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

America pays 40% of the world's health care 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. I really welcome back on my side for this one, David. Thank you for joining us. Great to be here. So for the four or five people out there who don't know who you are, can you kind of explain who you are a little bit of your background and then go from there. Please don't tell me that's 100% of your audience. That's it. I know it isn't.

But for the many people who don't know who I am, David Goldhill. The founder and CEO of SesameSessMeCare.com, which is a marketplace for health care services. There you go. So what have you done before you got to Sesame. So people are like, "What are we walking into? What are your claims to fame?" Well, I don't know if any claims to fame, but I did have a long career as an entertainment executive. Mostly in television. I ran television at Universal Studios. I ran the gaming show network.

I built a television network in Russia, which is now a very popular place in Bay of Bonds, distributed by two television channels also helped run a movie theater chain. So you're a classic entertainment executive goes to healthcare store. Yeah, that I've heard it so many times, because our healthcare system works. Oh, so well, right now. It's one of the things that you and I are completely aligned on, and that healthcare is just a

shell. And it's my own shell, and I should be able to curse, but yeah, it's just so I should. So in this situation, healthcare is ridiculously broken. And I wanted to talk about that, because we paid more than anyone else, and we subsidized the entire world. You know, I've had this conversation before we started 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?

Well, we first see is people around the world seem to get healthcare for a lot less money than we do. Many of those systems, particularly in Western Europe, feel more universal and easier, exist in 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 or 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 an American market. Every innovator, no matter where they are, makes the bulk of their money selling to Americans and 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 manufacturer trying to sell something. Is it a result of this? And again, not easy, not intuitive. Basically, the quality of healthcare everyone else everywhere else on Earth depends on the United States. The example I like to use from 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 to say. And you can say, if you've been to a crappy movie theater in the United States, point of movie industry and 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 on 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? And face that argument? Yeah. So it's very difficult. I mean, I sort of compare it a little bit to NATO, which is, you know, we're defending Europe in NATO. The European country spend almost not knowing that I'd say it's going to fundamentally be the force 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 in NATO. Health care strangely enough is a bit like NATO. That quality of care on Earth depends I'm merrily on the American market. Just to put some numbers on it, the United States is 40% of world health care spending. We're 3% of world population. 40%

equivalent of 3% or 3% of world health care spend, they're almost insignificant. So the US is driving

the most important thing in health care, which is the quality and level of care. Innovation.

Innovation finding new treatments, new cures, is what health care is about. We drive that, but we do it by bearing very, very high prices at all of the risk and reward of investment. It's been a tough not to crack. I mean, just stop there. Yeah, 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 our current.

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 what, 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 die. And we're like, well, we're not going to do that because no one else is going to kind of kind of step up and take that role. If we stop cutting the funding collectively across the world, it just drops because we're so used to this.

“I think it's a byproduct of what we did after war war two 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. We're going to go against the communism. We're going to hit our America. We're going to do this and we change that for the entire world. What we've done that at your point is tornado 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 at a point where the market doesn't fit that anymore. Because going in and going and getting a pill somewhere else costs $1, here it costs $1,100. That system is trying is creating this head bunny. And there's a specific reason about that. I love you to talk about how that, why this system is completely

in the early broken and how you're trying to fix it. Yeah. On the one hand, it's a great thing that America benefits more from medical innovation than anyone else. So, therefore, pays more than anyone else. Not a great thing. We're paying 70, 80% of the cost of innovation and getting three, four, five. Maybe ten percent of the benefit. That's an imbalance. The question is,

“can you solve for one problem, which is Americans you're paying way too much for health care?”

