Dentistry Uncensored with Howard Farran
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1455 Dr. Siv Raman on Understanding the US Healthcare System : Dentistry Uncensored with Howard Farran

1455 Dr. Siv Raman on Understanding the US Healthcare System : Dentistry Uncensored with Howard Farran

9/8/2020 3:00:00 AM   |   Comments: 0   |   Views: 245
Sivakumaran "Siv" Raman is a physician who has spent most of his career in Medical Informatics and Analytics. With the experience of leadership positions at several large US health insurance companies, health systems, and information technology firms, he has extensive knowledge and expertise on the American healthcare system. His new book, “Just Enough Healthcare”, is a short primer on the US Healthcare System.

VIDEO - DUwHF #1455 - Siv Raman

AUDIO - DUwHF #1455 - Siv Raman

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It is just a huge honor for me today to be podcast interviewing Dr Sivakumaran Raman um he goes by Siv now he's an MD MS is the president and lead health i.t consultant at lobola a health it healthcare analytics and healthcare health software product management consulting service providing independent healthcare analytics product management and health it consulting services to healthcare organizations including hospitals healthcare payers and private equity firms shiv is a physician who has spent most of his career in medical informatics and analytics with the experience of leadership positions at several large u.s health insurance companies health systems and the information technology firms he has extensive knowledge and expertise on the American health care system his new book just enough health care is a short primer on the u.s health care system his previous book was just enough r a freely downloadable primer on our programming language published on smashwords and barnes and nobles um it's just a huge honor for me to get an md and ms to come in and talk numbers because I have a very strong feeling that um especially when it comes to healthcare and politics and things that people just have beliefs and they just want to believe something and then some guy like you comes along and shows them all this data and if it shows them something they don't want to believe it's stressful but um my first question is um this month was my 30-year anniversary of lecturing to dentists around the world I’ve lectured in 50 countries and it just seemed what I don't understand is healthcare is so more emotional in America than so many other countries I mean the bottom line is like um take Canada um like I always read that like except for childbirth like 99 of people don't spend the night in a hospital each year so 99 it's no big deal but man Americans they're just they're just so special um why do you agree that um health care is more of an emotional thing in America than say the next 20 richest countries I agree it is actually a very emotional subject and it lends itself to politicization as well and I would consider personal finance and health care to be two of the most important things to know as an individual because these things can affect you on a daily basis and what I find is personal finance is not that politicized most people know how to invest they don't put their political leanings into it but when you start evaluating and thinking about health care politics comes into it big time and that's something I’ve made sure in my book I have tried absolutely to give you the facts without taking sides left or right well you're a pretty accomplished guy I mean if you're wondering about this guy's credentials stop this guy is going to know more about what he's talking about than any of my homies that are that are dentists give a give a review of uh just enough healthcare and how you see the market right so uh the book seeks to be a primer uh you know a primer in less than 100 pages because when I talk to my clients when I talk to lay people about health care I find emotion I find a lot of confusion however I don't find an understanding that is good enough to make sense of the system and eve especially in an election year healthcare is one of the big topics and people are going to go and vote one or the other way without really understanding how our existing system works and if there's something to be changed how do we change it because you're going to understand before you can start to effect change and I think that is what the book seeks to do that it's not a long academic text it's 100 pages it explains health insurance health care providers pharmaceutical companies pharmacy benefit managers how insurance and how government works and everything else about the system and its players and it does it so that you can read through in a single setting yeah it's a hundred page read summary and I love it because it's all numbers uh there's so much uh facts on it but I wanted to um knowing my crowd uh knowing who uh we're talking about today let me um let me see if I can get uh um I want to get what uh Buffett said uh um but anyway Charlie munger is my favorite investor you know him and warren buffet I went to Creighton university in omaha Nebraska and warren was so sweet back then in the 80s he actually liked uh the guy in charge of business Creighton came over there and lectured once I got to meet the guy um but um Charlie munger is so smart and he's only made two quotes on health care and I want to read them both to you the quality of the medical care delivered including the pharmaceutical industry has improved a lot I don't think it's crazy for a rich country like the us to spend 15 percent of GDP on health care and if it rose to 16 to 17 it's not a big worry and then he said it but then he goes on to say his other quote um I think that if you have a single-payer system and an opt-out for people who want to pay more for better service I think it would be better and I think we'll eventually get there it wouldn't be better at the at the top or current system is the best at the world at the top but the waste and the present system is awesome and we do get some very perverse incentives do you agree with Charlie munger on those two quotes I wouldn't want to go so far as to say single payer is the solution but I would want to lay out both sides right the main what he's right I mean I think as a percentage of GDP healthcare spending in America has gone up to about 18 or even 19 so it's already passed the 15 or 16 percent he was talking about uh that being said the issue is not that there's so much spending what are we getting in return for it is out of all of the oecd countries I believe America has the worst health indicators in terms of mortality rate life expectancy disease rates cancer rates all sorts of things right so the problem then becomes why are we spending so much to not get the kind of clinical outcomes that these countries that are spending a fraction of what we are spending are able to achieve and I think that's the uh and I have thought a lot about