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Harris to 500-500. I'm

1:10

as mad as hell and I'm not going

1:12

to take this anymore. Hello

1:18

friends. Welcome back to the show. In

1:20

my endless pursuit of trolling

1:23

Binghamton alumni to

1:25

be guests on this show, I

1:27

stumbled upon Dr. Adam Harris. He

1:30

is a clinical assistant professor at the

1:32

Department of Medicine at NYU Grossman, but

1:34

he's also the senior director of strategy

1:37

at Oscar Health. Disclosure, this

1:39

show is not sponsored by Oscar

1:41

Health, nor does he represent the

1:43

interests of Oscar Health throughout our

1:45

conversational shenanigans, but it was

1:47

great to see him in person at the studio.

1:50

Of course, we channeled the Southern tier and Binghamton

1:52

being the belly button of New York and how

1:54

much we love the school and what our experience

1:56

was like there, but we really got

1:58

into the weeds. about what it's

2:00

like to be a modern-day MD with

2:03

all the crazy healthcare fuckery afoot in

2:05

this country and debating whether

2:07

healthcare is broken, it's working by

2:10

design, what people can do to

2:12

fix it, and how the rising

2:14

tide of advocates supporting millions of

2:16

Americans every single day in

2:18

the most complicated system on

2:20

earth is moving

2:23

the needle for real and helping real

2:25

people every day. Dr. Adam Harris, and

2:27

here we go. All

2:37

right, just say your name for volume. Adam.

2:40

All right. Pull it up a little bit. Huh?

2:43

Vertical. How about this? A little lower. Mm-hmm.

2:47

Still good? Say,

2:49

ah. All right,

2:52

I think this is fine. All right.

2:54

You can project, too, right? Yeah, I

2:56

talk quite loudly. So what's your stage

2:59

voice? Ooh, all

3:01

right, I could really project if you want me to really project.

3:04

Like, acting, remember that? I've

3:06

never done that. I've taught, been a TA. Well,

3:09

that's why I was reading, are you still a, I'm

3:11

gonna read this one, a clinical assistant

3:13

professor, Department of Medicine at NYU Grossman

3:15

School of Medicine. I am. LinkedIn

3:18

is accurate. That's right, it is.

3:20

I mean, I could have gone to NYU's website and verified

3:23

this, but I chose not to. Yeah,

3:25

I probably am on their website. I don't think I've ever looked at my own page. I

3:27

wonder what the hell's there. Like, what photo

3:29

are they using? Yes, almost certainly

3:31

the photo of when I was in residency. Or

3:34

like your driver's license from 1997?

3:37

Wow, I should really check on that. I

3:39

have loads of their own hindsight. I'm not quite sure.

3:42

I'm thrilled to have you here. My

3:45

listeners know I'm like a

3:47

spokesperson for Binghamton University, or as we would

3:49

call it, SUNY Binghamton, which they hate, and

3:51

I love that they hate it because I

3:54

keep saying it and they like stop saying

3:56

it. And anytime

3:58

I find an alarm, alumni

4:01

who is, you know, whether they transect,

4:03

that's not a word, whether they Venn

4:05

diagram, we made up a

4:07

word, transect. There you go. With

4:10

my world or not, it's just

4:12

always fascinating to see where we

4:14

wind up because of the brain,

4:16

which for those not knowing, the

4:18

campus of Binghamton is in the

4:20

physical shape of an actual human

4:22

brain. Yes. Little did

4:24

you realize. I definitely, I mean, the

4:27

brain is the brain. Yeah. It's just, you

4:29

know, it was cliche at the time and in hindsight it

4:31

feels even more cliche, but I love it. I mean, it's

4:34

what it is. So my default question

4:36

to anyone on the show or anyone

4:38

I meet in general is were you

4:40

aware of Wegmans before you went to

4:42

school? No, of course not. Right. I

4:45

was born and raised in Brooklyn. So,

4:47

yeah. So, there was no way. We

4:49

had this the supermurky Gestalt moments. Yeah.

4:51

Right. Orientation, they took us to Wegmans. No

4:53

one does this. Both Wegmans

4:55

and Walmart were a legitimate culture

4:58

shock for me. Were you there

5:00

when they opened up the movie

5:02

theater? No,

5:04

I think that was already open by the time I got there.

5:06

Yeah, because I think it opened in like 1993. Oh

5:09

yeah, I got there in 2004. Okay,

5:11

so it was probably, you were well done.

5:13

Yeah. Yeah, so you're welcome that I was

5:15

part of the the

5:18

post IBM Uncollapse. Yeah. That's so funny.

5:20

That was like the, you know, the

5:22

history. Everyone would talk about how it

5:24

was like an IBM town. It

5:27

was. Yeah. And honestly, the school

5:30

was the reason that everything

5:32

got revitalized. It was fantastic. Yeah. Yeah, you could tell.

5:34

I mean, it was parts of the town at the

5:37

time I was there was pretty decrepit.

