Mark Cuban: How I’d Reform Healthcare If I Were in Charge

“That’s what this whole conversation is about — how can we get doctors to be able to golf on Wednesdays like they used to?”

Mark Cuban is a business mogul, the “Shark” every entrepreneur wants to make a deal with, the former owner of the Dallas Mavericks, and, most recently, an online pharmacy CEO. In 2022, Mark co-founded Cost Plus Drugs in an effort to lower prescription drug prices. The direct-to-consumer company makes generic drugs affordable by cutting pharmacy benefit managers out of the distribution chain.

But, once Mark starts talking about tackling the pharmaceutical market, you get the sense he has his sights set on an even bigger goal: reforming the healthcare system at large.

Offcall co-founder Dr. Graham Walker recently got the chance to interview Mark on How I Doctor, a podcast that explores the lives and careers of physicians who are practicing medicine differently. Mark, of course, is not a physician. But, as Graham notes, “I'm talking to him because I think he actually gives a damn about healthcare, and more importantly, he's doing something about it.”

Mark pulls no punches in this episode, and frames American healthcare as a David- and Goliath-style fight between good and bad actors.

Physicians are on the good team: “I happen to be a fan of people who save lives and make other people feel better, you know? Call me crazy.”

Who’s on the bad team? Anyone trying to game the system and extract money from it for their own benefit — insurance companies, hospitals, private equity firms, and others: “In healthcare, that $4.9 trillion wherever anybody can arbitrage whatever they can out of the system, that's exactly what they are going to do.”

With clarity of conviction and a hard-charging spirit, Mark shares his vision for how to fix healthcare. Here are nine ways Mark would change the system if he were in charge.

1. Pay doctors more

“Let me just tell you: Doctors are underpaid. When I look at individual bills, like a heart transplant: $25,000. Amount paid to the doctor: $2,200, for literally taking a heart out. If I’m getting a heart transplant, I want that motherf*cking doctor to make $10,000, so that he or she is paying attention, and not worried about getting to the next heart transplant or worried about the patient who’s got a boo-boo. It’s a f*cking mess.”

2. Criminalize insurance practices that screw over doctors

“Insurance companies are the worst of the worst of the worst of the worst of the worst. If you look at how insurance plans are designed, it should be criminal. It’s the antithesis of trying to optimize for patient care. If they design a high-deductible health plan and they make it available to somebody with a take-home pay of $25,000, and there's a deductible of $5,000, [doctors] are screwed. Even if the patient is broke as a joke and doesn't have two nickels to rub together, you still have to care for them. That risk of debt default is something [doctors] have to take on and now you're the one also responsible for figuring out a payment methodology if there is one.”

3. Make medical school 100% free

“Would it be worth it so that we can expand — not only expand, but also make med school free? So you truly get the best of the best as opposed to the best of the people who can either afford it or are willing to take on the debt? If you put me in charge, I’m like, $24 billion is nothing, but it changes the dynamics considerably to improve the quality of care.”

4. Eliminate residency programs to help stem the physician shortage

“If you can add 10,000 doctors and there were residencies for them, or you create a different program that doesn't require a residency, you're just an apprentice in a primary care organization, great. You have to deal with some of the most simplistic things first.”

5. Get rid of prior authorizations

“Prior auth is designed to drive doctors crazy. But here’s the real reason: If you have a billion dollars a year, let's just say you work through prior auths and you just extend them as long as you can, 4% of that is a shi*load of money, that's $40 million. If you're a bigger insurance plan, it's $10 billion and now it's $400 million. So if I can keep a bunch of doctors pissed off at me, but I'm making an extra $400 million, what am I going to do?”

6. Ban hospitals from charging facility fees

“Now the hospitals are playing all kinds of games in how they over-charge. So you've got facility fees. Are you kidding me? Like, I'll pay for what I need. I had my hips replaced, bam hit me. But a facility fee for the doctor that’s coming? Anybody who complicates the program, who complicates the economics takes responsibility, at least at some level, for being the bad guy in all of this.”

7. Allow direct contracting between employers and hospitals/physicians

“If a hospital or a doctor or a practice walked into Shark Tank, how would I redesign their business? Do a direct contract deal with the employers. There’s going to be no deductible from the employee. We'll cover all of it so you have zero risk. Now, in exchange, I want a better price than you’re giving insurance companies.”

8. Get rid of RVUs (Relative Value Units, a method that determines what physicians get paid from reimbursements)

“RVUs? That stuff's insane. You're getting paid based off an RVU that's going to the hospital, who then has to pay you. But what if all that just came to you?”

9. Do everything we can to restore trust and empower the good guys, aka doctors

“I happen to be a fan of people who save lives and make other people feel better, you know? Call me crazy. You guys bust your ass. You guys go through a whole lot of shit to get where you are and it's so stressful just trying to keep up.”

