 Welcome to Building Tomorrow, a show exploring the ways that tech innovation and entrepreneurship are creating a freer, wealthier, and more peaceful world. As always, I'm your host, Paul Matzko, and with me in the studio today is Matthew Feeney, Kato's director for emerging technology. Joining us remotely is Dr. Ryan Newhoffel, who's medical practice in Lawrence, Kansas, which will go J-Ox here, is part of a growing movement in healthcare called Direct Primary Care. Welcome, Ryan, and why don't you start us off by telling us what Direct Primary Care is and how it differs from the experience most folks have when they visit the doctor's office. Yeah, well thanks for having me, Paul, and Rock Chalk. So Direct Primary Care is simply put a relationship between a patient and a primary care doctor or provider. And I think it's different in a lot of ways. The first and most important way is that it removes all of the normal middlemen and third parties that are involved in traditional healthcare in America. So whenever a patient is joined by practice, it's much like joining a gym or subscribing to Netflix, and we are serving our patients directly. And by doing that, it allows us to create their needs in a much more, I think, efficient and creative way utilizing technology and just a better experience for their healthcare needs. Yeah, so like the Netflix comparison, I assume that means you have a large catalog of services that very few people actually want to watch, but have to because there's nothing else on it. We have the best programming here. We have the best programming. That's good. So if I, I've never had a Direct Primary Care physician, and to my detriment, it sounds like, after reading up on what you do. So I'm used to going to the doctor's office. I want to be checked out because I don't know. I have a, I have a rash that's been persisting on the embarrassing part of my anatomy, and I want the doctor to take a look at it. I go in, I wait quite a while. The doctor pops in for about five, 10 minutes says, yeah, that's a problem. Here's some random steroid cream. Come back if it doesn't clear up. On your way out, you go, you pay like a $20 copay, and then maybe a few months later, you get, who knows, maybe that $20 copay covers part of it, but you get a bill for some amount of money and insurance may or may not cover the entirety of that bill. Like, so how's that experience different? Yeah, I think you described it perfectly. I mean, there's so much wrong with the American healthcare system, you know, both from an economic and, and personal standpoint. And I think most people feel that, and that includes doctors, you know, I think a lot of, a lot of patients are frustrated, but physicians, particularly in primary care, are just as frustrated and know that things could be a lot more transparent and efficient if we built a new way of interacting with our patients. So that situation that you just described is on top of the exorbitant amount of money we spend to access that system. So whenever I ask people how much they pay to go to the doctor and they say a copay, it's like, well, the average American is spending $10,000 per person per year to access the $20 copay. And so it's even more insane than just the terrible experience, it's how much we pay for that terrible experience. And if that were, if that were any other industry, I think we would be marching in the streets and have pitchforks and say, you know, this just is not acceptable. But in healthcare, I think we've just been, you know, beaten down to the degree that that we kind of accept it and live with it and direct primary care movement and practices are trying to change that, but it's not easy because people's mindset is that, well, healthcare is healthcare, it's important. And so it's okay if it's inefficient, it's okay if it's not transparent. There's all this funny stuff that happens that no one understands, but that's okay because it's healthcare. And I think we have to kind of get beyond that mentality and restore kind of transparency and innovation back to healthcare. And I think the DPC model is doing that for our patients. So in the situation you described, I would, first of all, start with just discussing the situation with my patient remotely. I would say at least 50%, if not more of all medical care could be delivered remotely, you know, through phone call, through a text message, some type of online service. And we've seen glimpses of that in what we call telemedicine. But telemedicine has kind of become this industry that's apart from, you know, a normal relationship with your doctor. And so I think what we do is we just communicate with our patients like we would our friends and family. So that's where I always start things. So if I can manage something with a quick phone call or text message and get to the bottom of it, then that's great. It's good for me. It's good for the patient. The notion of having to bring someone in every single time they have a simple question or a simple rash is kind of ridiculous in 2018. Are there particular technologies on the horizon or emerging at the moment that are particularly exciting in this sector? So text messages and Skype have been around for a while. But this does seem like an area where you could certainly take advantage of a lot of emerging tech. Is there anything in particular that you are keeping your eye on? Well, the funny part is that in healthcare, I