 So I'm going to talk about how we can change our thinking and how we can think differently so that we can create and start to build the foundation of the healthcare system anew. Hopefully we're getting to a better place with our healthcare system. So we all have our points of awakening or our moments of clarity in life. And one of those for me was when the Affordable Care Act came up for its final votes. I honestly had not been paying that close of attention to the legislative process. I just kept thinking, we have to at some point actually get to dialogue. We have to at some point actually start to talk about what this law is going to do. And we never did. We just passed it. So for me that was I think a point of awakening that the politics is pretty badly broken, the healthcare system is pretty badly broken. The group think that exists among scholars of healthcare, among policymakers, among politicians, even among the public is pretty alarming. And so again for me that was a little bit of an awakening. So I want to start by talking a little bit about to just set the stage. And a lot of this has been covered previously. But for at least 80 years we have been talking about lowering the overall spending in the healthcare system. And yet spending continues to climb. Quality is uneven. A lot of people still cannot access affordable care. So the reforms that we keep putting in place aren't working. The Affordable Care Act and prior reform efforts have failed to produce the hoped for improvements. Yet we just keep piling on more and more bureaucracy, more and more of the same sorts of changes based on the same sorts of thinking. And we are now at a point for the first time where middle class Americans are with the Affordable Care Act coverage are financially vulnerable. The premiums are so high that they don't have money to set aside to pay for those high deductibles or to pay those costs that are coming about before they hit their deductible. So that is definitely a concern that we're at. I don't know if it's a tipping point but we are at a point where this is not at all working. And Congress continues to work to talk about healthcare reform all the time. Just last month Congress released a request for information about a public option. So they're continuing to try and do more and more things. Again, with the same sort of thinking underlying it. And I believe that is what the problem is. Physician burnout and dissatisfaction are at all time highs. And even from the private sector side, you probably heard about Haven. It was launched to great fanfare with Amazon, JPMorgan Chase and Berkshire Hathaway. Putting forth this initiative where they're going to bring all these smart people in and they're going to fix healthcare. Well, less than three years since all that fanfare, it has now completely disbanded. So again, we're not seeming to have success in reforming healthcare and getting it to be a better system with better results. So I believe we must think differently. So prior reforms take the current system as a given. They fail to consider the interconnectivities. We were just talking about all the complexity. And they fail to consider how all of these things are interrelated. You can't, you're not going to have a successful reform like with the ACA tried to do. They focused largely on increasing the number of people with coverage. Yet there wasn't much attention paid to increasing the numbers of providers to take care of these patients newly enrolled through Medicaid expansion. And the cost was not something that was considered thoroughly enough. All these things interact. We don't have a sustainable system. Like others have said, the economic impacts are bringing down the economy of the country and threatening the economy of the country. Not to mention state employer budgets and personal budgets. We tend to think that more government is the answer. That's kind of the status quo thinking. More and more government, more and more programs, more and more subsidies. And thinking healthcare is different than other goods and services. We're going to get to that a little bit later. But I think that's really a central piece of what we're doing wrong in our thinking. To think differently, I propose that we examine the fundamentals. So we're going to talk about the nature of healthcare transactions and the importance of the doctor-patient relationship. The use of insurance, of course, is an actuary. That's kind of where I go. But it's really central to how we think about healthcare. And in my view, what the problems with this thinking are. This gets to the role of the individual versus the role of government and primary care. So primary care to me is a great starting point because that's where the bulk of healthcare happens. It's where almost everybody in almost every situation should be accessing the system for whatever their issue is. And so we'll talk a little bit more about that. I do want to mention what the problem is and isn't. So I would say the problem isn't that doctors and nurses don't care about patients. The problem isn't that we don't have any doctors or researchers or scientists looking for better treatments. The problem isn't that there are large swaths of healthcare that are driven by profit. That's how we do everything else. And we have a lot of success with that method. So those aren't what the problem is. The problem seems to be how we finance and deliver healthcare. That's where all of these problems with costs and access come from. So let's take a look at the healthcare system. So you may recognize this diagram. This was created after the Affordable Care Act passed. And it's intending to represent, for one thing, that big bubble in the center is where the Secretary of Health and Human Services has some say, has