178. The Cost of Secrecy in Insurance: Why Transparency Matters | Dr. Vincent Marchese, D.O.

Welcome to Medicine Redefined, a podcast focusing on helping you reclaim ownership of your health. I'm Dr. Darsha, and I'm Dr. Altamasharaja, where your hosts, hair to challenge conventional practices and uncover the stories behind pioneers shaping the future of medicine. Our conversations not only focus on the individual level to dissect common practices for health optimization, but also zoom out to enhance systemic change. Join us as we look to break the status quo, move the needle forward, and put the help back in health care. Our guest today is Dr. Vince Marquesi. Dr. Marquesi is a board-certified family medicine and sports medicine doctor. After completing his residency and fellowship at Cruiser Health, Dr. Marquesi returned to his South Jersey roots to open up Apex Sports Medicine in Hadin Heights, New Jersey. Apex offers a unique, direct primary and specialty care model that removes insurance barriers and delivers highly personalized care. The practice integrates advanced sports medicine, primary care and longevity services, and a performance and recovery lab as well. He's helping active individuals prevent injury, optimize health, and perform at their best. In this episode, we discussed Vince's path to sports medicine, and how a single lecture steered him from orthopedic surgery into family medicine training, a sports medicine fellowship, and ultimately his own practice. We talk about why he quit the insurance treadmill and built Apex Sports Medicine, while launching a direct specialty care clinic that emphasized quality care and price transparency above all was Vince's dream. We then shift the decoding some of the technical aspects of insurances, Vince unpacks premiums, tiers, deductibles, co-insurance, and explanation of benefits, and then compares a 30 step insurance visit with his three step schedule C pay model. We talk about some money hacks for patients, why stopping cash rates, like an MRI that's 500 versus 2500 through insurance, using HSAs wisely and never paying the first bill and cut cost dramatically. Then we shift the discussing life as a direct pay practitioner, focusing on more autonomy, deeper patient relationships, and longevity as a provider. We close by looking at the scope of tech and scaling these business models. How using AI and the first principles approach can help us strip medicine back to the provider and patient relationship, as it should be. Now without further delay, please enjoy this discussion with Dr. Vince Markezi. All right, Dr. Vincent Markezi. How are you, man? I'm good. Thanks for having me. Yeah, thanks for being here. Shout out to Sassy, because that's how we got you on here by calling you out on that episode. Yeah, and I think I connected the two of you guys. That's right. Well, it all comes full circle. That's right. She just cut the line and showed up right here. But do it. We've known each other for, I guess, coming up on three years now, and it's cool, because you know, we had this parallel journey, as we, well, actually, I don't know why I'm going to tell your story. Let me let me let you tell your story. So for the listeners, so we can introduce you to the listeners, why don't you tell us a little bit about your origin story, what led you to sports medicine and kind of where you are today? Yeah. I mean, I think I had the classic story of kind of always wanting to be a doctor, 12 years old, watching house and like wanting to do it all, then, you know, gotten to medical school, thought I wanted to be an orthopedic surgeon quickly, didn't even know what sports medicine was at the time, quickly realized I didn't want to spend my life in an OR. And yeah, had a really cool lecture with a sports medicine doc in medical school and it totally changed my life and the direction of my career. And through then, you know, as you guys know, you got to make a decision on what pathway you want to kind of go into through that. So I chose family medicine, which I really enjoyed my family medicine residency. And I think we'll talk about it later. I'm starting to do a little bit more of that again. And then ultimately a sports medicine fellowship. And yeah, and now practicing sports medicine, kind of hybrid mix, I guess. Part of that is what we'll talk about. It came from a traditional insurance model and now, you know, started my own direct specialty care business, which is I guess what brings me here today. Yeah, I want to get in that a little bit, right? So you came out of fellowship, you went right into private practice, right? I did. So yeah, I joined a small private practice with two providers that I knew well, one of which I did some training with, who were trying to break them mold themselves. And by that meaning, you know, in this area, it's really dominated by some big ortho groups. We won't name names, but you know, they practice a certain way. And they tie volume and these doctors were trying to kind of break that mold and get back to like some, some different, you know, more time with patients, kind of more personalized boutique care, but still doing it through the insurance model. So I helped them start a practice. They had an established practice for a year. I helped them start a satellite campus in New Jersey there in Pennsylvania and just kind of quickly realized that I just, I hated insurance for lack of a better term and I thought it was. And yeah, I'm going to hold no punches today, so I'm sure it's companies. I just thought it was just not the version of medicine I wanted to practice for the next however, 20, 30, 40 years took, you know, decided to leave that practice, took some time to kind of make some life decisions. And then funny enough, truly, guys, you guys had Dr. Eun on like the Dr. Dorothy and heard her podcast of you guys read the book on the beach on vacation one day and was like, I'm doing this like I'm just going to start a practice. So you guys are really with the initial inspiration for this practice, so it's for all that comes back. Yeah, I love it, man. When you told me that like I was, I was super excited. I actually was not able to make that and so the interdarsh would do in that solo. So we'll give all the credit to him for being a great host there. I forgot the if I was there, I probably would have ruined it somehow. But you mentioned you hated the insurance model. So let's, let's talk about that like you, you, what was your, your breaking point and I'm curious, you know, was there a specific instance that was kind of the, the straw that broke the camel's back. Was it just kind of death by a thousand cuts? Why did you do switch aside from the inspiration of Dr. Eun? Yeah. I never truly had the traditional orthopedic job, but a big ortho group where I was seeing a million patients an hour. You know, I got that experience through, you know, residency and fellowship, obviously. And I knew I didn't want to go into that. And, you know, so the start of going into the private practice I went into to start for the first couple of years was already trying to get away from that, right? Trying to get back to spending time with patients, you know, not seven and 10 minute appointments, but 20, 30, 40 minute appointments and really trying to practice good medicine. And unfortunately, while we were trying to do that, if you are in the insurance model, there's a reason those practices do it that way, such high volume is because the financials don't make sense. And that's ultimately what I saw or what I felt I was seeing was that, okay, I want to practice this way, but financially it just doesn't work. And so, yeah, ultimately I wanted to, I wanted to get back to, you know, personalized care. I really, I shouldn't even take it back because I've been searching for this since I've been out for three or four years now, you know, I want to practice this way. And I don't really feel like I need to compromise and practice any other way. So yeah, that's kind of the start of, the, the start of how this practice was built. It's funny because I think a lot of students, they're going into medical school and they have that this sexy, you know, mindset of down the road in terms of how you're going to practice medicine. It's altruistic. I get, I don't know many people who are going to medicine because they want to make money. Yeah. It's just not the case. The classic term is we want to help people, right? I thought we do. And they have this idea of, okay, I'm going to do this preventative care proactive, particularly in the current generation of students going to medical school, maybe even our generation. And you don't really have a sense of what, you know, what it's like the business of medicine, which always dictates the practice of medicine and darshan, you, you, I think you've talked about this before. We're like entertaining. You have no idea, or like the students don't know what, uh, residency and residone of fellows and that kind of stuff at different levels. And then you get into it and you're like, Oh, this is, this is real life. This is how it goes, right? It's, it's a business driving. You've got to admin who are directing decision you're making, like how you are actually seeing patients, how you're delivering care and how that's compromising care, which ultimately, you know, that's, that's kind of the moral injury that builds up over time and leads to burn out a lot faster than, then, uh, then we'd like to, we'd like it to, you know, and so I think that, that makes it really, really challenging. And yeah, there really isn't a point where you're getting back to it. It's maybe getting back to this dream that you had when I'm getting, and certainly the case with me and, and I know, I know, Darshtool, and that's why we connected, but a lot of people, uh, listeners, students that are reach out to me. And so you started your direct specialty care. You mentioned your kind of doing hybrid bottle. I'm curious. I wasn't aware that we were doing more sports performance types, though. So tell us a little bit about, um, how far along are you? And what are some of the earlier challenges that you've experienced? Actually, let me back up here. I'd like to start off looking at from the patient lens, because I think Sassy did a great job highlighting the practitioner side, and I do want to come get your take on that. But let's maybe start off at the, from the patient centric view on this and talk about some of the challenges patients face with traditional insurance models, you know, whether it's deductibles, super bills, limited access, et cetera, et cetera. Yeah. I think, and I, you know, part of what I did was actually wrote down a list of terms. So I think one of the things I wanted to, like, deep bunk or demist, or demisticizes, like, all these terms, because the insurance model, or I should say the medical business model right now, big industry medicine, um, has really done their best