The Hidden Incentives Shaping Healthcare with Brian Klepper
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🎙 Episode 5 | Endocrine Matters Podcast
In Episode 5 of Endocrine Matters, Arti sits down with Brian Klepper, a nationally recognized healthcare analyst, strategist, and entrepreneur, to discuss the deep-rooted challenges within the U.S. healthcare system. They examine how financial incentives shape care quality, why chronic disease management—particularly for conditions like diabetes—often falls short, and the overlooked role of primary care in improving outcomes.
Brian, who advises healthcare organizations and employers on high-performance solutions, shares his perspective on the dysfunction of traditional insurance models and how data-driven approaches can realign incentives to benefit both providers and patients. He and Arti explore the public’s misconceptions about healthcare costs, the hidden barriers preventing physicians from fully understanding their own performance, and why endocrinologists must actively demonstrate their value in patient care.
This is a must-listen episode for anyone interested in improving healthcare transparency, data-driven medical practices, and the future of endocrinology.
Listen to the Full Episode
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Key Topics & Timestamps
Skip to specific parts of the episode:
03:00 – The State of Chronic Disease Management
05:54 – Understanding the Healthcare System's Failures
09:09 – The Role of Data in Patient Care
11:58 – The Impact of Financial Incentives on Care Quality
14:58 – The Importance of Primary Care
18:02 – The Need for Collaboration in Healthcare
20:58 – Tracking Outcomes and Patient Engagement
24:11 – The Future of Healthcare Solutions
40:49 – The Hidden Incentives in Healthcare Systems
44:08 – Challenges in Traditional Insurance Models
48:00 – The Perception of Healthcare Costs
51:40 – The Role of Endocrinology in Patient Care
56:55 – The Future of Endocrinology as a Specialty
01:01:58 – Demonstrating Value in Endocrinology
01:06:42 – The Drive for Change in Healthcare
Episode Highlights
Key Takeaways:
The Healthcare System is Failing Patients: Chronic disease management, especially for conditions like diabetes, remains inadequate, with only 10% of patients under control.
Financial Incentives Prioritize Profit Over Care: The current system rewards volume over value, limiting patient access to the best treatment options.
Data is Key to Better Outcomes: Tracking patient health metrics can improve care quality, but physicians often lack the time or tools to do so effectively.
Primary Care Must Go Beyond Gatekeeping: Physicians should act as patient advocates, ensuring comprehensive and proactive care rather than simply referring cases.
Collaboration Among Providers Leads to Better Care: A team-based approach improves patient outcomes and efficiency across the system.
Physician-Led Solutions Are Underutilized: Doctor-run companies could transform healthcare delivery, but barriers prevent their widespread adoption.
Endocrinology is Undervalued and Underfunded: Despite its complexity, the specialty faces inadequate reimbursement and limited recognition.
Aligning Incentives Can Drive Meaningful Change: When providers and patients share goals for better outcomes, the healthcare system functions more effectively.
The System Must Prioritize Patient Well-Being: Until structural changes shift focus from financial gain to patient health, achieving sustainable, high-quality care will remain a challenge.
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Brian: [00:00:00] There's no good reason, for example, why the overall health status of Americans has dropped for the 14th year in a row when we are the wealthiest country on earth. It says that we don't have, we don't have our priorities right. We're, we're not looking out for the welfare of our, of our people. That makes this a less desirable place to live than we've always imagined it. It should be.
Arti: I am beyond thrilled to welcome Brian Klepper, an incredible healthcare activist and someone I deeply admire to the show today. Brian has dedicated his career to promoting better health care at lower transparent prices, all while fearlessly calling out the unethical practices of major players in our traditional health care system, like insurance companies and hospital [00:01:00] systems that harm our communities and economy. Brian introduced me to one of the most mind blowing and little known aspects of healthcare policy, the AMA's RUC, or Relative Value Scale Update Committee. This committee, sanctioned by the AMA, determines how physicians are reimbursed by Medicare, which heavily influences how commercial insurers set their rates. The RUC operates in a way that pits physician specialties against each other because the Medicare payment pie is fixed. If one specialty gets a bigger slice, another specialty must take a smaller one. This creates a system of division among physicians, ultimately empowering those who profit off of our work and the care of our patients. What's even more concerning is the representation on the RUC. Higher paid specialties are over represented, while lower paid, prevention focused specialties like primary care and endocrinology are under represented, or in the case of endocrinology, not represented at all. This disparity perpetuates a vicious [00:02:00] cycle. Lower reimbursement for critical specialties leads to fewer physicians entering those fields. Worsening shortages in areas like endocrinology, even as diseases like diabetes, one of the most prevalent and costly chronic conditions, continue to rise. This system disincentivizes preventative care and high value service while rewarding reactive, procedure heavy care in hospital settings. The result is a system that doesn't prioritize patients best interests, and it's all happening under the radar. Shockingly, 99. 9 percent of physicians don't even know the RUC exists, let alone how it affects their work or pits them against their colleagues. When they do find out It feels inherently wrong because it is. In this episode, Brian and I dive into the RUC and so much more. We discuss the importance of outcomes data analysis and accountability in improving health care and how we can address systemic issues that put profits ahead of patients. Brian's perspective and [00:03:00] expertise are invaluable. And I am so grateful to call him a friend and have him here today. I hope you enjoy this enlightening conversation as much as I did. Be sure to check out the show notes for all the links and resources mentioned in the episode. Let's get started. Today we have Brian Klepper on with us and I am so excited to have Brian here today. I have learned so much from Brian throughout the course of the past several years in this. new space that I have been exploring and learning about and working in, in terms of direct care, in terms of value based care, in terms of trying to solve the very important problems that we're trying to solve for diabetes and endocrinology patients, and Brian's insight into this space has been Taught me so much. So Brian, welcome to the show. And I know you had something that you wanted to open with. So [00:04:00] please just go ahead and get started.
