Healthcare Fixed: No Insurance Needed, Same Doctors, 60% Less - David Goldhill

0:00Welcome to the proven podcast where we don't care what you think only what you can prove. America pays 40% of the world's healthcare bill. We're 3% of the population. Today, David Goldhill, founder and CEO of Sesame, joins the show to break down why that happens, why the system is broken and what he's building to fix it. The show starts now. Hey everybody, welcome back. I'm excited for this one. David, thank you for joining us. Great to meet you. So for the four or five people out there who don't know who you are, did you kind of explain who you are a little bit of your background and go from there. Please don't tell me that's 100% of your audience. That's it. That's I know it isn't. But for the many people who don't know who I am, David Goldhill, I'm the founder and CEO of Sesame, SesameCare.com, which is a marketplace for healthcare services. There you go. So what have you done before you got to Sesame? So people are like, what do we walk into? What are your claims to fame? Well, I don't know how many claims to fame, but I did have a long career as an entertainment executive.

1:01Mostly in television, I ran television at Universal Studios. I ran the Game Show Network. I built a television network in Russia, which is now a very popular place and made a bunch distributed, a bunch of television shows also helped run a movie theater chain. So your classic entertainment executive goes to healthcare store. Yeah, that I've heard it so many times because our healthcare system works so well right now. It's one of the things that you and I are completely aligned on. Is that healthcare is just a show and it's my own show and I should be able to curse, but yeah, it's so I should. Yeah, so in this situation, healthcare is ridiculously broken. And I wanted to talk about that because there's we pay more than anyone else and we subsidize the entire world. You know, I've had this conversation before so recording. Let's get the audience kind of caught up on that. When we talk about that, we're subsidizing the rest of the world. Let's walk through that form. Well, it's, you know, it's it's a little complex because it's not what we first see, right? What we first see is people around the world seem to get healthcare for a lot less money than we do.

2:08And many of those systems, particularly in Western Europe, feel more universal and easier. Existing ours, that's terrible. Underneath it is something much more complicated, which is the United States has the only free enterprise healthcare system on earth where we don't control prices and we don't have hospitals and doctors as either employees of the state are owned by the state. And a lot of people think that's bad, but the interesting thing is that's why almost all of the innovation in healthcare on earth is designed for the market market. Every innovator, no matter where they are, makes the bulk of their money selling to Americans in the American healthcare system, whether it's new drugs, which gets a lot of attention or new devices or new software, even new treatment protocols tend to come from people practicing first in America. Why? Because you're free to do so. You have an incentive to do so, even your local doctors probably competing against somebody. So she's more likely to buy the latest equipment and get a start to that

3:09manufacturer trying to sell something. Is a result of this? And again, not easy, not intuitive. Basically, the quality of healthcare, everywhere else on earth depends on the United States. The example I like to use for my own industry is you can go to a movie theater in Brussels and you can see the latest Marvel superhero film in a fantastic screen and a comfortable chair and great concessions and price the same. And you can say, if you've been to a crappy movie theater in the United States, why the movie industry in Brussels is much better in the movie industry in the United States? And you'd be wrong because all of the capital investment, all of the risk, all of the complexity is American there. And it's even more so in healthcare. So when we have that, you know, the audience is going to say, because we hear this all the time, and for those of you catching up, I spent eight years in hospice watching people die. So we're going to be, I'm very familiar with this world. They're going to say, hey, you know, the same treatment in another country costs fractions of this. Where do we dispel that? How do we face that

4:16and face that argument? Yeah, so it's very difficult. I mean, I sort of compare a little bit to NATO, right, which is, you know, we're defending Europe and NATO. The European country spend almost nothing knowing that I think this is going to fundamentally be before defending us, defending them. So what do we do? We can say we're not going to defend you, but that's not in our interests. We can say defend yourselves, but they're all relatively small. And we've never been able to figure that out of NATO. Healthcare strangely enough is a bit like NATO. But quality of care on Earth depends, I'm merely on the American market. Just to put some numbers on it, the United States is 40% of world healthcare spending. We're 3% of world population. 40% of world healthcare spend no other country matters. You know, systems we talk about as being equivalent to 3, 4% of world healthcare spend. They're almost insignificant. So the US is driving the most important thing in healthcare, which is the quality and level of care, innovation. And innovation, finding new treatments, new

5:20cures is what healthcare is about. We drive that. But we do it by bearing very, very high prices and all of the risk and reward of investment. It's been a tough not to crack. And I'm sorry, let me just stop there. Yeah, George, I think, you know, what we talked about it before, you know, one of the great things about having the off record calls is we go back and forth and we say things that we probably shouldn't say, but it makes it fun. But it's not recorded. One of the things, you know, we talked about is like, yeah, we can reverse this. You know, we can sit there and say, you know, we're not going to be 40% we're not going to spend all that money. Not a problem, we're just going to let all of our people dot. And we're like, well, we're not going to do that because no one else is going to kind of kind of like step up and and take that role. If we stop cutting the funding collectively across the world that it just drops because we're so used to this. I think it's a byproduct of what we did after World War II. Or so listen, I don't care who you are, where you are in the world, we're going to make sure that you can ship anything from one side of the planet to the other side of the planet. And we're going to protect the oceans. We're going to make sure you can do that. That was the idea of us be a part of us. We're going to protect that.

