Simplifying the access to quality care

Chris:

I'm so excited because she is one of the true change agents within healthcare. Paula is a practising vascular and general surgeon, physician, entrepreneur, CEO and founder of UBERDOC designed to directly connect patients that need a specialist with the great specialist. We'll be talking a lot about equal access as a woman entrepreneur and surgeon. And as important as a patient that's trying to access quality care, and the systemic roadblocks that make it hard to do. And of course, Paula is doing something about it with the UBERDOC, and we'll learn about that too . Paula, you're an advocate for patient centric care and women's health. I read two of your letters published in The Wall Street Journal, and got the sense when we last spoke that you say a lot of things that many doctors are thinking, but not saying or don't know how to articulate. I hope to hear those too. I'm so happy to have you on the pod Paula. As we dive in, can you please introduce yourself and what you do and how in the world you do it all?

Paula:

Well, first of all, I want to thank you for having me on your podcast. I think what you guys are doing are great and the more voices that we have out there, the ways to communicate I think are really important, especially when it comes to health care. So yeah, I'm, I'm a surgeon, by trade. By birth, my dad was a surgeon, my brother's a surgeon, I married a surgeon, two uncles, you kind of get the picture its the family business. And so I also passionate, I love what I do. And I love being a surgeon, I hate the system. And I thought maybe it was time to try to change it. So I became, kind of fell into this as an entrepreneur, I have two kids, my youngest went off to college. And I said, Now what do I do? Do I just keep doing surgery alone? Or do I try to change it? And then I found, I have a third child now UBERDOC, and I became the CEO of a tech, disruptive tech startup in my 50s. So yeah, so it's been an interesting journey.

Chris:

Yeah, that's amazing. And I would love to touch, as I mentioned, quite a bit on access, and what's fair and right when it comes to healthcare. But as we're diving into that, I would love to know a little bit more about your journey, and either as an entrepreneur, or a woman entrepreneur and physician, and were there any experiences that you had, that you felt like were unfair, or you had to overcome to access the same things that say, men in the industry, or the positions don't have to deal with?

Paula:

So it's interesting, as a surgeon, in a family of surgeons, I was kind of used to going into an all male world, you know, the only girl in your math class, you only, you know, you kind of all along, you kind of say, Okay, I want to get there. But ultimately, what I do is as a doctor, you know, women find a pathway, we may be the only ones in the room. But ultimately we hone our skills, we get our license to fly, and we get to get in the cockpit, right? Because we follow the rules. And it's a meritocracy, pretty much and as long as you do what you're supposed to do,you build your practice. That isn't to say that women in medicine, of course, you're still I think it's actually 70%. We're not quite on parity. But the point is that, you know, you kind of know the path ahead of you, you know what the challenges are, and like many women in many fields, you find a path to success. When I started this journey as an entrepreneur, my first supporters were doctors, that was easy. They didn't see me as a woman physician, they saw me as a colleague. So I got a lot of support from, from physician investors, physicians, I love them dearly, but they don't have enough zeros. When you have to kind of pitch your product to a bigger world, and suddenly enter the business world. It was a completely different story. I mean, I pitched my product and who isn't going to like fall in love with, Hey, you want to get direct access to a specialist, you know, without waiting and pay a transparent price. Like everyone has a moment in their lives, where their family's eyes when they knew they couldn't get in and needed to get in. So it has, people have a visceral response to Burdock. But it was crickets. I mean, I didn't get any invitations back or any interest in terms of investment. And I'm like, What's going on here? Do I smell? So then it took, it was a Wall Street Journal article and an NPR report and a lot of research that came out a few years ago about the amount of money that gets funded. Women founded companies only get about 2% of the money that's out there in venture capital. 2%, I was pretty floored by that statistic. I was not aware I was completely naive. I was working with an attorney and also a PR firm that was very feminist. I called both of them and I said excuse Did you know this? And I, the response I got I was a little unhappy with was oh we weren't aware. So,So I told them I said, Well, if a patient came to me as a doctor Muto, you know, that surgery you performed on me? Did you know that it wasn't going to work? And if I said why I didn't know, they wouldn't be able to actually, you know, a very good doctor, isn't it your job to know? Right? Isn't it your job to know? So I, you know, and so I'm, well, I don't blame them? You know, I don't think you're lying. I feel that many people don't ask the question, and many people don't know. And that's been something that I'm very sensitive about in this journey, and I'm quite outspoken about is that once a woman, once we find that path to success, we need to leave crumbs in the forest for the next woman, because there is no playbook on this. And I think it is terribly unfair. And you know, in other industries, you know, when you think of like the, I think we talked about before about, like, when you audition for Symphony Orchestra, you audition behind a screen, and they don't know who's there, but they just choose the musician based on their ability to play. And when you get time on the web telescope, you just put it in, you know, you put it in blindly, without any name attached, so that you get time because the idea is good. You know, I think that, that investment probably needs to go into that. So it is unfair, but I think that's kind of the nature of investment.

Chris:

Right? And you talk about leaving those breadcrumbs for the future generations of women entrepreneurs, what are some of those bread crumbs? Or what are some of the advice that you would give to a woman entrepreneur today, now that you've gotten through to the other side, and you're successful? And

Paula:

Now the other side? I don't know if there is another side, Chris. Is every time you get an audition another staircase, right, another another door, you have to find so but, I think that the expectation is important, it's so important to know, wow, someone else had the same experience. That was true even in like medicine, right? When women were complaining about harassment, people were quiet about it, right? You could only,  because people didn't want to talk about it. Because you were going to be perceived as weak. If you complain, and the only way we could change it is when people felt comfortable to share their story. And so with women entrepreneurs, I think it's important to just say it what, be truthful? Don't it's like sound like, oh, it's never happened to me. It's like, well, let's it's the statistic, we can't lie about 98% of the funds. You know, money doesn't lie. You know, it may not be correct, but it doesn't usually tell us the truth. So I think that is a big part of it is opening the communication, and making women feel comfortable to share. And to question it and not have them fear that if they do question it, they'll be kind of ostracised in that I just think it's wrong. And it's and we want young people to follow it. And in this path, they have to be given the same, they have to at least be given the clue of which door to knock on.

Chris:

Right? Yeah, that makes a lot of sense. And then I guess backing up to, as a physician entrepreneur, I'm sure there's some things that you had to either learn on the business side or unlearn from the world of physicians in order to be successful. What are some of those things?

Paula:

So, you know, being a self employed physician, first of all, I think most physicians are small business people, even if you work in a big institution, the contract you make with your patients every day is a small business contract. So by nature, we're, we're entrepreneurial. That's just the nature of medicine is that. So that being said, you know, running a practice is different than running a business. I mean, there's some things that are similar, you know, taxes, payroll, and so forth. But, but there are other things, especially in the cadence of a practice versus a business. I mean, I've worked with life and death, you got to make your decisions quickly and move on. When I was building the platform, my tech people said I was the best entrepreneur they ever worked with, because as a surgeon, I made my decision so quickly, right? I could do the Agile method easily because it was just a decision tree risk, benefit, risk, benefit. A surgeon is like that's what we do is risk benefit all day. But once the tech was built, and now you have to penetrate the marketplace, and you have marketing and you have sales, and you have like investment and it's suddenly a different timetable, and I'm very impatient. So I think that is what I had to learn where we're being doctoring, where everything we're used to have that scalp in our hands, getting things done quickly. And if they don't, we get to, you know, get angry about it, because we know we can, you know, we're supposed to fix that. But in business there, it's just it's just not that way. It follows its own course and, and you have to constantly be informing and you have to be flexible, much more flexible than you were in medicine, you have to be able to kind of move in the direction where, where you think you're going to find those opportunities.