Brian: Well, I'm delighted to be here, especially with you. So here's what I was thinking this week, the international foundation of employee benefit plans, which is a union. Health care organization issued, uh, a report this week that said that none of the cost containment, uh, approaches that are in the marketplace, there's, there's no evidence that they can find that they work. And I'll put that, I'll put some context behind that. My response to that is, I think they're asking the wrong questions and I, I think they're, they're focusing on general approaches. That are, uh, applied with huge variation across different care delivery organizations or care management organizations. And that the, you shouldn't be looking at the, at the category of what they're [00:05:00] doing, you should be looking at what their results are, and you, if somebody is a practitioner of diabetes care, for example, you, you can't just say, oh, well, they're, they do coaching, you have to say, this organization, um, has a particular approach that it uses, and they have taken it to a high level, and they, that organization needs to be scaled. There is no evidence that that, that that category of of approach needs to be scaled. Those are two entirely different, different processes. So, for those of your, um, watchers who, who don't know me, which is probably almost everybody, for the last ten years I have focused on identifying and vetting very high performing healthcare organizations. And the [00:06:00] definition of that is organizations that consistently deliver measurably better health outcomes. And, or much lower costs than conventional care and particularly in high value niches where the money is. So, I'm not particularly interested in wellness, for example, because there's just not a lot of data that shows that it works. Or maybe another way to say it is at all. There's, there's just nothing showing that it works. I'm very interested in areas where the money is. I'm interested in management of cardiometabolic chronic disease. I'm interested in management of musculoskeletal care and of complex disease generally. So for example, complex disease generally is. Think of that as the cancers, the neurodegenerative diseases, like Alzheimer's and [00:07:00] ALS and Parkinson's, which I have, and the rare diseases. Those diseases affect six to ten percent of the U. S. population, and they eat up more than a third of all the money. And so they are, to put it in crude terms, they're a high value target. And when you dig into areas like this, and it, and the same thing goes for diabetes, actually, there's very little that's done that is standard of care. And it's reflected in the poor control rates of these, of these diseases. So, for, for those in your audience who aren't familiar with that term, what I'm referring to is the percentage of, of patients Who have a particular chronic disease where if you test them, they, their numbers are within acceptable limits or they're [00:08:00] not. And if they're not in, if they're not in within those, then they're out of control. So American chronic disease control rates are terrible. They're embarrassingly terrible. So if you go to the CD, C and you say, what percentage of. People with hypertension have it under control. The number is currently 44%. So 56 percent of those people are out of control, which means that they're going to go on to have other more terrible things. They're going to suffer a lot more and they're going to cost a lot more and die younger. And we sort of don't do anything about that. And if you go to, and you talk to the docs about it, and you say, well, why do you suck so badly at this? And then, and they'll tell you, well, the patients don't do what we tell them. Which turns out to not be [00:09:00] true. It turns out that to, to properly, to accurately prescribe for these patients, You have to, the clinician has to accurately juggle 50 different variables in their heads at the same time. And that is pretty much beyond the limits of human capability. The more you get into the, the cardiometabolic diseases, the more complex ones. the worse the control levels get. So, if you look at diabetes, 10 percent of the patients are under control. If you look at, if you look at heart failure, 1. 5 percent of the patients are under control. And so, until recently, there have been no real concerted efforts to use evidence to create standardized practice patterns. It can defeat this, this [00:10:00] most serious of all healthcare problems at a societal level. And I think that where you are headed is exactly in the right place as a result. And that is not a small thing. That is a, that is a very, very big thing.
Arti: Well, thank you. There's so much to unpack there. So I think, um, that first it's a travesty, right? I mean, 10 percent of people living with diabetes are under well control and Probably those people are getting some sort of care in air quotes That, you know, really begs the question, is that care? Um, Brian, why do you think it is that we are, we have such poor control of these chronic cardiometabolic diseases?