Without undermining this other 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, will sell to the Americans, because that's where we'll get 67% of our property from. And if we can then sell to the British dollars. 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 at price. And the impact on health care on our finances, on people's affordability, on the choices they have to make in the lives, it has become enormous, as you would expect when something went from four to five percent of GDP to almost 20% of GDP and three generations since extraordinary. So, this is a problem we have to solve without destroying the engine of innovation. If we just go to

a sort of socialist system, a British dollar system, a Canadian system, we'll simply destroy the engine of an engine, you know, profits that in an innovation, and without American profits in an innovation they're all beginning. 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 the 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 with your 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 the penny. The problem is the first one to get it right cost

nine because it took all the research in the studies and doing all that. I think where we'll get pushback is the idea to like, well yeah, it should cost everyone. They should also burden a great deal of this. They should say pay for some of those costs. And how do we ship that? Because I don't think it just does again. And 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 your, it was actually 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 for approval and developing the drug and all the

ones that fail. And you know, the second pill is a penny to produce that's usually a terrible business

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. What I want is a competitive price. And there's almost no corner of health care in which we let good old fashion competition drive people's prices down in the national cost. And so it should be a bad

“business model. Why's it being too good a business model? They're protected in price. And I think”

this is where you know, people like, oh, are you a Republican or a Democrat or a liberal conservative or conservative or conservative? Are you a capitalist or your socialism? Whenever I get

asked that because I get asked at all time, my answer is always, yes, well, I'm sorry, why? I'm like,

it depends on the topic in depends on where we are. There's there's different structure to for 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 in 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 and I can't afford this. I just I 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 and exit and I'm going to go by a bunch of euros. And I'm going to go to 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 it. 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 were, you're point about being idiotologically permissuous. Oh, that's okay. I call you permissuous. Okay, don't say it to not. But it works really well in healthcare. Because what a lot of health directs we're talking about is what's the one perfect way to pay for healthcare? Well, healthcare is 20% of JGP.

It includes things from drugs that have been in existence for, you know, 80, 90 years to miracle personalized viewers 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 JGP

are gigantic. And the idea that they should all be paid for the same ways. So you started party in church when it's got, is 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 net 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. Yeah, 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 actually considering, I'm saying, what's the one best way to pay for

everything. The biggest thing I'm saying is, everything shouldn't be done the same way. There are some things insurance does really, really well, which is, cover 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 years ago and the price limit was something like 120, 130,000 dollars, which is a gigantic amount of money

for everybody, 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 decided to protect and insurance is still terrible to go for me. And we don't like to think about those numbers, right? We don't like to do that, Matt. It's uncomfortable to think about it,

“but it is why healthcare is so expensive. I think those are the numbers that are going to get”

the audience 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 and how it's just astronomical. It is astronomical. I mean, when I wrote

a book on healthcare, catastrophic care in 2012, I looked at what an employee starting at my company

pretty memes are share, pretty memes are share, pretty memes are share, pretty memes just come out of

“what we would pay or get out. So it's like that, but Medicare tax is Medicare, and just everything”

out of pocket, just estimated over lifetime. And I assume she didn't get really sick. And I assume she had a couple kids and had a partner, and but that the partner didn't work. And it's 2012, the

amount she would put into the healthcare system over her lifetime was 1.2 million into the healthcare

system. There are 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, depending 10 and 15% directly of the cost of care, which is astonishing. Several thousand dollars a year, and it 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-oxid, the first thing that guy asked here is this an insurance job or not. He paid for it and bought it, because that's a completely different price. The biggest thing you have, and when I say this, people say, "But, 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 lower in 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 going up healthcare. There's no Walmart in healthcare. There's none of the competition we see

“at anything else. And for a lot of services there could be. Not for all of them, but for a lot. I think”

this is that goes back to your point. Things are changing. I don't think they're changing fast enough, but I get, I've had, because I grew up in Florida, and we have tons of mold, I get signing protections. So to get whatever spray or whatever it is that I would need to offset that, it used to be extremely expensive. Now, and I'm not plugging in Walmart in any way, shape or form, I was like, "Hey, Walmart, maybe this is like, oh, yeah, four bucks." I'm like, "I'm sorry,

what just happened?" So there are, 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, doing their patients, they're trying to run them through and they're trying to do all this, but there are pockets depending on what 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 is a core part of your business is,”

yeah, 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, like, I can't fulfill, because when I get sinus infections now, I don't go to see my doctor. I'm very blessed with the insurance, I have, I just do teledoch, and I get on the, like, hey, I'm like, just pull up my record, like, "Oh, yeah, I was excited to infect, and I'm like, "Uh, okay, have fun. We're going to send it over."

