Hey, welcome to Relentless Health Value. Okay … so, on today's show, we are talking about (Andrew Tsang and I) revenue cycle management, which—I say this with real affection—is maybe the least sexy phrase in all of healthcare. It sounds like a back-office spreadsheet problem, but yet it is not a back-office spreadsheet problem.
For a full transcript of this episode, click here.
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It is, in fact, probably one of the most consequential forces shaping American healthcare right now. And most people, including a lot of people who work in healthcare, do not actually understand what it is or how it got this big.
So, today I am so pleased to have Andrew Tsang explain revenue cycle management (RCM). The 14 steps to RCM that begin before the patient encounter actually include the patient encounter and then all of the back-and-forth afterwards.
I have learned a lot from his writings and LinkedIn posts. There is a couple of infographics that I would highly recommend, especially this Revenue Cycle Management interactive graphic from his Substack.
And Andrew makes a point that I have not heard made so precisely before. Many folks kind of bucket RCM into, again, some backroom spreadsheet function. But if you think about this from the patient perspective, patients probably spend more time dealing with RCM-type functions than they do getting clinical attention.
RCM may actually be the front door of any given clinical organization or clinical encounter—or at a minimum, a bunch of boards in that front door. Patients see RCM, they see it clearly, and they may judge their patient experience accordingly.
So, let's just start here. Revenue cycle management is basically the entire mechanism by which healthcare gets paid for:
• Front end—figuring out if a patient is covered before they even see anyone
• Middle—the actual clinical encounter (again, the coding, the documentation)
• Back end—the claim, the adjudication, the appeals, the whole slow-motion tug-of-war between the provider and the payer about who owes what to whom
And look, in a rational world, this would be a footnote—a necessary but boring administrative function like, I don't know, invoicing. Instead, it is a 200-plus-billion-dollar industry. Some people say it's creeping toward being a fifth, some say a third, just some meaningful fraction of every healthcare dollar spent in this country is spent not on care. It is spent on the fight about getting payment for the care.
Andrew Tsang and I, in the conversation that follows, we came up with a phrase for this; and I will be using this phrase for the rest of my natural life, which is that revenue cycle management is basically an endless game of hot potato.
Everybody—patients, providers, payers, employers who are self-funding their own health plans—everybody is trying very hard to, kind of like, not be the one left holding the financial bag when the music stops.
And because almost nobody at almost any point really sat down to put the infrastructure in place to decide prospectively who is actually going to be responsible for what, the hot potato just gets passed around and around; and whoever has the least leverage, the least administrative skills in any particular moment is the one who winds up eating the cost.
Sometimes that's the patient who, like, thought their colonoscopy was a free preventative screening; and then suddenly it's diagnostic and there's a bill on the kitchen counter. Surprise.
Sometimes it's the independent physician practice, you know, like Sheila at the front desk, who's doing eight prior authorizations a day with none of the administrative army that a big, consolidated health system has.
And sometimes it's like the two-person HR department at a 500-person self-funded employer who just found out one of their employees needs a fantastically expensive medical miracle, maybe, kind of treatment that just got lasered out of their stop-loss coverage this year.
That hot potato is a big deal, and no one wants to wind up with it either from the "paying for it" side or maybe from the "not getting paid" side.
We're not talking about villains here. That's the part that gets me sometimes. This isn't a story about villains. It's a story about an industry that built an entire multibillion-dollar economy around having claim-by-claim fistfights. May the odds forever be in your favor, I guess.
So, today I'm talking with, again, Andrew Tsang, who is right now an independent healthcare analyst. He has been writing about healthcare full-time and, through that, doing industry analysis on healthcare markets, healthcare institutions, just the overall business and policy therein.
Prior to that, yeah, he spent a lot of time in the trenches of revenue cycle management and is so uniquely qualified to discuss how incentives in the healthcare industry these days really reward those who are able to out-administer or out-leverage, rather than oftentimes much to do with providing great patient care.
I did ask Andrew for advice. I asked whether there's actually a way to opt out of this hot potato game entirely, and yeah, there is. It's funny how often direct contracting has been coming up lately.
This podcast is sponsored by Aventria Health Group. I want to also thank our 2026 series underwriter, Payerset, for their support and also Patient Rights Advocate, who gave us a really, really nice donation to help further our work.
Lastly, thank you so much to Arielle Bose, who gave us a really nice donation the other day that we are going to use to pay for our annual subscription to our newsletter vendor. Thank you so much.
Okay … so, this is a good one. Let's get into it. Here is my conversation with Andrew Tsang.
Also mentioned in this episode are Stan Schwartz, MD; ZERO.health; Aventria Health Group; Payerset; Patient Rights Advocate; Arielle Bose; Zack Kanter; David Scheinker, PhD; Sheri Mancini, MD, FACS; Sarah Emond; and Tom Nash.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at Andrew's Substack and follow him on LinkedIn.
Andrew Tsang is a healthcare writer and advisor with over 15 years of experience across providers, payers, consulting, and policy. His work explores how the American healthcare system actually operates—the revenue cycles, organizational structures, and invisible processes that shape outcomes for everyone involved.
Through his Substack, Health Is Other People, Andrew writes long-form essays and builds interactive data visualizations that make the machinery of healthcare legible to the people working inside it.
Previously, Andrew held consulting roles at Deloitte, Chartis, and Point B. He is currently writing The Cycle, a book about how the American healthcare revenue cycle shapes—and traps—American culture.
00:00 Introduction to this episode.
02:13 What revenue cycle management is.
03:22 How RCM is an endless game of hot potato.
07:10 The conversation with Andrew Tsang.
07:16 LinkedIn post by Andrew (with Revenue Cycle Market Landscape interactive chart).
08:24 Is it actually a cycle?
08:54 How big the RCM industry actually is.
09:49 Defining revenue cycle management.
11:47 EP363 with David Scheinker, PhD.
12:13 Why patients may spend more time doing revenue cycle tasks than with their doctor.
16:49 LinkedIn post by Sheri Mancini, MD, FACS.
17:12 Who pays and why?
19:56 An example of RCM working within something like a colonoscopy.
22:55 The worst part about this whole revenue cycle.
24:49 How RCM affects independent doctors.
29:51 How RCM affects self-funded employers and stop-loss carriers.
Recent past interviews:
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Stacey Richter (EP520), Dr Lisa Rosenbaum, Claire Brockbank, Stacey Richter (EP517), Ophelia Johnson, Michelle Cera, Matt Cantor, Brennan Bilberry
NOTE This file was generated by Descript
00:00:00 --> 00:00:02 Episode 521.
00:00:02 --> 00:00:08 How Revenue Cycle Management, RCM, Became an Over $200
00:00:08 --> 00:00:12 Billion Healthcare Hot Potato.
00:00:12 --> 00:00:15 Today I am speaking with Andrew Tsang.
00:00:23 --> 00:00:27 American Healthcare Entrepreneurs and executives You Want to Know, Talking.
