Believe In Arkansas
Believe In Arkansas
Solutions to Rising Health Care Costs
Arkansas has significant challenges in healthcare accessibility, transparency, and affordability. These, of course, lead to poor healthcare outcomes for the state.
Arkansas health systems are ranked 47th in the country.
Accessibility: Fifty-nine counties are medically underserved.
Affordability: High out-of-pocket costs, high deductibles etc., are an affordability barrier to getting diagnoses and needed treatments for many Arkansans.
Transparency: Healthcare consumers deserve transparent pricing and options information.
Ryan talks with Dutch Rojas. Dutch is an expert in supply side healthcare strategies. He's a sought-after speaker and advisor, His work regarding all-inclusive prices and SurgeryFutures gives him important insight into policy changes that could eliminate many of our challenges.
To learn more and see how AFP-Arkansas can help you or your organization increase your impact in our state, email us at infoar@afphq.org or visit us at believeinar.com.
Welcome to Believe in Arkansas, where we believe free people are capable of extraordinary things. Now, here's the host of Believe In Arkansas, Ryan Norris.
Ryan Norris:Welcome back to Believe In Arkansas, the podcast that believes that free people are capable of extraordinary things. That's what I love about our system of culture that we've set up when there is a problem. There is going to be individuals lining up to help us solve those problems. And there isn't a problem that seems to be at the forefront of the mind more often than the issue of health care, you know, in Arkansas has some significant challenges in healthcare accessibility, and health care affordability. And this has contributed to poor health care outcomes. Every time that I speak with folks from outside of, of Arkansas, and they they talk about what their perception of Arkansas is, it's usually a state where we're in poor health, and we don't have the resources that we that we need. And there's some studies that have come out recently Arkansas health systems are 40 ranked 47th in the country, that the Arkansas Center for Research and Economics when we're talking about accessibility, 59 counties are medically underserved and another 15 are partially underserved. In this country. This is where we're talking about not being able to get health care because it does not exist there. And then among the Arkansas primary physicians, the Association of American Medical Colleges reports from 2020, it's reported that Arkansas has 83 primary care physicians per 100 residents, and this is well below the national median of 95 primary care physicians per 100 residents. So we're about 10 physicians short of what the national meaning is. And this puts us at about 37 Out of the 50 states. That's only accessibility side affordability is also an issue. And in 2021, the health care affordability state policy scorecard said that we ranked 30th Out of the states including the District of Columbia. And though we were commended for establishing an all payer claims database, we're still not doing so well and lacking in policy solutions to address rising health care prices, such as a strong price transparency tool. Now, we do have some hospitals that are starting to put their information out. But there's recent articles in the Arkansas Democrat Gazette, about the success and or the the ability to interpret what those prices really are and what they mean and making them uniform so that you as a consumer of healthcare can make an informed decision. So it's still being worked on. Regarding transparency, it exists as a tool as a policy that is mandated, but yet we're still having some compliance issues in that space. But the state's performance on making out of pocket cost affordable was particularly concerning. They said that they in fact, Arkansas received a policy score of zero, and that there was a significant percentage 16% of adults were unable to receive needed medical care due to high cost most of them from out of pocket. So you may have insurance, and you have a deductible, and yet you're not able to meet those deductibles or meet that out of pocket expense. So to help us discuss the state of US healthcare access outcomes and solutions, and talking about how we can potentially lower health care cost is Mr. Dutch Rojas, Dutch is an expert in supply side health care, including his work with all inclusive prices and surgery futures. This has made him a sought after speaker at physician specialty conferences, health and welfare, trade shows, consultant facing conferences, as well as a financial institution symposiums. He's a social change entrepreneur, having been a limited partner or advisor in 19 healthcare startups. So this is a gentleman who studies the market looks at the needs that the market has and tries to come up with solutions. So Dutch thank you so very much for being here with us. I Believe in Arkansas.
Dutch Rojas:I love it! I'm so excited about your intro. I thought it was fantastic. Well, hey,
Ryan Norris:you know, two things about it is accessibility and affordability. These are top of the mind for individuals and I had a conversation with a young lady over the weekend. And we have some different philosophies about government. And we were sharing with each other and she said that her solutions that she came up with particularly with health care, you know, kind of a single payer top down approach to it. The government gives it all to us. It's because of millennials, having hit the the real estate crisis of 2008 and other financial crises and then COVID, etc. And they just feel like the cost of everything, particularly health care. is making it to where their quality of life is diminished in their certainty around access to health care and the longevity of their life even is something that's on their mind. I hadn't considered that, really. So I was glad she shared that perspective to me. But, you know, what do we need to do to solve health care here in the United States? I know we're gonna wrap it up all in one prepared.
Dutch Rojas:I'm reminded of this great book by Thomas Sowell, you know, and he said that Margaret Thatcher and Mikhail Gorbachev had a conversation. And this is what I talked to Gen Z, millennials, even baby boomers, right to the Bernie the Bernie left, who I really enjoy talking to. I'm probably the one person that likes to have these conversations besides you, apparently, because I can hear him from all sides. And I'm certainly happy to just talk through and have great conversation. But Mikhail Gorbachev couldn't understand how England did it. And he said, Well, how do you supply all the needs for all the people he said, we have a meeting every single month where we go through different industries, and then we centrally plan and like this made a lot of sense to him. It makes a lot of sense to a lot of Americans. They say, Well, you know, we elected these people, why don't they just tell us how many grains of rice we need? And how many, you know, silos of corn we need. And then we'll just go on our merry way. And we can just do our jobs and everything will be handy dandy. And then of course, she said, Well, it's prices. Prices are the number one indicator of value. When we think about what Wall Street, how Wall Street works is price discovery. What's the actual price of the equity? What's the actual price of the bond? How do they perform? And how can we use them to our advantage, right to build companies build buildings, you can't centrally plan the city of Little Rock. You can't centrally plan Bentonville and Fayetteville, northwest Arkansas, you can't do it. It's impossible. You have to have private capital that does these things. And so I think working in the private sector, working in the private industry, is the right way to go. But like, again, that's my philosophy. Right. And it has written since 1997. When I graduated from college, and said, This is how I'm going to make my mark on the world. Its price discovery. Everything in healthcare begins with transparency. So you know, that's always a good conversation starter, because most people don't realize that price is the single factor that dictates everything. Want to know if a peloton is worth anything? What's the price, learn know if your car what it's worth, what houses are worth, it's always the price now how they've been manipulated in the last 20 years. Right? That's a different conversation, when we're talking is free market capitalist who see a problem, as you've mentioned in your opening, and then we say we're going to take a market approach and solve that problem with a discipline of free market economics. And so that's generally how we begin.