And that doesn't cost me what, so I have to do that. But there are doctors who work extremely elite, and I want to talk about how AI is going to change medical access to the thing that I demode excited to talk about for a while. 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, but some other services, some procedures, labs, diagnostics, et cetera. I cash prices. And the physicians themselves or the clinics or some cases hospitals just put services on our marketplace at a cash price with the 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 insurance pay. And one of the theories and health

care is, oh, these big insurance can drive prices down in Medicare and Medicaid drivers. We, we don't tell providers what to charge, but they have this basic principle. We all know, which is, we're want to get patients. I got to leave a price. Right. Because I was bringing the capitalism in. It's bringing the capitalism, but it's also just bringing in normalcy, right, which is, look, we just saw this with GLB ones with weight loss drugs. The price of weight loss

drugs declined in the last three years because insurers didn't cover them. Right. So if you were no more than you want to sell them, I had to sell them direct to a consumer. A couple of other companies sold compound versions of their drugs directly insurers. Guess what happened in prices?

it 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. Healthcare may be so different from everything else because we've structured and it's 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 wonderful that things are starting to reverse. Because people, there's many people I know who are just like, I'm just not gonna have 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 just not means artificial intelligence, AI doesn't mean always incorrect.

There's this fear that AI is going to wipe out everything that it is that AI is to humanity as the meteor was the dinosaurs and that one of the things that's gonna 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 were like, no, I'll see the hell that's gonna go with that and we had this little disagreement because I think AI is gonna be this little thing and you walk in, you put your finger down,

it takes your blood test and then, oh, congratulations, you have Ebola and your head's gonna explode in 20 minutes. I'm like, okay, and then, then Amazon drops a package in and I eat it and I love that. So that's the me of where it's going to go and, you know, there is this idea of medicine is now the longer geological walked. There's once something 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 geological. Well, I don't think AI is going to destroy an eliminate humanity, but obviously if it did that, we solved the problem of health care costs. We've been doing that. Yeah, done. Beyond that, I think AI is a great example of how health care is structured in such a strength 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 or ability to treat them for the variety of conditions and to find things. So you can paint in AI driven paralyzed, in which cost decline,

data improves and ultimately outcomes improve, new drugs are created, new treatments are

created and they're more personalized. That's very possible. And we can all see that. We can all see that vision and you know, doctors who look at AI at something other than as Luddled, I'd say, this could really improve the way I practice medicine and how patients. Today, the biggest impact on AI on health care has been in revenue management. Very simple stuff because you can't get away. So the revenue management is the negotiation between providers and insurers over to what

a provider should get paid. That's where it's been used, right? And what we see at CMS is AI provider saying, hey, we need a layer of skim added because if we're bringing AI to this, in other words, it's not the opposite of what's happening in the world, right? And it's a reminder that, you know, economic incentives are what will how new technologies get incorporated.

“You need to make a case of here's how AI is going to create a new type of health care company”

that could win customer dollars. And then remember who the customers are. They're insurers and governments. And that's important. And that's really important. And I think it's a different situation between what sesame doesn't what everybody else does. Where the sesame's customer is the consumer, where most health insurance and most health providers, the customer is the provider. Is like, oh, you're blue cross through shield, we're now to deal with you. You're, you're

at now or whatever the heck it is, we viewed that. And that's a huge differentiation because when we talk about innovation and to bring the audience along with the 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 wallething, 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 with the consumers.”

It's such a great metaphor because so many people, I got a lot of health care conferences. There's certainly a lot more fun than the old entertainment conferences I used to go to the parties to better their celebrities to better. But no, it's not given up at so much to do this. I want you to know that. But, you know, I mean, I mean, I'm in LA right now. So I'm like, what are you talking

but, yes, but, but your point is exactly right, which is the people of health care conferences say,

“okay, we're having cost-saving technologies exist. So prices will come down and you're saying”

they're going, yeah, that's all apples. 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. We have 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 spend. Yes. And then we had 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 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 insurance with room across your shield. I've had it for a very long time. It costs me an astronomical amount of money. I just, it's, 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, we're going to wait. I'm going to click a button. And so one of the remarkable things for us and I'd love to take more credit for it, but I think it says more about normalcy than anything else.