00:00:29 --> 00:00:31 Relentlessly Seeking Value.
00:00:33 --> 00:00:35 Hey, welcome to Relentless Health Value.
00:00:35 --> 00:00:41 Okay, so on today's show we are talking about, Andrew Tsang and I, Revenue
00:00:41 --> 00:00:48 Cycle Management, which I say this with real affection is maybe the least
00:00:48 --> 00:00:50 sexy phrase in all of healthcare.
00:00:50 --> 00:00:56 It sounds like a back office spreadsheet problem, but yet it is
00:00:56 --> 00:00:58 not a back office spreadsheet problem.
00:00:58 --> 00:01:03 It is in fact probably one of the most consequential forces shaping
00:01:03 --> 00:01:04 American healthcare right now.
00:01:04 --> 00:01:07 And most people, including a lot of people who work in healthcare
00:01:07 --> 00:01:11 do not actually understand what it is or how it got this big.
00:01:12 --> 00:01:17 So today I am so pleased to have Andrew Tsang explain
00:01:18 --> 00:01:19 Revenue Cycle Management, RCM.
00:01:19 --> 00:01:27 The 14 steps to RCM that begin before the patient encounter actually include
00:01:27 --> 00:01:31 the patient encounter, and then all of the back and forth afterwards.
00:01:31 --> 00:01:36 And Andrew makes a point that I have not heard made so precisely before.
00:01:36 --> 00:01:42 Many folks kind of bucket RCM into again, some backroom spreadsheet function.
00:01:42 --> 00:01:47 But if you think about this from the patient perspective, patients
00:01:47 --> 00:01:53 probably spend more time dealing with RCM type functions than they
00:01:53 --> 00:01:54 do getting clinical attention.
00:01:55 --> 00:01:58 RCM may actually be the front door of any given clinical
00:01:58 --> 00:02:01 organization or clinical encounter.
00:02:01 --> 00:02:04 Or at a minimum, a bunch of boards in that front door.
00:02:04 --> 00:02:06 Patients see RCM.
00:02:07 --> 00:02:11 They see it clearly, and they may judge their patient experience accordingly.
00:02:12 --> 00:02:13 So let's just start here.
00:02:14 --> 00:02:18 Revenue cycle management is basically the entire mechanism
00:02:18 --> 00:02:20 by which healthcare gets paid.
00:02:20 --> 00:02:26 For front end, figuring out if a patient is covered before they even see, anyone.
00:02:26 --> 00:02:27 Middle.
00:02:27 --> 00:02:31 The actual clinical encounter, again, the coding, the documentation.
00:02:31 --> 00:02:34 And then the backend, the claim, the adjudication, the appeals, the whole slow
00:02:34 --> 00:02:41 motion tug of war between the provider and the payer about who owes what to whom.
00:02:42 --> 00:02:46 And look, in a rational world, this would be a footnote, a necessary
00:02:46 --> 00:02:51 but boring administrative function like, I don't know, invoicing.
00:02:51 --> 00:02:56 Instead, it is a, 200 plus billion dollar industry.
00:02:56 --> 00:03:01 Some people say it's creeping toward being a fifth, some say a third,
00:03:01 --> 00:03:06 just some meaningful fraction of every healthcare dollar spent in
00:03:06 --> 00:03:08 this country is spent not on care.
00:03:08 --> 00:03:12 It is spent on the fight about getting payment for the care.
00:03:13 --> 00:03:16 Andrew Tsang and I, in the conversation that follows, we came up with a phrase
00:03:17 --> 00:03:21 for this, and I will be using this phrase for the rest of my natural life, which
00:03:21 --> 00:03:27 is that revenue cycle management is basically an endless game of hot potato.
00:03:27 --> 00:03:30 Everybody, patients, providers, payers, employers who are
00:03:30 --> 00:03:32 self-funding their own health plans.
00:03:32 --> 00:03:39 Everybody is trying very hard to, kind of like, not be the one left holding
00:03:39 --> 00:03:41 the financial bag when the music stops.
00:03:41 --> 00:03:46 And because almost nobody at almost any point really sat down to put the
00:03:46 --> 00:03:50 infrastructure in place to decide prospectively who is actually going
00:03:50 --> 00:03:54 to be responsible for what the hot potato just gets passed around and
00:03:54 --> 00:03:58 around, and whoever has the least leverage, the least administrative
00:03:58 --> 00:04:03 skills in any particular moment is the one who winds up eating the cost.
00:04:03 --> 00:04:07 Sometimes that's the patient who like thought their colonoscopy was
00:04:07 --> 00:04:10 a free preventative screening, and then suddenly it's diagnostic and
00:04:10 --> 00:04:12 there's a bill on the kitchen counter.
00:04:12 --> 00:04:12 Surprise.
00:04:13 --> 00:04:17 Sometimes it's the independent physician practice, you know, like
00:04:17 --> 00:04:21 Sheila at the front desk who's doing eight prior authorizations a day with
00:04:21 --> 00:04:25 none of the administrative army that a big consolidated health system has.
00:04:25 --> 00:04:31 And sometimes it's like the two person HR department at a 500 person self-funded
00:04:32 --> 00:04:36 employer who just found out one of their employees needs a fantastically
00:04:36 --> 00:04:41 expensive medical miracle maybe kind of treatment that just got lasered out
00:04:41 --> 00:04:42 of their stop loss coverage this year.
00:04:42 --> 00:04:47 That hot potato is a big deal and no one wants to wind up with it either
00:04:47 --> 00:04:53 from the paying for its side or maybe from the not getting paid side.
00:04:53 --> 00:04:54 We're not talking about villains here.
00:04:54 --> 00:04:56 That's the part that gets me sometimes.
00:04:56 --> 00:04:58 This isn't a story about villains.
00:04:58 --> 00:05:03 It's a story about an industry that built an entire multi-billion dollar economy
00:05:03 --> 00:05:07 around having claim by claim fist fights.
00:05:07 --> 00:05:10 May the odds forever be in your favor, I guess.
00:05:11 --> 00:05:13 Hi, I am Dr. Stan Schwartz from Zero.Health.
00:05:14 --> 00:05:17 Relentless Health Value has been a real source of insight and inspiration for me.
00:05:18 --> 00:05:22 Every episode feels like a thoughtful, informed conversation that really gets to
00:05:22 --> 00:05:23 the heart of what matters in healthcare.
00:05:24 --> 00:05:27 If you're committed to moving the needle in this space like I am, I
00:05:27 --> 00:05:31 strongly recommend subscribing to Relentless Health Value Newsletter.
00:05:31 --> 00:05:35 For me, it's the best way to keep up with new episodes and stay connected.
00:05:35 --> 00:05:36 Thanks for listening.
00:05:38 --> 00:05:41 So today I'm talking with, again, Andrew Tsang, who is right now an
00:05:41 --> 00:05:43 independent healthcare analyst.