5:39

I wonder how it looks today. I

5:41

assume the school has grown,

5:43

but I don't know. Well, I was up there

5:46

last year and you can't recognize the school. It's

5:48

a good thing to have new buildings, only endowments,

5:50

everything's history. The only thing that's still there, which

5:52

is like, it looks like, was it the administration

5:55

building looks like, I don't know, like the Munsters,

5:57

the house. It's just really this ugly thing that's

5:59

still there. just

8:00

made my way into Binghamton mostly

8:02

because I did okay on

8:04

the SATs and then in college I just sort

8:06

of got to take classes that I was interested

8:08

in. So you had like med school was not

8:10

even a blip on your radar. No,

8:13

not really. My way

8:15

of choosing medicine was very roundabout. I

8:17

didn't choose it. I

8:20

didn't come into college knowing I wanted to be a

8:22

doctor. No, not at all. I came into college not

8:24

knowing what the hell I wanted to do. I loved

8:26

philosophy of all things. I majored in philosophy

8:28

at the end. But

8:31

simultaneously I didn't want to be a philosopher

8:33

because their lives seemed terrible. So

8:36

you're always like psychoanalyzing the planet

8:38

and the universe like Camus, like

8:40

please, why? And like now

8:43

because philosophy is so esoteric it's like

8:45

other fields of like academia where

8:47

it gets so esoteric that you can't even talk

8:49

to people. Like it's not like the philosophy that

8:51

I liked in high school where like let's talk

8:53

about freedom of the will or something. It's

8:55

like do you believe in strict materialism or soft

8:58

materialism? And I was like I have

9:00

no idea what that means. Right. And

9:02

so it's like you can't even have a conversation

9:04

about the things you do all day. And academia

9:06

seemed very unattractive to me. And so like medicine

9:08

to some extent was a

9:10

way for me to be like well this

9:13

is like applied philosophy. Like

9:15

I get to go in the real world,

9:17

deal with life and death and help people

9:19

and do something that's productive. And

9:22

that's like the closest I'll get to applied philosophy

9:24

essentially, which is kind of how I chose it.

9:26

Which is really not typical. No

9:29

that is not typical. Like no one gets

9:31

the med school bug in undergraduate. Yeah. Yeah

9:34

and basically that was it. I was just like you

9:36

know I want to engage with life

9:38

and death and what it means to deal

9:41

with these things. And the best way I

9:43

could see of doing that sort of going

9:45

to war was going into medicine

9:47

and that's what I chose to do. So

9:50

you went back downstate. I saw you went to Stony

9:52

Brook. I did. So you were done

9:54

with the Southern Tier for life? Yeah basically.

9:57

The weather just got to you huh? Yeah the

9:59

weather. the vibes. I mean honestly

10:02

even Stony Brook, I'm just a city

10:04

rat. Like I can't, like

10:06

even Stony, anytime I need to get

10:09

into a car to obtain

10:12

basics like milk and eggs, it's

10:14

like not my style. Even

10:17

like at Stony Brook, it was still very suburban.

10:19

You know I had to hit 60 miles an

10:21

hour just to go pick up groceries. I

10:24

like just getting out, going for a walk. I'm

10:27

just born and raised on the sea. I don't know. It's

10:29

funny because you talk to people and they're like, ah New

10:31

York is so overwhelming. I'm like, oh my god, outside of

10:33

New York is so like, boy, stop,

10:35

boy, it's not my style. Well I talked about

10:38

this all that. I mean we do a lot

10:40

of talks until we probably cross paths in terms.

10:42

I was just in Idaho. Hmm. Man, Starbucks is

10:44

slow in Idaho. I could

10:47

imagine. Like why is it taking this song

10:49

just to give me a coffee? And I'm

10:51

like, oh, I'm in Idaho.

10:56

Yeah. Yeah. So you do a lot

10:58

of talks now. What do you talk about? I do

11:02

a lot of talk. Didn't you say you talk a lot? Or you

11:04

just talk a lot? I talk a lot. Yeah, I don't give a

11:06

lot. I mean I, you know, I talk,

11:08

I've never spoken public. This is my first

11:10

time speaking publicly in which I'm recorded. Wow.

