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      Healthcare Rethink - Episode 5

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      Healthcare Rethink: Giving You a Rich Body of Insights to Make Change

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      Brian Urban: [00:00:22]
      Yes, this is the Health Care Rethink podcast. That's how you open up the show. I am your host, Brian Urban, and today we have a very interesting topic needed now more than ever on podcasts across our country. Payer and provider collaboration. What both sides need to do to have better health outcomes and less confusion and challenges for the patients the lives in the middle of that relationship. And here to join me in this discussion is an expert, I'll say a celebrity level influencer across LinkedIn and other platforms is Doctor Eric Bricker. And I'm just so excited to have you on the show to discuss this. Welcome to the show.

      Eric Bricker: [00:01:07]
      Dr. Bricker Yeah, thanks so much for having me, Brian. And hello to everybody out there. Appreciate you tuning in.

      Brian Urban: [00:01:13]
      So in most of our shows, we open up with some this or that or some interesting trivia to get to know our guests a little bit better for our audience. Actually, I think your guests on your show and your audience will get to know me a little bit more because you have so many followers. It's amazing. So I thought we could kick off our conversation with a little bit of trivia. Just to highlight your, I'll say, historian level expertise across the health care ecosystem. So I got just five questions for you. Painless. I'll go quick to keep you on your toes and then we'll really get into the meat of our conversation.

      Eric Bricker: [00:01:51]
      All right, shoot.

      Brian Urban: [00:01:52]
      All right. Question number one. Here's a softball for you. The Hippocratic Oath first originated by which Greek philosopher Plato, Socrates or Hippocrates.

      Eric Bricker: [00:02:03]

      Brian Urban: [00:02:05]
      Ding, ding. Correct. Do no harm. Whatever you do, don't make it worse. Right. All right. Question number two What agency originally administered Medicare? Was it the health care financing administration?

      Eric Bricker: [00:02:19]

      Brian Urban: [00:02:21]
      Actually, I was. You're so fast. In 1965 to 77, it was the Social Security Administration. And then after that, whenever Secretary Califano came in. So. But you're so.

      Eric Bricker: [00:02:35]
      Fast. That's great. Thank you for teaching me that.

      Brian Urban: [00:02:39]
      Cms.gov is teaching you this. This is some great questions from a resource from them. All right. Question three What year was the stethoscope invented? 1918 16 or 1865.

      Eric Bricker: [00:02:53]
      Oh, okay. I'm going to go with 1816.

      Brian Urban: [00:02:57]
      Correct. Rene Lynch, a French physician, invented that. Amazing.

      Eric Bricker: [00:03:03]
      All right. I did it because he felt awkward getting near the chests of his female patients.

      Brian Urban: [00:03:10]
      See, I learned something, though. That's a little more context.

      Eric Bricker: [00:03:12]
      Because that's how that's how they used to auscultation. Listen to the heart is they literally would put their ear against the chest of the patient. And he's like, it's kind of awkward.

      Brian Urban: [00:03:21]
      I bet that's preference sensitive care right there. That's how you do it. The French knew what they were doing back then. So awesome. All right, a couple more questions. Medicaid was expanded to cover additional low income pregnant women and children. In what decade spans here? Was it the 1980s? The 1990s? This was expanded, the 1950s, the sixties or the sixties to seventies?

      Eric Bricker: [00:03:47]
      Yeah, it was. It was the same time as Medicare. So it was sixties and seventies.

      Brian Urban: [00:03:51]
      The sixties and seventies. And then it really started expanding in the eighties and through nineties.

      Eric Bricker: [00:03:55]
      Okay. All right. Fair enough. I made a health care see video about this. I think it was originally Medicare the now anyway, it was the original passage was going to have a state level administration and the state level administration became Medicaid and then the federal administration became Medicare.

      Brian Urban: [00:04:16]
      Yes, exactly. And then actually, I love that. I love that piece that you did. You used your grandfather as an example. I think you you kind of looked at the history across the the Medicaid being established. So let's put.

