“Research in Progress: The Primary Care Squeeze”

Transcript

• 00:08Okay. Well, good afternoon, everyone.
• 00:10Welcome to the
• 00:12new academic year.
• 00:13Here we are.
• 00:15There's an echo coming out
• 00:16of my pocket.
• 00:17Oh, that's all.
• 00:21Figure this out here. Okay.
• 00:24So,
• 00:26welcome to our first research
• 00:27in progress meeting for the
• 00:28year. To those of you
• 00:30here and those of you
• 00:31online,
• 00:33the,
• 00:34CME code for today is
• 00:36five four one zero two.
• 00:37Five four
• 00:39one zero two.
• 00:43So mark your calendars.
• 00:45Our retreats are
• 00:47dates have been picked. December
• 00:49ninth, we'll be having our
• 00:50research and scholarship retreat on
• 00:52the West Campus.
• 00:54On February sixth, our professionalism
• 00:56development retreat, led by Abba
• 00:58Black on the West Campus.
• 01:01And on May twenty ninth
• 01:02of twenty twenty six,
• 01:05our education retreat on West
• 01:07Campus. That's a tentative date.
• 01:09So book the first two.
• 01:12If you're a clinic director
• 01:14or program director, be sure
• 01:15to
• 01:16free up your faculty to
• 01:17attend these retreats.
• 01:21The other,
• 01:22thing that won't require freeing
• 01:24up your faculty to attend
• 01:26is the
• 01:27annual Yale GIM day at
• 01:28the Yale ball. This year,
• 01:30it's gonna be September twenty
• 01:31seventh.
• 01:33The Yale Bulldogs versus the
• 01:35Cornell
• 01:36big red.
• 01:38And I know that, Susan
• 01:40Kashif and, Chris Russo are
• 01:42Cornell
• 01:43folk. I'm not sure who
• 01:44they'll be rooting for, but
• 01:45they'll let us know.
• 01:47And there are other Cornell
• 01:48folk, on the section as
• 01:49well. I'm quite certain.
• 01:51Should be a great day.
• 01:52Skybox opens at eleven o'clock.
• 01:54Of course, families are invited,
• 01:56and it's always fun to
• 01:57see all the kids come.
• 02:01Next week,
• 02:02we're gonna have our grand
• 02:03rounds. It's gonna focus on
• 02:05genetic testing,
• 02:07with two speakers here, doctor
• 02:09Geary and doctor Healy,
• 02:11as indicated on the,
• 02:14slide.
• 02:15And then,
• 02:17at noon on next Thursday,
• 02:18we'll we'll have our first
• 02:20of the,
• 02:21administrative
• 02:23faculty and staff meetings.
• 02:25Among other things that that
• 02:26meeting will be introducing the
• 02:27new faculty who just joined
• 02:29us,
• 02:29this year.
• 02:32Here's our disclosure slides.
• 02:34So David Rosenthal, a man
• 02:36who needs no introductions, but
• 02:37I'm gonna introduce him anyways.
• 02:39David,
• 02:40attended Harvard College in Northwestern
• 02:42University.
• 02:44Upon receiving his MD at
• 02:46Northwestern,
• 02:48he went on to the
• 02:49Brigham,
• 02:50to do his internal medicine
• 02:51residency in their,
• 02:53management and leadership track.
• 02:56Fortunately for us, we snatched
• 02:57them out of graduation and
• 02:59brought them here to Yale,
• 03:01where he joined us as
• 03:02an instructor then promoted to
• 03:03assistant professor in two thousand
• 03:04thirteen.
• 03:05And for,
• 03:07ten years, he served as
• 03:08the medical director of the
• 03:09VA HPAC, which is the
• 03:11homeless,
• 03:12patient aligned care team.
• 03:15And he did amazing job
• 03:17addressing homelessness,
• 03:19in veterans in Connecticut during
• 03:20that period of time.
• 03:23Unfortunately for us,
• 03:25he left the full time
• 03:26faculty in twenty twenty one,
• 03:28during which he was chief
• 03:29medical officer at two four
• 03:31catalyzer companies in Guilford.
• 03:33But fortunately,
• 03:35once again, he joined the
• 03:36full time faculty
• 03:37in twenty twenty two.
• 03:39He was subsequently promoted to
• 03:40associate professor of medicine earlier
• 03:42this year.
• 03:43In addition to his roles
• 03:44in medicine, David's careers
• 03:47career experience spans roles in
• 03:48technology, education, the arts, and
• 03:50He has written on these
• 03:51topics
• 03:52in a variety of venues,
• 03:53including the New England Journal
• 03:54of Medicine,
• 03:55JAMA Healthcare, and has published
• 03:57his work in books and
• 03:58other media formats.
• 04:00His documentary
• 04:01film entitled witnessing death, a
• 04:03grandson's reflection on Alzheimer's
• 04:05has been shown widely across
• 04:06the country, and this gives
• 04:07you a little hint that
• 04:09David has a skill set
• 04:10as a filmmaker. You're gonna
• 04:12be hearing more about that
• 04:13today with his new project.
• 04:16So this week, he'll be
• 04:17delivering a presentation entitled work
• 04:19in progress,
• 04:20the primary care squeeze. David,
• 04:24the podium is yours.
• 04:26Thank you very much.
• 04:28Thank you all for coming
• 04:29in person, and it looks
• 04:30like we have, hopefully, a
• 04:31bunch of people online. We
• 04:33do indeed.
• 04:35So really excited to be
• 04:37here. Let's see if this
• 04:38switches over.
• 04:40I have a number of
• 04:40roles and I'm really excited
• 04:42to be back here in
• 04:43front of a very friendly
• 04:44audience here at Yale. I
• 04:46have a couple of different
• 04:47hats.
• 04:48I will just say I
• 04:49have a bunch of disclosures
• 04:50as an advisor, consultant,
• 04:52shareholder, or even an investor
• 04:53in a bunch of things
• 04:54that are pretty not relevant
• 04:56to what we're gonna talk
• 04:57about.
• 04:58The bottom though, I do
• 04:59get grants for this film.
• 05:00I'm gonna show a thirty
• 05:01minute cut from two organizations
• 05:03I just like to highlight.
• 05:04The Gimme a Luth Casita
• 05:05of Greater New York and
• 05:06the Minky Family Funds who
• 05:08have supported this this work.
• 05:11So the last time,
• 05:12in front of you, this
• 05:13group
• 05:14was a few years ago.
• 05:16And the two things that
• 05:17I remember from the previous
• 05:19ones, one was about tackling
• 05:20the innovation chasm, where I
• 05:22sort of was talking about
• 05:23some of the innovation work
• 05:24here at Yale,
• 05:25broadly with the work that
• 05:27we do at,
• 05:28Center for Biomedical Innovation and
• 05:30Technology or Yale CBET, where
• 05:32I'm a,
• 05:33I have a role, which
• 05:34is now part of Yale
• 05:35Ventures, and we do a
• 05:36lot of hackathons.
• 05:38And then before that, the
• 05:39previous one was about our
• 05:40home induction
• 05:41buprenorphine app, which still exists,
• 05:44for those of you who
• 05:45are interested,
• 05:46in learning how as a
• 05:47clinical decision support tool for,
• 05:50prescribing buprenorphine starting people on
• 05:52that first seven days. It
• 05:53still exists in the App
• 05:54Store.
• 05:55And,
• 05:57you know, today, just briefly
• 05:59I mean, I think Patrick
• 06:00mentioned it, but just for
• 06:02the relevant folks who don't
• 06:03know me, you know, I
• 06:04actually started as a documentary
• 06:05filmmaker.
• 06:07I was
• 06:09fell into filmmaking at, as
• 06:11an undergraduate at Harvard, studied
• 06:13visual environmental studies,
• 06:15and ended up,
• 06:17in interviewing and doing work
• 06:18for a documentary about my
• 06:20grandfather and Alzheimer's.
• 06:21Got really interested in neuroscience
• 06:24and and medicine, and,
• 06:26did some work in patient
• 06:28narratives,
• 06:29for a few years and
• 06:30actually,
• 06:31worked on a a a
• 06:33book chapter about using film
• 06:34to teach, medical ethics, which
• 06:36is called the picture of
• 06:37health.