Ryan Norris:Yeah, and what I also love about is that it's not a one solution, there are multiple individuals who see multiple components of the problem, to where at some point, all of them have a Nexus at which they converge, to really get the maximum effect of all those solutions coming together. You mentioned Thomas Sowell, I've always loved I pencil the Milton Friedman approach that no one knows how to build a complete pencil. There's someone who knew how to get the rubber for the eraser, but they didn't know how to get the graphite that they needed to go in there. But there was someone who got the wood and someone who got the paint, and there was a chemist that mix the paint, and there was a cetera, et cetera, you know, all of these little components, that's what I love about in Charles Koch's book, Good Profit, he talks about the Republic of science to where different people solve different problems. And then other people took their solutions, and put them together to form an even better solution. As we move forward. That's what I love about, you know, if you give people freedom, and they take that freedom and create opportunities for themselves, those opportunities will cascade and and, you know, increase exponentially. And then that's how you get to prosperity. So I think our session is about, you know, prosperity and health care what in the world, would that even kind of look like, but and what are some of these variable costs that you see or that lead to this, the cost of health care or the pricing in health care? What do you see as being the major contributors
Dutch Rojas:to the to the increase in expenses and price? It's, it's, you know, in 33 states, you still we've eliminated two states this year, thanks to a lot of help from you guys and others. We eliminated two cod states this year certificate of need has been shown to increase expenses by 30%. Right? I mean, imagine if we could just drop 30% Off the top line of every single healthcare institution, Arkansas, that'd be huge. Right? And then you take price transparency, we use price transparency for about 4 million people. So it's not a little number. It's not a big it's not a small number, but it's just the right kind of number where you say, one 4 million people you can to kind of say we have some really good data. And so by using price transparency, we've been able to decrease the price of healthcare expenses across the board by more than 25%. Now, you might say, well, that's only 4 million people. And those 4 million people are scattered across the country. But it's still a good representative dataset. And so when you look at that, and you say, Well, how do we decrease expenses? Well, one of the things you mentioned was access. Here are two solutions that we've provided for access. One is we've asked for a kind of a slight differential on the moratorium for position on hospitals. So if I'm a Wall Street insurance company like optim, right, I am not going to deploy capital in places where the return on investment doesn't meet my portfolio requirements. Right. Right. That makes sense, right? Yeah. So. So what happens is they go into these rural locations, right? Arkansas has lots of rules. I'm in Oklahoma, they have lots of rural locations. And they say, well, we bought this asset in this rural location. But you know, we have an orthopod there, we got a neurosurgeon there. We got all of these specialties there. And if we bring them into little rock, or if we bring him into northwest Arkansas, we can increase our return on investment. So it's not a good idea. But if we have a segue from the moratorium, that's on positional hospitals, physicians are inclined to go out there and do it anyway. Right. Right. Like yes, yes. Do they want a return on their own capital? But guess what, they're mission driven, purpose driven, God fearing driven individuals who say, I've had this calling on my life since I was in eighth grade. Yeah, right now, just to give background, I've interviewed more than 18,000 individual physicians in my career 18,000. So I think, while someone might say, Well, you're not an expert, I think I have a good idea of the background of physicians. Yeah. Right. And so we need that. And then secondly, in 2007, I was living in a very blue state called New York, I was living in Manhattan, loving every second of it. And I found a young doctor who had built a asynchronous chat application that allowed physicians to communicate via chat with patients. And I paid $19.99 for it. And that app was my doctor, right? So a doctor sitting behind eight screens for half a day. And they are talking to patients about non physical interventions. This product cost me $19.99 a month. Wow. And for large users, like large employers, it was like got down to like five or six bucks, right. And there's no way that we 20 years later, or I guess 17 years later, can't afford to deploy capital to do those things. In Oklahoma, I'm pushing really hard to get every single Oklahoman a virtual primary care doctor. Why? Because they live in the boondocks. And that's where they want to live. And I don't want them to leave their parents, or their cousins, aunts and uncles, I want them to stay right where they are and do the job they're doing. But I do want them to be able to turn on their phone, whether it's an iPhone or another one on Android, and I want them to have access to a position. And it's proven. I mean, like it the data is all there. The studies are all there, right? Like we're not talking nonsense. And it says that out of the 2000 conditions, we can treat 1000 without seeing someone in person. So why would we do that? Right? Like that just seems pretty easy to chop down the the accessibility deal. And by chopping down accessibility, I mean, an unnecessary ER visits, unnecessary doctor visits. Right now it's a one on one versus like digit I just typed it in. Now all of a sudden you have access, like 40 or 50. People can talk to a doctor in three hours versus a one on one. Right? And so you and I, I mean, you said it. Well, I love the way you say things because you put them so concisely, I just like talk like a brainstorm. But really those two tools alone, plus 10 others that different entrepreneurs and physicians have built at different times come together and they say, Hey, we reduced expenses by 1%. But if you put all 10 tools in, we reduce it by 20%. Right? It's pretty amazing how that works. Yeah. And you know, so in Arkansas, we've worked and have already seen how it's working well, on in expanding telehealth, and we have stories of individuals who because of telehealth they were able to make to have access to behavioral therapists, etc, do some group therapy. There's different ways that they can approach it to where they're like in my rural town. I did not have access. I now have access. I'm I've got a job. I'm keeping a job. I'm buying a house my light quality of life is improving all because they now have access to someone they don't have to travel two hours back and forth to different places. Another thing that we've done in Arkansas representative Dr. Lee Johnson, champion this into one Knee 21 For scope of practice, allowing our nurse practitioners to, after a certain amount of hours to go out and practice primary care on their on their own, they're trained for that. So the opportunity again, lower the cost a little bit