to just make everything as confusing as possible for everyone, you know, with thinking about this podcast, I was like, oh, who needs to know these terms? And it's really like, it's patients, it's providers. I'm sure that you have medical students and residents and fellows who listen to this. And maybe even some attendings that just have no concept about how medicine actually works. So, yeah, as I've said, my big gripe has been with the insurance companies, and I truly think that they're ruining medicine or have ruined medicine. And there needs to be some big drastic changes that aren't going to happen overnight. But this is my, uh, this is my attempt at making my small little change for that. Um, I think it's important to, if you don't mind me, like, go back and let's talk about where all this came from and what medicine looked like. So just kind of brief history and not to bore people, like, where did insurance, where did insurance come from? What was it? So really like early 1920s, you had mostly hospital, you either had hospital-based care or outpatient-based care, which is very similar to today. Um, and nobody had insurance, right? And then, you know, every so often, you know, somebody would get a large hospitalization or a major surgery or, you know, catastrophic event. And it would ruin them financially, right? And that's not a good deal. So catastrophic care was built out of these, out of these scenarios. And actually, Blue Cross is one of the, one of the first providers and started out as a non-for-profit entity who was really there as a safety net for patients, right? And it's funny to say that out loud and now think about where that is all at. Um, you know, then post-World War II, this all transitioned into, um, more employer-based programs. Then in the 60s, you get Medicare and Medicaid coming in because the elderly and the, and the low income who don't have jobs. Need insurance and then the kind of bohemus happens in the 70s and 90s where you get, you get kind of managed care and network-based care and all hell breaks loose and all the sudden, you know, you get insurance companies that went from being the safety net for patients. So all the sudden being gatekeepers and profit-mongers in the healthcare industry. Um, so that's kind of the history of it, right? And then so I think let's walk through like what a typical, like if you need healthcare in the United States, what happens, right? So most people, if you're employed, get an insurance policy through their job, which I often now get texts and calls and emails from friends and family and other people about how to decipher these things when they're trying to pick a plan because that's like step number one is how to pick a plan and nobody's, nobody understands what they're reading. Um, and the first thing you're doing is paying a premium, right? So you're paying to be part of this insurance, insurance is network and however much comes out of your paycheck and then comes out of your employer side is the premium, which have gotten crazy, right? I think people don't realize that they see what they can, what's come out of their paycheck, but what they're not really realizing is also what's coming out of the business side as well. But an average premium for a single person may be anywhere from 15 to 20,000 dollars a year in cost for both the patient and the business, add a family to that. It could be 30 or 40,000 dollars. If you're, uh, if you're a small business, um, which I had a conversation with somebody the other day, it could be 50 or 60,000 dollars for the year. So you think you get really out of hand, um, and that's just step one in the process, right? So then a patient calls the, an appointment or calls a place, an office to get an appointment. They first try and figure out are they in network, right? Everybody, that's the step number one. Are they in network with my insurance, which is a question I get all the time. I now get to say no, which is nice. And then what people often miss and I try and have this conversation with a lot of people is tears, right? So yes, okay, step number one, you're in network, step number two, what is your tear, right? So like how often would you talk about this? Do you know if a patient comes to see you tomorrow, like do you know what tear they are with you based on their insurance? The answer is probably no. Uh, when you go looking for these things, uh, they're purposely hidden and hard to find. And basically for the, you know, the patients who are on there, even I guess for the medical students and such, you know, tear one is kind of most coverage. tear two is, you know, middle coverage to your three is, is a small coverage. And that's basically how much out of pocket are you going to pay? So then you get to your appointment, you pay your co-pay, which could be different for a specialist in private care. You have your visit. If you're lucky, you know, maybe it's seven minutes long and you get spent a little bit of time with your doctor, then you think all as well. You either do or don't get the treatment that you thought you were going to get. And then six months later, you get a random bill or an explanation of benefits as, as it will be sent to you. And what you'll forget was what plan did I pick and what was that deductible? And why did I pick the one that was $10,000? And this office visit that I thought was going to be covered by my insurance that the office now charged five or six hundred dollars for with my $10,000 deductible. I'm on the hook for the whole 600 bucks. And now I got to meet this deductible for, you know, the rest of the year. And guess what? I didn't think things were going to cost me six hundred dollars. I'm not going to the doctors anymore, right? Let's say you do have a good deductible and it's low and it's a couple of hundred bucks in that same, that same appointment at six hundred dollars. Now you're only on the hook for whatever the 300 of it or you think so because then there's co-insurance. Wait, we didn't talk about co-insurance yet. So that's the 20% that your insurance does not pick up. So even if you meet your deductible and you know, you're over that limit, then you're still on the hook for 20% up to wait. What's the next one? Out of pocket maximum. So then I now I got to look at my plan again. We'll kind of do a kick. Now that my out of pocket maximum, maybe it's $20,000 for the year, okay? So if I have huge surgeries and hospital bills and all that kind of stuff, I could end up paying another 20,000 on top of the 20,000 premium that I've already paid already. So I know that was really long-winded. I said it purposely just to prove a point of how confusing that is. Let me tell you how an appointment goes at my business. You schedule your appointment, you have your visit, my price is posted online, $150 for a new patient visit. You pay that price at the end of the visit, you never see a bill again. So I just took a 30 step process and broke it down into three steps, schedule, visit, pay, and you know exactly what you were getting into exactly what you paid for. And I purposely have people pay at the end of my visit, I've never had this happen, but God forbid somebody didn't feel like they got the care they needed. I would not charge them. I do it at the end of the visit, because I want them to feel like they got something for their money, right? They knew what they were going to pay coming in. Did I provide what I said I was going to provide and you pay for your visit, right? So I just took this gigantic complicated system and turned it into a three step transparent system. So I know I just threw a lot out there, I'm curious, I'm curious your guys thoughts, but I really, I've been thinking about that all day long. I'm like, I really want to say all these terms, infusing terms and put them out there because they are confusing. And again, the whole model is too confused patients so that they end up picking something they shouldn't pick. And then the insurance company doesn't have to pay in the whole nine years. Dude, that was amazing, and I think at our 170 plus of the service we've done, I don't think we've had it. We've never had a 15 minute Instagram reel right there that I wish Instagram allowed us 15 minutes. I would just post it. Everything you just said into that because I think me being a brand new attending half that stuff, I'm still trying to learn, right? At least I have case managers and stuff to do it for me, but yeah, I mean, providers have no idea what the back end and you should know, right? Absolutely, absolutely. I've got my oral boards tomorrow, right? And I'm prepping for it and there's actually like some insurance questions on there and I'm like, oh, man, I got to start asking chat GPT here to give you the high yields that I need to know about about insurance. But before we go into your business, I want to stay on this topic and I'm interested because you gave the whole history of up to where we are now. Where does insurance go from here in your eyes as you look at where medicine is heading? Right? There's a lot of physicians. I think there's an article on docs in me just recently actually talked about how even these older generation doctors want to get out of medicine. There's us, this fresh blood that has ultimately alluded to that we have this vision of how we wanted practice and when we see reality for the first two years, we're like, oh, no, we're not doing this. Let's get out. Which is what you guys are trying to do, right? So where does insurance go from here? What are the tradeoffs that we might see? What are they trying to optimize for? Is it still money? Are they seeing this big picture? Just your thoughts on that? Yeah, I think no, right? I think they just have too much control. Now I'll preface this by saying I know I'm making light of this in joking because sometimes like a humor is the only way to stomach some of this stuff. But it's gotten so big and out of hand that there's not an easy answer and I'm aware of that. Anybody who says they have a quick fix is lying, right? This is a really complicated system. Each one of those pieces I just talked about could be an hour's long conversation. But just some simple facts to the business of medicine, ensure every dollar that is spent in health care, every single dollar that patient spends in health care, 51 cents of the dollar goes to insurance companies. That's outrageous. There's no other business that that happens. And I have this conversation with small business owners all the time to ask me why I'm doing what I'm doing. I'm saying, imagine if 51% of all the revenue you brought in went to another company that managed you and gave you all your rules and gave you headaches all day and all that kind of stuff, right? So to start, where are the insurance profits at, it's, excuse me, insurance as a little like subtle thing. The insurance companies are headed, they're, it's all about profit, right? How do we increase