The ER Doc Who Quit the System - and Built His Own

Episode Summary

Dr. Noah Kaufman - board-certified emergency physician with 20 years in the ER, seven seasons on American Ninja Warrior, and a new direct acute care practice in Denver - joins Drs. Koka and DiGiorgio to talk about why he walked away from the employed medicine model and built Cough Care, a cash-pay, fully transparent urgent care. The conversation covers the broken economics of emergency billing, why most urgent care is a race to the bottom, how price signals change both patient and physician behavior, and what a parallel direct care system could look like at scale -including the franchise model Kaufman is already planning.

Chapter Markers

00:00 Introduction — Meet Dr. Noah Kaufman

02:12 What led to leaving the ER after 20 years

04:53 Becoming the patient — the moment everything clicked

09:33 What is Cough Care and where it sits between urgent care and the ER

13:54 Why he doesn't take insurance

16:30 How ER billing actually works — the 2.6 cm laceration rule

19:49 Can urgent care be shopped? The free market argument

21:17 One month in — what he's actually seeing

41:00 Does cost-consciousness lead to undertreating?

43:39 The culture of over-treatment and the evidence behind it

45:48 Longevity, peptides, and the gray market

54:25 Patient autonomy vs. clinical responsibility

1:01:36 What happens if every burned-out ER doc does this?

1:07:33 The franchise vision — scaling direct acute care nationwide

Co-Host Handles

@anish_koka and @drdigiorgio

Show Handle

@drsloungepod

Subscribe Links

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Apple Podcasts: https://podcasts.apple.com/us/podcast/the-doctors-lounge/id1832097658

YouTube: https://www.youtube.com/@TheDoctorsLoungePod

🔗 Connect with the Hosts:

• Dutch Rojas on X

• Dr. Anthony DiGiorgio on X

• Dr. Anish Koka on X

• Dr. Dan Choi on X

• Dr. Sanat Dixit on X

Transcript

SPEAKER_00 0:00

If you like your healthcare plan, you keep your healthcare plan. Nobody knew that healthcare could be so complicated. It finally beat Medicare. This is the Doctor's Lounge.

SPEAKER_02 0:16

Welcome to the Doctor's Lounge. This Thursday, we have the honor of having Dr. Noah Kaufman. Dr. Kaufman, I've been following for some time on X. I discovered him on X, just like I discovered most people on X. And he always had these scintillating opinions that were clearly forged in the, you know, forged in in real life. You know, he definitely not a policy wonk type person who was talking about he kind of understood things from kind of the coal face, as they say. And then since then he started a venture, which is partly why he's he's here to discuss that. So he's kind of putting his money where his uh mouth is, and and we kind of love that. So so so to introduce you, uh Dr. Kaufman, Noah Kaufman, he's a board certified emergency medicine doctor. 20 years in the ER before pivoting to our our venture that we're keeping a secret. He's trained at Tulane Med School, internship and residency at Akron General Medical Center. We won't say when he completed his residency, so we don't give away his age. He is he is perhaps most famous for, until now, until X, he's most famous for his stint on NBC's American Ninja Warrior as the Ninja Doc. Seven seasons. Fluent in Japanese. He is truly the American medical samurai. Um he's done a bunch of he does he does expert witness work. He's co-founded, you co-founded other stuff as well. So it's something I saw, the physician Tax Solutions. And now he is here to talk about his latest venture, Kough Care, which is a advanced urgent care. So, Dr. Kaufman, welcome to the Doctor's Lounge.

SPEAKER_00 1:49

Thank you. I love what you guys are doing, Anish, Anthony. Big fan already. So I'm flattered to have the invite. And it's it's gonna be fun to talk about this because I think it fits right in with what you guys are doing and the passion that you have for helping patients and redefining healthcare.

SPEAKER_02 2:06

Yeah.

SPEAKER_00 2:06

So d tell us tell me a little bit, Noah, about what it is you've decided uh to Yeah, well, you know, I think that so many of us as physicians are suffering from everybody calls it burnout, right? And we know physician suicides rate rates are high and and uh some people are calling it moral injury. I think everybody is frustrating with this frustrated with the system, whether it's from patient's side of point of view or physician's point of view. And I think the fundam fundamental problem is that there is a really broken transaction in in medicine. Like when you break it down to to to its most basic form, you know, being in this system also you don't go to medical school uh and spend like most of your life until you're until you're in your thirties to you know and be in debt and and to work a hundred hours a week, etc. If you don't have some fundamental love for helping people and wanting to make the world a better place and and wanting to just heal people, you know, I think for most of it's still a calling. Um and it and I think though that being a part of the system is very frustrating at a time for physicians. And, you know, I I think that feeling it on the front lines as an ER doc and and being there with like the raw reality, like you said, which is which is the safety net of society and medicine practice on the front lines where the unexpected can happen and you're just seeing everything day to day. I I think being a part of a system that is doing great financial harm to people makes us feel, whether it's subconscious or whether we really acknowledge it, makes us feel bad. I mean, I think that it's a problem to be part of this system that's doing great financial harm. And as we know, there's so many people extracting value in so many ways that are not beneficial for the patient. And being a part of that system, you know, like I think waking up and realizing what my career was and compared to what I wanted was just a very big eye opener. So that's part of what what led to it. Of course, it was multifactorial.

SPEAKER_02 4:16

What was there a specific moment where you said enough is enough? Like, you know, you spent 20 years in an employed job, right?

SPEAKER_00 4:24

Yeah, mostly employed. I did locums work, but I was a partner in in Tahoe for like eight years. I was a partner at UC Health here in Colorado, staffing most of the big ERs in northern Colorado for for eight years. Um and I started doing uh locums. I always loved doing locum tenums, which is basically part-time work as a 1099 and getting to see what other emergency departments are like, other populations, and just to mix things up and do you know a few fewer shifts in the in the big trauma centers uh was always eye-opening. And I worked in some very cool places and got to see that emergency medicine is definitely different depending on your patient population. So, for example, I worked in Los Alamos for a while and it was like all PhDs, right? It was like the highest per capita PhD place around. And the problems were very different than your standard ER. Uh, not not much methamphetamine, um, but other other problems and uh, you know, that were germane to that population, to that cohort. I think the the moment though, the flash point for me was I became a patient. You know, I stopped ER shifts last August, and uh I've I've been having a back issue for the last year, year and a half. I think I'm 51. So uh uh, you know, I I finally um got to that point where I have a spondy, spondylolysis, so my vertebrae are are like this, and they've been rubbing, and there's no disc anymore. So I started having to see guys like you, Anthony.

SPEAKER_01 5:55

Uh I was just gonna say, come on down. I'll I'll see you tomorrow.

SPEAKER_00 5:58

I know you will. And actually, I I need to connect with you and ask you because now I know subsidence and like all this stuff, cages, and I've been talking to orthospine and and neurosurgery, but I will hit you up at the time. Happy to help.

SPEAKER_01 6:10

We should have a whole episode on spondylisthesis and lumbar fusions.