this and I think it boils down to a few things right now in most modern societies modern countries developed countries healthcare is seen as a right now it's not an inalienable natural right in the in the words of somebody like john Locke or you know one of those conservative thinkers but because it takes money to provide health care and most of the natural rights are pretty much god given and that's the assumption however since we have decided as a country to say that everybody deserves health care has a right to health care that's when you get into trouble with how do you then then make the economic arguments that apply when you're talking about the free market so if you think about healthcare as just another good or service just another economic good or service then you have to apply cold hard economics to it but it gets complicated when you're talking about human beings who are thinking that this is a right that they need to get right so I think that's where a lot of what manga is saying in his second quote is let's provide a basic level of health care to everybody and those who are you know seeking more who are obviously who are better off can buy extra so if you want the latest cancer treatment you buy a plan which is providing you all those but then you have some sort of a basic uk like or Canada-like system that provides basic preventive and basic treatments for everybody with a lot of rationing now that's the trade-off because there would be a lot of rationing you would be seeing things like quality adjusted life years you would be seeing issues with people being denied treatments because it's not covered in their current nationalized or socialized healthcare plan and so if richer people are able to buy a plan which provides all those treatments it might be okay but there could also be resentment so there's no I would not say that there is a perfect solution uh because this is economics intertwined with emotions and politics oh my god it's uh it's crazy and what I am one of the things about the argument about all the talk about that this this I it makes me not like the conversation is because I’m a dentist and dentists are more likely to own their own business and understand revenue in revenue out overhead costs where a lot of physicians are salaried people in institutions and hospitals and they they've never missed a payroll or stayed up all night worrying about payroll they're kind of this protected class um but when um when they always talk about um the other countries like Canada like well in Canada she wouldn't had an operation she didn't have a co-payment and I’m like okay I’m a dentist but I have an MBA from Arizona state university so I’m like oh so do you think we should just throw away economics I mean from Adam smith to yesterday was is that just all junk I mean how could you not have a co-payment I mean you clearly see that say a set of a knee replacement was 50 grand and I think everybody should have a 10 co-payment just across the board and you said to grandpa hey grandpa you need a new knee it's 50 grand and your portion's 5 grand and he said ah hell with that I’m just going to take aspirin and I’m not doing that okay he won't pay five but I’m supposed to pick up the other 45 as a taxpayer and the coping okay so you're in for lung cancer and emphysema because you had ten dollars a day to buy cigarettes from age 20 to 70 and then they're proud that when he had his hundred thousand dollar uh chemo or a million dollar lung transplant I’m supposed to pay a million dollars in taxes for a lung transplant and this guy won't pick up 10 percent I mean it just seems like with health care that the incentives they have to fall on you because you can affect your health care more than whoever the mayor is I mean if you're going to smoke drink and eat out of packages and boxes and never eat any healthy food um so when Canadians tell me that they're so proud that there's no co-payments I just think they're crazy yeah so I mean I wouldn't say they're crazy but let me tell you what has what's happening there so when you when you subsidize something you get more of it if you tax something you get less of it that's economics right in America to some extent healthcare is highly subsidized because half of healthcare is paid for by the government there's a huge employer-based insurance uh now there's still people who don't have insurance there's medicaid there's medicare but there's still I guess a lot of people without insurance now what suffers in all of this when you make something free or almost free is you will get consumption through the roof so how do countries that have socialized or nationalized healthcare deal with it they ration care right so if you're 85 years of age or 80 years of page in Canada and you want a knee replacement or a hip replacement you're not going to get it they will or in the uk they'll say hey you know for based on your station in life and your age and your health status and everything else we're going to do some sort of calculation of quality adjusted life years and we don't think you should be a candidate if you were 60 years old maybe we could have thought of a knee replacement for you so that doesn't happen in America right so I think the trade-off is if you haven't socialized nationalized healthcare system yes there's no copay yes there's no but you won't get everything in a non-socialized healthcare system you will be able to get everything but it's going to get more uh there's going to be more consumption and personal responsibility to some extent goes for a toss well in America I know you're never supposed to talk about religion sex politics violence um but um we're trying to be adults here and I’m just going to be an adult but in the united states I mean you've seen how hard it is to get them to wear a mask um they refer to all quality adjusted life year um as government death panels who are going to decide who will live and who will die and um you know because if it bleeds it leads and rupert murdoch's figured that out around the world that this type of stuff just sells ads um but the bottom line is where um I think we failed Americans is they want all this health care because the centers for disease control and the fragmented healthcare system isn't showing them how many hundred thousand plus Americans die each year from going in the hospital you know so you know you might say um well you know the um quality-adjusted life year there's not the value and we're not going to pay for this on a 89 year old man but as a dentist a doctor who works with my hands on patients um I would worry that a 89 year old going into a filthy us hospital uh might be one of the hundred thousands that that um don't come out alive and i'll have to give you a personal experience that I’ve seen in my life you cannot get into intel it's very you know they don't want espionage and all that but back in the day um I had a patient there and he gave me a tour and I was like amazed where these people they