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Hello everyone and welcome back to the overlap.

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I am Joshua.

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Will is still out for the holidays, spending time with his family.

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So it's just me today, which means we are skipping the small talk and getting right into
the good stuff.

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And when I say good stuff, I mean, we're diving into the head first chaotic nonsensical
Rube Goldberg machine uh that was invented by human beings, the American healthcare system

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yet again.

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Now I know what you're thinking.

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you see healthcare.

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You think.

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Skip button you think boring heavy confusing.

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We're not doing that today.

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We're not gonna sit here and read actuarial tables We're gonna poke the bear.

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We're gonna look at this system for what it actually is the world's most expensive
practical joke Now you always hear politicians say the health care system is broken.

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We need to fix the broken system I am here to tell you that's a lie The system isn't
broken to call it broken is an insult to the architects who actually built it

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It's actually working perfectly.

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It is a Ferrari, a finely tuned machine.

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It just happens to be an engine designed to vacuum money out of your bank account and
transfer it to shareholders portfolios.

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That's not a bug, it's a feature.

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To show you how absolutely crazy this system is, we have to take the logic of the American
healthcare system and sort of apply it to like literally any other business.

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Because if we ran...

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a lemonade stand, the way we were in a hospital, we'd all be in prison.

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So I want to sit there with you and I want you to imagine a restaurant.

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Let's call it, I don't know, Chez American.

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Five stars, very fancy.

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You walk in, you're starving.

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You sit down.

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The waiter walks over very casually and says, ah can I get anything for you?

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You say, can I see a menu?

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The waiter just laughs and says, well, we don't do menus with like,

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prices that kind of destroys the mystery.

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You say, okay, well, how much is a hamburger?

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The waiter says, well, that's a great question.

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Who are you with?

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Are you with the blue group, the Etna club?

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Are you unaffiliated?

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You tell them very succinctly that you're with the blue group.

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He says, fantastic.

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So a hamburger might be $12.

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It might be $600.

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It's kind of a range depends on what kind of mood the algorithm.

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is in today.

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But you know, go ahead, live a little.

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So you order the hamburger and you decide you're a little low on vegetables.

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You haven't had some in a couple of days.

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You order a side salad, you eat it.

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It's okay.

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You ask for the check.

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The waiter looks at you absolutely offended.

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Um, we don't settle up now.

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Go home.

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We'll send the bill to you later.

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It'll be a surprise.

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After about three weeks, you're just living your life when a letter arrives.

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It's not a bill.

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It's an EOB.

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explanation of benefits, which is Latin for we're about to gaslight you.

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It says the restaurant billed $450 for the hamburger, but your discount club, the blue
club, got it down to $200 and you owe $50.

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Not bad, right?

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And then you see it, the red ink.

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Side salad denied.

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Reason?

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Not necessary.

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You call the restaurant.

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Why was my salad denied?

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I ate it.

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It was fine.

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And they tell you, well, the medical director of the blue group, Steve from accounting, he
looked at your case and he decided that because you also ate a pickle with the hamburger,

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the salad was kind of redundant.

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So you owe us $85 for the lettuce.

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And just when you're about to scream, you get a second bill.

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This one's from the apex utensil partners, LLC.

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They're charging you a hundred dollars.

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Why?

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Well, because while the restaurant was in network and the waiter was in network, the fork
you used to eat your hamburger or the knife you used to put the mayonnaise on your

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hamburger, whether or not you actually use those items is irrelevant.

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Having the silverware there and available, the silverware was actually an independent
contractor who is actually out of network.

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If this happened to you at

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chilies, you'd probably burn the building down.

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You would be absolutely well within your rights to riot, complain, scream to the high
heavens, and leave the worst Yelp review that that chilies has ever seen.

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But in healthcare, we just kind of accept it and write the check, or maybe not.

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We have normalized this insanity.

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So why is it like this?

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Is it because doctors are evil?

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No.

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Most doctors are actually pretty decent human beings.

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Is it because we're stupid?

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Well, you know, no, it's because of something economists call the third party payer
problem.

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In a normal world, you'd buy a thing from a person.

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I love when they call them widgets.

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You'd buy a widget from a person, right?

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You look at the price, you look at the quality and you go, yep, I'm gonna have that exact
widget and you know what you're paying for it.

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But in healthcare, you have a chaperone, the insurer.

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You don't buy healthcare.

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A chaperone or third party and mediator buys it for you using your money, but they don't
tell you the price until after you've used it.

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It's like sending your rich, eccentric uncle to buy you a car, but he hates you, and he
owns stock in the dealership.

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The structure kind of breaks the market.

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Nobody's shopping, right?

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Nobody knows what anything costs.

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So the price has just flowed up into the atmosphere like a balloon that's lost its kid,
right?

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To keep the circus running, and boy, is it expensive, we're not paying for innovation.

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That's the lie.

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You hear all the time, yeah, but what incentive would there be to innovate?

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We're paying a complexity tax.

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The United States as a whole spends about a thousand dollars per person a year just on
administration.

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What does that mean?

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Paperwork, literally all that billing and talking from the billing department to the
medical director to the healthcare provider to the third party payer system to Visa to

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MasterCard, all of that you're paying for.

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And that's a grand out of your pocket every single year to

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pay an insurance company to deny your claims.

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Comparatively, and you know we love the northern Arctic Circle area, in Sweden they
actually pay about $45 per person per year.

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Because in Sweden, the doctor sends a bill and the government pays it.

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That's it.

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In America, you've got to have

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an army of coders and billers and then there's adjusters and then managers to fight a war
over every single aspirin and whether or not it's needed.