margins? How do we get people to pay high premiums and how do we pay out the lease? That's the name of the business, right? It's not the safety net that it was once meant to be. So how I talk about this typically to patients and how I think it makes the most sense to simplify as best as possible is it should be like car insurance, right? I truly think, in my vision, the way this would work is that most people have what they used to have in the 20s, which was catastrophic care, premiums would be much, much lower. The majority of people would never use their insurance. You would use your insurance if you have a huge hospital stay, if you have major surgery. We're talking things that they cost 20, 30, $40,000, although we could have another conversation about they actually don't cost that. But bills of that such and everything else, you would pay for cash, right? The same way you do with your car. Nobody uses their car insurance to get a car wash. Nobody uses it to get an oil change or to, you know, God forbid, there's a, you know, little issue with their car. Nobody goes and runs and uses their car insurance, it's for catastrophic care. So that, that's to simplify things, I think that's where they need to go back to, which would take a lot of the gatekeeping and bureaucracy and inflated prices and all this stuff, kind of reel that back and make it a transaction between a provider, a medical provider and the patient, which is ultimately what it should be, right? I got, if you allow me, I always joke with my barber about this so I'm close with. I said, imagine if somebody came into your barber shop, he owns his barber shop and said, you know, he has clients that I have patients said, imagine if somebody walked in like the insurance, they're basically the miles and said, I'm taking over this business now. You're going to keep the business, you're, your clients are now going to be my customers. They're going to pay me to come to you when you do a service, you're going to send me a bill, I'm going to tell you what I'm going to pay you. And then you just, you, you'll be happy with whatever I give you. And by the way, most of the time, I'm going to make it really hard for you to get paid. And all along the way, I'm going to try and put in roadblocks so that it's difficult, well, difficult for you to get your money and that you hopefully eventually give up and then I keep more of the money. Like, no, I said, would you bill for that if somebody left for that? And he's like, no, that's insane. Exactly. That's medicine in a nutshell. And not only that, you're also going to make it harder for those clients to get some of the services that they're trying to get. Correct. And every so often, we're going to, you know, you're going to keep jacking the prices up because, because I'm not paying you enough. And then every so often, we're just not going to pay it only and then the patient's going to be, or your client's going to be on the, on the bill for, for an inflated bill that we're not going to cover. Yeah. But then, then you're going to give these amazing discounts. You forgot about that. Yeah. 100% discount. Right? Yeah. Only if you know about it. Only if you know to ask. That's right. That's right. These are the conversations I have with people right now. Yeah. Yeah. Yeah. I think I was recently telling you about the stars. You're like, yeah, I think I was trying to get a CTA done. My cardiologist thought that it was appropriate. Like, I've got rejected and then I was like, okay, well, what's, I think the first institution that I'd called, they were like, oh, yeah, listen, you know, we, it's not covered, but we can give you, I don't know, like, the price went from $1,100 or like, we give you to 88% discount to bring it out of $300. I was like, well, why don't you just charge 300? There's an idea. So it's just because we know when you shop around a little bit like that, that's not really what it costs. On average, the discount is 90%. That's the self-pay or the drain. Yeah. Yeah. Yeah. Yeah. Yeah. I want to echo what Dar said. I think it's really important for us to have covered those terms. I think there's, the fact of the matter is the majority of the people do not understand what they're getting into when they're, and a lot of times they don't even get to pick, right? Your employer is the one who's picking the plans and you just have like option A or option B. And like, you're going to pick the lower premiums because that's what's looking like, and people don't understand the differences. And then that's, I'd probably say that's one of the main reasons, and I think this is true. Last I checked, the number one reason for bankruptcy in America is medical debt for that reason. Yeah. You're right. It's going to change, though. There have been some things put in the place where medical debt is not going to be able to basically consume people the way it was before, but yeah, on that note, I think a couple of resources. We've got these from Marty McCarrie. Talk about, say if I can remember this. Halfway through his book, too. Yeah. Yeah. Which one are you? Are you the first to pay? Or basically pay? Yeah. Yeah. Yeah. I think there's a fair consumer dot, or like, it's just like the, the Kelly blue look for that one. There's another one. So basically, like, this one allows you to go look at like, price shop, regionally, like, what a service might cost. So what does an MRI cost in New York City? Where's an MRI cost in Philadelphia? And then see, like, if you are paying a cash pay rate, which I'm sure like many of your patients do, because they're paying, you know, whether they're going on a network. Is that something that's appropriate? And then you can actually shop, shop around and maybe you can even bargain or try to ask for that discount. Yeah. One of the things I wrote down, and this, I think I might have stole this from Marty's book, is, uh, and what my whole model is really, if you boil all this down to, and I guess really to answer your question, Dars, the question is, the one key term is transparency, right? Out of all of this that's going on, it's lack of transparency on every single aspect from the patient scheduling to the patient, um, to the patient paying. And the quote from the book was free markets rely on transparency, right? So like, medicine is not a free market, it has not been in a long time. Um, and if we're ever going to get back to it, we need transparency, you know, people need to see what they're paying. They need to know what they're getting into before they, you know, they have services. And they need to see where the money's going and, and what these insurance companies are making, what the doctors are making, and where, and where their funds are ultimately going. Yeah. And the reality is people are starving for that transparency, right? Yeah. I think over the last six months, we've seen the healthcare insurance industry just under the microscope and some unfortunate events have also happened in terms of how certain people have handled it. We've talked about it before with Brian Thompson, what happened in the response on just for the, from the entire world, from the entire, uh, social media platform in terms of, like, lack of any condolences. And I think Darce, you talked about this is like people in a sense like felt like just of being served, even though people weren't really celebrating murder, they were just celebrating like getting back. Yeah. In response. And so to speak, and you know, this reminds me, uh, I think I'll have to define the episode at 43 CC. I remember them interviewing this anesthesiologist based out of Ohio or somewhere in the Midwest, where he started his own surgical center and it's 100% cash surgical center off. And so, you know, this guy, uh, and he's been doing it since the 90s, late 90s. So he's way ahead of the curve. And what he found was that making things transparent, like he was just undercutting hospitals left and right. And not only that, people from all over the world, all, you know, people from Canada were coming out to get like a triple bypass and things of that nature. Just because they're like, oh, yeah, I can go to this place in Ohio and get a triple bypass for, I don't know, $6,000 versus my insurance company with a deductible and everything and all the, well, the things that you mentioned, it's going to be like $16,000, it makes no sense. So I'll link that because there's a funny story that they share where a urologist like actually ends up going to his, his own hospital. And he yells at his admin. He's like, this is the second patient I'm going to lose this week to this institution because you guys are killing my patients with prices and ended up giving them, bringing the price of some urological procedure that I can't pronounce from $36,000 to $4,000. So it was insane. But yeah, we could do the all to say we love fashion insurance companies. But I think one key point is that if you're not able to certainly find somebody who's in direct specialty care, we'll talk more about that where you have that transparency. But if you are hamstrung for a little while and you don't have the ability at the very least putting your head in the sand and expecting the things to go well and somebody else looking out for you, whether it's your employer or somebody else, that's not going to happen. So you have to understand every single and you'll, once you understand, maybe you can learn how to navigate a little bit better to and advocate for yourself. I think that's really important too. Yeah, 100% that's ultimately, I mean, part of, I feel like part of my mission with the business and like part of the conversation I have with almost every new patient is kind of teaching them how to navigate the system. And unfortunately, the system's really broken right now and that's not going to change tomorrow. So how do we play the, how do we as patients, you know, and I kind of put myself in their shoes, how do we play the game back towards the system, right? Competition I think really transparency greets competition and competition is ultimately what's going to drive down prices and make things more sensible again. And patients have rights, right? They might not realize it. I think the thing that's, it's going to take a little, or it's going to be the hardest thing to do is to kind of break away the concept that everybody thinks they just pay in insurance premium and then like they get free care. And that's just like not the way it works. And they think that before they, until they actually start to use their health care. And most people don't even use the amount of health care that their premium costs them for the year, right? You know, if it was in a direct pay model and I'm going to, I'm going to put that out. I like using entire direct pay. I think cash is a negative connotation to it. So whenever possible, I do try to say direct pay because that's really what it is, right? It's a direct transaction