6:22We're going to go against communism. We're going to go to America. We're going to do this. And we change that for the entire world. What we've done that at your point is today, though, or to medicine that we've stepped into the world like, hey, we're going to take the hit here. We're going to pay all of this and we're going to do all this because we want this certain level thing. But we are in a point where the market doesn't fit that anymore because going in and going and getting a pill somewhere else costs a dollar. Here it costs $1200. That system is creating this head bunny. And there's a specific reason about that. I'd love for you to talk about how that why this system is completely normally broken and how you're trying to fix it. Yeah. So on the one hand, it's a great thing that I'm going to benefit some more from medical innovation than anyone else. So therefore, it pays more than anyone else. Not a great thing. We're paying 70, 80 percent of the cost of innovation and getting, you know, 34 or five percent of the benefit, maybe 10 percent of the benefit. That's an imbalance. The question is, can you solve for

7:24one problem, which is Americans are paying way too much for healthcare without undermining the subterge. Great thing, which is where the engine of World Health Care progress. And just to be clear, because some people often confuse this, it's not that everything is invented in America, far from it. It's that everything is invented for America. So researchers all over the world, their business model is we'll sell to the Americans because that's where we'll get 60, 70 percent of our profit from. And if we can then sell to the British and all of us. So the issue becomes exactly as you frame it, which is can we get at this one thing, which is as people were paying too high a price and the impact on healthcare on our finance is on people's affordability, on the choices they have to acknowledge, it has become enormous, as you would expect when something went from four to five percent of GDP to almost 20 percent of GDP and regeneration. Since extraordinary. And so this is a problem we have to solve without destroying the engine of

8:24of innovation. If we just go to a sort of socialist system of British style system, a Canadian system, we'll simply destroy the engine of innovation. You know, profits that innovation and without American profits and innovation and all of that. So we can't do that. What can we do? And so the argument that I think I and others have made is that we can bring market forces into a lot of things in healthcare that bring competition around buying and selling and can drive price down. I mean, you know, there may be an argument that that pill should be $1,200, that first year when it's saving lives kind of hard to make that argument for here out 10 years and there should be competitors. And that's something where we talked about this before. And you know, like the first pill cost $9 million. The second pill costs a penny. The problem is the first one to get it right cost nine because it took all the research and the studies and doing all that. I think where we'll get pushed back is the idea that like, well, yeah, it should cost everyone. They should also burden

9:26a great deal of this. They should pay for some of those costs. And how do we ship that? And I don't think it's just again, I don't think it's just a medical issue. It's across the board to your point with NATO. We have this redynamic. Yeah, I mean, it's you're exactly right. And but interestingly, the point you made is usually this is a tough business model because if I've got a business for the first one cost, you know, $900 million dollars because I did I had to do all the regulatory testing and all of the applications were approval and developing the drug and all the ones that failed. And you know, the second pill is a penny to produce. That's usually a terrible business model. Right. If lots of other industries, that's a horrible business model. In health care, it works. Why does it work? Well, the reason it works is because instead of having people compete for customer business, we have third party payers pay for everything. And what do they do? They walk in and say, what's a fair price? You don't want a fair price. That's not how capitalism works. Well,

10:28I want is a competitive price. And there's almost no corner of health care in which we have good old fashioned competition drive people's prices down to marginal cost. And so it should be a bad business model. Why's it being too good a business model? They're protecting a price. And I think this is where people like, oh, are you a Republican or a Democrat or a liberal conservative or conservative or a capitalist or a socialist? And whenever I get asked that because I get asked at all time, my answer is always, yes. Well, I'm sorry. I'm like, it depends on the topic. It depends on where we are. There's there's different structures, different folks. And we as Americans are capitalist or communist or socialist or liberals or conservatives. We're all of it. It just depends on what we're talking about. And I think there's a time and a place for everything. And I think the medical environment has gotten way out of control. I've taken lots of clients or doctors. We've scaled them. I can't afford this. I just cannot survive anymore. I've got to go to a concierge based environment or forget it. I'm just going to do a roll up and we're going to take all these practices together. I'm going to exit. I'm going to go buy a bunch of poros and I'm going to go

11:30to flood the fleet because it's just a broken model on every level. So I think your approach to it, this idea of bringing more capitalist competition based is viable. But I don't think the audience would fully understand that. So I have the benefit of talking to you. Can you explain what that model is? And then in turn, why we don't think the government could do it on their own anymore? Yeah. And I think you know, you're you're point about being ideologically for Ms. QSL. It's okay if I call you for Ms. QSL. Okay, don't say too long. It works really well in healthcare because what a lot of health care experts talk about is what's the one perfect way to pay for healthcare? Well, healthcare is 20% of JBP. It includes things from drugs that have been in existence for you know, 80, 90 years to miracle personalized cures that are going to be designed just for you. It includes things from the most complex surgeries to a regular checkup that involves sitting with someone for 10 minutes and talking, right? The range of human activities and goods and services in that 20% of JB are gigantic. And the idea that they should

12:35all be paid for the same way as should we use third party insurance when we've got ease absurd on its face. Yes, some of those things you're going to get relatively little benefit from competition. Some of those things should be fully competitive, right? And the same way about the safety and that aspect of it, right? We certainly don't want people starving in America and we have all sorts of ways to make sure that people who don't have food get food. We have food banks, we have food stamps, we have explicit subsidies, but we don't say because of that, Michelin starred restaurants should be paid for the same way. We're okay with a broad variety of ways of paying from barbecues and picnics and school lunches and luxury meals and you know, that's fine. And we understand that complexity everywhere in the economy except for healthcare. We're experts in it and say what's the one best way to pay for everything. The biggest thing I'm saying is everything shouldn't be

13:35done the same way. There are some things insurance does really, really well, which is covering you against unusual risk, something major, something rare, something, but before you say, well, every healthcare condition I have is unusual and rare. I had open heart surgery a couple of years ago and the price of it was something like $120,000, $130,000, which is a gigantic amount of money for everybody, right? Right. Except my family insurance policy costs $35,000 a year. So roughly every four years I pay for an open heart surgery and I guarantee you we're not using one every four years. So here's someone who had a major thing, right, that the insurance system is designed to protect and insurance is still a terrible deal for me. And we don't like to think about those numbers, right? We don't like to do that math. It's uncomfortable to think about it, but it is why healthcare so it's not. I think those are the numbers that are going to get the audience