Chris:

Right? Yeah, no. And that's commendable that you're able to make those quick product decisions, because a lot of people get hung up on that. But then also, in our experience, what in my experience is a fruit when I was a first time entrepreneur, the thing you learn the first time out of the gate is okay, building it and launching that MVP is literally the start right of that next skill sets you said. And it doesn't matter how good what you created it is, you know, you don't have to build it. And people come right, you have to take something to market iterate for different markets. And yep, you have to grow a business. Yeah

Paula:

You do, and that requires a team, you know, you can have a pretty trim team if you have a vision and the right tech and so forth. But then once you move out of the box, you know, you're now kind of out in the world. It's, it's complicated. There's a lot of different directions to go. And, and but yeah, I think that world of business just again, follows a different type of, you know, structure, than, than  diagnosing and treating a patient.

‍

Chris:

Right, right. Yeah. And I think what we'll get more into UBERDOC in a minute, but I love that you also start to solve that problem for physicians that come onto your platform, right as in making that not just half the battle of getting onto a platform, but driving people to them to subscribe to the same needs and ideals. But, yeah I know, I love learning about your journey. But, and before diving into UBERDOC solution, I would love to set the stage and foundation for the problems that you see in our healthcare system. And in particular, I think it's important for any entrepreneur to understand how the business model works within healthcare, and the trade offs they support or don't support when they're adopting one. And just starting out, what are the different types of business models that exist within the healthcare industry?

Paula:

So, um so healthcare is, you know, people say, it's complicated, right. So we separate what I call medical care from health care, doctors always say what's so complicated, we trained for hundreds of years, we can treat, you know, we trained to treat something specifically to do it well. So that's the practice of medicine, but healthcare is different. Healthcare is the industry around it to deliver the care. And that's where I think, credit of the rubber hits the road. So, so you so in healthcare, you know, you talk about, you know, patients seeking care, you know, people talk about payers, you know, how, you know, how is how does that equation work and patient can walk into a doctor's office, what happens? Well, how do they get to the doctor's office, you know, they have to have an insurance card, our entire, you know, health care system is based on sort of a universal universal insurance model, where everyone by mandate, at least, at least state by state now, not the federal mandates, not there anymore, needs to have access to health insurance or carry health insurance, where they will get a penalty. So the concept of health care is that you can you use your insurance card, there's a third party in there that does the negotiation between the patient, the doctor, or the patient, the hospital. And so and that, I mean, we can talk about where all that came from, but it comes back to actually World War Two goes back to World War Two. And and, you know, when, when Truman didn't want people to leave factories in the war, they put a wage freeze in so rather than raising wages, they added benefits and benefits. Part of the benefits were the fact health benefits. And then after the war, you know, if you were too old to work, or you were too poor, you didn't have a job, they created Medicare, Medicaid, Truman and his wife were the first to two recipients of Medicare, and then the employer based employers paying for your health care just kind of came out of that. And then it continued to grow. And as things became more complicated, more expensive and more business minded payers started to come into the marketplace, government subsidies continued. And then you basically have taken the equation of doctor patient out, we're no longer the buyer and the seller of the health care, were the service provider. Right. And, and the patient is, in fact, you know, technically is paying but not directly, right. And then you have this third party in between. So so our health care model is not direct to you don't buy your health, your medicine, right. You don't buy your health care. You buy it through insurance, and we're through a third party and that system had might have fit way back when when, you know, doctors knew what was best for you. But we have a completely different health care delivery system now very patient centric and technologically diverse, where this system is no longer functioning.

Chris:

Right? So I think what you're talking about is the evolution of this fee for service model. But it's not really fee for service, it's fee for service with this middle entity in between all the insurance company.

Paula:

Right? And yeah, and when people talk about, we don't like fee for service, we like this global payment, because it's much easier to have a global payment in that model, right, just have one size fits all, here's your fee. That's it. But we, but that requires that doesn't require transparency. In fact, if you put transparency into that system, it takes it down. So we built this, you know, no fee for service model over the years, which has actually constructed a complex paying scheme that allows for lots of middlemen and no oversight. And every day, like they just sued CVS just got sued for data breaching and changing prices with PBMs. You know, so there's a lot of opacity in the system. When they're when you know, if there's a lot of opacity, and there's a lot of money, what does it do? What doesn't matter? Right? You just go to the doctor, you swipe your insurance card and your gut leave. But that's not what's happening, all the costs are now shifting directly onto the patient. So it's sort of like we can't, we can't afford the lack of transparency anymore in the system. Because it's just, you know, it's just that we can't control where all the, all the, you know, where all the money's going. 

‍

Chris:

Can we unpack that a bit? Like, why can't be transparent, when there's an insurance company involved. And I've had this experience Bimal,  who you've met, has had this experience where we go into a hospital, and they just cannot answer how much is this procedure going to cost? Why is it so difficult to get that answer? It's frustrating.

Paula:

So I guess my question is, and my dog is answering, but I guess my question is that, you know, so the cost of care is finite, right? There is a cost to a procedure, there is a cost. But if you knew that cost, would you buy insurance to negotiate it?

Chris:

I guess it just depends on the cost. Ive seen many bills where

Paula:

You just gave me the answer. It depends on the cost. So if I didn't tell you what that cost was, you would have no choice but to pay a premium. Right? So , so you see how like transparency? Why is it this way? I don't know. When I, when I started practice, when I set my fee schedule, they said, Okay, your fees are going to be set, you know, two and a half times Medicare, I'm like, what, what does that mean? It's like, in other words, if your fee was $100, if you were me, if you were gonna get in the Medicare allowable was $100 on something your fee was $300. They will want well, like, why, why I just, I'm just asking, they're like, oh, cuz this is the way it is this lady. So all the time, I thought, this fantasy, that this some insurer out there, that's gonna pay me the big amount, because that was what they told us while some insurers pay more. But no one really pays  the fee that we set. And then I realised the fee that we set is because the insurance companies encouraged us to do so. Because then they can turn around and say, hey, look, she's really expensive, you know, this procedure didn't cost you $500. But because you have insurance, we're gonna take care of it. And we're gonna bring that cost down to like, $200 you know, what, they're gonna bring the price down. So, so that negotiation, I think, is part of why no one can give you the answer. And the people at the front end really don't know the answer, the best they can do is look at the fee schedule. And my charge Master is going to give you that crazy price. If you, you know, if somebody looks at my charge master, they say oh, she's she charges $5,000 for that, it's like, that's just this crazy fee. That's way higher than we collect. So, yeah, so I mean, so it really is  the opacity in the system is, is set so that, you know, insurance becomes more relevant. It's weird because when you get car insurance, you know, you go to your I go to my mechanic, you know, I have this wonderful place that fixes my car when I dent it ,and they tell me what it's gonna cost. And it's weather, and I know my deductible. It's like, you know, history. And in the system when it gets layered, because now it's not just my surgery. It's my surgery that you need anesthesia, you need a pathologist. You Need, you know, there's other fees that are attached to so then they. And all those fees are finite as well and fairly routine, like they're fairly repetitive, give or take a few quotes that you might add or subtract most of the time that falls in a range and a bell curve.

‍

Chris

Right. And so what about alternative business models within healthcare? So we've talked a lot about fee for service, but then there's alternatives that some people see as a panacea, some people don't like value based outcome based direct pay, and so on. What do you view is the material differences between those business models?