00:05:44 --> 00:05:47 He has been writing about healthcare full time and through that doing
00:05:47 --> 00:05:51 industry analysis on healthcare markets, healthcare institutions, just the
00:05:51 --> 00:05:54 overall business and policy therein.
00:05:54 --> 00:05:59 Prior to that, yeah, he spent a lot of time in the trenches of revenue cycle
00:05:59 --> 00:06:03 management and is so uniquely qualified to discuss how incentives in the healthcare
00:06:03 --> 00:06:10 industry these days really reward those who are able to out, administer or out
00:06:10 --> 00:06:16 leverage, rather than oftentimes much to do with providing great patient care.
00:06:18 --> 00:06:20 I did ask Andrew for advice.
00:06:20 --> 00:06:24 I asked whether there's actually a way to opt out of this hot potato
00:06:24 --> 00:06:27 game entirely, and yeah, there is.
00:06:27 --> 00:06:32 It's funny how often direct contracting has been coming up lately.
00:06:32 --> 00:06:33 My name is Stacey Richter.
00:06:33 --> 00:06:36 This podcast is sponsored by Aventria Health Group.
00:06:37 --> 00:06:43 I want to also thank our 2026 Series Underwriter Payerset for their support
00:06:44 --> 00:06:49 and also Patient Rights Advocate who gave us a really, really nice
00:06:49 --> 00:06:51 donation to help further our work.
00:06:52 --> 00:06:55 Lastly, thank you so much to Ariel Bose who gave us a really nice
00:06:55 --> 00:06:59 donation the other day that we are going to use to pay for our annual
00:06:59 --> 00:07:01 subscription to our newsletter vendor.
00:07:01 --> 00:07:03 Thank you so much.
00:07:03 --> 00:07:04 Okay, so this is a good one.
00:07:04 --> 00:07:05 Let's get into it.
00:07:05 --> 00:07:08 Here is my conversation with Andrew Tsang.
00:07:10 --> 00:07:12 Andrew Tsang, welcome to Relentless Health Value.
00:07:12 --> 00:07:13 Thanks for having me, Stacey.
00:07:13 --> 00:07:16 It's humbling and an honor to be here.
00:07:16 --> 00:07:20 I have learned a lot from your writings and your LinkedIn posts.
00:07:20 --> 00:07:23 There is a couple of infographics that I would highly recommend.
00:07:23 --> 00:07:27 Today, however, we're gonna be talking about revenue cycle management,
00:07:27 --> 00:07:30 which is everyone's favorite topic.
00:07:30 --> 00:07:36 I say with, I don't know, some level of probably accuracy and also sarcasm.
00:07:36 --> 00:07:41 If you were gonna explain what revenue cycle management is just for
00:07:41 --> 00:07:42 our friends and family here, how?
00:07:42 --> 00:07:43 How would you do that?
00:07:44 --> 00:07:45 It's so funny.
00:07:45 --> 00:07:45 You're right.
00:07:45 --> 00:07:48 That is the vibe about revenue cycle management.
00:07:48 --> 00:07:53 First of all, it's such a jargon filled term when someone says revenue cycle.
00:07:53 --> 00:07:56 It is really the mechanism for healthcare finance, right?
00:07:56 --> 00:07:59 In healthcare, things aren't paid with cash.
00:07:59 --> 00:08:02 It's not just a agreed upon transaction.
00:08:02 --> 00:08:06 There is a service delivered and then there is generally a
00:08:06 --> 00:08:07 claim that comes along with it.
00:08:07 --> 00:08:14 And revenue cycle management is the entire end-to-end process prior to a
00:08:14 --> 00:08:19 patient encounter and after, and all the billing and payment and write off
00:08:19 --> 00:08:24 mechanisms that go into adjudicating these claims and getting providers paid.
00:08:24 --> 00:08:27 I know one of the things that you have written more than once
00:08:27 --> 00:08:29 is that, is it actually a cycle?
00:08:29 --> 00:08:30 It's really misleading.
00:08:30 --> 00:08:35 Like it's funny how I talk to like digital health companies
00:08:35 --> 00:08:39 and healthcare institutions and everybody has to do revenue cycle.
00:08:39 --> 00:08:40 It is inevitable.
00:08:40 --> 00:08:41 Yeah.
00:08:41 --> 00:08:42 It's not really a cycle.
00:08:42 --> 00:08:45 I wouldn't call it episodic, but it is a transaction.
00:08:45 --> 00:08:51 Revenue cycle management is just a necessary component of the
00:08:51 --> 00:08:54 entire process that it takes to get healthcare finance moving.
00:08:54 --> 00:08:56 Is this a very big industry?
00:08:56 --> 00:08:57 What are we talking about here?
00:08:57 --> 00:08:59 Is it a massive industry?
00:08:59 --> 00:09:00 Absolutely, it is.
00:09:00 --> 00:09:03 It is, by some estimates., it for sure, it's a nine figure
00:09:04 --> 00:09:05 industry, let's put it that way.
00:09:06 --> 00:09:12 I've done my own math on it, and I came out to about $217 billion in
00:09:13 --> 00:09:19 market cap related to the companies that do all the services around
00:09:19 --> 00:09:20 revenue cycle, which we'll get into.
00:09:21 --> 00:09:24 Investors have forecasts showing that revenue cycle is
00:09:24 --> 00:09:26 just a massive growing market.
00:09:26 --> 00:09:30 People even estimate that it is like a, you know, 20, 30%
00:09:30 --> 00:09:32 of our healthcare industry.
00:09:32 --> 00:09:42 RCM, it is a little bit ill-defined, especially with this growing spidery web
00:09:42 --> 00:09:48 of the vendors and actions and reactions, et cetera that we have right now.
00:09:49 --> 00:09:52 But if you were going to define what are the different pieces that
00:09:52 --> 00:09:56 you are thinking about relative to revenue cycle management?
00:09:56 --> 00:09:57 How would you do it?
00:09:58 --> 00:10:04 It's often construed that revenue cycle management is this back office function,
00:10:04 --> 00:10:07 but nope, it's not that revenue cycle management, it can be broken down
00:10:07 --> 00:10:12 into three sections, like the front end, the middle, and the back end.
00:10:12 --> 00:10:15 In the front end, it's everything that happens prior to your visit.
00:10:16 --> 00:10:20 So when you get scheduled for an appointment, everything from checking your
00:10:20 --> 00:10:24 insurance and eligibility verification.
00:10:24 --> 00:10:25 Getting prior auths.
00:10:25 --> 00:10:29 Everything prior to your clinical encounter is the front end.
00:10:29 --> 00:10:33 Then in the middle is where the clinical encounter happens, and
00:10:33 --> 00:10:40 honestly, that's probably like the shortest activity of the admin there.
00:10:40 --> 00:10:44 Where at the coding, the charge capture, like different quality
00:10:44 --> 00:10:46 measures and clinical documentation.
00:10:46 --> 00:10:50 And then really what people often think about the revenue cycle is, and this is
00:10:50 --> 00:10:55 where it fits into people's kind of mental mind, is the backend function of it.