mean, we're literally 20 or 30 years behind most other industries. So the healthcare system, the normal healthcare system still largely operates on fax machines. And so it's funny whenever I say I text message my patients, people ooh and all and think that's innovative. But it's kind of funny to me because I'm like, well, that's how I communicate with everyone in my life. I think even just, even getting to the point where healthcare operates like 2018 is impressive. But yeah, I mean, whenever you strip away all of the normal insurance and regulatory things that come along with traditional healthcare, I think it allows you to rethink how we do everything. And so the problem in healthcare technology, if you ask most doctors, do they like electronic medical records? Do they like anything related to technology in their job? They say no, we hate it. It makes us miserable. And it's not because the technology itself is inherently bad. It's just being asked to do the wrong thing. It's being asked to maximize codes and documentation for billing purposes or regulatory purposes, as opposed to making the experience of the patient and the doctor or the decision making of the doctor better. So I think there's this whole untapped potential in healthcare and technology because we've been asking computers to do the wrong things for so long. So trolling around in your website a little bit, my impression of how the DPC model works for consumers is there's no co-pays. You pay, like you mentioned, a membership fee, an annual or a monthly fee for you or your family anywhere between 50 and I don't know, $130 for access to primary care services. But that's something that if I was part of your practice, I would be able to contact you 24 seven. I could shoot you an image of email you an image of my rash or I could send you a text and ask you a question. Even if I paid a little bit extra, you would come to the house for a house call. Absolutely. It's at least in theory, like on the website, I would know what basic services cost. I mean, that membership fee would pay for visits, doctor's visits and some other basic services. But then if I wanted, say an X-ray, I go on your website and it says, here is X dollar amount, I forget what it was, 50 bucks or something for an X-ray, $450 for an MRI. There's also price transparency there. Yeah. So what we try to do for our patients is we try to not, I mean, obviously, my decision making and my judgment is probably the largest part of primary care. But whenever we have patients who need something else, an X-ray, a procedure, we try to do everything we can in house. And I think people underestimate how much a primary care physician could do if given the opportunity in the time. So we try to do as much as we can in house. And that's obviously easy for us to be transparent because we don't bill insurance companies. We have to tell people upfront what it costs. And so we see enormous savings in things like labs and medications and radiology procedures across the board. Our patients pay much less than what they would using insurance. But even if someone needs something outside of the scope of primary care, we still are in a position to advocate for transparency and fair pricing. So if my patient needs an MRI, I don't own an MRI machine myself. But we aggressively make sure that our patients are getting a good deal and good service. So I think that's the role that primary care could and should play is to be kind of a quarterback and a partner for patients in all of their healthcare. Hopefully most of the time it's just primary care. But if it goes beyond that, we can also help. So question about the pricing on the website, I think it's rather odd that when I first saw that, I think that's really interesting. But why isn't this the norm? It seems like we expect prices to be transparent. And most things we do, when we go to the grocery store, we can see what things cost. And do you see the lack of price transparency in the current healthcare system as a feature of any particular kind of regulation? Or is it just something we've grown accustomed to? Not that there's an issue exclusive? Yeah, I mean, if you go back in the history of American medicine, there's many things that have happened from a regulatory standpoint that have led to what we have now. And really what we have now is not insurance. It's called managed care. So if people use the term insurance in the healthcare sector, much different than they would use the term insurance in the automobile sector, the house sector for insurance. And so what we're really doing at this point is giving all of our money, whether it's something expected or something unexpected to a third party, a managed care organization, private or the government, and expecting them to manage all of those dollars for us. And so inherently, when you do that, it's going to remove transparency because it's a third party paying for it. And there's going to be a lot of backroom negotiations and deals for what that price is. And ultimately, the patient is already kind of prepaid for that. And so there's really not like a motivation for the provider to tell the patient what it's going to cost because they think someone else was paying the bill. So you can imagine if we did this with our groceries, right? And you layer employers on top of that. It makes it even more complicated. So imagine if we did this with our groceries, that an