Paula:

So so the value based care is just another permutation is another manifestation of like, you know, managed care? You know, again, it was born out of those, the like, the sense that, oh my gosh, you know, the health care costs are so expensive, because everyone's going to get unnecessary surgery, right? Going to specialists and so on. So we're just going to create this primary care model where everyone's gonna go there first, right and get all your stuff done, and maybe never get a disease, right, because, and therefore be healthy for the rest of your life and never need any kind of procedure. So that was kind of, came out of a world of public health, people who think that you know, not medical people, public health people who think you can, like eradicate all disease, right? What, in those models, value based care is kind of part of that where the primary care is, that is the one who kind of manages your care, parcels out your, the money that they would spend on you. And if they didn't, if they if they saved money on you, theoretically, if they kept you healthy, or prevented you from getting a referral from, you know, for to an orthopedic for that knee that bothers you say, well, I'll live with it or do this or do physical therapy do something else, then they ostensibly get some kind of refund or bonus back in their system. So I personally think that that model can't exist today, because that was existed when patients didn't have access to the information they have now, patients are much more well informed, they actually have informed consent, they are more than capable of authorizing their own care. And, and you know, my patients watch my surgery on YouTube or like or someone else doing, they come in way more informed than they did. So, so I don't think patients really need to, they have other resources now that they can kind of figure out Gee, I've got something sticking in my eye, I can't see out of my eyes, maybe I need an eye doctor. I think we, and primary cares are overwhelmed with their own patients that need them to manage their complex medical disease, they do not need to be a rubber stamp bus station like to hear start here first, to get your you know, to get your, your state your passport stamped before you get to go to the to, to the specialist, because that's just added, added waste for them as well, and why they get overwhelmed. So those value based care models, managed care, it all comes, stems from  an assumption that specialty care is more expensive, and that they're somehow going to limit access to that. You know, direct pay is a completely different model where, you know, it started in the, in the direct paid primary care world where those primary cares could say, Hey, forget it, I'm not a bus station. Okay, I'm, but I'm going to take care of you. And I'm going to limit my practice, and I'm going to spend time with you, I'm not going to limit you to five minutes, I'm going to be your doctor in the old fashioned way where I'm here for you, I can answer your call. But in order to do that, I have to limit my panel. And so people would say, Okay, your direct pay. So sometimes you can still use your Blue Cross or whatever, but you pay an extra concierge fee for that doctor to be available. And there's a direct pay component to it. So that is a very honest, accountable method of taking care of patients because the doctor answers only to you, right, not to a third party. And they can provide care that rather than what the insurance is incentivizing or disincentivizing, they can feel free to offer the care for you. That they, they do. The only problem is they need a network to provide the, the next step of care, right that worked in the DSD world. And that's where UBERDOC comes in. Because now they're specialists also that can take care of you for those that same transparency. So that direct pay marketplace is emerging, we call it the DPO is very significant growth in employer based models as well as individual

‍

Chris:

Got it and yeah, let's talk about value because there's a lot wrapped up in even calling Something value based care of like, Oh, hey, you're gonna get more value subscribe to whatever it is, and then also quality of care. And yet when you unpack it, it's actually defined as things like knocking readmitted within 30 days or good survey scores. But really, in your experience, what, as a patient centric advocate, what do patients care about in terms of feeling like they're getting value from their care.

Paula:

So the three drivers of health care, the cost, knowing the cost, the the speed at which you're seeing the wait time, and the quality of the three, the one that is always ranked. Third is quality. Because patients assume quality, right? They assume quality, you're not going to, you don't choose your, your, your pilot, you choose your airline. And you expect that, that Jet Blue is going to choose a qualified pilot, right? You don't know you're pilot, so, but you choose the roof, and the price. Right? That's what you do for efficiency. So that is actually how patients behave. Always. Now, outside of people looking for a second, third, fourth opinion on like some, you know, rare cancer or melanoma or something, most people behave this way. If I tell you, Chris, you asked me Paula who's a good urologist or something, I say, oh, Chris, you gotta go to Joe down, you know, doctor, whatever. And, and you go to try to make an appointment, and that doctor, whatever is on vacation, but this doctor, second doctor, Dr. Smith, so Dr. Jones is the way that Dr. Smith and you're like, Alright, fine, you know, I can see that Dr. Jones tomorrow, okay, I'll try that. And then that person becomes number one for you. Because when you go in, you're like, Okay, this guy's great. Because most of us are on that bell curve. Most of us have done a lot of years and so forth. So, so again, you know, the insurers and the people that are we trying to control where the dollar flows, think that quality, is quality can be measured, I can tell you, patients don't see it that way at all. Patients might go to the, have the best outcome, but didn't like the doctor because the waiting room, I mean, that was not clean, or the front end was been, the person who answered the phone isn't nice, I can't stand that office, right. And at the same time, you can be like, I have patients that I've had complications with, and they keep coming back to me, you know, it's like, wow, you know, I mean, they still adore and love me, and I'm like, wow, they give me they, they trust that I will take care of them. And even if when they've had complications, so, so it's really hard to predict those relationships. And, and like everything, when they choose a measure, they have to choose something to measure. So it's easy to measure readmission. It's easy to measure, you know, the, the number of times, you know, patients in the emergency room, right. But it's really hard to measure, you know, that, you know, the complexity of their anatomy that require the readmission, or the fact that the family situation, I mean, I have a patient now whose wife was just diagnosed with dementia, you know, it's like, you know, she's supposed to take care of him, like that's not happening. So those are all other factors that don't factor in, you know, the social determinants of health care do not factor in, to all of those quality measures, but you need something to measure. Right? And you can't measure how pretty is the incision? How the patient takes

Chris:

Right, any direct pain model? How do you measure the value or predict or surface? So for example, if I go to Yelp, I can see what everyone rated a restaurant and I can choose to believe them or not, usually I read the reviews because I don't trust the overall ratings anymore, etcetera. Do you have like this, synthesised value system? Because what I'm hearing is that value is very subjective, right to the patient, and that people should have the choice, right to prioritize what value they need from the health system or from a physician directly. Do you UBERDOC do anything to surface those criteria?

Paula:

So UBERDOC is a, is not a platform that anyone can join, First of all, everybody on UBERDOC is credentialed, they have to be a specialist which includes you know, again, primary care physicians or specialists remember, pediatricians, internal medicine, everyone has to be boarded in the in the specialty that they are listed in and they have to be licenced in the state that there, they have a license and they have to be credentialed at a hospital. So so we we, you know, those are pretty strong criteria to be on UBERDOC. And then of course, we do one step further, we make sure that somebody isn't, you know, hasn't lost their license or hasn't been investing. Add, you know, or you know, has been in any kind of, you know, you know, criminal investigation. So we, we do that when they get on the platform. And that's important. Everything else really again, it's not the way people access care. I mean, I could be, you could go to the emergency room with Appendicitis. You don't choose whose arm you just get, you know, and you turn to the nurse and say Hey Dr. Muto because you do the job. And, and the nurse is going to tell you Oh, don't worry, she's great. She or she's gonna say, oh my god, get out of here. Better get out of here fast, you know, find someone else, right? I mean, it's just not the nature of the business. It's not down carries. Medicine is just not not that way. And, and it's not. So it is a we're trying to do with UBERDOC is create a consumer driven model where you get to choose your appointment, right, to a specialist, that's what we give you, you know, whether or not you know, I can get you to the, you know, the Italian restaurant, I can't tell you what you're going to order and whether you're going to like it, right, but I can get I think we're more like Ticketmaster, I get you into the show. You know, and , and then it's up to you, you know, if you liked the show or not I, you know, we don't have any control of that. But, but again, you know, your ratings. It devalues what we do. And it's one of the reasons why we call ourselves UBERDOC, because we're not just an average doctor.