Mark's big idea …

To finish off the conversation, Mark puts on his "Shark Tank" hat and proposes a big idea for how doctors can truly take back their power: Unite to form a virtual hospital that eliminates insurance from the equation.

He didn’t pull this out of thin air — in recent years, more doctors are moving away from traditional insurance-based care and turning to alternative practice models such as direct care and concierge medicine. But Mark is pushing to go a step further: “If you're able to aggregate enough doctors, you can create a virtual hospital network.”

For hospitals and doctors, Mark points out, the primary value of big insurance companies is patient flow. “If the cause of most of these problems is insurance companies, and their value proposition is patient referrals, you need to look for other ways to get patient referrals. Instead of being in the networks. I would organize and take that as far as you can.”

Mark knows that this kind of epochal change won’t happen overnight. But, for now, Mark urges doctors to do two things:

• Only work for employers who treat you fairly. “I would identify the hospitals that really simplified things, that are being innovative with payments. Because as long as there's a shortage, you're gonna be in demand.”
• Be entrepreneurial and think differently about how to set up a practice today. “PE understands how to do arbitrage, that's what they do. And so they come in and they buy everybody up, and now you're working for the hospital. When that happens, where there’s change like that, that’s where there’s opportunity.”

This sentiment couldn’t be more perfectly aligned with Offcall’s mission: If doctors put on their Shark Tank hats, the best days of practicing medicine might still lie ahead.

Connect further with Cost Plus Drugs on LinkedIn here.

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Offcall exists to help restore balance in medicine and improve the wealth and wellbeing of physicians. Sign up for Offcall here to bring about more physician compensation transparency and join our physician movement.

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Transcript

​​Mark Cuban:

Let me just tell you upfront, doctors are underpaid. When I look at bills, individual bills, and it might, just to pick one out of thin air heart transplant, right, $25,000. Amount paid to the doctor, $2,200.

If I'm getting a heart transplant, I want that motherfucker doctor to make $10,000. So he's paying attention or she's paying attention and not worried about getting to the next heart transplant or worried about the patient that's got a boo-boo. And so it's such a fucking mess, right?

Graham Walker:

Most of the time on this podcast, you'll hear from physicians doing transformative purpose-driven work, but today we're making an exception because while my guest is not a doctor, he has taken that same mission to heart. And while he's a household name, I'm not talking to him because of his celebrity. I'm talking to him because of think he actually gives a damn about healthcare, and more importantly, he's doing something about it. I'm excited to talk to Mark Cuban today because he's an insider outsider. He's probably the most informed person outside of healthcare on the way that money flows inside it. And frankly, Mark, you might have the best understanding of medicine, including the people inside it as well. Mark, I think you believe in trusting experts, reading the fine print, challenging interests, and disrupting industries with trust and transparency, and honestly just common sense.

MC:

That always helps.

GW:

Thank you so much for joining me today. It's really a pleasure to meet you and talk with you.

MC:

Thanks for having me on.

GW:

I think the reason that you're so good at that insider outsider role is you boil down stuff, really complex stuff like healthcare to simple stuff that humans can understand. So let me just ask you, who are the good guys? Who are the bad guys in American healthcare today?

MC:

Wow, you get right to it.

GW:

We're going for it. We're going for it, Mark.

Healthcare is actually a simple business, and it's gotten over-complicated

MC:

So first you got to ask a question, what are the complications of healthcare? Because healthcare really is a simple business. It is one of the simplest businesses on the planet. You go to the doctor, hopefully the doctor says nothing's wrong. If there's a complication or some need, the doctor tells you what you need. You need this medication, you need to go to the hospital, whatever it is. And there's really only two questions. What's it going to cost and how are you going to pay for it? That's it. It's just a two-questioned industry.

And what happens is, rather than just keeping it at that simple level, the entire industry, because of this scale, has grown in complication because every complication you add is an opportunity for arbitrage. You get a chance to squeeze your nickel, your dime, your quarter, and you multiply that by some big number and boom, right? Or it might be just a minutia in terms of percentages, times a big number. Somebody's happy all the way to the bank. So when you ask who are the bad guys? The bad guys are anybody who complicates it because that's where all doctors, physicians in particular start to get away from just doing medicine.

GW:

Yeah.

MC:

Because the reality is, whether it's an emergency room, whether it's primary care, whatever it is, specialty. If everybody walked in and had a daddy's credit card and all the pricing was transparent, so everybody got to see what everybody else is doing, and we still had the alps of the world. So we have some sort of transparency for better or worse, on the quality of care. You guys would just take care of your patients, take your notes, put them in the EMR, and that's it. There would be nothing else for you to do. And guess what? You'd be golfing on Wednesdays again, because that's what this whole conversation is about, how can we get doctors to be able to golf on Wednesdays like they used to?