between the provider and the patient is the providers out there like to the point that are their direct pay like it's, I'm not, I'm probably making less money than you are in a, in a traditional insurance model. It's not a cash grab. It's just a, it's a resort back to back to my principle a lot. But yeah, to my point, they don't know what they're paying and the message I often say to them or kind of the quick takeaway here probably for any patient listening is you have rights. You don't have to tell anybody you have insurance. It's part of HIPAA, right? You're health insurance, a privacy protection act, you don't have to give any of your information to anybody, which includes your insurance. And the first thing you can do when you want medical care is, you know, go on something like fair consumer or something like that and see what things should cost. And then call and ask what the cash rate is or what the cell pay rate is or what the direct pay rate is and what the discount is and then see what that cost. And then go back to your insurance, you know, not to your insurance directly, but look at your plan and see what your deductible is to try and calculate how much medicine you think you're going to use for the year, right? Like a quick example, this is every day at my practice with MRIs, right? If a patient has a $10,000 deductible and they want an MRI, first of all, we're going to have to fight to get it approved and that's a whole nother conversation for another day could take as much as six weeks, whether it's right or wrong to have. Then once it is approved, the imaging center is going to jack up the price of your insurance to try and get every little bit because they've had arguments for ever about what kind of discount they have to give the insurance provider. So that's that MRI might be 25 anywhere from $2,500 to $5,000. And if you call and get the cash or the excuse me, the direct pay rate, it will be somewhere in the range of $400, $500. So if you have a $10,000 deductible and you don't think you're going to use $10,000 with the healthcare in the year, why would you go pay $5,000 for your MRI? What you can call somebody say you want to pay direct, you don't have insurance. That is your right and pay $500. I mean, it's simple map, right? That's what breath competition is by that being out there and not just willing, nearly going to a place, not knowing what something's going to cost and then getting stuck with a bill six months later for $5,000 for something you thought your insurance company was going to cover. I think, yeah, this is one of those things that we didn't have an answer to, right? Like I was, I know that, I don't know if this has happened to me or where the provider, they'll always ask do you have insurance if they find out that you have insurance. At that point, they are not allowed to charge you cash 100% so yeah, it's a great question and this is where I was like on the edge of my seat with Doran Sassy's thing and I've looked into this a lot because that, you know, I want to play by the rules like I don't want anybody to do anything that could potentially get them in trouble as a provider, whether it's a healthcare provider, an imaging center, a pharmacy. If I know you have insurance, I cannot, if, let me back up, if I know you have insurance and I'm in network, then I cannot charge you cash, right? That is when somebody says they're in network with your insurance, let's break down with that really means it means that the insurance company is setting agreements to that provider, they sign a contract to a list of rules that they're going to abide by and also a list of payments that they are, you know, percentages that they're going to get. It's an negotiated race. So that would be going against or breaking your contract, right? If you're an out of network provider, it just means that you never signed a contract with the insurance company. That's what I am with all the insurance companies for my practice. I can charge whatever I want theoretically and I have the ability to take a direct payment from somebody. So that was long winded, but as the provider, if I know you have insurance and I'm in network, I must use your insurance. As a patient, I have no, I'm not bound to tell you that I have insurance, right? Now if they want to look, they have ways of looking you up through the system and they can do that. But if, but most of these places, and you'll see, I've had these conversations, especially with imaging centers, they're, which you don't realize is on their cash or excuse me, their direct pay rate is actually probably slightly higher than what they get, remember average? Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. They don't have to pay anybody to do the billing. They don't have to get it authorized, right? So they're cutting out a lot of costs. So they love that rate. They're happy to take your money to do that MRI the same day. Most of the most places, especially MRI machines, their goals to just keep the machine running as much as possible. Keep patients coming in. So they're happy to take that rate. So I've had this conversation with them. This is kind of all-freckored stuff, but they're like, yeah, if people call and say they want to pay direct for an MRI and get that done that same day, they're happy to do it. They're not going to go looking for their insurance and have those headaches. And patients are within the right to do it. So to answer your questions, sorry, I know that was long-winded, but the patients have, it's not in the wrong, it's not in the wrong for the patient to not use their insurance and go pay direct. They have that right. It's in the wrong for a provider to knowingly take a patient's direct paid payment if they are in network with that insurance. That's beautifully said, right? It's unfortunate because as you highlighted, it's almost like for clinicians or providers, it shackles, right? Yeah, it's a violation of a contract, but it's a way for the insurance company to mark up the prices. And because you're in network and you made, which you didn't agree to that, you're your boss, right? Like I'm an employee, he's an employee, right? Like so, I actually know you're an independent contractor, sorry, but you still are in network darts. Like if somebody came in for, on the inpatient setting, actually, I've experienced this on the inpatient setting, if you were to see somebody and they were technically like you were not in network, whatever the balances you can't build, like balance billing is illegal, definitely. And that's, that's new though, right? Like, like Marty's book, Marty's book, which is written in 2019, that was not a thing. Yeah. Like people were getting balanced all the time, getting their wages garnished, which is just insane. I think this all new in the one or 2022 that came right around there. But this is not new. Yeah. Surprise billing and balance billing is very, very new that that was not allowed. Yeah. Yeah. Then the new surprise act or something. It's called, but that was a good thing, right? Certainly kind of like 100% like the medical debt was, was getting out of hand. That's a really good point. You know, I love this, this thread that we're on in terms of transparency, but also really tactics to empower patients for making informed decisions. That's what we're talking about, right? So you've highlighted a beautiful tactic here. I love that. Anything else that comes to mind in terms of from a patient-centric view, what can patients do while they are caught up in this insurance-based model? Like, how can they advocate for themselves, maybe, you know, save a couple of bucks, things of that nature, even if it means shopping around, et cetera. Yeah. I think rule number one is just like, never pay the bill right away. I have this conversation with people all the time is like, and it's, we have to back up on this, too, because we got to talk about why the prices are inflated, right? Because you kind of have to spoke there, too, it is, it's like, we are, as providers, we're inflating the prices, right? It may not be our fault, but we are the one who charges the inflated prices. This is the beauty, and I should set back the reason I'm even sitting here today having this conversation and down this road is like really the experience I got with the private a group that I was with, like, I got to see behind the curtain finally, and my, you know, my financials or how I did was directly tied to all this stuff. So it was behooved me to learn what this, what the business of medicine was, right? You know, so I, I credit them a lot for that, but, you know, these, and we would inflate prices, right? That's just what would happen. What happens is, is kind of starting base was here, right? You got providers, and you got insurance companies. So providers increase the price, insurance companies, every time they negotiate a lower reimbursement rate. So then the providers got an increase the price, and the insurance companies negotiate a lower reimbursement rate, and it just keeps going, right? Now all of this is based off of Medicare pricing, which you can go look at, and I wrote some notes down for myself, you know, what things actually cost. It really talks about a percentage of Medicare when they, when they negotiate reimbursement rates, and Medicare's pricing is out there. And now, sadly, the past, I think it's 10 years, Medicare has decreased 20% reimbursement over the past 10 years. The newest cut, I think, was supposed to be three something, not, it's two in change. But anyways, so for the past 10 years, the reimbursement rates are decreasing to the providers. But there's who set the rates, and then everybody negotiated based off of that. So that pattern of price up reimbursement down, price up, reimbursement down, it has led us to where we're at now, where you seek very, very inflated bills for things that shouldn't really cost that much. And it's all fine and dandy if the system works, but unfortunately, it often doesn't, because again, that inflated bill, if you have a high deductible or got forbid you don't have insurance and you don't know your rights and you don't know that there are discounts, these secret discounts, right? You're going to pay that inflated price. So the office visit that should have been $150 is now $750, and you have no concept that what it really costs is $150 because you don't, there's no transparent rates. So that's where, sorry, I know I got all attractive, but that's where all that comes from. And that's not changing, right? That every year insurance companies are going to negotiate with providers to try and pay less because that keeps money in their pocket. And providers are going to try and inflate their bills to try and keep the revenue that they have to try and keep up with the poor reimbursement rates. And it's just this vicious cycle that just doesn't seem to end. Yeah. So what should people do, right? So not paying the