Sesame has 95% patient satisfaction rates. We have NPSs or MADs. We trust pilots in the high

force. Why? It's our providers. We're not the ones providing care. We're a market place for providers to list. But if you're providing a listing on sesame, you know that you've got a satisfying application, just to ease of use, convenient, showing up on time, by 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 it to the rest of the health care 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. So there's a, there's a place in Miami. It's called Josephs. And it is the most profitable restaurant in the world. It's called Joe Scrapes. And my family goes there. We've gone there for years. I mean, my family's from South Florida. In order to get a table, you have to walk into concierge and you handle 100 bucks. That's before you can get to sit down. That's just the game. It's how the game's played. And then the prices, the crabs are astronaut, nothing more than

they should be and all that. But you're doing that. But that's the game. And as long as you know that those are the rules in the game, you don't ship to a football game wearing ice states. You don't go to Joe's without having to ice your way in and we're glad we're being the health care 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 in the fact that we hate each other. We're going to come in and we wanted to talk about what that looks like. Because you know, 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 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 had me on is 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 they did, they built Joe's takeaway next to us. Yep, they had takeaway. Yep. I had not been to Joe's the restaurant in 15 years. Like most people who are

they're regularly and not looking for a big naia, I go to Joe's takeaway. 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. 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 health care?”

And then you remember, yes, wealth care tens of thousands of skews. What we've been lacking in health care 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 vote Bay the argument that health care is too complex to be served by government. And the traditional extra argument is it's too complex to be a normal market. Now, I do think governments got a big role to play in health care. But I actually think markets will drive innovation around service. Let me use another example you're just using. Sesame's taken enormous in marriage on this.

Telemedicine and remote medicine generally are going to be extraordinarily disruptive to health care

on a patient to diagnose your monitor, he's shrinking this. And we're even getting to the point

“where we can see robotics, there's robotics surgeries being done in false 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 a 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. What I've argued is we need a health care economy that incense 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, prices like Sesame does.

Well, on Sesame, you know, if you don't need to be in person, the doctor's happy to see you by video, you're happy or to be seen by video, palms 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. Now, I think this is where we talked about”

people in the garden, we weren't allowed to wear pants so that's you didn't tell me. That's easy for everyone who's not watching this, we're both making. So this is where it talks about geolact. And I mean this is nice this way possible. You're talking about your travels. I love Switzerland more than I could possibly tell you. There are great doctors

in Switzerland. There really are. There are great doctors. I'm sure 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 can't get to your doctor. So I'm going to have to deal with this smock that lives down here. That's going away. We're getting ourselves in an

environment where that's no longer a problem, where I can simply connect to you and we could 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 geo 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 permits 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. Yeah. And the question we should be asking because I think we've had declining marginal cost of care for 20 years. This is how do we make sure that it's the marginal cost of care declined? It's reflected in the price we pay. My belief is that we're going to rely on governments to pay the price of one more. Because they will simply, I don't think that's a belief. That's not a belief. We've seen it. We've already

seen for wanting plus years for decades now that that hasn't been the case. That it's only increased and it's getting worse and worse and worse and worse. And it's not that it's a skinny and worse because like, oh, it's going up. Therefore, the doctors are making all this money. Doctors are broke. And I mean, this is nice. It's very 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 they're 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 the same more. I would make more money if I went and bought three apartment complexes and I'd make more rev. So it's not. It's an opinion. We know it's not working anymore. So everything. So if you're in your audience, you are usually hearing the cost of healthcare in very early releases. 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 then think about what you just said Charles, which is, if you look at doctors in comes and it's really through the last generation, they've been flat. In some cases, down with