11:12

Okay, okay. Well I can make it very

11:14

inappropriate way to break to something, but I'm

11:17

not gonna say that. That's there. Thank you

11:19

for that. I, I mean, I

11:21

talk, I'm very extroverted. I can't

11:24

tell. Yeah, right. And

11:27

I do a lot of teaching. I've done

11:30

a lot of teaching my whole life. Ever since I

11:32

was basically starting college, I

11:34

started doing TAing,

11:37

teacher's assistant for in philosophy, in

11:39

biology, in organic

11:41

chemistry, if I recall correctly. And then I,

11:43

when I took the MCATs, I then taught

11:45

for the MCATs in medical school. I taught,

11:48

you know, again. Well you went hard and fast. Like

11:50

once you saw them doing this, it's like this straight

11:52

shot. Pretty much. I mean I took a year off

11:54

in the middle and did research at Mount Sinai in

11:56

their interventional cardiology department,

11:59

but That basically I just I

12:01

went straight through until I had a cord life

12:03

crisis In the middle of my residency

12:05

in which where I decided not to do clinical full-time for

12:07

the rest of my life So you want to talk about

12:10

that sure? I mean I was I

12:12

only heard like midlife prices But I guess if

12:14

you're if you live the 60 quarter life is

12:16

I don't know like that's an odd map I'm

12:18

betting on a hundred so that is 25. Yeah,

12:21

I try to be optimistic I just I'm gonna

12:23

be 15 if you're and I would love to

12:25

have a midlife crisis right now Exactly

12:28

instead of a 35. They'd reel it

12:31

into existence. Yes, exactly. So it was

12:33

so what happened? So

12:35

I was really gung-ho cardiology. So I

12:37

did cardiology Research

12:39

prior to starting medical school at Mount Sinai.

12:42

I really loved the folks I worked with.

12:44

I love the clinical sort of Way

12:48

of thinking for cardiology, it's like plumbing, you

12:50

know, it's very concrete and I really enjoyed

12:52

that and then there's kind

12:55

of two pieces There's one piece that's strictly

12:57

clinical in nature which made me decide like

12:59

I didn't want to be sub sub specialized

13:02

And then there's another piece that was more system in nature,

13:04

which is why I end up going the way I did

13:06

so The

13:08

first I guess from the clinical perspective I

13:11

came to learn that So

13:14

I was very interested in something called cardiac

13:16

electrophysiology, which wait lots of syllables. Yeah down

13:18

there tech Yeah, so that's that's

13:20

the that's the type of heart doctor that focuses

13:22

on the electricity that goes across the heart Right

13:24

when people have arrhythmias and things like that super

13:27

cool stuff very tech-heavy very

13:29

like cognitive in nature and

13:32

then You know,

13:34

I went and shadowed them for a while and

13:36

it felt You

13:38

know, no disrespect. I love that people do this stuff. They

13:40

should do it just very very In

13:43

a way, it's not so repetitive But like

13:45

everyone has a bread and butter like surgery

13:47

that they do and it's like

13:49

how many times can you burn? Like

13:51

atrial fibrillation which is like a four to six

13:54

hour procedure Is that what they snake the thing

13:56

up your femoral artery and yeah, those guys go

13:58

up the vein who put

14:00

in the stents go up the artery. Right,

14:02

my dad had that a few times. Yeah,

14:04

yeah, the stents. The stents are super common.

14:06

This sort of stuff, the ablations where they

14:08

burn, so that's like where they go

14:11

into an artery and they open it up. This is

14:13

where they go up and they burn different pieces of the

14:15

heart. They could do a lot of different procedures,

14:17

but this particular one I'm talking about, to prevent,

14:19

because your heart, basically, electricity can come from any

14:21

cell in your heart. It's not like the regular

14:23

cells of your body. It could

14:25

discharge electricity from anywhere, and oftentimes that'll

14:27

lead to an arrhythmia. One of those

14:29

arrhythmias is called atrial fibrillation. So the

14:31

procedure, it's very, very common. I forget

14:34

the numbers, but a significant proportion of

14:36

Americans over 65 have atrial fibrillation, and

14:38

under certain contexts, they

14:40

get it ablated. They

14:42

literally go up there and say, screw this thing

14:45

and they burn it out. It's amazing. It's like

14:47

a four to six hour procedure, and I'm like,

14:49

wow, I can't do this all the time. And

14:51

so, then I was like, okay, maybe I'll just

14:53

be a cardiologist. And then I did a bunch

14:56

of shadowing, and I'll never forget, there

14:58

was one cardiologist who I respect

15:01

greatly, super smart guy. I loved the way he thought

15:03

about the body, and a patient

15:05

got mistreated to his clinic. And

15:08

the patient said, well, I have diarrhea, and it's

15:10

abdominal pain. And he was like, okay,

15:13

any chest pain, palpitations? And the guy's

15:15

like, I have diarrhea.

15:17

Sir, this is the Wendy's. Yeah, exactly.

15:19

And he looked at me, and he's

15:21

just like, I

15:24

don't even know how to, and I was a second

15:26

year resident. And he's like, I don't remember. He's

15:28

been a cardiologist for 30 years. And he just looked at

15:30

me like, I don't even remember what questions to ask at

15:32

this point. I was like, okay, this

15:34

isn't my idea of what it is to be

15:36

a doctor, where you sort of lose all these

15:38

other clinical capabilities, which is totally

15:40

reasonable, right? When you get sub sub-specialized, you get

15:43

into a whole world where you're like, okay, I

15:45

don't deal with that anymore. And that sort of

15:47

melts away over time. So you want it to

15:49

be a little more general? Exactly, so I want

15:51

it to be more general. And that's ultimately threw

15:53

me off the path of

15:55

my sub sub-specializations. That was the first sort of kink

15:57

in the sort of direct shot at being a...