first bill, we certainly don't want it to go to collections, although that's never like medical debt doesn't really go to actual collections. That's another thing that they scare you with. At least that's what I'm understanding. Correct me if I'm wrong. There are events. Yeah. So I've been looking into this a lot. You're not wrong assuming that the page, so it used to, and that's part of Marty's book, right? Some of the first chapters are very, very interesting on that. They could, it could go to collections and they could garnish your wages. So that was craziness over an inflated bill that, you know, that's, that was truly highway robbery. But so it can go to collections if you do not make credible efforts to pay your bills. So step one, I would say for a patient, it's like the first, when you get an explanation of benefits, look at the fair consumer, you know, report and see what things should cost. Make sure that they, if you have insurance, they actually ran your insurance. A lot of times they get caught without the insurance, which can go both ways. We'll talk about a funny video in a second. And then, and then if it is at that price, or if you are stuck, you know, that's kind of where you're at, I would call them and you can't, you can't afford what, what that bill is. It'll save it actually correct. Then you call and you negotiate and you say, hey, what, what would the uninsured rapie? You know, I'm willing to make payments. So you have to make a value effort to, to pay. You can't just let it go, but yeah, assuming that you're, you're willing to make payments and you're willing to negotiate, will not go to, it will not go to collections. Now, what did just change in 2024 is that it will not, even if it goes to collections, it will not affect your credit. So maybe that's what you're thinking about. So it can go to collections, it can go to collections, but from 22, I think it's January of 2024, it will not affect your credit anymore, which I think is, which is, which is pretty big. The funny video I was talking about, so this is where all this pricing stuff gets really, really interesting. I don't know if you guys saw this like Instagram, real TikTok video, where this guy, he's a dad and his daughter needed an ambulance ride, shake it your head, and he, the bill is like 1200 bucks and he realizes on the bill that the, the, or excuse me, the bill is 600 bucks. He realizes on the bill that they don't have his insurance. So he calls the company and he's like, hey, you didn't have my insurance. So they say, okay, and they run his insurance and they go, okay, it's now 12 on, it's okay. And he's like, wait, what? He's sort of 600 now. Now you have my insurance and now it's 1200 and they're like, yeah, that's this, that's the self pay discount rate. And he's, wait, should I get rid of my insurance? And he's like, well, we can't do that. We now know that you have insurance. We have to charge you that rate. So it's like you're paying money to a company who's supposed to like protect and serve you basically and they're negotiating rates higher than what the self pay direct pay rate would be. It's like just put that perspective for a second, like you're literally paying a company so that you can pay higher prices. Yeah. That's like having an Amazon account or something and like you pay more than everybody else who doesn't have the Amazon account. Just doesn't make sense. Right. No, I'm British. I reassured that. And I think it was funny because this is an actual call. I mean, the guy is like, he's asking the other person online. He's like, so should I cancel my insurance and he's like, sir, we can't advise you to do that. And he keeps asking, he was like, so you're, but you're telling me it would be better if I didn't have health insurance, who's like, we can't advise you. This is too funny, man. Yeah. And for sir, patient, I would say, and I don't say this lightly, but it's probably what I'm getting ready to do myself soon. Where we've gotten stuck in what really stinks is that federally, there's no mandate on insurance. So that used to be a saying people talk about the Obamacare Act and all that kind of stuff. federally, there's no longer a law that people need to have insurance. Your federal tax will not, will not penalize you, you know, at the end of the year when you do your taxes, you don't have to have insurance federally. State by state and New Jersey is one of those states that I'm in, you do have to have insurance. And basically, if you do not have insurance, when you go to file your taxes at the end of the year, they're going to ask you, did you have insurance for 12 months? And if you didn't, or if you didn't have insurance for portion of those months, they're going to charge you a penalty on your taxes. That is equivalent to the lowest rate that you could get through their state insurance program, which roughly now is around $350 a month. They call it like a liking on the name, but it's basically like you're, it's, it's you participating in the program, which you didn't sign up to participate for. I guess you did by moving to Jersey, but so for certain people, and if you're in a state that doesn't require insurance and you have enough money saved, you can be self-insured, right? Ultimately, like if you, like if you're a small business owner and you have a size of a decent savings, why would you pay $30,000 premium when you could just like save $30,000 a year or best $30,000 a year and pay someone like me to manage your care for, you know, my, we'll get to it, but my primary care service is $150 a month, like, you know, and you can see me as much as you want and, and save your money. And then God forbid something happens, you negotiate self-pay rates. And you're going to pay a much lower, lower cost. And these are the prices that don't know, people don't know, right? Quick ones like having a baby, right? So, you know, if you, if you have a baby, you have insurance, it's probably going to be somewhere charged somewhere between $60 and $80,000 for that whole stay. I just negotiated the rate the other day out of curiosity. If I go have a baby at virtual hospital in Jersey, it's $6,000. Why wouldn't I just, if I might, if I'm going to be a self-employed paying $30,000 premium in the only healthcare I'm going to use for the years having a baby, why wouldn't I just pay $6,000 and I'll save the other $24,000. So for, I know that's not for everybody and I know I'm getting into a little bit of any share, but there's a world where like, if you have a reasonable rainy day fund that like, you really don't need insurance. Yeah, the challenge with that is that what does it say? Most people don't have a rainy day fund for, I get it. Yeah, they can't pay their bill for the mall if they didn't. They're paid check, they're paid check. 100%, but it's a good point. You know, the challenge I think becomes like, you know, God forbid you get cancer or something like that, but I guess my question would be. So they emergency insurance? Well, that doesn't ask you. You mentioned you're looking to do this or you're looking to get catastrophic insurance for like big, crazy bad things. God forbid, never happens. Yeah, yeah, I mean, what I would want to do ultimately, I'm in New Jersey, so like basically what I'm end up handcuffed to do is either pay that that state minimum and just have a really, really high deductible plan. Knowing that, like, I'm never even going to touch it and I'm just going to pay, I'm just going to, I'm just going to negotiate with providers for direct pay rates that the plan is only there one because I don't want to pay the tax penalty at the end of the year and two, God forbid, I got cancer, I had a major surgery or something, then I would end up paying my $10,000 deductible, but then the rest of my care or whatever my out of pocket maximum was and then the rest of my care would be covered. But yeah, otherwise, if I didn't have to do that, I would probably try and self-insure myself or I would get a catastrophic only plan knowing that I'm not going to use it only God forbid, something really, really bad happens and just try to limit that premium as much as possible. Yeah, you know that I'm thinking about this actually, not a terrible strategy, although I want to caveat, this is not financial advice for anybody, but we could not financial advice. Not medical advice, no types of advice, but what I'm thinking is what we could do, somebody could do in that, because those high deductible plans often come with HSA, and HSA is the triple tax advantage, right? It's the only way you can get out of paying taxes and you can start contributing to an HSA fund on the side and you're putting money aside, but that's got a big thing like you're talking about. You've got to be putting money aside, and now that's actually going, growing tax-free as well, and so if you don't use it in the year, you do something with it, you know? I'm glad you brought it up because have you explained that on this podcast before because I don't think people realize that. I have this conversation all the time. Why don't you go ahead and do it again just in case for anybody catching up. Yeah, Dar, you need to know this too. You start doing this. So this is what rich people are doing too, not, you know, it's everybody. It's not us. That's none of us are rich here. No, none of us are rich. So let's make that very, very clear, right? We went in the medicine if we should have went to or insurance probably. You know, I'd be a great insurance CEO maybe, but I don't think I think I have too much of a heart. But yeah, so let's talk about HSA real quick. So wonderful, wonderful program, and it's really, I argue you should really never use it for healthcare. There are some ways around and I can tell you how patients are doing it now in my office with insurance and with HSA. But basically, I think the limit this year for solo is like $4,000, roughly, don't quote me on these numbers and then family is like somewhere around six or something like that. But you can take this money out of your paycheck, pre-tax, right? It goes into an investment fund or an investment account, you know, fidelity has Vanguard, all these places. That money came out pre-taxed. It grows in value in the investment funds. You can invest it whatever you'd like. You can buy all the Trump coin or whatever you want. And that grows tax-free. And if you don't take it out until you're 65 or you use it for a medical expense, that is tax-free as well. So the majority people, like if you don't, if you don't need it, do not use your HSA for to buy whatever your glasses and your band-aid. It's different from FSA, which we can talk about, but HSA, yeah, you should and you should purely use that as an investment fund. And then that's kind of a self insurance fund. If you could do that for long and off, then yeah, it got to be something really, really bad happened to you. You could pay, you know, your medical debt