00:10:56 --> 00:10:59 Once all that stuff is captured, like the codes, then a claim is put
00:10:59 --> 00:11:06 together and it's sent on this wild ride of going through a clearing
00:11:06 --> 00:11:11 house and you know, getting scrubbed and meeting the payer's format.
00:11:11 --> 00:11:14 And then the payer adjudicates it and makes a decision if
00:11:14 --> 00:11:16 they're gonna pay it or not.
00:11:16 --> 00:11:18 If they're gonna pay it in full or impartial, they have
00:11:18 --> 00:11:20 to look up some contracts.
00:11:20 --> 00:11:21 It's a whole thing.
00:11:21 --> 00:11:24 Then there's the denial and appeal process.
00:11:25 --> 00:11:29 Like the payment posting process, charity care and write offs happens here too.
00:11:29 --> 00:11:34 It's a whole process that spans like a large part of
00:11:34 --> 00:11:37 the kind of medical encounter.
00:11:38 --> 00:11:41 For two additional shows that you might wanna listen to, if you really
00:11:41 --> 00:11:45 wanna dig into what Andrew just said is definitely the show with the Zach
00:11:45 --> 00:11:51 Kanter on clearing houses and the show with David, Dr. David Scheinker on the
00:11:51 --> 00:11:55 admin burden, because there's a couple of deep dives into the things that
00:11:55 --> 00:11:56 you were just talking about Andrew.
00:11:57 --> 00:12:00 You said you, the way that you think about revenue cycle RCM
00:12:00 --> 00:12:03 these days is that there's a front, there's a middle and a back.
00:12:04 --> 00:12:07 And a lot of times people just kind of contemplate the back because that's where,
00:12:07 --> 00:12:09 dare I say, the magic happens, right?
00:12:09 --> 00:12:11 Like and the fight happens.
00:12:11 --> 00:12:15 If we're talking about this front door though, there is something that you said
00:12:15 --> 00:12:21 or wrote at one point that really struck me and that was that patients might
00:12:21 --> 00:12:27 actually spend more time doing revenue cycle stuff than seeing their doctor.
00:12:27 --> 00:12:28 Oh, absolutely.
00:12:28 --> 00:12:33 Like you said, this metastasized growth of, administrative burden.
00:12:33 --> 00:12:38 It doesn't just impact medical practices or hospitals or even
00:12:38 --> 00:12:41 like the staff it takes to manage this process on the insurance side.
00:12:42 --> 00:12:46 It really bleeds out to even the front end and how it
00:12:46 --> 00:12:50 impacts the patient's experience accessing our healthcare system.
00:12:50 --> 00:12:51 Right?
00:12:51 --> 00:12:54 Everybody talks about the most critical parts of our healthcare
00:12:54 --> 00:12:58 system being a trade off between cost, quality and access.
00:12:59 --> 00:13:04 And quite frankly, access is how people can, you know, getting medicine
00:13:04 --> 00:13:06 or getting treatment for an illness.
00:13:06 --> 00:13:10 Because of the revenue cycle burden you need to have an insurance
00:13:10 --> 00:13:12 card in America to get healthcare.
00:13:12 --> 00:13:17 You need to like navigate your benefit design to figure out what you
00:13:17 --> 00:13:20 can have covered by your insurance.
00:13:20 --> 00:13:25 When you try to get scheduled with them a lot of that lead time is just
00:13:25 --> 00:13:29 due to the fact that they need some administrative process to verify the
00:13:29 --> 00:13:31 insurance and check the eligibility.
00:13:31 --> 00:13:37 So really revenue cycle becomes an access issue for patients and they spend
00:13:37 --> 00:13:41 more time trying to navigate the stuff, looking at their benefits brochures
00:13:41 --> 00:13:43 than they do actually receiving care.
00:13:44 --> 00:13:48 Because Wow, to your exact point, has this bled into your
00:13:48 --> 00:13:50 average patient's consciousness.
00:13:50 --> 00:13:53 For example, I was on Reddit the other day.
00:13:53 --> 00:13:56 I'm not proud, but I probably do spend way too much time over there.
00:13:56 --> 00:14:03 There was probably a 450 posts conversation.
00:14:03 --> 00:14:06 These are patients talking to patients that these days prior
00:14:06 --> 00:14:07 auth is not a guarantee of payment.
00:14:07 --> 00:14:11 It is simply a certification of medical necessity and, right
00:14:11 --> 00:14:16 like, you have patients that are understanding the nuance.
00:14:16 --> 00:14:20 I'm not, certainly not saying everyone, but yeah, they definitely are spending
00:14:20 --> 00:14:23 more time doing this than they are seeing their doctor, and that is
00:14:23 --> 00:14:27 certainly something that we all should spend a moment and, and think about.
00:14:28 --> 00:14:33 There is this huge component where, heck, you need a MHA, Masters
00:14:33 --> 00:14:36 of Healthcare Administration to navigate some of this stuff.
00:14:36 --> 00:14:40 It's incredibly burdensome on everybody involved, including
00:14:40 --> 00:14:40 the payer and the provider.
00:14:41 --> 00:14:45 If you want to succeed in the US healthcare industry, it's not
00:14:45 --> 00:14:46 just being a have or have not.
00:14:47 --> 00:14:48 That matters too.
00:14:50 --> 00:14:53 It's also being a know or a know-not you have to be a have and a know
00:14:54 --> 00:15:00 because, and one of the reasons why is frankly, I mean we probably could
00:15:00 --> 00:15:02 put this on revenue cycle management.
00:15:03 --> 00:15:12 It's almost like this whole industry has evolved to organically and
00:15:13 --> 00:15:19 in a case by case transactional way, solve the hot potato problem.
00:15:20 --> 00:15:22 It's like that trolley.
00:15:22 --> 00:15:25 You have to decide whether you're gonna run over the old lady or the
00:15:25 --> 00:15:28 three children, or I forget exactly what it is, but you actually have to
00:15:28 --> 00:15:31 make an upfront, proactive choice.
00:15:32 --> 00:15:38 The trolley problem is arguably one of the most famous moral thought experiments
00:15:38 --> 00:15:43 involving hypothetical ethical dilemmas about whether to sacrifice one person
00:15:44 --> 00:15:46 to save a larger number of people.
00:15:46 --> 00:15:51 It is usually a scenario where a runaway trolley is on course to collide
00:15:51 --> 00:15:56 with and kill a number of people, traditionally five, who are tied to the
00:15:56 --> 00:16:01 tracks, but a bystander can intervene and divert the vehicle to kill just
00:16:01 --> 00:16:03 one person on a different track.
00:16:04 --> 00:16:09 So if your mind works the same way as mine, you can see why I thought of this
00:16:09 --> 00:16:16 in the context of trying to proactively determine who, not only just from a
00:16:16 --> 00:16:23 policy perspective, but who actually always is going to get access to some of
00:16:23 --> 00:16:30 these really, really expensive medical miracles and who proactively is not.