• 06:38And then,
• 06:40this sort of meandering generalist
• 06:42view
• 06:44through medical school got really
• 06:46interested in digital
• 06:47health and IT at Northwestern
• 06:49in Chicago. And,
• 06:51in between med school and
• 06:52residency, started a company called
• 06:54Keyas with the head of
• 06:55Google Health and then was
• 06:56working with some of those
• 06:57groups out in California, the
• 06:58Journal of Participatory Medicine
• 07:00and a group called LodgeNet.
• 07:02And then kind of got
• 07:03interested in primary care. You're
• 07:04gonna see this weird journey.
• 07:06When I went to the
• 07:07Brigham and did some work
• 07:08at IDEO and, Harvard Business
• 07:10School, thinking about primary care
• 07:12redesign and human centered design,
• 07:15then came here,
• 07:17thirteen years ago and, had
• 07:19the privilege to be on
• 07:20the faculty and join the
• 07:21the amazing folks. Hopefully, many
• 07:23are are joining from the
• 07:24VA,
• 07:25helping to really start
• 07:28a new program,
• 07:29the HPAC program at the
• 07:31Arrerra Center,
• 07:33with
• 07:34supportive
• 07:35faculty and supportive,
• 07:37colleagues in primary care and
• 07:39in mental health.
• 07:41And,
• 07:42I think from that, I
• 07:43I you know, I'm trying
• 07:44to remember what happened first.
• 07:45There was then there was
• 07:46COVID that happened.
• 07:48And, there was this weird
• 07:50time for all of us
• 07:51about five years ago,
• 07:54and, you know, I think
• 07:55it was a it was
• 07:56a change for a lot
• 07:57of us. And for me,
• 07:58it kinda made me rethink
• 07:59about sort of the next
• 08:01kind of things that I
• 08:02wanna learn and the next
• 08:03things for growth. And so
• 08:04for a couple months, I
• 08:05was working at the,
• 08:07mayor's office. We deployed from
• 08:09the VA to go help
• 08:10with their COVID response, and
• 08:11we started up this career
• 08:13high school facility, a sixty
• 08:15bed facility for homeless individuals
• 08:17who are experiencing COVID in
• 08:18a medical respite there.
• 08:20And then when that was
• 08:21over, I realized I couldn't
• 08:22go back to my normal
• 08:23job at the VA. Not
• 08:24that I couldn't, but it
• 08:25just things needed to evolve.
• 08:28And so in the evolution,
• 08:30I got recruited away to
• 08:31this group called four catalyzer,
• 08:33which is really focused on
• 08:34sort of democratizing,
• 08:36medical devices. They've got a
• 08:38couple public companies. Butterfly Ultrasound
• 08:40is the one that's most
• 08:41well known. There's a new
• 08:42one called Hyperfine, which is
• 08:44FDA approved in our hospital,
• 08:45which has built a portable
• 08:47MRI product.
• 08:48And, I'll explain I'll take
• 08:50two seconds just before we
• 08:51show the the the film
• 08:53days to talk about one
• 08:54of the projects I'm working
• 08:55on with that group.
• 08:57And then as Patrick said,
• 08:59I came back. I realized
• 09:00that doing that full time
• 09:02in industry was not, you
• 09:04know, going from homelessness care
• 09:05and the VA to full
• 09:07time industry and Wall Street
• 09:08stuff did not,
• 09:10sit well,
• 09:11internally with my value system,
• 09:12and so I have come
• 09:13back.
• 09:14And so, you know, for
• 09:15the last really, two and
• 09:17a half years back on
• 09:17the faculty or three years,
• 09:19I've sort of had this,
• 09:20what I call as a
• 09:21portfolio approach to career where
• 09:23I'm seeing patients at Cornell
• 09:24Scott,
• 09:25with residents and in the
• 09:26hospital here at York Street
• 09:27as well as at the
• 09:28VA,
• 09:29and doing some work as
• 09:30an investor at a group
• 09:31called AllyCorp,
• 09:33which is a venture
• 09:34capital company in New York.
• 09:36And then, for the last
• 09:37three years, I'll I'll talk
• 09:38about the work I'm doing
• 09:39at the Aspen Institute, and
• 09:40that's what this talk is
• 09:41gonna be about, that venture.
• 09:43Okay. So just a quick
• 09:45update, and then I'm gonna
• 09:45get to the film in
• 09:46a second here on the
• 09:47medical device work. So how
• 09:48it started was seven years
• 09:50ago through
• 09:51the CBIT hackathon. You can
• 09:52see there. I'm a part
• 09:53of this group called IAI,
• 09:55which we won second place
• 09:56at the hackathon for an
• 09:58idea about using the retina
• 09:59as a new platform for
• 10:00biomarker
• 10:01development.
• 10:03We won a little bit
• 10:03of a check. And if
• 10:04you can see interestingly in
• 10:05the corner of that screen,
• 10:07the front the, over here,
• 10:09it's for catalyzer. And so
• 10:10I met one of the
• 10:11folks,
• 10:13ended up realizing that we
• 10:14couldn't start a company here
• 10:15within Yale, and so we
• 10:17ended up starting that company
• 10:18outside of Yale through the
• 10:19Fort Catalyzer network.
• 10:21And we were able to
• 10:22raise a lot of money
• 10:23in twenty twenty one. So
• 10:24we raised twenty eighty million
• 10:25dollars for that company
• 10:27at that time, and I
• 10:28joined as when I joined
• 10:29as a chief medical officer.
• 10:31And I'll just mention it
• 10:32only because how it's going
• 10:33last week. Little plug, and
• 10:35I have to be careful
• 10:35of my conflicts of interest
• 10:37that we did launch our
• 10:38retinal screening platform for diabetic
• 10:39retinopathy last week.
• 10:41So if anybody's interested,
• 10:43I will say they are
• 10:44actively looking for implementation partners
• 10:46for diabetic retinopathy screening in
• 10:48primary care settings.
• 10:49For conflict of interest reasons,
• 10:50I need to stay at
• 10:51arm's length, but this is
• 10:52the device that we created.
• 10:55And it's a, FDA cleared
• 10:56medical device.
• 10:58And you can reach out
• 10:59to the CEO, Vicky, who's
• 11:01wonderful.
• 11:02Last little plug is, on
• 11:04September twenty fifth, for those
• 11:05people who are interested through
• 11:06Yale Ventures and CBIIT, we
• 11:07have our Yale Health
• 11:09Tech pitch night,
• 11:11which is coming up at
• 11:12one zero one College Street.
• 11:13This is a picture from
• 11:14last year. You're gonna scan
• 11:16those cards. There's a couple
• 11:17different activities we have throughout
• 11:19the fall.
• 11:20But if anyone wants to
• 11:21pitch, they can reach out
• 11:22to Michelle Nantel.
• 11:24And these are quick pitches,
• 11:25three minute pitches of an
• 11:27idea and looking for help.
• 11:28Right? I need help. I
• 11:29need business school folks. I
• 11:31need engineers to help build
• 11:32an idea.
• 11:33I have an idea. I
• 11:34have a pain point. I'd
• 11:35like someone to help me
• 11:36solve it. And that's and
• 11:37we have a lot of
• 11:37students who come to that
• 11:38to come help. So and
• 11:40then we have our large
• 11:41health care hackathon in January.
• 11:43Okay.
• 11:44So today, I'm gonna talk
• 11:45about something very different.
• 11:47In some ways, I'm gonna
• 11:48go back to our my
• 11:49original roots as a filmmaker
• 11:51because because I still haven't
• 11:51lost that, and I'll explain.
• 11:53So the learning objectives are
• 11:54quickly to just talk about
• 11:55the historical and structural factors
• 11:57contributing to the underinvestment in
• 11:59primary care, which I think
• 12:00will be relevant to this
• 12:02group, deconstruct the strategies employed
• 12:03to translate a complex bureaucratic
• 12:05and often opaque health care
• 12:07system into an engaging and
• 12:08accessible film noir narrative,
• 12:10and maybe analyze a documentary's
• 12:12role as an investigative tool
• 12:13and a catalyst for systemic
• 12:15change,
• 12:16aiming beyond mere information dissemination
• 12:18influence public perception and policy.