14:36the most excited. You and I talked about these numbers, how it's radically changed. Normally in the last year, but in the last decade, in the last few decades, we've run it up to it. You deep dive into this pretty intensely. Can you talk about those numbers more about how things are changing and the numbers that a single family is trying to deal with if they're employed versus unemployed, how it's just it's astronomical to be bad. It is astronomical. I mean, I, you know, when I wrote a book on healthcare, a catastrophic care in 2012, I looked at what an employee starting at my company would put into the healthcare system over her lifetime. And I just included everything. Her share of premiums, our share of premiums, our share of premiums just come out of what we would pay her. You know, so it's like that. But Medicare taxes, Medicare, just everything out of pocket, just estimated over a lifetime. And I assumed she didn't get really sick and I assumed she had a couple kids and had a partner and but that the partner didn't work. And it's 2012, the amount she

15:36would put into the healthcare system over her lifetime was 1.2 million into the healthcare system. There are very, very, very, very few treatments that can absorb anywhere near that type of spend. Well, where does it go? Well, a very large part of a shocking large part of it goes to administer the payment system, which costs somewhere to pin 10 and 15% directly of the cost of care, which is astonishing. Several thousand dollars a year and at over 80 years of life, you're paying hundreds of thousands of dollars for the benefit of a third-party payment system, just for its operations. But even beyond that, the distortion that third-party payment creates is enormous because it encourages people to consume things they otherwise would not. We've all been through this. You have an auto accident. The first thing that guy asks you, is this an insurance job or not? Are you paying for them in a pocket? Because that's a completely different price. The biggest thing you have,

16:37and when I say this, people say, but and then they think about it and they realize it's right, nobody in the healthcare system can make more money, can be more profitable by lowering their prices. So that's not true in any other business. And the reason for that isn't because people wouldn't be happy to have lower prices in competition, it's because third-party payment keeps up the level of prices and determines how many customers you're having. And so there's no cost-go of healthcare, right? There's no Walmart of healthcare. There's no none of the competition we see anything else. And for a lot of services, there could be. Not for all of them, but for a lot. And I think this is that goes back to your point. Things are changing. I don't think they're changing fast enough, but I've had because I grew up in Florida and we have tons of mold, I get sinus infections. So to get whatever spray or whatever it is that I would need to offset that, it used to be

17:38extremely expensive. Now, and I'm not plugging Walmart in any way, shape or form, I was like, Walmart, maybe there's like, oh, yes, four bucks. I'm like, I'm sorry, what just happened? So there is movement. There are things that are changing. But I also noticed that when you work because I've worked with a lot of doctors, there is a lot of downtime. There is a lot of, like doing the patients, they're trying to run them through and they're trying to do all this, but there are pockets, depending on the type they do with practicing, not a GP normally. But when they're doing this, there is these pockets at downtime, where they could monetize that and they could go into it and you could do it. It was something that you brought up and I think it's a core part of your business is we have these things where you have an audience that desperately needs fulfillment and you have someone who's a literally just sitting there at his desk, I can fulfill because when I get sinus infections now, I don't go see my doctor. I'm very blessed with the insurance I have. I just do teledoc and I get on them like, hey, I might just pull up my record and I go, yeah, I was excited to factor in how I'm like, have fun, we're going to send it over and that doesn't cost me much. I want to do that. But there are doctors who are extremely elite and I want to talk about how AI is going to change medical

18:40access, the thing that I'm the most excited to talk about right now. But walk me through that into what Sesame does that does really well. Yeah, so I think that's the foundation of Sesame, which is there's a lot more spare capacity in the healthcare system than we often see. And so what Sesame does is we list mostly consultations and appointments with doctors, with some other services, some procedures, labs, diagnostics, etc. at cash prices. And the physicians themselves or the clinics or some cases, hospitals just put services on our marketplace at a cash price with a specific time and the patient buys it. And the interesting thing about Sesame is that those prices are much, much lower than the prices that insurers pay. I mean, one of the theories in healthcare is, oh, these big insurers can drive prices down and Medicare and Medicare drivers. We don't tell providers what to charge, but they have this

19:40basic principle we all know, which is we want to get patients. I got to leave the price. Right. And that's bringing the capitalism in. It's bringing the capitalism in. But it's also just bringing in normalcy, right? Which is, look, we just saw this with with GLP ones with weight loss drugs. The price of weight loss drugs had declined in the last three years because insurers didn't cover them. Right. So if you want, if you were novo and lolly, you wanted to sell them. I had to sell them direct to a consumer. A couple of other companies sold compound versions of their drugs directly in consumers. Guess what happened to prices? And if you listen to the way politicians and experts talked about weight loss drugs three years ago was these guys are going to keep their prices up. If we don't cover it with insurance, people won't be able to afford it. People won't get the benefit of these new drugs. What happened? The insurers didn't cover them and the prices came down. There's an important lesson to that. Right. It's a lesson we refuse to learn, which is that healthcare may not be so different from everything else because it's healthcare.

20:40Healthcare may be so different from everything else because we've structured it in such a crazy and bizarre way. I think I think we are having to be forced to listen to it, though at this point. Because we're in a situation where it's so much of GDP and it's so unaffordable that things are starting to reverse because people, there's many people I know who are just like I'm just talking about insurance. I'll just deal with it and we'll figure it out and that's not a healthy model either. It's because we know how much that costs above and beyond if you're not getting the overall treatment. And we also don't reward it properly. We talk about AI and for those of you playing at home AI does not mean artificial intelligence. So AI does mean always and correct. There's this fear that AI is going to wipe out everything that it is a that AI is too humanity as the media was the dinosaurs and that one of the things that's going to go after specifically is healthcare. And it's one of those things that you and I even on our pre-call, I had an opinion, you're like, no, see the hell it's going to go with that. And we had this little disagreement because I think AI is going to be this little thing that you walk in, you put your finger down,