in rural areas, nurses that may have grown up in their hometown are passionate about their hometown and want to go back and help people with their heart issues, their diabetes, etc, etc. So, again, I love how it's not a one, it's not one solution. There isn't one, give everybody tell me how many medical hospitals I have to build government because they really don't know what the individuals need or what the communities need. Well, it's the Gorbachev issue again, right. So one of the things I'd like to say is one of the biggest diff challenges I've had, right and I learned English at 16. That's one six, right? I'm now 47. So it's been a minute. But one of the difficulties I've had in healthcare is when I say the word telemedicine, or I say the word virtual primary care, I say on site near Site Clinic, what the other person hears is not what I'm trying to convey. Right. And so, with legislators, especially as we talk policy in Washington, DC, as you know, I spent a good amount of time up there, you do, too, we try to spend time in our own states. One of the challenges for me, has been to articulate exactly what I'm saying with precision. And so like, telemedicine is amazing when most folks hear telemedicine, right, because without the employer benefit space, they hear I call someone and I get a random physician every single time I call them, and they can handle 16 conditions, versus a virtual primary care doctor, that's actually a physician that can handle over 1000. Right, right. And so what I like to say is we do virtual primary care. Then we move into specialist telemedicine, where I have a one on one conference, you need to see an orthopedic surgeon. Okay, can I have a quick seven to 10 minute consult? Which by the way, that's all you're getting? Anyway, when you make an Oh, 50405 appointment? That's all you're getting? So I like to have a conversation via via telemedicine with a physician. And I've seen our employers do it. And it lowers expensive, right? Because now they say, You know what, Dutch you really do need to come in. Ryan, I think this problem can't be solved this way. I really think you need some radiology or some PT, why don't you come in and let's kind of figure this out, I need to do a physical exam. And so the solutions are partly like, can we get distributed means? And can we actually understand what everyone's saying, when I go to DC, I see this a lot. A politician will stand up and say, and they're so well intentioned, right on the right and left, they're well intentioned, they want to lower expenses. But they just say things and they go and you go, well, that's not what that means. That's not like, I wish I could stand next to him and just say, here's what you actually said. Yeah. Right. And it's hard for them because they have 50,000 things that they're trying to help their constituents with.
Ryan Norris:Right. And, you know, and this goes to were having experts that can break it down to what's really going on, and what the solutions are. And then always the best of them talk about the trade offs. Because not everything's a silver bullet. There's going to be a ton of trade off here and there. But we have to decide which one, which of the trade offs how do we prioritize them, and then come up with a solution based on that be like this is an acceptable trade off on this. They don't necessarily think about that in that way all the time. They do have considerations to also, how does this look politically comes up. And that's a whole other podcasts that we could talk about. But what I've found out is exactly what you're saying, I have yet to find, left, right or center, a politician or a legislator, let's put that well, legislator who really added their core wants to try to improve life for their constituents, they really do want to do that. Coming up with one connecting the voices of their constituency to them so that they know exactly what they need, and then finding those that understand the problem enough to articulate it to where they can understand and then solve it. That's what was so brilliant about, you know, in the scope practice, I Dr. Lee Johnson, a State House member in Arkansas, understood the issue and the problem, walked through the concerns that the doctors would have the concerns that the nurse practitioners would have, and then created a solution to where everyone was like, my fears are alleviated quite a bit here. So yeah, I can get on board with this. And so now, we're seeing the ability of putting some of those nurse practitioners into rural areas. And in that, again, that's an access issue, but helping people understand what the issues are. We've talked about this a couple of times. Now, we talked about cost, and we talked about price. And you know, where did you get your idea for building this transparent pricing network for employers?
Dutch Rojas:Oh, that's such a great question. Well, I was I I got a scholarship from Oral Roberts University in 1993 came from the Netherlands. And by the way that the Netherlands has done healthcare all wrong, right? And that's a whole other podcast so we could spend time talking about it. And when I talk to millennials and Gen Z people, I say, Well, I lived in a universal payer environment, let me tell you how terrible it is. Okay, like, so that that's a whole other thing. But I got the idea from Oral Roberts, he, you know, the first story I heard was that he stood up in a tower and said, If you don't give me$9 million, I'm gonna die tomorrow, right? Well, that's all not true. And so his idea was, how do I build affordable and accessible care? Right. And so, as a student, you kind of learned about those things. And while you were in class, and one of the things that I got when I started, I was an accounting major. And one of the things I learned early on was, Wow, there are 18 billion medical treatments that are consumed each and every year in the United States. And then, you know, I mean, just kind of being a quantitative person, you go, Well, how many of those need an emergency room? Right? It's like, it's a number so small, and so minute, it doesn't even factor in. Right. It's it, it's less than one quarter of a percent of the 18 billion. But what happened was, every time he stood up and said, I want to build a medical school, and I want to build the largest hospital in the world to serve all Protestants around the world. What happened was people said, What happens if I get in a car crash in Nashville, Tennessee? What happens if I'm in Los Angeles, you know, his hometown, where, where I have an emergency heart attack? What do I do? I can't fly to Tulsa. Right. And he let that kind of lower his understanding, because he didn't know what you and I know today. Yeah. Which is just what we said. And so I came out of college thinking I'd gone on some mission trips, both medical mission trips, and I thought, you know, I really want to be in the healthcare world. And so I started working on surgery, center development, doing the real estate analysis. And from that, you know, I'm a price person. I mean, like, I literally walk around the grocery store for fun and look at prices like that is the person that I am, and thankfully, my wife puts up with it. And so it's one of those things that came together where I said, Well, price solves everything. Here's someone who wanted to do something different, or