employer said, you know what, food's expensive and some people can't afford it. And maybe it'd be better if we just managed your food dollars for you. And so the employer itself can't really manage food dollars. But we'll hire a company that manages your food dollars. And so we'll give your food management company all of the money. And then that food management company will then network with a bunch of stores in your neighborhood, hopefully that you like. And then you'll go to the store and you really won't know what anything costs, but don't worry when you check out. There might be a copay. There might not be. There might be a deductible. And you can't get this and that because the rules of the plan say you can't get that. But at the end of the day, you'll get a bill later on. And then everything will be fine. I mean, you can imagine what would happen to the grocery store industry if we attempted to do that. And I think it would look very much like what healthcare looks like today. What a mess. I mean, so I like the idea that what we call health insurance is not really health insurance. So now your practice, just for our listeners, you don't take any insurance at all. This is all out of pocket payments from your customers, right? Now, I've heard you talk about, I might get the exact number wrong here, but you're like 80% model where you're trying to provide, you basically say primary care doctors can provide a large majority or 80% of the healthcare needs for most people for about 80% of their life. And at the beginning and end, like end of life care, that last 20%, which is a very expensive, most of your healthcare expenses do fall during the end of life care. But what you're trying to say is for most people, for most of their life, you can provide a service much more efficiently and with better quality than how our current system provides this same kind of care through insurance. Am I getting that number right? It was 80%? Yeah, absolutely. Yeah. And so I think probably one of the biggest challenges of this model and movement is because of the powers that be that for decades have undervalued primary care. And I won't go into all the boring details of this, but primary care is kind of considered the bottom totem pole of healthcare. So if you're a specialist, you do procedures, you're glorified, you're paid a lot more money, your value is much higher according to the people that control the money, whereas primary care is in the bottom of that. And so what has happened unfortunately over decades of time is that primary care has kind of become kind of a gatekeeper more than an actual provider. I joke sometimes that some of us become referralists, as opposed to like doctors. And so I think most people don't even appreciate or realize the amazing scope of care that a primary care provider could offer them if given the opportunity. But because of our time is so limited, we get so rushed, your knee hurts, you go see a knee specialist, you have a problem with anything related to your heart, you go see a cardiologist. But we went to medical school, we're physicians, I'm very capable of caring for most people's needs, most years of their lives. And so I think you have to understand that before this type of thing starts making sense. And so because we have more time with our patients, we can do more research for them. I think that personal relationship is really important, but also the time that I have to care for them increases. And so our model works much better if you understand that primary care should be what most people need most years of their life. Of course, you could walk out in front of a bus or you could get hospitalized or need major surgery, but that's not going to happen to most people most years of their lives. So you still see a value for insurance that's truly insurance. Like you should have some sort of catastrophic, high deductible system or insurance program for most of your life for those low likelihood but still present dangers that could happen to you and cause like medical bankruptcy if you do have insurance. Yeah, that's a financial arrangement. And I think what we conflate, healthcare, health insurance, government assistance, we throw all this in one pot and just call it healthcare. And what is healthcare? I mean, healthcare is this extremely diverse set of goods and services that range anywhere from pennies to tens of thousands, hundreds of thousands of dollars and everywhere in between and stuff that's really common and stuff that's not likely to happen to you. And so we throw all of it into this just messy box of insurance care, government assistance, all these things. And if you can kind of separate those things out and think about it just from a financial standpoint, yes, if something is unexpected and expensive, insurance starts to make sense. The trade off of that makes sense. But if it's relatively affordable and you can manage it yourself, if you expect it to happen, then insurance doesn't really make much sense. So I think if you separate those topics out and realize that most people's primary care, outpatient care could be managed without insurance and in a much, I think, much more efficient way, then we could reserve insurance. However, we arrange that for those big things because insurance is the most inefficient way to pay for anything. I mean, it's inherently inefficient because there's lots of people involved. So if we reserve