Chris:

Yeah, that's interesting, because, you know, and I think that working assumption that people have is that the average consumer would prioritize quality of care over anything else, right. But the reality of it is, like you said, that's number three. And it's really going to be immediate access and convenience and things like that. And that's, by the way, how I access those system as well

Paula:

He wants to get along with your doctor, right, and when I see when you don't meet your doctor, I had a patient of the day, has been going to a specialist for close to two years and hasn't met the specialist. She's meeting her for the first time in October, I say, Excuse me, how does that work? You're very complex biologic, I'm like, how is that even possible? Yeah, she's working with their physician assistant or nurse practitioners like, so we don't have what we call mid levels on the platform. There are no, you know, when you see an UBERDOC, you see in the doctor, there are practices that work really closely with their pa’s and nurse practitioners, but the doctor is present or is, you know, because we don't want to get into that sort of like world where you're not seeing what you're getting. You know, these? We then, people again, that's what, that's what people are, you know, we wanted to keep it simple. What you see is what you get

Chris:

RIght? Yeah, and I've had that experience, too. I've had kind of ear problems all my life and Felicity atoma that kind of consistently recurs. And, Gosh, for the past seven years, I've been in Portland, Oregon. And I do have to have these yearly checkups. And sometimes every six months, I have to have a deeper one and a hearing test. And I've seen the actual specialist for five minutes, right, in those, in those seven years. Now, it's just to look at one of the tests that I've done one of the times of three visits a year. Yeah, so it's not like, you don't get access to the specialists in general. So now,

Paula:

If you were paying for that, you probably are paying something for that. But say as if you were paying completely for that, they may or may not opt to test your ears three times a year, if they're not changing anything they're doing for you. Right, it changes the equation entirely what you just said, because if there you have a third party payer, that is, you know, the patient and the doctor now not negotiating price is just I'm telling you, if you have a third party payer, then you know, you're,you're like, Okay, we'll just order another test, or, or maybe the insurance company very strangely, oftentimes say, Well, you won't be able to water another prescription safer, a hearing aid or something without another test. So it's strange, where the insurance company think that they want to save you money, makes you get extra studies. So, so this is where those third parties oftentimes can, you know, can lead patients down and doctors down a path that they don't need to go down, that just increases the cost for everybody, and without, without the value. So, So that's about value. Right? So how do you measure that, that they better probably check in every box in that practice?

Chris:

No, it's true. And I've considered getting a hearing aid. And the first on my list is Costco, not, not my provider to get that, just because of the experience.

Paula:

Again, healthcare as you're explaining, it's your medical carries person. And that journey is personal and private. And the more someone else kind of tells you what to do. In today's world, I think that's where we run into problems. And I think people should very naturally like to take care of themselves, as long as they're given the road signs, right. And given the, given the opportunity to have choice to go somewhere. I think that's really important. But when they tell you, you have to do this, too, you've got to have three, you got to have hearing tests three times a year. What do I need that for? Well, you just have to

‍

Chris:

When we last spoke, you said something that struck a chord that we've lost the core mission of medicine, because we've become embroiled in the systems of health care. So I just wanted to unpack that a little bit. What is the core mission of medicine and how Have we gotten away from it?

Paula:

So again, medicine is the, is a science and an art to make you better. But it is also to deal with disease,  you come to us with a problem, we solve that problem, we don't eradicate disease, we don't remove it, we just help make sure that it doesn't harm you or kill you. We manage, you know, cancer, we don't cure, we just we just keep it in remission. You know, we don't take away high blood pressure, we give you a medication to manage your high blood pressure. So I think that there is sort of this tendency to think that you're either, that medicine can, is sort of like, if you do it all correctly, you will eliminate disease. And I think, again, that gets back to that the public health world, they love these MD, mph people that are like policy leaders that sort of those blur those lines between medicine and public health, because public health is all predicated on yes, we're going to eliminate this and eliminate that eliminate this through initiatives. So, I think that, you know, I, I like to think of healthcare and medicine is somewhat separate. And then as we move forward, our technologies, you know, again, the doctors should be in control of the medical part of that equation. Right. And, and this is where we've lost control of that.

Chris:

Yes, yes. And I want to circle back to those physicians being in control of that in just a second. But we've talked a lot about the patient centric view, and, but not as much about the physician and nurse side of the equation, and how the systems of healthcare the business models of healthcare, are impacting people like your livelihoods, and quality and missions, what is like the boots on the ground physician or nurses staffs perspective on how you're being constrained or what your life is like.

Paula:

So, medicine is driven by data, right? We take vital signs, we take information, we take your blood tests, we take your you know, your physical exam, we look and we obtain data. In the last 15 plus years, the data acquisition has gone beyond the needs for to make a medical decision, it has included taking all sorts of information about you, your,  you know, your financial data, your social security, your credit score, all those other things, right. The insurance and then put on top of that people are trying to acquire more information, they want to know all they want us to be data gatherers. So the electronic records have been really, they when they were introduced, you know, at first, they were a wonderful depository of important information, you could get your X ray information, you get your blood test. And again, even when I was a resident, we had electronic records. And it was wonderful, because you didn't have to go down to the medical workers report and pull a charter, you could sit in the ICU and suddenly pull up that person's op note from the last time they were there and know exactly what's wrong with them. And there was a tremendous efficiency in that. And that's important data that we use to make medical decisions. Over the course of the last decade or so it's evolved into an inverse, it has become a billing interface. And we continually add more and more information that's no longer relevant to the patient outcome, but instead to some other reason, other purpose. That other purpose is related using the dog bark. The and that other, it's related to another purpose. And the other purpose has to do with whether it's gathering it to set actuarial tables for an insurance company, whether it's to set a premium, whether it's to unfortunately market your ICD 10, market your diagnosis to know like, oh, look, there's a population that is like, has this type of like a highly obese, obesity population, oh, they're going to need a lot of like diabetic medications for this zip code or something, right? There's all sorts of things that that data now is leading to in the, in the world of marketing, and business. And so when a nurse, you know, my nurse in my office, who's brilliant nurse, she's like the greatest nurse ever, and she's an ICU nurse for 50 years. She talks about the 75 minute hour. Okay, so when a nurse in the ICU is trying to take care of you, you're critically ill, they're hanging medications, they're talking to consultants, they're turning the patient, they're, you know, recording vitals, the way the whole system is structured. There's so much data that has to be entered into the electronic record in particular ways, it's impossible to do all of that and take care of the patient in 60 minutes, per hour. So the tasks go beyond that, and I was talking to an informatic person yesterday who put in another workflow in our pre op hold area, that would require the doctors to electronically enter all of their pre op antibiotics, because they thought that was a safety issue. And I said, Well, we have a conversation at the bedside with the doctor, the surgeon, the anesthesiologist, the nurse, the patient, about that antibiotic, right? Now, you're gonna get somebody who's remote, who's running late, who's just gonna go on the computer for their 10 cases a day and pop in the same antibiotic, just to make it more efficient. And there's, it's like, you can't tell me that that's not going to lead to problems. Maybe somebody has a new allergy or just didn't get recorded. You know, many times patients tell us Oh, I'm not allergic to anything, they tell the nurse something differently. You know, so, so the nurses and doctors are very, very frustrated over the, the amount of data that we have to acquire, the amount of time we spend away from the patient. And we have very little recourse when we complain. It's weird, considering they tell us we're not technologically savvy. You tell a surgeon who like uses new technology every day. You guys aren't right. Now, when they tell me that we did yesterday, Dr. Muto, you're not tech savvy, I said, I raised my hand, I said, I actually created a tech platform. But, but this is the problem. So doctors and nurses are very, very frustrated. And it has to do with data, all of the data acquisition and the time spent away from patient care.

Chris:

Got it, And is it at that breaking point because I've seen so many different stories in particular through the pandemic of physician burnout of nurse burnout,of people feeling overworked and underappreciated? Where are we at today?

Paula:

Oh, huge. Well, the pandemic just kind of unveiled a lot of weaknesses in our system to begin with, you know, the nurses were asked to work like these crazy shifts, and then oftentimes they were replaced or substituted by traveling nurses that came in made more money than they made. Some nurses actually quit and started to travel, have their own hospitals. And so you had tremendous hours that were expected. There, you know, the, it was a really pandemic ,emotionally was difficult, because so many patients were isolated from their families, the nurses at the bedside became their family. So there's a huge emotional toll, I would say PTSD, for sure,for people that were in those ICUs. In the, at the height of the pandemic, you know, you know, it was, I think, coming out of all of that. There, you saw big retirements, you saw lots of people who said, Hey, I'm done with medicine, a lot of physician colleagues of mine have decided that's it. The pandemic was kind of a press and pause for most doctors, where you know, that you didn't have control of what was happening, you obviously didn't see as many patients as you used to see because, you know, everything kind of stopped. And when you came out of that, many doctors said, hey, you know, I was only working three days a week during the pandemic, I think I'm going to continue to work three days a week. So so so , a lot of doctors came back kind of half time, and other doctors who said, I'm probably going to retire, because they kind of ,they saw it differently. And so we have a huge exodus in medicine on both of nursing and doctoring, and staff, medical assistants, front ends, receptionists , there's a huge exodus from healthcare right now.