SPEAKER_00 6:14

Well, I'm right there, and that's and I'm you know trying to push it off as long as I can. But becoming the patient and being a part of this system where I was like jerked around and got bills with different amounts and tried to make insurance, heads or tails of insurance and switching to crowd health, uh, you know, which which I really enjoy now. Just going through it, it was really painful. And I was like, if I can't figure this out, like how can anybody figure this out? And then getting all these different bills and you know, deductibles are so high for insurance that everybody's like practically cash pay anyway, because most people don't ever hit their deductible. So the real problem was I was started becoming a patient, and then people would come to the ER. And of course we have recidivism, people come back for problems. And I had a patient come back and say, you know, doc, last time I was here, I got a bill for like $12,000. Are you gonna do that to me again? Literally. And I was like, oh my gosh, like, I don't know what any of this stuff costs. I'm part of this system that is doing massive financial harm. I mean, we know that medical bills are like a massive cause of financial ruin, of bankruptcy, and contribute to depression and psychiatric problems and suicide, even. And so being a part of that system, I felt like I was, you know, for so long an unwitting accomplice in this system that was, like I said, doing great financial harm. And, you know, our oath is to first do no harm. So I couldn't reconcile those. And uh I I just had to do something, you know, like I have a 14-year-old and I've had the benefit of being out for 20 years, and so I have some financial fortitude, you know, something to fall back on. And I just, you know, my my hero Helen Keller said life is either complete daring or nothing at all. And I've always been a little bit of an outlaw. So I just felt like it was time to do my part. I I saw others before me who who have gone much further and much higher, but in my neck of the woods, acute care, there has not been a direct acute care. There's DPC, direct primary care. But I was like, you know what? I'm gonna go for it. And it's time to like live my oath and deliver care to people and just take really good care of people. And yeah, I mean, it's been it's been amazing. As a doctor, it's been deeply fulfilling so far, although at times terrifying.

SPEAKER_01 8:36

So you you basically created a transparent pricing, like you said, acute care, urgent care, right? That's essentially what cough care is. I mean, I I've got the the website pulled up here. I can see, sorry to hear about your back, by the way. I don't see lumbar fusion transparently priced on here, although that's probably a little tough to do in an urgent care. But if someone wants to go in and get an X-ray, it looks like it's $195. Certainly that's pretty cheap to compared to what your local ER would cost.

SPEAKER_00 9:06

Yeah, we have a pricing comparison tool on there and we publish all of our prices. And there's a lot that goes into it, you know, a lot of research to find out what the prices are, what the prices in the ER are. And uh, you know, it's it was kind of hard trying to define ourselves, and I think that's a mission still because we had to say something. We're we're we're some kind of practice, right? Like you come out, you can't call yourself an ER. I'm a board certified emergency room physician of 20 plus years, so that's what I know how to do. And, you know, just I couldn't intubate people anymore. My back was getting like I can't lean over and lift sort of thing. But I'll tell you, we chose advanced urgent care because it would be the least confusing for people. But that being said, when you look at the gap between an ER and the urgent care, it becomes striking that there's a middle ground ripe for disruption that really can be filled. So you've got the ER, which is maybe you'll be waiting six to 10 hours or something. You've got really high level care generally, but you've got stressed out people, you've got heart attacks and strokes. And if you go in for a perinechia, like an infected nail or an ingrown toenail or you know, something, you're gonna wait for a long time. And and you should. There's people with heart attacks and gunshots and all kinds of things there. And if you go to the urgent care, on the other hand, half the time they refer you to the ER because most of the urgent cares, especially where we are, it's like a race to the bottom. They're owned by private equity. And look, there's some really good APPs. I've worked with some of the best, and they're operating like at a physician level. There are frequently huge variables in the care that you would receive at an urgent care. And I know being an ER doc that frequently they refer stuff to us, like a big cut across the arm or a shoulder dislocation, or even a finger dislocation, you know, a pinky facing the wrong way. We I can deal with all of that if I have an X-ray machine and some lidocaine, you know, Marcane and some and a needle. And so I really saw room for improving this kind of race to the bottom urgent care model and and not seeing like a board certified physician. And then the ER, where it's it's overpriced, there's no price transparency, nobody can tell you what it's going to cost. And it just costs different amounts for different people, and you're gonna wait a long time. And so that was, you know, and and that's what I do. I'm an ER doc. So I was like, man, I can do urgent care way, way better because I can do most things that they can't do. And so like I can make the cheap things even cheaper, like a strep throat, you know, it's like 120 bucks, versus like all the local urgent cares, it's 179 bucks or whatever. And then like the expensive things or like a big abscess or something, like I removed a a a piece of ceramic from somebody's finger the other day, and it was like it was deep, and and the urgent care had sent them out and wanted a hand surgeon and wanted x-rays, and they wouldn't do it. And it's like, that's all we've, you know, that's what I've been doing for for so long. So that was the opportunity that I saw, and I figured it would be a good way to take care of patients and build my own thing. And and that's why, you know, I put my name on it too, because I I really want quality care directly between a physician and a patient, and just cut out as many of the middle people as possible.

SPEAKER_02 12:18

Why not take insurance as an urgent care? What's the what's the decision point there? Because you could still I mean it you could still have a cash rate for patients that don't have insurance, right?