look like they were walking on the moon making these fab plants and the air was circulated to less than one part per billion and then you could leave the intel plant go across the street to um chandler memorial hospital pull up in your car with your tennis shoes walk all the way up to the surgery room and if you just washed your hands and put on and I thought god intel making a chip is a thousand times more sterile than any hospital in America so the point I’m trying to make is that when you tell people that health care and prescription drugs are all free they want to believe it works and a hundred thousand plus Americans die every year from side effects from pharmaceutical pills and in hospitals for things they didn't go in there for do you agree with that number or do uh some say institute of medicine I think put out a report like that about hospital uh or uh avoidable uh healthcare events yeah and I mean I mean who would say give away free candy bars if this certain candy bar killed a hundred thousand people a year they would treat it like a illegal substance right so the one of the reasons for over utilization and over treatment in America is the fee for service system right because there is no incentive to keep people healthy there's actually every incentive on the provider or physician or hospital side to treat people as much as you can now whether if that involves drugs or visits or treatments or surgeries or procedures all of that contributes to the top line because that's additional revenue and that's the way the system has been laid out so that's one of the reasons why you see medical cost inflation has pretty much outstripped uh regular consumer price index inflation by two to three percentage points every single year for the last 20 to 30 years because there's no limit to the amount of utilization and of course newer therapies and drugs are also more expensive so there's unit cost inflation for the newer therapies whether they are better or not you know many times they are but sometimes they're not but they're just out there and uh secondly all of the over utilization is all uh driving the industry in a way so uh you're right I mean in a perfect world there should be more preventive care there should be more holistic medicine there should be more emphasis on keeping people healthier through diet exercise wellness coaching etc rather than getting them into the hospital to do a cabbage or a stenting or a knee replacement or whatever else uh yeah and the data is America won I mean we're number one we spend more on health care than anyone and it's because of the incentives the economic incentives to treat so we don't have lines you know the old joke is that in the old communist days everybody had money and there was nothing to buy in America you have everything in the world to buy and not enough money in capitalism um so there's got it is there a middle ground or is it just going to be um you know runaway cot and for runaway costs are um government sponsored death panels that that tell I mean I’ve seen the data when I um when I lecture around a lot of dentists like to show me what they see when I was in hong kong which I think has an amazing health care system this dentist was showing me all these chemotherapy treatments that actually shorten your life 30 to 60 90 days while you lose all your hair and throw up and have surgeries and all this stuff like that whereas the epidemiologist model at um hong kong they said no that you have not proven value we're not going to give you money to have them live a day shorter with vomiting and hair loss and surgeries I mean do you see that too in the data yes some of the treatments are like that and even if they do extend life by let's say six months or two years you're spending three and a half million dollars and the patient is not really enjoying himself or herself or is not productive so that's true but then again when you get into those discussions what happens is um individual rights come to the fore and people say who are you to deny somebody two years of life just because they're vomiting they might like being close to their grandchildren so it's always these emotional arguments that come into the picture I guess but what about the emotional rights of my money I mean so every homo sapien since mitochondrial eve which you're dating about like at 200 000 years back um every single human has lived and died and now it's your turn to die and you're entitled not to free health care you're entitled to my money I mean you look at these countries with uh free health care um with no co-payments and they're all you know just like united states japan their runaway deficits I mean uh these 20 countries have 40 trillion dollars in debt so they've taxed their people the most they can without raj and then they borrowed on the future and then they have the nerve to tell me that I have to spend three and a half million dollars of my money so you can live two more years I mean life's tough life sucks life's hard but it just um it's funny how they're entitled to free stuff which really means they're entitled to my money and if I don't pay the irs they will send out force to kidnap me and put me in a cage so I will be kidnapped and in a cage uh if I don't give you my money isn't that a mafia mob shakedown I mean shouldn't would be a partner well the government is what they call the legitimate use of force right you know whether you call it by any other name government is the legitimate use of force so whether it's to take your money or tax you or whatever else that's that but in terms of health care I do think that at some point we are and we are very close to it truthfully because right now you have two presidential candidates one has just stopped short of saying medicare for all bernie sanders position was medicare for all joe biden's position is slightly less than that but on the other side president trump is saying that hey we want to go back to a different kind of system which is more driven on personal responsibility and repealing obamacare now as I said there's no panacea for all of this right there's no one solution there's going to be people on both sides who are going to be unhappy no matter which system America goes to the trade-off is if you are somebody who is generally healthy and you just want to make sure that catastrophic care when you need it is provided for you in that case are not very happy with the American system because you're seeing these premiums go through the roof you're seeing copays and deductibles and everything go through the roof but most of the time you're feeling that you're paying all of this but you're not really using it on the other hand if you're somebody who has an advanced condition a rare condition or something that is not and maybe it's your own fault right a lot of diseases that we suffer from nowadays chronic diseases heart disease diabetes hypertension they're all lifestyle diseases they're not all genetic they're not all environmental