• 12:20And so the origin of
• 12:21this was a confluence of
• 12:22three things. One was I
• 12:23was doing this Aspen Institute,
• 12:26fellowship venture project.
• 12:28So as part of this
• 12:28fellowship, I had to come
• 12:29up with something that was
• 12:30uniquely something that I was
• 12:32interested in and skilled at
• 12:33and passionate about.
• 12:35It could be a for
• 12:36profit, a nonprofit, could be
• 12:37an arts thing.
• 12:38And through that
• 12:40making process or thinking process,
• 12:42I realized I had to
• 12:43do a film.
• 12:45That was something that I
• 12:46still sort of I feel
• 12:47like is an important way
• 12:48to disseminate information in a
• 12:50unique way.
• 12:51It's also I have a
• 12:53deep friendship,
• 12:54with I'll talk about in
• 12:55a second with, and then
• 12:56three important publications that are
• 12:58relevant.
• 12:59So first was this Aspen
• 13:00Institute HIF Fellowship or the
• 13:01Health Innovations Fellowship. So I
• 13:03was in the class six,
• 13:05go sixers from twenty twenty
• 13:06two to twenty twenty four.
• 13:07The only, I think, other
• 13:09Yale person who's in the
• 13:10fellowship was, Megan Rainey, who's
• 13:12now the dean here at
• 13:14Public Health School.
• 13:15And it's a pretty amazing
• 13:16group of people. There's about
• 13:18a hundred and fifty of
• 13:18us now around the country,
• 13:20a network that's really doing
• 13:21incredible work all over the
• 13:23place.
• 13:24And so I mentioned the
• 13:25venture that we needed to
• 13:27create as well, and so
• 13:28that was the impetus for
• 13:30this film.
• 13:32This deep twenty five year
• 13:33friendship that I've had with
• 13:34a a friend of mine
• 13:35and a filmmaker collaborator who's
• 13:37a professor,
• 13:38associate professor at Miami University
• 13:40in Ohio, he and I
• 13:42started making films together, at
• 13:44Harvard,
• 13:45in film classes. We then
• 13:46worked together as a film
• 13:47production company a little bit
• 13:48after college.
• 13:50We made a TV pilot
• 13:51for a travel channel,
• 13:53and he does tremendous documentary
• 13:55work,
• 13:57Really sort of interesting things
• 13:59around performative
• 14:00documentaries and reenactments,
• 14:02and that will come up
• 14:03in the film that you
• 14:04will see the preview.
• 14:06And we had been noodling
• 14:08on ideas that we said
• 14:09we, you know, he doesn't
• 14:10know anything about health care
• 14:11except that it costs a
• 14:12lot.
• 14:13And then there were these
• 14:14three important publications that kept
• 14:16coming back into my, into
• 14:18the brain and and one
• 14:19is Elizabeth Rosenthal's An American
• 14:21Sickness,
• 14:22which is how health care
• 14:23became big business and how
• 14:24you can take it back.
• 14:26The other is this book
• 14:27that most people haven't heard
• 14:28of, which is fixing medical
• 14:29prices, how physicians are paid,
• 14:32by Miriam Logison, who's at,
• 14:34public is at Columbia on
• 14:35faculty.
• 14:36And then more recently,
• 14:38a publication in twenty twenty
• 14:39one that kinda got buried
• 14:41in its announcement because it
• 14:42was COVID time by the
• 14:44National Academy,
• 14:46called Implementing High Quality Primary
• 14:48Care,
• 14:49Rebuilding the Foundation of Health
• 14:51Care. And,
• 14:53you know, it came to
• 14:53this idea that, you know,
• 14:55as a primary care doc
• 14:56and for most of the
• 14:56folks in this room who
• 14:57are doing general internal medicine,
• 15:00it comes down to this
• 15:01idea of, like, how do
• 15:02what do we value in
• 15:03health care?
• 15:04And,
• 15:06I was walking one day
• 15:07next to Smilow Cancer Center
• 15:08right out front, and you
• 15:10look at this beautiful building,
• 15:12gorgeous,
• 15:13right? Glass,
• 15:14beautiful building
• 15:16that we have constructed for
• 15:19folks who are experiencing cancer.
• 15:21And then you look literally
• 15:22across the street at the
• 15:23Connecticut Mental Health Center,
• 15:26and you see that.
• 15:27And you just say, what
• 15:29are we valuing?
• 15:30What have we done in
• 15:32this country, and what is
• 15:33the underlying reason for that
• 15:35structural
• 15:36difference. And when you start
• 15:37asking five levels deep, why
• 15:38does this happen and why
• 15:39does this happen and why
• 15:41is that the case?
• 15:43You get to some really
• 15:44uncomfortable conclusions.
• 15:46And that's what this documentary
• 15:48is about.
• 15:50And I was in many
• 15:50ways inspired by,
• 15:52Al Gore's work in An
• 15:53Inconvenient Truth
• 15:55because
• 15:56what wasn't a really wonky
• 15:58film, something that's really kinda
• 15:59hard policy to digest, he
• 16:01made it very,
• 16:03translatable and digestible by a
• 16:04general public and audience.
• 16:06So
• 16:07with that said, that's the
• 16:09point of this film.
• 16:10I'm gonna just show real
• 16:11quick. This is rough cut.
• 16:13I literally got it this
• 16:14at twelve fifteen in the
• 16:16morning last night from my
• 16:17from my friend Andy in
• 16:18Ohio.
• 16:19It represents some ideas we're
• 16:21working on. I'd love any
• 16:23gut reactions, good, bad, ugly,
• 16:25clear, unclear.
• 16:26There's gonna be rough things
• 16:27that you're gonna see, some
• 16:28black stuff, you know, in
• 16:29terms of, like, cuts and
• 16:30jump cuts. The goal is
• 16:32to handle a wonky topic,
• 16:33educate a little, entertain a
• 16:35little bit, but definitely, we
• 16:37want the general audience to
• 16:38care.
• 16:40We've done this with about
• 16:41eighteen thousand dollars,
• 16:42money. We've filmed about a
• 16:44hundred hours so far over
• 16:45the last two years,
• 16:47and we're gonna show about
• 16:48thirty minutes. We think it's
• 16:49gonna be probably ninety minutes
• 16:50eventually when it's done. We're
• 16:51not sure. It could be
• 16:52longer. It could be a
• 16:53docuseries. But, anyway,
• 16:56that's what I'm gonna do.
• 16:57So I'm gonna stop and
• 16:58switch over,
• 16:59and, hopefully, you'll be a
• 17:00little entertained here. So so
• 17:01if I share screen,
• 17:05I'll go replace
• 17:06current share
• 17:08with time player.
• 17:11Okay. And, hopefully thank you
• 17:13so much.
• 17:14This shall work.
• 17:17Alright. And, actually, can we
• 17:18dim the lights in here?
• 17:20We can't.
• 17:21We can turn them off.
• 17:22Stop share. What's that? Stop
• 17:24share. Stop share for a
• 17:25second. Okay.
• 17:26Then share. Yep.
• 17:29For sure.
• 17:31There we go. Okay.
• 17:33Yeah. The lights. Okay. Here
• 17:35we go.
• 17:37It's a good day in
• 17:38New Haven, Connecticut.
• 17:41I'm a primary care doctor
• 17:43who teaches at Yale Medical
• 17:44School.
• 17:45And today,
• 17:46I get to see my
• 17:47students become doctors.
• 17:49So this is the town
• 17:50green of New Haven.
• 17:52A lot of our patients
• 17:53will go here because it's
• 17:54a safe space, certainly at
• 17:55night, during the day,
• 17:57to be around other people.
• 17:59For the past decade, I've
• 18:00been a primary care doctor
• 18:02for veterans experiencing homelessness
• 18:04and now care for a
• 18:05diverse population of adults at
• 18:07a federally qualified health center
• 18:08in Connecticut.
• 18:11The US needs more doctors,
• 18:13especially those who choose to
• 18:14work in primary care.
• 18:16We're often the first doctors
• 18:18you see when you get
• 18:19sick, need a vaccine,
• 18:21or when you or your
• 18:22loved one needs help managing
• 18:24complex problems over time.
• 18:26We build relationships with patients
• 18:27over years.
• 18:29Move down, move down, move
• 18:30down.