with that. But the majority of people, if you, I shouldn't really say the majority, but you know, if you're financially sound and you and you don't need to spend that money every year on health care, you should absolutely save it. The way I get around it, and this is totally legal, this is, you know, a, a, a, a, a, a, a, a, a, word, you are allowed to reimburse yourself. So like, you can pay, like a patient in my office can come pay direct pay, right? They can or pay with their HSA card. They can then submit the bill to their insurance or out of network reimbursement. If they have, you know, those benefits or, you know, they met their deductible, they could get reimbursed and then put the money back in the HSA or really theoretically put the money anywhere they want. And it's still tax-free money at the kind of the way the loophole works. But you can kind of double dip on the system there. You can use those funds, but then also get reimbursed by your insurance. Let me just understand this correctly. Yeah. A little bit of a mind bed for a second. If they, you're taking, you're taking money out of your, your HSA, out of your, well, you're taking money out of your pay, right? Okay. Free tax. Uh-huh. You haven't paid any tax on the money. Right. That's in the HSA account now. Yep. Correct. Which is theoretically being invested and, you know, hopefully in the markets down right now, but hopefully going up, you can use that money to come pay for a doctor like me, 150 bucks for my visit. If your insurance has out of network, um, out of network, benefits, you then submit to them, they will reimburse you. Probably 80% of whatever it is. And then you have that money back. Check. Yeah. But it's still tax. You still never paid any tax on it. That's interesting. Yeah. Correct. Yeah. So, but they can't use their card at that, in that case, right? Or can they still use a card and still get reimbursed? Yeah. They can. Oh, my God. Yeah. Now, I would argue don't do it. Like just like the money in the HSA, let it grow. Like that's what I plan on doing. Yeah. But you can theoretically have people double dipping that way all the time. Interesting. We're probably taking this for granted. So just so people know, HSA helped savings account. Yeah. FSA flexible savings account. The, so you mentioned, self-only covers limit for 2025, 4,300 family 8550. Just look this over here. Yeah. They haven't hired you. If you are 55 or older, you can do an additional thousand. It's like a catch-up rate they call it on top of those deadlines. So maybe just because we mentioned it, FSA, can you briefly touch on that? Yeah. It's basically it's a use that will lose it account, right? So a lot of times these, this money will either come through you. It still comes out of your, it's still come out of your paycheck tax-free. Oftentimes your employer is giving it to you as a benefit. That's how I see most of the time. And if you don't use it by the end of the year, you lose it. So I think they're kind of crappy accounts. I wouldn't use them. Maybe for certain 500 bucks rolls over or something like that, 500 or some people lose the dough. Yes. Some people don't have any roll over. Yeah. Every account's different, right? Whoever it's whoever does the account, but but anyways, like that's my understanding of it. I've never had one. I wouldn't use it. But unless, you know, if you work for an employer and they give you the money, then yes, use it. But I wouldn't be putting any of my money into it. Cool. Darsh, I see you nod in your head and you're excited. Any questions that we should talk about that. I mean, you go ahead. Yeah, I'll just I've been quiet because I've been learning, man. This has been great. So you've, you've got to learn today. Exactly. I've just been circling all in, man. This is this is good stuff. I don't have anything else in regards to insurance. I didn't know if he wanted to hop over to the DSC side of things and kind of talk about more sports and get a little nerdy. But yeah, hopefully we haven't lost people on this. Certainly the disremisement conversation. We had way back in the archives with Peter Valenzuela, people to go check that one out as well. We touched on some of the similar threads that we're talking about. You know, I think so today was maybe more individual side. And that was more macroscopic business policy related stuff. But yeah, if people have more questions they can reach out to us and maybe we'll do a deeper dive and maybe more systematic in terms of how we approach this step by step. Although, I think you did a phenomenal job. But let's shift gears, right? So let's switch over to the practitioner side and look at it for the practitioner lens. You've obviously alluded to the fact that in terms of stress, it's far less stress, this 30 step process. And earlier, your example that you were giving with a organization that's giving MRIs and whatnot, even if you're making 10% less by getting the patient to pay direct paid, that headache, like you alluded to, of not getting paid for 60, 90, 120 days and if it all going back and forward, correcting little codes, etc, etc. Like that's worth the 10%. You know what I mean, that's 30 bucks on a 300 all MRI, whatever it's going to be. But what other benefits have you noticed since switching over? And again, you were in a private practice model. So you weren't even salary-based. But what are some of those things that people can really look forward to if this is something that you want to embark on as a DSC or direct pair doc? Yeah. I would say, and I think Josh got a question earlier, like, where is this going? I would love to see more docs go this way. I think part of the reason they're not is like, you gotta then learn how to become a business person, right? So like we are always say like medicines the easy part, like, you know, like we train for 10, 12, whatever, many years to become really good doctors and we're really good at what we do. But like nobody taught us how to balance a checkbook and how to get paid and how to run a business or any of these types of things. So that's the big learning curve on having now. I find it fun. You know, I'm a type of person I kind of always maintain that attitude of a student. So I enjoy the learning process of all this. But that's the challenge I would say. So I know you didn't like leave it that you were asking, what are the benefits? But I can't talk about the benefit without first talking about that challenge. The benefits of that challenge come with autonomy, right? Like, I truly, I don't answer to anybody. And I've kind of joke with you occasionally about this. Roger, like, yeah, just like the red tape is gone. I just don't care about it. And I don't have to think about it. And like when I write my note, I don't like play wordsmith to see if something will get covered. Like I just don't care. Like from my standpoint, and I know it sounds like altruistic, but like really, I just want to provide good care. Like when I leave my office at the end of the day, I sleep really well because I know that like I gave my best. Like I, everybody that walked through my door, you know, a new patient and my practice gets anywhere from 45 to an hour of my time. They got my undivided attention. And I think I provided a really good service. And it's a different model, you know, it comes with different headaches. But at the end of the day, you feel really good about it. I get control over my schedule, which is nice, right? A buddy of mine texted me that he really wants to like off next week at his place. And I'm like, yeah, great. I can move my schedule around and do that. So, you know, and I don't have to answer. I don't have to talk to my boss. I don't have to talk to the healthcare organization. I don't talk to anybody. I get to make the decisions about where I see this practice going. So maybe that's a good transition to like what I'm doing. So I started this as as a sports medicine practice because that's kind of what I always wanted to do. But I am family medicine trained. And I always really liked family medicine. I liked the ideals of family medicine. I didn't like the way it was being practiced. I hated just throwing medicines at diabetes and hypertension and depression and all these types of things and got a little bit into like lifestyle medicine when I was in residency. And for years, you know, part of this thing is creating really good relationships with your patients. So people have always kind of asked like, hey, would you be my doctor? And what they mean by that is like, will you be my primary here to doctor? And for years, I've kind of always said no. And then I, you know, I said, you know, actually, I think I would like that. I think I would like to take this kind of, you know, whole person view of health and really, you know, guide people on these journeys of getting better or staying, staying healthy. So I've added like a, you know, more concierge or or a membership based primary care service. And then the last little piece, I look at this at three pieces. I have my traditional sports medicine. I have a primary care service that's membership based. And then I have a recovery and a performance center that kind of ties all this together with some different things like VO2 max testing, lactate threshold testing, RMR. We do a little IV hydration, talking about doing some hormone replacement therapy and peptides and all the things that everybody keeps asking me about. So that's the beauty of it. You know, like the cool thing about my practice is like literally most of this stuff, like VO2 max testing, like I just had enough people asking about it. And I was like, yeah, sure, let's do it. You know, so things are within reason and their evidence informed. And like, and I think patients are going to benefit from them. I just make the decision to add it. And I don't have to talk to anybody. I want to take you to get PRP approved. Yeah, don't ask me. Yeah, it took me 30 seconds. Oh, I want it. Okay. It took me calling the rep, right? Yeah. So yeah. So I say that jokingly, it won't mean to come off that way. But and again, this style of practice has its other, you know, downsides, at least in the gico, but the cool thing is not answering this. But getting to getting to practice medicine, ultimately getting to practice medicine the way I want to practice it. That's awesome. And can you take us through a little bit about how you structured those three buckets? And the reason I ask is do you ever fall into a trap? Maybe it's not a trap, but maybe giving too much advice to the point where hey, they should be paying for the recovery subscription. Is she giving them that same advice, even though their patient of mine or or the sports med category? I mean, yeah, I take a really like, you know, how I characterize this, but I just feel like my kind of like guiding morals or just like, if I provide really good care, people will use me, right? So I don't get stingy over