SPEAKER_00 12:29

Yeah, and it it would be the easy way to get volume. It would make my life a lot easier, honestly, because patients need to really have some education there. And the the reason is this. I feel that the whole insurance system is just topsy turvy. It's lost the plot, and it has become an extractive player or party participant in the system. Even though it would really help get my practice off the ground and help me make a dozen cough cares all over the place, it's it's not what I want. At the end of the day, first off, I hate the fact that we even have to take money at all. And look, I am deeply American and passionate about our country and about the American dream and all those things. And everybody has to make money. Money is like kind of a weird reality. But imagine this like if you were making a system where people who are passionate about helping other people sacrificed a big part of their life to study and become the best they could be to try and just really care for people, why would you kind of like mess that up with incentives around money? If I could have my way, medical school would be free and you would just doctors would get out and get a card or something, and like as long as they were practicing and ongoing, you know, what whatever it was, then limits you would just okay, if you, if you know, you never have to worry about food, you don't have to worry about stuff. You just have you just take money out of the equation. Because I'll tell you, being in the emergency department, I've been a part of groups that like it's eat what you kill, which is like, you know, you get RVUs, you get all this stuff. Um, this is the kind of thing that I that I've learned. Laceration, if it's 2.3 centimeters, it's gonna cost $100 or $200. If it's 2.6 centimeters, like 2.54 centimeters is one inch. Okay. So if it's 2.6 centimeters or 2.7, it costs $800. And this is the silly little rules that we've developed for how we bill people. Um, and because of that, how many lacerations in the emergency department do you think are less than 2.6 centimeters? And not only that, but yeah, very few, right? And so not only that, you're allowed to stretch the skin and you're taught all these ridiculous things. And then when you're charting, you need to chart like three to ten elements out of like, you know, so somebody comes in for an ankle sprain and you listen to their heart, you know, or you don't. And you people on the template, it says regular rate and rhythm. It says you listen to their heart. How many of us in, you know, look, you know, use Epic? And it's like, I mean, it's just nuts. And that's just part of the system. And so in the ER, there's very few level ones, twos, and threes. And for everybody who doesn't realize, there's level one, two, three, four, five, and then critical care. And as you go up these levels, you get billed more and more and more. And the doctors don't bill you, the doctors just document. And the doctors are constantly told document better, document as well as you can, because it'll protect you from medical legal risk and being sued, and you have to document everything. And so half the time, these charts are over-documented. Everybody who comes into the ER with like a little problem, like a mosquito bite, it's literally billed $800 or $1,000 because they had to see the ER doc. They wait for six hours. And it's like, I mean, I hate to say it, but I think a lot of ER docs out there would agree with me. It it's like fraud. You know, it's uh and it's not on, it's just how the system is designed. It's the templates, it's the like when you create a system that is incentivized to extract maximum value out of people, like in in um in terms of money, then you're gonna fulfill that, you're you're gonna keep creating additional systems to take more and more money out of the people who are paying for that with their, you know, their blood, sweat, and tears. And so I just couldn't be a part of that system anymore. And insurance is just lost the plot. And I'm not saying insurance is all bad. We still need insurance for some things, and maybe there's going to be some viable alternatives, but you know, it's it's become a real problem and it's it's changed medicine. And like I said in the beginning, I think that insurance, and even more so, these nonprofit hospitals that have consolidated have just broken the fundamental and foundational trust, which is the patient-doctor relationship. And that needs to be restored. You know, like I wanted to be a doctor since I was two years old, always romanticized, taking care of people. My I I'm the eldest of three boys, and we were always in the ER getting stitched up, broken bones, throwing rocks at each other. We were, we were hellions. But I'll tell you, the docs always took time, explained things to me. I thought it was the coolest thing. I never thought about the money of like being a doctor. And like as I grew up, I oh yeah, you would make good money, you get respect, all these things, and people want to, you know, go into medicine. I'll tell you, boy, I just can't take insurance. I just can't be part of that system. I'm not trying to make millions of dollars. I'm trying to take care of people.

SPEAKER_01 17:27

But it seems the I mean, when we talk about these, the reason you know Nisha and I like free markets and price signals and how that can help direct resource utilization, the the rejoinder is always, well, you can't free market won't work in healthcare because of emergencies, right? People dying of a heart attack can't shop. And that's true, of course. But you're even proving that many urgent things can in fact be shopped, right? So if I have a shoulder dislocation, I can look up your price here. It's 950 bucks. Um, you know, I maybe I'm not the one looking it up, but my wife who's gonna be driving me to the ER might look it up and and say, hey, you know, our deductible is ten thousand dollars. Why don't we just go pay 950 uh in cash and and not worry about whatever insurance is gonna hit us with? Because it probably will be a higher bill if you go to an ER. So it to me, you're you're even showing that more um more things can be shopped than we had previously thought. And and again, in in looking at your list, you offer some things that really would be almost like a primary care, like a sports pre-participation physical is 125 bucks. So are you are you getting a lot of these kind of I mean, I guess what I'm asking, how many of your patients are like, hey, I broke my ankle, I need to be seen within an hour, or how many are like, yeah, I just I realized I needed a sports physical and and saw your prices listed online?

SPEAKER_00 18:44

Almost no sports physicals yet. Actually, none. We've seen about a hundred people. We've been open in a month, and it's scaling, it's growing quick. Lots of broken bones using the X-ray machine a lot, which I am like putting on the lead, positioning them, shooting them, reading the X-ray. I'm doing everything. I I do my own ultrasounds to rule out DVTs and their legs, you know, and I'm ultrasound certified. I I I went through all that and it's been fascinating. And I gotta know my limits and stay within in my lanes, but yeah.

SPEAKER_01 19:10

Are you are you sending many people to a higher level of care? Does that I imagine you have some relationships set up where you'll be able to do that?

SPEAKER_00 19:18

Yeah, I know I know the cath lab guys, and we're not doing CLIA tests yet, so we don't even do troponin. So I had somebody with a high heart rate and high blood pressure and age and risk factors. I sent him to the ER. And I and uh we took his blood pressure, didn't charge him a thing, sent him to the ER and called ahead, talked to the charge nurse, you know, talked to the ER doc. I had another guy with rhabdo, kidneys failing, sent him to the ER. You know, like so there's definitely a place, and by the way, as an ER doc, that's all I want to see. I just want to see the emergencies, the 95% of stuff, like the stuff that like takes a lot of time, you know, and and is non-emergent. People don't know. Everybody's scared, you know, if you if your patel is dislocated, it really hurts your kneecap. It really hurts. And like, you know, that your buddy doesn't know that he could just like pop it back in and you'd be fine. And like, so you go, you go to the ER. And then you sit in the in the root in the waiting room with your arms or your legs straightened out and your patella off to the side in agony, and they can't see you for a long time. They give you an ibuprofen in the waiting room if you're lucky. And so I've ironically, I've seen a ton of people with insurance. I've even seen Medicare and Medicaid. I've sewed people up with Medicare and they're like, I didn't want to wait for six hours. This looked great, you know? And the other thing is, you know, like a shoulder reduction for $950. What people don't also realize is you're getting intra-articular marking, you're getting x-ray, you're getting like um a package, and you're getting a 20-year experienced shoulder reducer who's actually reduced a shoulder on television, which is a funny story, but you know, who worked at ski clinics in Tahoe and has reduced literally hundreds and hundreds of shoulders. So, like the people who shop around, I think are only looking at price, but I think people are starting to come back to look at quality and look at experience. And it's weird for us, right? Like as an ER doc, I'm paid hourly, like a McDonald's worker or whoever. And and that's actually good because, you know, in the ER, and God bless my colleagues uh, you know, but who are just slaving away right now in the ER in the busy ER, that that makes it so that, you know, we are just paid by the hour. We can tell patients, like, look, I'm just doing the best thing I can for you. I'm paid by the hour. And as we know, less than 10 cents on the dollar goes to the healthcare team of nurses and doctors and the rest of it's extracted and whatnot. But I think people are coming back to quality, coming back to wanting that experience. And that's what cough care is predicated on. And that's what this concept is predicated on. I think people will pay for that experience. Like if you want an attorney, the first year attorneys are making. A couple hundred bucks an hour, you know, and they're part and they they go through apprenticeship, but then senior attorneys are making seven, eight hundred dollars an hour. And medicine is not like that at all. If you're in the you're in the ER and you get a first year postgrad out of residency, they're being paid the same as generally, especially if it's a locums hire or locums company, they're being paid the exact same hourly as somebody who's been doing it for 20 years, which by the way is pretty similar to what it was 20 years ago. So there it hasn't gone up. It's remained relatively flat while the purchasing power of the dollar has just gone down. So, anyhow, so digress.