Brian: For one thing, we don't track them. We don't track control levels by doctor. Uh, there are, they do in a few parts of the country. [00:11:00] But, um, the American healthcare system is so crazy. And as a quick aside, I'll tell you that I have spent the entire last week writing about with, with other, with other people, um, the killing of the, of the UHC, uh, CEO, which is a terrible tragedy, but I think the important thing about that event is that. On social media, particularly, which covers a huge swath of American opinion, this was not a normal event, and there are, there have been an overwhelming number of people, of all political persuasions, of all demographics, who have stood up and, and said, we have no sympathy for, for this, this. Organizations like [00:12:00] United preyed on the, on the American people and they have done it unethically and more often than not illegally. Nobody takes them apart as a result. And it's all about the money. My 45 year old attorney's son gave me an earful about that last, last night, uh, which was, which was actually enlightened, um, the healthcare systems structure has not incentivized quality of care and it has not incentivized efficiency of care either, but it has, they have exercised control. Which allows them to skim off the top and to make immense amounts of money. So because we live in a [00:13:00] society, which has decided that the way we write laws is to give, give your Senator and Congressman more money than other people will give him so that he'll do your thing in your favor. We have a system that is utterly dysfunctional and it's absolutely not in the patient's interests and it's absolutely not in the. interests of anyone but the, the guy who's making money on it, which is the cynical answer. It also, it threatens democracy. It also threatens professionalism. And so the, the physicians today have a completely different experience and mindset than the physicians did 50 years ago. In my day to day work, I'm now, among other things, I am doing performance reviews On [00:14:00] worksite primary care clinics and trying to see whether they they actually deliver value to the employers. And more often than not, the data says they don't, and that's not because they can't, it's because they, they don't have an incentive to really be accountable and take the steps necessary to be effective, so they coast, because, because nobody's looking at the data. Patients are the, are the victims in that.
Arti: Yeah.
Brian: The reason I became so interested in you so quickly. Was because you are you are antithetical to that you were all about the patient and you're all about the science Which is the only way to really be effective
Arti: in the data. I think that it is what you mentioned about the data is I, I have always tracked my [00:15:00] data from the second I graduated from fellowship, mostly out of curiosity. I was an employed physician when I first came out and I wanted to see if some of these newer therapies were actually working for my patients. And that's kind of where this obsession with with. data came from. Um, but I want to ask you a question about what you said. Um, you said the system is only working for the guy who is making money off of it. Who is that guy?
Brian: Well, as you've seen, they're typically nameless and faceless. And they're, they're hiding, and now right, rightly so. There was an article in the Wall Street Journal yesterday that said Brian Thompson was just a guy doing a job. But he wasn't. Six or seven years ago, I wrote a piece about a, about a United, a United Health Group subsidiary that, that [00:16:00] provided behavioral health benefits. And so employers bought, paid the premiums, they bought the benefit design. Then this, this organization systematically denied all the claims and pocketed the money and um, it went, they got sued and it dragged on and on and on and on. And in the ruling, the judge wrote that United, United's representatives had been, been evasive during the entire process. And even deceitful, he said, well, when you are the biggest insurance company in America, and one of your subsidiary organizations is truly and fundamentally dishonest, and there's a documented record of that, and they, they tolerate that and they defend it, that [00:17:00] says the entire enterprise is. Is a criminal enterprise. And that's where we, that's where we are with, with United. So this guy who everybody refers to as the family man, and he had, he had young kids and so on, and he was a great guy and all that he's like Michael Corleone. And the problem that has, that has emerged is that companies like this are preying on the American people and they know about it and this. Overwhelming celebration and, uh, skepticism and mocking, mocking discussions about, about him is a sign that people aren't just responding off the cut, the cut. They've had years to, to experience this and, and be fearful and vulnerable to it. And they really are expressing [00:18:00] how much they loathe these organizations. I think it's a big moment in healthcare, and I think it's a big moment for all the different problems that we have, including how we treat patients, poorer than we could.
Arti: Absolutely. And I, I love that you brought up this idea that clinicians say, Oh, the patients don't listen. Because in my experience, Certainly, there are the rare few that perhaps won't listen, but those patients probably, in my experience, also have very complex socioeconomic issues or other issues going on that disable them from following their prescribed plan or working as a partner with you in, in their care. Um, for the most part, patients do listen. And I know this. Because of tracking data, and I know this because we worked [00:19:00] with a population of poorly controlled people living with diabetes, but were poorly controlled. So with a one C's greater than nine and we intervened with them and. That intervention was introducing me as an endocrinologist, nothing else was added to, to them. They weren't given any other support outside of an endocrinologist who gave them time and support. And I watched their A1Cs come down, and more importantly, they were engaged, they were listening, they were hearing me, they were partnering with me in a plan, they were learning about their lifestyle, and they were engaging in that. And these patients dropped their A1c from above nine by more than three percent. So many of these patients went from poorly controlled to well controlled, dropped their risk of complications tremendously, and reduced their risk of [00:20:00] potential cost to their health plan or the health care system tremendously, and that was just changing One thing. And so I think we have this idea, or maybe it's, um, shirking the responsibility, um, because we feel like we're not in control or we're not tracking our own data. I think data is the most empowering thing for a physician. And it's an educational tool, right? I started it because there was these weight loss medications that came out close to when I graduated from fellowship called, uh, there was one called And there was a guideline with it in it, and it was expensive, and I wanted to see does this really actually work for my patients. And my personal data kind of showed that it didn't, it wasn't really worth their time and money. And I think that data actually enabled me to reduce their out of pocket spend because I was like, eh, I don't know if you guys really should [00:21:00] try this. You can if you really want to, but in my experience with the last 50 patients that I tried, tried it in, didn't really work in my personal experience. I think that's incredibly empowering and I think patients are coming to us, yes, for us to know the evidence that exists and, um, you know, for our knowledge and expertise and training, but they're there for our opinion and we can only have an opinion with, with data. And some of that comes from experience, but also. I think it really strengthens our, our argument for our patients when, when we have facts.