16:00

Cardiacal I saw you worked at McKinsey was before after

16:02

that no that was after this so basically what happened

16:04

was after that was like Okay, now. I'm like I

16:06

want to be more of a generalist. I'm not sure

16:08

how that's gonna work I'm not sure exactly what I

16:11

wanted to do and then so

16:13

NYU Are you familiar with

16:15

the NYU School of Medicine the hospitals that are

16:17

associated? I just don't like Tisch Yeah, so Tisch

16:19

is one of the three hospitals. We work at

16:22

the other two are all up first Avenue from 23rd to

16:24

33rd Tisch is

16:26

on 33rd, then there's Bellevue on 28th and Manhattan

16:28

VA on 23rd Is that what used to

16:30

be Rusk? Rusk

16:33

no, I think Rusk is like a physical therapy

16:35

thing okay. Yeah, that's up on 38 or something

16:37

like that right But anyway as

16:39

a resident we work between all three of

16:41

them and like Tisch at the

16:43

time I was there I think had the highest

16:45

profit margin of any hospital in America I think

16:47

it was topping out at like 10% the average

16:50

hospital has like a profit margin of like negative

16:54

So like they were they were a machine they

16:57

I assume they remain a machine I'm not

16:59

familiar with their current state Bellevue is a

17:01

city hospital lot of free care to homeless

17:05

I'm not like the most visited busiest hospital

17:07

in the city. It's great. I love Bellevue.

17:09

That's where I work today That's like my

17:11

like I like my heart and soul I'm

17:13

at Bellevue and then Mavia is like the

17:15

NHS like everyone's employed by the right. Yeah,

17:17

and like I would walk Five

17:19

minutes north or south and despite having

17:21

the same clinical opinions between my ears

17:24

I would practice completely differently because

17:26

the incentive structures are different the capabilities

17:28

are different and that That kind

17:30

of is what was made me think put

17:32

two and two together of like, okay I don't want

17:34

to be a sub specialized clinician and

17:37

what I do want is have the most impact So

17:39

that's not at this level anymore. It's not at

17:41

the widget making level to some extent Mm-hmm don't

17:43

mean to say that derogatory to my clinical colleague,

17:45

right? I still make well, they don't listen anyway

17:47

I'm like my dad's on the line. That's it

17:50

Yeah, so, you know that made me think like okay, I need

17:52

to get to the system side of things I really need to

17:55

get to understand how the sausage is made how things are getting

17:57

Sort of pulled around from the top and that's what Ultimately

18:00

led me to do

18:02

end up at McKinsey two and a half years later

18:04

after working for a bit So let's take a quick

18:06

break and we come back. I want to find out

18:08

like what's an MD to do at McKinsey? Hmm. Okay,

18:10

so think about that. We'll be right back friends So

18:32

what's an MD to do at McKinsey? What

18:35

the hell is that going on there? Yeah It

18:39

was quite a culture shock. That was very

18:41

very different and the truth of the matter

18:43

is is that So

18:45

the top line answer to some extent is

18:47

that McKinsey is just looking for minds They

18:51

like when you come in with different

18:53

experiences because they could train you on

18:55

the business stuff You know what I

18:57

mean? And this sort of what they call the consultancy toolkit

18:59

of like how to use Excel and build decks and things

19:01

like that Right, but like what they call now

19:04

they have all this jargon that I end up

19:06

getting embedded in my brain I'll

19:08

take my jargon button out. Yeah So

19:11

then they have what's called the intrinsic just how what

19:13

are your capabilities? Like what's your horsepower? What are you

19:15

able to sort of problems you're able to solve and

19:17

that's really what they care about So when I went

19:19

there in the beginning, you know As

19:22

after I got my legs under me I did work

19:25

on things that was relevant I was a doctor but

19:27

probably for the first six months. They just threw me

19:29

in random random stuff like You

19:32

know large IT transformation at

19:34

some private equity portfolio company

19:36

that was burning Whatever

19:38

it was million dollars a day and it was like

19:41

Okay, I'm a doctor Too

19:44

high do yeah, I couldn't sum a

19:46

column in Excel But you

19:48

learn really quick they throw you in at least they threw

19:51

me in at the deep end I don't know about everyone's

19:53

experience at McKinsey. It's a huge firm So

19:55

a lot of people have different experiences, but threw me in at

19:57

the deep end. It was like figure it out I had to

19:59

study at night about like, just

20:02

take classes on basics of accounting,

20:04

basics of like Microsoft Office. So

20:07

like how do you use Excel? It's like college

20:09

civic shit though. Yeah, I didn't know that stuff.

20:11

I didn't know what EBITDA was. I didn't know

20:13

what the difference between that and just profits were.

20:16

I didn't know what... Addressable, wait, total addressable market.