‍

Chris:

As in who are the right people to fix this last time, you mentioned something that made sense that, hey, it's the people who do the jobs to be done the best that you know, and know how the system works today that may be best to fix it. And you mentioned physicians who run for office. So I'm wondering, why is it important for physicians to run for office and what excites you about this movement?

Paula:

So, I in general, I think physicians need to step up to the plate and fix medicine, and subsequently healthcare, we've been pretty much sidelined during all of this. So my fellow physician entrepreneurs, I give them a great deal of credit, the people who attend innovator, MD, it is just, you know, unbelievably talented, brilliant people all coming together, all physicians who have seen solutions. So ,I think doctors, you know, our, you know, our entrepreneurial, as we said, by nature, we're problem solvers by nature. One of the things that I learned to appreciate is that, you know, here I was in my 50s, taking on a task, taking on financial risk, taking on personal risk to kind of devote time and energy into a startup to change the world, right to fix something. Running for office is very similar for a lot of physicians. And I didn't realize that we have doctors around this country who were very successful physicians, many of them are still in practice. And they were like me, and they hit their, kind of their 50s. And so when they said, I want to fix something, how do I fix it? I complain all the time. We need more doctors in Washington. That's kind of how the vets worked. Right? You know, you have a lot of veterans and a lot of bad things happen to veterans and veterans started to run for office. And then now you have members of Congress who are vets. So guess what? They get it? Right. So when you're talking about defense bills, they talking about appropriation for like military combat, or what have you got people that are sitting there who can raise their hands, and you know, what, I've, you know, I've been there, you know, and I think that is so important, we need to have physicians and nurses, pharmacists, people in health care, frontline people going into office, I think is, is so important. Because,Because again, very much like me, and my fellow physician entrepreneurs, they're entrepreneurs, you know, they're doing so they're, they're entrepreneurs. And they're, they are, you know, and they're running for office, they're raising money, just like they're pitching, they're raising money, they're doing exactly what a lot of us are doing. And, and then when they get there, they have to make a change. And it's really good to have ears in Washington who, who've been in operating rooms, who taking care of patients who understand the fundamentals of medicine. When we have doctors that are in office, who are in policy, we have a lot of Doctor, you know, again, a lot of mph, MDs, people who like major architects of Obamacare, they were not practicing very hard, they weren't in front of people, and  in the trenches every day. So you didn't get a sense that what they constructed made any sense, like the electronic record implementation, if anyone had ever been practicing would realize it was completely opposite of the workflow of a hospital setting or clinic setting. And yet, so somewhere along the way, when they were designing that, the user experience, they didn't think of the end user. So to use tech terms, you know, we have to design a system or policy, and we have to think of our end users. And the end users in healthcare are patients and doctors. Those are the ultimate end users. Right?

Chris:

The biggest system in health care. Yeah, it's designed for the middleman.

Paula:

It's just designed, we think about the insurers and we think of the payers, the employer, we do not actually put the doctors and patients into that equation.

Chris:

Right, Gosh makes a ton of sense. And now you are making a difference with UBERDOC, you've invented something awesome, that doesn't necessarily address all the problems of health care, but does wisely choose which problems it's going to deal with and allows patients and physicians to sidestep parts of the system if they both agree, and I think that's great. So what is UBERDOC and what made you start it?

Paula:

So , UBERDOC is a platform, it's a network of direct pay specialists where a patient can find a doctor who's nearby and available, and make an appointment, go and see them in person or via telemedicine and pay a transparent price through a health savings account or credit card. So it doesn't require a phone call, referral. You know, you were it's again, to try to bring care local, you know, like, way back when, I was when I was writing, like, still write angry letters. But when I started writing angry letters, I was reading an article about a woman in New York City who twisted her ankle, okay, she goes to the local to the walking or the ER, the ER, wraps her up and then gives her a referral. She goes to a primary dutifully, who then promptly refers her to an orthopedic in Stamford, Connecticut. Now she doesn't have transportation, she has a, she's on crutches. You know, she lives in Manhattan. She Googles orthopedic surgeons near me, and finds about 15 of them. She picks up the phone, makes an appointment goes and pays cash. And she said, why can't it be that way? And that was my aha moment. I'm like, Absolutely. Why can't it be that way? Right? Why can't it?l What, what makes it not that way. And then I looked at it. And I said, there's nothing that makes it not as long as there's a doctor who's willing to put a seat aside and take a cash pay patient without a phone call, you know, through, you know, through an appointment scheduler. And as long as there's a patient who's willing to pay the transparent price for the visit. It can be that way. And so that's where UBERDOC was born.

‍

Chris:

That makes sense. Are there any rules for doctors that are enforced by their employer so that the,the health system they work for, for example, in some technology companies, they try to have these that are considered generally unenforceable contract terms around moonlighting working on something during your spare time, or intellectual property that you create while employed, that company is all under the company that you work for. Do doctors have to deal with that? If they want to also be an UBERDOC? Or is it

Paula:

Oh, no UBERDOC is just an appointment make, Right so any doctor anywhere can be now naturally, the independent doctors and join easily they're like, Oh, sure, it doesn't cost anything for doctors to join, they can join in minutes. And they can post their appointment slot. So there you go. And it's and it's easy, say, Okay, I see my patients every Tuesday morning at 9am. So at 8:45, there's a slot, there's my, there's, it's like a tick, right? It's like I, I perform eight shows a week, and I'm gonna put a house seat aside, you know, for the, for my Wednesday, matinee, whatever, that's how it works. So now doctors who are employed by big groups or institutions, you know, they have to kind of like push it through the, the, the, they have to push it through the bureaucracy, right? They say, okay, great, I'm gonna post an appointment slot, but then who gets the payment? It's easy when you own your practice, because it's your bank account. But when it is somebody, when you're owned by someone else, that's where it contracts come in, where like, you can't do it, you can't practice medicine. You know, if you're gonna get paid to see a patient, the institution has to get the payment. And most doctors are perfectly fine with that. It's just that when they go to their office manager, say, Do you have the bank account number to put in the office manager, oh, my God, we got to go up the channel. We talked to the director, the director goes to this and the director, then all of a sudden it goes all the way up to like the CFO. Now, no one really has an objection at UBERDOC, I started with all the boardrooms in Boston and got, you know, very good responses and standing ovations, right, because who wouldn't take a patient for cash? I mean, come on. It's like, why would you turn business away? . But, but their bureaucracy and the way institutions work? It's like, it's like a 10 year sales cycle. I mean, it's terrible. It's right there, you know. And then of course, COVID hits, because oh, we can't do anything until after COVID,Right? We're dealing with COVID now. So COVID  became the great excuse. So now of course, access is huge issue. Those receptionists are not there answering phones, they're no one's going to work in a cubicle with no ventilation for 10 bucks an hour anymore. You can outsource it to some degree, but patients really want the convenience. They just want to make an appointment. They don't want to put on a whole day waiting for someone to call them back. It's just not, just doesn't make sense. So, so we're approaching a lot of US institutions say let's just make your appointments for you. You know, just buy a few seats. You know, so, so, again, so we're system agnostic. We can work with anybody. My goal is a seat in every waiting room, whether it's a big institution or whether it's a rural practice,

Chris:

And how were the whole system's responding to you as they're scheduling

Paula:

So again, the,the people were always really excited about the model. My,my biggest fans are CFOs. Because the, the chief financial officers see the bottom line, see and control the patient access. But then as it filters through the layers, you know, again, it's just, it's, it's one of those things where it's just easier for us to just go right to the doctors and I, and I kind of feel like it has to come from the doctors. We have some doctors that big systems, they're just UBERDOC on their own. You know, because if they wait for the system to sign off on it, took six months with, with partners, our biggest in their legal team, just try to tear it apart. And then they realized they really couldn't tear it apart. It's just a health savings account, your credit card?

