Tech Uncensored - An Altitude Accelerator Podcast

Samie Husain

Good afternoon everyone and welcome back to another session of Tech Uncensored. My name is Samie Husain and today we're going to talk about the healthcare system. Is it broken? We don't know. There are a lot of conflicting messages out there. But I've got the right person to talk to. Today, I've got doctor Rishad Usmani, an urgent care physician, an entrepreneur, and an Angel investor. Thank you Rishad, for coming on the show.

Rishad Usmani

It's great to be here Samie, I am excited for this conversation.

Samie Husain

I'm going to just give you an example. I'm going to talk about what happened to me, a personal experience. I mean, I grew up in Saint Catherines, a small town. I had two doctors my entire career. The only reason I got the second family doctor is because the other one retired. And it was a very personal relationship. The doctors spent time with you, they got to know you, they know your whole family. And now we fast forward to today. Doctors don't want to get to know you anymore. It's like you're going through a numbers game. You just gotta keep going and everyone's going through there and they want to get as many patients through. You feel like “where has the personal aspect gone to? Where has the healer gone?” It was such. It's such a noble profession. And I just feel some of that has been lost right? And you know in the long wait times for specialists.... I had to go see a specialist myself for my asthma and it took eight months. So I'm going to turn it over to you. Is it broken? Am I wrong in what I'm saying?

Rishad Usmani

Yeah, I think that there's a lot to unpack there. I'll start by saying no system is broken. It's perfectly designed to produce the results it's producing, and that's a code from quality improvement from Don Berwick. Medicine and medical knowledge doubles every five years. So if you think about it, we have to know about 12 times more than we had to know 20 years ago.

Samie Husain

OK.

Rishad Usmani

Are you getting interference as well?

Samie Husain

Yeah, I'm going to just mute myself, Rashad, because my fan is going on. Hang on here.

Rishad Usmani

So the amount of knowledge we have to know has grown exponentially over the past 20 years. That coupled with the administrative workload and burden, electronic medical records, more insurance paperwork than the way our notes are supposed to be now, has added quite a bit more on our plates in terms of the amount of work hours needed. As a recent study shows, we need 26 hours in a day to take care of the patients that we currently take care of with the same volumes. So obviously we can work 26 hours a day. And I think that's why we're seeing a shift in physicians practicing in an environment which prioritizes volume and the reimbursement structure encourages that. The way we are rewarded financially in medicine is by seeing more and more people and we get paid per consult. We make about $25 per consult after overhead. If you think about it, given our training and our opportunity cost, that's not a whole lot and that's why people are seeing 40-50 people a day.

Rishad Usmani

So I'll stop there. I mean, I hope that provides a bit of context why this is happening. I'll add one more thing. Most issues are system issues that are individual issues and we should look at systemic changes like changing the reimbursement structure, changing the amount of patients we take on over a year to look at improving the system. I do agree with a lot of what's being said in terms of team-based care with physicians as managers of teams as likely the future. But again the reimbursement structure, the decision-making structure and the liability structure all have to follow in accordance to that.

Samie Husain

So that's interesting. I'm glad you said that that. You spend so much time on paperwork and you know that would not have occurred to me. I would have thought that there's an admin. I don't know why, but I thought an admin person in the background was doing that for you.

Samie Husain

I agree that $25 just does not make sense particularly the amount of investment. And you know very few can go to medical school. Let's face it. It should be a very rewarded area as well. So what's the solution to that?

Rishad Usmani

I think when you dig deeper into problems in healthcare, you always land on reimbursement. Prevention is cheaper. To give you an example for lung cancer, delayed diagnosis and treatment is about $250,000. And early diagnosis and treatment is about a couple thousand, so there's a big gap between the cost of treatment and the cost of prevention. The problem is you don't realize those savings for years down the line. So we live healthier lifestyles if we don't smoke. We're not getting lung cancer, or if we do smoke, till well into our 60s and 70s. And given the way funding flows and given the time spent of when organizations, government insurance payers want to save costs, it's hard to design a system which incentivizes prevention. Showing the financial ROI will not be captured for 40 years.