00:16:31 --> 00:16:33 And it is a very difficult choice to make.
00:16:33 --> 00:16:37 So it's easier and maybe more palatable to just be like, okay, well we'll
00:16:37 --> 00:16:38 just see whatever the driver picks.
00:16:38 --> 00:16:41 because I don't wanna take responsibility for whatever happened there.
00:16:41 --> 00:16:43 It's almost like revenue cycle management is the same thing.
00:16:43 --> 00:16:47 We have uncontrollable price increases.
00:16:47 --> 00:16:49 We have market failures all over the place.
00:16:49 --> 00:16:53 I keep reading Sherry Mancini's posts about infrastructure, but in the
00:16:53 --> 00:16:58 absence of that, you have healthcare inflation that is wildly over CPI
00:16:58 --> 00:16:59 and no one wants to pay for it.
00:17:00 --> 00:17:04 So this whole revenue cycle management, if I just wanna drill this down into
00:17:04 --> 00:17:09 a philosophical construct here it is basically like us not wanting to play
00:17:09 --> 00:17:11 the trolley game up front, right?
00:17:11 --> 00:17:15 We're just like, who's gonna get left with this hot potato?
00:17:16 --> 00:17:18 Like, who's not gonna pay for this, or who's gonna get paid?
00:17:18 --> 00:17:25 Let's just tussle it out and see who the stronger fighter is on kind of
00:17:25 --> 00:17:28 a transaction by transaction basis.
00:17:29 --> 00:17:34 It really is that because ultimately who, who pays and why, that's
00:17:34 --> 00:17:34 really the question, right?
00:17:34 --> 00:17:36 Who pays and why?
00:17:36 --> 00:17:39 And in a game of hot potato at school, right?
00:17:39 --> 00:17:42 When you're playing with the kids, like the slowest person loses, right?
00:17:42 --> 00:17:44 The the person who gets caught with hot potato.
00:17:44 --> 00:17:45 It's a little different in healthcare.
00:17:45 --> 00:17:49 It's the person who's weakest, the party that doesn't have the
00:17:49 --> 00:17:51 leverage to deal with this system.
00:17:51 --> 00:17:54 And who pays and why is a number of things.
00:17:54 --> 00:17:58 Obviously the payer should pay, but to what extent, because we
00:17:58 --> 00:18:00 are talking about insurance here.
00:18:00 --> 00:18:04 It's not like, Oh, I get sick and all of a sudden I get everything that
00:18:04 --> 00:18:05 happens to me deserves to be paid for.
00:18:06 --> 00:18:08 Well, you're in a pool with other people.
00:18:08 --> 00:18:11 You're probably in a pool with your coworkers.
00:18:11 --> 00:18:14 If you are part of a company that is like self-funded, you are
00:18:14 --> 00:18:16 part of a carrier's pool, right?
00:18:16 --> 00:18:22 And ultimately actuarially, someone in this pool will incur
00:18:22 --> 00:18:25 an outrageously tremendous cost.
00:18:25 --> 00:18:29 Premature baby, or maybe to have a major surgery that was unexpected,
00:18:29 --> 00:18:33 or maybe someone is prescribed, like something really expensive.
00:18:33 --> 00:18:36 Who pays and why is really the question of this.
00:18:36 --> 00:18:40 And it's really easy to say that, yes, everybody should
00:18:40 --> 00:18:41 be entitled to all this stuff.
00:18:42 --> 00:18:47 And as a human, yeah, I think so too but we live in a society.
00:18:47 --> 00:18:52 We live in a society where there are resource constraints and these
00:18:52 --> 00:18:54 decisions kind of have to be made.
00:18:54 --> 00:18:59 And we've kind of decided to outsource this to this process, essentially.
00:18:59 --> 00:19:03 And this process really just makes it worse.
00:19:03 --> 00:19:07 Like the, the cure is worse than the disease in this figurative case here,
00:19:07 --> 00:19:13 because now people, everybody has to go through the same hoop jumping, the same
00:19:13 --> 00:19:18 hold times the same, let me navigate to this blue and white website with
00:19:18 --> 00:19:23 stock photos of seniors on their like computers and oh, let me figure out which
00:19:23 --> 00:19:25 thing I need to do and it's impossible.
00:19:25 --> 00:19:29 So then people end up going to Reddit threads or asking their friends or
00:19:29 --> 00:19:34 asking their healthcare adjacent friends to help them navigate this
00:19:34 --> 00:19:35 because who knows where to start.
00:19:35 --> 00:19:39 Because the fundamental question of who pays and why isn't
00:19:39 --> 00:19:41 ever really clearly answered.
00:19:41 --> 00:19:45 I think just another ground truth is exactly what you just said, that in
00:19:45 --> 00:19:47 this country we are revenue constraints.
00:19:48 --> 00:19:51 No one makes, wants to make a sweeping decision.
00:19:51 --> 00:19:56 Therefore, we spend $217 billion playing hot potato.
00:19:56 --> 00:20:01 So let's talk about the example of like, let's just say a colonoscopy, some service
00:20:01 --> 00:20:03 like that, which is sort of expensive.
00:20:03 --> 00:20:07 It's mandated that from a screening perspective, the US I think preventative
00:20:07 --> 00:20:12 task force has some kind of timing interval on that over a certain age.
00:20:12 --> 00:20:16 But let's just say we're dealing with a patient who meets these criteria.
00:20:16 --> 00:20:20 How does rev cycle work in this case?
00:20:20 --> 00:20:22 Again, front, middle, back.
00:20:22 --> 00:20:24 That's a great example, right?
00:20:24 --> 00:20:29 Because of the ACA, they say it's a free screening, so hey, it says it.
00:20:29 --> 00:20:31 It's mandated that it should be free.
00:20:31 --> 00:20:35 The front desk and registration, they're verifying the patient's
00:20:35 --> 00:20:38 insurance, getting an authorization.
00:20:38 --> 00:20:42 The patient actually goes to do the clinical encounter and they find a couple
00:20:42 --> 00:20:47 polyps and you know what, because they actually did the right thing during
00:20:47 --> 00:20:51 the clinical encounter and removed those polyps, that actually changed
00:20:51 --> 00:20:52 everything that happened before it.
00:20:52 --> 00:20:56 It ended up flipping the procedure to be a diagnostic procedure.
00:20:57 --> 00:21:00 Okay, so patient went in for their free screening colonoscopy.
00:21:01 --> 00:21:01 Mm-hmm.
00:21:02 --> 00:21:06 Again, you know, let's just also acknowledge pricing differentials
00:21:06 --> 00:21:09 between different hospitals, because you have some hospitals where a screening
00:21:09 --> 00:21:13 colonoscopy, you know the charge is gonna be $3, and then you have others
00:21:13 --> 00:21:16 where it's 12, 15, right, or higher.
00:21:16 --> 00:21:19 So there's some big money that could be at play here.
00:21:21 --> 00:21:26 The second that a polyp is discovered, now all of a sudden it's not a
00:21:26 --> 00:21:27 screening colonoscopy anymore.