Roberts, and how do I make that work? And it took me, I mean, I worked for surgery center development company for eight years, it took me a while to figure out the benefits world took me a while to figure out what was necessary was needed. The nice thing was I was working the whole time in the business. The thing that the employee benefits professionals do not see is the supply side of the business. They think, well, I'm representing the employer and the people. Therefore, we should do A, B, C, and D. And if you look at the congruence between A, B, C, and D, and what the physicians need, like they don't align at all. And so what I found myself being and there's other people like me is being a little bit of a bridge maker, right saying to the consultants in the country, hey, listen, here's your solution. But guess what you got to tie it to because this is how practice works. And if you and I really free market people, we believe in decentralization of centralization, right? Like, I want more physician practices, which we're why we're fighting certificate of need, I want more entrepreneurial physicians, I want more supply, because as we increase supply prices, ought to go down. Right, right. And so that's where the idea came from. In 2010, I really started in earnest, we got our first big client, the large multi national corporation, who said we're spending too much on MSK. Please help us. And so as I started working for them, as a contractor, I identified most of the procedures. As you know, the top three are musculoskeletal cardiology and transplant, identified those three specialties and said, Okay, CFO, here's what you can do to reduce expenses there. And look until we have a market. I mean, I know I've talked to you about this before. You know, we're working on surgery, futures and options market, which is beyond the understanding of most people. I don't understand how, especially in Oklahoma, I'm like, Look, we sell futures every day. Right on wheat, right? In Arkansas, in Kansas. In Texas. We do this every day, by the way, when I talked to the ranchers, large employers that, you know, either ranchers or food processors, like they get it so quickly. It doesn't like it'll make your head spin, right? They're like, No, no, yeah, we'll sell him on futures. How far out do you want us to buy him? I'm like five years they're like, I'll buy all the radiology appointments I need for the next five years. I'll be like all the general surgery I need and all the orthopedics what does that do? It lowers expensive. Yeah, right. Yeah. Yeah. So that's kind of the genesis of this idea. That's where it came from. You know, I sold the company last year. And so, you know, now I'm now I'm just a working man.
Ryan Norris:So, and that's, that's what's so neat about this is that we're as many of us that are just you know, your average citizen, we're just seeing our bills, we're going to our doctor for following through. But at that moment, when you look at things you're like, you know, no one ever talked to me about this pricing, and why is it they've sent me two different bills, and you started start digging into it? You, you're like, something's not quite right. You could say, you know, something? Was it something smells in Denmark that we used, right? Oh, Hamlet, you know, something's not quite right. And then you start digging into it. But it's, it's awesome to connect with experts like yourself who have made a passion out of like, I want to demystify this, and come up with a solution that breaks the paradigm down because the paradigm we currently have is really a mystery to people. And they just walk in and think that everything they need will happen. But in this system, two, you don't get necessarily everything you want. There are layers of decision makers, between you and your doctor. And that has come up over and over again, as I've talked to doctors, they're like, you know, I'd love to help you. But I can't or I would actually do it for this amount for that treatment. But I can't. Does this. Does this idea resonate with you this this anecdotes that I'm sharing? And sure, how does this maybe feel go with flow into your support for private practice?
Dutch Rojas:I think that people are constantly having challenges with health care. You know, if I asked him, Do you know there's a certificate of need in your state? Do you know what that is? 99% of constituents say, I don't have a clue. I've never heard that. Right. Right. And you explain it to them. They go, Oh, my goodness. They've never heard of the moratorium on physician on hospitals. They don't understand why their favorite university, right, including in my state in all 50 states, their favorite university has a hospital academic setting that has five business plant five businesses inside of it. None of it really works for their help. I mean, we broke down UVA several years ago, they they were putting they were taking away people's homes. The legislator in Virginia took care of it, but they didn't get rid of Con. But I mean, some 2000 people in three years lost their houses for medical bills that they didn't know anything about didn't sign on vicarious liability. Like, there was no sense to it. I think that hospital health systems, you know, and I don't mean, this is an unkind way. I just mean it as a fact. They work in partnership with Blue Cross, United, Cigna, and Aetna. And those businesses, right, have a fiduciary obligation to making an extra buck, right? And people will say, What about the not for profit hospitals, they have the same fiduciary obligations. If you're if I'm an officer of BlueCross BlueShield, right of Oklahoma, I have an obligation to my company, right? The company is a person, and I owe my I owe my fealty to them. Right. And when you begin to explain this to people, they go, now it makes sense. And I say that's why I don't That's why don't rage against people, rage against institutions, right, separate the sin from the center, if you will, it's the wrong thing to do. You cannot get mad at an academic, you cannot get mad at a doctor, an academic center, or a hospital administrator. They are doing exactly what they've been purposed to do. It's my job and other free market thinkers to use disruptive methods, technology, innovation, price transparency, to lower their profits, generate competition, and slowly get them out of the businesses that they're in. As much as I love policy. I don't know if policy solves these challenges. It's one of the essentials maybe. But I think, you know, Clayton Christensen is another hero of mine. He is the father of disruptive innovation. And he's given us several pathways, specifically in healthcare, on how to disrupt and how to solve these challenges. By the way, it's amazing, I hope, like if I get one thing out of this podcast, just one and I'm gonna get 20 But I hope that the effect is that every person who listens to this gets on YouTube, looks up Clayton Christensen and says, hospital healthcare, Clayton Christensen, and all of a sudden they because you know, you can't tell people things, right? People like me are stubborn, probably you. And it's like, well ask me enough questions, get me interested. Let me hear it for myself. And I'll use my deductive reasoning skills, right? And then it will be profound and when it's profound, like it was for me, then it makes a life changing moment.