Rishad Usmani

So I think if we can solve that problem, everything else will fall into place in terms of incentivizing prevention. We'll have more physicians working in primary care. We'll have more and more monitoring softwares telling us, you know, are you getting good sleep? Are you eating well? Are you walking enough and then providing us the appropriate positive reinforcements to encourage healthy behaviours. There's a lot to unpack there. The immediate solution that is being proposed is expediting licensure for IMG's, International Medical Graduates, people who graduated abroad. I think that's a noble thing, and I think that's needed but it's a Band-Aid. If you look at the per capita of physicians in Canada, it's not too bad. We have 1.2 family physicians per thousand patients. The problem is more than half of them are not working in outpatient longitudinal settings. Now if we expedite the licensure for these IMGs.

Rishad usmani

I can't hear you, Sam.

Samie Husain

What does that mean in outpatient longitudinal settings?

Rishad Usmani

So what you described. Like having a family doctor, what we call cradle to grave care.

Samie Husain

OK

Rishad Usmani

From when you’re baby to your end days.

Samie Husain

OK.

Rishad Usmani

We're all practicing in that setting because the reimbursement model doesn't encourage it. So you can throw in as many physicians as you want. They're still not going to choose that setting. And some of them might, but I think it's a Band-Aid solution that's going to last a few years, and unless you just want to do this cyclical care, where we just keep bringing in IMG's. And again, I'm an immigrant myself. I'm a proponent of immigration. I think we need a way to do it, but it won't fix the lack of people not having a family doctor.

Samie Husain

So what if fixing this means giving doctors an opportunity to set kind of a benchmark about how many patients they see and paying them a flat salary? Was that the solution?

Rishad Usmani

So I think value-based care where value is measured by the process as family doctors have in place and not only the outcomes is the answer. If you place the value on the outcome.... so say weight loss is a perfect example for this. If you incentivize people for a strict BMI, they will starve themselves. What you want to incentivize is a good diet and exercise. If you take that analogy to healthcare, you want family doctors to be available to their patients. And to just provide the access to care that the patients need. The way to do it is I think should be around 500 patients. Right now it's routinely anywhere from 1500 to 2000. And what happens is because it says there's so much we can't provide good care because there's too many people to provide care to. We don't feel good about ourselves. This is not to like play the victim, so to say. But that leads to more burnout and then we work less. So many physicians trying to find ways out of clinical medicine because they're not finding clinical medicine sustainable in the way it's designed right now.

Rishad Usmani

So yeah, I think a team-based care and it's OK for us to have 2000 patients if we can hire nurse practitioners, physician assistants, even clinical assistants who are IMGs to facilitate the care provider. Right now as it stands is we can hire nurse practitioners, but we can't bill for them. So essentially we can't hire them. We still have to see every patient. So I think if they could just change that, we could bill for nurse practitioners. It would open a lot of doors for a lot more people to get family medicine care. Now, the caveat there is if we do it for family doctors and specialists, again, specialists get paid more than nurse practitioners, we’ll go the specialist route. The key is to increase the value of family medicine, both from a societal perspective but also financial perspective compared to specialists. And this is a staking point. Where I think not a lot of people will agree with me.

Samie Husain

Yeah, because specialists presumably make what? A lot more? Significantly more?

Rishad Usmani

Yeah. So in an urgent care setting and internist would bill $84 after 30% would take home 55 dollars? 50 dollars? Whereas I'm taking home $25. After all, it's double for providing the exact same service. And you know, part of that is they have more training. So they do two more years of training. Now they're extending family medicine residency for three years, which is another thing I don't agree with because if I can train one more year... and we've already trained 12 years at this point. So if I can train 13 years instead of 12 and make double per patient, why wouldn't I do that?

Samie Husain

Yeah, of course.

Rishad Usmani

It doesn't make sense to train the lesser amount.

Samie Husain

So if it went to this model though than you would require more doctors. Would you not? Because you'll be seeing fewer patients. It would be a more holistic way and more going back to the roots of why you went into medicine presumably, right? So you would require more doctors into the system then we would have a shortage, would we not?