00:21:27 --> 00:21:31 It's considered a diagnostic one because they're doing stuff with
00:21:31 --> 00:21:33 this polyp and now it's not covered.
00:21:33 --> 00:21:37 So you're a patient, you go in for a free thing, and now all of a sudden you
00:21:37 --> 00:21:42 get hit on the back end after it goes through this whole, you know, cycle.
00:21:43 --> 00:21:46 And the hot potato comes on the patient who now has to meet their
00:21:46 --> 00:21:48 deductible or whatever, whatever it is.
00:21:49 --> 00:21:50 Did I get that right?
00:21:51 --> 00:21:52 It's not even just deductible.
00:21:52 --> 00:21:55 So now the case has changed.
00:21:55 --> 00:21:59 The provider, they have to send that to, like the pathologist to
00:21:59 --> 00:22:03 determine whether or not the polyps indicate anything more malignant.
00:22:04 --> 00:22:06 Then that has to get captured and charged.
00:22:06 --> 00:22:09 That just changes the entire nature of the clinical encounter.
00:22:10 --> 00:22:13 And then, then there's gonna be this back and forth, right?
00:22:13 --> 00:22:14 Like, Hey, wait a minute.
00:22:14 --> 00:22:18 You said they were coming in for like a screening colonoscopy, but now you're
00:22:18 --> 00:22:20 charging us for a diagnostic one.
00:22:20 --> 00:22:21 This costs more.
00:22:21 --> 00:22:24 And then there's gonna be 12 weeks of back and forth between the
00:22:24 --> 00:22:25 payer and the provider, right?
00:22:25 --> 00:22:27 They're, they're sending faxes to each other.
00:22:27 --> 00:22:29 They're calling each other through their portals.
00:22:29 --> 00:22:32 In the meantime, systems aren't talking to each other.
00:22:32 --> 00:22:37 The patient gets this EOB and then they get a bill that they didn't
00:22:37 --> 00:22:38 expect 'cause they thought it was free.
00:22:38 --> 00:22:39 Right?
00:22:39 --> 00:22:42 And ultimately, yes, the patient probably shouldn't pay for it and they might not
00:22:42 --> 00:22:45 have to, but that doesn't, you know, that's not their experience, right?
00:22:45 --> 00:22:49 The patient gets this in the mail and is sitting on their kitchen countertop and
00:22:49 --> 00:22:50 they're just like stressing about it.
00:22:50 --> 00:22:52 It's like, wait a minute, I thought I did everything right and now you're telling
00:22:52 --> 00:22:55 me there's some mistake that I did wrong.
00:22:55 --> 00:22:57 And the worst part about this, by the way, is the patients
00:22:57 --> 00:22:59 internalize this as their fault.
00:22:59 --> 00:23:03 The revenue cycle and the healthcare industry has taught patients that
00:23:03 --> 00:23:08 like you should have been more careful in figuring this out.
00:23:09 --> 00:23:12 Therefore, this whole headache is kind of because of you a little bit.
00:23:13 --> 00:23:15 And that's a real bad problem for everybody.
00:23:15 --> 00:23:20 Because then patients are deterred from utilizing healthcare in the
00:23:20 --> 00:23:24 ways that they should, which is in a preventative way and reducing costs later.
00:23:24 --> 00:23:29 Yeah, and anyone, I know that there's a lot of talk these days about having
00:23:29 --> 00:23:34 catastrophic coverage and then having, you know, giving everyone a certain chunk of
00:23:34 --> 00:23:37 change and then they shop for services.
00:23:37 --> 00:23:43 It is things like this that definitely would need to be taken under consideration
00:23:43 --> 00:23:47 because you have a patient who shopped, or like, let's just say that they checked,
00:23:47 --> 00:23:51 they looked at the codes for a screening colonoscopy, and they found the entity
00:23:51 --> 00:23:56 that had the cheapest prices and maybe that entity knew that people were shopping
00:23:56 --> 00:23:57 right, and put the screening colonoscopy.
00:23:57 --> 00:24:01 I don't know what percentage of screening colonoscopies turn into a diagnostic
00:24:01 --> 00:24:07 colonoscopy, but it would take a really, let's just say, a really strong shopper
00:24:07 --> 00:24:10 to figure out that you don't look at the screening colonoscopy number, you
00:24:10 --> 00:24:13 look at the diagnostic colonoscopy number, and also you gotta figure
00:24:13 --> 00:24:15 out if there's a facility fee here.
00:24:15 --> 00:24:17 And also you gotta figure out how much the pathologist is
00:24:17 --> 00:24:19 gonna cost and how much the path.
00:24:19 --> 00:24:21 And then the person who reads that, if there's like any
00:24:21 --> 00:24:23 imaging or anything like that.
00:24:24 --> 00:24:29 Like you start thinking about how difficult it is to actually shop and if
00:24:29 --> 00:24:33 I wanted to, to shuffle ducks, right?
00:24:33 --> 00:24:35 Someone who thinks they've got their ducks in a row and I wanna shuffle
00:24:35 --> 00:24:38 them, I just make the screening colonoscopy super cheap, and then I
00:24:38 --> 00:24:40 make everything else really expensive.
00:24:40 --> 00:24:43 And I have just undermine anyone who's trying to shop.
00:24:44 --> 00:24:46 So just saying.
00:24:46 --> 00:24:48 Let me give you another example, Andrew.
00:24:49 --> 00:24:53 Let's just say though that we've got an independent doctor trying to
00:24:53 --> 00:24:56 play hot potato with a big payer.
00:24:57 --> 00:25:00 You sort of said the weakest one catches the hot potato.
00:25:00 --> 00:25:06 Independent doctors provider organizations tend to be not necessarily have a
00:25:06 --> 00:25:10 position of strength when dealing with some of these large payer organizations.
00:25:10 --> 00:25:11 What's a case study there?
00:25:12 --> 00:25:16 Yeah, well, so for the indie practices, just like everything else.
00:25:16 --> 00:25:20 It's funny in the healthcare system, everybody is, I would say oppressed a
00:25:20 --> 00:25:24 little bit, but it's definitely clear in the healthcare industry it favors scale.
00:25:24 --> 00:25:29 That's why we see M&As we see like massive growth and people are trying
00:25:29 --> 00:25:31 to like expand their footprints.
00:25:31 --> 00:25:34 It's a little bit of like, okay, how can you know this capitalism?
00:25:34 --> 00:25:38 But another part of it is also, Hey, look, it favors scale because
00:25:38 --> 00:25:40 they are more resources this way.
00:25:40 --> 00:25:46 A major health system has a whole floor of people in an office like end-to-end walls
00:25:46 --> 00:25:52 of cubicles of people doing medical coding call centers full of people appealing
00:25:52 --> 00:25:54 and sending claims and faxing things.