spent in the hospital have been defining meaningfully, almost no matter when they're diagnosed with. If you look at the commanding heights of care, they've moved from things that were surgical and labor intensives almost entirely to pharmaceuticals, which have a very low in some cases zero marginal

cost of production. Your, you know, the first pill is 900 million dollars a second pro cost of

a 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 health care. That's about health care is paid for because the reality is in any other industry where we see those things happening, prices decline. And they didn't put on in health care, I would argue because the payment system prevented it from and what we're doing in sesame is saying,

okay, for this corner of health care cash paying customers. Let's look what normal looks like and what happens, prices decline. Yeah. And services 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-censored and are making tough decisions about affordability and what they're going to be able to pay for their family. And the idea that health care treatment should invariably go up and up and up and up.

Is it disastrous one? Yeah. And people shouldn't have to make that choice. Do I eat or dig at my kid his meds? That we shouldn't live in a world like that even exists. And what we're trying to do is we're trying to pivot that. And 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 an inpatient care, it was six and a half days. Like to get them there, we get them to two weeks, hey, Mosul, where everyone's making money, you know, the person has better quality, the quantity of life, but better quality anyway. Well, then Vitas came in and I was working for not for profit and Vitas came in and the doctors started realizing, hey, you know, we could squeeze a 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 down to 47 hours and we left. It was less than 16 hours. Because people were holding onto it to that point. So they were transforming 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,

it just gives you the chills to think about. It's interesting that hospice were 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. And some of the hospice companies were keeping patients for the maximum number of days and then discharged 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 capitalism and

“serving people well. And that's why it's scary to think of more capitalism or more markets.”

It's probably a better way to put it in healthcare. These results are not great results. Unfortunately, when your government's 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-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 role. 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, you know, so we give the

economic incentives to do so. And I would love to sit there in completely bash. Okay, it's the government and how horrible the government's done it. And these healthcare providers and you know, the insurance providers and the combat they are and Yadiyada, I will give an example that I will take no credit from for I was 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 was that there was the average that they had at the people who were on the system that 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. And I'm like, oh, well, that's the case. And Mazel. So they went there another kid because it dropped out another 40 to 60 kids in New York and

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

It isn't a binary solution. It's not black or white. It's like, hey, we got to get some

“great here. Yeah. And I think that's. I think I think that tone is so important because I'm”

personally, I'm someone who doesn't believe in villains, which is why I made terrible films, no legends, but I don't know, I just, but 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 well. And people who work

in insurance companies overwhelmingly are trying to do well. It's, it's the problem is incentive always

will. 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 to bulk it out anything anyway? Well, guess what? We're coming up on a world where the bulk of health care spend would have been

seen in previous generations as preventive. It's managing chronic conditions. And Netflix, you have that suggests you're going to have health issues down the road. My heart surgery was preventive in a sense. I had an 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 much, 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 by 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 that. I'm just fit the system in something that's eight years old and out of date. And that's the problem. It's not the evil this guy and evil like. I know it's fun and

he's going to talk about that. But everyone's trying to be the best. He just cannot get a square peg to fit in a round hole. And that's our health care and payment systems today. It's outdated 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. It doesn't matter what side has been in office. The lonely intern that the load level is running around with duct tape holding this thing together. You would be

shocked. If 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 system's built. It's held together with duct tape. And that's just been humanity since the dawn of time. We're just people are trying to do their best. You might idolideologically 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 ship 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 turned to the left a little bit then I think bringing in those different, because it's not we're all going to die. This isn't going to work. We've proven this hasn't worked for over generation. We need to pivot. And once we get away from, oh, it's this political party or that political party or it's this evil empire or this,

what yeah, there's there is. That's a humanity. But until we sit down collectively and say, you know, we need to have other options than 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 patience 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 and I expected to, I need to think a bit more as a as a customer. I think is one thing financially. I think

a 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 okay, even if someone's paying for it, I'm not sure I got one. And so the simple, and this has helped us me enormously, the simple English language communication of a bill of your data is some thing 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. Health care system in the mid 20th century

was entirely reactive because that's all we can do. The health care center of the second half of the 21st century is going to be entirely proactive, which is another reason this architectural won't work. On the provider side, one change is exactly what you mentioned, which is more and

just for their sanity and often for their economics. I think another thing that's happening though is the big hospital chains, which if gobbles up a lot of these practices and they're trying to do integrated care and all the rest. They're not going to work. I don't want to be, I do want to be a nerd. I mean, be a nerd. Outside of reimbursement rights, economies don't really, hospitals don't really have economies of scale or a scope. They're kind of a senseless institution.