insurance for what it's intended for, it would be much cheaper and I think the care that most people need most of the time would be a lot better. What is the financial background of a lot of your people who use this service? I can imagine some listeners thinking, well, this sounds like something for the upper middle class or the rich. It's fancy concierge medicine. Is that true or what kind of people do you see using your service? In my practice, and I think I'm relatively reflective of most DPC practices, it's probably the opposite. With our price point, as you guys mentioned, most DPC practices are $40 to $80 a month for adults. So it's very affordable. It's a monthly basis. There's no huge upfront costs. And I think most of the patients we're serving are actually probably middle or lower middle income and suffering with high deductibles or some people who are uninsured. And so in my practice, probably nearly half of my patients are uninsured. Another quarter of them have extremely high deductibles and couldn't afford care in the traditional system. So I think because of, I guess, the high quality of what we do, when we say we do house calls and longer visits, there's a history of something called concierge medicine, which is doctors catering to rich people and charging them thousands or tens of thousands of dollars for better access. So I think we kind of got lumped in with that because of the fact that we say we're providing better service. But from a financial standpoint and in the trenches for our practices, we're serving as many lower income people as we are upper. But my practice runs the gamut. And so I think it's a great value for anybody. And I think we're probably serving more people who fall through the cracks than people who have great insurance or who are wealthy. Your mention of house visits reminded me of a thought that occurred to me. I remember years ago with the emergence of ride sharing, I thought, well, eventually you'll have services like Uber for doctors that you can have technology that will actually directly connect patients with their doctors in that way. Are you aware of anyone building an app or anything like that for these kind of practices where you already text and Skype patients, but why not have something where you can press a button and a doctor will be on their way? Yeah. I think medicine, healthcare is unique to those other industries. But I think there are a lot of parallels with things that have happened in other industries that have been disruptive. There are lots of vendors and companies out there trying to innovate in that way that you're describing. But I think that healthcare is challenging in a lot of ways. I mean, it's challenging for us to grow our practices and our model. And until we move outside of this kind of insurance, third-party managed system, I think that a lot of those things are probably not going to happen. But if we returned control of the dollars to individuals themselves, I think you would just see a floodgate of innovation on what you're describing open. And I think DPC would be one way to do that. And I think it's a really efficient way to do that, personal relationship with your own provider who could meet you online or meet you at your house or meet you anywhere that you needed. But I think it would be amazing to see that type of innovation take hold. But until we move away from this insurance-centric system, I don't think it's likely to happen. So I think our audience is going to have a robust appreciation for the old TAN-staffel acronym. There ain't no such thing like a free lunch. And we're getting a sense of how this model is good for consumers, right? Like I'm getting better care, personal relationship with my doctor, more time with them, more input from them for less money. And that sounds great. But I think the logical thing is, hey, this is less money. So does this mean doctors are getting less money? Can doctors still get a decent paycheck with lower costs for patients as well? Yeah. I mean, so if you look at the money in healthcare, everyone has their scapegoat or their bogeyman about why healthcare is expensive. But the truth is, across the board, American healthcare is more expensive at every single level. So physicians in the US, I mean, certainly some specialties in the US get paid way more than other countries. But for primary care, we're really not that much different than most other countries. And the DPC model, the reason that we can charge what we charge is because we have reduced administrative costs. So even though my revenues aren't that great based upon what I charge and the number of patients I have, I employ one nurse as opposed to an army full of coders and billers and clerical people. So at the end of the day, my salary is going to be about average for a family physician in the US, which is just fine by me. Some DPC doctors will make more than some certainly make less than that when you start a business. But I don't think the real driver of this model is physician income. But we have to make it competitive with what else is available or otherwise physicians aren't going to take an 80% pay cut most likely. So that brings something else to mind. I have a partner who's a health professions advisor. And I know one of the big concerns for students looking at medical school are concerns about physicians own mental health. And my understanding is the suicide rate for physicians in