they're lifestyle diseases so in that case though you're kind of happy because you're now one of those over utilizers and you like it that you don't have to pay for every treatment and every so you need a knee replacement you get it if you need the latest sglt2 inhibitor for diabetes you get it prescribed if you have something else you know so I think that's the trade-off that you yes the economic argument says this cannot go on forever uh the compassionate nationalized healthcare says hey we can do it but we will just ration care so that we will only give it to people who are absolutely going to require it so that's the trade-off and the other I what I think's the worst thing about um healthcare systems generally is um once they get it a treatment like say uh renal um you know um what do you call that when you go in dialysis and you take any one of those subjects you just take about all the money spent on dialysis every year and just say for the whole globe the earth spends a dollar a year on dialysis um well you would think at least five percent one nickel of that dollar would go into research and development to make sure and that we could fix it and it seems like they're so interested in all this billing out health insurance and I just don't see um a wise use of money whereas when I go to fortune 500 the great companies have like intel I mean r d and google and intel I mean it's more serious than anything look at elon musk I mean nasa would spend you know like a billion dollars uh planning on a on a mission and then you know and elon's like well I could do it for a tenth of that and I just uh we're so caught up in spending the whole bank on treating grandma and i'd rather a lot of that money go on or indeed actually cure the damn disease that's true I mean um the point is that it's uh in some way uh every healthcare provider the ideal situation would be for them to not require to provide their services to every anybody because everybody's so healthy right but then it'll be like utility companies that ask you to reduce consumption even though they would actually want you to increase consumption so I think that's the that's the issue here that yes if we could spend more on uh preventive health social changes living healthier as well as r d to cure the diseases you would probably not want to uh you would probably not need to spend so much on treating advanced diseases because eighty percent of a person's expenditure healthcare expenditure happens in their last two to three years of life right so it's a it's a wasted expenditure to some extent well no to a large extent because the planet has dropped 385 000 babies a day I mean it's the most amazing species it's the apex it's uh it lives a hundred years like the turtle I mean you take every category of species wish well do you want to live three months like an insect or a hundred years like a turtle we're a hundred years like the turtle I mean you know we're just we won every category but they shift so much money I mean these babies are being born and at birth their first president is they inherit forty thousand dollars of debt from their grandparents on interest and uh and then and then they and then what's the baby gift they come by and give you know a new outfit that they bought for three dollars like three dollars you gave them forty thousand dollars of debt and you and your some shoes that is so wrong I would rather be spending grandma's money on the baby and when the baby's born they should have a savings account not forty thousand dollars a debt and all this I mean the math is just not adding up and you know the deficit of America I mean how can I mean they've been adding a trillion dollars a year both parties you know you can't say it's politics they they're all doing this and now they added three trillion this year I mean this party could come to an end I agree I mean it's changing topics a bit uh I don't know if you've read this new book by Stephanie Kelton about modern monetary theory which pretty much says that you don't have to worry about deficits and printing money at all and it's like mind-blowing and I there are people actually believing parts of it so I don't know if that's the way um I guess they're only able to do that for the short term because the u.s dollar is the world reserve currency if that were not the case we would already be seeing runaway inflation maybe yeah but you know when they talk about the reserve currency they talk about like it's some holy roller thing that's only um exchanging money between two countries of trade 99 of the money is inside a country circulating there so they think they're this big international currency and it's like I mean there's a billion 100 million people in India there's a billion 300 million in china there's a billion people in Africa there's a billion people in the Americas and probably not even 10 percent of that is foreign exchange between continents most of people are doing all their eating cooking cleaning and baby stuff but I want to go back to your book which I wish my homies would read um you got to read his book um it's called just enough health care but I want you to go through I mean we know we're dentists we know our issues so you know you talk about health care systems and providers doctors but there's health insurance and payers there's pharmaceutical companies there's medical billing payment healthcare data analytics and then there's a government role pick another one besides the providers we've been talking about providers but how do you see the health insurance on all this right so health insurance is uh is kind of the backbone of the American healthcare system today because it's the third party payer system in fact health insurance is you some people say it's almost socialism because to some extent it is from each according to his ability and to each according to his need because everybody pays the same premium but many people do not utilize any of the care if you're paying a seven thousand dollar premium and another seven thousand dollar deductible most people don't uh use that much care in a year so it's actually going to the people who are high consumers of health care right so in a way insurance is socialism but it's a free market solution to addressing healthcare costs and healthcare services so would you say okay so in dentistry we say um people always talk about dental insurance when we say there's no such thing as dental insurance because dental insurance is an actuarial risk analysis versus moral hazard there's a hundred people in the town they all buy car insurance one guy wrecks the car so everybody pays a little because they don't know who's going to wreck the car fire insurance on your house everybody pays a little and there's only one Irish guy drinking and smoking in bed that burns his house down but health insurance how do you have health insurance when every single person needs health uh healthcare everybody sees the doctor and the dentist health insurance in America