00:25:54 --> 00:25:58 They have whole registration desks to make sure they're doing all this
00:25:58 --> 00:26:01 administrative work, which is why you see that really famous chart of
00:26:01 --> 00:26:05 the healthcare administrator growth compared to the flat clinician growth.
00:26:05 --> 00:26:09 So the point that you're making is that if you're an indie doctor, you've got
00:26:09 --> 00:26:12 Sheila and Frank in the front office.
00:26:12 --> 00:26:14 It is a small operation with limited people.
00:26:15 --> 00:26:20 If you are a pick, a consolidated health system, you have the market
00:26:20 --> 00:26:25 leverage to get higher prices, and one of the things then you can do with the
00:26:25 --> 00:26:30 dollars that you have now collected is have floors in your building that
00:26:30 --> 00:26:35 are filled with administrators who are involved in the RCM Hot Potato game.
00:26:36 --> 00:26:39 And the more administrative support that you have, the stronger position you have
00:26:39 --> 00:26:45 actually to manage, to get paid and to have anti-competitive contracts so that
00:26:45 --> 00:26:50 your bills can't be audited to do a lot of the different things that an indie
00:26:50 --> 00:26:53 provider just is not gonna be able to do.
00:26:53 --> 00:26:57 Yeah, I mean, the administrative burden for this is just incredibly high.
00:26:57 --> 00:26:58 Let's just be honest about that.
00:26:58 --> 00:26:59 And, and it's, it's a cycle.
00:26:59 --> 00:27:00 It feeds itself.
00:27:01 --> 00:27:03 Because a prior auth rule just pops up, right?
00:27:03 --> 00:27:08 And you know, between like a 200 physician system, they have whole
00:27:08 --> 00:27:11 departments to help them deal with this new prior auth rule.
00:27:11 --> 00:27:14 Or maybe it's like some compliance measure to comply with some
00:27:14 --> 00:27:15 regulation from the state.
00:27:15 --> 00:27:16 It doesn't matter.
00:27:17 --> 00:27:21 The three doc practice does not have the same resource to deal with that.
00:27:22 --> 00:27:22 What is it?
00:27:22 --> 00:27:28 I think somewhere the average politician does about 39 prior auths a week, so about
00:27:28 --> 00:27:30 eight a day or so in a five day work week.
00:27:31 --> 00:27:33 And a whole health system has a department for do this.
00:27:33 --> 00:27:38 But the indie practice, like Sheila at the front desk, she mans the phone call.
00:27:38 --> 00:27:42 She's rescheduling, she's getting signatures for the school forms
00:27:42 --> 00:27:44 or something like that, right?
00:27:44 --> 00:27:47 And she has to do all this stuff in the meantime, deal with this huge
00:27:47 --> 00:27:49 administrative burden just to get paid.
00:27:49 --> 00:27:51 So what happens is then, you know, denials.
00:27:51 --> 00:27:52 There are rules to this.
00:27:52 --> 00:27:54 There's timely filing requirements, there's things like that.
00:27:54 --> 00:27:57 So these things just age out, they get written off.
00:27:57 --> 00:28:01 And these small practices, they ultimately lose a ton of revenue for this.
00:28:01 --> 00:28:02 They lose hours, they lose time.
00:28:03 --> 00:28:05 Now I just wanna make a, a, an important point here.
00:28:06 --> 00:28:06 Okay.
00:28:06 --> 00:28:07 What's the goal?
00:28:07 --> 00:28:11 The goal is to ensure that we're containing costs,
00:28:11 --> 00:28:12 making healthcare affordable.
00:28:12 --> 00:28:13 That is ultimately the goal.
00:28:14 --> 00:28:19 Now we've got this metastasized Franken machine where honest actors who are just
00:28:19 --> 00:28:20 trying to get care for their patients.
00:28:20 --> 00:28:24 I just read something the other day that the reason, the stated
00:28:24 --> 00:28:27 reason that most clinicians are leaving the practice of medicine
00:28:27 --> 00:28:29 is because of inner quotes, hassle.
00:28:29 --> 00:28:33 For example, primary care doctors who gets seven prior auths and you know what?
00:28:33 --> 00:28:34 They tell that patient, you know what?
00:28:34 --> 00:28:35 Just go to the emergency room.
00:28:35 --> 00:28:36 Just go to the emergency room.
00:28:36 --> 00:28:37 They don't have prior auth there.
00:28:37 --> 00:28:39 Okay, so now everybody's prices go up.
00:28:39 --> 00:28:39 Are you kidding me?
00:28:40 --> 00:28:43 Additionally, you've got indie practices who are like, I just can't even deal
00:28:43 --> 00:28:48 with this for all the, I need a wall of administrators, so I'm just gonna go work.
00:28:48 --> 00:28:51 You have the majority of doctors these days that are going to work for
00:28:51 --> 00:28:52 these consolidated health systems.
00:28:52 --> 00:28:56 The more health systems consolidate, everybody knows at this juncture,
00:28:56 --> 00:28:58 the higher healthcare costs are gonna go up for everybody.
00:28:58 --> 00:29:02 So here we have, it's like there's probably some cliche where you're
00:29:02 --> 00:29:06 trying to do one thing and you fail so miserably you actually make it worse.
00:29:06 --> 00:29:07 Oh yeah.
00:29:07 --> 00:29:11 I mean, this is the perverse incentive that it creates too, through revenue
00:29:11 --> 00:29:16 cycle management is, right now the performance of our healthcare
00:29:16 --> 00:29:19 systems aren't on clinical outcomes.
00:29:19 --> 00:29:22 It's not the best doctors get out, competed on who has the best medicine.
00:29:23 --> 00:29:24 It gets outs staffed on paperwork.
00:29:24 --> 00:29:26 That's really what it comes down to.
00:29:26 --> 00:29:30 Your practice can stay afloat because you can handle the paperwork the best
00:29:30 --> 00:29:33 is really what it comes down to as opposed to having the best outcomes.
00:29:33 --> 00:29:37 And that's, that's sad because that's not what we want for our healthcare system.
00:29:38 --> 00:29:41 So we invest all this time and energiy and make it so that if you're
00:29:41 --> 00:29:44 not keeping up with the Joneses on this, then you can't compete.
00:29:44 --> 00:29:47 So yeah, people are gonna burn out and the whole system just degrades,
00:29:48 --> 00:29:51 and instead it just feeds this monster that just continues to grow.
00:29:51 --> 00:29:55 What about an instance where there's a self-funded employer involved
00:29:55 --> 00:29:57 and maybe even a stop-loss carrier.
00:29:57 --> 00:30:02 That's another entity that could, often enough does wind
00:30:02 --> 00:30:04 up catching the hot potato?
00:30:04 --> 00:30:07 Is there anything mentionable there?
00:30:08 --> 00:30:12 Say you're working for a company that has like 600 employees and they self fund.
00:30:13 --> 00:30:17 They have this pool of money that pays claims directly.
00:30:17 --> 00:30:21 And these claims sometimes can be astronomically large.
00:30:21 --> 00:30:24 I mean, that's just the nature of modern medicine.