Brian: I used to own a, uh, a primary care, a work, a worksite primary care company. And one of the things I learned was primary care is not about, about being a gatekeeper or anything like that, that that's silly. No competent primary care physician that [00:22:00] I know thinks like that. They are there to be patient advocates and guides and to manage complexity and also to manage. Risk, clinical risk and financial risk, wherever it occurs in the continuum. So the primary care clinician sits at the center of power in healthcare, which is also, it also happens to be at the front door of the healthcare system and should be using data to identify who needs to be in the queue right away and, and is the core source of trust in the entire healthcare transaction. The programs that I'm working on, we think that we could, that we'll be able to go to employers and say, if you work with us through this, through [00:23:00] a design of, of advanced primary care clinics, which are focused on traditional primary, primary care functions, prevention, modest acute care, and management of chronic disease, If they, if we can marry those to specialist organizations that are hyper, that are truly high performing and that are focused on very high value niches, uh, chronic disease, complex disease, drug spend, uh, maternity surgery, all of those costly areas, we can guarantee a 25 percent reduction in total healthcare spend within two years. With better, with better health outcomes, you know, along the way, we think that that's already achievable. And the thing that I want your, your listeners to, to get [00:24:00] is that you represent the leading edge of the new wave. That is capable of participating in and leading that, that effort, because you've already demonstrated.
Arti: Oh, well, thank you. I think, you know, that is how primary care should be. And I think it's important to address that primary care doctors are. well trained, board certified physicians. And because of the way the healthcare system has gone, they're almost treated as though they're secretaries or, uh, uh, an avenue to a specialist that you really want to see. And That's only true if they have five minutes to spend with you and all they can do is refer or write a prescription or, and no support in between. And so I think, and we're going to talk about [00:25:00] this much more, but the way reimbursement has dwindled for specialties like primary care and endocrinology. I don't know if you saw the recent Medscape physician compensation, um, report, but we actually fell below pediatrics as the lowest paid specialty in endocrinology. But the way the compensation structure has gone to prioritize reactive specialties that are more in the hospital performing surgeries and kind of dissuaded medical students from going into primary care or other fields that actually focus on prevention and are cost saving in that way has changed the way that people perceive primary care. And my hope is that As we show with real numbers, how much cost [00:26:00] savings primary care doctors can do when they're given an environment where they can perform at their highest level. My hope is that that perception will change, but do you think we're anywhere close to that?
Brian: The problem that you're, that you're describing, the culprit in that, Is there has been a, an unholy relationship between CMS and HICFA before CMS, which is the previous name and a secretive committee of the AMA called the RBRVS update committee. And in between 2010 and 2013, I threw everything I personally had at, at, uh, Exposing the RUC, which is a, the committee is made up of, I want to say, uh, 31 physicians of whom five are primary care and the rest are all specialists [00:27:00] and they have a sole source contract with CMS to define the value in RVUs of every medical procedure. And it is, uh, hidden. The processes are all hidden. Uh, there's no, there's no transparency. It's run by horse trading between different, different specialties. And it's designed to do everything possible to make, to go around primary care and get the patient directly to The specialists were much more lucrative diagnostics and, and procedures can be done. Um, the GAO ultimately took the work that I did and they did, uh, an analysis and they went, ah, this guy's right. Um, and, but they didn't, they didn't do anything because there's so much, there's so much political power behind it. So it's, yes, that's another really big problem, [00:28:00] and it's a problem for, for endocrinology particularly.
Arti: What is the GAO?
Brian: Uh, the, the General Accounting Office.
Arti: Okay.
Brian: The, the U. S. General Accounting Office, who, that does investigations into different things in, in the country, but the, uh, since diabetes is, I think our most, um, costly single disease, and it's exponentially getting worse because of, because of the diets that we're on, um, this stuff matters. So, every day of my life, I get calls, every working day of my life, I, I get calls from, Startup companies or somewhat established companies that want to tell me how wonderful they are.
Arti: Mm hmm.