SPEAKER_02 22:36

One of the things that you were saying about um not going into medicine to make money, I think is a really important point. And and I think there needs to be some level of discourse to kind of get out to the wider public that the current model that we have of third-party payment with insurance payment actually does not align patient values um with dollars really. So you you know, you end up in a place where just like that example you gave, since somebody else is paying, you there's gamesmanship that can happen um in terms of size of scar and and and whatnot. And and all of that can happen because uh somebody else's somebody else is paying. If if it's a contract directly between patient and and uh and physician, if that that's the only players, then uh physicians really have to be held to a much, much higher standard, if you will, right? 100%. In the current system, doctor recommends whatever you get some battery of seven or eight tests, it's like, all right, I'm not paying, like whatever. Let's do it, Doc, right? You don't have to really show and demonstrate that value. So my strong contention has been for a very long time is that if we if we had a much smaller imprint of third-party payment, you would actually have a system where doctors in general, as a group, probably would make a lot less money. Because I think there's a tremendous number of doctors in the system that are doing extremely well and are getting rich, very rich off of Medicare, off of Medicaid, in doing services that the patients don't value. And if you had to actually convince the family of the 95-year-old, again, we're gonna be accused of you know killing tsunami people and killing grandmothers and stuff, but but if you had to con to really sit down and talk to the family of a 95-year-old about the fact that you're gonna do this CAT scan on on on you know on whoever, and it's gonna cost $12,000 or whatever it is a health system is is charging for that for that uh thing, then I think there's gonna be a very, very different conversation, right? So I'm actually not opposed to physicians that are highly valuable, you know, a tremendous I mean make making whatever amount of money you know meaning making a making making money. I mean, I think I think if you if you demonstrate significant value, and then you kind of are saying it yourself, right? I mean, look, if you and uh you have to you have to show that, right? You're you're like you're you can see you you're going through the whole, well, it's $900 for a shoulder, but remember, I'm a guy that's done this for 20 years. I mean, do you want you can if you want, go pay $200 to some PA who'll you know maybe maybe not put Narcan in uh put uh uh Lyticaine into the right spot and they try to reduce it. Yeah, maybe they won't use Nancy Narcan.

SPEAKER_00 25:18

Intra-articular Narcan. Does that work? Yeah, yeah. And well, you're also getting follow-up. Our team is on you, like texting and like like making sure you're okay. And if you come back in, you know, and like and we prescribe medicines, we dispense medicines right from cough care. I mean, the way I've optimized this, it's like the way you would optimize it, the way like an intelligent physician would optimize it. Like it's like I save the pharmacy for the the more esoteric drugs or the bigger drugs, but I have I have drugs on site. Um, and and and you know, I don't prescribe, I actually do electronic prescription that, you know, and follow all the guidelines for narcotics. But if somebody's got a UTI and they need some macrobid, it costs me like literally $30 for a bottle of 100 macrobid or something. It's nothing. So I can pass those savings on to them. I've got a little Dymo label printer, I've got pill bottles, and in Colorado, it it this is differs state by state, but I can just dispense a medication, like a full medication. So I can dispense, you know, um, you know, Neproxen and Zofran and and whatever it is I want. And so we have memberships so that people don't have to pay for an x-ray and get all these discounts and and uh and then I also you know envision some really cool pricing power with populations. So for example, I could take care of 10,000 people in Denver. Let's say I had a cough care plan and I could take care of 10,000 people. Everybody pays 10 bucks a month. It's like Netflix, okay? I've got $100,000 in revenue so I can keep the lights on because I I have a lease. I got a lease, I got to pay the staff. You know, I've got three employees. I'm not taking a salary right now. Uh as a matter of fact, I've been liquidating my Roth. Although we're we're we're starting to make money. We're getting to the like, it's not existential point anymore, which is beautiful. It's it's been a quick ramp off this month. And so I'm very thankful for that. And we're really going to start marketing hard. And the business side of it is fascinating and it's really fun. And I've been like vibe coding that website and all the tools on it, and I've got back-end tools. But suffice it to say, like, imagine a plan where you had 10,000 people from different small businesses, and all these small businesses are starting to self-insure because the prices just keep going up and up and up. And so people don't realize they're paying because it comes out of their W-2 salary or something, but they're paying 35k for insurance. And they would be paid more for their job if they and so the companies are self-insuring here in Denver because the healthcare costs are very high in Denver, especially emergency room care. But imagine, you know, I could like make a plan and then everybody pays 10 bucks a month, and then I don't have to charge them anything because I get $100,000 a month to keep the lights on and make a small a profit or whatever, and like pay for the x-ray machine, which you know is $70,000 of and then finance charge, and then like all the all the stuff I'm getting from McKesson and the Trephanation and the Foley Catheters and the Ultrasound machine, everything that I have costs a lot of money. And so if I had like a recurring monthly revenue, then how many people would actually utilize that? Maybe not many. Pre-existing con uh conditions wouldn't matter, and people would be paying 10 bucks a month for like a free not free, but for an ER subscription. And then, yeah, you'd have to have caught some kind of catastrophic backstop. And so we want to partner with the local hospital to do that. But then we're the DAC, the direct acute care. And then there's a DPC for the chronic CHF and diabetes and cancer and the stuff that I I I need to stay in my lane. I don't do hormone replacement therapy and stuff that is a little, you know, like like I'm just like skimming off the surface of some peptides could be because like, but it helps keep the lights on and I think it's good.

SPEAKER_02 29:04

So the criticism will be that this is exactly why I I don't want to try to doing to do this piecemeal. Meaning, you know, why am I paying you a $10 a month membership for for an episodic urgent for what you're providing, which is essentially episodic acute care. You don't want to see super ill patients, right, who have a bunch of different maladies necessarily walking through the door with significant high BP and and whatnot. So there's a chronic care management stuff that really requires like the infrastructure that like primary care folks provide. And so essentially you're marketing yourself to the worried not the worried well, the the relatively healthy folks who have an acute episode that happens.

SPEAKER_01 29:45

And I think why should to to small businesses, right? I think that's kind of the point you're making. If if local business X could offer cough care membership to its employees and steer them away from expensive ER care to low-cost urgent care, right? Then but it then it takes a uh aware HR manager at a local company who realizes that that's possible and then gets the word out to their employees. Have you seen any of that yet?