20:18

That's am. What was tam? I never

20:20

heard that term. So, you know, there was a

20:22

steep learning curve, but

20:24

that part is much... The

20:27

plateau comes much lower than anything like the

20:29

clinical world, right? Right. Such

20:31

an insane body of information. So did

20:33

this further reinforce your midlife

20:35

prices or kind of reverse it a bit or

20:37

give you a different direction? No, I think... Sorry,

20:41

your quarter life prices. My quarter, excuse me. Where

20:44

am I going to go to 100? Yeah, you just cut

20:46

my life expectancy. No,

20:48

I think it's an interesting question. I

20:51

think it reinforced it in the sense that

20:54

I really did come

20:56

to feel that this is where the

20:58

levers are pulled and understand... Not like

21:00

at McKinsey particularly, I mean like at

21:02

the administrative levels that are making these

21:05

larger decisions. And it

21:07

also made me realize or made

21:09

me appreciate that there's a

21:11

low, what the difference between that and

21:13

just profits were. I didn't know what...

21:15

Addressable, wait, total addressable market. That's am.

21:17

What was tam? I never heard that

21:19

term. Mm-hmm. So

21:22

is the supply level embarrassed to be higher? Or did

21:24

you go on the top or back? The

21:27

price is higher than the quality shelves. It's neck at the bottom. I

21:32

have a lot of questions about

21:34

financial review now. Sometimes,

21:36

I am December whist Jamie :) With

21:39

a..... Yeah, I mean. We're

21:43

both going to go to 100. Yeah, you just cut my

21:45

life expectancy. No,

21:47

I think it's an interesting question. I

21:49

think it reinforced it in the sense that

21:53

I really did come

21:55

to feel that this is where

21:57

the levers are pulled and understand.

22:00

McKinsey particularly, I mean like at the administrative

22:02

levels that are making these these larger decisions.

22:05

And it also made me realize

22:07

or made me appreciate that

22:09

there's a lot of value to being

22:12

a doctor who's also who

22:15

has that lens and that's why I

22:17

keep doing medicine. Because in my mind

22:19

similar to that cardiologist that didn't continue

22:21

to do general medicine, if I just

22:23

went into business and didn't

22:25

continue to do medicine, I'm not

22:27

really, I don't really have that feel anymore.

22:29

You know what I mean? And so that

22:31

you need the humanity. Exactly. Hippocrates matters. Exactly.

22:34

Yeah and like getting touching grass is the

22:36

kids. Yeah, like putting your hands on patients,

22:38

understanding what it means to deliver care and

22:40

like what that feels like and looks like

22:42

and bringing that back to the decision-making that's

22:44

happening. I think it's really, really valuable. Now

22:47

I don't want to, I feel

22:49

conflicted about saying such a thing because we have

22:51

a doctor shortage and doctors we

22:53

need people to do medicine. Right. So you know I'm

22:55

not like all doctors should do this that would

22:57

be a total catastrophe but for me

22:59

I felt that I could I could have a

23:01

lot of impact and sort of get

23:04

the best of both worlds for me personally

23:06

because I continue to practice which is challenging.

23:08

It's a bit of a workload but I

23:10

think it's worth it for me. So

23:12

this is a generational, so I'm Gen

23:14

X, you're like elder millennial. Yeah, I'm

23:16

dead center millennial. Right, what's

23:18

the Gen Z doctor interest?

23:20

Are you seeing a waning of people that want

23:23

to go with the medicine that are Gen Z?

23:25

You know it's hard for me to say my understanding

23:28

from just being peripheral consumer of

23:30

the trends is that

23:32

is that competition for med school remains extremely

23:34

fierce. Okay, good. And so there's still a

23:36

lot of demand. The problem is the number

23:39

of slots are limited so we

23:41

could fill up many more

23:43

doctors if we made the decision

23:45

to but medicine isn't like law

23:47

school in the sense that like you can't just

23:49

say here's more books a couple of more teachers

23:52

and train more lawyers like need an associated hospital

23:55

and like rotations and ultimately

23:57

the most biggest bottleneck is

23:59

residents. training spot, which

24:02

is not up to the free market to

24:04

decide. So there's a big bottleneck

24:06

there. So

24:08

the demand definitely outstrips supply. Having

24:11

said that, and I have

24:13

a sampling bias here, because I have this

24:15

unusual background relative to the average doctor, when

24:17

I'm working, I mean, I'll very frequently, maybe

24:20

every month or every other month, I'll have

24:22

someone from NYU School of Medicine or one

24:25

of the residents just reach out to me and be like,

24:27

hey, I'm super interested in pursuing

24:29

a similar sort of path where I'm

24:31

part clinical, part business, let's talk.

