Industry veterans, degenerate gamblers & besties Chamath Palihapitiya, Jason Calacanis, David Sacks & David Friedberg cover all things economic, tech, political, social & poker.
Wed, 01 Jun 2022 02:44
This talk was recorded LIVE at the All-In Summit in Miami and included slides. To watch on YouTube, check out our All-In Summit playlist: https://bit.ly/aisytplaylist
0:00 The Lanby's Tandice Urban breaks down why healthcare has a customer service problem, and how to fix it
12:28 Bestie Q&A: changing American's perspective on healthcare, opportunity for DTC health brands, why is medical spend at all-time highs while avg lifespan has flatlined/slightly decreased?
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What's going on? Let your winners ride. Rain Man, Davidson. We open source it to the fans and they've just gone crazy with it. Please welcome tandis. Hi everyone. So. What I want to talk about today is the problem that I'm obsessed with, which is bad customer service and health care. So I'd like to start out by walking you through. A day at the doctor's office can look a little bit like this. You have to start out by making an appointment, so you call in. You talk to someone very unpleasant on the phone. They put you on hold. You wait. There's bad hold music. You're waiting, you're waiting. They come back. You go back and forth a little bit on your calendars. You've got an appointment. It's in 21 days. Now it's 21 days later. You go to the doctor's office. Someone very unpleasant checks you in at the front desk. You sit down. Super depressing waiting room, bad wall art, very old issues of parenting. Magazine. Smells like Purell in there. That's fine. This is your hangout for a little bit now, and now it's maybe 30 or 40 minutes later someone calls you back. As you may have guessed, they're very unpleasant. They take you back to the exam rooms. Very small blab, fluorescent lighting. Everywhere they take your vitals, they hand you essentially a sheet of printer paper. They tell you to change into this. Now you're in sort of a secondary holding chamber, except this time you can hear the doctor and the other room and they're saying, hey, it's so great to see you. And so, you know, they're just getting started in there, even though your appointment was an hour ago at this point. Pull up your phone. You start to go through your little question list, got up the courage to to ask everything you came in to ask. And then finally the Doctor knocks, like you could possibly still be changing. He comes in, does a little small talk with you. He goes and sits down, starts asking you some questions. You're maybe like 8 minutes into the appointment at this point and you're like, OK, also I have some questions and you pull up your little question list on your phone and you get through maybe like two or three of these questions and then the doctor starts to give you a look, like let's wrap this up. And so you wrap it up, you ask three questions. The appointment is over. You go outside, you check out. If you're lucky, they'll tell you how much you owe. If not, you will just find out later in the mail. So my guess is that maybe many of you in this audience have a concierge doctor, but most of us have had some iteration of this experience at some point. There are a lot of terrible things about our healthcare system, but the one I want to complain about specifically today is why the customer service at the point at which you're actually consuming the healthcare. So appallingly bad. And when I refer to customer service that's that's anything that touches the patient experience while you're while you're going to the doctor. So a long wait time is as much bad customer service as the the unfriendly front desk person. There's this really great quote that I love from Bill Gurley, prolific investor and my relationship hall passed. Didn't know he was going to be here. The US healthcare market is the least customer centric of any customer service industry. We are so numb to the pain that we rarely object or complain. So that's part of what I think is so crazy about this is that we kind of just take it. And so that got me curious to explore three questions that I want to go with you through with you here today. #1, why are things so bad? How did they get this way? #2? Why should we care that things are so bad? And #3, what can we do about it? What's a little something we can do to make it? Better, so let's start with why are things so bad. A big part of this is our customer service problem is really more of a consumer service problem. And what I mean by that is patients are consuming the healthcare but they're not exactly the customer in the traditional free market sense of the term. So who is the US healthcare system as we know is an employer sponsored model. This was not very well thought out. It's more of a World War Two relic that was came from a national mandated wage freeze in 1942. And we kind of just kept going with it. And now today, the doctor is not getting out of bed in the morning for your $15 copay. They're really making their money off of the major stakeholders in the industry who are the employers and the insurance companies. They're the payers. They're the real customers in this story. And doctors don't love this either, by the way. There's major burnout in the medical community. But when you play this all the way out, you're left with misaligned incentives between physicians and patients. Physicians and the traditional fee for service model, which is our predominant model today where our physicians are paid per patient encounter, they're incentivized by volume and not by quality and not by good health outcomes. So it's no surprise that practices are not designed to cater to the patient. And once that becomes the norm, it becomes the culture. Every doctor's office can get away with it. And now you're left with these two really bad stats. The first one is in primary care, specifically the average NPS were provider is 3. That is so embarrassing. #296% of patient complaints are about the service itself, only 4% or about the care delivered. So patients are really noticing how bad the customer service is. And yet to go back to our earlier point, patients have this sort of Stockholm