thing. I give people discount a lot. If I didn't think somebody could really pay them in my services, I give it away for free. Like, you know, like it's, I'm able to kind of be that way because of this autonomy. But ultimately, like, it leads people to coming back. I had a conversation recently, I'm starting to get some like business mentorship. And one of the things they talk about is like lifetime value of a patient, right? The new patient walks in your door, the kind of underlying things are like, how much did you pay to get that patient? What's you just done on advertising, all that kind of stuff? A lot of my businesses were to mouth. And then like, how long that patient going to stay with you? And what's their lifetime value? And even in six months, so I've been open since September, well, really full month and October, like sometimes I have a six month left value on some patients of multiple thousand dollars because they just keep coming back. So I don't ever get really worked up about in my giving something away for free. I just know that like, if I'm practicing good medicine and providing good care, they're going to come back. They're going to tell their patients. And ultimately, it's like self-sustaining that way. And yeah, I don't know if that answers your question, but yeah, that's kind of the way it's been. Yeah. And that's not even including the referrals, right? So if that patient's getting good value, good care from you, and they're going to tell their mom and then somebody else and, you know, be like, they're family members, because they want their loved ones to get the same quality care. Correct. The biggest, I think some of it satiles together to kind of, it's kind of say like, because it's interesting. What the provider wants and what the patient wants are really the same thing, which is why I started this practice, right? So the patient wants to, wants access to you, right? So for me, that means, you know, my office phone number comes directly to me. I often, you know, this may be a bad habit, but I often, you know, answer people at all hours a night. It can schedule online, right? The beauty of not having insurance is like, you go on my website right now, you will see my availability. You can just pick an appointment. There's no hassle of you giving me information or whatever other than, you know, I don't even ask for payment information. And that's your slot. And I hope that you show up. We have, you know, had some cancellation issues, but I hope that you show up so you have access to me, right? So the patients want access. When they get there, they want time, right? So I spend, like I said, 45 minutes to an hour with any new patient, half hour for follow ups. I'd never see more than two patients in an hour. How amazing does that sound as a provider, not to rush from room to room? I only have one room here because I only need one room. I only have two chairs in my waiting room because nobody waits, right? So they want access. They want time with you. And they want good care, which comes with that. And I guess the last piece really that I should say is they want transparency and pricing, right? And affordable care. And I think while it comes off initially, it's like, oh, this, this doc is cash or direct pay. It's going to be more expensive. What I often have a conversation with people about is like, I'm way cheaper than if you use your insurance, right? If you go to the big box orthopedic, who's going to inflate your bill, you have a 5,000 hour deductible that initial visit is going to be $500 to $600. You're going to be on the hook for all of it because you haven't met your deductible yet. You don't even know that you're on the hook for all of it is you're going to get a bill six months later. It ends up, it's way cheaper to come see me at $150. So those three things are the same things that provider ones, right? They want to spend time with their patients. They want transparent pricing on what they're going to get paid for their service. And ultimately that leads to less burnout and better work like balance and all the I've left less notes, right? A full day for me is 12 patients, 14 patients. You know, so these things just align very well. So that's why part of the reason I was so excited and felt like the business was going to thrive and it has been so far is that like what I want and what the patient wants are the same exact thing. So it's kind of like if you build it, they will come and like that's what I'm seeing so far. And nobody seems to be blinking an eye at the direct pay. I'm sure I'm losing some patients that don't quite get it yet with the insurance, you know, not taking insurance. And they might they might view me in a certain way. But once they walk through my doors and they have the experience, they're patients for life and they tell their friends and I and the circle continues and I get to provide really good care to some really good people and try break away from the bad medicine mold, right? I just don't ever want to be a part of that. Yeah. You know, I do want to say as excited as we get about this, I think it is worth mentioning that it's not for everybody. Like you mentioned, like if you're not interested in learning about the business aspect of it, then you're going to have a very difficult time. If you're somebody who just wants to clock in and clock out, which recently, it's not for me, but I've come to learn, you know, I think I got this from Sahul Bloom talking about this, that if you're a job, and we always talk about this sexy idea that your job has to bring you joy and satisfaction and contentment. But maybe that's not true. Maybe your job is a way for you to get contentment outside, elsewhere. And I think it darts jump in here. If this was your thought process as you was going on inpatient rehab, I kind of felt like you were thinking about this. You were like, hey, I'm going to do this and I'm going to provide a good amount of value and I'm that's going to give me freedom to do x, y, and z and all the other things I love outside. And there's nothing wrong with it, right? Maybe you're not the person who's going to be going through a direct pay and like you talked about, you know, like there are times where you're working for free a lot and you're not making as much money as I am curious why your rates are so low, but you're not making as much money as you might be in a traditional insurance based model. So that's important to understand for people too. I would argue while I can increase my rates and you know, maybe in the future, I do as demand increases. I don't think they need to be. And I think the math, you know, I'm not a mathematician, but the math seems to be working out. You know, this kind of gets back to it. I don't want to get political here, but those like, you know, those first principal models, right? The CEO talks about you strip everything away from medicine and like what you really need. And maybe this, this is like the heart of the issue we're talking about here, right? You need, I feel like I thought about this a lot as I started in the practice. How do I get started? Right? It's like a, it's a big overwhelming task of like, wait, all of a sudden now I'm just going to like have a medical practice like what? Really what you need is you need an office space and you need a provider, a chair, a table, and in our business, some injectable materials and an ultrasound. And like that's it. I don't need billers. I don't need insurers. When I started this, I had no help. I ran the business myself. I scheduled patients while I let technology do that for me for the most part. I took the payment every once in a while if my system isn't here. You just strip everything away to the bare necessities and you can provide really, really good medicine without all the nonsense. So one of those things that I've really been thinking about to your point is not everybody wants to be the business owner, right? And I get that. But I will say that every doc wants to practice medicine the way I'm practicing. I don't know any doctor who says, yeah, no, I really want to see 50 patients a day. And I want to provide not my best level of care because I can barely even get it. Do I even know the patient's name that's in front of me? And yes, I want to write 40 to 50 charts at the end. And I want to do 10 MRI prior authorizations because they denied it all. No, nobody wants to do any of that. So the thing I've been thinking about a lot is like, how do I scale this, right? And that's ultimately what's going to happen. I'm young this, you know, as a business, I'm young. And this is going to hopefully grow. But then my next, my next question is like, how do I make this a vehicle for other providers to practice medicine the way they want to make a reasonable salary, but not have to deal with all the nonsense that that traditional insurance based medicine provides. So what'd you come up with? How do you do that? I think first proving that it works, right? And proving that care can be provided this way for like a provenable rate. Now I get it. Some people look at like $150 from as a big expense that I understand that I would argue like, look at what you're spending on insurance and what you're not using all that money that's kind of getting wasted there. Then I would argue like, look at some of the other things that you're spending money on my classic one. I don't know why you're going back to hair, but like what women pay for their hair? Like two, three, four hundred dollars, right? I think I'm worth a hair appointment. And I know it sounds weird to say, but like we have value, right? I think that people living this like idealistic world where we're just supposed to like go through all this medicine or excuse me, go through all this education for free. And I've a mountain of debt student debt. And then I'm just like supposed to practice medicine under somebody else's thumb and like not make any money like that. Nobody's going to choose to do that. And then you're not going to have bright and intelligent people going into medicine, right? So things need to change. But yeah, we have value and I think I think that value is higher than people think. But I also think that the price of all of to put on medicine or to do medicine is just much lower than what people think it is. So I think to answer your question, I think I proved that I think I proved that it works. And then I try to be a good businessman and I try and slowly expand this so that I have more office space and that so that more patients know about this. And you really need buy in ultimately, I'm going to need things to change probably from an insurance model. And once if it ever happens and things kind of get broken down and we start to get like true transparency in medicine and competition, then I'll be in the driver's seat. And I'm hopefully ahead of the game is my hope that 10, 20 years down the line that this is just like ready to go. From