24:34

And so for me, that feels very

24:36

frequent. It feels like a very common

24:40

desire to have that sort of mix, but I

24:42

definitely have a selection bias because people are reaching

24:44

out to me because I have that background. The

24:46

one thing that I would say, however, is my

24:49

millennial colleagues that I speak with, who

24:52

are mostly hospitalists, so that's itself a selection

24:54

bias, they don't necessarily

24:56

wanna do business, but it's very, very,

24:58

very common for clinicians to wanna not

25:00

be full-time clinical, whether

25:03

they do part-time administrative

25:05

work, part-time teaching, part-time research, that's a very

25:07

common thing. Well, I'm sure it's like an

25:09

emotional diversity that balance out the burnout with

25:11

real world or tangibles. I mean, you've still

25:13

gotta go home at night and hug your

25:15

family or if you have, but whatever it

25:17

is, you need to be you at three

25:19

in the morning. Yeah, yeah, and the

25:21

thing that I think is also that I

25:24

didn't really understand until I got

25:26

into business side of things

25:28

was when you work in the

25:30

business side of things, I'm sure you know, right,

25:32

as you built out this organization, is the

25:34

decisions you make yesterday can

25:37

pay you back tomorrow if they were

25:39

good decisions, like it compounds your work.

25:42

Like don't have the Twinkie. Yeah,

25:44

exactly. And the

25:47

problems that you solved can go over

25:49

months, years even, right? Medicine, once you

25:51

get out of training, you

25:53

are like the next patient, the next patient,

25:55

the next patient. It's very volume focused. And

25:57

you watch Seinfeld, I assume. Yeah, sure. You

26:00

know that episode where Newman Jerry asked

26:02

Newman like You know

26:04

Newman why why is it always the postman that like

26:06

go on shooting sprees? although that was kind of a

26:08

meme that doesn't exist anymore, but I used to be

26:10

a kiss and Newman is like

26:13

well because the male comes in you take it out

26:15

and the male comes in you take it out All right bugs

26:17

out and creamers like Newman and it's like oh,

26:19

it's funny at the time and then in

26:21

hindsight I'm looking at I'm like, yeah, I

26:23

think that's probably a big driver burnout for

26:25

gradations like rinse repeat rinse repeat Yeah, when

26:28

it's a volume. It's it's a weird volume

26:30

game. It's like a volume game where you

26:32

have essentially zero upside I

26:34

mean the upside is you help a person right? It's

26:36

not like you're gonna get paid more advanced in your

26:38

career or anything like that if you really do a

26:41

great clinical job No one has no one even knows

26:43

But isn't the volume job now a

26:45

little more strict and mandated than ever was before you could

26:47

you don't get to spend the time With a person you'd

26:49

like to yeah, I mean it's it's

26:51

not really a mandated thing. It's just it's the incentive

26:54

structures that exist Yeah, you don't you don't yeah I

26:56

mean depending on the type of clinician that you are

26:58

but the most common clinicians that the average person is

27:00

seeing is yeah they don't get to spend a lot

27:02

of time with their patients is

27:04

because the incentive structures don't allow it and And

27:08

that's tough. I think that that's that's a big

27:10

burnout and the truth of the matter is each

27:12

patient has significant downside risk So that's really stressful,

27:14

right? You could fuck up like you could really mess

27:16

up and you could hurt somebody and you do that over

27:18

and over and over and over again I Don't

27:21

know to me I don't know when I hear people talking

27:23

about burnout and I think it's partially true is like they

27:25

talk about the charting and the Tech and this stuff and

27:27

that is annoying But I think that

27:30

the the cadence of the work is

27:32

really could get really draining Is

27:35

there any data? I mean, it's maybe a loaded

27:37

question Is there any data as I asked this

27:39

naively that would substantiate

27:41

that this incentive based volume is

27:44

a detriment? to wellness

27:46

and outcomes You Know

27:49

I know that I'm familiar with I have Mackenzie. Yeah,

27:51

they might have something. I mean, I think Intuitively,

27:54

it just makes tons of sense, right? You Don't

27:56

give people the time and opportunity to think about

27:58

things you turn everyone's triage monkeys. The words with

28:00

like do you fit the box of what I

28:02

do yes know if now go to somebody else

28:05

my own for the patients. This is crazy fragmentation.

28:07

No one sit down just thinks about what's happening

28:09

to you. The other thing that you could look

28:11

at is just kill. Top line numbers Pride like

28:13

America. Is. Doing all this

28:16

tree as any between different specialties. And.

28:18

You're not seeing the top light. Outcomes: Very

28:21

helpful. I I have lot of conflicting opinions

28:23

about that, but I think that it doesn't.

28:26

It's that the dispositive or anything. but

28:28

it's.adeptly think it seems to be driving

28:30

it doesn't it's not driving their address.

28:32

That ago. But. We're going to get into

28:34

insurance sukkary cause you're at Oscar. By the

28:36

way, the show not sponsored by article says

28:38

an honest conversation Here it is full disclosure

28:40

or manager I don't speak on behalf of

28:43

I've known on I went out when I

28:45

think that but it sure as fuck are

28:47

you something about another had about and I

28:49

see this phrase a lot and I've always

28:51

been sort of contrapuntal to it. It's not,

28:53

But I don't believe that here in America

28:55

is broken. Notice. I believe

28:57

it is working by design as A

28:59

and it is the responsibility. Like anything

29:01

else in government you don't like. To.