the US is the highest of any profession. It's something like three to four times higher than the general population. Doctors deal with higher levels of depression with mental illness. So when you refer to something other than the financial benefits for doctors, I mean, is that what you're thinking of? I mean, how has being a DPC physician affected you personally or doctors, you know, in those aspects? And I say this literally in some cases, it's been life-saving. What you mentioned is absolutely true. And, you know, just in the last few years, there's been a lot of media attention to this. I don't know the statistics of physicians are the highest risk of suicide, but I know it's much higher than the general population. And I think if you really break down this problem, physicians went into medicine, particularly ones who choose primary care for lots of reasons. But to have a rewarding career, most of us are very mission-driven and want to have a good relationship with our patients and really help people. I know that some people in America believe that physicians are just a greedy bunch of money-driven people. But the truth is, as most of us didn't go into it for that, particularly the ones who went into primary care. If we went into the money, we would have went into dermatology, not primary care. But so the problem is when we get out, into the real world, we're met with all these other administrative things and a lack of opportunities to develop the relationships and to care for people in the way that we always envisioned that we would when we decided to become a doctor. And it's really, really hard to become a doctor. It takes a long time. It takes a lot of money. You give up most of your 20s. And then when you get out, you kind of say, okay, well, there's a light at the end of the tunnel. And I think what a lot of doctors find is there's not a light at the end of the tunnel. They're hit with a whole other set of stressors, and they're not able to fulfill that vision of what they wanted to be. And that's obviously becomes like an existential crisis, I think, for a lot of doctors. And so we use the term burnout, which I really hate because it kind of means that there's something wrong with the doctors that they're just not tough enough or resilient enough to withstand it. But I think the pressures of the system are just too much for a lot of doctors. And so, you know, doctors can kind of put their head down and trudge along. And that's where that depression and burnout comes from or doctors quit. You know, a lot of doctors, you know, halfway through their career decide, I can't do it anymore and they take a job that's not clinical. They take the administrative job or they retire early. And so I think DPC is great for patients, but it's also really great for doctors. And I don't know how many people know doctors, but you definitely do not want a doctor who is burned out and stressed and depressed. That is not a good way to provide medical care to people. Because if you're not happy and healthy, it's really hard to be a doctor even with those two things. But if you have a doctor who's feeling crummy themselves, then it's not the best situation for patients. So maybe I should have asked this question at the beginning. But where did this idea come from? Where did you come up with the idea? How much of it was looking at the current system? How much of it was looking at the mental health of your colleagues? What was the genesis of all of this? Really, it was a grassroots movement. I started my practice seven years ago in 2011 and there was a handful, maybe a dozen at most doctors operating in this model in the U.S. And each of them kind of had their own story of we've had enough and we're not going to take it anymore. And we're going to do something different. And we all kind of did this on our own way. We started from scratch and said, what would it look like if we designed a practice that wasn't centered around insurance? And a lot of us kind of came to the same conclusions that this is how things should look and have our own flavors of that. But since 2011 now, there's been nearly a thousand other doctors in the U.S. adopt this model. And most of us operate in a pretty similar fashion. But there's no governing authority. There's no single organization that's telling us how to do this or how to bill. It's truly a grassroots movement of doctors helping other doctors do this. And it's awesome to see so many doctors do this over the last six or seven years without a mandate or some type of governing authority to make it happen. So since you started the practice, and I know even actually I looked at the DBC frontier map of practices and it looks like there's been a lot of growth for the direct primary care movement just in these last couple of years. So let's imagine the future where 90 plus percent of primary care physicians are DPC. Is there any ripple effect on other medical professions? So would this affect surgical care or specialist care, the hospital system itself? Or is this something that really is just going to be contained to primary care physicians? Well, I think it depends because I said health care is this really diverse thing. I think there's a lot of services outside of primary care that could be delivered in an affordable, direct manner. DPC is kind of the epicenter of that. But there's definitely people on the margins who are showing that we could do