syndrome. When it comes to going to the doctor specifically, we'll like request a non talkative Uber because we don't feel like chatting with the driver or we'll leave a very scathing Yelp review for a restaurant, but when it comes to this service. Even though we're not an easy to please generation, we become very submissive and it's the most important service across any service industry, so this is not a good thing. Why is this happening and why should we care that we're having such a bad time at the doctor's office? It's because bad service is bad for our health. So good medicine is a partnership between a patient who's coming in with real information on how they're feeling and then a physician who's coming in with real expertise to bring to that information. And they work together. But if the patient is feeling very anxious and exhausted and the doctor is feeling very rushed and dismissive, you're left with losing a bunch of really important information that you need to make nuanced diagnostic and treatment plans. So to give you an example, doctors are far more likely to prescribe. Antibiotics in the afternoon than they are in the morning for the same patient with the same issues, because they're just running late and they're dealing with decision fatigue. If you leave with anything from this talk, it should be to make morning appointments. And then patients on the other hand know all of this and they felt this before. And So what many of them end up doing is deferring treatment altogether. So patients feel like it's a hassle. They're not getting anything out of it. They will just their Med school friend Healthcare has a patient buy in problem because they've made the experience of going to the doctor's office so bad that we only go when we absolutely have to go and what do we lose when we go when we only absolutely have to go? Preventive care and preventive care is really the reason it's so bad that we're not going to the doctor's office. They lose out on going when things are early. We lose out on all the upstream life saving, cost saving benefits of prevention. So I'm gonna hit you with three stats on that. The first one is 40% of annual deaths caused by the top five causes of death in the US are preventable with good preventive care. According to the CDC, for whatever that's worth to you, avoidable chronic disease accounts for 75% of our healthcare spend. And finally on the other hand, patients with a PCP, a primary care doctor, spend 33% less on healthcare overall because they're front loading that spend toward prevention. So bad service is bad for our health. What can we do about it? The good news is this, we are starting to see more and more practices shift towards models that incentivize physicians to care about good customer service. So there are two models we can use here to change the compensation model to allow physicians to have time and space to think about service. So the first one is direct to consumer, so that's making the patient the customer again in this scenario. And the second one is leveraging value based care models where the insurers are reimbursing based on quality instead of over volume. And so in that case, the insurer is still the customer, but we're now rewarding a different outcome here. So those are kind of. The two options that we can leverage, but as we can see, we have the tools that we need. It's really now about shifting norms in the healthcare industry and the industry is very clunky and it's red tapy and it's sort of crotchety at times. And so the change might feel a little bit slower than it does in other industries. But we're starting to see more and more companies push back. And as they push back, patient expectations change, we start to expect more out of our healthcare and now we're starting to treat healthcare the way we treat. Any other service that we interact with and we start to say goodbye to that Stockholm Syndrome era. But as we move towards these models that change the incentives for physicians, we still need a framework to think about, OK, how do we get that good customer service? How do we actually get the patient buying? How do we get people to want to go back to the doctor's office? Because doctors and hospital administrators are not used to thinking about this. They're not used to training on customer service or bedside manner. So we need to look to another industry, which is the hospitality industry. So I brought you on this journey here today to tell you we need to be stealing. From the hospitality industry, they have figured this out already. They know how to treat people like people. They know how to provide human to human service, which is ultimately today, what healthcare still is. So I really think this definition of hospitality from Danny Meyer is really great. Esteemed restauranteur my other relationship Hall pass. Hospitality is present when something happens for you. It is absent when something happens to you. So we want health care that happens for patients and not two patients really. Michelin worthy or at least very effusive. Yelp Review worthy healthcare and I want to share a few ideas on how I think we can get there. I'm the cofounder of a primary care membership service called the Land Bee and we do what we call a healthcare hospitality training with all of our team members, all of our providers. And I want to share a few central tenants from that training with you that I think are the ones can that can be applied into any practice. They can be implemented at very low cost and can really start to to shift the norms and shift the culture, which is what we need. Some of these may seem obvious, but they're not in healthcare. So here we go. These are my top five, number one followed the golden rule. Patients are entrusting us with their most precious resource, which is their health. Treat them the way you would want to be treated, as the doctor, or you'd want your family to be treated. #2 set clear expectations. This is not a subway track. Nobody wins when we hold information like running a few minutes late to ourselves. #3 be a good, active, empathetic listener. Ask good questions to get good clues. Treat every case like it's a medical investigation. If someone didn't think something was