29:04

Fuck back. As voters,

29:06

as citizens and as activists. But it's

29:08

harder than ever to know how to

29:11

do that. Yeah. Yeah,

29:13

I mean, I agree with that. I think

29:15

that I think that there's a compounding problem,

29:18

which is, I don't think it's very clear

29:20

what to do, right? I think I'm There

29:22

are good examples outside the United States that

29:24

go. Died. And go better.

29:27

Ah is not quite single malik is

29:29

used for a single person fiber probably.

29:31

Net net is better than the Crazy

29:33

Sir Frankenstein. Have a system that we

29:35

have today but probably optimal the something

29:37

more similar to to like Germany. israel

29:40

also as similar as early as it

29:42

is insist the astro as well worth

29:44

like privately run highly regulated but universal

29:46

nature my so you maintain these incentive

29:49

structures are you going of the amex

29:51

platinum yes exactly as you'd like is

29:53

like idol the exactly so you at

29:55

so everyone wants universal care so we

29:57

don't accomplish as that major failing grade

30:00

And then but then the question is the cost at

30:02

which you do it and this is a very very

30:05

tough question That I think

30:07

so definitely weird. There's a tremendous amount of

30:09

waste in the American healthcare system. Oh, really go

30:11

on I think it's a

30:13

quarter on the dollar is assumed wasted Probably

30:16

higher than that. But like, you

30:18

know, there's other pieces of it that are harder

30:20

to disentangle like for

30:23

example, we just are wealthier

30:25

and so You just

30:28

see a strong correlation between wealthier countries

30:30

spending more on services including health care,

30:32

right? I don't defend the system, but

30:34

I articulated it this

30:36

way Nothing can help 330

30:38

million people a day every day Nothing

30:43

can help 330

30:45

million people that need health care every day in this

30:47

country. Sure. Yeah, like I'm just making For

30:50

arguments sake. Yeah, name me anything

30:52

on earth that can serve that

30:54

many people Every single

30:57

day. Yeah. Yeah. No, I agree in that

30:59

and at the end that was gonna be the second

31:01

point Like how do you disentangle? what

31:03

I don't know what I may be callously called the

31:05

substrate right like the the people

31:07

like there's like if you took the American

31:09

population with an obesity rate of 30 35

31:12

plus percent and Then

31:15

expose the Japanese health care system to that

31:18

Which has a obesity rate of like sub 3%

31:20

or something like that. Mm-hmm How

31:22

much would that system cost? Well, we don't know

31:24

right like so to say that the Japanese spend

31:26

so much less than we do It's not an

31:28

apples to apples comparison really so you have to

31:30

correct for the rate for the rate of disease

31:33

Which is I haven't seen the

31:35

study that done it personally maybe it exists, but it

31:37

seems very challenging to do that So to

31:39

me, you know, as you said, I actually like that

31:42

because at the end what takes care of 330 million people a day is

31:46

Themselves making decisions every day and having

31:48

a culture of walking more

31:51

Yeah, that can make I was talking to a

31:53

friend of mine earlier. I mean as of this

31:55

recording like earlier today That

31:58

if you compare Certain

32:00

off-the-shelf products in the supermarket

32:03

in any of the country it would be

32:05

banned if the American version was

32:07

there Yeah, and

32:09

only in America can we have a

32:11

more toxic version of potato chips Then

32:14

and even something as simple as like

32:17

I think pathogen free meat is mandatory

32:19

in Europe Versus

32:21

there is no pathogen free mandate

32:24

of anything poultry meat or fish in this

32:26

country Okay,

32:30

you know reminds me of my favorite little factoid

32:32

of that was that like there was

32:34

some mandate or requirement I forget if it was

32:36

a state New York State government. I guess it

32:38

was maybe New York I don't remember which which

32:41

government was that was like in schools

32:43

They have to serve a vegetable a day and so

32:45

they ended up trying they ended up getting

32:47

tomato sauce Well, what Dan

32:50

Quayle said ketchup was a vegetable remember

32:52

that something along those line where it's

32:54

like I think technically tomatoes are a

32:56

fruit and So

33:01

yeah, that's I totally agree that there's Let's

33:04

say systemic constraints to people changing their

33:06

culture, but you know top line

33:09

I think it's a very challenging problem to say

33:11

how can we become the same

33:14

cost with the same outcomes as

33:17

Societies that are completely different than ours. I think that that's

33:19

a very Under

33:22

under appreciated question. I don't have an answer

33:24

Well, there's also Different incentives on the part

33:26

of the people that are in charge of

33:28

whether you are gonna get the medicines that

33:30

you need and The

33:32

hubris to assume that if my

33:34

doctor says this is best for

33:37

me What right does this

33:39

company have to say? No you have to

33:41

go on this shittier one and Not

33:44

do as well until you're fucked up enough to

33:46

go on the one that your doctor thinks you

33:48

should be on Yeah,

33:51

it's it's a really You

33:54

know there this is a really double-edged sword that as

33:56

a doctor and so funny because I see the both