21:41it takes your blood test and then, no, like congratulations, you have Ebola and your head's going to explode in 20 minutes. I'm like, okay, and then Amazon drops a packaging and I eat it and I love that. So that's that's the me of where it's going to go. And you know, there's this idea of medicine is now no longer geo-locked. There's one thing that you and I were talking about. I'd love to bring the audience into that conversation. So walk me through how what you think AI is going to do and then what we're talking about with geo-locked. Well, I know the AI is going to destroy and eliminate humanity, but obviously if it did that you'd solve the problem of healthcare costs. Refixing that? Yeah, done. That's done. Beyond that, I think AI is a great example of how healthcare is structured in such a strange way, right? There's a vision of AI that says we can meaningfully improve diagnostic results. We can meaningfully improve how doctors practice, how patients records are kept and how automatic our ability to treat them

22:45to the variety of conditions and to find things are you can paint in AI driven parallelize, which costs decline, data improves and ultimately outcomes improve, new drugs, upgraded new treatments are created and they're more personalized. That's very possible. We can all see that. We can all see that vision and for you know, doctors who look at AI at something other than as a lot of I'd say this can really improve the way I practice medicine, how patients. Today, the biggest impact on AI and healthcare has been in revenue management. Very in full stock because you can't get away so the revenue management is the negotiation between providers and insurers over to what the provider should get paid. That's where it's been used, right? And what we see at CMS is AI providers saying, hey, we need a layer of skin added because we're bringing AI to this. In other words, the exact opposite of what's happening in the last two years. Right. And it's a reminder that, you know, economic incentives or what rule how new technologies get incorporated. You need to make a case.

23:52Here's how AI is going to create a new type of healthcare company that could win customer dollars. And then remember what the customers are. They're insurers and governments. They're not you and me. And that's important. And that's really important. And I think it's a differentiation between what Sesame does and what everybody else does, where the Sesame customer is the consumer, where most health insurance and most health providers, the customer is the provider. It's like, oh, your blue crossbushield we now have to deal with you. Your your your your at know or whatever the heck it is, we viewed as that and that's a huge differentiation because when we talk about innovation and bringing the audience along with this story, Walmart did not decide to bring organic foods into their stores until they saw that there was a profit to do so when their consumers were doing with their wallets and I want to buy organic. You don't have organic. Then Walmart decided, oh, we're going to be organic and we're going to protect the environment. They're not protecting the environment. They're not they're driven by profit. Period, full stop. And I think people don't understand that because you have to identify that the consumer is.

24:54It's such a great metaphor because so many people I go to lots of healthcare conferences. There's certainly a lot more fun in the old entertainment conferences. I used to go to the parties are better or celebrities are better. But I've given up so much to do this. I want you to know that. I mean, I mean, I'm in LA right now. So what are you talking about? I wish this out. I'm like, what are you mad? I may well have been mad to do this. But yes. But your point is exactly right, which is that people at healthcare conferences say, okay, we're having cost-saving technologies exist. So prices will come down and you're seeing that going, yeah, that's all that happens. Right. It's the business that causes us to do that. Sesame has three types of customers. We have people who don't have insurance at all. No coverage. We have people who have very high deductibles or high deductibles and are managing the deductible part of their spend, which for most families now is pretty much all of their annual

25:56spend. Yes. And then we have a third type of customer, which is somebody and this sounds kind of crazy, who's basically indifferent to the price of routine services and wants it easy and fast. And it says, I don't care about not using my insurance. This is what I pay for the haircut. And I can speak to that because that's me. But I have very good insurance with me across your shield. I've had it for a very long time. It costs me an astronomical amount of money. I just, it's more than a damn mortgage payment sometimes. I'm just like, better, I go ahead and it is what it is. But when I want to get something done, I want to get it now. Now, in a way, I want to click a button. And so one of the remarkable things for us, I'd love to take more credit for it, but I think it's more about normalcy than anything else. Sesame has 95% patient satisfaction rates. We have NPSs or M8s. Trust pilots in the high floors. Why? It's our providers. We're not the ones providing care. We're a marketplace for providers to list. But if you're a provider listing on sesame,

27:00you know that you've got to satisfy a patient just to ease abuse, convenience, showing up on time, prices, doing what you said you were going to do, and follow up, and the data kept. You're just driven by normal things. And compared to the rest of the healthcare experience that most of us have, and it's an extraordinary difference. And it's extraordinary, just by being normal. And I think this normalcy is important to exercise this. So there's a place in Miami. It's called Joe's. And it is the most profitable restaurant in the world. It's called Joe's Scrubs. And my family goes there. We've gone there for years. My family's from South Florida. In order to get a table, you have to walk into concierge and you hand her a 100 bucks. That's before you get to sit down. That's just the game. It's how the games played. And then the prices, the crabs are, as you're not more than they should be and all that, but you're doing it. But that's the game. And as long as you know that those are the rules in the game, you don't trip to a football game wearing ice skates. You don't go to Joe's without having to ice your way in and we're growling

28:03the healthcare system. We haven't had this ability to pay to play. We haven't had the ability to cut out our insurance companies without just destroying us. And it's one of the things and it's probably the main reason I'm going to bring you on and the fact that we hate each other. We want to come in and we wanted to talk about what that looks like because if I want to have a certain level of treatment, whatever it is, I want to be able to go to a website and click like, and then it's there. And it's ironically not costing me as much as if I went through my health provider, which is just mind blowing for most people. So the real reason you have to be honest, because the year I lived in Miami, I lived one block from Joe's. And I can actually extend your analogy because it's really good. Joe's realized at some point 10, 15, 20 years ago that there was a limit to their business model. Very high price, sit down. There was only so many diners they could accept. So what do they do? They built Joe's takeaway next door. Yep, that takeaway. Yep. I have not been to Joe's the restaurant in 15 years. Like most people who are there regularly and not looking for a big Naya, I go to Joe's

29:05takeaway. What happens to Joe's takeaway? I can get the really expensive stone crabs at a really expensive price, but they're not limited by how many people they could serve. Correct. Doesn't have to be, you know, tablecloth service and all the rest. And you look at that and you say, well, could we have that in healthcare? And then you remember, yes, healthcare tens of thousands of skews. What we've been lacking in healthcare is the competitive urge to serve different types of customers because there's been three customers, insurers, Medicare and state Medicaid agencies. And those three customers actually don't demand the level of innovation that 330 million customers demand. But interestingly, those three customers also don't really well match what human beings need, the diversity of what works for us. I've made the argument that healthcare is too complex to be served by government. And the traditional expert argument is it's too complex to be a normal market. Now, I do think government's got a big role to play in healthcare,