is not really comparable to property insurance or car insurance because it's not just covering um catastrophic care it's covering pretty much everything that you use so I compare it to it's like an extended warranty on your car that covers not just repairs but also oil changes it's supposed to cover everything it's like prepaid medical care it's not really insurance right so that's a big difference your thank you for pointing that out but or bringing that up because yes health insurance is not like car insurance it's not like uh firing each other and let me point out something that I want to point out something I’m a dentist I’m an MBA I’ve been doing dance for 32 years but I see a lot of stuff in my own eyes like when you go to the free clinics in Arizona that for dentistry and they're all free you go to the head dentist well what's the problem what's the biggest problem with your clinic he goes well half the people don't even show up for their appointment oh because it's free and then you go tell the person you know if everyone that came here had to pay ten dollars to make an appointment and if they missed the next appointment is 20 they start looking like god are you evil or you you're just a mean person meanwhile that patient who didn't show up is that micaio's eating mexican enchiladas and a margarita with a pack of cigarettes on her way to go buy a dime bag at the dispenser I mean I mean these socialistic um well i'll tell you another thing um they always like norm chomsky I like listening to him I really do I think he's up here in Tucson he's a great mind of just pointing out every bad thing every government ever did and I love the flu I love the information but he presents it from this theory that the eight billion people oh those were just innocent sheep they didn't have anything to do with anything I mean their remember I mean they're hard to govern people are challenging why because they're wild animal homo sapiens and for him to point out everything uh the uh the governments did wrong and just to give the people like well they're perfect and all the government spends like well everybody running the government were babies from this herd and the herd is bat [ __ ] crazy so um you know he so everything should equal you know the equal sign both sides equal your assets uh liabilities the equal but a lot of the views are just like oh government bad people perfect or uh people bad government perfect I mean there's you know there's got to be some equal thing here um if I have to pay for your 50 000 knee transplant uh you should have to chip in I mean we're all in this tribe together and they don't want to do that they're just like the people are innocent the government the employers should pay everything or you know vice versa but it's so hard to get him to realize that it's not insurance there's no one we can spread the risk around it's a transfer of wealth that we're just going to do and I believe it should be there because I always check people on their um you know they can say something but in that match up like if you say if you came out of a grocery store and there's a six year old kid there and if it doesn't go to see the doctor right now and today it'll die well a hundred percent would say well we've got to get this kid to a doctor okay well then don't say you're against government umbrella health care I mean it's same thing if you saw a kid playing in the middle of interstate everybody be calling 911 saying hey there's a kid so don't tell me about you want to defund all the police I mean um you know people are calling the police asking you to come out now granted there's some crazy police officers like there's crazy everyone because we're all wild animals I am I believe we're called homo sapiens and all the other homos are gone homo neanderthal homo denosavan hapolis I mean and I doubt they died went away peacefully I have a huge feeling that homo sapien probably violently led to their death and demise uh so you know it's predator or prey uh but um but I want you to talk about um pharmaceuticals um what do you think of the pharmaceutical industry my pet peeve on the pharmaceutical industry they when they spend more on marketing than they do on r d I already don't trust you I mean if you were 10 r d 5 marketing I would I would I would listen to you but they spend more on marketing than they do on r d so to me it's a sham I would I wouldn't call it a complete sham but yes I would say that the real groundbreaking drugs and other treatments I think it's one out of every five or six or ten is really something that needs to hit the market you know because the what you find if you talk to a lot of physicians especially primary care and people who are not doing the intensivist or hospitalist stuff they'll tell you a lot of these things that people suffer from diabetes and hypertension etc can be treated with 20 year old drugs so in a way the pharmaceutical industry yes is kind of inventing a need for the newest drug which may or may not be significantly better than something that was out there and that's why they need to market it they need to say that it's so much better than anything that was uh available before and so yes that that that becomes a problem with a free market system to some extent because what you're saying is if you if you create a product you have to make sure somebody buys it somebody wants it and so you have to market it you have to advertise it you have to sell it and you have to create a need for it to some extent also create a you have to create a differentiated diagnosis for it sometimes even yeah and I want to um have a big shout out to uh dr maurice ralph hillman whose birthday's day after mine my birthday is august 29th is august 30th he was born august 30 in 1919 died on april 11 2005 who developed eight of the 14 vaccines routinely scheduled for measles mums hepatitis a hepatitis b chickenpox meningitis pneumonia and hemophilus influenza and he single-handedly has saved more lives than anybody known I mean what would be the opposite of him mao de sung uh idiot means stalin hitler I mean this is the guy and to think that his life's work I mean one of the greatest men and no one will even say his name because the anti-vaxxers you know they they'd probably rather bring back mao and idiot mean and stalin and hitler uh before they want to bring back maurice hillman I mean could you imagine your life's work being mocked by people who don't even know the difference between geometry and trig I mean what a uh what a weird case we're in right now right yeah no I agree and see the thing with what he did is that he helped so many people right now today you take a drug like remicade which is used for uh ulcerative colitis crohn's disease rheumatoid arthritis etc it's a game changer but the number of people who have that condition is not that many uh you compare it to finding something that really works well for diabetes hypertension or heart disease or some of the common cancers that you