important, they went and brought it up with us. Another Danny Meyer line be an agent, not a gatekeeper. So an agent lets people in. A gatekeeper builds up barriers to keep people out. We don't want to be that kind of practice. If a patient has a good reason to be asking you to break one of our rules, and there's an easy way to break it within the bounds of the law, then just break it. Finally, for extra credit, surprise, and delight, how can we make this the best interaction of a patient's day, even if they're going through something really challenging? I think that's the fun puzzle of applying hospitality into the healthcare context, is finding a way to bridge that gap. How can we remember something about someone and make them feel seen and make them feel like, yeah, I want to come back to the doctor's office? All right. I don't have a super punchy ending here, so I'm just going to wrap this up with healthcare. Hospitality treats patients the way they deserve to be treated. We're all patients at some point, and when that point comes, the stakes will feel inherently high. Too high to get worse service than you would at your favorite restaurant. Thank you. I think the thing that struck me about our dysfunctional system is the Bill Gurley quote and then what you're doing there is no customer and how does that change over time in America? I know you're what you're doing with your company is part of it. So how do we change that in American's perception? Because I got my knee done and I didn't know how much it cost and then I found out just cleaning out my meniscus with $60,000 and that was like how much, $60,000 ten years ago for a meniscus? Surgery in New York, and then somebody said, that's your cost, like 10,000, and there's no menu. So we're going to a restaurant. You know, when you go to the restaurant in Italy, like the ones you go to and there's no prices? Yeah, you know, you're ******. I love those. Yeah, you love it. And then you hand me the check you didn't when we were in Vegas that time. So how do Americans start changing how they perceive this? I think that's part of the problem, is it not? Definitely part of the problem is that we all are kind of just OK with it and assume that this is this industry where we're not supposed to know the prices until afterwards. No other industry works this way. We don't put up with it anywhere else. And so I think direct to consumer models play a huge role in getting patients to think, oh, I can treat this like other services. It's not like we're not annoying consumers in other ways. We already are. And so we just need to apply that. Name annoying attitude to health care and then by leveraging direct to consumer models. Part of this is getting on higher deductible plans. So we start to treat our dollars more like normal, normal dollars, putting money into HSA's and FSA's. It gets us to start thinking more like a traditional customer and think about where we're spending our money. And we we see that a little bit with direct to consumer drug companies. Yep, hymns. Hers get Rome and all the stuff that Freeberg uses to get ready for battle. Even nice to meet you. How are you? Your hair looks to prepare for war. Those are a start, right? People will just say nice things from now on. Come on. I love you. Yeah. But this is part of it that people are saying. It's so dysfunctional to go to the doctor. It's so dysfunctional deal, my insurance company for certain things. Yeah. I'm just going to go on a website and order. That is part of the frustration. Right. And yeah, that gives you a little taste of it. And then alternatively, if you don't want to go to the doctor, you'll go to urgent care, which has much more of an easy pricing menu. In many cases that you can look at. So again, we're starting to get a taste of it and I think patient expectations will change and doctors will have to follow suit. We tend to index the quality of American health care when you look at the average life expectancy. First you do men, women, and then you, you know, you look at white men versus black men versus brown men, you know, white women versus black women, et cetera. And white men have always sort of been the standard bearer. And then this odd thing has happened over the last three or four years where their life expectancy started to get worse and worse as our percentage chair of healthcare expenses as a percentage of GDP have gone up and everybody gets up in arms because they're like, well, wait a minute, we can't. Something is clearly so structurally broken that we're spending fifteen, 2030% a year. Increasing every year, and we're dying now under the age of 80 where this thing should be a thing where we're living to 100. Why exactly is that thing happening? Like, I could understand, like where you could say maybe it's segregated to, you know, minority men or women or something, but this is not, this is basically everybody. So why are we dying sooner as we spend more? Because we're also increasingly spending on a lot of things that kill us and we're not. We're overspending on healthcare because we're spending on things that kill us. And then our healthcare gets very expensive because we have terrible, terrible lifestyles and everyone is drinking way too much. Across all communities, everybody is eating totally processed foods. These are becoming more and more readily available increasingly so every year. And so, yes, in the very upper echelons, there's sort of a movement towards Wellness and more holistic lifestyle, but that has not really swept the nation yet. And so we're all living really, really unhealthy lives, not caring about our preventive health and then spending a lot on healthcare down the line. So you're saying it's really not, we just can't outrun our lifestyle? Exactly. Exactly, which is not our fault. I mean, corporations make it very, very difficult to live a healthy lifestyle. I'm in the US and do you find examples of countries that have gotten population level health issues right, whether it's with respect to costs or outcomes where you say that is directionally something that we can learn? No, I have no good answer to that question because every company besides the US thinks it has like the best healthcare system. But then anytime I