some authority where she shall do this and she shall do that, which is in the Affordable Care Act virtually almost every page, it seems like. But all of these agencies, all of these just different aspects of the healthcare system, it's tremendously complex. So the technical actuarial term for this is a craft angle. So I would urge you to join with me in a thought experiment. So let's imagine what a healthy healthcare system would look like. So that's the purpose of what I'm trying to do here is to join with you and talk about what that would look like. And again, this is to look at it from the fundamentals, from kind of the beginning. And so we're going to put the craft angle aside and just start at the beginning, just put all of that existing stuff aside, all that complexity, just for our thought experiment. And let's start at the beginning and think about, well, what does it look like? What is the nature of a healthcare transaction? So I'm starting with primary care because it is foundational to the healthcare system. I mean, you'll hear people say it's the backbone of the healthcare system. It's actually something where there's pretty good agreement and scholars are pretty consistent in talking about how fundamental primary care is. There's a lot of research that talks about the better primary care, the better access people have to primary care, whether it's comparing countries or regions of the country, the better health people have. The lower spending is, the more efficiency in the healthcare system, the less utilization of emergency departments and other high-cost delivery mechanisms because people can't access primary care. So it's important for those reasons. About 80% or more of healthcare can be handled in primary care. And primary care is akin to oil changes for your car. If you think about you have insurance for your car, for the liability, for the expensive, unlikely things that could happen with your car, but you don't use insurance and we would be silly to use insurance to pay for oil changes because we all know it would make it very complicated, it would make it very expensive. And so we need to think the same way about healthcare. Primary care is not unpredictable. It is not random. It is not expensive. We should not be using insurance to pay for primary care because it introduces just massive bureaucracy, which all of you know, all of you experience, the bureaucracy that is unleashed once you bring insurance and third-party payment into it. So if we're trying to cut costs and make it more efficient and simpler and work better for everybody, we really should stop using insurance to pay for primary care. And my calculations, which are consistent with others I've seen, which were also published by an actuary, but I hope they're in the ballpark of, if you pay for primary care directly versus paying with insurance, it changes, it increases the cost of primary care by 50 percent because you're asking people at the practice that they have to employ, you know, three or four administrative people per full-time physician to do paperwork, to do pre-approvals, to do quality reporting and data gathering and all of that. Plus you have a more expensive EMR that's required for you to gather a whole bunch of information that doesn't give you better care. It's just feeding the bureaucratic beast. So it adds dramatically to the cost of primary care. The most common way to deliver primary care without using insurance is DPC, which Dr. Wheeler talked about. And I'm using, you know, the same kind of definition he used on his slide, where he had the different examples. I mostly think about the one where he had it labeled as DPC Frontier, where it's just individual doctors concentrating mostly on directly with patients. So not as much concentrating on it with the employer. That's usually how I think of it in terms of like a membership model. Maybe an average of $75 a month is about a national average for an adult for direct primary care. So that's what we want to use as the foundation of our thought experiment. So why am I saying direct primary care is the foundation of the healthy healthcare system? First of all, the benefits of more and better primary care, better access to good primary care are pretty well documented, better health, lower spending, efficient use of services. Incentives and behavior with direct payment adds another layer of good things for the patient and for the system. So when you have the doctor and the patient working together directly, without a third party in the middle, you have fiduciary trust. The patient believes the doctor is acting in their best interests and is suggesting the treatments that will be best for them and is considering their financial considerations and their other preferences. So we have a strong doctor-patient relationship when it's a direct relationship because the doctor isn't trying to please some third party, some insurance company. And then on the insurance side, for the insurance you will carry, most people would still want to have that protection, you would have less moral hazard and anti-selection when you're not using insurance for those routine services for the primary care. And then dramatically less physician burnout and dissatisfaction with direct payment. So there's a number of pretty good behavioral and incentive-based benefits. And then I think the key is thinking about, for our thought experiment, we're thinking about how patients are starting with primary care, they're starting with direct primary care, they're working directly with their doctor, they're much more empowered, they're essentially taking back their power, taking back control over their health care, their health care spending, their health care decisions by just working one-on-one with the