• 18:32Ideally, about fifty percent or
• 18:34more of these a hundred
• 18:35and three talented students would
• 18:37go into primary care fields.
• 18:38I need a couple of
• 18:39people to
• 18:41Thank you. Yeah. Nice to
• 18:42see you. So nice to
• 18:43see you so much for
• 18:43doing this. For you. But
• 18:45this year, there are only
• 18:46three going into primary care
• 18:47fields, Lina and Akhil here
• 18:49and Jessica. So I'm Jessica
• 18:50Cedrena. I'm originally from North
• 18:52Jersey, right outside New York
• 18:53City, and I am going
• 18:54into family medicine at Middlesex
• 18:55Hospital. And there's so much
• 18:57of a need for primary
• 18:58care physicians. In family medicine,
• 18:59I feel so convinced. It's
• 19:00just like the heart and
• 19:02soul. We get to see
• 19:04babies when they're born. We
• 19:05get to care for moms
• 19:06when they're producing those babies.
• 19:07We get to see older
• 19:09folks when they're, you know,
• 19:10at the end of their
• 19:11life. I think we all
• 19:12come in bright eyed and
• 19:13bushy tailed to some degree.
• 19:15I think we all have
• 19:16some sort of sobering exposure
• 19:17to the medical system. But
• 19:18to see it play out
• 19:19in the hospital can be
• 19:20can be really disheartening.
• 19:22The reason isn't exactly a
• 19:23mystery.
• 19:25I actually remember having a
• 19:26resident in the clinic who
• 19:27said, I love this. I
• 19:28will do this, but I
• 19:29have two hundred fifty thousand
• 19:31dollars in debt.
• 19:32The students were actually making
• 19:33a rational choice.
• 19:35They were seeing
• 19:37how hard it is to
• 19:38do primary care well
• 19:40in the current environment.
• 19:42They were
• 19:44seeing that other choices,
• 19:46choices of other specialties could
• 19:47lead them to a career
• 19:48with more prestige
• 19:50and certainly more money. There's
• 19:52this story in here or
• 19:53a lesson in here for
• 19:54gender equity, but beyond that,
• 19:55it actually says a lot
• 19:56about how backwards and and
• 19:59insufficient fee for service payment
• 20:00is. Right? Because not just
• 20:02women, all PCPs, all doctors
• 20:04want more time with their
• 20:05patients.
• 20:07Residents are often,
• 20:09placed into situations where they
• 20:12are caring for really complex
• 20:14patients both medically and biopsychosocially,
• 20:17and oftentimes with limited
• 20:19resources.
• 20:20The National Academy of Sciences,
• 20:22Engineering, and Medicine committee thought
• 20:24a lot about whether there
• 20:26was even a need for
• 20:27another primary care report. There
• 20:29had been one
• 20:30in nineteen ninety six. It
• 20:32had thirty something recommendations.
• 20:35Very little had been implemented
• 20:37from the report.
• 20:38And the bigger structural problems
• 20:40aren't exactly a mystery either.
• 20:43Costa Rica
• 20:44has a single public payer,
• 20:47spends about nine hundred dollars
• 20:48per person per year on
• 20:50health care.
• 20:52And they have a life
• 20:53expectancy
• 20:54of eighty one or eighty
• 20:55two, which is way higher
• 20:57than the US,
• 20:59that spends about twelve thousand
• 21:00a year on health care
• 21:02per person.
• 21:04But given that so many
• 21:05other countries have figured out
• 21:06how to provide health care
• 21:07more effectively for less money,
• 21:10the question is why? Why
• 21:11does the US pay five
• 21:12thousand dollars per person more
• 21:14than any other wealthy country
• 21:16for results that consistently rank
• 21:17around thirtieth?
• 21:19I was gonna build a
• 21:20new primary care practice from
• 21:22scratch.
• 21:23As we grew, we started
• 21:24getting a little press coverage.
• 21:25And then, maybe as not
• 21:28unexpectedly,
• 21:29we started getting opposition.
• 21:31I got a call from
• 21:32the CEO of the health
• 21:33plan that they wanted to
• 21:34meet with me and said,
• 21:35we hear about this practice
• 21:36you're doing. Yeah. I don't
• 21:38like it. I was like,
• 21:39why?
• 21:40And he said, well, patients
• 21:41might think
• 21:42you're working for them and
• 21:44not for me.
• 21:47And while health care is
• 21:48complicated, it turns out that
• 21:50the answer might not be.
• 21:52We just need to follow
• 21:53the
• 21:54money. And now the problem
• 21:55with Medicare,
• 21:56in general, it's got a
• 21:57fee schedule. It's fee for
• 21:59service. And that fee schedule
• 22:00is set by congress, a
• 22:01thing called the RUC. And
• 22:02by the way, it completely
• 22:03undervalues primary care. Have you
• 22:05heard of the RUC? No.
• 22:06No. No. Do you know
• 22:07what the RUC is? Have
• 22:08you heard of the RUC?
• 22:08I have not heard of
• 22:09the Ruck. Okay. Alright. Imagine
• 22:11that's next in my residency.
• 22:12Have you heard of something
• 22:13called the Ruck?
• 22:15No. I haven't heard of
• 22:16the Ruck. What's the Ruck?
• 22:18That committee has a lot
• 22:19of power.
• 22:19The Ruck is a secretive
• 22:22committee of the AMA
• 22:24that has thirty one members,
• 22:26and twenty six of them
• 22:27are specialists and the other
• 22:29five are primary care.
• 22:31They said, we'll we'll put
• 22:32together this group for you,
• 22:34and we'll figure out the
• 22:35value of every medical procedure
• 22:38with a coefficient that became
• 22:40relative value units.
• 22:42Do the multiplication
• 22:44and that's how you get
• 22:44the money. It became a
• 22:46horse trading operation.
• 22:48It's completely opaque.
• 22:50You can't attend a meeting.
• 22:53And if you do attend
• 22:54a meeting, you've got to
• 22:55sign a nondisclosure
• 22:56agreement that you can never
• 22:58talk about anything that happened
• 22:59at the meeting.
• 23:00It's a star chain. Be
• 23:02because of the structure of
• 23:03it, it adds about a
• 23:04trillion dollars a year extra.
• 23:07And the goal is to
• 23:08get people around primary care
• 23:10directly to the more lucrative
• 23:12services
• 23:13in the specialties
• 23:14specialty sector. What is a
• 23:16star chamber?
• 23:17Or A star chamber is
• 23:19a small group of people
• 23:21who who have control
• 23:23invisibly
• 23:24over an immense operation.
• 23:26And this is why nobody
• 23:28else in the world can
• 23:29understand why the American
• 23:31system is built like it
• 23:33is.
• 23:34It's just because it's crazy.
• 24:26Where's the other part to
• 24:27the if this is trachea
• 24:29or is it the bronchus?
• 24:30I won't see the rest
• 24:32of it. That's okay.
• 24:35How was your night?
• 24:37Yes. Why do we start
• 24:38every day with the same
• 24:40words? Can you guys say
• 24:41it with me? Ready? Today.
• 24:43Today.
• 24:44Today. Not tomorrow.
• 24:46Thank you.
• 24:47Hi, everybody. You can call
• 24:48me doctor Jazz. I am
• 24:50a pediatrician,
• 24:51and I'm excited to share
• 24:52with you guys today all
• 24:53about the respiratory system. When
• 24:55I think about Black MedConnect,
• 24:56I think more of the
• 24:58pre meds, medical students, and
• 25:00upwards, you know, residents, fellows,
• 25:01attendings. But iDream is all
• 25:03about the younger generation. So
• 25:05college students, high school students,
• 25:07getting them excited about health
• 25:08care.
• 25:09One thing is missing is
• 25:10there's a lack of role
• 25:11models.
• 25:12When you don't have enough
• 25:14black and brown professionals around,
• 25:15that means communities
• 25:17don't necessarily have role models
• 25:18to show the younger generation
• 25:20what it's like to be
• 25:20in medicine.
• 25:22Exactly. So we got a
• 25:23dilemma going on. Right?
• 25:25Michelle was just going to
• 25:26visit family.
• 25:28A new cat shows up,
• 25:30and now she's having trouble
• 25:31breathing. Right? What do we
• 25:32think is going on?