30:06but I actually think markets will drive innovation around service. Let me use another example you're just used. And Sesame's taken enormous advantage of this. Telemedicine and remote medicine generally are going to be extraordinarily disrupted to healthcare if we allow because the number of things a doctor needs to physically be in a room or even lay hands on a patient to diagnose a hormon or a shrinking. And we're even getting to the point where we can see robotics, there's robotic surgeries being done in fast different continents. Now, when you think about what remote really means in terms of bringing the cost of care down, the resource cost of care down, it's gigantic. The need to see a doctor, by the way, doesn't just create difficulty for having to maintain offices and having a, but the patients got to lose half a day at work and take care of child care or parent care or it's enormous amounts of cost being taken out of the system.

31:10What I've argued is we need a healthcare economy that incents those costs to be taken out and to have it reflected in price. When you have cost plus payers, whether it's insurers who get 15% of the amount spent or Medicare that has no actual budget and can spend whatever it wants, you're not going to drive that type of innovation. So places like Sesame does. So when Sesame, you know, if you don't need to be in person, the doctor's happy to see you by video, you're happier to be seen by video costs have been taken out of the system and it's reflected in the price. It's very much like this podcast. You don't know if I'm wearing pants or not because I didn't have to go to the studio. No, I think this is where we talked about before we got in the toilet. We were allowed to wear pants to this. You didn't tell me. See? For everyone who's not watching this, we're both making. This is where it talks about geolocks. And I mean, this is nice this way possible. You know, you're talking about your travels. I love Switzerland more than I can possibly tell you. There are great doctors in Switzerland. They're really hard. There are great doctors. I'm

32:14sure all over the world. But predominantly, the best doctors out there are here. And now those doctors can literally turn on a webcam and service and be in support to anybody, anywhere, ever. And that changes how we work at healthcare completely. Because in the past, it was well, I know you've got a great doctor in New York, but I'm down here in South Florida. I take it to your doctor. So I'm going to have to deal with this smart that that lives down here. That's going the way we're getting ourselves in an environment where that's no longer a problem, where I can simply connect to you and we can do it remotely. And now I don't have to be under your plan or with your provider or anything else, that's going to change the market. It's going to make things easier to do because God knows we know the government can't do this. Yeah, I mean, I think so I share that radical vision. I mean, I think you're right that changes are going to be far beyond what people think. All of these national health systems are based on helping people pay for care. But the way they work is that they've been able to

33:20geo-fence who could provide care. And I think that's going to change. I think no matter where you are in the world, you don't want to see the best oncologist in your neighborhood. You want to see the best oncologist you can possibly see for your condition. And we'll have to figure out ways for those people instead of having a patient panel of a few hundred or a few thousand to have tens and hundreds of thousands in different pyramid structures under them and probably involving AI and technology. But the most important thing I think about that is that these are business models where you've got declining marginal cost of care. And the question we should be asking, because I think we've had declining marginal cost of care for 20 years, is how do we make sure that it's the marginal cost of care to clients? It's reflected in the price we pay. My belief is if we're going to rely on governments to pay the price of one month, because they will simply allocate a belief. But I don't think that's a belief. Data, that's not a belief. We've seen it. We've already seen for 20 plus years, for decades now

34:23that that hasn't been the case, that it's only increased and it's getting worse and worse and worse. And it's not that it's just getting worse because we're like, oh, it's going up there for the doctors are making all this money. Doctors are broke. And I mean, this is nice as much possible. I've been working with them for two decades. Doctors don't make what they used to make. They're, they're nickel to dime and their insurance is astronomical. So there are most of the doctors I know who have been doing it for a long time come to me and they're like, hey, how do you exit me out? Because I'm done. I can't do this anymore. I wouldn't make more money if I went and bought, you know, three apartment complexes and I'd make more rev. So it's not just an opinion. We know it's not working anymore. So everyone. So if you're in the audience, you are using the mirroring the cost of healthcare invariably in pieces. And the more, the better we get a treatment, the better we get a science, the more we bring in advanced technologies, the more personalized we get, it's going to get more and more and more expensive and much of that money. And then think about what you just said, Charles, which is if you look at doctors' incomes and it's really for the last generation, they've been flat. In some cases, down with inflation. If you look at what's happened

35:27with hospitals, the average number of days a patient spends in the hospital have been defining meaningfully, almost no matter what they're diagnosed with. If you look at the commanding heights of care, they've moved from things that were surgical and labor intensive, almost entirely to pharmaceuticals, which have a very low, in some cases, zero marginal cost of production. You're, you know, the first pill is $900 million a second pro cost of the penny is true. So all of those things have happened in the last 20 years and yet the price of care keeps going up. And it shouldn't. I mean, what you and I are saying is that wasn't necessary. That's not about healthcare. That's about how healthcare is paid for because the reality is in any other industry where we see those things happening, prices decline. And they didn't perform in healthcare. I would argue because the payment system prevented it from. And what we're doing in Sesame is saying, okay, for this corner of healthcare, cash paying customers, let's look what normal looks like and what

36:30happens. Price is decline. And service is fantastic and quality is regarded as very good. And, you know, patients are helped because many, most of the people on Sesame are very price-sensitive and are making tough decisions about affordability and what they're going to be able to pay for their family. And the idea that healthcare treatment should invariably go up and up and up and up and up. Is a disastrous one. And people shouldn't have to make that choice. Do I eat or a drug at my kid his meds? That we shouldn't live in a world that that even exists. And what we're trying to do is we're trying to pivot that. I remember when I was working at hospice, the average stay, the break even point was I think six and a half days for a patient to come in when they were doing inpatient care. It was six and a half days. Like, you get them there, we get them to two weeks, a model where everyone's making money, you know, the person of the better quality, the quantity of life, but better quality of life. Well, then VTAS came in. I was working for not-for-profit, and VTAS came in and the doctors started realizing, hey, you know, we could squeeze