Ryan Norris:It's something else I would put in here is that you know, you're talking about you know, low lower in the profits and things like that, like that. The, what I would like to say is that the systems that exist, those may be I'm gonna give you an assumption of good good total goodwill, those may be a system that works for some kind of things. What I'm asking for, is don't use public policy to exclude innovative ideas that are coming. There's where I have, that's where I have the conflict is, you know, if I've said this often about several public policy issues in the state of Arkansas, Arkansas is in such a state, that we shouldn't take any of the potential solutions off the table, we need to consider how we create such an open environment, that there is always a opportunity for innovators to solve someone's problem. It's when you say, these are the solutions, you get to know more, you know, the Henry Ford story, you can have it in any color you want, as long as it's black on your model T, that's not the environment that we need, we need the ability to make the decisions for us more decisions being made by us than for us and so much in healthcare and other areas, economy, education, as well. Other people who you don't know who don't know, you are making decisions about what you can and cannot access. That's where I really started,
Dutch Rojas:do you think central central planning is not the best solution,
Ryan Norris:It can't be. And you know, I, I'm a Carl Jung fan. And something that really resonated with me reading his book, I believe it was modern man in search of a soul. He said, If you have a box of stones, and you weigh all the stones, and you get an average, and the average is 40 grams, put them all back in the box, and it is unlikely you're going to reach in and pull out a 40 gram stone. In fact, the 40 gram stone may not exist that exists. Yeah, they do not exist. And so that's where there are no average people. Because the individuals are so unique, we need to have it to where each individual can have access to what they need, when they need it have a selection of options that they can choose from, and quit saying, We found this works over here. So that's what everybody gets, and this works over here. But that's what everybody gets. That is counterproductive. I think it creates these frustrations. Because in in private practice, I have. I've met a doctor here in the state who worked for a very prominent, you know, hospital, and had 1300 cases going on at all times 1300 patients, his quality of life was eroding the amount of money he actually makes was not that great, per se, he's like, you know, I just, I felt like I was still struggling. He's not living high on the hog. I've noticed this recently about the doctors back in the day used to think oh, the wealthy doctors that enough case anymore. They're, you know, they're driving the same cars, same cars that I am, and you know, I'm not a wealthy guy, the but he decided what he was going to do is he's going to go to, you know, this direct primary care model that Arkansas does allow for. And he went down to like a 200 patients, they're paying him a subscription, he takes care of their primary care. And then he does his time also with the homeless, and the homeless, do make a little bit of money here in there. And we'll pay him for some of those treatments. And here's what's so cool about it. When he calls the lab and says I would like to get this test that lab says Well, that's gonna be$150. And he's like, I'm gonna pay for it with cash, like, oh, that's $1.50 then. What is how is it that there's $1.50 for the actual costs, but it's $150 for what they would call what they would have us pay if we're paying via say, insurances.
Dutch Rojas:Well, what I love, but, you know, I mean, with people follow me on LinkedIn or Twitter, I love direct primary care. You know, I mean, there's nothing that I love more, especially for outside of jumbo businesses, which can't seem to make direct primary care work for them. I think every person in the United States ought to have direct primary care, right? It's virtual primary care for rural and it's direct primary care for everybody else. And the direct primary care guys will probably get upset and say, Well, you know, we can do rural too. And I'm like, hey, whatever you guys want to do to make it work. For a family of four today, no longer single, I finally got married at the age of 41. And I have two children. And we pay $95 a month. For four people. We're on a SaaS model, right software as a service type model, where I pay the $95 a month, and if my son who's 19 months old, is sick every day for the next five days. And I want to go in and see the doctor, I go and see the doctor. It is amazing to me how they've made it work. But it works because now they're not tied into the middleman, the grifter, the rent seeker, basically known as the carrier. Yeah, right. That's a whole other conversation. Uh, denying claims and not denying claims How does that work and not work? I, you know, talked at nauseam about that whole other podcast but that's a whole other deal. The price issue is twofold. One is one, it makes sense to every business person in the world. If you've already paid for everything, right, you've paid for your fixed costs, then you have to say to yourself, if someone walks in, there's no cost of acquisition. And they say, Hey, I'm here to rent a hotel room. I just showed up on my own. Normal rooms are 100. I'm here at 11 o'clock, I'm gonna stay till six o'clock in the morning, I'm just traveling through Amarillo, how much you willing to give this river? Right? They go 30 bucks, because they know what their cost of goods sold is 30 bucks. And they just want to cover their costs and just move on. By the way, I don't even know if they're actually covering the costs because it might be marginal 100% profit, right? Yes. You weren't expecting it. You didn't try for you didn't work for it. Somebody just came in. Right? What we found with cash prices is that cash prices relative to actual paid claims. Remember, somebody like me has access to billions, literally annual paid claims a year like, I know what the what the employee paid. I know what the carrier allowed. I know where they had the service. And I know the NPI of the doctor who actually performed the service, or the nurse practitioner or PA, look, I know all of those. When you look at that, there is generally an 80% markup. Right? So if I told somebody my gross margins are 80%, I mean, like, hello, right, this is pretty great. So in labs, what we found was we did a lab deal with the two largest lab companies in the country, were able to cut expenses 90%. So now, we just talked to employers, and we say, Listen, you don't have to believe us about direct contracting. You don't have to believe us about building networks. But here's one way, like, take this card and have all of your employees use this one card, you'll reduce your expenses 90%. And if you don't, I'll give you the money back. And guess what's happened over the last five years? They reduced their expenses by 90%. Because there's theoretically a cash pay patient. Yeah. So you if you walk into any MRI, or any radiology center, and you tell them and they say, Well, what's your insurance, you say, I don't have any, right, and you say, I'll give you a cash pay today. One, they'll seem faster. Now, that's not that's not factual, every single location in entire United States, but it's factual in the 30 largest MSA is in the country. It's 100%. factual, because I see it every day. I mean, it's why we're, you know, it's why I'm now working on an E commerce platform. Because I want every single physician to have their own e commerce platform. And I want every single nurse practitioner that works in an autonomous state to have their own. And I want every single physician possible, like, this is the way the regular world works. You get a hotel room, you don't go I'm gonna call Hilton. You don't do that. I'm gonna check what my availability is through my employer. Right? No, you just go hilton.com. And then you're like, Well, you know, Priceline says, they have a better price for that, no, this guy, kayak says they have a better price. And you just shop or use Google, and all of a sudden, they tell you what the differences are. Right? Right. And then you make a deal. And I don't know why health care, or specifically medical treatments and services aren't like that. And so we got to push to make it that way.