• 25:35She
• 25:37allergic to cats. Here we
• 25:37go. She's allergic to cats.
• 25:38That's what
• 25:40it sounds like. That's what
• 25:40it sounds like. Sounds like
• 25:42a.
• 25:43I'm trying to keep listening.
• 25:44Yeah. See what's going on.
• 25:49Y'all hear that?
• 25:51That's what it sounds like.
• 25:53It sounds like an elephant.
• 25:55Right? Yeah. Very
• 25:57really rough sound. Right?
• 26:01What's the name of that
• 26:02sound? We already talked about
• 26:03it a little bit. Go
• 26:04ahead.
• 26:05It's wheezing. Right? That weird
• 26:07whistling noise,
• 26:09that's wheezing.
• 26:10Right? And
• 26:11why is Michelle short of
• 26:13breath and wheezing?
• 26:14She was diagnosed with a
• 26:16asthma attack.
• 26:18I'll tell you a little
• 26:19secret. That's Michelle is me.
• 26:22My auntie had a cat
• 26:23that she brought home for
• 26:24Christmas, and then I got
• 26:26sick and had to go
• 26:26to the hospital. Right? This
• 26:28is how I found out
• 26:29I had asthma.
• 26:30And so some patients find
• 26:32out when they're really little,
• 26:34some patients find out a
• 26:35little bit older, but ultimately,
• 26:37the coughing and the wheezing
• 26:38and the shortness of breath
• 26:40is what really challenged my
• 26:41asthma. Does anybody here have
• 26:42asthma? Do you mind sharing?
• 26:44Being with an asthmatic, I
• 26:46remember missing about a week
• 26:47of school, almost every year
• 26:49for a while in elementary
• 26:50school. So being home with,
• 26:52you know, nebulizer treatments every
• 26:54few hours, my parents were
• 26:56being respiratory therapists and didn't
• 26:58know it.
• 26:59And so, for me, that
• 27:01really connected me to
• 27:02the pediatricians, and that's why
• 27:04I chose pediatrics because I
• 27:05knew they have a huge
• 27:07impact on kids. They really
• 27:08do. It doesn't feel so
• 27:09good. You had a you
• 27:11have asthma too? Tell me
• 27:12what it feels like for
• 27:13you. It kinda feels like
• 27:15something's clogged kinda in my
• 27:17throat.
• 27:17Mhmm. And and it feels
• 27:20weird.
• 27:21It does. Right? Like, your
• 27:22airways and narrow Wanna be
• 27:23a pediatrician
• 27:25because I like kids.
• 27:27And,
• 27:29and I don't really wanna
• 27:30be, like a surgeon because
• 27:31it would scare me.
• 27:34So now we're gonna use
• 27:35our stethoscope. Who's who's fair
• 27:37enough?
• 27:38We're gonna listen to each
• 27:39other's lungs. Okay?
• 27:42As an African American woman
• 27:43seeing, you know, the disparities
• 27:45in health, always wanted to
• 27:47think about how can we
• 27:48improve upon those, and I
• 27:49think
• 27:50increasing the diversity within the
• 27:51workforce is one way in
• 27:52which to do that.
• 27:54I worry that, especially with
• 27:56even urban and rural, that's
• 27:58a huge thing. There's a
• 27:59lot of rural counties that
• 28:00don't have enough primary care.
• 28:03I think some of the
• 28:04solutions to that are making
• 28:05sure you're reaching back into
• 28:06those communities at a young
• 28:08age, hence I dream to,
• 28:09like, get them excited about
• 28:11medicine. And a lot of
• 28:12times, they wanna return to
• 28:14their communities because they know
• 28:15the disparities that exist there.
• 28:17Oh my god. Hard. Sounds
• 28:19weird?
• 28:20Yes.
• 28:46Nice out. So in here,
• 28:47we got to see all
• 28:48of the Medical College of
• 28:49Georgia. Yes. Okay. CPC was
• 28:51started thirty years ago, and
• 28:53we have grown to, I
• 28:54wanna say, eight offices.
• 28:56We are the primary care
• 28:58provider for this area.
• 29:00The building and the layout
• 29:01was sort of the brainchild
• 29:03of my dad's.
• 29:05How many providers
• 29:07of these? Thirty ish. Thirty
• 29:09ish? Mhmm. In this space
• 29:11or across No. No. No.
• 29:12Across all the offices, eight
• 29:13offices. So we're in, the
• 29:15CSRA, which encompasses north and,
• 29:17North Augusta,
• 29:19South Augusta.
• 29:21So we're in South Carolina
• 29:22and Georgia and all the
• 29:22spaces in between. Okay. Yeah.
• 29:24Which I guess was, like,
• 29:25almost fifty thousand maybe. That's
• 29:26a lot of people. Okay.
• 29:27That's a lot of people.
• 29:29As a kid, I,
• 29:31was employed at CBC.
• 29:33I did filing a patient
• 29:35charts back when we had
• 29:36paper charts.
• 29:38I wrote the newsletter. So
• 29:39it's what is sun care?
• 29:41How do you look for
• 29:42skin cancer?
• 29:43Yeah. I've basically grew up
• 29:45in this clinic. I've known
• 29:47people here for a very
• 29:48long time. It's funny when
• 29:49I have patients who used
• 29:51to see dad who see
• 29:52me now,
• 29:54because they will call me
• 29:55Shereen, but to them, I'm
• 29:57doctor Moore.
• 29:58But, you know,
• 30:00he told them about my
• 30:01potty training and when I
• 30:02went to college and all
• 30:03these sort of things. So
• 30:04they have a long history
• 30:06of who I was before
• 30:07I was doctor Moore. So
• 30:14Around the dinner table,
• 30:16we,
• 30:18play difficult diagnosis every night.
• 30:20You know, and this is
• 30:21a thirty seven year old
• 30:23woman that comes in complaining
• 30:24of,
• 30:25being tired all the time.
• 30:27And
• 30:28it was just fun to,
• 30:32see her develop as a
• 30:34diagnostician.
• 30:35But, you know, after she
• 30:37was
• 30:38in high school, she was
• 30:39making all these, you know,
• 30:42great
• 30:56which
• 30:57would be I think,
• 30:59an unusual thing to figure
• 31:01out, you know, in high
• 31:02school.
• 31:06Do you have a shirt
• 31:07that says I suit the
• 31:08rock?
• 31:08Do you have that here?
• 31:10Do you have that here?
• 31:11No. I have four of
• 31:12them. You have four of
• 31:12them. You can take one
• 31:13off. To see one.
• 31:15I mean, I have a
• 31:16lot of show and tell
• 31:17things we
• 31:19Oh, man.
• 31:25Somewhere.
• 31:27I ended up in court
• 31:28with RJ Reynolds for two
• 31:30and a half, three years.
• 31:32At the time, my,
• 31:34son was about three
• 31:36and I took him out
• 31:37to dinner one day and
• 31:39he was taking his straw
• 31:41and playing with it and
• 31:42he pretended to smoke it
• 31:43and I said, what are
• 31:44you doing? And he said,
• 31:45dad, when I grow up,
• 31:46I wanna be a man.
• 31:47I wanna drive fast cars
• 31:48and I wanna smoke cigarettes.
• 31:50And in my mind, that
• 31:52really crystallized,
• 31:54something that I had never
• 31:55thought about before because most
• 31:57of our research had been
• 31:58looking at teenagers.
• 32:00The two biggest studies that
• 32:02we did, one was where
• 32:03we used eye tracking and
• 32:04we had children looking at,
• 32:06advertisements.
• 32:08And in particular, did they
• 32:09look at the surgeon general's
• 32:10warning or not?
• 32:12That pretty conclusively showed that
• 32:13the warnings were ineffective.
• 32:16Most people would have guessed
• 32:17that, but it was the
• 32:18first time that it was
• 32:19documented in a really thorough
• 32:21way.
• 32:21The other tobacco study that
• 32:23got a lot of attention
• 32:24was we had
• 32:26three, four, and five year
• 32:27old children play a game,
• 32:31match logos from products
• 32:33with the products themselves.
• 32:38Most amazing children as young
• 32:41as three were able to
• 32:42match the old joke character
• 32:44with a cigarette and by
• 32:46age,
• 32:47five, they were universally able
• 32:49to make that match And
• 32:50that was equivalent
• 32:52to their ability to match
• 32:53the Disney logos with, Mickey
• 32:55Mouse.