know and what dr holman did is way more than that he pretty much did away with a bunch of infectious diseases that were terrorizing the population so yes that's the kind of medicine we would want that's the kind of health care we would like to have but right now because of various things in motion in the economy and in the populace personal responsibility is down you have diseases of lifestyle and so you you're kind of getting into a system of consumption and fear and consumption again and that includes drugs and healthcare um one of the things um I’m always disappointed with dental insurance companies like in my backyard like I’ve been dealing with delta dental of Arizona for 32 years and you talk about the cost well it's their digital information is so bad that a lot of times people came to the appointment but they didn't have their insurance forms they got a dr reschedule drive back to intel motorola go to hr cut down a tree make a piece of paper and um and you're like why isn't this an app I for 32 years I’ve had to have a full-time employee now I love kalani but she has to physically call each one of those deals and physic and it's so crazy like obama obamacare tried to do this big reform you know that that Biden was his vice president and they knew that 30 percent of the cost of health care it's just paperwork yeah I mean I mean I mean we got fintech we got apps I mean I look at what I can do on my app and I mean the low-hanging fruit we wouldn't have to talk about whether or not you can have the surgery we could save a third of the bill if you just automated that is that what you're seeing I mean you're the health care informatics guy on spades what do you see all the waste and confusion and overlap that could be easily fixed uh you know and that's actually one of the causes it's one of the huge causes of what is known as physician burnout because the paperwork and like a simple thing uh there's something called prior authorization so there's a bunch of drugs or procedures for which the physician's office has to actually get pre-approved by the health insurance company before they administer the drug or the treatment to the patient and I find it so hard to believe that even now very few health insurance companies have a streamlined system for prior authorization it's just phones it's uh delays it's because it shows their soul their heart and soul is they want to sell the premium and not pay any claims for instance if you look at health insurance you know um you look at um dentistry the everything they're doing is trying to deny a claim I’m asking well what are you doing to improve the quality I mean do you do you um show the consumer that okay there's a thousand people in Arizona that do root canals and this guy only loses five out of ten um fail in five years this guy loses 25 out of 50. um do you did you asked uh his name and he's eligible well did you ask what implant I put in there I mean some knee transplants and hip transplants failed a lot in dentistry we saw this some of the some of these um implant systems for tmj some of the disastrous things they never cared about anything like that they didn't want to track what materials were using anything to increase quality control it's just money honey we sold the premium and we don't want to pay the claim and our ceo wants to make a million bucks a year and it's in they just do enough for show in fact instead of r d and improving this stuff uh they'd rather do a pr campaign for their image then I mean I just don't see the data where medicare medicaid and every dental insurance company from blue cross united to help any of them are doing anything other than to make more profit and not pay the premium as opposed to doing something with all that data to where it's going to be a better system improve the quality yes in health insurance they have started doing quality reporting on providers and physicians but the sad part is very few members and patients look at that stuff before they go to a physician or so it pretty much becomes useless and obamacare did address one part of it that you know there's something called a medical loss ratio and there's a floor on it of 80 which means that out of uh if you collect a billion dollars in premiums you have to pay out 800 million in claims to providers otherwise you have to send it back out as rebates to uh members so in some ways yes there has been a limit to how much claim denial and other things have happened because of something like obamacare on the other hand yes the issue is that there's nobody out there who's trying to improve quality and reduce costs at the same time there's this thing called the triple aim in healthcare which is a concept that was devised by the institute for healthcare improvement and it says that the aim of a healthcare system should be three things one would be lowering the cost of care the second would be the improving the health of the population and the third would be improving patient satisfaction in terms of quality a patient experience of care in terms of quality satisfaction and access so i'd say the affordable care act okay so yeah the three things were the aim of a health care system would be to one lower the cost to improve the health population and three was what it's uh improve the patient experience which is a combination of quality satisfaction and access as in do you have access to health care right so it's a the third one is made up of kind of three parts and what was the three thing um the third thing was improve the pacing experience with access quality and satisfaction right so obamacare did address access it did reduce the number of people on the rolls uh of the uninsured right or increase the number of people on the insured rolls however we have pretty much not done much to have do anything to uh the cost of care or improve the health of populations so we have a long way to go yeah first of all I want to point out that a lot of these issues that I’m talking about um I mean I could go either way because I mean look at one of the deals of health care which the other side like people say well we spend 17 percent on health care well that means 17 cents of every dollar spent on health care um if we cut that down to 7 percent do you realize that 10 out of 100 people in health care are now unemployed and when those people are redeployed to make an iphone my diet coke whatever the hell I’m buying I mean they're going to they're humans they're going to spend all their money and all they can borrow because you got macroeconomic data every democracy is like um getting rid of the teacher and they say well we're going to get rid of the teacher okay we're going to vote you want to study math or go into recess we're going to recess um you know do you want to um in the cafeteria do you want to eat broccoli or ice cream ice cream and America is the ice cream country of the world they're not going to eat their broccoli they're not going to learn math um that's the system and I don't care