37:32a little bit more out of this because again, they're just trying to make, they're not and survive. And the patients went from being there for two weeks to being there for 47 hours. That was the average intake that we would have when we would get a patient. The person would be done to 47 hours. And we left, it was less than 16 hours because people were holding onto it to that point. So, they were transferring and taking every dollar out. That's a broken system. That's an absolutely broken system and there's no humanity to it. And while that has absolutely no humanity to it, and it just gives you the chills to think about, it's interesting that hospice when Medicare first started covering it had the opposite problem. They were paying per day and people were taking hospice patients who weren't really dying and Medicare had to extend a maximum number of days hospice. And some of the hospice companies were keeping patients for the maximum number of days and then discharging them because they were still alive. And neither of it is a good human response. And this is something, again, for people at home who think there's a fundamental difference between

38:32capitalism and serving people well. And that's why it's scary to think of more capitalism or more markets. There's probably a better way to put it in healthcare. These results are not great results. Unfortunately, when your governments run these things, they have to have relatively simple one-size-fits-all rules. And here's the thing about healthcare. When we invented these systems in the mid-20th century, one-size-fits-all, probably okay. There wasn't a lot of healthcare could do. One-size-fits-good, right? Now, it's catastrophic for a lot of families because it means that patients' specific needs are not being addressed. They're being driven by a rule. That's not good. And interestingly, as we get better at what used to be intelligence is now artificial intelligence, we have the ability to serve people in a much more personalized way. We usually give the economic incentives to do so. And I would love to sit there and completely bash. It's the government and how poor the government's done it. And as these healthcare providers and the insurance providers and the

39:34Calbat they are in Yadiada, I will give an example that I will take no credit from for. I was at an event and this individual, and I'm going to clear all the names and the nouns off of this. But basically, you said, okay, the average number of people that were on welfare in this specific environment, that kids with five kids, there was the average that they had, the people who were on the system, they had five kids. And then they saw this radical change in less than 24 months that it rocked up to six. And they're like, what the hell happened? How did we go from the average of five kids to six kids? And what happened was the plan said, oh, we'll cover six kids. I'm like, oh, well, that's the case. A model. So they went there and another kid because it dropped out another 40 to 50, 60 K in a year or whatever the numbers are. And I think that speaks to humanity as a whole. It's not always the system. It isn't always government. Sometimes we as humans kind of suck. And we kind of abuse the system as well. So being able to face that as well, because it's not a single pill solution. It isn't a binary solution. It's not black or white. It's like, hey, we've got to

40:36get some grade here. Yeah. And I think that's. I mean, I think that tone is so important because I am personally, I'm someone who doesn't believe in villains, which is why I've made terrible films and television. But I don't. No, I just, that's not what, you know, the government's not evil. Right. People who work in the government are trying to do wealth. And people who work in insurance companies overwhelmingly are trying to do well. It's the problem is incentives always win. And we made a mistake in thinking that mid-20th century health care is what health care will always be like. Right. When there were only a handful of things, health care could do well. Most of the stuff that cost money was sort of urgent and pretty rare. And so we said, you know what, we'll fund everything. We'll fund it like insurance. Does that powers the bulk of anything anyway? Well, guess what? We're coming up in a world where the bulk of health care spend would have been seen in previous generations as preventive that's managing chronic conditions and

41:43networks you have that suggest you're going to have health issues down the road. My heart surgery was preventive in a sense. I had a valve that was going to fail. Didn't fail. It was going to fail. Some period of time, right? That's what the bulk of it is now. It's far more personalized. We are far more, we each have far more information than we ever did about our health, far greater ability to deal with it. And they top down insurance-based system no longer matches health care. Need correct. And so you've got all of these people trying the best they can. And I do believe not. I'm stupid. This system in something that's eight years old and out of date. And that's the problem. It's not the evil this guy in the evil act. I know it's fun and he's gonna talk about that. But everyone's trying to do the best. You just cannot get a square peg to fit in around whole. And that's our health care and payment systems today. It's out dead in this broken. And I want to speak to what you said about people trying to do the best. I've been in DC a lot. A lot. It doesn't matter what side has been in office. The lonely intern that the low level is running around

42:50with duct tape, holding this thing together. You would be shot for you to see how the sausage is made. They're like, wait, if it wasn't for Susie, who's literally an intern, that wouldn't have happened. What? Because it's just that's just how the systems build. It's held together with duct tape. And that's has been humanity since the dawn of time, which people are trying to do their best. You might ideologically disagree with one thing about them. But trust me, at the end of the day, they're trying to do their best. And it is a big shift to turn. And I think until we put in different factors into the market until we bring in different providers or different solutions, it's never going to change. And what we have right now is all of us are sitting in a bus driving a thousand miles an hour straight into a wall. And we've got to sit there and say, hey, maybe we should turn to the left a little bit. But I think bringing in those different, because it's not wrong. We're going to die. This isn't going to work. We've proven this hasn't worked for over generation. We need to pivot. And it's and it's once we get away from, oh, it's this political party or that political party or to this evil empire or this one. Yeah, there's there is. That's

43:52this humanity. But until we sit down collectively and say, we need to have other options, then those options much like the Walmart example I gave, it just won't do it. So what are the biggest changes you've seen for your patients or for the market now that could you be doing this for a while now? What are the biggest changes you've seen? Well, I think there's on the on the demand side, patients are getting much more sophisticated about managing their own money, right? And deductibles had a lot to do with that. There's the growth of deductibles. But recognizing that I wind up paying for a lot more of this than I expected to, I need to think a bit more as a as a customer. I think there's one thing financially. I think the second thing is that people are willing to pay for convenience because convenience is, well, but I mean, but a lot of people have a variety of economic circumstances say this thing is so opaque that even if someone's paying for it, I'm not sure I got one needed. And so the simple, and this has helped us me enormously,