SPEAKER_00 30:12

Oh, tons. I mean, that you guys, the demand is is insane from small businesses, and there are health brokers uh out there who are trying to make this happen for cash pay. And like the head of the five families, you know, are getting together in Denver and elsewhere, and we're starting to make programs and think through how we're gonna do this because yeah, maybe it's ten dollars for cough care, but then maybe it's also ten dollars for pinnacle direct primary care in the Denver area. And then and then it's ten dollars for Smith surgical, you know, direct sur specialty care. Um, and those guys are great, and you know, Lisa with with Smith and Travis uh with Pinnacle, these guys are incredible and they have got the same passion and fire for helping health care and helping to like take a stab at like really fixing healthcare. And so these guys are partners and they're different businesses, but you know, I'm like the direct acute care, the DAC, and everybody gets 10 bucks a month or whatever. You can like maybe it's a little bit different with the surgeries, and surgeries cost different amounts. Um, but you can really maybe it's $30 a month. And I mean, imagine you've got a million people in this plan, okay? City by city or or whatever. Uh, and it's beginning to like almost look like insurance or something. But there there's something here, and it's not fully fleshed out. We are the direct acute care, and either way, we're seeing walk-ins, we're we're booking patients. But I'm just saying I think that there's we're at a f an inflection point in history, in American history, where the incentives have been so perverted in American health care that it is hurting people badly. And whether we are witting or unwitting accomplices, as physicians, some of us are really a part of that. And I think it is hurting us. It hurts us in our hearts. It hurts us as loving, caring, compassionate healers who who want to take care of people and who are called to this noble profession. And the the reputation of the profession it has been marred and it's been damaged. It's because we we are no longer in control. We're kind of like in it with the patients and we're like frustrated and tearing our hair out. But like now is the time to really live up to our oath and try and help our patients and stick up for our patients and take out this 80% or 70% or whatever you want to call it of layers of bureaucracy and BS and tax loopholes and urban rural hospitals and consolidated nonprofit hospitals who are nonprofit but have billions of dollars and don't pay taxes on. Like, I am infuriated and disgusted, and so are patients. And it's like, oh, I just want to like change it all, right? Like it needs to be changed. And I think if we don't really try hard to do it, like we're smart, we we've put in time, we know we're part of the system. The fix comes from outside of the system. The fix comes from making a new system or trying. And like, if I try, and I'm trying now, I feel good. I'm taking care of people, and I can't tell you how fulfilling it is. Like my patients, I love my patients. I I love staying late. I love, I brought a guy in on Sunday last week to repack his pile of nidle cyst because for free, but because like it was the right thing to do. You can you can ask my staff. They're like, you know, Dr. Noah, stop. Dr. K, you gotta you gotta stop giving away care. The hardest thing I have to do right now is charge somebody for something. It's like, even though I know it's way cheaper than the ER, it's like, and I gotta keep the lights on, I gotta play this game, I gotta be like, you know, and so that I don't think I think people are willing to pay for stuff that they want, right?

SPEAKER_01 33:54

Like I don't I don't feel bad that In and Ar In and Out charges me for a hamburger because I really like their hamburgers. So I think and I think, you know, but I mean look I'm looking at your Google reviews, you've got 29 five-star reviews there on on Google. So it's you know, it people are people are clearly don't mind paying $600 for a laceration repair because I think they know that, again, if they go to the large hospital, it's going to be substantially more, even though they're quote unquote insured for that laceration, right?

SPEAKER_00 34:23

And rushed to care. No, and you're you're right. Look, I I think that it's just it's just hard because when I was in the ER making whatever an hour, and it varied across my career and and place, um, I never had to think about it. I just got paid an hourly wage. So it didn't matter if I ordered a CT scan. I mean, maybe I would get like like I was an underutilizer on CT scans. Like I was like 0.5 and then one, and then there were over, there were there's a bell curve. There's a Gaussian distribution or whatever. And like I would always get talked to. And it wasn't because of RVUs, it was because of medical legal risk. Even though I've never been sued, knock on wood, somehow it's better to be lucky than good. Like most of us are sued by my age in the ER, but like I would get in trouble because the risk, because I wasn't doing CT scans, because I would call the surgeon, I'd say, Hey, I've gotten appy, and I'd never I didn't do a C I didn't do a C T scan. It's like I would get in trouble for that, you know, for practicing good medicine. And uh that that's ridiculous. So now, you know, I have to think about how much it costs for people. And so if anything, I've been erring on the side of recommending against things or saying we can wait, or you know, saying like, look, we could do this, but I don't really think you need it. Or no, and I and I'm being very careful and practicing really good medicine, but you know, especially in the ER, with like it's so there's so many things. Like we're Jack of all trades, maybe master of like the the golden hour, the emergency, right?

SPEAKER_02 35:54

But like do you think that that do you think that having to think about the cost of doing something, do you think that would potentially lead to under treating? So we talk about over-treating all the time, and of course the third-party system is like, you know, fuel for like over-treating, doing every every single test you can do. But if you got to think about costs all the time, especially if a patient's in front of you, do you want physicians to have that layer of, do I really want to do that CTA and this person is tachardic and hypoxic? Uh of course I'm making up making that up. No, that's my point is, you know, there's a bunch of gray area stuff right where where um you may not you may under treat.

SPEAKER_00 36:31

Do you worry about that? And how do you guard against that? So I don't worry about it. And the reason I don't worry about it is because I have the patient's best interest at heart. If I think they need something, they need it. But in medicine, especially in what I'm doing, you know, there's like a small abscess. And you know, I might talk somebody out of a $600 incision and drainage and say, you know, look, you can take sits baths and this is very early. You can try and mash on it and see if you can't open it yourself and you know, tell them what's going to happen if they're surrounding cellulitis or put on some antibiotics or something. But no, I mean, there's there's a there is a prospective reasonableness of care, right? And there's always a range of reasonable approaches. We're professionals. There's not always like a hundred percent right answer. Sometimes there is. You know, you give aspirin to somebody with a TIA or with, you know, a heart attack or something like that. There's well-studied things that, yes, 100 out of 100 docs should do. But a lot of problems have a lot of different solutions. And as long as I have the patient's best interests at heart, which I do, and I'm very fulfilled by that like central focused, laser-focused goal, then I just discuss collaps, I discuss care, I discuss risks and benefits. And, you know, and you guys, you know, I mean, Anthony, you know, as a surgeon, sometimes the best move is to not do surgery, often. You know, and when you're a hammer, everything looks like yeah, usually, right? And there's downsides to every to things that we do. So there's a risk-benefit ratio. And, you know, I think patients really like that when you say, I don't know, you know, I'm not 100% sure what the best thing is. And the these are the pros and the cons, and I've been doing this for a long time. But no, I don't worry about under treating, you know, if if anything, I think that as a culture, we over-treat partially because of medical legal risk and partially just because of our training. I think that it's much worse. You know, it's like insidious, right? Because you don't see the ill effects of over-treating for a career. You just don't. You just normally, you just it's hard to see that. But if you under-treat and you miss something, you really see that. So that shifts the goalposts deeply into over-treating. So I think that even when we think we're under-treating, you know, like go to Africa and deliver care. Go like, you know, like I've done some care in other countries, and like if you think, you know, like what we like, even our under-treating is probably still over-treating.