So they charge a ton of money. They get way too big a share of the health care 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 bill of driving of birthments, but they can't be well-run because they don't have economies of scale or economies of scope. 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, or some of what different actually might be winners. But general hospitals increasingly just have a bad business model. And then the last thing I'd go into, particularly everyone with people hate their insurance company, the big insurance companies now are basically words of the governor. Yeah, say they're they're acting on their stuff, and down, based on Medicare policy and Medicaid policy because you, your amount of their revenues come from running

those programs for the government and the government is in fact private insurance companies,

because Medicare and Medicaid are now run almost exclusively with Medicare is only 60 percent,

but Medicaid now entirely through private insurance companies. So this thing, all of us believed about how the health care system works is changing right in front of our eyes and most people

“I don't know. I think one of the things we missed out on is that the consumers now becoming”

significantly more sophisticated. You want to take something like true diagnostics or anything I know we're getting your blood work. I know what's in my blood. I do it routinely every 30 days we're doing blood work, we're checking things because I'm my partner. So we just keep an eye on this. So like, hey, what is this doing and what is that doing? And 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 putting

it in your mouth. If it's white, don't put it in your mouth sugars bad for you. Don't put it in your mouth. White, flower, bad for you. Don't put it in your mouth. It doesn't work. I think that 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 see a specialist doctor for like I have a torn labor, I'm not going to a hospital to have that

conversation. I'm going to go to the person who helps measure the pitchers 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 changed

“change my bargain. When you go win, it's hard to let's just go say I think that's that's really”

right, which is we're seeing that, which is the boundaries of what's health care, what's personal responsibility are changing very, very vastly. And a lot of the more holistic things in health care are things like you mentioned where the patient's going to do it on their own with or without medical advice. In purpose, there's a ton of medical advice that can get from being on a lot,

but for just remember, AI does mean always incorrect because, you know, my AI is completely

convinced that I need to have my uterus fix that I'm very confused by that. So I think there there is this idea. It's a different thing, you know, whatever you want to identify us. I think, you know, as we come into this and we have 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's helpful ownership, but that's never happened in humanity. So I'll hold my breath on that one.

Well, I want to actually comment on that because I think that's a really interesting thing. So one of these year all the time in health care is you can't have consumer dress directed economies because consumers don't know. All right, they're not sophisticated enough. And I don't think

“you're responsible, no, not that you're just kidding. But here's the thing, here's the thing, since”

consumer driven economies aren't driven by consumers, they're driven by sellers chasing consumers. Correct. I don't walk into Walmart or Costco and get a tube of toothpaste. So I'm going to make sure this is the cheapest. Let me look at the ingredients and compare it to its costs. They just say, I'm pricing at the lowest cost. It's, and 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 current

health care economy. Third party payment doesn't take them work out of your hands. If anything,

it makes it even harder. Consumer driven economies, I mean, if I look at Sesame, I had 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

through a ton of work. It's less work. Yeah. 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 invite sure, sorry for the goams, you're going to complain about, you know, your health being so bad and you'll be no B. So whatever it is, maybe just maybe don't stop at 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 health care. So I think that level of responsibility”

hasn't stepped into it yet. Just get off the couch and go for a walk everyone's in a while. I don't think that stepped in yet because there's so many people who, as 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 it's a weird 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 raising the level of awareness against some pretty intense juggernauts. As a founder, as someone who's a CEO, that's running into this. You, 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, you have some pushback to the market's given you.