Rishad Usmani

No because if majority of doctors took on 2000 patients... say 50% of us took on 2000 patients and had nurse practitioners and PA's, we would cover the whole population. As I said earlier in this podcast, the ratio is 1.2 family doctors per thousand patients. So if you know 0.6 of us took on 2000 patients that works out to we cover the whole population. The problem isn't the exact number. Now with an aging population you can say as family doctors retire and physicians retire and our population grows, there will be a shortage. But if you take a snapshot in time right now the problem isn't necessarily the number of doctors, it's more how they're practicing, how many people they're taking care of because the work is not sustainable.

Samie Husain

And is that why doctors are not locating to more rural areas where perhaps you're not going to be able to see that the number of patients and... I mean the study showed that the health issues there are far more acute in less affluent areas than they are in affluent areas. That's a different problem. But how is that being addressed?

Rishad Usmani

The problem with the rural area is..... and in some places you only need one doctor to take care of the population. If you lose that doctor you have no doctor. If you look at the percent or the numbers of people who don't have a family doctor, it's the same. And I think the rural population is more societal of where people want to live. I like practicing in rural medicine way more than urban medicine. The medicine itself, the science and the cases you see is just more rewarding. And you do get a bonus. In BC it's up to 30% on top of what you make. In Ontario the bonus isn't as much, but they give you stipends, they give you incentive bonuses and some of the places are giving you 100,100 and 50,000 over four years which is a decent amount, but I think that is more to do with that some people are city people, some people are rural people.

Samie Husain

So from a specialist perspective, why is there long wait times there? Surely they're not seeing the same amount of patients.

Rishad Usmani

So it depends on the specialist. So we can talk about psychiatrists, and I know a little bit about this for my startup. I looked into this. The ratio of psychiatrists to the population on Ontario is 1 to 7800. Which is an OK ratio. The ratio it should be is between 7500 to 10,000 to one psychiatrist. But again, less than half of them are practicing in outpatient settings. A lot of them are working for hospitals, but also a substantial amount are working for private insurance companies. You get paid better, you have better lifestyle, better work life balance; which is different from surgical specialists in which there is an over-abundance of specialists, but there aren't enough jobs in Canada. Plastic surgery, orthopedic surgery are a couple of examples here where the OR times are so restricted, partly because of politics, partly because of nursing staff, that the specialists don't have jobs. I did my residency in Campbell River, which is a town on Vancouver Island. It's called “salmon capital of the world”. But you know, small town like 25-30 thousand people. They posted an opening for a plastic surgeon and they got 10 responses in two days. And these were people who were Harvard, Yale trained wanting to work in Campbell River, which is not too like harp on Campbell River, it's a beautiful place and UBC is a great school. But you wouldn't expect that. You wouldn't expect that there would be an abundance of specialists, plastic surgeons who have trained five years of residence, sometimes have done some specialties wanting to go to Camp River because there are no jobs.

Samie Husain

That's sad to hear.

Samie Husain

But what about the ones that there are like for instance for me when I had to go see my respirologist or for my mother, who has been waiting eight months for cataract surgery. So that hasn't happened. In fact, she told me last week she's been booked. She's going to cataract surgery. And then my sister called me and said no, no. She's going in for a consult. Hasn't been booked yet.

Rishad Usmani

So I mean, I'l call in a colleague, Mike Warner. He did a great video on this. And how are all ORs close at 4:00 PM and they're not open on weekends. So if you could just open the oil, especially they want to operate. They are surgeons. They like operating. That's why they train for 17-18 years total. And since they don't have the ability or the operating room available to them to operate, I think that's the easiest fix. The other answer I would give is because specialists don't have jobs, they leave. They go south of the border, they establish their lives there. And once someone is settled, you have kids. It's hard to move once you're settled and your kids are settled in. You know, like my daughters daycare is down the road. I have to have a really strong incentive to move at this point.

Samie Husain

OK, so let's talk about what Ford is doing. He wants to privatize. There's some disrupting technology that's coming out where they're doing online healthcare, yeah. Are these models sustainable? I don't understand what Ford's plan is because he says he's privatizing, yet he's saying don't worry. The system will still cover it. How is that different than now. With the online healthcare why would the problem go away?