SPEAKER_01 39:00

But yeah, uh, oh, sorry, go ahead. I was just gonna say you're basically rehashing the two randomized trials we have that look at the effect of of um payment and cost sharing on treatment volume, right? And uh, the Rand and Oregon studies both showed that as the patient faces less upfront costs, they utilize more treatments, but they utilize both high and low value treatments. Um, and I think the the thinking is that we bring it up all the time, but people say, Oh, you know, insurance is gonna cover it, so sure I'll I'll do that extra appointment or I'll get that extra scan or or things like that. So and that that's why I'm such a big fan of price signals because nobody knows the acuity of that condition better than the patient on the ground. I mean, right, if they're the one that's writhing in agony because they have a spondylisthesis, right, they're they're gonna be willing to pay for that that extra MRI scan, whereas somebody who maybe just has a minor backache probably wouldn't want to pay for that. And giving that decision to the patient instead of some far-off bureaucrat is much more fair and equitable.

SPEAKER_00 39:58

I couldn't have said it better. I don't have anything to add.

SPEAKER_02 40:00

No, I I see um you are also getting into the longevity space. Is that is that one of the services that are offered? How do you decide to do that?

SPEAKER_00 40:07

Well, I think that we are making swift advances with AI and medicine, and I think the future is genetic medicine. You know, Wayne Gretzky said, you know, skate to where the puck is going. I I mean, I think we should be focused on health, right? I think I think people have correctly identified that we are a sick care system. And when we focus on treating the sick and like a reactionary, I had a 19-year-old the other day who was on protonics. And uh I was like, oh, you know, how long have you been on this? Oh, since I was 16. What? Like, like that's not okay. That's not okay. So this is your first med. You're culturally like we start collecting meds, everybody's on 30 meds, 40 meds, you start early. Like the system loves that. And so really we need to focus on health care, keeping people away from the doctor. Like, I don't want to see the doctor. I don't trust doctors mostly. You know, like I have had like five opinions on my back. And guess what? The ortho guys want to do a totally different thing are they were they five opinions from one person? Because then that often happens. No, no, no, no, no. I you're right. I've got five different docs, and uh they've all been great. And you know what? They're all right. Honestly, I would trust any of them to cut on me, to be honest. But you know, A-lift versus T-Lift and you know, restoration of lower doses, all this stuff and and uh cage size. And you can imagine what I've been through as a physician, you know, being a patient now.

SPEAKER_01 41:29

Yeah, but it's been that fourth opinion before. So I know exactly how it goes.

SPEAKER_00 41:33

Right. Yeah, totally. And and I I need you for a sixth. Happy to. I was talking to Dr. Hirsch. You guys know Brandon Hirsch. He went out on his own, and or he's going out on his own, and uh, he took some great time with me. What a great doc. What a great guy that that guy is. But anyway, um, you know, get getting getting back to it, um, and I think I kind of lost the thread.

SPEAKER_02 41:57

Well, no, you were talking about you're talking about how uh you know you want to keep people healthy and not be on meds. Yes, longevity. I was waiting to see how you would segue into they need peptides.

unknown 42:07

Yeah, right.

SPEAKER_00 42:09

You need BP 157, man. Well, no, okay. So here's the thing. I think that if we start focusing on on health and keeping people away from the doctor and away from sick care and trying to focus on like living longer and living better and living better, healthy lives. Like that seems like common sense, and it seems like everybody would would want that. And mostly the, you know, our jobs as doctors is to take care of the sick. And there are people who take care of the well and the healthy, and there's nutritionists and um, there's trainers, and and there's all sorts of people and and you know, to already kind of do this to some degree. But I think we're at the forefront of this genetic medicine. Like right now, you know, we are all at an N of one. We all look differently on the outside, we all look differently on the inside. And so it's been fascinating over my career to see, you know, penicillin kills one person with anaphylaxis and it heals another person. And medications are like this. And so we each have like really different genetics when it comes to how we react and how we respond and you know what's good for us and what's not. And so that's been fascinating as a pastime for a good number of years. And some of it is very well studied, like, you know, Umax and longevity or how long if you're 80 years old and you can walk, you know, three miles an hour for like three blocks, you've got a 90% chance of living to be 90. That's a big deal, and that's really important. But we don't really talk to our patients about that. We're dealing with problems usually. I care about my patients. I want to see them healthy and succeed. You know, peptides aren't for everybody, and I think everybody's getting peptides from everywhere off the gray market, and it's like this crazy wet wild west free for all. I'm interested to see what happens here regulatory wise. But, you know, like people should have like some base. Line medical N of one, you know, how do you react to this? Is this something that even makes sense for you? What's your BI, BMI? What's your DEXA? You know, what are let's make a decision together if this is a good thing because these are powerful medications. And so, you know, there's already been people who I've said, you know, I don't, I wouldn't feel comfortable. I don't think you need any peptides. So like the young bro who's trying to get ripped. It's like a biohacking experiment. And that's not a lot different than a diabetic with a BMI of 40, you know, or somebody who's like morbidly obese, who is already facing the specters of severe heart disease, through cancer, you know, all these things. And look, there's actually a medication that could help them uh in a lot of ways, if if done uh correctly and you know done safely with someone who really understands and has spent a lot of time with physiology and just loves this stuff. So I I just threw my hat in the ring and you know, it's not a big part of our practice. I've got three patients doing peptides.

SPEAKER_01 45:02

But I am trying to get ripped, so I'm gonna show up and pay some bit, and I'm gonna get some peptides and pay pay you in Bitcoin.

SPEAKER_00 45:08

Well, you'll get a discount. Yeah, I I love that. Um, you know, and and we've got a great group of Bitcoiners in Denver. And Bitcoin is see, you know, it's a big eye roll moment for a lot of us in medicine, but I've I've always had some Bitcoin, some gold and silver, and I have no idea what's gonna happen. I hope it doesn't go to zero. It might, I didn't YOLO my life's worth into Bitcoin, but we take Bitcoin, and that is a whole different interesting thing. And look, I have motorcycles, I did American Ninja Warrior, I'm already kind of out there. Of course, I'm gonna take Bitcoin. It's freedom money. I'm gonna support those guys.

SPEAKER_02 45:39

So why why did well here, let me finish the thought in terms of the peptides and longevity thing in the in the sense that like Dr. DeGiorgio is one of the biggest fans of healing crystals that there is. I mean, he makes the point frequently that look three billion dollar a year industry. Yeah, we need to preserve the right of patients to be able to access the colloidal silver. Yeah, to access healing crystals if they want.

SPEAKER_01 46:01

If people want to, exactly.