“Yeah, I mean, I don't think the market's given us pushbacks, but I think some of the conventional”

wisdom and healthcare gifts of 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 price. Yes. And we take that cost away.

The first one I heard is doctors are never going to be willing to post an actual price because

they may be on the services they need to do and it's like, "Get what?" I think there's other professionals that figured this out. Doctors will figure it out too. Then there were things like, well, good doctors are not going to just discount prices, but the interesting thing is, more and more of the best doctors in the country say, "I don't want to get out in the third party payment system because I didn't go to medical school defense, spend 20% of my time in

insurance club." And if you take insurance in your pockets, your physicians, your nurses, are spending meaningful amounts of time managing insurance. Not a great use of that education. And so what Sesame's benefit from is some doctors are trying to diminish the amount of third party pay or just go cash pay, and for some nations that will offer discounts. For other patients they have price-considered treatments,

structures and, you know, others are in between the point being like we see in most markets, 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 Salm Day one is we have a customer's pay upfront. Reducing the cost of collections for doctors is a gigantic administrative system, and causes them to give the best price. And, you know,

Sesame customers is a horrible customer who's already paid before you started your appointment. And I say that, again, reminding you, we've got 95% satisfaction rates. So it's, you know, a lot of the conventional wisdom when you've got a little market place out there, boost wrong, pretty quickly. Yeah, it does. I think 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 selling for the elimination of pain. So if I'm a doctor and it's in Friday night and on your patients, I flick on and up like yours, I flick on Sesame. Okay, let's hear him. I'm going to do it for XYZ 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

“which great about it. 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 because we'll get there because I don't think Americans are willing to have crappy insurance, not a crappy health care. I don't think they're willing to do that. So I don't see the costs coming down, but I don't think they see the demand of standard coming down. Like, I'm not going to go to doctor and have instead of giving me a cast is going to write me a duct tape.

I'm like, no, no princess, I don't have it. 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 it all because it will sink the 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

our life, different elements of health, different needs, different practices. 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 personalized. It's going to be even more targeted, recognizing the enormous differences in the way people live, in the preferences as to how they live, in the relationship between what they choose to do during that. I mean, they're going to be people who eat at McDonald's. They deserve healthcare. They're going to be people who pay a lot of attention and 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 down the way to do so.

The only way we've ever figured out how to do so and complicated businesses is by having markets

and letting people get paid for finding a consumer a patient, they treat well.

“And I think that's what we're doing here and I think having the ability to change the”

ballgame that easily and that quickly, this is just going to speed up. We're great because people want to be able to control this. So if someone's going around David, 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 your 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 a hold of you? Well, I mean, the best way to get a hold of me is just

[email protected]. Or you can just drop by my house. And yeah, that's how much people do it. On the 1600 Pennsylvania, not quite. Obviously, the best way to assess me is to use Sesame. You don't need to be a member of Sesame. You don't need to be a subscriber to assess me. We have both depending on what your needs are. Next time something comes up and you think, you know what? I'd like to talk to a doctor

“in the next five minutes and find out what this is. I'm using this. I'm trying us. I think you'll”

be surprised how easy it is how great the doctors are and how good the value is. You know, 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 we should let Costco restructure the healthcare system. I would vote for that, but we'd be a part of it, which is great. As long as they 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 this psychology, but stop moving my stuff. Costco, sorry, woman. Next time I meet it, I will pass. Would you give me the

particular idea that I will? Yeah. They're never going to do it. The virus psychology is brilliant.

You move it and I got to run around the store and find other 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, you know, your model of it makes so much sense because it isn't trust me, give us a shot. It's, we already have all these proof. We already have these things. These are, this is already working. You can already see the reviews here. Give it a shot. That's a different model. I think I think

people will be surprised, not just the price, but just how great a service is and how motivated the providers are. I'm afraid the doctors and nurses and clinics are to be right at what they do for our patients. Thank you for taking the time out and trying to focus on this, that this massive issue that's going on in our country and, you know, the whole entire world, I really appreciate it.

“Great to see you, Donald. 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.