Rishad Usmani

So I'll speak to both issues. For the privatization our healthcare is publicly funded, but the vast majority is privately delivered. We have more privately delivered healthcare than the states. So in some sense, we're more private than the states. Although the funding is where usually when people say private care, they mean private funding, not private delivery. What private delivery means is you could open a hospital and we have lots of hospitals like Mount Sinai which are private hospitals. But you bill the government and you're not allowed to bill the patient directly.

Rishad Usmani

What he's doing is essentially saying you can open your hospital and bill the government. The main problem people have with that is, well, where will the staff come from? But if there are surgeons who are looking for operating room and the current hospitals are not providing it, then yeah, they will go to the private centers. Now a much easier solution is just to open the public hospital hours for a longer time frame so you don't have to build a new facility and fund it and waste more taxpayers money. For online care we had these codes we were billing in COVID, billing codes for OHIP. So how billing works is when you go see a doctor, we bill the government and then they pay us. Before COVID, we didn't have virtual billing codes outside of a specific network called OTN. But during COVID they opened these codes as I could just call a patient and I could bill. And I could bill the same amount I would get as opposed to in person. So this led to some abuse from family doctors where they would just build 80 consults a day, and you can't do 80. And they would do them, but they just cut them really short. The billing is based on an honor system. The audits are kind of frequent, but like if you're a high biller and then they'll kind of go audit you.

Rishad Usmani

What happened with this is I think I don't know why they made this decision, but they cut the billing codes to about 1/3 of what they paid previously. So now essentially online care and the public system doesn't exist. Because from my perspective it takes the same amount of time, aptitude, mental energy to do a phone call with the patient as opposed to see them in person. If anything, I'm much faster in person because I can examine you. If you come in and you're saying, you know, “My belly hurts, my throat hurts,” I can look. Whereas if you're on the phone, I have to ask you a lot of questions and maybe have to ask you to push on your belly on different spots. So it takes longer almost to do a phone consult than an in person in some instances. So what a lot of physicians are saying is they're just not offering phone care, and they're saying, ‘you know, we can provide better care in person and we will just do that.’ So now inadvertently the access to online... and I think this is terrible for rural communities specifically. Because they're the ones most affected. When I run my telemedicine company, a lot of my patients were from rural and, they were very thankful because if I wasn't there or if one of the physicians we hired weren't there, they would have to drive an hour or two to the next clinic.

Samie Husain

That's a good point. So there is a role for telemedicine. It's just that there's also a danger of it being abused. I certainly have seen it myself where my doctor will call me for a 2-minute call and then go to the next call. How are you going to do a physical on the phone with me? I mean there are people who are just going to believe it. But there's people like us. We're going, ‘OK, this is just being abused.’ Right? I know people like you who are offering real value and services and as a result of these outliers it gets cut. So you think the root of telemedicine, and we see tech startups that are doing this telemedicine..... You think that it's not viable?

Rishad Usmani

No, I think definitely a digital first home-based care model would be an amazing innovative process. It would allow people to get care in their homes. When you're sick you don't want to go to urgent care or an emerge or a hospital even. You want to stay home and be taken care of at home. We have the technology to do it. We have the medical knowledge to do it. It's simply we don't have the reimbursement structure to provide that care. I think that's the answer. I think we can screen better on the phone. Now the caveat there being some people will abuse it and maybe there needs to be more monitoring or more structure around it and say, if you're vomiting, come in. Don't allow that code to be built virtually. But if you need a refill on your blood pressure medication and you saw your doctor last month and I have all the information I need, then I don't need to see you we can do it over the phone. So I think the digital first home first care model should be the future. I don't know if it will be the future, but I think it should be.

Samie Husain

It should be the future. Well, that's good to know. So in emergency rooms, why are there long wait times? Why are there 22 hour wait times on average?

Rishad Usmani

Yeah, I mean the biggest reason is lack of access to primary care. People are going to emergency rooms when they don't need to. I think that's kind of the short and sweet answer there, yeah.

Samie Husain

But then I mean, I know there's some outliers where people have died in the emergency room. I don't know if this was just a one off or it was an error. It doesn't make sense because I would think that somehow these patients would get triaged.