00:30:24 --> 00:30:29 We're seeing so many really high cost encounters, and that's actually a
00:30:29 --> 00:30:33 miracle due to like medical science, we have cell and gene therapies.
00:30:33 --> 00:30:39 I think there's something, a stat I saw a while ago about 40 new gene therapies
00:30:39 --> 00:30:41 that are gonna cost nearly $4 million.
00:30:42 --> 00:30:47 So that means that in your 600 person pool, someone might be eligible to get
00:30:47 --> 00:30:53 that treatment that costs millions that could like potentially bankrupt your pool.
00:30:53 --> 00:30:56 Those self-funded employers need to, they need to buy stop loss
00:30:56 --> 00:30:59 this reinsurance that protects them from these catastrophic claims.
00:30:59 --> 00:31:01 Well, what happens then?
00:31:01 --> 00:31:03 Like, yeah, the first year that worked out good, but then the second year,
00:31:03 --> 00:31:09 by the way, they have to laser out this case and functionally say that
00:31:09 --> 00:31:13 this employee is now uninsurable.
00:31:13 --> 00:31:20 Essentially they are saying that, look, we can't afford to be paying for this medical
00:31:20 --> 00:31:23 treatment for year two and year three, if you know, if that happens to go on.
00:31:24 --> 00:31:27 So what they do is they laser that out and who catches the hot potato there?
00:31:27 --> 00:31:27 Right?
00:31:27 --> 00:31:30 So, it is a tough situation to be in.
00:31:30 --> 00:31:30 Yeah.
00:31:30 --> 00:31:36 I think in the past it's been 5% of plan members or about 50% of the costs.
00:31:36 --> 00:31:39 I just heard someone say the other day that these days, just given the cell
00:31:39 --> 00:31:44 and gene that you were talking about, given just the medical advances, that
00:31:45 --> 00:31:51 2% of plan members are gonna be 50% of the cost in any given plan year.
00:31:52 --> 00:31:54 And to your exact point, I definitely would go back and listen to the
00:31:54 --> 00:31:59 episode with Sarah Emond because she makes this point very crisply.
00:31:59 --> 00:32:01 These are medical miracles.
00:32:01 --> 00:32:05 We're saving people's lives, like people that had a death sentence
00:32:05 --> 00:32:07 now have the potential to be saved.
00:32:07 --> 00:32:10 In her parlance these are high value therapies.
00:32:11 --> 00:32:15 At the same time, however, who's gonna pay for this?
00:32:15 --> 00:32:24 The medical science is outpacing the pool of dollars which can possibly be allocated
00:32:24 --> 00:32:26 towards paying for these medical miracles.
00:32:26 --> 00:32:33 So on one hand it's an amazing feet of human ingenuity.
00:32:33 --> 00:32:37 On the other side, it's a financial toxicity is clinical
00:32:37 --> 00:32:42 toxicity, and here we are and the weakest is gonna wind up paying.
00:32:42 --> 00:32:46 The weakest link in the chain is gonna wind up where the burden falls.
00:32:46 --> 00:32:48 So let's land this plane.
00:32:48 --> 00:32:50 Let's talk about takeaways here.
00:32:51 --> 00:32:54 I'm sure our listeners are gonna be lots of thoughts, many
00:32:54 --> 00:32:56 thoughts they probably have.
00:32:56 --> 00:33:00 If you were going to give people a handout walking out the door
00:33:01 --> 00:33:02 how would you sum this up?
00:33:03 --> 00:33:03 Hmm.
00:33:03 --> 00:33:04 That's a good question.
00:33:05 --> 00:33:05 Okay.
00:33:05 --> 00:33:09 If I could come up with it, I would say first playing hot potato is expensive.
00:33:10 --> 00:33:15 Roughly a third of every healthcare dollar pays for this fight, not for care.
00:33:15 --> 00:33:17 So revenue cycle management, huge industry.
00:33:18 --> 00:33:22 It's a huge expense that is not going towards clinical outcomes.
00:33:22 --> 00:33:27 Two, I would say it's a fundamental nature of our US healthcare system.
00:33:27 --> 00:33:33 We have never decided who's responsible, and because of this indecision, the
00:33:33 --> 00:33:36 burden lands on the weakest hand, right?
00:33:36 --> 00:33:39 Whoever has the least scale to get this done.
00:33:39 --> 00:33:40 And sometimes that's the patient.
00:33:40 --> 00:33:42 Sometimes that's the indie practice.
00:33:42 --> 00:33:44 Sometimes that's just a small employer.
00:33:44 --> 00:33:47 And then I'd say the third thing is probably a hot take.
00:33:47 --> 00:33:51 My hot potato hot take is that it's really optional.
00:33:51 --> 00:33:58 Ultimately, the people that are caught in this cycle are ones that are caught up
00:33:58 --> 00:34:00 in this game where they can't walk away.
00:34:00 --> 00:34:03 But really the people who can escape it are the ones who agree
00:34:03 --> 00:34:04 to pay on the price upfront.
00:34:05 --> 00:34:09 So if they do something like direct contracting or direct to consumer or
00:34:09 --> 00:34:14 something where they have more market driven healthcare, then this is a
00:34:14 --> 00:34:16 way to get out of this hot potato.
00:34:17 --> 00:34:20 I love what you just said there, that just a fact playing hot potato is expensive.
00:34:21 --> 00:34:23 Number two, for example, direct contracting.
00:34:24 --> 00:34:27 If you figure out what the price is and who's responsible upfront, then
00:34:27 --> 00:34:29 that's how you make this optional.
00:34:29 --> 00:34:36 Andrew Tsang, if someone is interested in reading your writings or interested
00:34:36 --> 00:34:39 in your work, or wants to know where they can find this book, when it comes
00:34:39 --> 00:34:41 out, where would you direct them?
00:34:41 --> 00:34:41 Oh man.
00:34:41 --> 00:34:44 Okay, so now I'm really committing to a book publicly now, but
00:34:44 --> 00:34:46 yes, I, I am committing to it.
00:34:46 --> 00:34:47 They can find me on LinkedIn.
00:34:47 --> 00:34:50 I post a lot there and that's how a lot of people find me.
00:34:51 --> 00:34:53 I'm also on Substack, "Health Is Other People".
00:34:54 --> 00:34:57 So I've got my website up there and you can reach out to me, read my writings,
00:34:57 --> 00:35:02 see my illustrations and visualizations there, and all types of other media
00:35:02 --> 00:35:07 that I'm putting together to explain how the healthcare industry works.
00:35:07 --> 00:35:11 Andrew Tsang, thank you so much for being on Relentless Health Value today.
00:35:11 --> 00:35:12 Thank you so much, Stacey.
00:35:12 --> 00:35:13 It's an honor to be here.
00:35:13 --> 00:35:17 Hi, this is Tom Nash, editor and producer of the Relentless Health Value Podcast.
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00:36:11 --> 00:36:12 Thanks so much for listening.