Ryan Norris:I totally, totally agree. And another thought that came to my mind, you talk to you said, you talked to over 18,000 doctors, you know, in the course of of your your research and your career. And, you know, one of the one of the things that's puzzles, me too, is that if, if we have a doctor from another state, they can't immediately come in and start practicing Arkansas, they have to go back through, you know, we don't have a medical license, I believe that is universally recognized. So with medical professionals in particular. So I was wondering about that, you know, is there enough in the United States, from your perspective, that where a doctor train just about anywhere should be able to practice just about anywhere, and the quality of that knowledge that they're practicing under is sufficient?
Dutch Rojas:Yes. 100% And there's some states allow you to let's say that I run a surgery center. That's a fellowship, right? So I'm training physicians on how to do interventional pain. We did a similar my practices. They would we had 17 state locations, different states. And so what we'd say is listen, you finish your fellowship here. You want to practice in will come up and say Florida, because everybody likes Florida lately. What they would do is for a certain amount On a month, they could practice under the NPI number that covered the facility, we could get paid for any treatments or services the physician rendered. But that is a temporary thing where you then have to apply for a full licensure. This is where, you know the Federalists have a problem. Like this is kind of where policy comes in where you say, well, listen, if there's licensed in the state of Texas, why wouldn't they be okay to be licensed in Oklahoma? Like, is Oakland like the stance is is Oklahoma that great? And what the medical board will tell you is, well, we have our own credentialing process, and they need to go through it. And I'd say, well, listen, data works really quickly. You ought to like if someone can let him tell me, I can buy $100,000 car in about three milliseconds, someone ought to be able to tell me based on my background, if I can practice in another state in four milliseconds, like it shouldn't be a thing. So I agree with you. It's one of the things we've worked on is is access. Look, we do a ton of work. And I have for I guess, since since college since 94, when I went on my first trip, I got involved with a group out of Guyana, Nicaragua, and the Dominican Republic, they build surgery centers during the summer. Right, and they take care of people that need to be taken care of for No, no price to them. They're all tied into orphanages, in all those areas. Well, those when you go down to the Dr. The Dr. Medical Group doesn't say, Oh, are you really an orthopedic surgeon from New York City that's trained at Columbia? And does you know, spine surgeries at hospital perspective? They don't do that. Right, they go, okay, you've submitted, we do have to submit paperwork, we do have to get approval, right. But it's not a six month process. And it seems to me and I'm just agreeing with what you're saying is the process takes too long. It's too bureaucratic, like stop, it would use some technology. And people just keep telling me, it's always like every standard answer I hear it's like a computer program and people's brain isn't? Oh, we don't have the budget for that. Yeah, we don't have the budget for that. No, it's not you don't have the budget for that. That's not that's the that's not true. Right. That is that is completely not factual. Right. It's just we don't we don't want to allocate the resources for it today. That's, that's the that's the factual answer.
Ryan Norris:Yeah. And, and when I looked through it, you know, just like, at the top, when I was doing the introduction in saying that, you know, we are about 100 off, or 10 off per 100,000 residents on primary care physicians. This could be a way of getting primary care physicians in invited into the state, you know, come in and, and help us with that access issue. You can have, you can even have
Dutch Rojas:a little rock, what if what if a direct? What if a direct primary care doctor got together with a bunch of other private direct primary care doctors and Little Rock and said, you know, what, we're gonna do our virtual process first. And we're gonna deploy that and then make up for the 10 deficit tomorrow. Yeah, right. I mean, it's technology. And you know, like, I used to hear this from the unions, and then I heard it from Medicaid, people in so many states, I can't count. Well, our members can't use a cell phone. They don't know how to use mobile technology. And I'm like that is that is 100%. Not true. Yeah. Stop saying that. I mean, my grandmother turned 90 on Sunday. She can use Facebook, she knows how to text. So you can't tell me that these people don't know how to do it. Because we represent union members across the country. We represent all different types of people. And you know, what all of them unless they're disabled in some way, can use and have the ability to use technology. So use that to your advantage?
Ryan Norris:Well, you know, same saying what certain demographics can or can't do and those perceptions that people have plays into another question that I have here about, and we've talked about a little bit, you mentioned it, but physician owned hospitals, and the moratorium that currently exists, can you give a little bit of background as to why we're why we're at where we're at, with the moratorium, and then what some of the benefits could be if we started allowing physicians to have more control over their practices and of course in physicians own hospitals.