SPEAKER_02 46:03

Do you but so what do you think about that? No, I mean, no, there's there's things that each one of us believe that does not work, right? Like there's I try to get physicians to kind of stop um shooting at each other. There's all these physicians that should be under one tenth from a from a number of different fundamental core issues. But man, you you know, you get them disagreeing about like ivermectin, and it's like, oh my god, there's like flaming this person and flaming that person, and this person is a quack, and oh my god, I can't believe you think vaccines do this or vaccines do that, or COVID did this, and it's like, oh yeah. Like, obviously, there's a lot of different opinions. So, what what do we do about this? And I'm sure you have these, I'm sure you you as well believe that there's certain things that there are other ER physicians are doing that don't work, right? Or, you know, like for instance on your website, you have the you have a post in about med spas and and how they're doing peptides and how you're not a med spa that does peptides, right? But that kind of goes gobsmacks into I think that's the wrong word, headlong, goes head headlong uh you know, into what Anthony's saying, right? Anthony's saying, hey, patient wants to get a peptide and a med spa is willing to sell it as long as there isn't cyanide inside of it, then why not let him get it from the peptide? You're saying, well, hold on here. I'm I'm a guy that understands physiology. This is this gray market, I can kind of make sense of it. So do you have a problem with patients getting peptides from, say, you know, not ER physicians?

SPEAKER_00 47:26

Well, no. I what okay, that is a nuanced question. And let me start by saying that the patient has the right to do whatever they want. If a patient wants to smoke, if they want to do crystal meth, like I'm in I'm just there to care for them and help them and be their guide through through this journey of life from a healthcare perspective. I'm not there to judge them. Okay. However, we know that doing crystal meth and doing cocaine or having alcoholism or any one of these other problems, and those are very obvious examples, can lead to early death and all kinds of morbidity, all kinds of like healthcare problems that that make you suffer and need your belly to be tapped and turn your skin orange and it causes problems, right? So when people decide to do things, I'm I'm total libertarian with this. I think you know, people can decide to do all that. But the problem is there's there's a lot of misinformation, there's a lot of incentive to make money, a lot of money. And if there's incentive, if if your incentive is to make like a ton of money and you are just like a peptide factory giving everybody peptides, there are going to be people who have problems. And there are gonna be people who, you know, aren't managed correctly. And and then by the way, what is the actual research show about peptides? And is there research? Or are there questions to be asked? And if there's not, having that, you know, conversation of like, you know, this is a risk and benefit thing. You're not in a place where like medically this is something that is necessary. And if this is something you want to do, well, let's talk about it. Let's talk about like a little bit about the physiology and like like I'm gonna support you, but I I I think that in a society that like really praises your business selling for $10 million or making as much revenue as you can in a year, a lot of med spas are incentivized to sell as many peptides as possible. And I just don't think that that's necessarily healthy or right. And I think that people are impressionable. And I think that like it's really important to let people know that we don't know. Like a lot of stuff we don't know. As doctors, like we we don't know a lot. Like, like we don't know probably more often than we do know, but we are able to help formulate decisions based on experience, based on what we've seen over a career, and then based on what the evidence shows. And if there's no evidence, okay, well, then there's still room for treatment, you know, like and and certain things won't hurt you at all. Like acupuncture. Acupuncture may help. And there's room, certainly outside of Western medicine and allopathic medicine. I do think there's some kind of magic to healing where we don't need to be like 100% evidence-based medicine. Because guess what? Things still go really wrong if you've tried to follow some kind of evidence-based medicine. Like there is room for like a gut and for like a healing desire to be a good doc and use, you know what I'm saying? But like if you're collaborative with your patient and if you just let them know and you're trying to do the right thing and you put their interests first above everything, and you care for them like a fellow human being, like a family member, you're not gonna, you can't like like that. There's no way to reconcile that with giving peptide, peptide, peptide, you know, coming. Oh, here's your peptide, here's your peptide, which flavor you want? You know, you want this peptide? Okay, here's another peptide. Like, here it take this with your crystals. Dr. DeGiorgio, what say you? I don't know. I I don't have a problem with it.

SPEAKER_01 50:58

I'm gonna go to Noah's clinic, get peptides, and do crystal meth. I'm gonna feel great. MDMA, baby. Dr.

SPEAKER_02 51:04

Giorgio, do shouldn't we support um should we support patients getting treatments that we have no idea whether they work or not? We have no idea what the right dose of BPC 157 is. We don't know if it we don't know if it works. If and if you're giving it, we don't know exactly what dose to give it. If you take it orally, we don't know if it how what gets so complete, you know, it's it's a black box. There's one clinical trial in humans out of Croatia. So is there really Yeah? So should we I uh should we so should we support this, Dr. George?

SPEAKER_01 51:35

Or should we not be protecting patients' wallets from well, so you know uh there's two issues there in each of the So there's the the FDA issue and there's the payment issue, right? And so I and we've talked about these at at length, and and the FDA issue is uh I think the FDA is supposed to protect us from ingesting things that are harmful. We can argue about whether or not their charge should also include efficacy, uh, but right now it does. And so the uh you know, if FDA is gonna have a say in whether or not peptides uh can be given, then I think they should have a say in that. And then you're talking about payment policy, and and that's a totally separate thing, right? Healing crystals, if again, if people want to pay for healing crystals on their own, I have no problem with that. I think it's ridiculous. It's a two I correct myself from earlier, it's a two billion dollar a year industry. So there's clearly a lot of people it really is in the US. Healing crystals are two billion dollar a year industry. I don't think there's any evidence that they work. Maybe I'm wrong. Please let me know and tweet at me if I'm wrong. But if people want to spend their money on that, as long as it's not through a third-party payment, as long as you're not socializing that cost, I don't have any problem with it. And the same goes for peptides. If the FDA says they're safe, I have no problem with people paying out of pocket for peptides as long as they're safe and as long as they know what they're getting into, even if they're not safe, you know, if they know what they're getting into, you can have a risk-benefit discussion with them. But that's where I think the the efficacy, safety, and payment policy are actually separate issues. And I think we often conflate that's a good point.

SPEAKER_02 52:58

Well, so getting I we're we're nearing the end of our hour. I have I have um so we'll get out of peptides. But I I could I couldn't help but when I saw that, I was like, I gotta get I gotta get Noah's uh Noah.

SPEAKER_00 53:08

No, yeah. I've never I've never given someone BP 157 for the city. No, it's okay.

SPEAKER_01 53:12

No, I'm not saying but have you given them for healing crystals?

SPEAKER_00 53:17

I need to get some healing crystals just to have the aura in the I'm not even gonna tell people, I'm just gonna put healing crystals behind all the plants. Yeah, apparently it heals business finances too.

SPEAKER_02 53:27

So I should get some too. Anyway, uh so okay, but back to back back to Kafka and back to this, you know, uh new new branch that you have uh forged and it's a journey that you're on. Uh say every good ER physician does this. Say every 20-year ER ph every 20-year, you know, uh in the weeds ER physician is like, but they get to this epic inbox, they're like, that's it. I'm done. I'm gonna go do my own thing. All right. Night shifts done. Yes. Doc, yeah, and I I saw Dr. Kaufman, your your business, 9 a.m. to 9 p.m., Saturday and Sundays off. I know you're starting, you're new, obviously you can't, you can't, you gotta have to take some time off. I get it. But my point is if everyone does that, right? If all the art if all experienced CR physicians do that, then then what what do we have left? Meaning, are you able to do what you're doing because a bunch of your brethren are putting in the yeoman's work, taking care of the sick, the unpaid, you know, the nah miss.