Brian: And they recite all the things that they can do. Then I ask them a set of questions [00:29:00] that are designed to have them tell me the basics of what, of what they're about. And the questions are, they're really quite simple. Um, and it's taken me a while to develop them. Not the brightest bulb here. So, so. I asked them, and they show me longitudinal data, long term data that, that demonstrates that they consistently get better health outcomes and or lower costs than conventional approaches. Most of them don't have the data, they can't share that. Are they willing to go at risk? No, they, they're not willing, willing to do that. Um, so they're not willing to guarantee their results. Do they have seven testimonials that they can refer me to, to talk, to talk to clients that they've got, that demonstrate, that'll, that'll back up, back them up and say that they, they deliver? Are they sticky? [00:30:00] You know, do they get more participation over time as a result of their, of their work? And so on and so forth. There are very few organizations that, that do this well. And, and the, because diabetes is such a, a big target, and there's so much money that flows through it, there are lots and lots of companies. that are in this space and that claim to manage it very well. Um, the most notable and or rather notorious of them was Livongo, which basically used its money for marketing and didn't, couldn't prove that they did anything that was, that was worthwhile. They, they ultimately sold to Teladoc for 18 billion. And then Teladoc took a really big icky on that. But they were just a, a worthless play. They got [00:31:00] tremendous buy in from the fortune companies until they did. And I see the, I see companies like this every day. And so the reason that I was, I was so interested in, in having. Uh, a public talk with you, uh, with you is because you're in a very interesting position. You have a, you have developed a genuinely better way. It's not like rocket science or anything, but it's, but it's sensible and you get consistently better health outcomes at lower costs than almost all of your competitors. I can think of maybe one that is in the same league. Employers in this country. And brokers in the country have been reluctant to move to work with Point Solutions, and [00:32:00] they would consider you a Point Solution, because it requires somebody, somebody in, at the employer in HR to manage the contract outside of the health plan. And that's sort of onerous, and people in, at the employer, they don't know anything about this. And so you, we end up with, with employers who have a lot of point solutions that they don't, they don't understand and they don't perform and they don't know what to do about it. And that means that it's more, it's more and more difficult for the point solution company, even those that are doing fabulous jobs to get into the marketplace so that they can generalize what they do and succeed. So what I realized was, was that. What we need to do is get through high performing point solutions from, from all different niches [00:33:00] and get them to collaborate to functionally create the basics of a, a new high performing health plan that takes risk where the, where the, the vendors each take risk it's integrated with, with primary, with advanced primary care and it, it pushes what it does out into the marketplace because, The major health plans are not going to buy in, into it. They, they want healthcare to cost more because if it costs more, they make more money. So the task ahead of us is for organizations like yours to get enough footing to work with other, other organizations that are your true colleagues, but in different spaces than you. And to offer a range of services to, to populations that you wouldn't otherwise have access to.
Arti: You're [00:34:00] absolutely right. I think that is the, the whole foot in the door thing is, is the hardest part. Getting people to, you know, you have the outcomes, but getting people to, to take it seriously and how it, figuring out how it fits into their greater plan is, is the challenge. Um, we've had some great employers that have taken, uh, Uh, I guess taking a risk on us, and I think that we have performed very well and had You know, we track not only hard clinical outcomes, but also patient satisfaction scores, and I think we've we've done well But I think that's a great idea as far as kind of collaborating coming together and creating a multi specialty outcomes driven truly high value product that can be more palatable and less onerous as far as an admin for, for a client. Um, [00:35:00] it's just finding those solutions. You know, what I've learned is physician run companies are great, but they're very few and far between. And physicians, it's very difficult to get them to wrap their head around tracking their own data. I, I've been pushing my colleagues to do it for six years now and Literally zero have done it, except one endocrinologist who I hired, who's on my team, um, and she did it for me. And so, because, and not, not even on a large scale, but it's, it is a little bit. It's tedious to do it, to do it correctly, and perhaps they don't have buy in by their hospital systems if they are working in a large EMR, but getting physicians to track their outcomes, I truly believe is almost our ticket to freedom from [00:36:00] some of these big corporations, because if we can say we can do it better without you, then, and for far less cost to the patient, then, then we have something there, but Getting people on board to do that has, has proven challenging for me, for sure.
Brian: Tell me what, why it's difficult to get, get that done. Wouldn't it be interest, in the interest of the provider organization to simply? Make that data available to every, every clinician.
Arti: I have a theory on it that maybe isn't, isn't the most positive, but I don't think that systems want their physicians to know how good they're doing. Right. Because then they'll leave.
Brian: That's almost certainly true, yeah.
Arti: And, and so I think that they make the, I've, I've been, I've had my own company for years, and I've sort of tracked [00:37:00] data. I've anonymized data on my own and tracked it separately on like Excel. You know this. I'm very high tech, right? Um, on Excel, by myself, you know, I haven't always gone through the system to track it. Mostly out of curiosity and now. Just for the sake of our business, but, um, so it's essentially like having an Excel spreadsheet on one monitor and your patients on the other day, other monitor and putting it in as you go. That's that's how you track your own data and. That's another step on top of seeing the patient doing their orders, all that's in a short window, too short for even doing those tasks. So going above doing something else on it, I just think is unpalatable. Um, and also I don't think many physicians, I think physicians are so on the hamster wheel. You know, they're, busy taking care of patients that [00:38:00] it's difficult to step back and see the big picture. Um, I remember I left my practice in January of 2019 when I was employed and I told my husband two weeks later That I felt like my brain worked again and, um, I had no idea that my brain wasn't working and the craziest things happened because I wanted to start my own practice, but we were a year and a half out of fellowship. So we had a lot of medical school debt. We were paying off and. We had two very, very young children and I came up with a plan of how we were going to tackle some of these things and how I was going to tackle starting my own business because I was free from, from that. And we saved so much money that year without me. Practicing full time like I had been that my husband and I decided there's no reason for me to ever go back to practice like that, because [00:39:00] we save too much money with me not practicing for it to be worth my while to practice in that type of setting. It had to. It was crazy. So, um, so I wonder you what you were saying kind of led me to think since these since You know, our big Bucca insurers, Blue Cross United, Cigna, Aetna, is what I mean when I say Bucca and hospital systems make money off of illness. Essentially, they aren't incentivized to have these tremendously good outcomes to prevent hospitalizations. Do you think that we can make massive change within traditional insurance?