44:58the simple English language communication of a bill of your data is something that people are willing to pay for. And then I think the third thing, of course, is people are becoming far more proactive about their health. Healthcare system in the mid-20th century was entirely reactive because that's all we can do. The healthcare century of the second half of the 21st century is going to be entirely proactive, which is another reason this architecture won't work. On the provider side, one change is exactly what you mentioned, which is more and more doctors are no longer independently practicing, that being part of an institution is essential just for their sanity and often for their economics. I think another thing that's happening, though, is the big hospital change, which if gobbles up a lot of these practices and are trying to do what I've graded care in all the rest, are not going to work. You know, I don't want to be, I do want to be a nerd. Let me be a

45:58nerd. Outside of reimbursement rights, economies don't really, hospitals don't really have economies of scale or scope. They're kind of a senseless institution. So they charge a ton of money, they get way too big a share of the healthcare pie, a share that hasn't gone down in 60 years in the hospitals by much less than we're all. They're all about their political power and their ability to drive their investments, but they can't be well run because they don't have economies of scale or economies of scope. And so over time, they're unlikely to win and seeing how that plays out is really interesting. The general hospital I'm referring to, especially hospitals with some work different actually might be winners, but general hospitals increasingly just have a bad business model. And then the last thing I'd point out, particularly at Rodnic, when people hate their insurance company, the big insurance companies now are basically rewards of the government. They're they're acting on us go up and down based on Medicare policy and Medicaid policy because huge amount of their revenues come from running those programs for the government. And the government

47:03is in fact private insurance companies because Medicare and Medicaid are now run almost exclusively. But Medicare is only 60%, but Medicaid now entirely through private insurance companies. So this thing all of us believe about how the healthcare system works is changing right in front of our eyes. And most people are not just. I think one of the things we missed out on is that the consumer is now becoming significantly more sophisticated. You want to take something like true diagnostics or anything I tell you, we get your blood work. I know what's in my blood. I do it routinely every 30 days. We're doing blood work or checking things because I'm a hypercontra. So we just keep an eye on this and like, hey, what is this doing? What is that doing? And you know, for those of you who aren't paying that much money to when it comes to all these things, just be racist when it comes to paying anything in your mouth. If it's white, don't put in your mouth. Sugar's bad for you. Don't put in your mouth. Whiteflower bad for you. Don't put in your mouth. It doesn't work. I think that's the basic. You had this more sophisticated environment where consumers are coming in. It just a matter of how long can the specialist doctors hold on versus these juggernauts because when I go

48:04see a specialized doctor for like, I have a torn labor. I'm not going to a hospital. I'll have that conversation. I'm going to go to the person who helps majorly pictures and like, hey, what do we do? And we have that. We also, you know, stem cells is a thing and I can't tell you how much I love stems. They're just absolutely amazing. My insurance won't touch them. But stem cells completely change my body. But you know, when, sorry, so that's just because I think that's that's really right, which is we're seeing that, which is the boundaries of what's healthcare, what's personal responsibility are changing very, very, very actively. And a lot of the more important things in healthcare are things like you mentioned where the patient's going to do it on their own with or without medical advice. In fact, because there's a ton of medical advice that can get from being online. But we just remember AI does mean always incorrect because, you know, my AI is completely convinced that I need to have my uterus fixed and I'm very confused by that. So I think there is this idea

49:06of time. It's a different time. You know what? Whatever you want to identify us. I think, you know, as we come into this and we have a more sophisticated, because that's happening, I would love to see the market have a more responsible consumer as well to take that ownership, that self-ownership. But that'll, that's never happened in humanity. So I'll hold my breath on that one. Well, the, I want to actually comment on that because I think that's a really interesting thing. So one of these here all the time in healthcare is you can't have consumer direct, directed economies because consumers don't know. All right. They're not sophisticated enough. And I don't think they're responsible. No, not that they're not just kidding. But here's the thing. Here's the thing. Consumer-driven economies aren't driven by consumers. They're driven by sellers chasing consumers. Correct. I don't walk into Walmart and or Costco and get a tube of toothpaste. I've got to make sure this is the cheapest. Let me look at the ingredients and compare it to its costs. Right. They just say, I'm pricing at the lowest possible. You know, I will. And that's why you're buying it. And what we forget is that consumers have to do a ton of work in our car and healthcare

50:11economy. Third party payment doesn't take the work out of your hands. If anything, it makes it even harder. Consumer-driven economies, I mean, if I look at Sesame, I have to look for the price on Sesame because every provider on Sesame knows I can't get a penny of business without posting my fixed price. Very full stop. There's no requirement. There's no law. But we can sell anything without a price, right? And we think that, oh, that requires consumers to do a ton of work. It's less work. And it's also it's right there in front of you. But I do think there is a sense of responsibility. For example, if you're going to sit there and you're going to compete for the goyms, you're going to complain about, you know, your health being so bad and you being obese or whatever it is, maybe just maybe don't stop at the McDonald's. Just saying, maybe just maybe don't eat food that you know is just not healthy for you. Make better choices and don't just blame healthcare. So I think that level of responsibility hasn't stepped into it yet. Just get off the couch. Go for a walk everyone's in a while. I don't think that's stepped in yet because there's so many people who,

51:16as I travel the world, and I know our food system is completely broken here in the United States. And you know, you've got some travel coming up. I can eat gluten outside the United States. No reaction whatsoever. Here in the United States, it's not good. So we know that things are changing. We're becoming more aware and this awareness is great, but awareness without action creates problem. And I wanted to kind of circle that back into what you're doing because you're taking action and you're laboring and you're raising the level of awareness against some pretty intense drug or not as a founder, as someone who is a CEO that's running into this. This is working. You're proving this is working. What are some of the things that you've run into? These walls of okay, you're going to run, they're going to have some pushback that the market's giving you. Yeah, I mean, I don't think the market's given us pushbacks, but I think some of the conventional wisdom and healthcare gives you pushback, right? Which is, I'll give you an example, which is, well, doctors aren't going to price less than insurance. Of course, because insurance imposes an enormous amount of cost on a medical practice. Yes. And we take that