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Well, who wins in that scenario?

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Who's the bigger winner in this casino?

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It's definitely the house, just like any other casino.

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Let's check the scoreboard.

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Andrew Witte.

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He's the CEO of the United Health Care Group.

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Don't at me.

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I mean, that's just a fact.

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Now, I don't know Mr.

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Witte,

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Personally, I'm sure he's a wonderful human being and I'm sure that he loves his mother
and I'm relatively certain his mother loves him.

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But in 2024, Andrew took home $26.3 million.

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That is 348 times what the average employee at his company makes.

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While people are starting literal GoFundMe campaigns to pay for insulin,

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Andrew is making enough money to buy a small island every single quarter.

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See, it's not broken.

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It's working great for Andrew.

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And that's kind of the vibe today, right?

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We aren't here to be sad.

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We're here to laugh at the emperor who isn't wearing clothes, right?

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We're here to look at this absurdity and say, okay, you got us.

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This is a scam, but at least we know how the trick's done.

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Speaking of scams, let's talk about my favorite one.

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We have to talk about the fact that for some reason, the American medical system has
decided that your teeth are not part of your body.

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It's about to get ridiculous in here.

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So we established the healthcare system is a restaurant that basically hates you.

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But now let's talk about the strangest room in that restaurant.

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Let's talk about the dental divide.

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Have you ever stopped to really think about how weird it is that in America,

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your mouth is considered a separate legal entity from the rest of your body.

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According to the insurance industry, the human body stops at the neck.

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Your heart, that's medicine.

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Your lungs, also medicine.

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Your kidneys, medicine.

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But your teeth, your gums, the literal gateway to your respiratory and digestive systems,
oh no, no, no, no, no.

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Those are premium add-ons.

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Those are seat warmers.

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Those are, and Reddit has dubbed them this, luxury bones.

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The logic here is more than fascinating.

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The insurance companies have decided that the ability to chew food without screaming in
pain or to not speak with a lisp is basically akin to getting heated seats in a luxury

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sedan.

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It's a nice to have, it's a perk, but it's not essential biology.

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If you go to a cardiologist and say, hey, look, my heart hurts, your insurance says,

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Watch your costs, but we've got to fix this.

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This is your heart.

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That's what you're paying for.

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If you go to a dentist and say, my tooth hurts, I can't eat, your insurance says, well,
you did need to lose weight.

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How much do you really need to chew?

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Have you thought about smoothies?

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How did we get here?

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How did we end up with a system where you need one card for your liver and a completely
different, much worse card for your molars?

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Like everything in American history, it starts with a mix of academic snobbery and a weird
accent.

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Let's go back to 1840.

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We're at the University of Maryland.

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Two men, Horace Hayden and Chapin Harris, kind of the fathers of modern dentistry.

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walk into medical school.

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say, hey, look, we have a new science.

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It's called dentistry.

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We fix teeth.

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We treat gum disease.

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We think that this should be part of the medical curriculum.

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Can we join the club?

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And the doctors at the University of Maryland looked at them and basically said, ew, no.

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They rejected them.

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They said dentistry was quote, a mechanical trade.

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They viewed it as manual labor.

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like being a barber or a hamburger flipper or a blacksmith.

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Real doctors didn't get their hands dirty with teeth.

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So Hayden and Harris said, well, fine, we'll start our own school with blackjack and
fluoride.

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And they did.

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They started the first dental college.

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And from that moment on dentistry and medicine were two separate professions, different
schools, different degrees, different cultures, different subject matter.

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Fast forward to 1954.

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This is where the insurance trap starts to snap shut.

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In the 50s, we had wage control.

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Unions in California and Washington wanted to get more money for their workers, but
legally they couldn't ask for higher hourly wages.

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So they started asking for fringe benefits.

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We have all known these and if you're in a highly competitive industry, that is what you
essentially win with.

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and how you shop when they're all paying the same salary.

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They went to the dental societies and said, can we build a prepayment plan for teeth?

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And this is the key, right?

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They didn't design it as insurance.

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Medical insurance is designed for catastrophe.

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If you get cancer, the insurance pays hundreds of thousands of dollars, sometimes millions
to save you.

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Dental insurance, in quotes,

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was designed as a maintenance plan.

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It was designed kind of like a coupon book.

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What those coupon books we used to sell in high school to have basic things like funding
our education and extracurricular programs?

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Yeah, it was a coupon book for, I don't know, an oil change.

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It basically covers your cleanings, maybe a filling or so a year, but it was never
intended to cover a crash, right?

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Like a major

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a major situation.

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And that's kind of the most infuriating number in the entire healthcare industry, that
annual maximum.

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If you have dental insurance now, go look at your card.

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I'm not gonna wait for you.

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You can pause this and go and look for it later.

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But somewhere on that insurance card or in your policy, it lists your annual maximum
benefit.

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For most of us, that number,

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is either a thousand dollars or fifteen hundred dollars per person.

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Sometimes there's a family number as well if you're on a family plan.

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That's the most that the dental insurance company will pay in a single year.

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After that, you're basically on your own.

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Now, here is the kick in the teeth, pun entirely intended.

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Do you know what the

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standard annual maximum was in 1970.

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It was a thousand dollars.

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They have not changed that number in 54 years.

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Let's do the inflation math.

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I'm sorry, I'm struggling with the fact that it's been 56 years.

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since 1970.

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But to do the inflation math, because this is where kind of the scam reveals itself, if
that $1,000 limit from 1970 had kept up with inflation, let's look it up here.