Brian: No, we have to co op, and the only way to do that, they captured the regulatory process with lobbying. And so, all the [00:40:00] laws and rules get written to their specs. Because they have the biggest bribes and our system of government is receptive to that. The only way to, to work is in the market. And it boils down to giving people a better mousetrap and making them an offer they can't refuse. The thing that will work to break employers from the, away from the brokers who are, who are setting them up with health plans that, that are paying them huge commissions. under the table is to offer something that is so much better for so much less money. If the benefits manager blows it off and the CFO finds out about it, the benefits manual manager will lose your job. But other than that, they've, they've got us hog pie, which was one of my son's [00:41:00] issues, by the way, says. It says everybody I know knows that they're being forced to play a game with the health plans. They had, there's no alternative to that. And they, they, you know, we lose every time they're in a, they're in a control situation. And so there, there's this pent up fury and it's corrosive, it's corrosive to the country. So the, so the op, the only opportunity is to find models where everyone comes together, everyone comes together so that you have enough momentum to, to succeed in the marketplace. And be disrupted that way.
Arti: I think so, but I think that people in general are so brainwashed, I think, [00:42:00] into thinking that their insurance card is a card that they can give out for their health. It's like a credit card that they give out for their health care and someone else pays the bill. And we have our employer based company and we also have a direct credit card. Care clinic, and there are some people who understand they're people who have probably had experience with the health care system, but there's perhaps it's cognitive dissonance, but trying to get people to understand that a clear, upfront, transparent price is better than a here's my insurance card. Bill you later. Good luck is is. Actually better and more straightforward is a confusing challenge, because if you're talking about groceries, right, nobody would be like, Okay, yeah, let's go put whatever I want in my basket, and then take it home, eat it. And then they'll send me a bill later. Nobody [00:43:00] would. Nobody would do that, because that sounds like the grocery store would take advantage of you. Right. But that is exactly where we're at with health care. And people are so comfortable with it. Right.
Brian: Right. Well, on the other hand, they may, they may be comfortable. I think that the events of the last week with this shooting has revealed that there are a lot of people who do not think that those people are going to take care of all, care of all of us. Um, when I was running the primary care company, uh, the worksite primary care company, I learned we had a model where are If you got your care from the clinic, you paid nothing to go to the clinic and your labs and your drugs and your images were free to you. And if you, if you needed to get a referral for a normal [00:44:00] population right now, 25 to 35 percent of the enrollees see a specialist during the course of the year. We were, we were at 11 percent with better health outcomes because we allowed the specialists to practice what they had been trained to do. And so we had, we had very low, low specialty referral rates, which dropped the cost dramatically and the patients got the drugs put into their hands. And if they, if they got referred, they, and they went to the referral, referral physician that we recommended, they paid no copay. The incentives just need to be aligned and they need, and they need to be enforced. But you've got to, if you're going to take that approach. You'd better have integrity about it.
Arti: I think this steerage is helpful for cost savings, but the integrity piece sometimes gets lost in that it leads [00:45:00] to, like with Medicare Advantage, like less care, delayed care, denied care, as opposed to truly referring to a high value. Cost saving approach, you know, all this makes me so there's no endocrinologist on the rock I don't know when the last time there was an endocrinologist on it and it makes me wonder realize that
Arti: Yeah, I looked, I have, I have everybody's name, and there's 32 members, um, no endocrinologist, and it makes me wonder, this conversation makes me wonder if it's worth our time to get on that committee, because I don't, probably
Brian: not,
Arti: yeah, I don't know if that sort of environment where we're a preventative specialty, at least. We should be, and inherently, that should mean we're cost saving, but if cost saving is not the goal of [00:46:00] anybody, then That's not going to be an argument that serves us on that, and I wonder, you know, I'm sure you've seen the trends with psychiatry going out of network, and now it's almost a norm. People can accept that if they're going to see a psychiatrist in a reasonable way, um, They're going to pay out of pocket. I wonder if that is the trend that endocrinology should follow.
Brian: That's a conversation for, for another person that I know that I can introduce you to. A guy named David Belinsky. Um, David runs a company called Wire Health that is dedicated to management of high acuity mental health patients. So here we're talking about the 0. 3 percent of the population that consumes 12 to 14 percent of all the money, [00:47:00] and these are, their patients are potential suicides, uh, anorexics. Uh, sharp objects, swallowers, people who are, who are very severe pain and, and the, they have learned how to manage those, those kinds of patients well to make them functional in society and, and, and to make them costs a lot, a lot less. And so the question is, I mean, you're asking a legitimate question is. Which is, what role should our profession play in the overall scheme? And is it a, is it a, is it a vibrant profession? Does it represent current science properly? I would argue that it may be that cardiology as a profession maybe doesn't so well.[00:48:00] We've come a long way to realize that. These are intricate systems that are, that are not organ based. They're, they have all kinds of, of dimensions and, uh, there needs to be broader training to, to do, to do it properly. Endocrinology is so important simply because it's, it's such a big part of, of overall disease. And it also is the keys to the kingdom as, as Dr. Besterman has done a pretty good job showing the keys to the kingdom on understanding how chronic disease works and how aging works and how they're all part of the same mechanisms. One of the great things about, about Dr. Besterman is that he's. Focused on sort of a unified field theory of, of chronic disease management at, at the molecular level. You know, I'm, [00:49:00] I worry that this conversation has been all over the map. So, it's been, maybe, some people have thought of it as a short attention span theater discussion, but, Uh, but I, I think when you're sitting in the center of the cyclone, there are all kinds of different things that you have to think about simultaneously. And especially when you're trying to build something that is meaningful along the way, which is what you're trying to do. And I admire it so.
