.MD. 37:59 Our clinic is of course, Atlas MD family practice. 38:03 I feel like I'm like George, he named all his boys George. 38:06 I name all my businesses Atlas and so we also have atlas.direct that's the website for an insurance company designed specifically around direct care patients 38:17 which of course is a whole other topic and seems counterintuitive but if insurance big insurance was going to fix it we thought we would ourselves so when 38:25 you combine directcare and insurance you know it's like chocolate and peanut butter. 38:32 Now a family of four under 45 years can be $450 or less a month for $100,000 in coverage each. 38:41 We can take big bites out of a broken healthcare system. 38:45 But all of our consulting is free to anyone interested in direct primary care. 38:49 So you can reach us on the website and it's our favorite topic. 38:53 we love helping and whether you're a patient, a doctor, a company interested in trying to fix healthcare, we're happy to be your easy button. 39:01 Man, Josh, thank you, I appreciate you taking the time to do this. 39:04 I find it fascinating, and I'm confident others listening to this will be like, oh my goodness, i have got to talk to Josh. 39:09 So be aware, there'll probably be some people emailing you and contacting you because this is fascinating. 39:15 It has a chance to really make a difference across so many different areas of medicine. 39:19 And if you're feeling burned out as a doctor and you say I've got a change to something to cut out the middle man. 39:24 Josh Umber has got your solution here. 39:26 Thank you again, josh. 39:27 Appreciate you for taking time. 39:29 My pleasure. 39:30 Anytime. 39:32 Thanks for tuning in to the Doctors Making a Difference podcast. 39:35 And thank you for what you do to help your patients and your community. 39:38 Your work truly helps so many people. 39:40 We produce this content to have the tools you need to stay in medicine and to highlight the amazing work being done by physicians around the world. 39:47 Please note that while I am a physician and many of the guests on this program are also physicians or other professionals, 39:53 the discussions on the podcast do not represent my employer or any professional organizations to which I belong. 39:59 This podcast is for your information and entertainment only, and should not be taken as professional advice. 40:05 You should seek appropriate professional advise pertaining to your own situation. 40:09 Please check out more of our content on our website, doctorsmakingadifference.com. 40:14 Also, please follow, like, or subscribe on your podcast player or YouTube channel, and give us a five-star rating. 40:20 It really helps to spread the message. 40:22 Finally, if you'd like to be a guest on 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