Dutch Rojas:The moratorium on physician or hospital exists exists for only one reason and it's political. You can anybody can research do all the work do everything you can position on hospitals in numerous studies, non biased studies, right done by independent think tanks, left right and center, have said that physician on hospitals have lower costs, right, therefore lower prices and higher quality outcomes. They use innovation as a first principle tool where As an academic senator or a state funded senator, or a large health system run by carriers and Wall Street, right, or large nonprofits, they don't do that. That's not their approach. Right? That's just a business problem approach. So what happened is in 2010, in order to get the approval from the American Hospital Association in the buy in on the Affordable Care Act, they said we have one demand. Well, they had several, but they wanted to eliminate ambulatory surgery centers from private practice, which is about call it 6700 of those. And there's about 350, physician on hospitals. And they wanted to make those both mandatory surgery centers and physician on hospitals illegal, and the lawmakers who negotiated that deal said okay to the physician on hospitals, but not to the Ambulatory Surgery setting. And so, we have for now, 13 years suffered by not having physician on hospitals. And what I where I try to challenge people is, okay, the carrier's now own large, like their large shareholders in publicly traded health systems. They're large bondholders in the nonprofit side. Right. So nonprofit hospitals work, they do large bond buys, I guess that's easiest way to say, and the buyers of those bonds are the carriers. And so they do that, to have a financial compression, and to be on the same page. And so now what we have is we have health systems, acquiring small hospitals and big hospitals, what the general public doesn't know is that health system, whichever one you can think of in your head, gets paid about five times for the same procedure, as much for the same procedure, as a private practice doctor does down the street. So an orthopedic surgeon spine surgeon does a laminectomy and gets paid $15,000? Well, a hospital get paid five times that from the carrier. Right. And so that's how they've been able to buy up everything and get rid of everything. Right? The the challenge with physicians and hospitals is that they continue to perform, but they can't grow. They can't. So if I had 10, oh, Rs in 2010, I got grandfathered in that fit. So what's happening is now you have public companies putting hospitals next door. And doing what the oil companies used to do the gas stations in the 70s. Before that was outlawed. Federally, they've put them next door. And they said we're going to do exactly what those guys are doing. They get a bunch of their employees to come over. They pay him gargantuan amounts of money. Right, because there's a spread between the five and one. And so they put them next door, and they say haha, those guys can't grow, we're going to drop our rates. And then we're going to tell BlueCross United Cigna not to do managed care contracts with him. Right? And then they take all the business. I mean, it's the most crony capitalist deal going on in healthcare today. By the way, the way that I know that your listeners are educated is I was a part of this problem from 1997. Until 2008. This is what my business was, I would find private practices work in the private practices, advise the private practices to say, hey, you know that you can sell on this kind of multiple for this kind of money to the health system, and we would sell it, that's how we exited. And by the way, I had no idea what it was doing. Because I didn't understand benefits. I didn't understand self funding, I didn't understand how the whole ecosystem worked. So I just thought, hey, I'm bringing my clients lots of money. And as a 2728 year old accountant, I was getting paid ridiculous amounts of money. By the way, I didn't deserve that money it was on it was extracted revenue from the wrong thing. And a market capitalist does not do that. Right? That is sincerely crony capitalism, and I'm not going to get on.
Ryan Norris:Well, that's that's a whole we could go into the philosophical underpinnings of these these issues as well. And but I appreciate you saying that, you know, again, it took it takes humility to show how we have evolved and transformed our thinking, when you're like, I'm really want to solve this problem. But the problem never continues, is always taught discussed, but nothing ever gets solved. Why is this and then all of a sudden, your conscious awareness of the issue starts to expand and you see the systems and these modes of thinking that prop them up. And so that's why again, I say, we need an environment. I'm not even saying the deconstruct those, per se, I'm saying allow for solutions to come to the table that are not protected by government policy. Allow the physicians own hospitals to grow in my mind allow for for medical, you know, medical facilities to grow, without having to ask their competitors via a con board to allow them to participate. Lau physicians and medical professionals from other states who want to become to Arkansas, the fastest pathway from the time they crossed the border to the time they can see their first patients lets you know, safety first. Of course, I'm not saying you know, Wild West, it necessarily, I'm just saying that find the easiest, quickest route to getting that person who's in pain and in suffering, the health care that they need. That's prioritize people.
Dutch Rojas:You and I are on the same page, I think, you know, affordable and accessible care for every single person on the planet is doable. Like the thing, one of the things I'll leave you with is my plan, since the beginning has been to provide health care for everyone on the planet. Right? I've spent a bunch of time in Asia a bunch time in the Middle East, which I really didn't love. No offense, but I didn't like it. But I wanted to do that. And I still want to do it. And we know how the thing that drives me a little bonkers is that national policy folks can't see the bigger picture. Like there's about $12 trillion of spin on healthcare a year, do you know that our private practice prices in the country are better than most universal and single payer countries. So let's just take total joints, which happen about 2200 times a calendar day, a million times a year, we have better prices in the United States from private practice for those than the costs at NHS, in France, in Germany. And in the Netherlands. I know that for 100% back, because I spent a whole bunch of time doing research and paying people to do the research. Right. And so it also helps I speak all those languages, so you can actually talk to people in their own life. Yeah, even in the UK, even in the UK. So the thing is, like, what I've been saying is, look, we could attract all that business to the United States. Think about the jobs think about GDP growth. What if we could actually have four or 5% GDP growth? And I'm like, you know, how you do that? You build really competitive markets, and health care? Yeah. And then, you know, what happens is people fly here. We have, we have over 120 Canadians a month, flying to one of our hospitals in Phoenix, why? Everybody else tells me we have a domestic we have we have travel plans that are like, you see two people a month, maybe I see over 100. Yeah. And that's for major surgery every single month. Like the solutions, as you know, Ryan are out there. But it's going to take a whole bunch of market capitalist, to just decide not to listen to what all the experts say, and just do what they know they're supposed to do. It's in their heart, it's in their brain, God's given them a reason and a purpose. They just need to go out and do it.
Ryan Norris:Love it. Well, this is kind of the final... packaging this all up. We've talked about, you know, affordability issues, access issues, that the solutions are out there that there are entrepreneurs such as yourself, that are that are focused on how do we bring care to the most amount of people, and we've hit on certificate of need physician don't help physicians on hospitals, price transparency, we've talked about how tech can help with with access a ton. So what do you see as the future of healthcare, you know, what does that look like in the world? And then, if there's a priority of a policy or ways of thinking that we should kind of frame that around to get to the solutions was that look like the future of healthcare for the world? priority of policies and new mental models?