because they're all going to die anyway what I care most about is the species and then when you look at the fact that they give birth to 385 000 babies a day I mean for anybody to say anything's wrong with healthcare on the planet I mean what do you what do you what do you think the giraffes are saying and the zebras are saying when they hear you say something like that they're like dude are you kidding me I’m a zebra how the hell what's wrong with you guys so the humans are just they're beating every expectation known to man and um those people if they weren't spending 17 on health care they'd be spending 17 percent on Starbucks coffee chocolate you know all that kind of stuff um but what I um but I as a businessman I just think it's um I’m just wired to where everything could be done faster easier higher quality lower cost and make it smaller and obamacare you can tell these guys never own their own business because again I lived through in Arizona um every time someone would bad mouth obamacare within four seconds I could figure out they were using I say well um well what insurance did you use when you had your baby oh I have access okay well there's 50 different states and they all call their medicaid something differently so all most of the people benefiting from obamacare had no idea same with the providers I was blown away that you could have eight years of college be a doctor of dental surgery and not know that you're a pediatrician and all these pediatric patients paid by access um that that's obamacare you know and then when you cut those things um they so it was a branding problem I mean they just call this coke they don't call it 50 different things for 50 different states and that's why I like medicare for all better than obamacare medicaid for any other reason just for branding they all know grandma has medicare and loves it so the children don't name it 50 different things is so it was it was the worst branding ipo launch i'd ever seen in my life I mean they couldn't have launched a worse branded ipo in the history of government I mean just complete amateurism um so um and again but anyway so uh on your I’m trying to um what was the other thing on the book I wanted to talk about um we talked about the uh medical billing payment healthcare data analytics um what do you see in the healthcare data analytics I mean you've been looking at this stuff for a long time you also um used to work at uh z omega right as a chief analytics officer I mean a huge company with uh sam rang away and your friend I noticed you wrote the review on his book uh pal of sharda um he is the um he works for google healthcare um what do you think your friend uh paola what do you think google's going to do with all that healthcare data they got 23 and me they got an entire uh on the uh healthcare it's very interesting what they're doing the data what do you what do you think of so they google tried to get into healthcare a few years back with google health and they didn't make much of an inroad there because they went about it the wrong way now they are doing it in a different way as are other companies like ibm and microsoft that they are partnering a lot with health systems and providers and even insurance companies to get access to the data now that does leave or bring up some privacy concerns because sometimes the data is being accessed without the patient not knowing that their data is being used I mean it might be de-identified data but it's still data at an aggregate level about people that you're studying however there is a hope that you might be able to find patterns of disease you will be able to find patterns of treatment and you would be able to do what is known as personalized healthcare where you target the treatment to the person in whom it is likely to work the best and that's the that's the future of healthcare I think within the next five to ten years with people like elon musk and the google guys and microsoft and amazon and walmart also entering healthcare so there's going to be a shake-up the reason why it's difficult for a lot of these innovators to do big change in healthcare in a snap is because it's a highly regulated industry so once the regulatory pressures go down a bit I think innovation in health care can happen much faster well that's the 5 000 year playbook of government they create a big problem and then all the people need them to solve it and uh and when people go to the government to help them it's like okay you know this is all the problem they created I mean they just they can do it's like a four-year-old child they can do no wrong then go outside and whatever they do they can do no wrong one of my best friends when he was two uh started a fire in in his uh um closet burned the entire house down and his mom actually now thinks it's funny uh they just can't do anything wrong they government they ruin everything go back to um go back to the um hipaa uh you know I mean go back to hipaa so you know they it's not a business like you said with google so they started healthcare and they went and they found out after they went in their first time they did it wrong so they pivot they come back and they re-enter a different way look at hipaa it's like they spend five years writing a monster document then it passes one time and then remember dot your eyes and cross your t's came from the king would write a rit w-r-I-t and people were getting hung and killed and the king didn't apply that and they always say king write dot your eyes cross your t's because you said it so vague all these people that you weren't talking about and um and hipaa I mean it's not like a um a business to where as data comes in they modify they change they adapt it's like they'll just pass this one big colossal nightmare and then over the next 20 30 years what does it do drives up costs I mean I mean look at the government with the eu um about website deal so now the government's idea about cleaning up the websites now every damn website I go to the rest of my life I have to accept the cookies thank you government god what was your next best idea you dumbass I mean I mean and having to approve the cookies is just like hipaa it's like they try to do something and over the next decade it's far worse than if they would have done nothing at all and so then what will they do they'll come out with another one I seriously think hipaa should just be abandoned just completely erased I think I mean yeah to some extent there's really no expectation of privacy in the modern world so oh there is privacy you don't know where the privacy is the government and the 18th they have all your knowledge um facebook google and amazon have all your knowledge facebook's obviously selling it to so the all the communist countries of putin and north korea and china and our government they all there's no privacy they know everything about us you know who's private us we don't see what they're seeing because of their own laws so all privacy so we have privacy