Arti: Oh, well, thank you. And I admire your work so much, too. Um, you know, I think endocrinology, I thought a lot about the RUC when I was preparing for this, but throughout, it may not be the, it may not be getting power there that seems to be the solution. Endocrinology feels like sometimes the red headed stepchild of specialties and primary care, because [00:50:00] specialty care is not Many people will say drives up the cost of care. Whereas, and the idea that people have is that primary care is cost savings, which I agree with. Um, but endocrinology is a specialty. We train as long as the orthopedic surgeons and cardiologists, but it is also preventative. And if we don't seem to fit in either one of those buckets, because When we consider specialty care that, that's high cost, that's not really us. Um, and when we think about reimbursement too, I think a lot of times people think about when physicians are fighting for better reimbursement, it's kind of seen at least by the public as physicians want to make more money, and I think we need to Walk away from that narrative because ultimately, you know this. I [00:51:00] have certainly sacrificed my my income to provide better care in a different model. But I think reimbursement enables. Care, right? It enables us to provide for our patient and if the reimbursement is low We can't do as much for our patient because we don't have the support staff and the necessary tools to do that So changing that narrative I think is is important and it's important for doctors to see it that way, too So that we can communicate that well with patients, but in your opinion, what do you think we could do to Lift endocrinology up is a specialty. As you know, there's a huge shortage. There's only about 7,000 endocrinologists in the country with about 38 million people living with diabetes. Not to mention the rest of the, the conditions we treat. As well as the fact that endocrinologists are retiring faster than we are minting new [00:52:00] fellows and Interest in the the subspecialty is going down due to the fact that the training is long and the reimbursement is low What do you think we can do to uplift the specialty?
Brian: That's a very good question And it's a tough one. I mean first of all, I think the entire uh methodology for how how physicians are paid It's crazy. And it's, it's been very destructive. A few years ago, I was asked to give the keynote at the North American Spine Surgeons Conference. And, um, that's a pretty confident group. And I got up and I said to them, I took a deep breath when I did this. And I said, you know, it's an open secret that half or more of all the surgeries you guys do are inappropriate or unnecessary. And guys like me can see it in the data, and there's going to be [00:53:00] hell to pay, and you need to stop. Um, but they do it because they make so much money at it. I think that what endocrinologists need to be, need to do is they need to be able to demonstrate the value of what they do and how that plays out, how what they do translates into better lives for people. There needs to be an appreciation of what you're doing and there needs to be a strong effort within endocrinology for everybody to practice. in the way that, um, the very best clinicians in endocrinology do with metrics that demonstrate that, that are, that patients are better or not than, than before. But it needs to be, it needs to be a very [00:54:00] open and transparent celebration of what you do and why you do it and what happens as a result. Because patients have no idea. I mean, take this to the extreme, How many people do you think know what a, what a rheumatologist does?
Arti: Yeah, not until they go see one or they have a autoimmune disease that needs a rheumatologist. I think we have a couple things that give us a disservice. We're a very cerebral specialty. We don't procedurize anything. People can understand surgery. This person is trained to do my knee replacement, but when it's cerebral, people can't really see the amount of. Thought. But like I mentioned, our training is as long as an orthopedic surgeons. So there is a lot going on and and many fields train outside of medicine train for a long time. And we [00:55:00] appreciate that expertise. But in health care, it's different. Our specialty is called endocrinology, which is intrinsically difficult to understand. People are like, what, what is that? Um, I think those two things make it, make it really difficult for people to understand what it is that we do and what we can do better than, you know, somebody who doesn't have our training.
Brian: Right. And I'm pretty sensitive to it. I've got a, you know, I've got two of my daughters are type one. And it's a, I mean, it dominates your life.
Arti: Yeah, it's with them every second of every minute of every day. And I also think that since our reimbursement structure is similar to primary care, but we are tasked with the most complex patients, you can't see the same volume. Um, and so what has happened is. This adversarial relationship with people living with diabetes or other [00:56:00] hormonal diseases who aren't getting the adequate support that they need from their endocrinologist because their visits are so short and far between, it's actually almost impossible to even get into an endocrinology clinic as a new. newly diagnosed, um, person with diabetes, which there's a lot of systematic issues that have led to that, but that's not what the patient sees and experiences. They say, this doctor doesn't care enough about me to spend time with me or get me into their clinic.
Brian: Arti, what you've been working on, what you're working on now for a few years now, and you're in a very dynamic organization and a, in a very dynamic marketplace. What is it that you're, that you are thrilled about and what is it that you, that you fear at this point?
Arti: I'm thrilled about the fact that we can make a difference [00:57:00] in the lives of other human beings. Every single patient review or remark about what we're doing that is positive, and there are many, it's still just like, it still lights up my day. And that's really That's the point. It gives me joy, it gives me purpose, and it gives me the will to keep forging forward even on the hard days. It's the patients that are doing better and living better and are happier. Um, what am I most scared about? Um, I don't know. I think maybe I'm most scared that I one day will lose the fire. I'm nowhere close to that, but, um. It is, it's a very challenging space. It's very hard to get taken seriously. Not only am I in a competitive space, I'm also a [00:58:00] woman, a woman of color, and there's a lot of, there's a lot going against me and I know that, and I see that, but, um, I think that's my biggest fear of losing the desire to continue to, to grow a movement for better care.