33:58

sides of it Now because I'm practicing and clinician where

34:00

I have to get on the phone with insurance

34:02

companies and argue with them to get

34:04

my patients the things they need. And oftentimes we already gave

34:07

them the things and now they're just saying they don't

34:09

want to pay for it. I'm like, hey, you're gonna bankrupt

34:11

them. Like this is totally unacceptable. And

34:13

then on the flip side, now I'm in the insurance

34:15

side. And the truth of the matter is

34:17

that there has to be some degree of

34:19

utilization management or else costs just go through the

34:21

roof. And so like, because

34:24

doctors, so this is like

34:26

the classic sort of setup for why value-based

34:28

care medicine is like supposedly

34:30

the cure-all for things. I use- Supposedly. Supposedly. I

34:32

used to be a very big VBC evangelist. Again,

34:34

I do not represent how I'm hearing any way

34:37

you say before. And I've become

34:39

a little bit more cynical about it over my

34:41

time on the business side of things, but there's

34:44

misaligned incentives in the insurance

34:46

industry. So to put it super like

34:49

basically, when you buy an iPhone or buy any

34:51

phone, you want the battery

34:53

life to be very long and it

34:55

to do the things you want. And

34:58

Apple and Samsung want that, want to give you

35:00

the longest battery life, right? Like you're totally aligned

35:02

incentive. They want to give you the cheapest best

35:04

product you can get. Medicine is not

35:06

like that at all. It's like, okay, you

35:09

pay into a payer, which

35:12

is an insurance, typically insurance, but it could be

35:14

the government, right? You pay into it and what

35:16

they want to do after they get your full

35:18

dollar is pay out as little

35:20

of that as possible and still charge you for

35:22

going to the doctor as well. Yeah, fair. But

35:24

then what the doctors want to do is get

35:26

as much of that dollar as possible. And

35:29

then what do you want? Well, you don't care about any

35:31

of that. You just want to be healthy. Well, it's like

35:34

we're never the end user. Exactly. So

35:37

the incentives are in line with the patient. And

35:39

so like the thing that I thought before going into

35:42

the business side of medicine was like, I thought the

35:44

doctors were the good guys along with the patients against

35:46

like the system. And then I got

35:48

there and I was like, and it's not the individual daughters.

35:50

I've never met an individual doctor who

35:52

makes decisions consciously. It's not in the best

35:54

interest of their patients. I'm sure that happens.

35:56

There's fraud, there's abuse. Those

35:58

are called douche bags. Those are assholes, but

36:01

like the like vast majority I've never met

36:03

one who wasn't just like literally completely focused

36:05

on helping their patient as they should be

36:07

but the system the providers Yeah, they

36:09

they are not good actors. No They

36:13

are not they are not driving the system in

36:15

the direction that we would want And so they

36:17

they have a very strong incentive structure to over

36:19

utilize. All right, let's but end on a positive

36:21

note Yeah, tell me something good

36:23

that you've witnessed since your time in the

36:26

insurance world. I Think

36:28

I think one good thing is very similar to

36:30

the doctor thing where like people want to help

36:32

people so like in care management You

36:34

know We have these concierge teams that

36:36

get on the phone and help like

36:39

the systems crazy complicated, right? Like it's

36:41

super duper complicated and like when

36:43

a member calls and they're they're having challenges

36:46

Figuring out what's covered who covers it? How do

36:48

I get this covered and like they

36:50

work through it with them and help them because

36:52

like as you said none of the Individuals can

36:54

change the system right, right? So they're

36:56

just like in the trenches with them and I see

36:59

that all the time actually at Oscar We have these

37:01

all hands things where we always have this like member

37:03

success story where someone's like talks about how they've helped

37:05

out These members and I find those really quite inspiring.

37:07

I really think that that's

37:10

what that's really where why it's important to

37:12

continue delivering care because Get your

37:14

hands on people make sure you're remembering that this is

37:16

for the benefit of human beings who are

37:18

suffering Well, you

37:20

know the club you never wanted to join

37:22

no matter what it is and progress What

37:25

do they say the moral arc of progress

37:27

is not a straight line or so that

37:29

bends towards justice There we go. The arc

37:31

of progress is long but bends towards justice.

37:33

I think something along those lines Well, we'll

37:35

get course corrected by my listeners. But anyway

37:39

Doctor Adam Harris are gonna read this again for the paper

37:41

clinical assistant professor Department of Medicine NYU Grossman

37:44

School of Medicine and senior director of strategy

37:46

and operations at Oscar Health and a

37:48

Binghamton Alumni to boot

37:52

All right, go bear cats. Thank you my friend. All

37:55

Right later, friends. See you next time. Out

38:03

of patience with Matthew Zachary. Is it

38:05

Off script Health Production The executive producers

38:07

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