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1970.

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$1,000 in 1970.

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This calculator only goes up to 2024.

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So I assume it's a little more.

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It's actually over $8,000.

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$8,000.

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Now, an additional two years, and with the inflation we've seen there this administration,
we're probably closer to $10,000 adjusted for inflation.

233
00:15:33,377 --> 00:15:39,997
In 1970, $1,000 could literally buy you a mouthful of golden crowns.

234
00:15:39,997 --> 00:15:44,417
They didn't have all of the polymers and things that we have now, which are actually much
cheaper than gold.

235
00:15:44,417 --> 00:15:49,237
They used gold, but an entire mouthful would have cost you right around $1,000.

236
00:15:49,537 --> 00:15:53,377
$1,000 a year could fix almost anything.

237
00:15:54,097 --> 00:16:04,097
In 2026, $1,000 gets you two cleanings, maybe an X-ray, and maybe half of a root canal.

238
00:16:04,417 --> 00:16:07,961
So you pay your premiums every month you think you're covered.

239
00:16:08,212 --> 00:16:16,097
One day, you're biting into a chip or taking a bite of sticky toffee and you crack a
tooth.

240
00:16:16,378 --> 00:16:20,220
The dentist says, well, okay, you need a root canal, let's put a crown on it.

241
00:16:20,220 --> 00:16:20,761
That's $2,500.

242
00:16:20,761 --> 00:16:27,705
Your insurance pays the first thousand dollars and then they tap out.

243
00:16:28,146 --> 00:16:35,421
And usually they negotiate the cost down for that thousand dollars.

244
00:16:35,791 --> 00:16:37,742
then you're required to pay the overage.

245
00:16:37,742 --> 00:16:39,102
Sorry pal, you hit the limit.

246
00:16:39,102 --> 00:16:41,362
The other 1500 bucks is on you.

247
00:16:42,263 --> 00:16:43,783
It's not insurance.

248
00:16:43,802 --> 00:16:51,325
It's basically a gift card, like a Walmart, Amazon gift card that runs out halfway through
your shopping.

249
00:16:51,646 --> 00:16:55,106
Can you imagine if car insurance worked like this?

250
00:16:55,567 --> 00:16:56,507
Hi, Geico.

251
00:16:56,507 --> 00:16:58,308
Yeah, I totaled my car.

252
00:16:58,308 --> 00:16:59,118
Okay, no problem.

253
00:16:59,118 --> 00:17:00,828
We'll pay for the first thousand dollars of repairs.

254
00:17:00,828 --> 00:17:01,788
Good luck.

255
00:17:02,329 --> 00:17:03,449
Wait, what?

256
00:17:03,700 --> 00:17:10,885
I want to pause the snark for a second because while the math is stupid, the consequences
are deadly.

257
00:17:11,166 --> 00:17:13,407
Let's talk about Diamante Driver.

258
00:17:13,768 --> 00:17:21,194
Diamante was a 12 year old boy living in Maryland, ironically the same state where the
1840 split happened.

259
00:17:21,194 --> 00:17:22,820
This was back in 2007.

260
00:17:22,820 --> 00:17:30,170
uh Diamante came home one day complaining of a toothache, simple stuff he needed to have
the tooth extracted.

261
00:17:30,568 --> 00:17:39,926
It costs about $80 in 2007 to have a tooth extracted, but Diamante's mom was in between
jobs.

262
00:17:39,926 --> 00:17:44,740
So in between coverage, she was struggling with the Medicaid bureaucracy.

263
00:17:44,740 --> 00:17:49,563
She couldn't find a dentist who wouldn't take her insurance or perform the procedure for a
price she could afford.

264
00:17:49,563 --> 00:17:50,744
So they waited.

265
00:17:50,905 --> 00:18:00,742
They tried to kind of manage the pain or a gel, you know, those sorts of things, but your
teeth are connected to your body.

266
00:18:01,184 --> 00:18:05,584
The bacteria from this tooth abscess leached into his bloodstream.

267
00:18:05,584 --> 00:18:06,684
It traveled up.

268
00:18:06,684 --> 00:18:08,864
It infected his brain.

269
00:18:09,364 --> 00:18:11,904
Diamante started actually having seizures.

270
00:18:11,904 --> 00:18:13,484
He was rushed to the hospital.

271
00:18:13,484 --> 00:18:19,664
He had to go through two emergency brain surgeries and spent six weeks in the ICU.

272
00:18:20,024 --> 00:18:28,244
The total cost to the healthcare system for his hospitalization was $250,000, just a
little bit more.

273
00:18:28,444 --> 00:18:30,398
A quarter of a million dollars.

274
00:18:30,398 --> 00:18:33,389
And at the end of it, the Amante died.

275
00:18:33,640 --> 00:18:36,642
I want you to sit for a second with the logic of that.

276
00:18:37,603 --> 00:18:49,969
American healthcare system is willing to spend $250,000 on medical neurosurgery to try to
save his life.

277
00:18:50,390 --> 00:18:58,044
But it couldn't figure out a mechanism to pay 80 bucks to pull a tooth to save him from
the infection in the first place.

278
00:18:58,779 --> 00:19:05,392
because that tooth was a luxury bone as opposed to the brain, which apparently is a
medical organ.

279
00:19:05,713 --> 00:19:08,874
That distinction killed the 12 year old boy.

280
00:19:09,494 --> 00:19:10,435
Okay.

281
00:19:10,515 --> 00:19:11,045
Deep breath.

282
00:19:11,045 --> 00:19:12,676
Let's get back to the absurdity.