health care in a direct, simple manner. It may not make sense in a membership sense in all, you know, if you get a surgery that makes sense in a membership. But there are people who are doing quite expensive surgeries for a lot less than what people think they could be done for. So I do think that that kind of direct model can extend beyond primary care. But there would be a lot of other things that need to happen in order for that to be the norm. I keep coming back to this, but I think if we created a system where individuals controlled a decent chunk of that money, and it wouldn't have to be all of it, but if we had some type of system where everyone had a health savings account or a personal health account of some type, and maybe it would be subsidized for lower income people, maybe employers could contribute to it, that it would really change the way that health care providers had to serve patients. It would force us to be transparent. So instead of us answering to, you know, third parties behind closed doors, we would be answering to our patients. And I think it would really revolutionize almost all aspects of health care. But there's always going to be a need for, you know, some form of assistance for people, whether they be of lower income, or whether it be something catastrophic. We're always going to need some form of that. But I think, I think the vast majority of people could manage their own health care dollars most years of their lives. Yeah, imagine giving people agency over their bodies and their money. It's a radical concept. It really is. The, which actually reminds me, I mean, I've always thought one of the most damning indictments of kind of medical expenses is that any, it feels like any medical procedure that doesn't fall under the umbrella of health insurance has gone the opposite way of the general kind of cost curve, the upward bending cost curve of insurance provided health care. So stuff like elective surgeries like Lasik, plastic surgery, we've seen in those fields the exact opposite trend where something like Lasik is exponentially less expensive now than it was when it first came out on the consumer market. Which I think, again, goes to your basic point, which is that we've gotten used to a system of constantly increasing medical prices that are opaque, that we don't know what our procedures are. There's multiple intermediaries in between us and our actual physicians. And we've gotten used to that world, but there's this alternative medical universe that's at the margins, but it's in front of us. I mean, we have an example that things could be different and we could do it more, more cheaply. Yeah. I mean, we're doing it right now. I mean, you know, so people, Lasik is a great example. You know, critics of that say, well, it's elective. And so it's not, you know, lifesaving. Most medicine is elective. I mean, very few percent of healthcare dollars are spent on like actual true emergencies. I mean, most things now, especially with chronic diseases being so commonplace, most people's healthcare is going to be, it doesn't happen to happen today. It's an elective thing and we could think about things before we did it. But in my own practice, we have seen this with MRIs. People think MRIs are one of the most expensive imaging procedures, right? And so, oh, well, you know, we, well, primary care is okay, but MRIs, something like MRIs would be too expensive. In my market, because there's more and more DPC doctors and patients demanding transparency, you know, five or six years ago, if my patient elected to pay cash for an MRI, about the cheapest deal I could find was 600 bucks, which is actually not bad compared to two or 3000, which most hospitals charge. But over the last five years, we've seen that price go down steadily. And now my patients pay 250 to 350 for an MRI of the knee. And so, like, if you can realize that that a lot of medical care could be affordable and sometimes, you know, pretty expensive stuff like an MRI, it would change people's mentality about what's possible. So it's not just limited to, you know, Lasik or cosmetic surgery. I mean, I have diabetics who save, you know, hundreds of dollars a month on medications and labs. And, you know, this is managing diabetes. It's pretty important. So I think we need to think broader than those elective things. And DPC is showing people that we can do that. You know, if I have a patient who breaks an arm and doesn't need surgery, most likely I can manage it with a splint that costs about 10 bucks. An X-ray through our services is about 35 to $40. And if they need a cast a few days later, it's about another $20. So if one of my patients breaks their arm, it's less than $100 to manage a broken arm completely. Whereas if you're on the normal system, people say, well, broken arm, that's going to cost thousands of dollars. So it's not limited to just, you know, kind of elective things. It could be, you know, relatively serious injuries. It could be, you know, management of chronic diseases, you know, workup of complex problems. And I think we could see that same thing all across the board. So if there are any exhausted doctors listening and they've become inspired by this, I'm hoping you might be able to outline. It's someone who's interested in setting up a practice like this. What are the regulatory hurdles that exist on this landscape at the moment? How easy is it to set something like