‍

Chris:

Yeah, gosh. Yeah, it's so interesting how yeah, that behind it, it feels even now, just because as so many other industries have moved beyond that, right? Like, if I want a reservation at a restaurant, I can go to Yelp or I can go to OpenTable, I don't have to call the restaurant anymore. If I want food delivered to me, there's a number including Uber Eats, right that I can call and get food delivered to me. And this whole concept or, or Expedia and travel companies that do get to reserve slots, and they added so much efficiency and then choice, right, to the system and transparency to the system for the end consumer and yet the health care system.

Paula:

Wait, so at the very beginning of this, I was in contact with Aaron Sunder Roseann, who wrote the book called The sharing economy. So He's an economist at NYU. And, and it's about like the Lyft and Uber and Airbnb and how they came about. And the, the concept was that, you know, you have two versions of economics, you have these hierarchical corporate models, and you have peer to peer transactions. So, do you think that Airbnb, lifts are disruptive, because they're, they're, in fact, a peer to peer marketplace, like Amazon is a marketplace but peer to peer, right? People are buying and selling on it, peer to peer. But in fact, corporate, a corporate model is the disrupter. Because 90 plus percent of business transactions in the world are really peer to peer. They're your local business person to your cobbler making a shoe or a baker making bread, right? I mean, the most of these are peer to peer transactions, the corporate, the corporate model is actually the disrupter. So when you think about medicine, medicine is a pure peer to peer transaction. Always, doctor patient, doctor patient in a hospital nurse, but it's like it is a peer to peer. But we've tried to make it a corporate model. And those top down approaches again, work in public health, like everyone should wear a seatbelt. Nobody should smoke in public places. You know, that's a nice top down initiative, vaccination perfect example. But that's not medicine, medicine is not top down, medicine is like you have this particular disease, there are five choices for me to treat it, we're going to choose the one that is probably what we think is going to be best for you based on what we know. So it's a peer to peer transaction. So from an economic model, that's how it is.

‍

Chris:

Right, Got it. And what's still missing from direct pay model. So for example, now we have UBERDOC, which connects the patients who need an expert with someone qualified, willing to take money directly from them. Sounds awesome, so you've solved that networking, matching problem. But what else is needed in terms of technology, policy market readiness to really make. 

Paula:

Well, again, what happens with the next step, you see the orthopedic and they say, Okay, we want to do an injection. So now the orthopedic X ray, the orthopedic has to have a price for the X ray. And if they don't do their own X ray, they have to work with, with a imaging, and that's where green imaging comes in these amazing companies is really breaking the mold, to repurpose to, to optimize existing equipment, and staff and navigate patients into those spots for a transparent price. It's a brilliant model, right? So then, of course, you need to get a prescription, and you want to make sure that the prescription is transparent, you may need to go to surgery, but you want to make sure that that price may be transparent. So the moonshot for UBERDOC is you  start with the first step and the doctor's office, but then after that, if you want to proceed through a transparent model there the you know, there should be transparency doesn't mean that you set the price, because the prices are going to vary from like Texas to Oklahoma to Maine to New England, right? I mean, it's uh, you know, it's always you can't predict, but you can set the transparency and so, so ultimately you want to make sure that the, you know, the next steps are always good it'd be important UBERDOC is about that first step, because I believe that many things can be solved in that first step, you go to an expert who's seen it a million times, you're going to get the answer. And, and I think that we have spent way too long, assuming, again, that specialists are more expensive. They're not that they will order out waters tests, you don't need probably not, you know, it's like, you know, good behavior comes from good healthcare, good medicine is good behavior. And, like my dad said, Just take good care of the patient, and you'll be financially successful. So, so I think that, like you said, those next steps, you know, what comes next? What's the obstacle, the in terms of just Uber doc getting patients to change their behavior, to look for direct pay models, and that's really on us doctors to show that we, you can trust us, that we are going to give you a transparent price. And there's legislation about surprise bills, there's more consumer protections coming down the line, I think, five, six years ago, it was a lot harder to, to  convince people now, everybody's deductible is high enough. Everyone's paying no matter how great your insurance is. So, so I think now it's an easier sell, and to get that patient behavior to change and to get them rewarded, right? If cash back rewards if you pay cash for your care, you should pay less of a premium.

Chris:

Yeah, no, no, I think it's fascinating, and how quickly it, it seems to be turning and at least traction that direction. And I was listening to an Andreessen Horowitz podcast meeting a year ago, year and a half ago, where they were just, they were talking about Lasik eye surgery, and you know, in the malls, accessible, direct pay, get the insurance company out. And this is what consumers want, even for that level of specialization. So it's, I think it's awesome that you're supporting that, at that next step. And, yeah, no, I hear you that accessing the rest of what care could mean, whether that's more tests or procedures, etc, isn't important for the completionist aspect of having this alternate system. But I think what you have in terms of a direct primary care, plus the specialists are probably 80-90% of what you actually need or want. Makes a lot of sense.

Paula:

Right, I mean, you're gonna solve it in an office, you're gonna solve it. It's, again, technology's brought us so far, where we can do out patient knee replacements for goodness sakes, I operate my office this morning, it's like, the stuff I used to do in the OR I can do in the office. And, and many times I don't operate at all, I just give you a pill and it takes away your arterial disease. So there's so much in technology right now, that has changed the delivery of health care, the delivery of medicine, I should say, medical care that the health care system has to adopt to medicine.

Chris:

Right, right. And the system is never going to adapt as fast as a market, an open market.

Paula:

You are 100% right. And, so knowing that it's the patient, that is the one in charge, knowing that it's the pain that we don't live in it, we know what's best for you world anymore, right? You, you know, we respect autonomy, and choice. And in that environment, then of course, yes, the patient is the consumer, the patient drives it, and the patient should be rewarded for good behavior, the patient should get the bonus if they don't utilize, why are you giving it to your doctor? Give it to your patient, give it to the patient? Give it to the patient?

‍

Chris:

Yep. Yep. Yeah. Okay. I'd love to talk about the growth of UBERDOC. And in particular, of scaling it, because UBERDOC is essentially a marketplace and marketplaces are notoriously, some of the hardest problems to solve because you have this supply and demand that somehow need to be built in lockstep, or no one's gonna find value from anybody on either side. So you need doctors for patients to come, you need patients for doctors to come. How did you solve this chicken and egg/

Paula:

So we first built the platform, we put our first 45 doctors on and I'm like, Yeah, we're done. Right, and, and then we had one like TV spot, like they did a story on us on the local news. And, and the platform, like immediately, like we got patients and like, okay, that was my test. I knew it was going to work. Now we can't be on TV every day and that was really expensive. You know, we you know, like with everything, you know, when we started to drive more pay, you know, we have doctor patient like, to sell to the patient, you need a lot of inventory. You're absolutely right. You can't like open up for Black Friday until you have enough inventory on the shelf. So, so we've concentrated really on that inventory on those doctors. And we started with just six core surgical specialties and expanded it rather rapidly and then embraced our DPC colleagues in. And that really exploded the platform. We pulled away any subscription. We made sure the doctors could join without much friction. And then we just went across the country door to door, I went beyond my doctor's lounge, and beyond my stage and beyond my specialty. And, and I couldn't find a naysayer. So, so it was really hand to hand combat. A basically, and now, you know, we have a robust marketing campaign where, and we built the, largest network now in the country of direct pay specialists. And it's really solidly built, because it was built literally by hand. Right, and, and we're very proud of it. And now, now on the patient side, you know, we go to aggregators, you know, we have a contract with the state of Massachusetts, we have working with employers, medical Crusher groups to be TPAs to that they need direct pay specialists. They're using our network. But ultimately, this is a direct to consumer model. And I would love to get right to the patients. And how do you do that, this podcast? You know, he's Obrador, right? Because I used to think it should, it's the best kept secret, but it shouldn't be a secret now. And so we encourage our doctors to mark it to their patients and use it for their own appointment making. I do think it's an easy concept. I don't think it's hard for patients to figure it out. It's just another thing that they would have available to them. It's not situational. You don't have to use it every day. But when you need it, it's there. So, so I think that, like I said, getting it to the consumer, as you said that marketplace, I don't think it's an issue of changing behavior so much as knowing that it's there.