283
00:19:12,676 --> 00:19:14,797
Cause if we don't laugh, we're going to cry.

284
00:19:15,129 --> 00:19:17,218
Uh, I know that from experience.

285
00:19:17,298 --> 00:19:19,919
Let's talk about the missing tooth clause.

286
00:19:20,020 --> 00:19:21,240
Now this sounds like a joke.

287
00:19:21,240 --> 00:19:28,668
It sounds like a, you know, a weird elf that lives in the North pole, but it is a standard
in every dental policy.

288
00:19:28,668 --> 00:19:36,008
It states, will not pay to replace a tooth that was missing prior to the start date of
this policy.

289
00:19:36,088 --> 00:19:39,688
It's a preexisting condition exclusion for your mouth.

290
00:19:39,688 --> 00:19:45,988
You remember the American care act got rid of preexisting conditions for medical care, but
not for dental care.

291
00:19:46,128 --> 00:19:51,888
So let's say you lost a tooth in 2021 because you didn't have any money in 2026.

292
00:19:51,888 --> 00:19:53,188
You get a great new job.

293
00:19:53,188 --> 00:19:54,288
You have dental insurance.

294
00:19:54,288 --> 00:19:55,728
You think finally I can get a bridge.

295
00:19:55,728 --> 00:19:56,708
I can get an implant.

296
00:19:56,708 --> 00:19:58,088
can smile again.

297
00:19:58,448 --> 00:20:02,930
You go to the dentist, they send in the claim denied.

298
00:20:03,090 --> 00:20:04,050
Why?

299
00:20:04,371 --> 00:20:10,533
Because the insurance company says, hey, we agreed to ensure the teeth you have.

300
00:20:10,593 --> 00:20:13,874
We didn't agree to ensure the empty spaces.

301
00:20:14,175 --> 00:20:25,520
And there are reports, and I love this because it's so evil, it's almost impressive, where
people have called insurance sales reps saying, look, I have no teeth, I need dentures.

302
00:20:25,520 --> 00:20:26,864
The sales rep goes, great.

303
00:20:26,864 --> 00:20:37,573
here sign here for this plan the person pays the premium they go to get dentures and
they're denied because all of their teeth were missing before they bought the plan that is

304
00:20:37,573 --> 00:20:45,420
fraud that is is selling a swimming pool to a person who lives in the desert and telling
him you don't cover water

305
00:20:45,671 --> 00:20:50,573
This leads us to the final insult of the dental system, the class marker.

306
00:20:50,813 --> 00:20:55,255
In America, teeth are the most visible sign of your economic status.

307
00:20:55,255 --> 00:21:00,937
If you have straight, white, blindingly perfect teeth, you're rich.

308
00:21:00,957 --> 00:21:02,558
You're employable.

309
00:21:02,558 --> 00:21:04,318
You're moral.

310
00:21:04,319 --> 00:21:08,640
If you have missing teeth or decay, society judges you instantly.

311
00:21:08,640 --> 00:21:13,602
They think lazy, drug addict, unintelligent, unhireable.

312
00:21:13,603 --> 00:21:15,313
So the poor people

313
00:21:15,815 --> 00:21:17,435
get extractions.

314
00:21:17,856 --> 00:21:24,018
Because Medicaid covers pulling teeth, but usually doesn't cover saving them.

315
00:21:24,199 --> 00:21:26,139
The rich, they get veneers.

316
00:21:26,200 --> 00:21:29,621
We've created a caste system based on enamel.

317
00:21:29,872 --> 00:21:31,852
So that's the dental landscape.

318
00:21:31,853 --> 00:21:36,695
It's a mess of neglect, historical accidents, and frozen math.

319
00:21:36,695 --> 00:21:42,167
But at least with dentistry, the insurance companies are just cheap.

320
00:21:42,631 --> 00:21:46,822
When we cross over into the world of general medicine, they stop being cheap.

321
00:21:46,843 --> 00:21:48,703
They start being hostile.

322
00:21:48,964 --> 00:21:58,527
So let's leave the land of luxury bones and talk about the denial industrial complex where
basically an algorithm decides if you live or die.

323
00:21:59,408 --> 00:22:01,589
We covered the restaurant that hides the prices.

324
00:22:01,589 --> 00:22:05,650
We covered the luxury bones that don't count as a biology apparently.

325
00:22:05,711 --> 00:22:08,531
But now we have to graduate.

326
00:22:08,552 --> 00:22:11,985
We're leaving the land of neglect where the insurance company just

327
00:22:11,985 --> 00:22:16,308
doesn't want to pay for your crown and we're entering the land of active hostility.

328
00:22:16,308 --> 00:22:19,430
We're entering the denial industrial complex.

329
00:22:19,650 --> 00:22:25,494
See, somewhere in the last 20 years, the business model of health insurance changed.

330
00:22:26,015 --> 00:22:28,676
It used to be about managing risk.

331
00:22:28,676 --> 00:22:31,558
Now it's about managing denials.

332
00:22:31,558 --> 00:22:34,260
No isn't just an answer anymore.

333
00:22:34,260 --> 00:22:36,261
No is the product.

334
00:22:36,302 --> 00:22:37,962
It's the strategy.

335
00:22:38,343 --> 00:22:40,584
And they've built a machine to say no.

336
00:22:40,885 --> 00:22:41,925
Faster.

337
00:22:42,096 --> 00:22:49,941
cheaper and more cruelly than any human ever could, more and more utilizing AI
automatically.

338
00:22:50,341 --> 00:22:55,664
Let's start with a company you've probably never heard of, but who likely controls your
healthcare.