• 32:57That led to a great,
• 33:00deal of attention
• 33:05And eventually to the lawsuit
• 33:07against the tobacco industry.
• 33:10The tobacco industry came after
• 33:12me and and the research.
• 33:16The medical school
• 33:17felt they were obligated to
• 33:19do what the attorney general
• 33:20for the state of Georgia
• 33:21told them to do, which
• 33:22was to side with the
• 33:23tobacco company rather than me.
• 33:26And that was pretty uncomfortable
• 33:28time for me, and I
• 33:29decided that I would leave
• 33:31the medical school. So Augusta
• 33:33was a community that needed,
• 33:35primary care, and I said,
• 33:37I'm a primary care doctor.
• 33:38I can do that. So
• 33:39I opened up a solo
• 33:40practice.
• 33:42Being a family doctor or
• 33:44primary care doctor is one
• 33:45of the most rewarding things
• 33:46in the world to do.
• 33:47I mean, I still hear
• 33:48from my patients. I mean,
• 33:50as when you care for
• 33:51people for a long time,
• 33:52save their life. You know,
• 33:53I've saved many people's lives.
• 33:57And they I mean, clearly,
• 33:58I know it. They know
• 33:59it. Their family knows it.
• 34:01And so those are kind
• 34:02of relationships that,
• 34:06go on forever. I mean,
• 34:07I got a whole stack
• 34:08of letters and cards when
• 34:10I left practice.
• 34:14Dad, mom, and I are
• 34:15forever grateful for the care
• 34:17you have provided us over
• 34:18the last twenty five plus
• 34:19years.
• 34:21You have been my physician
• 34:22for eight years, and I'm
• 34:23not sure many people can
• 34:24say this, but I enjoy
• 34:26going to the doctor.
• 34:27You have always been precise,
• 34:29kind, and compassionate to our
• 34:30family. We are thankful for
• 34:32your treatment, care, and advice
• 34:34during the past twenty years.
• 34:36I can't believe eighteen years
• 34:38have passed with you as
• 34:39my physician, The best doctor
• 34:41anyone could have. You have
• 34:42been a great listener, guide,
• 34:44doctor, and more.
• 34:46You are the epitome of
• 34:47what we call the old
• 34:48time doctor. Your immediate attention
• 34:50and referral for doing a
• 34:52stress test were instrumental in
• 34:53saving my life.
• 34:55I appreciated your advice or
• 34:57sometimes drastic help, like doctor's
• 34:59hospital two thousand seven to
• 35:01ER with sepsis pneumonia that
• 35:03you detected and saved my
• 35:05life. It was you who
• 35:06diagnosed my myeloma
• 35:08and referred me to doctor
• 35:09Hudson for treatment.
• 35:11Thank you for saving my
• 35:12life. Thank you for being
• 35:13our doctor and friend.
• 35:17People wanna be family doctors.
• 35:19They love
• 35:20taking care of patients. They
• 35:21love being loved by their
• 35:23patients. If it wasn't for
• 35:24that, in America, nobody would
• 35:26be a primary care doctor.
• 35:28I've been practicing medicine thirty
• 35:30years before I I heard
• 35:31of the RUC,
• 35:32and that whole time, I
• 35:34felt and understood
• 35:37the fact that primary care
• 35:39was
• 35:40not a valued service in
• 35:42our health care system.
• 35:44I was at a CDC
• 35:46meeting, and one of the
• 35:48speakers was Brian Klepper.
• 35:50He talked about the rock.
• 35:53And I just said, this
• 35:54is this is wrong.
• 35:57We decided to sue
• 35:59Medicare
• 36:01for basing these decisions on
• 36:03the RUC.
• 36:04We were turned down not
• 36:06because we didn't have a
• 36:07good argument, because they claimed
• 36:08that we didn't have any
• 36:09standing.
• 36:12I figured the tobacco industry,
• 36:13you know, is the big
• 36:14evil force in America there
• 36:15for a while that if
• 36:17you could take them on
• 36:18and win, you could certainly
• 36:19take on the AMA and
• 36:20the Ruck.
• 36:23The tobacco industry was small
• 36:24stuff in comparison.
• 36:29So here are the rules
• 36:31the economic rules of the
• 36:32dysfunctional medical market. Number one,
• 36:36more treatment is always better
• 36:38default to the most expensive
• 36:40treatment option.
• 36:43Number two,
• 36:44a lifetime of treatment is
• 36:46preferable to a cure.
• 36:48Number three,
• 36:50amenities and marketing matter more
• 36:52than good care.
• 36:56In the nineties, if you
• 36:57had insurance,
• 36:58there weren't co pays, there
• 37:00weren't deductibles,
• 37:01your premiums were mostly paid
• 37:03by your employer,
• 37:04and you were
• 37:06fine. And then everything had
• 37:07gone haywire.
• 37:12I needed to have my
• 37:13first colonoscopy,
• 37:15and I thought that should
• 37:16be simple.
• 37:17So I went to my
• 37:18HR department. They said,
• 37:20just go somewhere in network.
• 37:24Then
• 37:25I get this chirpy bill
• 37:26from my insurer saying,
• 37:29you know, they billed thirteen
• 37:31thousand dollars.
• 37:33Good news,
• 37:34we paid ten thousand dollars
• 37:37and, you know, great news,
• 37:38you owe zero. And I
• 37:40was like,
• 37:42this is not really great
• 37:43news. I mean, it may
• 37:45be great news for me,
• 37:46but it's terrible news for
• 37:48a system.
• 37:49I did a series at
• 37:50the New York Times called
• 37:52Paying till It Hurts.
• 37:53And at the end of
• 37:54it said, do you have
• 37:55a bill you wanna share?
• 37:57And we had, I think,
• 37:59five hundred responses,
• 38:01and we were off and
• 38:02running.
• 38:08And not because, you know,
• 38:10we are we are in
• 38:11the end,
• 38:13journalists, the the,
• 38:15solution of last resort. You
• 38:17know, these are people who've
• 38:19tried with their insurer, tried
• 38:20with the hospital,
• 38:22gone to the attorneys general,
• 38:24done GoFundMe,
• 38:25and when all else fails,
• 38:27write to a journalist.
• 38:33That's
• 38:34a
• 38:35symptom of a really broken
• 38:36system.
• 38:42I've done everything. You've done
• 38:44everything? Oh, you're working. I
• 38:45mean, when we started our
• 38:46TikTok thing, I did a
• 38:48ridiculous TikTok that I hope
• 38:49no one ever sees. So
• 38:51because it's sort of investigative
• 38:52reporter, kind of, yeah Do
• 38:54you want it on? I'm
• 38:54sure if you don't mind.
• 38:59Sure.
• 39:01What? Do you wanna introduce
• 39:03yourself one more? Sure.
• 39:05Sure.
• 39:06Hi, I'm Elizabeth Rosenthal. I'm
• 39:09the author of An American
• 39:10Sickness,
• 39:11How Health Care Became Big
• 39:13Business, and How You Can
• 39:14Take It Back.
• 39:15And welcome to this film
• 39:17noir.
• 39:27Ah, film noir. A style
• 39:29of low budget cinema about
• 39:30cynicism and urban decay
• 39:32characterized by dark and rainy
• 39:34nights, backroom deals,
• 39:36corrupt officials,
• 39:37calculating femme fatales, and of
• 39:39course,
• 39:40fedora wearing private eyes.
• 39:42The convoluted plots, double dealing,
• 39:45and bad endings feel, well,
• 39:47kind of like our healthcare
• 39:48system.
• 39:58How's it going?
• 40:02And since we don't have
• 40:03access to the rock itself,
• 40:05we kinda have to make
• 40:06up the inside story.
• 40:09Cut the money.
• 40:11Cut the money.
• 40:17So for this section, we've
• 40:18hired actors to read lines
• 40:20spoken anonymously
• 40:22to author doctor Miriam Loguisson,
• 40:24who interviewed dozens of RUC
• 40:25members for her groundbreaking book,
• 40:28Fixing Medical Prices, How Physicians
• 40:30Are Paid. It was really
• 40:31the mention that
• 40:34the prices
• 40:36were partly derived from the
• 40:38American Medical Association
• 40:41that caught my attention.