this is what the model will look like for everybody. And I hope so for physicians and other providers because this is a really fun way and cool way to practice medicine. And I think patients think so too. I love how you brought up first principles. I think that's such a key to anyone getting started on something new, right? I mean, it's like the Elon Musk SpaceX has struck it down to first. I didn't want it. I didn't want to sing because I don't like it. That's all right. I'm a, I'll say I'm a huge fan because I read his book and I think, you know, there's pros and cons to everyone, but you got to love his acumen in terms of how to build things. Yeah. Yeah, but probably the, probably the best business mind of our generation. Sure. Oh, so yeah. But it's funny because a couple of months ago, a medical student was interested in, he started a podcast and he said, how do you, how do you guys do this? How do you record? And what you answered is the exactly kind of what I said. You have a microphone, you have a recording platform and a distribution. And then you need a voice and the smallest division. And then from there, you can scale it up just like you're talking about. Yeah. So I really like that idea of that. When we talk about scale, like when we talk about efficiency, when you start thinking about implementation, are you using any specific technology, AI, electronical medical record to really just help you get through the day so that you're not winding up doing notes at the very end or a better way of communicating with patients and if you like that. Yeah, I'm definitely, it's funny. I wanted to kind of, you know, the whole AI scribe thing has obviously been huge. And I think it's really good. I think it's going to be commonplace, you know, in the next 10 years. But I remember having this conversation even a couple years ago with the private practice. I worked for which I was an employee, not the owner. So I did make the decisions. And I was like, hey, this is the future. We all hate notes. Let's jump on this. And I just like got slapped down. And now I get to be like, no, yeah, I'm making that decision. So, you know, I'm currently within the MR that doesn't use it. But I'm in the process of switching to an MR that does. And yeah, in every way possible, I feel like you learn as you go. But, you know, you take on these tasks and you realize like, okay, I don't want to do certain tasks. And then you figure out how you how you can utilize technology to make those easier. And I think the first one is AI scribe. So I'm going to switch to an MR system. I guess free ad here has one built in and we'll also do a lot of management from like a membership standpoint and things like that. But there's a lot of them out there. That's probably the biggest one. And especially, I mean, the beauty of this is there's less administrative stuff. There's more like business side stuff as a business owner. But let's just say like as a provider, there's way less administrative stuff. Not dealing with insurances because there's just so much less red tape and that kind of thing. So yeah, so there's different, there's probably like different things for me is like running a business that like if I brought somebody else on who was just going to practice medicine, like having an AI scribe and seeing like 12 patients a day, like they would just be like live in the dream. Yeah, it's going to be it's going to be fascinating to see, you know, next to five, 10 years, what, how efficient we can be as providers just from notes, communication, diagnoses, all these things. I mean, I talk about chat GVT every day probably more than the five. And it's different problems a year. Yeah. We talked about it before this, but I used it to build the business every aspect of those business has like has some thumb thumb print of AI on it. And I wouldn't I wouldn't be here without it. I got it. I have to say real quick, though, back to your point, the way I view things is I always that that average of like how do you eat an elephant? Right. This is how I got through medical school. This is how I got the residency. Right. It's just one bite at a time. So I just like I taped the process. Whatever it is, I make the list and I just check off number one. And then I check off number two. I just keep going knowing that like I'm going to get it wrong most of the time. But then you just you new addition and a new version and you slowly get better and better and better. And I'm excited to see like what the product is right now, meaning you know what what the patients get. I'm hoping that 10 years now is going to be even I wouldn't be able to even comprehend it at this point because I just haven't reiterated it enough. Yeah. Well, it sounds like you're doing well and you're excited to grow and it's awesome to see and thank you for everything that you've kind of just highlighted. I do want to ask you, you know, it's an honor, first of all, to hear that you said, you know, store podcasts, Dr. Una reading her book and that it changed the course of your life and how you want to practice. What was it exactly that made you take the leap? Was it the ability to lose the fear? Was it seeking, you know, the opportunity? Was it the understanding of the life relipping and what was it that you could hold in on that made you take the leap? Yeah, honestly support of a partner. So I'd be on say we you know, we've been living together for a few years and she moved in and we were having a child. I have a one year old now, but this was basically a year ago and I just was like kind of fed up with the practice I was in and wanted to make the jump and had the conversation with her and she was like, you should do it and she even cut me the check to start and practice as like a as like a show of good faith of like I'm all in with this and I truly couldn't be here without her and she the nurse, she's from the medical field, she gets it. But yeah, that was really it. I knew I wanted to do it, but you know, there's always sounds like you have a new family and I know Roger you have kids like you you have so much so much responsibility as a father, as a husband, as a partner and you want to provide for your family. So that was like very, very scary, but like once you give a partner's blessing on it and that really changed the corner for me and that kind of took all the fear away just knowing that like if I fail, it'll be okay and I was I was okay. I went into this totally thinking that like I could fail and I still could fail and that's okay, but at least I know I give it my effort and having that support from her and then from the rest of my family. My my mom is now my my office manager. This has been it's it takes a village like this. I know I'm saying a lot of stuff that I've done, but like I didn't get here alone and you know my dad hung the sign the other day, you know, so like this is like it's a it's a it's a full village effort. I don't think you will man. I think you're too determined. You're obviously a brilliant person and you know, I can't thank you enough. I mean for like is that three years ago we met initially you were my doctor didn't care my hip and you know now you want to kind of say that hippo. That's all right. I said it and you know and now you you've been very much a role model to me and mentor. So I want to appreciate you. This has been long overdue. I'm super excited. I hope the people took away some interesting tidbits and we were able to shed some light on the inner workings of and the complexities of the insurance base model or just health care that don't need to be as complex. I also want to apologize because after the millions of listeners that we have listened to this, you're going to need more chairs in your waiting room. Okay. You should get ready for that. I'm okay. I'm okay with that problem. And yeah. And the author really stands like I'm happy to answer any question. I'm I'm an open book. Like even if patients, you know, you want to run something by me. I'm happy. Even if I if it's not my service, I'm happy to help. So yeah. How can people get in touch with me, right? You mentioned your website, socials, give us all that stuff. Yeah. So the practice is apex sports medicine. It's apx. Basically, I couldn't get apx website. So apx sports medicine.com. I'm on Instagram at apex sports medicine.com. And then my stuff is available. My office number, my email, everything is transparent. It's an underlying thing of this transparency. So you can find me easily and ask me any question you want. And hopefully you just go on my point on my schedule and you book an appointment. We get to have 45 minutes to an hour to to connecting that makes some changes and help you out or get you out of pain whenever you need it. Awesome. Vince, thank you again, man. Again, I was silent the whole time because I was just soaking in and learning so much. So this is going to be a sodium for me to go through again and just get that refresh run insurance. And that way I can explain to my patients too, because I mean, being in rehab, it's four days in, we get to find out how many they're length of stay, for example. And so it's always a headache and always a constant discussion. So thanks for everything that you brought on here. I love it. Yeah, I've been thinking about this. I would say removing the insurance-sized barrier between patients and providers and getting back to accessible, affordable, personalized care. I think the way you do that is go see either a direct pay, primary care provider, direct pay, specialty care provider, and make an investment in your health and see the difference in the care that you get. Thanks, Vince. Yeah. Appreciate it, guys. You guys are the best. Hopefully, in a couple of years, I'm back on here, we're talking about them then also. Amazing. Yep. All right, man. Oh, I will be. Yeah, we talked before this. I definitely want to, I definitely want to play some more golf and Florida. So we'll make that happen. All right. See you guys. See you. Have a good Thanks for listening to the other episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter, and TikTok at Med Redefined. We also want to thank our team for the production of this podcast, Arita Yepurian social media, Zana Blugmani on research, and Sarah Hahn for newsletter. Oh, and if you want to get similar bite-sized information delivered to your inbox every Sunday, please be sure to sign up for our newsletter. Also, if you enjoyed the show, please be sure to subscribe, review, and share with anyone who you think will gain value from this as well. Now, time for the ever so important disclaimer. This podcast is intended for general public use and is for educational purposes only. It does not cost you the practice of medicine, no should be construed as a medical advice. No physician patient relationship is formed and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal position regarding any specific health-related issues.