talk to anybody in one of those countries, like I was speaking to people in Canada the other week and they hate their healthcare and against the worst thing ever and they like wait eight weeks to get UTI medication. And so a, I just think it's too hard to compare. Are unwieldy country to other systems and BI don't even know people who are that happy with other systems. So no, I don't have a good answer. How how much of a role do you think Medicare or Medicaid CMS can do to break the logjam versus waiting for politicians to pass legislation like Obamacare to kind of try to reorient what's wrong? I think it's, I think it really is both. I think that HHS and is playing a huge role in trying to get more and more value based care models. Through Medicare and they're making a huge push to do that and so it's slow and clunky, but I think they have the right idea. They want us to move towards a value based care model. I've been thinking a lot about mental health recently, seeing what we've seen during the pandemic. A lot of young people are kids having these two years alone, and what the second or third order effects of that. And just trying to get consensus in America around Healthcare is very hard. But I think since we've all suffered some degree of mental health over this COVID break, which I think drove a lot of people crazy and created a lot of anxiety. Is there any way for us to think about universal healthcare but not have to have this nationwide discussion of all or nothing? And I was just thinking, mental health is something that everybody can appreciate. It's not that expensive to deal with. It's not surgery. Why can't we just agree as a country that anybody who wants to talk to a therapist or counselor will be able to do it for a sliding scale or a very small amount of money and maybe be able to just chip off one piece of the puzzle and say, you know what therapy will be 50? Bucks flat rate, they country will pick up the other 50 or 150, whatever it is to get this done. And maybe you just speak about mental health, you know, as as a larger issue because it it does seem to have so many downstream effects in terms of our physical health. Yeah we've thought about this a lot of the land because we've tried to figure out a way to to integrate mental health in a way where we would be able to make money and we can't just yet. So. So, yeah, there have been a lot of models that came out during COVID that allow for you to text. With somebody and do like virtual therapy, there are a lot of therapists who offer sliding scale. But part of the reason it's a little bit more difficult is that the patient panel size, the number of people they can take on is so much lower because it's such a higher touch experience. And so it's hard to integrate it into the traditional primary care model where in in the across the US1 physician has a panel of 2300 patients on average. And so you just can't do something like that for mental health. Are there large population health issues that you'd love to just get on the radar? Books in this room that are poorly understood. I'll give you an example like. There was somebody I follow. She's a writer, I think for the I can't remember. It's the New York Times something. And she said her best friend died of a heart attack in her 40s. But then she had some stats about the incidence of heart disease amongst women versus men. And I had always assumed that it was largely a male predominant issue until I saw those stats and I realized my God, like, this is a broadly pervasive issue. Maybe it's because of lifestyle, etcetera. So I I learned something in that moment I didn't know before, but any broad population level issues that you think are really important for folks here know about. Yeah, I mean sort of related to that, I would say. Nutrition Label literacy is so hugely important. There are so much scary marketing that people have to educate themselves on and it's such a part time job to have to learn about why this product that looks extremely healthy and is like using the new brand colors that are not dorito. Why that looks like it should be vegan and organic is actually really bad for you. So having more education on what makes for good food I think would cut out a huge, huge portion of our preventive lifestyle. How can people find out more about the it's Landry Landry. This is the nightmare of my life. The Lambi LA NY I'm a big screen, so it's just right there. Yeah, I'm sorry. How can they find out more about it? If they wanted to become a member, how do they become a member? Are there memberships available right there? Hold out LA, NY. There's gotta be a website, I'm assuming, or you have an e-mail or something. And then yeah, can can it become website is actually a ND Y. That's why it's Landry, mostly. People call it the Lamby like a lamb. So the landlord's. I keep hearing people mispronounce it's it's. I've already lived a life lifelong Candace life. And now I have like a mispronunciation with Lambie all the time. So you can just go to the nba.com. You can apply for membership at the top of the website. It's a New York can it scale and and and are you gonna raise money for this? Is it gonna be a venture based investment? Because it sounds fascinating to me as a as a business model, yeah. So we're actually raising our seed right now. We we predominantly raised money through our Members so far which has been really nice is having our consumers as investors. But yeah, it can reach mentor scale because the way we're doing it not to get too in the weeds is through a three person care team model. So we're able to take on more patients per panel because you're assigned not just a doctor, but also a nutritionist and a concierge manager who does all the patient homework for you. So raising a seed and yeah, let me know where to send the check. Sounds great. Let's thank Candice for taking the time. Now we'll let your winners ride Rain Man David Sachs. We open sources to the fans and they've just gone crazy with it. Thank you. Besties? My dog's driveway. Oh man. We should all just get a room and just have one big huge **** because they're all this useless. It's like this, like sexual tension, but they just need to release somehow. B. Where did you get mercies?