against what everyone else already knows about us and that should be reversed and I think the cell phone is the answer I really think that when steve jobs stuck a my music my phone a touch screen and the internet all into one it was the first time the human even had a platform where someday he could have he could have access to the same data that the big insurance the big government the big everyone could have so I think this is the equalizer and I think from 2007 to 2107 will be sapiens finest year not that they haven't had a finest year in the last million years killing anybody and anything in their way but I I’m really excited about the smartphone um to finally even the playing field from the individual to the hoa that you have to live under yeah no a few points that so one of the some of the few things that have been done by government in the last year or two are not that bad one is like the price transparency initiative yeah right because opening up these contracts and making hospitals and insurance companies reveal actually what they are paying for these procedures and treatments uh I think that's a good plan now but transparency everybody said be transparent historians government military when people are opaque that's where all the trouble I mean so nobody could disagree with transparency but it's funny how you had to start it out saying well there is one thing the government did that wasn't quite really that bad I mean that's how a compliment starts with the government well of all the horrendous things he did here's one thing that wasn't quite so tremendous but yeah transparency and there's no transparency in prices you don't realize when you go to the doctor that you're getting a filling done here's the worst thing in dentistry so if you don't if you there's a you know the average dental office takes six to twelve ppo plans so a standard filling the doctor might be getting paid from 100 to 180 but if you go in there in cash you're the highest you're the highest payer like if you go in and you have no interns you buy a crown thousand dollars but then all the 18 insurance companies you work with it's around 600 so and then the doctor says well I hate insurance companies I wish is all the cash market got you penalize the cash people they pay the highest the way to get more cash patients is give them the volume discount that you're given all the ppos and every one of these dentists if they gave the cash patient what they were given the ppos on the volume discount it'd be a game changer I addressed this it's similar in healthcare similar to dentistry similar in medicine rather so I address this in a chapter with where I explain what a charge master is and what how to read your explanation of benefits that you get at home and what because most people you know they read it they don't understand it where the charged amount is three times the allowed amount and then the paid amount is way less and then you're being asked to pay something a deductible a copay so I explained that very simply in the book because I really think that these are things that everybody should understand because we are getting these eobs these medical bills at home and we're paying for them but if we don't understand how this works then how are we ever going to uh make the change or demand the change that makes it better you know um i'll end on this time we went over an hour you're way too important and a busy guy to go over time with me but you know there's a couple things i'll never forget one was um when they started the uh um kennedy started you know the johnson the war on poverty and eventually uh john f kennedy um was working on it but he got assassinated it was linda b johnson who passed medicaid and uh medicare and I can remember all the old people all the wise men saying oh my god the doctors just got in bed with the government and if you get in bed with anybody you're going to get screwed this is going to turn out really bad and um and from 62 that was the year I was born to this day it just seems like it's just become a colossal um craziness and then the other thing was the other side that was worn as um milton friedman and free to choose and he said that um you know his clarity test because people just say crazy things they don't believe but he said here's the clarity test healthcare you're going to die tonight of a disease and I got a blue pill and if you take it you won't die tonight so how much will you give me for that pill and well obviously you give me your house your car your savings your foot you give them everything but what's weird is no one ever talks about housing like they do health care no one talks about cars like they do health care personal finance is the funniest thing you talk about um personal finance being emotional I’ve never heard anybody talk about personal finance that even talked about personal finance if you the number one cause of divorce is getting married and if you never get married you're never going to divorce and if you never have a kid you're never going to have to pay for their college if you stay single and have no kids that's financial planning and then what do you do you want to go out and get married and have three kids and whatever so end of finance planning but again I’m going to I’m going to end this seminar like I started it uh this podcast when I started is uh Americans won't talk about healthcare in the same ways they talk about houses cars restaurants yelp reviews whatever man when they talk about health care it's just like religion and politics they already have their belief system and I understand that the best because my two oldest sisters are catholic nuns I mean do you think do you think you could write a book and change them into hindus what do you think the is you could write a book and convert them to hindus probably less than none yeah I mean I’m going to I’m going to go on a date tonight with a unicorn who shows up on a mermaid uh before they would change their religion so it just is what it is and I don't care because I think the species is number one I mean it's just it's unstoppable in fact I would go as this far as much as I hate the government short of some crazy nuclear war I don't even think the government could slow down homo sapiens when you're dropping uh 385 000 babies a day oh my god every sea lion's saying are you kidding me I mean we're unstoppable so I don't care what anybody says or does with government health cares whatever we're still the apex uh species and I don't think anything's going to stop us unless it's some exploding star supernova or something um you know so um I’m optimistic so am I hey thank you so much uh for coming on the show Siv I mean um I could talk to you for 40 days and 40 nights um thank you so much for talking to all these dentists about um the world of um informatics it was very fun having me on the show thank you so much thank you for having me all right have a great day buddy 
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