      Eric Bricker: [00:04:29]
      Some hard ones. Wow. This is great tough ones.

      Brian Urban: [00:04:33]
      These are tough ones. But the last one here and this really gets us to what the heck is going on these days? How many in number of volume Medicare claims for physician, hospital and other services are paid every year? Is it about 750 million, about 1 billion or about 1 trillion volume of claims?

      Eric Bricker: [00:04:56]
      Oh, shoot, I'll go with the one with a B billion.

      Brian Urban: [00:04:59]
      Yeah, correct. That's good one to end on. All right. So that's the fee for service claims being paid every year, About a billion over a billion going back almost a decade plus. And Dr. Ricker, that kind of gets us into how the heck did we arrive here? That is maybe a lot compared to other countries, or is that on par for the US in terms of health? Health care consumption at the individual level just accumulated in a year. But before we get into the details of that, wanted to get to know Dr. Bricker before the MD. So we talked a little bit before Amazing career. You've now transitioned a lot into health care finance. You had your residency at Johns Hopkins University. You have some Pennsylvania roots that I did not know about that we have some some synergies on there. So take me back to where you grew up, how you got into medical care and then how you got into health care finance. And then we really we can talk about what we need to do today to make it better. Yeah.

      Eric Bricker: [00:06:04]
      So just real quick, I grew up in the suburbs of Washington, DC in Maryland and lived in a town that was very close to the National Institutes of Health, as in Bethesda, Maryland. And so we actually had a lady at our church who was one of the scientists there, and when I was a junior in high school, she said, Hey, we got this summer internship program, would you be interested in doing this? And at the time I was just mowing lawns. That was my plan for the summer and it paid $9 an hour and it was in air conditioning. And so I'm like, sweet, like, I'll do it. I don't care what it involves. And so I worked at a histology lab. So it's an images with a microscope and an electron microscope. And this is in the nineties they were still taking like actual pictures with film. It wasn't digital and I was literally in a dark room for the entire summer developing the the film from the electron microscope. So, you know, I don't know if you've ever seen like the old school photography where you got like the different like baths, you got to put the film in. And so I did that and I guess I did it well enough that they asked.

      Eric Bricker: [00:07:05]
      Be back the following summer. So I did that for multiple summers and it's fantastic and was a great experience. It was at the National Institute of Diabetes, Digestive and Kidney Diseases and DK Building eight, which is sort of building one. If anyone knows the NIH that all the buildings have numbers, but Building ten is the really big building that has the hospital. And then I was like, Oh, this is great, but I'm kind of a social dude, you know? And so the head of the lab, Joan Blanchard, Mackey, said, Hey, you should maybe think about being a doctor if you like the people part and the science. Okay, I'll look into that. So I was pre-med in college, graduated in 1998 when they were just giving jobs away. Right? Internet boom, yada, yada, yada. And so instead of going straight to medical school, I'm like, Oh, I'm going to work for a couple of years. I'm kind of sick of having my nose in a book. So I got a job at a hospital finance consulting firm that was kind of small. It was like 100 employees. I was about employee number 100, but they ended up being actually the sort of premier consulting firm for revenue Cycle consulting. It's called Stocking Up and Associates. They did the revenue cycle projects for the majority of academic medical centers in America, like they would only do these like big behemoth hospital revenue projects, projects for hospitals that were doing, you know, three plus million dollars worth of business a day.

      Eric Bricker: [00:08:26]
      They were they were trying to build and collect like $3 Million a day. And so it's fantastic experience. Learn all about the coding and all the different payers. Medicare, Medicaid, commercial insurance is in the nineties. There's a lot of managed care, HMOs, prior authorizations, denials, yada, yada yada. So learned all about that, but still wanted to practice medicine. But I knew I didn't just want to be a regular doctor. Nothing wrong with regular doctors, but I knew there was so much confusion and frustration and complexity and it was just it was just a mess that I'm like, okay, well, I can see how this is like bad for doctors and bad for patients and bad for the hospital and kind of bad for everybody involved. And so if I could do something that kind of work to improve that, that's what I would want to do. So that's how I ended up, you know, long story. Long That's how I ended up getting into medicine and also finance at the same time.