• 40:43How does that actually work?
• 40:45Because studying political science, you
• 40:47get
• 40:48interested in in how different
• 40:50interests shape policy.
• 40:54It can all fit in
• 40:55the screen, and then I'm
• 40:56just gonna move it down
• 40:57just a little bit.
• 40:59Perfect.
• 41:00Perfect.
• 41:02Yeah.
• 41:10Who made what comment that
• 41:11led the panel to a
• 41:12certain recommendation or not?
• 41:14It's all part of the
• 41:15game.
• 41:19Now it is. Now it's
• 41:21going.
• 41:21Action.
• 41:24At a very fundamental level,
• 41:26the rock is an example
• 41:27of the fox guarding the
• 41:28hen house.
• 41:32It's about the money. It's
• 41:33about the power, and that's
• 41:35where the party line comes
• 41:36in. Because the way it
• 41:37is currently constructed, the proceduralist
• 41:40can do what they want,
• 41:41basically. They can push through
• 41:43anything they want.
• 41:45We're pretty sure it looked
• 41:47something like this.
• 42:14So what's the angle?
• 42:16Two angles, doctor. AC.
• 42:19We've got doctor. Sober in
• 42:20here from vascular surgery
• 42:22with news of a new
• 42:23device,
• 42:24maybe a new procedure,
• 42:26and more RVUs.
• 42:29Here.
• 42:34It's an eight centimeter radio
• 42:35frequency ablation catheter. It closes
• 42:38up the varicose veins using
• 42:39a new heat element.
• 42:41What's the market?
• 42:43Same as before.
• 42:44People don't like the way
• 42:45varicose veins look. They say
• 42:47they're in a little discomfort.
• 42:49Medicare pays out.
• 42:52We get a new RVU
• 42:53for every vein we find
• 42:54once we're in there. The
• 42:56additionals are where the money's
• 42:57at. It's another minute or
• 42:59two of work, but I'm
• 43:00guessing we can add another
• 43:02code to push the RBUs.
• 43:04And we can make the
• 43:05argument that patients feel less
• 43:06pain after.
• 43:09So there's social
• 43:11value. The rock is all
• 43:12about time intensity, not value.
• 43:14They don't care, so we
• 43:15don't care.
• 43:16The RVUs are good, though.
• 43:18The dogs will use this
• 43:20thing.
• 43:22Do we know who makes
• 43:23the device? Do we own
• 43:26that?
• 43:27Wonderful.
• 43:28Wonderful.
• 43:29The PCPs and cognitives won't
• 43:31go for it, but if
• 43:32we get the surgery block,
• 43:34we secure the vote.
• 43:37Alright. What else?
• 43:39Doctor Miller's urology clinic has
• 43:41a new way to treat
• 43:43Peyronie's
• 43:44disease.
• 43:45The FDA just approved an
• 43:46injection for clients who say
• 43:48they're in pain. It removes
• 43:49the,
• 43:51kinks, and there's evidence that
• 43:52the procedure thus elongates the
• 43:54penis.
• 43:55The market's
• 43:56huge for this one.
• 43:58I bet. And it alleviates
• 44:00the pain.
• 44:02Right.
• 44:04What RVUs can we get?
• 44:05Well, to be honest, it's
• 44:07not a time consuming procedure.
• 44:08It takes maybe two, three
• 44:10minutes to inject the drug.
• 44:12But it's high stress and
• 44:13it's high liability given the
• 44:16sensitivity of the area. Plus,
• 44:18potentially, we can bill for
• 44:19four different injections.
• 44:21What can we do with
• 44:22that?
• 44:28I'm guessing
• 44:29three point two RVUs for
• 44:30each injection.
• 44:32Three point two RVUs?
• 44:34That's more than a fifty
• 44:35five minute visit with my
• 44:36primary care doc.
• 44:39Will they shut us down?
• 44:41They don't have the numbers.
• 44:44I think it'll slide by
• 44:45if we give radiology a
• 44:46pass on their old base
• 44:48codes and cut a deal
• 44:49with the heart guys.
• 44:52It's hard to measure stress,
• 44:55and I don't think the
• 44:56PCPs know the time on
• 44:57this one.
• 44:59How many of these can
• 45:00you do in a day?
• 45:02I don't know exactly.
• 45:03We're growing. If it's the
• 45:05procedure alone, maybe fifty, eighty,
• 45:07we can delegate to physician's
• 45:09assistants and charge
• 45:11the same rate. No wonder
• 45:12all you
• 45:14urologists are millionaires. We do
• 45:15alright.
• 45:16You get our votes for
• 45:17the rest for the rest.
• 45:19I bet we do.
• 45:21What's the target, JJ?
• 45:23We go for three point
• 45:25five RVUs for each Peyronie's
• 45:27injection.
• 45:27A six three split for
• 45:29radio frequency ablation for the
• 45:31varicose veins.
• 45:33Work the pre facilitation
• 45:34committee.
• 45:35Get the proposals clean.
• 45:37Keep it quiet outside of
• 45:39surgery.
• 45:40Maybe they adjusted down ten
• 45:41percent to three point two.
• 45:43We still make a killing.
• 45:45I think it'll pass.
• 45:48You two will find a
• 45:49way to cut me in
• 45:50here. AC
• 45:52likes the cuts.
• 46:24The idea
• 46:25that these guys think that
• 46:27they have the right to
• 46:28decide a hundred and fifty
• 46:29billion dollars of federal spending
• 46:31in a closed room,
• 46:32financed and organized and staffed
• 46:34by the AMA,
• 46:35in my opinion, is a
• 46:37disgrace.
• 46:38And the only reason it
• 46:39goes on is because nobody
• 46:40understands it.
• 46:42But if you took away
• 46:43the rough, the AMA would
• 46:45probably implode.
• 47:02So a little different,
• 47:03than the normal.
• 47:06So I'll just stop because
• 47:07I realize we have a
• 47:08few minutes,
• 47:10for time.
• 47:11You can all see that.
• 47:14Love,
• 47:15any reactions
• 47:17at all? Good, bad, ugly,
• 47:19pristine?
• 47:20General love.
• 47:22And what's really?
• 47:28You know, as big, you
• 47:29know so so the audience
• 47:31for the same depends. Right?
• 47:32I I think the ideal
• 47:33would be something like Netflix,
• 47:34a general audience.
• 47:38My only concern is that
• 47:39it feels like it's an
• 47:41awesome,
• 47:44And I don't think it's
• 47:46really in our interest to
• 47:48alienate
• 47:49surgery and
• 47:50specialty medicine and procedural medicine.
• 47:53I think it's just more
• 47:54if you want the primary
• 47:56to drive, you gotta follow
• 47:57the money and money's not
• 47:58there. Mhmm.
• 47:59I don't think anybody would
• 48:01argue that observation.
• 48:03Right. But the the way
• 48:05you set it up, it's
• 48:06kind of like it's their
• 48:07fault. It's a zero sum.
• 48:08Right. Well, it's more than
• 48:10a zero sum. It's their
• 48:11fault,
• 48:12which is the part that
• 48:13I think is maybe problematic.
• 48:15I
• 48:16I appreciate that feedback. That's
• 48:18definitely a concern that that
• 48:20I certainly have,
• 48:21on our production teams
• 48:24of of creating that.
• 48:25I'll just I'll just respond
• 48:26to that, which is, I'd
• 48:28encourage you to read Miriam
• 48:29Logison's book about that, about
• 48:31sort of
• 48:32Disagree. That that that no.
• 48:34I know. I've I've what
• 48:35the future of, like, how
• 48:36how it's become co opted
• 48:37and sort of who sits
• 48:38on that committee in terms
• 48:40of how it is it
• 48:41is set up currently as
• 48:42a zero sum game.
• 48:44And,
• 48:45that committee I mean, there's
• 48:47a lot in here that's
• 48:48not that you know, I
• 48:48think that that's a reaction
• 48:49that I I know and
• 48:51a lot of we have
• 48:51lots of specialty colleagues and
• 48:53friends and relatives.
• 48:56It doesn't look at least
• 48:57the way it's portrayed now,
• 48:58it doesn't look very good.