Dutch Rojas:Well, remember, the priority for me is health care, affordable and accessible health care for everyone, whether they're in whether they're in Chile, which we built a clinic there, or they're in South Africa, Zimbabwe, Niger, or, you know, they're in Saudi Arabia, right, like, it's affordable, accessible care for everyone. And it's, and it starts with price. And it starts with price transparency. This CMS is price process is built on a Cost Plus model. So if I'm an account at every large health system in the country, I'm building my cost to be as high as humanly possible. So I can add a margin. Right. And that doesn't work. We need market capitalism in this country. So we're working on a futures and options model. We're working on an exchange for the futures and options because that's how futures and options work. Right price transparency will deliver this for everyone. Now, the country that chooses to do this first will win. And if someone says to me, Dutch, would you fly to the Middle East to get care? 100% I've been to Thailand. They're beautiful hospitals in Thailand, by the way, colonoscopy, there's $10 Wow. $10 I had 110 bucks. They throw a pill down your throat. It's got a camera in it. It's amazing. takes no juice, no stuff. No time off. It's absolutely amazing. And why can't wait to your point. Take innovation. Why are we saying no? Let's say yes. Let's say yes to no nation, let's save as many people as we can. And let's get back to health. I mean, the other, you know, the other big issue that policy makers are going to have to tackle is food. I mean, the food problem in the Midwest, specifically, is pretty horrific. We have people eating processed foods every single day. Now, you can't tell someone to stop drinking Coke if they're addicted to coke. But what can you do, and I'm not a policy guy, but like, there are certain things you can do to incentivize people. And most of the employers we we service, the larger employers who pay for their benefits within like a week, or to write up their total budget. Some do, like, some tech companies are like two days, they have 100,000 employees. They literally pay their employees to do what we've asked them to do, Hey, have surgery over here. Do your MRI over there, do your CT here, we'll pay you. Like we have to get a hold of a food problem. We have to get a hold of the government cannot be your almighty Jesus, he cannot be the resurrected Christ for you. Because you have to take care of your body. Right? Like, this is something we know our bodies are temples and yet we don't treat them as such. Yeah, if we want if we want to solve healthcare, we also have to we have to do our part to its you know, I tell everybody, I love math, right? I'm a math guy. I'm like, in algebra, basic algebra, what do we look for? We look, well, you do one side of the equation you do to not you? You should or you could, but you must. Yeah. And so you must expect this from government and from physicians and the private markets. But you must also do for yourself. We must take a look at ourselves and say I go to a quick trip seven times a day. And I fill up my 64 ounce cup of coke. Yeah, that's really not beneficial. I can't eat chocolate cake and ice cream every day. You can't do it, or hamburgers and hot dogs and fast food. You can't do it. Right. So like, as I think about healthcare, it is a systematic thing. And trust me if government gets involved in health care in this country, they will shut it all down. Wendy's be out of business tomorrow. So we'll Chick fil A, because why would you let anybody eat crap that makes them sick and have cancer later on?
Ryan Norris:Yeah, yeah. The, you know, again, there's components that there's there's something for business to do. There's something for government to do something for community do something for education to do that. I saw this, there's an overlay on on this because he was saying the personal responsibility. And I love many of the places that you're you're talking about, but I can't have it every day. I cannot, you know, you just you can't build your health out of that. So there's a conversation to be had about health care, medical care, and what we can do on healthy lifestyles, and a lot of the healthy lifestyle stuff isn't coming on us. We have to be able to do that. I I'm preaching to myself on this. Me too, right. But even this morning, you know, when I went to have breakfast, I was like, you know, instead of having toast with a huge smear of strawberry jam on there, I'm just going to have it with butter today, you know, and making those little bitty bitty adjustments on things. But well, Dutch thank you so very much for being a part of the believing Arkansas podcast talking about this large topic area of healthcare, accessibility, affordability. how can listeners get in contact with you or get connected to you and what you're working on? What's the best
Dutch Rojas:99% of people they get a hold of me get a hold of me through Twitter or LinkedIn. Dutch Rojas, R O J A S? Listen, if you just type in Dutch Rojas in Google, they'll show you my phone number. My addresses really show you everything. I'm like the easiest person in the entire planet to get a hold of.
Ryan Norris:I agree. That's that's how I connected with us following you on. That's right. That's right. That's right. I just emailed you and boom, within 24 hours, I think you and I started a conversation.
Unknown:I try to do it man. Like I tell him I try to be real fast. I want to talk to everybody that wants to have a conversation around health care. Well, we've certainly enjoyed I've enjoyed it.
Ryan Norris:Well, we're definitely going to have more opportunities for you to speak to people of Arkansas. So again, reach out to Dutch at his Twitter, Google and you'll find his phone number and his email. And then this podcast will of course be on the believe in ar.com. website and with more information about certificate of need physician to in hospitals about transparency. Americans for Prosperity is working on these issues under the omnibus campaign called the personal option. We're just believed that more decisions need to be made by you than for you. That's the simplicity of every policy that we look at, but particularly health care. And then you can also reach out to us for more information at infoAR@afphq.org. And then for those that would be interested in connecting with us a little further, you can let us know what your sentiments are. What are your thoughts around health care the economy Free speech, education, immigration, go to Arkansasspeaks.com. Take that quick survey to connect with us. We'll be in contact with you. As you know, we host events around the state of Arkansas on a weekly basis. We're really ramping them up for the summer. There's all kinds of opportunities to where we can be a partner with you. On the issues that you care about. This isn't just about hearing from AFP and hearing from the experts. But we want to engage you, in the conversation train you on how to advocate for yourself. There is where the power is with the people. And how do you get together? How do you organize how do you create a message? And then how can you advocate for these policy issues that you care about? AFP is there to be your partner and to help you train yourself in that skill set. So believeinar.com for general contact information with us, and then Dutch thank you so very much for being a part of believing Arkansas, and we'll have you back soon.
Dutch Rojas:Thank you so much.
ANNCR:Thank you for joining us for Believe in Arkansas, where we believe free people are capable of extraordinary things. If you believe in Arkansas, and we'd like to help unlock our state's potential. Go to www.believeinar.com to learn more and join the movement today.