GW:

Clearly, that's the most important piece of all this Mark.

MC:

Right. Because that means you can afford it, you can afford the country club, you can afford to take the time off. You don't feel so stressed by your patients and you feel trusted and those pieces are missing. And anybody who gets away from that is the bad guy. Now, that doesn't mean that we have the ultimate solutions on pricing and paying, but that's where the focus needs to be. First of all, there's not enough physicians.

GW:

Yeah.

Making med school free would help solve major problems in medicine

MC:

There's about 900,000, and not all of them practice and maybe 10,000 per class in med school at any given time. And so the first question becomes, in terms of the pricing variable in all this, well, how do you increase the supply to deal with the demand? And so I did some back of the envelope math, and if there's 10,000 students, right, and let's just say for easy math, it's $60,000 a year.

That's $6 billion. Times four that's 24 billion. Would it be worth making it so that we can not only expand, but make med school free? So you truly get the best of the best as opposed to the best of the people who can either afford it or are willing to take on the debt. So you increase the competition there. So that's a positive. And then in terms of residencies and the like, can you expand it even further and deal with the economics of expanding residencies and some of the issues there. Now, I haven't really dug in there, but that's nothing to,-

GW:

It's a drop in the ocean of the healthcare,-

MC:

Right.

GW:

The almost 5 trillion we spend. Yeah.

MC:

Yeah. And but it changes the dynamics considerably to improve the quality of care. And so that's the first step. And then you dig in on the number of residencies and can you, because your marginal cost to add another 10,000 doctors is your $6 billion a year. And if you can add 10,000 doctors and there was residencies for them, or you create a different program that doesn't require a residency, you're just an apprentice in a primary care organization. Great. And then if you get a residency three years from now, five years from now, whatever it is, okay, you can change specialties or go where you need to go. And as physicians, I understand you're just trying to get through the day and it's hard enough to deal with this, and that's why you created this company. To try to solve the problem, you got to get to the root of the problem. And so one is supply.

GW:

Well, Mark, you're right. I don't think the number of residency slots has really increased much. It was set in the 80s. It went up a little bit, I think in the 90s or 2000s, but nowhere near our population growth, nor our life expectancy, nor the level of complexity of the human beings walking around on the earth today.

MC:

And so you would know better. How would you increase the number of residencies?

GW:

Well, we have great ways of already training residents. Right now, hospitals get paid by Medicare to train residents, and we think that probably it's by third year, the resident actually becomes a profitable entity for the hospital. First two years, they're slower. They need to be trained and learn. But by year three, they actually become profitable to the hospital. And so what is happening today is hospitals are trading residency slots or it's like, okay, well if we're going to go down by five urologists, let's go up by five ER doctors, but they have a fixed number. And so that's the other challenge, is we don't have enough supply on the physician side to get everybody the care that they need.

MC:

Well, it won't be hard. I mean, there's a couple of medical schools that have opened up, and again, the marginal cost to either expand the classes, so that number goes from 10,000 in a given year to 20,000 isn't dramatic relative to the value and relative to the overall cost of healthcare. And so there's 1000 ways to do that, but it's just about getting everybody to agree because like you were talking about they get profitable the third year, and if you have five urologists, well, is that the specialty that the hospital thinks they're going to maximize their earnings with? Because they have their super urologist that charges more than any other urologist in the world, takes a peek in the door and then turns it over to the residents, but they still,-

GW:

We bill at the attending level. Yeah. Yeah.

MC:

Yeah, exactly. And it's almost like being instead of site neutral, doctor neutral.

GW:

Yeah.

MC:

So there's always the gamesmanship, and I don't know what the AMA would think about that, if the doctors want more constrained supply because that allows you to charge more, but I think there's a path there, and that's the place to start.

GW:

I think the doctors of 10 years ago or maybe 20 years ago wanted that constrained supply. But today, I mean we're down to like seven-minute appointments. Sometimes the ERs are often six to 12 hours in some places to be seen. And I think today physicians are very aware that we need more supply and that there's plenty of work to be done.

MC:

Right. Oh, yeah. There's no shortage yeah, of work to be done.

GW:

Yeah.

Insurance plans are not designed to optimize patient care

MC:

Yeah. And plus this thing gets smarter and people get smarter and AI gets better, et cetera, et cetera. Part two then is how do you simplify the whole economic process? If you look at how insurance plans are designed and the responsibilities associated with those plans, it's criminal. It should be criminal. It is the antithesis of trying to optimize for patient care. And so if you look, let's just say you own an insurance company and you're creating a variety of plans that you want to sell. Well, it's up to you as the insurance company to determine the premiums you're going to charge, the features you're going to offer, and the patient responsibility, the deductible, the out-of-pocket, the co-insurance, whatever it may be. Well, guess what? You go then to CMS and if it's a Medicare Advantage plan or an ACA plan, you try to get it approved, and typically they'll approve it with some constraints.