339
00:22:55,865 --> 00:22:57,005
Evacore.

340
00:22:57,546 --> 00:23:11,555
It sounds like the evil corporation from uh a sci-fi novel or some video game, uh but
Evacore has a, you know, I could just see a spaceship out there with

341
00:23:11,661 --> 00:23:16,195
EVA Core building a better tomorrow by denying your MRI today.

342
00:23:16,195 --> 00:23:20,278
They are a quote, medical benefit management company.

343
00:23:20,278 --> 00:23:25,122
They manage prior authorizations for over 100 million Americans.

344
00:23:25,342 --> 00:23:28,645
They work for the big guys, Cigna, Aetna, United healthcare.

345
00:23:28,645 --> 00:23:32,809
Their sales pitch to the insurance companies is very explicit.

346
00:23:32,809 --> 00:23:39,374
They basically say for every dollar you pay us, we will save you $3 in denied claims.

347
00:23:39,875 --> 00:23:41,055
How do they do it?

348
00:23:41,285 --> 00:23:43,286
Do they carefully review every file?

349
00:23:43,286 --> 00:23:50,238
Do they have an in-house team of house doctors sitting around on a whiteboard solving your
case?

350
00:23:50,238 --> 00:23:51,098
No.

351
00:23:51,218 --> 00:23:54,219
They have an algorithm and increasingly AI.

352
00:23:54,379 --> 00:23:56,839
Insiders actually call it the dial.

353
00:23:56,940 --> 00:23:58,860
And this is not a metaphor.

354
00:23:58,860 --> 00:24:00,941
It is a literal adjustment.

355
00:24:00,941 --> 00:24:09,603
If an insurance company is having a bad financial quarter, maybe they paid out too many
flu claims or the CEO needs another airplane.

356
00:24:09,977 --> 00:24:14,390
They can call EVA Core and tell them to turn the dial.

357
00:24:14,430 --> 00:24:19,714
They adjust the algorithms so that the threshold for approval gets higher.

358
00:24:20,095 --> 00:24:28,781
Procedures that were automatically approved last month are suddenly flagged for manual
review, which is code for we're going to stall until you give up this month.

359
00:24:29,121 --> 00:24:34,585
They are calibrating your access to healthcare based on their quarterly stock performance.

360
00:24:35,346 --> 00:24:37,417
But look, algorithms are abstract.

361
00:24:37,903 --> 00:24:41,084
Let's talk about what this looks like when it actually hits a person.

362
00:24:41,125 --> 00:24:43,566
I want to talk about Christopher McNaughton.

363
00:24:43,886 --> 00:24:47,428
The story comes from an investigation by ProPublica.

364
00:24:47,428 --> 00:24:54,992
uh Christopher was a student at Penn State, had a severe debilitating case of ulcerative
colitis, UC.

365
00:24:55,553 --> 00:24:58,514
And we're not talking about, you know, basic diarrhea.

366
00:24:58,514 --> 00:25:02,916
Like we're talking about life-threatening inflammation, blood clots, arthritis.

367
00:25:03,397 --> 00:25:07,979
He was restricted to eating the same bland meal for two years straight.

368
00:25:08,163 --> 00:25:10,404
and was in and out of the hospital.

369
00:25:11,105 --> 00:25:17,388
He goes finally and sees a specialist at the Mayo Clinic, arguably the best doctors in the
world.

370
00:25:17,548 --> 00:25:19,329
They found a treatment that worked.

371
00:25:19,329 --> 00:25:24,572
It was basically a high dose cocktail blend of biologic drugs.

372
00:25:24,572 --> 00:25:35,998
If you haven't seen biologic drugs, are, uh they compromise your immune system, but
ultimately suppress your immune system to keep immunocompromised.

373
00:25:35,998 --> 00:25:37,779
um

374
00:25:37,901 --> 00:25:43,382
or immune attacks on your body suppressed.

375
00:25:44,383 --> 00:25:48,034
So for the first time in years, Chris had his life back.

376
00:25:48,034 --> 00:25:51,675
He could eat, he went to class, he was alive.

377
00:25:52,035 --> 00:25:54,126
But the drugs are expensive.

378
00:25:54,126 --> 00:25:56,156
Biologics are incredibly expensive.

379
00:25:56,156 --> 00:25:58,657
And that flagged him in UnitedHealthcare's system.

380
00:25:58,657 --> 00:26:00,897
He became a high dollar account.

381
00:26:01,077 --> 00:26:05,118
So UnitedHealthcare assigned a specific team to him.

382
00:26:05,118 --> 00:26:08,599
Now you might think, look, he's got a team to help coordinate his care.

383
00:26:08,599 --> 00:26:11,890
No, a team to cut him off.

384
00:26:12,788 --> 00:26:16,410
ProPublica obtained internal recordings of this team.

385
00:26:16,610 --> 00:26:25,065
On one tape, a quote, nurse liaison, whose job it is theoretically to help with patients,
was laughing with a colleague about the case.

386
00:26:25,065 --> 00:26:32,799
She laughed and said that if the family tried to appeal the denial, it would be a waste of
time because the insurer would still say no.

387
00:26:32,980 --> 00:26:37,362
She was laughing about cutting this man's life support.

388
00:26:37,613 --> 00:26:38,424
And then Dr.

389
00:26:38,424 --> 00:26:39,664
Gerald Cates.

390
00:26:39,698 --> 00:26:39,978
Dr.

391
00:26:39,978 --> 00:26:44,002
Cates was the medical director, quote, who signed the denial letter.