      Brian Urban: [00:09:14]
      And what a great way to experience the business side and the challenge with transactions, let alone the patient care interaction side. So you blended those skills and you definitely are a social butterfly, so it mixes in so well to who you are as a physician, but also a business leader in this space in terms of health care, finance, revenue management as well. So, Dr. Bricker, tell me about your time at Hopkins and and then tell me about maybe a turning point that you kind of felt that took you purely in the health care finance direction?

      Eric Bricker: [00:09:48]
      Yes. So I went to University of Illinois for medical school, and then I had the opportunity to go to Hopkins for residency because I thought I wanted to be a policy wonk. And I'm like, okay, I can be on faculty at an academic medical center and do health services, research and policy stuff. And it was just too slow. I'm just too impatient of a person and I needed to see kind of the fruits of my labor kind of faster. And so one of my nothing wrong with research. I mean, the people that do it are obviously much more patient than I am. And so the one of my consulting colleagues who I worked with before I went to medical school, he and I were kind of batting around ideas and we really saw that people were having a hard time just navigating the health care system, you know? So I'm an internal medicine doctor, and so like 80% of what internal medicine doctors do is like helping people navigate the health care system, which they don't. There's no billing code for that, at least there didn't used to be. And so it was all this uncompensated stuff. So the internist really didn't do a lot of it. They didn't do it as well as they could. They didn't really understand how to do it.

      Eric Bricker: [00:10:43]
      So my friend had become the EVP of Finance for a large hospital system here in Dallas. And I kind of knew from the patient interactions kind of how to talk to the patients. And so we took what we knew and we're like, okay, we're going to start this health care navigation company. We didn't call it health care navigation, but we didn't we didn't know what we called it, but we went and we sold that to employers. And this is when consumer directed health plans were starting out. So the copays were going away. People were getting money on an HSA card and they're like, I don't know what to do with this thing. I don't know how to be a health care consumer. So companies would hire our company professional health services as sort of the health care administrative ninjas to help their employees and their family members navigate the health care system. And we grew that to 2000 employer clients, supported about 1.8 million people. And so I wasn't an entrepreneur because I liked business or entrepreneurship. It was just it's just a way of like solving a problem, right? And you can solve that problem on a on a patient level by by seeing patients. You can solve that at a research level by discovering something new or making some sort of new observation, or you can do it through starting a business.

      Eric Bricker: [00:11:49]
      So I'm not really a business guy. I ended up doing all the sales and marketing and account management at Compass, so I kind of had to learn how to be a sales guy. And that's a really important because essentially, you know, obviously so many people in health care are working for. Change that you really have to, quote unquote, sell the idea of change. So if anything, it was really as a quote unquote salesperson, I was really more of like, okay, well, how can I facilitate? Change was really the way I looked at my job. So, you know, at the end of the day, know, the money dramatically impacts the care. Like, I mean, listen, I'm not I'm not interested in money for the sake of money. I'm interested in money for the sake that it impacts the care, Right? I mean, your cancer diagnosis and treatment, your your prevention of heart disease, your treatment of osteoarthritis, I mean, the financial issues for the doctors and the hospitals and the patients are huge and they dramatically impact the type of care you get, the quality of care you get the access to the care you get. Yada, yada, yada. So like, if you don't, I'll leave this with this one last thing. Is that what the founding physician of the Department of Medicine at Hopkins, this guy, William Osler, very famous guy back in the early 1900s, like worldwide famous.