Rishad Usmani

Yeah, I think there's a couple of things here in which the system is designed. And it goes back to about 20% of people admitted to the hospital don't need to be there, but they're there because there is nowhere for them to go. And that's because we don't have enough nursing homes, enough community, home care, infrastructure for those people to be discharged. And that follows downstream, where people are admitted to the hospital but still in the emergency room because there's no bed for them upstairs. There's no bed for them on the ward. And that goes further downstream is for an emerged physician to take care of a patient, they have to be in the emergency room. So if you're waiting in the triage bay or in the emerge...... yeah, like a nurse will lay eyes on you once in a while. But unless you're coding, or unless you get really sick, you're not going to get continuous care because you're not on a bed. The other thing is the way our paramedic system works is the paramedics have to take the patient off the stretcher, onto the hospital bed before they leave, and they have to do a sign out. If the hospital doesn't have beds and these paramedics are stuck as well. And they can’t go out in the community and provide care. Again, going back to incentivizing care at home would help here. I don't know enough about do we have enough emergencies room spots or capacity. Your intuitive guess would be we don't, but I can't comment on that with accurate numbers because I don't have that information on hand.

Samie Husain

So the problems you're highlighting I can see it's almost a cascading effect if you don't fix this here, it's just going to trickle all the way down the whole stream, the vertical stream here. But even the private model that's being suggested by the province of Ontario, the billing directly to the government, I mean, isn't that what we do now? Isn't that what doctors do now anyways? So what's changed? I don't understand what's changed.

Rishad Usmani

Yeah, nothing.

Samie Husain

How does it make it better?

Rishad Usmani

It allows people to open more facilities so we can open clinics and bill the government, but as it stands right now, I cannot open a hospital and bill the government. I need approval or I can't open a surgical center and bill the government. So now they're allowing more people to open surgical centers and bill the government. So in that sense, people will get more surgeries, but I think the problem I have with the system is if it's public funded, it should be public delivered and care should be streamlined. When you get all this decentralization techs here, but all this segregation of scattered care, their incentives aren't aligned. And it leads to more inefficiencies and misuse of and misappropriation of funds. I think the private system could work with the appropriate structures in place. And I like the Swiss system here, in which everyone is mandated to have health insurance, but you have to pay for it. If you can't pay for it, then the government will subsidize you. It does create some tiers of healthcare, so you can pay for faster access. Obviously you can't pay for faster access if you're having a heart attack. Everyone who has a heart attack gets the same access. But say you have acne or something cosmetic, which again not to pick on acne cause it can have very real mental health effects. But say you have something that most people would agree or your belly hurts when you eat once every week. Something that is less or not as significant people can pay for expedited cares instead of being seen in a week, you could be seen today. That in some ways goes against the Canada Health Act. Now the Canada Health Act only applies to physicians. It does not apply to nurse practitioners. It does not apply to pharmacist. It does not apply to physician assistants. So the way around that could be..... because I think changing the kind of Health Act or removing it is too big of a project at this point. But yeah, I think a tiered system like that with rules in place saying that, you know, you can't expedite care for heart attacks. Everyone needs to get the same efficiency and speed of care delivery for something like that. That could work well here.

Samie Husain

In a perfect world or your solution, if you could go to a Ford or to Trudeau and say ‘this is what we need to do. These five things’ what would they be?

Rishad Usmani

So I think that the Swiss system borrow from that allow people to pay a little bit more for more care in a structured manner, change their reimbursement for primary care, allow us to bill for nurse practitioners. I think just those, even if they just change their reimbursement primary care and allow us, but only primary care to bill for nurse practitioners. Because what you want is more physicians to choose outpatient longitudinal primary care. That will ensure that the 20% of Canadians who don't have family physicians get them. I'll keep it simple. Just do that one thing.

Samie Husain

Well, Doctor Rishad Usmani, thank you so much for taking the time to chat with me at Tech Uncensored. As always, I will be in touch with you, but thanks and have a great weekend. I think we've got a snowstorm coming, so stay safe.

Rishad Usmani

Yeah, it's been a pleasure Sammy. It was great being on today.

Samie Husain

OK. Thanks a lot. Take care.

Rishad Usmani

Bye.