doctor. And then if there is a need for downstream services, for specialty care, for hospital care, for surgery, for something like that, they are much more empowered because they have this, you know, they've kind of started out engaging with the system in a way that is more empowering to them, they're spending their own money, they behave like a consumer in other parts of the economy. So from there the benefits go, like Hunter was just saying, the benefits spread beyond just that starting point and they spread throughout for the downstream care as well. So as more people, as more patients and more doctors embrace this healthy health care system, they will demand better choices downstream even. And we'll hear from Dr. Smith in a little bit. Surgery Center of Oklahoma is a great example of a downstream practice, a downstream provider that caters to and understands this empowered patient, the patient spending their own money, the patient that wants transparent pricing and, you know, wants to be treated like a consumer, like they do everywhere else for all other goods and services. So this healthy health care will, these physicians and patients in this healthy health care system in this empowered way of doing things will demand better choices and the big entrenched, unaccountable players will have less power because we're taking back our power. So this healthy health care system will transform health care over time. And again, what I'm, what I'm envisioning here or what I'm looking at is how we need to change our thinking. And over time, as these ideas spread, it will transform to use a word that we say we don't like using, but will affect the entire system as we become more empowered and take back our power. A little bit more about downstream care, I've talked mostly about primary care. But first of all, with DPC, we do have a little bit of research, even though there's not a lot of research yet on DPC, we do know that DPC patients use much less downstream care because you're, the, the doctor and the patient are working closely together from the beginning. So they're figuring things out. They're getting on top of problems. They're preventing a lot of ED use that happens because patients, you know, can't get in with their primary care doctor. DPC doctors tend to have a broader scope of practice because they're trying to please their customers. So they do more and they try to do as much for their customers as they can. They want to keep a customer. They want to, you know, get more customers. And improved health is another aspect of that that means they just need less downstream care in the first place. We do know that we do have some options emerging and I think more are, are coming on all the time to provide not only the downstream care, but also additional ways to facilitate cash payment and to, to help these empowered patients to pay for care. There's a number of entrepreneurial things that have started up that can, can help with this. But I feel like as more and more of us, you know, come over to the healthy side, we will need more and more entrepreneurs and doctors and providers that can embrace this new way of thinking. We still will need protection against catastrophic costs. So this is where the true insurance comes in. For a lot of people, they can, you know, presumably people that want to embrace this healthy health care system will want to lower their premiums by choosing a catastrophic plan or choosing a health cost share like a health sharing ministry. And they would, they would want to take the premiums that they're saving by getting rid of the, the comprehensive plan. They would want to take those premiums and set them aside to pay for their deductibles to pay for their DPC to pay for their, you know, whatever costs that they do incur. So ideally for a lot of patients, a savings vehicle, maybe an HSA, maybe some other kind of account, plus either a health cost share or a catastrophic plan would be really ideal and would be a much less expensive way. And plus you have much more control over what's happening. We do, however, need some legislative changes. Catastrophic plans right now are essentially outlawed because of the Affordable Care Act. So we need legislative changes there to reinstitute the kinds of plans we used to be able to get. And some improvements in HSAs are also warranted to just remove some of the restrictions and make them more usable for people. And again, what we're trying to think about here is what options can we create? Not the government telling us we can do it, but how can we take back our power? And how can this be options that, that are available for people? So I'm not saying we have to push everybody into this kind of an approach. If they're comfortable with the current system, if they like having a first dollar kind of coverage and paying a lot of money for it, certainly that should be an option as well. But we're looking for options that provide a lot of savings, that provide a lot more control to just give people more options that may help us eventually to get a better system and to get in a better place as a country. And what I'm advocating is just the beginning. So building the healthy healthcare system, and actually I crossed out system because part of something we could talk about is just the notion that it's not even really a system. I think it's much better to think about it as we just need choices, just like we have in all other kinds of markets. So this will go a long way to improving healthcare for everyone. So as there are more and more patients and doctors in the free market healthy side of healthcare delivery and financing, the other downstream players, whether they're surgery centers or hospitals or specialists or a myriad of other kinds of healthcare and vendors and they