      Eric Bricker: [00:13:04]
      He's actually Sir William Osler, because he became a knight in England after he left Hopkins. And he said, medicine is not a business, you know, So he knew that all the way back in the in the turn of the century, in the early 1900s. But guess what? In America, it's totally a business. And so the only way that we're going to do anything to get it more along and what he when he said that medicine was not a business, what he meant was, look, when someone is on the verge of death and has pain and has suffering, there's what's called perfectly inelastic demand, which means that people are willing to pay anything to alleviate the fact that they can't breathe right now. Right. So when he says that it's not a business, that's what he means. Right. And so but the point is, is that, look, this is a reality in America that we have to address. Health care is a business. So how do you do that in a way that actually improves patient care and improves patient lives? And I've kind of made that my raison d'etre, if you will. So that's why we're talking.

      Brian Urban: [00:14:01]
      And that's and that's a great journey you took me through right there and us through, because now we're getting to how you have really chased down a problem with variety of solutions. And now it seems like in terms of revenue management and payment payment at the individual level, there are so many different vendors in the space. And it really I think you could argue it and philosophy is there's so many problems. That's why there's so many different startups in the place of health care ecosystem to actually try and fix things and make it easier for the patient, make it easier for the doctor to get paid for the services rendered rather than going through hoops. So not to pin your finger point on either side. There's challenges on both sides for sure, the payer and the provider. So I love that you just took us to that point of how do we have better outcomes and how do we have more patient centric care and business centric care around a patient and in their health? So I want to throw a stat out at you, and you probably know this, that this came out earlier this year, 17 billion, 17 billion is the quantified waste that we've seen in this country in terms of claims errors and about 20% of that some experts and health care economists attribute to inefficiencies actually just getting claims wrong off the bat provider, sending it to the payer payer, denying it, tennis match back and forth. So with that inefficiency, is that going to continue? Do you think these startups are going to change things? I mean, you've created and founded a startup in the revenue management space. Do you think this is going to change? Do you think there's going to be more vendors come in this space? Is it going to get easier or are we going to keep having more friction?

      Eric Bricker: [00:15:45]
      Yes, it's is fantastic topic. So so let's talk about errors in billing. And so to a certain extent, it's important to understand that an error is in the eye of the beholder. So what people view as an error, other people do not view as an error. So we have to and it's actually three sided. So it's not only the health insurance company, it's not only the provider or the doc or the hospital, but it's actually the employer as well for employer sponsored folks. And so really are sources of error. And what what is the really the error? It is essentially it is not meeting the expectation of the bill. Right. So the question becomes, okay, was it an error in in follow through or was it an error in expectations? So that's that's actually the first place I want to start, is that one of the major challenges. So there's three buckets. There's the employer, there's the doc and hospital, there's a provider, and then there's a health insurance company. So when it comes to the employers in America, so one of the main sources of quote unquote billing errors for for employees and their families is in the fact that, frankly, they just don't understand their health insurance. They don't understand the the percentage of people that understand the four basic concept of deductible premium CO pay and CO insurance is 4%. So the most basic aspects of how their health insurance works, people just don't understand. And health insurance plans are much more complicated than that. And that at a very basic level, everyone actually, if you have a family, by definition, you actually have four deductibles, not one, because you have your individual deductible, but then you have your family deductible. And the family deductible is actually two individual deductibles for most people.

      Eric Bricker: [00:17:22]
      That's called an embedded deductible, which means that if you're if your deductible is 1000 and your family deductible is 2000, if you as an individual have $2,001 worth of claims, you have not met your family deductible, you have to meet 1000. And then if you have three other members of your family that reach $999, you still have not met your family deductible. And then if you have a fifth member of the family that goes in for medical services, you haven't reached your deductible. It's going to go to their deductible. And they, too, can go to $999. And that is understood by 0.0001% of the population. Absolutely, that's one. So people say, oh, I got an error bill. It's it's a bill in error. Well, the error was that you didn't understand how your health insurance worked or really the error was your health insurance was more complicated than it should have been. There it is. Right. So that's the error. And oh, by the way, that's just two deductibles. Everything I just said then only applies for in-network doctors and hospitals. You have a completely separate out of network deductible for yourself and your family as well, which is usually twice as much. So you've got a $2,000 out-of-network deductible and a 4000 family deductible in this in this example. And so let's say you met your in-network deductible, but then you happen to go to an out-of-network doctor or facility. You're starting from scratch from zero again, and you're like, I got this bill. It's an error. No, it's actually not an error. It's an error in your understanding of how your health insurance actually works. And you're laughing at this because it's ridiculous, right? This is.