SPEAKER_00 54:20

I sorry, I don't miss, but I used to love doing burrholes and thoracotomies, and I've done my share. Jesus. Oh yeah. Tahoe storm. The art physicians do burrholes? Oh yeah. Yeah, like this, right? Yeah, here, right? Like this, and then here. That's the ER no comment. And honestly, and I and and the the the bur the the we had like the the mixer. You did the twist drill bit. Yep. Yeah, uh I can't believe we had one. This was in Tahoe, but wow. Um I've done a I've done a a couple of them. Big storm, no neurosurge, couldn't fly the patient out, took a header off a stairwell, young kid, big epidural. Oh my god.

SPEAKER_01 55:00

Jeez. Uh I mean that's that is life-saving.

SPEAKER_00 55:02

Yeah, it is. And thoracotomies, we do those. That's like, you know, like I knock on wood. I've I've been part of one perimortem C-section. I don't ever want to see one of those. I I'm fifty. I don't want to do that. I tubated a intubated a baby last summer. And I was like, I don't want to be doing this. Like, I got the intubation and we saved the baby, but it did so much cortisol. It's like a cortisol factory. So the kids want to do it. I loved that. I used to love that. I used to love taking care of the gun and knife club club. I it was it was fun doing Thorcom. It's fun, like, you know, like it's just it's just plain fun, problem solving under pressure when someone's life is on the on the line. And I know that might sound callous, but like when you're a young doc, I'm in and you guys went through trauma surgery rotations the same as I did. And like, it's fun. And and like like you, you you want to be that person's best chance at living, and you have to solve a problem. And like it's better than if it were like scary or but if you're confident and you know what to do, and like we're not gonna run out of young, strong women and men who want to save lives and be in there. What I want to do is take away the stuff they don't want to see, like the knee pain that needs a steroid injection, or you know, the ingrown toenail, or maybe they want to do an ingrown toenail. I have no idea, but but like the stuff I want to see in my clinic, like it's not critical care stuff, but a lot of most of us I, you know, ER docs, like we live for that like 8% or 5% of really crazy cases. So I don't think we're gonna put all the 20-year-old, guess what? I am actually making like I want to have cough cares all over the country, and I want to franchise out to board certified, very experienced, compassionate caring men and women who are 50 years old and who are done, but want to practice medicine, they want to keep going, and they want a new path. And honestly, I think extra you know, taking out the 80% of value, you know, the these like saprophytes, these like parasites that like are sucking value out of the system, like these leeches, all of a sudden you can you can literally take the patient's uh cost down 60, 70 percent and double the the healthcare team's uh reimbursement. Because I I totally agree. I think if you if you work hard, you should you know be able to pay off your student debt. I still have like $80,000 of student debt from like you know, I finished in 2003 from Tulane. And so anyway, like I I want to create a viable alternative path. Because right now, if you're an ER doc, like people are leaving medicine like crazy, getting side gigs, you know, whatever it is, what you know. I I was one of them. I was burnt out. And I made other, you know, all the businesses I made were just practice for this. And I worked with a private equity once on a really fun live events project that, you know, and we did live events, ninja events for kids and got all the ninjas together from American Ninja Warrior. And we did we did a show in Hong Kong and New York and in Atlanta and and a couple here in in Colorado. COVID killed our business as a live event business, but still, like everything I learned has led to this moment. And so now I know how to put together a PL, a balance sheet. I know how to create these back-end tools for enterprene prize value with AI coding. And so I've made our website, I made an app for us. And so, like, I'm really enjoying this problem solving and creating a business and now like trying to fix, not fix the system, but trying to create a new viable alternative system, parallel system. It just feels really, really good. And I'm not worried that it's somehow gonna make everybody stop being an ER doc because if I were young and brave still, I would want to be in the ER cutting people open and trying to save lives. And now it's just it's like physically hard and it's like I'd rather work on the system itself, get my back fixed.

SPEAKER_01 59:10

I think I think a key thing that you said there is that that the um the ER docs that love that rush, that love the burrholes and the thorachotomies, the key stat that you scave there was that's only about five percent of what an ER doc does. And again, when people bring up this argument that you can't have a free market because emergency care exists, think about what you just said. 95% of the care that we think is an emergency could be shopped, could be done at a transparent, cash-based place like Kough Care, even if for people that are poor, right? I mean, yet again, if you think about you think about somebody who's on Medicaid, has a food stamp for health care type cash equivalent debit card they could take to Kough Care, they could get their laceration repaired and not have to go to some inner city urban hospital where they wait for 12 hours in the ER because it's it's understaffed and has too much volume, right? So all of that, I think that's that's really the key. Yes, there's about 5% of patients that go to the ER that truly cannot shop and are dying, but we don't need an entire socialized system because of that 5% of people going to the ER. We can have a transparent cash-based system that has equitable access for poor people and better care, cheaper all across the board.

SPEAKER_02 1:00:18

Yeah, and I'm gonna answer my own question about you know, this idea, the question that I posed to you is like, well, why don't you do this and why don't you do that? It's it you know, this comes all the time from from certain folks uh up high. And and you know, they don't they don't have an understanding that what you need is not one system that solves every single problem, right? You can't solve every single edge, you know, it's like, oh, solve this edge case. It's like, you know what, like the five billion dollar health system down the street can't solve basic edge cases. Not basic, I mean, not even edge cases. They can't solve basic cases, right? Like they can't, they can't deal with scheduling, they can't deal with Anthony's OR uh, you know, preference cards or or whatever. So so so this whole idea that like you'll do something like what you do, or the Oklahoma Surgery Center does what they do, right? They're like, well, that's only because they only the affluent can do that. Like, what is their solution for the 12-year-old Somalian uh starving person? Like it's like, okay, I we we can't solve every single single problem. You need like so it's very important to have somebody like you as part of the tapestry to be able to be able to take care of that segment of the population that doesn't want to wait for six hours, that does want an experienced person to to be able to do their shoulder, that does want uh to get BPC injected in their bicep at some dose that we don't know about. Intraocular. Just kidding. But anyhow, so uh Noah, it's been fantastic having you. Uh thanks so much for kind of giving us uh a bit about your journey and uh what you're doing and your philosophy. Um you are in um Denver, correct? Jefferson Park? Denver?

SPEAKER_00 1:01:49

Did I get that right? Jefferson Park, yeah.

SPEAKER_02 1:01:51

And uh first location, but there's gonna be many more. Amazing, amazing. Well, thanks again, sir. Oh, and your your handle. Your the Kaufcare handle is at Kaufcare, K A U F C A R E. And uh your handle is just Noah Kaufman, at Noah Kaufman. It's Noah Kaufman M M D. At Noah Kaufman M D, yes. Okay. Excellent. All right, folks. Thanks so much.

SPEAKER_00 1:02:12

Thank you, Noah. Thank you guys. Wonderful conversation. Yep. Hold, don't, don't hang up.