392
00:26:44,002 --> 00:26:46,383
Now, medical director sounds important.

393
00:26:46,383 --> 00:26:48,104
It sounds impressive.

394
00:26:48,405 --> 00:26:52,508
You picture a guy in a lab coat reading charts, thinking deeply.

395
00:26:52,989 --> 00:26:55,671
However, in a sworn deposition, Mr.

396
00:26:55,671 --> 00:26:57,393
Cates admitted the truth.

397
00:26:57,393 --> 00:27:00,715
He admitted that he had not read Christopher's medical file.

398
00:27:00,876 --> 00:27:03,837
He did not read letters from the Mayo Clinic.

399
00:27:03,878 --> 00:27:09,232
He simply copy and pasted the nurse's recommendation into the system and clicked.

400
00:27:09,277 --> 00:27:10,156
Agree.

401
00:27:11,157 --> 00:27:12,608
It was a rubber stamp.

402
00:27:12,809 --> 00:27:22,496
He overruled world renowned specialists without even looking at the patient or his file to
save the company money.

403
00:27:22,577 --> 00:27:24,038
This isn't medicine.

404
00:27:24,098 --> 00:27:30,644
It's a bouncer at a club telling you that your name isn't on the list because the club is
over capacity.

405
00:27:30,895 --> 00:27:31,636
But even Dr.

406
00:27:31,636 --> 00:27:34,318
Cates was too slow for the modern area.

407
00:27:34,498 --> 00:27:36,279
He actually had to click a button.

408
00:27:36,660 --> 00:27:38,161
Let's talk about Cigna.

409
00:27:38,401 --> 00:27:42,981
Cigna actually developed a system called PXDX, Procedure to Diagnosis.

410
00:27:43,101 --> 00:27:47,041
This system actually automates the denial process entirely.

411
00:27:47,461 --> 00:27:53,121
An investigation found that Cigna doctors were signing off denials in batches.

412
00:27:53,121 --> 00:27:56,181
You know what the average time spent on each claim was?

413
00:27:56,361 --> 00:27:58,701
1.2 seconds.

414
00:27:59,081 --> 00:28:01,901
1.2 seconds.

415
00:28:02,521 --> 00:28:04,121
One Mississippi denied.

416
00:28:04,121 --> 00:28:05,381
One Mississippi denied.

417
00:28:06,229 --> 00:28:10,592
You cannot even read a patient's name in 1.2 seconds.

418
00:28:10,813 --> 00:28:14,355
You can't read a diagnosis code in 1.2 seconds.

419
00:28:14,376 --> 00:28:16,777
They weren't reviewing his care.

420
00:28:17,018 --> 00:28:20,120
They were literally clicking select all, reject.

421
00:28:20,241 --> 00:28:26,525
In a two month period, a handful of doctors denied over 300,000 claims using the system.

422
00:28:27,067 --> 00:28:30,629
They have essentially turned the practice of medicine into a click farm.

423
00:28:30,880 --> 00:28:33,722
But you might say, know, your doctor can fight this.

424
00:28:33,722 --> 00:28:35,082
They can do peer to peer review.

425
00:28:35,082 --> 00:28:36,023
Yes.

426
00:28:36,463 --> 00:28:37,644
The peer to peer.

427
00:28:37,644 --> 00:28:44,267
Ideally, this is where your specialist talks to the insurance company specialist and they
have a high level medical debate.

428
00:28:44,327 --> 00:28:46,728
In reality, it's kind of a joke.

429
00:28:47,329 --> 00:28:53,652
If your neurosurgeon calls to argue for complex brain surgery, do you know who they get on
the phone?

430
00:28:54,153 --> 00:29:00,176
It's usually a retired pediatrician or an OB-GYN who's been out of practice for 20 years.

431
00:29:00,553 --> 00:29:05,446
They are matching experts with random hires who reading from a script.

432
00:29:05,867 --> 00:29:13,251
There's actually a story of a doctor on Reddit who did a peer-to-peer for a stroke patient
who needed rehab.

433
00:29:13,272 --> 00:29:19,196
Now, the insurance doctor on the phone literally said, I 100 % agree with you.

434
00:29:19,196 --> 00:29:25,540
He absolutely needs inpatient rehab, but I am not empowered to overturn this denial.

435
00:29:25,941 --> 00:29:27,581
Not empowered.

436
00:29:27,802 --> 00:29:29,723
This is a phrase that should haunt you.

437
00:29:29,727 --> 00:29:33,148
The person on the phone agrees that you need care.

438
00:29:34,149 --> 00:29:37,280
The doctor agrees that you need care.

439
00:29:37,280 --> 00:29:40,201
The patient needs care.

440
00:29:40,201 --> 00:29:45,832
But the algorithm said no, and the algorithm outranks everyone.

441
00:29:46,083 --> 00:29:57,246
So we have a system where teeth are luxury items, your care is denied by a robot in 1.2
seconds, and the appeals process is rigged by people who aren't allowed to say yes.

442
00:29:57,246 --> 00:30:00,067
But wait, there's more in the circle of hell.

443
00:30:00,151 --> 00:30:01,692
Let's say you navigate all of this.

444
00:30:01,692 --> 00:30:06,096
You get approved, you get the surgery, you survive.

445
00:30:06,477 --> 00:30:09,138
Then you get to look at the bill.

446
00:30:09,599 --> 00:30:16,595
And if you thought denials were creative, wait until you see the key where they charge you
for a box of tissues.

447
00:30:16,595 --> 00:30:19,547
Let's talk about the billing circus.