      Brian Urban: [00:18:52]

      Eric Bricker: [00:18:52]
      Reaction to this is and this gets to the issue is how is it possible that we don't have consumer protection in America that allows this type of product to be sold? We essentially are allowing a product to be sold in America that is just not understood by the people that are buying it. So my argument isn't that the education is bad. What are we going to do better educate America? Like that's not going to happen. Like, the answer is, is that those types of policies should not be allowed to be sold because they're too complicated by definition. It's like, you know, in order for you, it's it's like it's like flying a plane. Hey, you need to fly a plane. Look, listen, You need a license to fly a plane. You can't just fly a plane. It's dangerous, right? You need to. So the point is, is that you don't make it a plane. You make it like a bicycle. You've got to make it a lot easier. So. Oh, by the way, that is only one of the three buckets. I'm only getting warmed up. Then we can talk about all the all the other areas with providers and health insurance companies.

      Brian Urban: [00:19:53] And that's that's a good basis, though, to kind of unpack the convoluted evolution we've come to with this space. And you're right, very little people know that. And we're not going to educate patients and individuals or families better. You can make as many pamphlets as you want, text messages, email campaigns. It's it's probably not going to hit everyone. It needs to hit in the right way and the right terminology. So how do you protect the health care consumer in that in that space? That's really tough. And if you have an answer for this, I.

      Eric Bricker: [00:20:28]
      Mean, there's a lot in what I decided to be the medical director for simple pay. So, I mean, you know, full disclosure, I'm the medical director for a new type of health insurance plan that's co pay only that has zero deductibles. What's the pay called? The price. You can actually know in advance. It's 20 bucks. It is $20. I never get a bill from the doctor or the hospital because all it is is a co-pay at 20 bucks. So, I mean, it's not rocket science. Like you can actually make like there's no law saying that you have to have a deductible and co-insurance. And for a doctor, there's no law that says you have to have that. And so the point is, is that like. All of these things, like it just takes all of these issues in health care. It's not a squishy issue of technology or skill. It's just a question of, well, like all of these problems exist because people don't want them to be fixed. It's a question of will not skill. It's not a question of ability. It's a question of desire.

      Brian Urban: [00:21:30]
      I love that because really, what's the incentive as this business model in terms of health to change or to evolve? Where's the urgency? Where's the pressure? Even though we have skyrocketing medical debt, third leading cause, I believe, of bankruptcy, individual and households. It doesn't matter like things aren't changing at the pace. So it's kind of interesting reaching back into your policy wonk side of your brain. The No Surprises act passed. It's it's in effect really otherwise known as balance billing. So it's kind of being as transparent as possible to the health care consumer of what they owe, separate to what is rendered and paid from their employer group or from what the doctor does for them and then what their health insurance company does. So that's a step in the right direction. Quite late to the game. But is that any indication for you from the policy side of, hey, maybe things now are going to snowball and there's going to be more regulation and more pressure put on us? Or are we we to down the evolution here that that's not something we should really bank on. We shouldn't really think that's going to happen.

      Eric Bricker: [00:22:44] That's a it's a great point now and then those surprises act really is very specific as it relates to quote unquote, surprise medical bills from out of network providers like like doctors and physician's assistants at in-network facilities. And as we discussed, that is only a very small corner of of the entire universe of quote unquote problem medical bills. So just because the No Surprises act was passed, in no way, shape or form means that people are no longer going to get, quote unquote, surprise medical bills, they absolutely still will get surprise medical bills. And if you'd like, we can go through all the other sources of surprise medical bills completely untouched by the No Surprises act.