Brian: I suspect that's not what you just said is not going to be the problem, but. I mean, it could be, but you seem pretty committed to dealing with this issue and you'll have your ups and downs, but it, it, in your heart, you're devoted. And I think you're right about the difficulty that you'll have in keeping it up. I think there are lots and lots of opportunities, um, for, for what you do. Some of it has to do with becoming involved with the. With the structure that exists in the country with organizations like the National Academy of Medicine [00:59:00] or organizations like that. But the problem is only going to continue to get worse and worse, and it's very frightening. And there just aren't a lot of people, there aren't a lot of people who are doing what you're doing. And when I look at the, when I look at the diabetes management space, everybody, everybody's program, except for a few. on coaching, but I think it's got to be much earlier than that. It's a much bigger reliance on a physician who's going, who's going to prescribe accurately and, and, and he's going to be there with you. All of that.
Arti: I believe I, I agree with you. I, I know exactly why coaching is the place where people are focusing. It's because that is You have the highest margins there. Physicians just don't have the same margins, and endocrinologists are very difficult to find. You [01:00:00] just can't hire somebody. It's, it's really difficult. I think the only reason that I've been able to hire two of the best endocrinologists in the game, as far as clinical acumen and as well as patient satisfaction and, and just compassionate, wonderful care that people want to have is because of the movement, like the movement to do something different. And of course they need to make a living, but it's not financially motivated for me or for them. And we are truly on the same team with shared goals, but otherwise, you know. It takes big hospital systems months to years to hire a new endocrinologist when they need one, and they all need one. Um, so yeah, it is, it is a challenge to do a physician focused diabetes [01:01:00] program with, with endocrinologists kind of leading the patient management.
Brian: It sounds like an opportunity to, one afternoon you should draw a flag and have that executed and then, and then recruit. Endocrinologists from around the country who want to practice like, like you're practicing and get strength that way. And then have more leverage to be able to do the kinds of things that you want to do.
Arti: Yeah, I think that's one of the, one of the motivations of this podcast is to tell other endocrinologists, you know, said over 70 percent of endocrinology fellows are women. So it's a group that I can speak to that there is a different way that we don't have to shirk our moral obligation to our patients to. survive and practice endocrinology, we can do it in a way that serves us [01:02:00] in every dimension, including our ethics, our families, and our intellectual curiosity, while also serving our patients.
Brian: Yeah. As sort of a closing comment, Let's talk about some more of that offline. Yeah. You know, how you might gain leverage and strength in what you're doing and, because I think that's a, I think that's what needs to happen. Life and, and influence are, are about, or life and success in what you're doing have to do with sphere of influence. And you've got the makings of that. So it's really very admirable and a pleasure to see.
Arti: Thank you. And honestly, you know, that checklist that you were talking about with your high performing, uh, companies and individuals. I wrote them down the first time [01:03:00] you ever saw, the first time you ever told them to me, and I have them on a, I screenshotted my, my list, and I refer to it to say, are we meeting these benchmarks? And, um, that spurred me to work with the Validation Institute to get our data validated because I wanted to, It was just such a great list and it was a clear sort of list of things that I could do to ensure that we're delivering a promise to our patients at a level that other people can, can understand and help us, help us help more people. So you have been instrumental in, in our business, whether you knew it or not. Um, but as we close, I wanted to know, do you have any closing? remarks or anything that you didn't get a chance to say that you would like to add?
Brian: I don't think [01:04:00] I hide the fact that I, I don't think very kindly of major healthcare organizations. And I think that we have, we've lost our way in this country in healthcare and a lot of other things where it comes to ethics and, and other core values. And I think that the value movement that I'm part of and that you're part of is an effort to bring that back to a homeostasis that we can, that we can all be comfortable with. There's, there's no good reason, for example, Why the overall health status of, of Americans has dropped for the 14th year in a row when we are the wealthiest country on earth. And, um, it says that we don't [01:05:00] have, we don't have our priorities. Right. We're, we're not looking out for the welfare of our, of our people. And, uh, that makes this a less desirable place to live than we've always imagined it, it should be. Um, and I, and so I'm, I'm very concerned about that. And I, and I hope that your listeners are very concerned about that.
Arti: Same.
Brian: But I think that you're, you're one of the answers.
Arti: Thank you. I agree. Aligning incentives between care providers and patients is truly the start of something beautiful and I hope that there are more people who are vocal about this like you are. I think a lot of people cower under Just the immense problem in front of them, I think, I think it's intimidating, but together we will be able to chisel away at it and make things better for those who want it to be better. [01:06:00]
Brian: It's a delight talking to you, Arti.
Arti: Likewise. And
Brian: thank you. Yeah, thank you so much for taking the time.
Arti: Thank you so much for spending some time with us today. We'll talk soon.
Resources & Links
Connect with Brian:
LinkedIn: Brian Klepper
Connect with Dr. Arti:
Instagram: @drartithangudu
LinkedIn: Arti Thangudu, MD
YouTube: @drartithangudu
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