this up? That would be an episode unto itself. But luckily, there now are organizations and resources for physicians who are wanting to operate in this model. I happen to be the president of a newly formed organization called the Direct Primary Care Alliance, or DPC Alliance. And we're a group of doctors who help other doctors do this type of thing. There are conferences. There's one upcoming in Orlando put on by an organization called Docks for Patient Care. They'll have hundreds of doctors there teaching each other how to do this type of thing. So when I started six or seven years ago, I literally was just like me and my laptop making up stuff. And luckily now there's some blueprints and there's some people who help navigate some of those things. But it's an entrepreneurial thing for most of us. So if people have an entrepreneurial spirit and they want to do this, it's definitely feasible. I mean, you don't need to be a business guru to do this. So one of the things we've touched on a couple of times here are health savings accounts, something that are only available to, I forget the percentage of Americans, but if you have a high deductible insurance plan through your employer, you may be eligible to set aside pre-tax income up to, I don't know, like $3,500 a year for individuals. And then that pre-tax money that's not, you're not paying income tax on, if you spend it on medical expenses, you don't have to pay taxes when it comes out. So it's heavily tax advantaged. Now my understanding is you actually can't, and this surprised me when I found it out, you can't spend health savings accounts money on direct primary care fees. Why is that? That's bizarre to me. Well, I mean, you should ask the IRS that. So we did and their answer is nonsensical. So there is a bill before Congress. In fact, it just got passed through the house. The recent HSA legislation, HR 6199, that included a lot of different HSA reforms will clarify this matter. But yeah, so originally when the HSA legislation was written, it's very complicated. It's tied to a bunch of different requirements, including being part of a high deductible health plan. And there's a bunch of other restrictions and definitions. So direct primary care didn't exist when HSA law was put into place. And so because it was never defined, they say that, well, it's not a medical expense. Somehow my services aren't at a medical expense according to the IRS, at least depending on which attorney and accountant you ask. So there will be a bill that I think is very likely to pass through Congress this year that will clarify this matter. But I think HSAs are just kind of a construct. I don't know if HSAs are really the best thing. If it were up to me, people would just own all of their own money and spend it and not have all these weird incentives to save or avoid taxes or all that stuff. But I mean, HSAs are what we have right now. And it's one of the few vehicles where people can think about spending their own money, even if it's not ideal, maybe from a, if I was designing a system from scratch, that's maybe not how I do it. But I think HSAs could be used in a lot of different ways. I don't think they should probably be tied to insurance. I think it should just be a vehicle for personal savings and to spend your own money. We could subsidize them. We're hoping to see that in Kansas. There's a lot of states who have who have considered implementing DPC into Medicaid plans, which I think would be fantastic. And I think the best vehicle to do that would be a savings account HSA or food stamp like program where where we could subsidize lower income individuals to manage their own dollars. And so there's some states experimenting with that. We've talked to CMS about Medicare doing such a thing. But again, it's moving, it's moving outside of that kind of normal thinking. And so I think HSAs or at least the idea of something like that could be much more broadly applicable than just helping people avoid taxes. There's, I mean, it feels like we're in a moment of like bipartisan interest in returning financial agency to people. I mean, part of this, I mean, some of that logic applies to the support for basic living income, replacing means tested, heavily regulated, bureaucratically organized welfare provision with just giving cash, giving money to people who know best how to spend that money for themselves. And so that same kind of attitude seems to crop up here and that bipartisan interest in giving people agency over their money. Now, my understanding with the DPC movement is that this is not a right wing or a left wing thing, that there's kind of broad bipartisan ideological interest in this from physicians of all different political stripes. Oh, yeah, for sure. Yeah, I mean, so I think sometimes some of us are cowboys and have political views. And so I think there's been some people who try to kind of pigeonhole us as some type of political movement. But my friends who do DPC are all over the map politically and ideologically. We do this because we see it's the best way to provide care to our patients. And of course, in healthcare, everything has just been so politicized that people have to figure out is this anti-Obamacare, for Obamacare, Trumpcare, whatever. I don't think DPC is any of those things. I think it's just a better, more efficient way to deliver care. And what we have seen when we spoke to people in D.C. is that there