      Brian Urban: [00:23:23]
      We can don't do that to me today. But I absolutely agree with you. It's touching a very small piece. The internal optimist in me sees this is a potential to to hopefully continue to cover off more of the services and interactions that a consumer experiences in the health care world. But I want to shift gears for a moment and talk about talk talk about the model that you just shared. So we have so many different things that are popping up now, rural, urban and hinterland areas across the US. So these direct pay models where physicians don't take insurance, they do direct billing with their patients, they see and they don't have EHRs. They they see a select amount of patients. So that's more popular popping up in rural areas, even some suburbs and city areas around Pittsburgh, Pennsylvania, and Appalachia and West Virginia and all through Pennsylvania, Ohio. But in terms of where you are in Texas, I mean, highly capitated market, heavy HMO for a long time, big health care systems, cancer specialties all over the place, is this going to this type of model going to grow on the provider side and you see it from your payment methodology in terms of the networks that you kind of build and do the direct payment with patients. But do you see these types of models popping up or is it going to be kind of a crawl walk run that you think will kind of scale up across the country?

      Eric Bricker: [00:24:58]
      Yes, that's a great question. At the end of the day, everything in health care is pretty much glacial. It moves super slow. So I don't think anything is going to be a run short of a pandemic. Right. What's the what is a great example of when we actually had something that happened very fast. It was the adoption of not by by patients, but also just by hospital systems of putting in telemedicine as a result of COVID and just not being able to to get around. So, you know, it takes a crisis, right? So we had a crisis and we had some sort of big change as a result of that. But as it relates to, let's call it direct primary care, the market in most of the Midwest and the South is actually not HMO. It's primarily a fee for service for commercial insurance and the whole direct primary care movement of basically direct pay on a subscription basis for your medical services. You can typically pay between 50 and $80 a month per person directly to a primary care physician for unlimited visits. You can do phone visits, you can do virtual visits, you can come in. That is essentially really just a cottage industry. And so what you're seeing is, is the sort of individual folks who are just burnt out of their practice, they see a better way of doing it, but it's not really done at.

      Eric Bricker: [00:26:25]
      Scale. Now, the closest attempt to scale that is through the onsite and near site clinic companies where their contracting with an employer, whether it be a school system or a municipality or a factory, and they're having an onsite clinic which is typically at a low co pay like $5 for the employees or. Lot of times it's free, free, unlimited primary care. And so in both of those settings, you get rid of any billing complexity because it's just on a subscription, there is no fee for service. And so this is where the fee for service, the whole billing problem goes away with fee for service when there's no bills. Right? So to a certain extent, one way to solve the billing problem and the billing complexity is just to have care without claims. Like there's no law that says you have to have claims in order to have. Care. And so fee for service claims based care is actually a really bad way to pay for primary care. The much better way is on a subscription basis whether the individual is paying the subscription or the employer is paying the subscription, or even the government is paying the subscription or the retainer, if you will, for the primary care physician services. That is a much better way. Now, the entire fee for service insurance system was created by doctors, but it was specifically created by. Surgeons at the Baylor University Medical Center in Dallas.

      Eric Bricker: [00:27:51]
      So. Health insurance in America today was invented in Dallas with a plan that was sold to schoolteachers now. Fee for service makes sense for surgeons because it's highly episodic. And if you don't have insurance and then you're on death's door with a burst of, you know, a ruptured appendix, then the the surgeon is in a very bad moral situation because what are they going to do, not operate on you because you don't have any money? So they're like, look, we've got to collect the money in advance, right? We've got to collect premium in advance so that when they do show up with the appendicitis that we've already got our money in this sort of subscription, if you will, in terms of the premium. And so we're not going to get into the history of health insurance in America today. But the point is, is that we don't have to boil the ocean in terms of, quote unquote, getting rid of medical bills for the entire medical profession. But a good place to start is primary care. And so probably one of the best place to place is to solve the billing issues, is just to get rid of claims and to get rid of fee for service for primary care. And there's a path to do that. There's absolutely a way that's already being done today to make that happen.