448
00:30:19,848 --> 00:30:23,131
This is the final seventh circle of hell.

449
00:30:23,491 --> 00:30:25,994
We've navigated the restaurant that hides prices.

450
00:30:25,994 --> 00:30:27,831
We learned that our teeth are luxury items.

451
00:30:27,831 --> 00:30:31,113
We survive the algorithm that tries to deny our care in 1.2 seconds.

452
00:30:31,113 --> 00:30:32,734
Now, let's assume you made it.

453
00:30:32,734 --> 00:30:37,317
You got the surgery, you beat the system, you're being discharged now, and then you get
the bill.

454
00:30:37,317 --> 00:30:43,200
This is where American healthcare stops being a tragedy and starts being a dark comedy.

455
00:30:43,760 --> 00:30:55,837
Hospital billing is based on a document called the Charge Master, which admittedly sounds
like a He-Man villain and kind of, you know, don't know, um acts like them.

456
00:30:56,838 --> 00:31:02,741
The Chargemaster is essentially a secret list of sticker prices for every single item in
the hospital.

457
00:31:02,921 --> 00:31:10,425
And these prices have absolutely no relationship to reality, cost, or sanity.

458
00:31:11,026 --> 00:31:12,206
I've got examples.

459
00:31:12,206 --> 00:31:14,848
Let's talk about a $39 hug.

460
00:31:15,628 --> 00:31:23,012
A few years ago, a dad posted his bill, his hospital bill on Reddit, after his wife had a
simple C-section for birth.

461
00:31:23,012 --> 00:31:26,544
He was scanning the thousands of dollars in charges.

462
00:31:26,789 --> 00:31:33,211
He saw a line item skin to skin after C-section cost 39.35.

463
00:31:33,211 --> 00:31:39,132
The hospital charged him $40 to hold his own child.

464
00:31:39,793 --> 00:31:49,546
Of course, Reddit being a cesspool of rage exploded and the hospital administrator
responded and said, that, you know, that wasn't for the hug.

465
00:31:49,546 --> 00:31:54,807
That was for the nurse's presence in the room while the hug occurred to ensure safety.

466
00:31:55,684 --> 00:32:02,609
We have monetized even the first moment of human bonding, but it gets pettier.

467
00:32:02,930 --> 00:32:09,775
If you get a box of tissues in your room, it might show up on the bill as a mucus recovery
system, cost $15.

468
00:32:09,775 --> 00:32:19,823
If a nurse gives a frightened child a teddy bear to calm them down, that will be billed as
a cough suppression device.

469
00:32:20,124 --> 00:32:25,584
And Tylenol, just regular old acetaminophen, the stuff that maha says will

470
00:32:25,584 --> 00:32:38,204
cause you to be autistic or something, the stuff you buy for pennies at CVS, hospitals
routinely charge anywhere from $1.50 to $30 per pill.

471
00:32:38,444 --> 00:32:41,284
That's like a 10,000 % markup.

472
00:32:41,684 --> 00:32:48,304
If a gas station charged you $10,000 for a gallon of gas, they would literally be arrested
for price gouging.

473
00:32:48,304 --> 00:32:51,624
But when a hospital does it, it's cost recovery.

474
00:32:52,164 --> 00:32:54,116
So how do they keep track of all this?

475
00:32:54,116 --> 00:32:57,158
They use a coding system called ICD-10.

476
00:32:57,519 --> 00:33:05,925
You might have a friend or family member who is a medical biller or coder, but now coding
is important for data.

477
00:33:05,925 --> 00:33:08,857
But in the U.S., it's kind of a minefield.

478
00:33:08,857 --> 00:33:14,331
If your doctor uses even a slightly wrong code, the insurance company will deny the claim.

479
00:33:15,072 --> 00:33:17,314
and the codes are magnificent.

480
00:33:17,995 --> 00:33:19,952
I have a list here of a valid...

481
00:33:19,952 --> 00:33:21,272
billable medical codes.

482
00:33:21,272 --> 00:33:22,552
I'm not making these up.

483
00:33:22,552 --> 00:33:25,692
I did validate them through the ICD-10.

484
00:33:25,692 --> 00:33:30,692
Code W59.22, struck by turtle.

485
00:33:31,412 --> 00:33:39,692
Apparently, I don't know, we have a problem with aggressive turtles in this country, but
there is an ICD-10 code for it.

486
00:33:39,692 --> 00:33:44,632
Code W5541, bitten by a pig.

487
00:33:44,883 --> 00:33:48,831
Code V91.07XD,

488
00:33:49,435 --> 00:33:53,679
Burn due to water skis on fire.

489
00:33:53,679 --> 00:33:57,261
I have so many questions about the physics of that one.

490
00:33:57,281 --> 00:34:01,965
My personal favorite though was code V97.33XD.

491
00:34:01,965 --> 00:34:06,108
Sucked into jet engine subsequent encounter.

492
00:34:06,549 --> 00:34:08,230
Subsequent encounter.

493
00:34:08,230 --> 00:34:14,194
How did you survive the first encounter and why did you go back near a jet engine?

494
00:34:14,856 --> 00:34:19,639
But the point of this complexity isn't just to be funny.

495
00:34:20,069 --> 00:34:21,551
it's to create traps, right?

496
00:34:21,551 --> 00:34:29,601
It turns reimbursement into a game of bureaucratic minesweeper, one wrong click and the
money is gone.

497
00:34:29,852 --> 00:34:32,113
Here's another thing that's not funny at all.

498
00:34:32,214 --> 00:34:33,894
The ground ambulance.