Chris:

Right? There is a better option. Yeah.

Paula:

Yeah, it's just another it's like people go to urgent cares all the time, like their behavior right now is to find something convenient, accessible, and affordable. So that behavior is already there. For medicine, right? So we're just saying instead of, you know, it's your eye, instead of going to the walk in, get the referral to your primary into the eye doctor, just go the eye doctor direct.

Chris:

Yeah, Yeah, Makes sense. And is there a geographic component to at least the early days of your growth? Like, okay, we're gonna focus on Massachusetts first, or this part of Massachusetts. I know, there was a offering component, like Amazon started with shoes, Zapp or sorry, yeah Zapp started with shoes, Amazon started with books. And yeah,  were there other ways, dimensions.

Paula:

You know, with our six core search, core surgical specialties, and you know, orthopedics, urology, Gynecology, gentle surgery, vascular, and, and ENT, and, and in Massachusetts, because that's where I live, and that those are my colleagues, those are my connections. Rapidly, we got people interested in other places and then and then we started to just, you know, everyone's had just concentrated in one area with one specialty. Well, that's just not the way it worked. I mean, it's like, that's easy to say, but So ultimately, you know, we started to get like, we, wherever we could get access, we started to , the word spread, like in Florida, it spread really quickly. And we did a lot of doctors in Florida, California, where investors were, we now have a lot in Texas, Ohio. And so next thing you know, it's like, yeah, it'd be great if we could just confine it to one area. So we did start playing with zip codes, and like drive traffic to certain zip codes. Psychiatry, for example, was always an important one. And because a lot of people don't want to use their insurance to see a psychiatrist, and, and so we concentrated on one specialty, in one particular area, we use, you know, Google AdWords, and so forth. And we were able to prove the model. Now, just sustain it on a scale, It's costly. And you know, and you could put a lot of money into Google AdWords and all that. So, So we kind of tested it in these areas. And again, the model worked. So then, essentially, then we said, well, you know, we scaled stuff back just because, you know, going direct to consumer, we kind of had that, we had the playbook for that. But to do it, right, you'd have more funding. So we pulled it back and just went straight organic growth. So now we have great organic growth on our platform. You know, like anything, how do you bring anything to a consumer market today? You can spend tons of money on ads and Instagram and all this stuff, and then the ROI on that stuff is so high.

Chris:

Right, right. What's the biggest challenge left for you to scale UBERDOC?

Paula:

It's really the patients, the patients, you know, letting the patients know that we have 20,000 appointments waiting for them,  that we're here for them and when patients don't find what they're looking for tell us, when an employer tells us, hey, I need my employees need to be covered in this area? Well, we'll find those doctors for you. We'll invite them onto the platform. You know, we want to be that,we want to be that network plus, you know, access to care. Because many times you have people now living in Austin, Texas, but working in New York. So how can they be supposed to fly to New York to their get their medical care? How are we going to control that cost? How are we going to like , How are you going to , in a modern workforce, How are you going to cover them?

Chris:

Yes, yeah. And it's along a lot of these trends that we've been seeing recently of decentralization. So in crypto currency and blockchain, all about decentralization, web 2.0 is the same thing. But really scaling the access to the responsibility out to the people themselves, rather than an entity controlling things i

Paula:

Its just a personal choice in your life. That's right, that's the very last thing you need to, you don't talk to your banker about it, you talk about you talk to your insurer, you talk your employer about your health, they should know anything about your health. That's not their business.

Chris:

Yeah, okay. Let me ask you some questions about your learnings. And are there any of the biggest learnings that you want to share? For example, the biggest mistake or misconception you had, or the best decision that you took, or advice that you think is just printed off this UBERDOC assembly line for digital health entrepreneurs, because, you know, it's something you glean by experiencing?

Paula:

So I think that on the mistakes side, you know, don't underestimate lawyers rates and time. No, just you know, that I was taken aback on that, you know, oh, we're having a chat,I'm just asking you a question. It's like, oh, wait, there's a there's $1 Bill attached to that. So, no, you know, so the attorneys fees that the whole you know, there's, there's the transactional people out there, that it's part of the business world. And my only mistake is not doing my homework on that and knowing ahead of time. And I think that's really important for entrepreneurs to know and appreciate. The best decision I think I took was when I pulled the subscription. When we saw the interest among the DPC doctors, and they really were great supporters of our model from early on saying, do this, build it, keep it going, You know, I, that was a really important decision, even though it took away the , the attraction of a SaaS model, you know, a subscription model. And it gave us a much longer runway, because  you need to, have to build revenue off a transactional model, as you say, building that marketplace first, it, you have to, you know, you take a sacrifice of that, but I think it was well worth it. Because it expands it, makes us infinitely scalable, which is what makes us unique in the marketplace. You know, and as far as advice to people, you know, I always say just be patient, right? You, you try to rush things, you try to think it's gonna happen tomorrow. You have to remember that the forecast is, it's a long play, right? It's a marathon, not a sprint. And even though you do get to the next level, the next level, like you say, the MVP is launched. It's just the beginning. It's not you know, every time you turn the corner, you think, Oh, I'm there, But you're not. But the exciting thing is every corner, you turn, you see more possibilities. And I think the, the difference between  success is that the more possibilities you have that don't stray from your initial mission, I think is key, right? So many people say, Oh, I pivoted, I pivoted, and they pivoted entirely away from their idea, right. They just, you know I had one person say, you know, you should really think about adding insurance into your equation. I like but that would really take away the whole purpose of UBERDOC

Chris:

Right, yes, yes, exactly. And that's what's happening in the de-fi world, decentralized finance world where we had this thing called cryptocurrency that is completely decentralized. And the first thing people tried to do of course with greed in mind is create a sense that the centralized banks that would take people's money and loan out different instruments and now they're all collapsing. Right so yeah don't recreate the system you're trying to

Paula:

Look like the Uber driver benefit. Like the whole purpose of driving for Uber as you work for yourself, Right? You know? Yeah, it's it is a it is a yeah, those those business models again, when you you take advice from people and vectors but you try not to pivot away from your core mission. I think the ones that have been successful have always kept to that mission. And be flexible. You add, you know, you nuance it, but you don't actually ever change the purpose.

‍

Chris:

Right,okay, I want to know, just two more questions, Paula's big ideas around healthcare, and one of them is just expanding on something that you shared with me and I hear different variations of this statistic, but they're always eye opening is that you mentioned that 73% of healthcare expenses, go to the middlemen, right, only 27% Go to the actual people that are delivering care. Can you, for our audience, explain the math here? And the numbers I've heard are both just a little bit above or a little bit below that? So absolutely, that seems accurate. And many people don't understand that math, how could that possibly be? And, of course, direct pay is a direct answer to taking out this middleman. But why is it 73%?