      Brian Urban: [00:29:02]
      I love that because it's being done at a grass root level and it's starting in primary care. And it's interesting because now you're mentioning primary care and I love what you are taking the fee for service model in terms of paying for the services and upfront, especially with episodic care and complex surgeries. And then talking about subscription model, arguably subscription models make sense across so many industry entertainment, retail, and you're seeing it explode and e commerce, maybe eventually e commerce, the I side of e commerce. So you're seeing all kinds of explosion in the space there in terms of subscription models, absolutely makes sense. So when you mention that fee for service and the subscription model, I'm thinking about value based care when you mention primary care, and that's where I think a lot of the value based contracts started to really ramp up about ten, eight years ago and narrow network type provider models that health insurance companies would go and contract, get anchor system. That's great quality care, low total medical costs and X amount of categories. And they would start with kind of the prevention, the quarterback of care, the primary care provider. So in thinking about how value based care is so touted and so needed in this country, would you make an argument for how value based care is going to be so slow? But if you integrated a subscription model that is value based oriented, would that take us away from fee for service and take us away from, Hey, we got to get docs to capitation and downside risk? Would that be more of a a logical place to try this type of model?

      Eric Bricker: [00:30:54]
      Yeah. So great question. And so the way that that's manifesting itself today is really through through Medicare Advantage plans. And so they're the sort of subscription, if you will, is the government is paying the health insurance company as sort of the intermediary and then the health insurance company, whether it be mostly, well, I won't name any names, but there have been basically contracting with the primary care groups and they're giving them a fixed amount. Let's just use some made up numbers. So the government is given a 1000 bucks per month, per beneficiary, 12,000 bucks a year. Then the health insurance companies turn it around and given about 10,000, 10,500 to the primary care practice and saying, look, you're fully responsible for all costs, they go to the hospital, they need to get surgery or whatever. It's coming out of that 10,500 and the individual hospital and surgeon or whatever, they can still build the health plan on a fee for service basis, but then they're just taking that out of the pot, the capitated pot that they're giving to the primary care practice. And there are, whether it's startups like devoted health or even one medical does some of this When they bought Iora or Chien Med as a private company that does this.

      Eric Bricker: [00:32:02]
      So that whole model gets rid of the bills at all. The patients never see a bill. So it is, you know, free primary care visits. They got a van that picks you up and takes you to the appointments. They've got integrated onsite pharmacy and a lot of the prescriptions are at zero out of pocket costs as well. So that exists in a corner of health care. Now it's a significant corner, right? It's almost 50% of all Medicare beneficiaries are on Medicare Advantage plans now. Now, not all Medicare Advantage plans actually have their primary care. It's probably actually the minority of Medicare Advantage plans that have that type of relationship with the primary care doctors for for a lot of the managed care excuse me, for the Medicare Advantage plans. The primary care docs are still billing fee for service, you know, with some risk and blah, blah, blah. But it is it is in its very early stages of scaling, but that's where it is happening. It's not happening in traditional Medicare. I mean, CMI is trying to do it, but by and large it is not and then it is not happening in the employer space.

      Eric Bricker: [00:33:02]
      Frankly, outside of the on site near site clinics. So the very, very small manifestation is is the near side onsite clinic movement and some degree of direct primary care on the employer side. So what's going to happen is, is that there's going to be, you know. Growth in the Medicare Advantage space for this type of model in the next two, three, five years. Will it expand outside of that? I mean, who knows? But it already has its foothold. It already has a path. It already has been shown to be successful for patients and for the doctors and for the health insurance companies. So there's a there's a big problem with it. There's a big problem in that the the risk adjustment that the insurance carriers use is often found to be fraudulent by by CMS. And in fact, I believe it was the Department of Justice just filed a suit yesterday against Cigna for their Medicare Advantage population for potentially fraudulent behavior as it related to risk adjustment there. So it's still fraught with difficulties. It's not perfect, but it is a quote unquote, alternative slash, value based payment model that has been executed and it has some momentum behind it. It's actually.