52:18cost away. The first one I heard was doctors are never going to be willing to post an actual price because they may be on the services they need to do. And I was like, get what? Tons of other professionals have figured this out. Doctors will figure it out too. Then there were things like, well, good doctors are not going to have this discount price. But the interesting thing is more and more of the best doctors in the country say, how do I get out of the third-party payment system? Because I didn't go to medical school to spend 20% of my time as an insurance clerk. And if you take insurance in your practice, your physicians, your nurses are spending meaningful amounts of time managing insurance. Not a great use of that education. And so what Sesame's benefited from is some doctors aren't trying to diminish the amount of third-party pay or just go cash pay. And for some nations, they're willing to offer discounts. For other patients, they have high-priced, fancy air streamers, structures. And others are in between the point being like we see in most

53:22markets, you price for different types of customers in different service. But you have no trouble saying, I'm happy to bring in a good customer who pays. One of the things Sesame's solved day one, is we have our customers pay up from reducing the cost of collections for doctors is a gigantic administration for them and causes them to give the best price. And Sesame customers are desirable customer. They're already paid before you start your appointment. And I say that again, reminding you, we've got 95% satisfaction rates. So a lot of the conventional wisdom when you've got a little marketplace out there, it's pretty strong pretty quickly. One of the things that proves correctly all the time is you were rewarded for how much pain you eliminated the market. Period full stop. That's what you're saying. You're serving for the elimination of pain. So if I'm a doctor and it's a Friday night and I own your patients, I flick on, like yours, I flick on Sesame and I'm like, hey, let's, here, I'm going to do it for

54:22X, Y, D box. You're good to go. Because at the end of the day, they don't have to deal with the insurance and the collections and all of that. That's just, it's a different mindset. And I think the more that people see this, that this could be a way to help fix the system. Is it the way? No, I don't think there is a magic pill. I don't think there is that $900 million pill that's going to save us all. I think there's going to be lots of these very specific actions where we take that ownership back from a very broken system. And what's great about it, and I think Churchill said it really well. He goes, Americans always do the best thing after doing everything else. And I think that's the process we're in right now. We've got to start trying these other things. Right. Because we'll get there because I don't think Americans are willing to have crappy insurance, not a crappy healthcare. I don't think that they're willing to do that. So I don't see the costs, I see the costs coming down, but I don't think see the demand of standard coming down. Like I'm not going to go to doctor and have them instead of giving me a cast is going to write me a duct tape. I'm like, no, no princess. That's not happening. I want the cast. So I think we're still have that demand. We just have to get the spending under control if not we're going to lose

55:25it all because it will sink to ship. I think that's definitely right. And I think you know, I would take what you said once that further, which is not only is there not a magic pill to solve the problem, they shouldn't be. Right. Healthcare is a massive industry that all of us are consumers of a different stages of our life, different elements of health, different needs, different properties. Those industries are supposed to be complex. If the service is going to match the broad range of consumer need, the attempt to do one size fits all doesn't just make it expensive and distorted and all the things that economists would hate. It makes it less human. It makes it less tied to the individual demand. The reality is healthcare looks nothing like it did in the mid 20th century. It's already far more personalized and it's going to be even more personal. It's going to be even more targeted, recognizing the enormous differences in the way people live in their preferences as to how they live in the relationship between what they choose to do. I mean, there are going to be people who eat at McDonald's. They deserve healthcare. There

56:29are going to be people who pay a lot of attention. I help they deserve healthcare. Probably different structures, right? Probably different relationships to the system. We got to be able to serve all of those people. There is no one dumb way to do so. The only way we've ever figured out how to do so in complicated businesses is by having markets and letting people get paid for finding a consumer, a patient, they treat well. And I think you did it. I think that's what we're doing here. I think having the ability to change the ball game that easily and that quickly, this is just going to speed down. Because people want to be able to control this. If someone's going around, David, and they want to track you down, they want to ask more questions because I have access to you, so you and I get to have great conversations. But if people want access to you, or they want to learn more about Sesame, how do they do this? What's the best way to get hold of you? Well, I mean, the best way to get hold of me is just David.goldtillattsessomicarid.com, or you can just drop by my house. And yeah,

57:29that's how most people do it. 1600 Pennsylvania. Obviously, the best way to use Sesame is to use Sesame. You don't need to be a member of Sesame. You don't need to be a subscriber to Sesame. We have both, depending on what your needs are. Next time something comes up and you think, you know what? I'd love to talk to a doctor in the next five minutes and find out what this is. I'm using some Trius. I think you'll be surprised how easy it is, how great the doctors are, and how good the value is. We have a lot of patients who come to us through Costco with whom we're partners, and it's a terrific relationship. And I know a lot of people think that maybe we should let Costco restructure the healthcare system. I would vote for that, but we'd be a part of it, which is great. Because you can stop moving things around when I'm shopping there, because it was here, and then they move it somewhere as I run around the store. I get the psychology, but stop moving my stuff. Costco, sorry, moving on. Next time I meet you, if I will pass, would you give me the particular question? I will. Yeah, they're never going to do it. The virus psychology is brilliant.

58:31You move it. I got to run around the store and find another stuff. I know why they do it. It just pisses me off that they do it. I would do the same thing. But I think your model of it makes so much sense, because it isn't trust me. Give us a shot. We already have all these proof. We already have these. This is already working. You can already see the reviews here. Give it a shot. That's just a different model. I think people will be surprised, not just the price, but just how great services and how motivated the providers are. I'm on the doctors and nurses and clinics are to be great at what they do for our patients. Thank you for taking the time out and trying to watch this. This massive issue that's going on in our country and the whole in the entire world. I really appreciate it. Great to see you, Charles. Thank you. That's David Goldhill, founder of Sesame. If you want to talk to a doctor without the insurance mess, check out Sesame Care. Thanks for listening and we'll see you next time.