• 49:00But
• 49:01I think your goal is
• 49:03to make people aware of
• 49:04the rock and how crazy
• 49:05that
• 49:08is. Mhmm.
• 49:11And I think you can
• 49:11achieve that goal
• 49:14without portraying
• 49:15specialty medicine and proceduralists as
• 49:18the villains.
• 49:20Yes. Appreciate it. Yeah.
• 49:22Just, like, also curious around
• 49:25timing because I think I've
• 49:27heard seen in the media
• 49:30that there is some attention
• 49:31about There is. Administration.
• 49:34There is. Doctor Oz and
• 49:35RFK are looking at the
• 49:36RUC right now. Yep.
• 49:37The AMA and RUC. And
• 49:39so I think there's a
• 49:41specific
• 49:42potential for a timing
• 49:44For sure.
• 49:45In terms of influencing public
• 49:48opinion. So much other
• 49:49There is. I mean, I
• 49:51I think you know? And
• 49:52and just to your point,
• 49:53there's some recent,
• 49:54so so it's not it's
• 49:56been published in stat and
• 49:57some other places that that
• 49:58RFK and and doctor Oz
• 49:59are looking very significantly and
• 50:01have sort of pushed back
• 50:02a little bit against some
• 50:03of the from Medicare side
• 50:05about taking all of the
• 50:06rucks.
• 50:07That that one of the
• 50:09challenges around that is that
• 50:10the ruck and not just
• 50:11the ruck, but the CPT
• 50:12code,
• 50:14like industry, which is about
• 50:16seventy percent of the AMA
• 50:17dollars. So of the four
• 50:19hundred or five hundred million
• 50:20dollars
• 50:21a year that the AMA
• 50:22has, about ten percent
• 50:24I mean, area about maybe
• 50:25thirty million is is,
• 50:27membership a little bit from
• 50:28JAMA, but seventy percent of
• 50:30the dollars come from royalties
• 50:32from the CPT codes and
• 50:33the RUCs.
• 50:35So about three hundred million
• 50:36to four hundred million. Yeah.
• 50:37So,
• 50:38my father's actually,
• 50:40was a urologist,
• 50:41but never made parts like
• 50:43this.
• 50:45I I can testify to
• 50:46that.
• 50:47I I actually thoroughly enjoyed
• 50:49this, but I think Amy's
• 50:50got a great point.
• 50:53You could show the the
• 50:54film noir,
• 50:56Separate that from the other
• 50:58parts of what you're showing.
• 51:00I don't see any problem.
• 51:02You just you know, you
• 51:03don't necessarily wanna know that
• 51:05a primary care doc
• 51:07is disparaging
• 51:08all these
• 51:09grubby specialists.
• 51:11And but I I think
• 51:13that's the kind of thing
• 51:15that would get a lot
• 51:15of attention.
• 51:16It's just a question of
• 51:18how much attention you wanna
• 51:19bring to
• 51:21your authorship.
• 51:23Appreciate that. Yeah. Rashma?
• 51:25As a suggestion, there's a
• 51:27American Public Health Association has
• 51:29a public health film festival
• 51:30every year that's sponsored by
• 51:32the Pulitzer Center.
• 51:34That might be something to
• 51:35consider in terms of a
• 51:36submission even if of, like,
• 51:37the
• 51:38this.
• 51:39And also to get,
• 51:42it and to this kind
• 51:43of point, I'm wondering if
• 51:45instead of kind of talking
• 51:46about the specialty is the
• 51:47institution.
• 51:48Right? Like, focusing more on
• 51:50how it's been set up
• 51:51by the AMA. There's pros
• 51:52and cons of this. Right?
• 51:53Because right now, we're also
• 51:55in administration
• 51:56that is, like, calling out
• 51:58medical professional societies,
• 52:00at in various ways that
• 52:01are not productive.
• 52:03But in terms of talking
• 52:04about, like,
• 52:06you know, how the institution
• 52:07has has set this up
• 52:09that initially excluded primary care
• 52:11physicians. That was, right, one
• 52:12of the big things that
• 52:13was not allowed in the
• 52:14rough before they allowed it
• 52:15six seats. Later on,
• 52:17maybe more of a comment
• 52:18on that and, like, opportunities
• 52:20for reform and improvement. Right?
• 52:21That's right. Trying to portray
• 52:23this towards, like, a positive
• 52:24agenda.
• 52:25That's good. I appreciate that.
• 52:27And, actually, the reason they
• 52:28opened up more seats for
• 52:29primary care was because of
• 52:30Paul Fisher's lawsuit
• 52:31in twenty twelve, and they've
• 52:33now published who is on
• 52:35the rock. It was not
• 52:36published. It was not open.
• 52:37None of the minutes were
• 52:38public until twenty twelve in
• 52:40that lawsuit.
• 52:41Yeah.
• 52:42Yeah. I I really enjoyed
• 52:43it, as well.
• 52:45I do get the point
• 52:46that there has to be,
• 52:47like, a a bad guy,
• 52:48and the bad guy can't
• 52:49just be, like, opacity
• 52:51per se. But, like, why
• 52:52is that the case? I
• 52:53mean, there's sort of a
• 52:54punching bag, but congress set
• 52:56it up this way, and
• 52:57and they, you know, set
• 52:58the rules,
• 52:59in the administration for the
• 53:00medic for Medicare. So, I
• 53:01mean, I think focusing more
• 53:03a little bit more on
• 53:03the government aspect of, like,
• 53:05the policy as to what
• 53:06the way it was set
• 53:07up may be one way
• 53:08to do it.
• 53:10And the only problem I
• 53:11had, which I really love
• 53:12the film, the only thing
• 53:13that felt slightly,
• 53:15not in line with sort
• 53:17of what the the idea
• 53:18that you're you're getting across
• 53:19there was the the sidetrack
• 53:21to the woman after his
• 53:22BMED. Yeah. Jasmine. Yeah. That
• 53:24yeah. It's a little it's
• 53:25got yeah. There's some other
• 53:27parts. Yep. Off
• 53:29the point of the I
• 53:30agree with that. The other
• 53:31issues. But, yeah, it was
• 53:32great. Yeah. Thank you for
• 53:33that point. Yeah. It it
• 53:34is different, and there's some
• 53:36other stuff that will come
• 53:37back later. But yeah. I
• 53:39I was gonna make the
• 53:39same point that, you know,
• 53:41I was expecting a more
• 53:43linear focus on primary care,
• 53:44but it looked like it
• 53:45was basically three components.
• 53:47You know, the earlier component
• 53:48of
• 53:49some overview of, primary care,
• 53:52some examples of physicians who
• 53:53seem to thrive in it.
• 53:54Then there was the b
• 53:55med segment,
• 53:56and then there's the rock
• 53:58segment.
• 53:58So, you know, as you
• 54:00I don't really think about
• 54:01filmmaking, but
• 54:03the the story arc, would
• 54:04be important,
• 54:07that fits under a a
• 54:08clear theme that people have.
• 54:10Yeah.
• 54:11Understand. That's
• 54:13spot on. And we haven't
• 54:14actually you know, we we
• 54:15have a lot more,
• 54:17that we're still trying to
• 54:18figure out where these things
• 54:20fit. Some things will get
• 54:21cut out. There's a there's
• 54:22a lot more interviews.
• 54:24As I mentioned, we have,
• 54:24like, a hundred hours now.
• 54:26We've shot different things all
• 54:27over the country.
• 54:29This is like a taste
• 54:29of the first stuff that
• 54:30they've kind of put together,
• 54:32which is I agree though
• 54:33that the BMED stuff feels
• 54:35different.
• 54:36But we'll we'll figure out
• 54:38how to incorporate that.
• 54:41It's a start. General public
• 54:42here. And it's a great
• 54:43opportunity
• 54:44to to get them up
• 54:45to speed on what's going
• 54:46on.
• 54:47I think this is gonna
• 54:48be a it'd be very,
• 54:50very impactful.
• 54:51So thank you. I realize
• 54:52we're out of time. So
• 54:53if people wanna send me
• 54:54emails or find other time,
• 54:56I'd love any feedback. Good,
• 54:57bad, ugly. I appreciate all
• 54:59of the comments because I
• 55:00think this is the first
• 55:01we've shown anybody.
• 55:03So thanks.