Paula:

Well, because the management, again, health care is costly,medicine is less costly.As we've moved away from expensive places, like think of cancer therapy, right? Used to get admitted to the hospital, get your induction therapy, and then go home, you know, it cost all that, all those days in the hospital, all those people involved, now you get a pill, right? That's made for you, and you take it at home. So the cost of the pill is one thing, but then the cost of delivery of that care is, is much lower,right? You know, we used to admit patients in a hospital before surgery, keep them in the hospital after surgery until their staples came out, went home. Now patients go home immediately, right, they don't get admitted to the hospital. So now the post op care is really, the family has to do that, right? That's where social determinants of health come in. But the cost of that delivery, the cost of that system has come down. So that's why you know, the pendulum kind of shifted, because that 73%, think of it as being that 73% being that kind of clunky, keep the lights on this big building, right? Say you have a big building, but all of your employees are now remote. But the big building still requires, a company is still paying the electric bill, and the gas bill and the cleaning service, right to keep the big, big building going. But your employees are at home. So only 27% of that of your cost is you know, you only need to spend 27%, the rest of that 73% is putting into a system that you don't need anymore. That's how I like to think of it right. It's like not that oh, my gosh, we have to take you know, you know, the middleman is taking all of it, it's like the two thirds of what we spend is no longer necessary to spend, you could repurpose that money somewhere else.

Chris:

Right, and technology and medical innovations have made it such that those tears are not necessary to spend,

Paula:

It's kind of a different take on it. It's not like oh my god, we, you know, medical care should be 100%. It's like, well, we're only using 27%. We don't need it, we are more fuel efficient. Right, we are more fuel efficient, we don't need to fill our tech guesting with the extra 73% anymore, we don't need that ,we need to modernize and use technology to streamline it. Because at the end of the day, medical care is finite. Right, it's finite. Now, part of that 73% is the marketplace of healthcare, that we have very little control over. You know, that's where the drug companies can decide a generic drug could be really high priced or low priced. And, you know, they're gonna just set their margin, because that has to do with the way businesses practice these days, right? You know, you know, forced obsolescence of technology, you know, technology so that you buy another phone or you buy something else, right. You know, we know that there's business practices that are designed in a boardroom to make money, right to make a margin, when it comes to medicine that's hard to sell. And it's just not something people want to, want to digest, right? You don't want to pay an exorbitant amount for this miracle drug, that saving your life and say, well, we can save your life, but now the price is up to 200,000. Now it's 300,000. That's for right. So prices for medication should not be set supply and demand. And they certainly should not be manipulated, right middlemen. So that's that 73% Right. So if the healthcare dollar which is heavily subsidized by the government continues to pour money into the system, they can stop the flow of cash to that 73% .They can say we don't need, we don't need to keep the lights on in that building anymore, right? We don't need to keep the electricity on, we don't need to, you know, keep the air conditioning going 24/7, right, we don't need to waste all of these resources, right? We're gonna, we can shut all that down. And that's where the government comes in. Because 30-50% of the healthcare of the federal budget goes to health care in one way or another, either directly through Medicare or Medicaid or indirectly through federal Blue Cross to their employees or they're paying for TRICARE for their military, right. 50% of the health of the federal budget is going to healthcare, and a full 73% of that goes to middlemen. That means one out of three of our tax dollars is fueling these inefficiencies. We can vote on that and say we don't want that, we do not want, we take that extra tax dollar and put it somewhere else. But don't put it there. And that's where the government can come in,you know, government doesn't do well with healthcare in general, but government does well for consumer protections. And we are the consumer. And as soon as they recognize the patients, or the consumers, putting consumer protection laws for us.

Chris:

Yeah, that makes a lot of sense.

Paula:

And protect our privacy, our data along the way.

Chris:

Yes, right, right, Exactly. Yeah, gosh a lot of bad actors in the ecosystem. And then yeah, for the

Paula:

So yes, but but again, you don't take down a system, you create an alternative, and you let the market force drive it. Because ultimately, there'll be a hybrid, you cannot eliminate insurance, you need insurance, insurance is important. You know, it's especially important for your health, you do not eliminate it, you just bolt into it, a direct pay model, in addition, where some of the small stuff you pay out of pocket and the big stuff you get covered. And that's fair, pay off, pay all the small stuff means when you go to the hospital is not deductible. Alright, when you need that cancer therapy you get it shouldn't be an argument. But the small stuff? Sure, you know, go to your doctor $100, right. Go to that ear specialist, Alright. There's stuff that we can afford to pay out of pocket. And that's how countries that are like socialized medicine work and for poor people, give them a voucher, give them health care vouchers. What is subsidized Obamacare has to be all 100% through an insurance managed care model? You know, do we really need all these managers? I will argue,  73% Worth and it is a system but think of all the money that we would save. So at the end of the day, doctors need to be paid more, or hospitals need to be reimbursed more. No, we need to lower our overhead, eliminate all of these,these because every middleman is taking a piece that require hires us to give them data for, right, we have to take steps in the way if we knew we could get eliminate a lot of our cost of getting paid, we wouldn't have to raise our fees, because basically, what does it matter? It's a margin.

‍

Chris:

Yeah. Paula last question, we've talked a lot around the business models of healthcare and how direct pay can evolve to be this alternative model. What other advances do you really want to see in the next 10 years, besides having these alternative models, and gosh best technology and treatment when.

Paula:

So I would like to see the, again,the participation of the putting the patient in the center of their care, I'd like to see protection over patients choice, not just women's choice, patient choice over everything from you know, vaccinating your child to, you know, turn on, you know, turning down a life saving therapy for an elderly parents. You know, I think that choice and health is vital to protect, I'd like to see a doctor patient relationship elevate to the point of an attorney client privilege, where what happens is private, and no one can ask a question about it, so that you can have a million laws on the books, but you can't reinforce any of them. I think that restoring the doctor patient equation is really important to do, protecting privacy, and rewarding transparency. By rewarding the patient, I think patients need to be part of this equation, they need to be incentivized. And I think that, that there, you know, again, they say, well, patients need skin in the game, that patients have more than skin in the game. Their bodies in the game. You know, again, medicine is, is beautiful right now, and could be so amazing. My residents are brilliant, they train forever. Their technology is again, breathtaking. The talent that's out there is amazing, especially when you combine it with technology and AI, there are so many answers to so many problems we get so quickly. But all of this is hidden behind a screen. That's a smoke screen at this point, we can't access it. And so to take down that screen, we have to make the system transparent, so that we can you know, we can know if a study is good or bad, who's behind it, things like that, you know, because, because again, we do a lot of good things in medicine. We were the leader, we were the leaders in the world in medicine, we're now number 37,37, Right behind Bahrain. But we're ahead of Cuba, which is unbelievable that we have fallen that far. Right? Or maybe the other countries have gotten that much better. Maybe I'm not giving enough credit. But

Chris:

It is unbelievable. And yeah, I mean, speaking of unbelievable when we first spoke. Yeah, I mean, I heard some, you know, so many different viewpoints around business models in healthcare in value based care, and what does patient centric mean? What is valuable. And I have to say that you've been one of the first people I've spoken to as authentically in the past six months or a year, convince me otherwise right, of what I was thinking and kind of change my mind on some things. And I really appreciate that. How compelling and of course experience driven, you've been. And Paula in general, I want to thank you for your time today, your contributions to advancing US healthcare, and your advocacy for many groups who represent whether it's patients, providers, entrepreneurs or women. And I think you're amazing and appreciate the the learning and sharing 

Paula:

You're being way too nice. But thank you, and I do appreciate that, you know, like I said, at the end of the day, I always think again, my dad just take good care of the patient. It's not that hard. And I say this a lot. Like it's not that complicated. And they look at me like, Oh, you don't understand. It's like, I understand,  what is it that I don't understand? You know, and, and like I said, simplicity. You know, simplicity is always the best answer. Sometimes the simplest answers are the ones that resonate.

Chris:

Right outcomes razor, simplest explanation wins. Yeah

Paula:

The simplest explanation wins.

Chris:

Okay. Well, thank you again, Paula. Have a wonderful day. And I hope this is the first of several conversations we'll have overtime.

Paula:

Terrific, thank you.

Chris:

 All right, thankyou.

‍