      Brian Urban: [00:34:21]
      Growing. That is that's refreshing to hear, too, and obvious that it's taking place in the HMA space. But how do we get it to commercial? That's the real the hope shot. Maybe that will occur in the future. So, Doctor Bricker, I've kept you a long time, and I actually have a lot more questions in regards to population, health based spend and claims errors that might occur more in a particular disease state that's more complicated than other maybe chronic conditions. So we're going to get to that, I think, and maybe another episode or another side conversation. But I really wanted to get down to the bottom here in terms of wrapping up this conversation. Three things the payer could do at the top level here and three things the health care provider world can do right now to have better collaboration. Is it is it data sharing? Is it more merger acquisitions? Is it more different digital front door investments? What are the three things both sides can do to come together and make a better outcome and experience for patients?

      Eric Bricker: [00:35:31]
      Yeah, that's a great question. At the end of the day, for the broad hand-waving, the the hospital systems and the health insurance companies, they don't want to again, it's a question of desire. They don't want to. So the way that they are doing that, the way that they could do it and the way that they should do it is that the health insurance companies are starting to deliver more care. Right. So Optum, UnitedHealth Group's Optum, they own a bunch of doctors now they are delivering care. They bought the Kelsie Siebel Physician group in Houston. They bought a big physician group in Boston. So they're you're right. They're collaborating. They're collaborating within their own organization. That's where the collaboration is going to come. Likewise. And I've talked about this many times, whether it be Geisinger or UPMC or Intermountain or the University of Utah Health System or even Sentara in Southeast Virginia. These hospital systems have health insurance companies that they run. So they're collaborating with themselves. So the best way for this collaboration to happen and actually occur is for it to be internalized. And so I, I, my, my sort of my vision that I would love to have happen is if every single hospital system in America also had its own health insurance plan that people could buy, that would be fantastic because the doctors in the hospitals, they know how to deliver a care more cost effectively.

      Eric Bricker: [00:36:53]
      They absolutely know how. And it has to do with social determinants of health. It has to do with cost accounting within the hospital. It has to do with better clinical pathways, yadda, yadda, yadda. Like they know how to do it. They just have to want to do it. And when they run their own health insurance company, they will want to do it. And so that's that's the best way to do it, in my opinion. Now, just like COVID caused a catalyst for telemedicine, there will be a catalyst. There will absolutely be a catalyst. So to a certain extent, everybody needs to understand that pain causes change. And so in order for folks to change, in order for health care to quote unquote, to change, it has to get worse. So just know that there has to be pain for these organizations in order for them to change. If there's any organization that does not have pain, they are not going to change. So just if you're looking for areas that are going to change in health care, look for the pain and then that'll give you a good clue as to when there's going to be change.

      Brian Urban: [00:37:52]
      I love what you do with that. The will not the skill, the pain will cause and lead to the change in terms of these businesses we talked about. And I love that you mentioned integrated delivery networks. A lot of those that you threw out there they are. Yeah. They're collaborating inside their own walls and they're doing this better. So a lot of great examples you mentioned there, especially UPMC, CIGNA, you mentioned before they have Cigna Medical Group out of Arizona. They've had them for years. But yeah, it's it's amazing what's what's happening in that microcosm. And maybe maybe that's the starting place. That's the model. But we'll keep an eye out for those places in pain that it's going to need to to see a change. So Doctor Bricker, a very special thank you for joining our podcast, The Health Care Rethink. I admire your show tremendously. Your knowledge is so deep and broad. I'm sure our audience will value that as much as I have. Thank you for being on the show and for more excerpts and insights into this episode and others, please visit us at finthrive.com.

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