will have to respond to us as we increase in numbers. They will have to have options for cash paying customers. They will have to be more transparent with their pricing because we're demanding it. And there's of course much work to do. It takes a lot of education of individual patients. We need to educate and encourage physicians, employers, researchers. Some legislation will be needed, but I really firmly believe that it's not the government that can fix this. I just really feel like we're at a point now and I don't know if you all agree, but we just it just seems like everything is so dysfunctional in the government and we need to just take back as much power as we can if we want it to be better. We have been trying to let them fix it. I don't I don't think it's working. So I think we should take back our power. We do need entrepreneurs and customers to create and test and grow healthy options. And like some of the prior speakers said, we don't have all the all the all the answers. I don't have all the answers even in this room with all these smart people. I don't know that we have every answer. I think it takes entrepreneurs like Hunter and others we're talking about to create options to try something to test it to explore to see what works what do patients like what do patients value and just like happens in every other part of the economy. That's a natural process of figuring out what works and what doesn't grow the things that work the things that don't work will fade away and we all are better for it. And also I mean this is just kind of a sketch this is just kind of a thought experiment. So we will want to you know come back around as this evolves and pay more attention to some special needs of certain populations like elderly like low income people chronic condition patients. There are other things that we have to of course pay more attention to. And finally this is only designed to look at financing and delivery. There are numerous other regulatory and other problems and challenges in the system. I put a few of them here but you can probably name five or ten more that need separate continued attention because it's not really part of financing and delivery. So we can't you know put our guard down and put all of our eggs in one basket. But I think it's worth thinking about how changing our thinking will help us in the long run. So just a note about paradigm shift. So I think maybe everyone in the room kind of has already shifted to this paradigm of individual empowerment believing in individuals you know whether you consider yourself a libertarian or an Austrian economist or maybe neither one but you just think some of the things that are happening around us aren't working very well. Thomas Kuhn wrote a very influential book and he coined the term paradigm shift and just a couple of things I think really jumped out at me from his book are relevant to this discussion. So a paradigm is in crisis when anomalies become intractable when results run counter to expectations and no amount of tinkering resolves it. It's hard to say more precisely what is wrong with healthcare. We keep trying the same things over and over they are not working but if we're just thinking the same way that we need more government more subsidies more regulations we're going to come up with the same ideas that don't work. The transition from a paradigm in crisis to a new one from which normal science can emerge is a reconstruction of the field from new fundamentals. So that's what I'm trying to promote is this rethinking from the beginning and I think you probably all are in a lot of the same vein of trying to rethink and reimagine how we can make this better. So just in summary the new paradigm for healthcare delivering and financing I think is a couple of points first of all healthcare is like other goods and services. I think that's probably the number one thing that jumps out at me when I look at kind of status quo thinking the typical scholars and you know folks in public health they think it's different and we know that goes back to you know a Kenneth Arrow paper from the 60s where he outlines you know several ways that he thinks healthcare is different and he's mistaken I believe and others have spoken up about that as well. Since healthcare is like other goods and services economic and actual principles apply as usual we should not be using insurance to pay for routine care if we care about spending if we care about patient empowerment that's just a bad idea. Empowered patients and physicians will drive the transformation of healthcare over time benefiting everyone and kind of connected to that is my belief that the government cannot fix our problems but we can. We includes everybody it includes people from the patient standpoint from the family standpoint physicians definitely have a huge role in this. Entrepreneurs employers we haven't hardly talked about that at all but that's a key element because you know most people get their benefits get their healthcare through an employer we just don't have time to delve into everything but everybody plays a role and actually employers in a lot of ways are kind of on the front lines of this a lot of employers are really embracing DPC they're embracing you know different approaches other than just going to the the humanities and the sickness and the United's and just getting their you know rate increase every year they're really taking a hard look at the money they're spending on benefits so that I have a lot of hope there because employers are really I think doing a good job of understanding this and really the final note is it's really up to us we have to change our thinking and take back our power I really feel like the government is not going to fix this but we can make a lot of headway.