499
00:34:34,395 --> 00:34:43,782
So a couple of years ago, might remember Congress passed the No Surprises Act, which
banned surprise billing for out of network ER doctors and air ambulances.

500
00:34:44,083 --> 00:34:47,945
You know, you might call them helicopters, but there was a loophole.

501
00:34:48,606 --> 00:34:51,308
Ground ambulances were excluded from this.

502
00:34:51,308 --> 00:34:52,188
Why?

503
00:34:52,449 --> 00:34:57,752
Because private equity firms own huge fleets of ambulances.

504
00:34:57,891 --> 00:35:01,991
and they lobbied very hard to keep their ability to surprise bill you.

505
00:35:02,531 --> 00:35:05,091
So we have stories like the Silva family in Colorado.

506
00:35:05,091 --> 00:35:07,051
Their daughter was in a car crash.

507
00:35:07,191 --> 00:35:09,371
The ambulance drove her to the hospital.

508
00:35:09,371 --> 00:35:11,331
The bill was $3,000.

509
00:35:11,331 --> 00:35:16,651
The insurance refused to pay for anything because the ambulance was quote, out of network.

510
00:35:17,652 --> 00:35:23,935
The ambulance company sent the bill to collections and then garnished the mother's wages.

511
00:35:24,556 --> 00:35:31,480
They ruined a family's finances for a ride that they had absolutely no choice in taking.

512
00:35:31,480 --> 00:35:35,462
You can't shop around for an ambulance when you're bleeding on the side of the road.

513
00:35:35,462 --> 00:35:38,103
Hold on, let me check the Yelp reviews for this paramedic.

514
00:35:38,103 --> 00:35:40,124
It's extortion, plain and simple.

515
00:35:41,045 --> 00:35:42,385
So here we are.

516
00:35:42,886 --> 00:35:47,538
We have a system that hides prices, ignores your teeth,

517
00:35:47,922 --> 00:35:55,758
a system that denies life-saving care in 1.2 seconds, and a system that charges you for
holding your baby.

518
00:35:56,009 --> 00:36:03,915
And we pay more for this, $1,000 a year, just in admin costs, than any other country on
earth.

519
00:36:04,756 --> 00:36:06,578
That brings us back to where we started.

520
00:36:06,578 --> 00:36:08,359
Is the system broken?

521
00:36:08,459 --> 00:36:09,399
No.

522
00:36:09,400 --> 00:36:15,865
For Andrew Witte making $26 million a year, it's working frickin' great.

523
00:36:16,303 --> 00:36:20,596
For the shareholders of UnitedHealthcare and Cigna, it is a gold mine.

524
00:36:20,596 --> 00:36:31,702
But for us, for DeMonte Driver, for Christopher McNaughton's, it is a predation machine.

525
00:36:31,953 --> 00:36:39,036
The third party payer problem, say that three times fast, the third party payer problem
has destroyed the market.

526
00:36:39,557 --> 00:36:43,549
We need to stop pretending that this can be fixed with a few tweaks to the tax code.

527
00:36:43,969 --> 00:36:55,957
And we need to stop pretending that healthcare is a luxury product like a flat screen TV
until we recognize that teeth are bones, just like any other bone, until we recognize that

528
00:36:55,957 --> 00:36:58,829
no is not a medical opinion.

529
00:36:59,630 --> 00:37:09,696
And until we recognize that healthcare is a human right, not a fringe benefit, we will
continue to be customers in the restaurant in the seventh circle of hell.

530
00:37:10,577 --> 00:37:11,718
And that's it.

531
00:37:12,559 --> 00:37:13,739
That's the show.

532
00:37:13,781 --> 00:37:21,957
I know, it's heavy, it's infuriating, but the first step to fixing this scam is seeing the
scam.

533
00:37:22,297 --> 00:37:32,565
If you enjoyed this episode or it made you angry in a productive way, do us a favor, share
it, send it to a friend, send it to your uncle who thinks universal healthcare is

534
00:37:32,565 --> 00:37:35,466
communism, send it to your dentist.

535
00:37:36,047 --> 00:37:41,589
We grow by word of mouth, so if you think someone needs to hear this, please pass it
along.

536
00:37:41,589 --> 00:37:46,961
Also, please take a second to rate and review us on Apple podcasts and Spotify.

537
00:37:46,961 --> 00:37:49,162
It kind of helps the algorithm find us.

538
00:37:49,162 --> 00:37:51,613
And as we learned today, algorithms kind of run the world.

539
00:37:51,613 --> 00:37:53,984
So we have to play nice with them.

540
00:37:54,325 --> 00:37:55,805
You can find us on the socials.

541
00:37:55,805 --> 00:37:58,006
We're on Blue Sky and Macedon.

542
00:37:58,006 --> 00:38:03,449
Come say hi, tell us your worst healthcare horror story, or just send us pictures of
turtles to watch out for.

543
00:38:03,449 --> 00:38:08,771
uh Check out our website for all of our sources, charts and data we talked about today.

544
00:38:08,771 --> 00:38:11,334
uh Will hopefully will be sitting in the chair next week.

545
00:38:11,334 --> 00:38:13,035
He'll bring the optimism, I'm sure.

546
00:38:13,035 --> 00:38:14,837
Until then, I'm Joshua.

547
00:38:14,837 --> 00:38:22,524
Don't get struck by a turtle or sucked into a jet engine once or twice and try to stay out
of network.

548
00:38:22,605 --> 00:38:23,766
I appreciate you.

549
00:38:23,766 --> 00:38:25,296
This has been The Overlap.