really wasn't an ideological divide in terms of what we do. Now, the HSA issue has become politicized because HSAs, as it's structured, arguably are more advantageous to someone of an upper income who's trying to get a tax deduction. So generally, Democrats are opposed to the idea or even the word of HSA at this point. But I think if we could reframe that around the, as you mentioned, the individual ownership of those dollars, I think it would be a little bit different. But I feel it's not an easy thing. I think there's some industrial opposition. I mean, managed care organizations, insurance companies make their money by managing money. And so the notion of returning some of those dollars to individuals, I think, I think will be met with some serious opposition. It probably wouldn't be political. It probably more business. Less likely to work with you practices that are insurance funded. Interesting. Well, and I can imagine that as the DPC movement was, as long as it was small and pretty niche, it's something that could be tolerated, right? But as it grows to be an increasingly large percentage of primary care physicians, it becomes more of a concern for insurance companies and their lobbyists. One last thing I want to ask you about, Ryan, that I came across a blog post you wrote about your position as a practice of accepting vaccine skeptics as patients. And I thought that was interesting. I mean, I'm not a vaccine skeptic myself, but it reminded me of this broader debate for healthcare consumers about distrust in kind of the medical establishment. I mean, so some of this is the homeopathic world is alternative medicine that because of how opaque the medical and insurance and managed care systems are, and because you only have eight minutes with your doctor, because you don't have any existing relationship, you're just a cog and a grand machine that people turn to things like vaccine skepticism or homeopathic remedies, partly because they actually feel heard, they feel listened to. So what's your experience been with allowing vaccine skeptics to be at your practice and interacting with kind of the homeopathic community as a medical practice? I honestly couldn't have said it better than you just said it. I'm not just blowing smoke. No, I am just to kind of set the stage here for what you said to the audience. I am a very science-based, maybe if you want to call it evidence-based, but in terms of funny term. So I am traditionally trained physician. I do diabetes management, strongly recommend vaccines, do procedures. So I'm not an alternative practitioner by any sense. In fact, I'm probably annoyingly the opposite way. I'm pretty strong skeptic in a lot of ways, but I think you nailed it. The truth is, is most people are not scientifically literate in these matters. They may try to educate themselves and read online, but they don't have the basis to understand a lot of what they read. And a lot of it comes down to that trust and relationship. And because people feel so disenfranchised from traditional medical care and feel so rushed and not heard, they gravitate towards things that make them feel like they're being heard. And so I think there's a lot of things that have taken a hold. I think the resistance to vaccine is probably number one. And it's a huge problem. And we can do lots of things to try to encourage or educate the public on vaccines, but I don't think anything's more important than having someone who's well-trained and educated have a good relationship with that patient. So my decision to take care of unvaccinated patients, it confuses a lot of doctors because I think a lot of doctors inclination is to reject people who don't do what they say, the paternalistic view. And I mean, a lot of my patients don't do what I say. I mean, I have diabetics who I say stop eating Twinkies and they keep eating Twinkies, but I'm not going to tell them they can't be my patient because they keep eating Twinkies. I'm going to tell them it's bad for them. I'm going to tell them they should get vaccines. But ultimately, they are owners of their own bodies and get to decide what they do. But I think unless we continue that conversation and have a good relationship with people, that we're never going to change the tide of that. And so I wrote that article basically to try to convince my colleagues that don't shut off lines of communication as frustrating as it might be. Because again, if we rejected people who didn't do the right thing as we saw it, then they're just going to go to find someone else who kind of affirms what they want to believe anyway. Well, Ryan, thank you for your time. Thanks for coming on Building Tomorrow. I'm just disappointed that you don't have your practice in New Jersey where I live. So if you ever decide to move to the Princeton area, let me know. Yeah. Well, I'm not that cool. But you mentioned earlier, if anyone's looking for a DPC practice, the best resource out there is DPCfrontier.com. And you can Google that as well. And there's, like I said, 800 to 900 DPC practices across the country. And so if you're looking for someone nearby, you could probably find somebody. Yeah, we'll definitely post a link to that in the show notes. But thank you again, Ryan. And to our listeners, until next week, be well. Wherever you get your podcasts. To learn about Building Tomorrow or to discover other great podcasts, visit us on the web at libertarianism.org.