And then you'll offer some for self-insured employers because more than 50% of people get their insurance through an employer. Well, then the goal from the self-insured employer is to try to make their employees and their families happy. Right. They're going to make determinations of which plans to offer. And then each of us, whether you're a doctor, whether you're a nurse, whether you're a janitor, whether you're an accountant, you're going to choose the plan that's appropriate, you think for your family. You know who's not involved in any of that?

GW:

The patient?

MC:

No, you.

GW:

Oh, the doctor. Yeah.

MC:

The doctor and the hospital, right?

GW:

Yeah.

MC:

The care. Right. But who takes the patient financial responsibility risk?

GW:

Me, me, me, me.

MC:

You.

GW:

Yeah.

MC:

Yeah. So if you're an independent physician that's seeing patients in your office and you happen to be in Humana, whoever, United, you pick one, pick one of any of the BUCAs networks. All right. Well, if they design a plan that you had nothing to do with the design and one of those patients walks in the door, you don't get to look at the financial statement fortunately of the patient, but if they design a high deductible plan and they made it available to somebody with a take-home pay of $25,000 and there's a deductible of $5,000.

GW:

They're hosed. Yeah.

MC:

You're screwed.

GW:

Yeah. Yeah. Guess that's the interesting thing. Yeah. I'm saying the patient screwed. Yeah, the hospital and the doctor,-

MC:

No, the patient's not screwed because the patient's getting care. Right. Your contract with that network says even if they're broke as a joke and don't have two nickels to rub together, you have to still care for them.

GW:

Well, and especially as an ER doctor, we have this rule called EMTALA that we have to take care of anybody and stabilize them regardless of ability to pay. Yeah.

MC:

We'll put that aside because of EMTALA, right?

GW:

Sure.

Doctors are taking on risk and taking blame

MC:

Put that aside as a unique situation. If you're seeing patients for whatever your specialty is, primary care, and you're in your office or you're at the hospital where you keep an office and they walk in the door and they have a boo-boo, and that boo-boo is going to cost more than a couple thousand dollars and they have $17 in the bank. Well, whatever the delta is, you're responsible for figuring it out. And, but wait there's more. It gets worse because that financial responsibility for that risk of debt default that you take on, now you're also responsible for figuring out a payment methodology, if there is one. And if that patient now all of a sudden is accumulating $5,000 in debt, then 10,000, then 20 and goes bankrupt, who gets blamed?

GW:

Yeah, me, because I charge too much.

MC:

Not even, yeah. And it's not even your fault, right?

GW:

Yeah. Yeah.

MC:

It's just the plan was designed in a manner,-

GW:

To fail. Yeah.

MC:

Yeah. So that you knew that there were going to be buyers of this plan who can't afford the deductible.

GW:

And the insurance companies surely love it because they have no risk because the deductible is huge.

MC:

Right. It's more profitable for them. Right. And so from a PR perspective, now all of a sudden, oh, medical bankruptcy, there's X 100 billions of dollars in medical debt, we got to get rid of it. There's X percentage of people and number of people who are declaring bankruptcy, which is for medical costs, which is horrible. But it all goes back to the simple side of it, the plan design. Right.

GW:

Mark, you're hitting at something that I was going to bring up later. There is a sense among physicians that we are the face of healthcare. We're the bosses. We're in charge.

MC:

Of course.

GW:

And so we are now, I think the big feeling that physicians are having right now is that we are also to blame. And so you're bringing up a really interesting side of it, that the feeling from the patients is that we're charging too much, even though we're taking on the risk. And the patients also similarly feel like, well, the doctor should be deciding if I need this CT scan or if I need to get this medicine. But so much of it now is controlled by the payers as well. The payer will refuse to allow the CT without the prior auth too. Yeah. Yeah. Yeah.

MC:

Oh, yeah. Put aside pre-auths. We'll get to pre-auth. Look, let me just tell you upfront, doctors are underpaid. When I look at bills, individual bills, and it might, just to pick one out of thin air heart transplant, right, $25,000. Amount paid to the doctor, $2,200.

GW:

Yeah. For literally taking a heart out.

Doctors should be paid more

MC:

Yeah. If I'm getting a heart transplant, I want that motherfucker doctor to make $10,000. So he's paying attention or she's paying attention and not worried about getting to the next heart transplant or worried about the patient that's got a boo-boo. And so it's such a fucking mess, right?

GW:

Yeah.

MC:

And then what happens is whether it's individual doctor at your own clinic or your own deal, right, then the hospitals have to deal with it as well. So now this falls, if you work for a hospital, it's their financial responsibility, it falls on them. So now what do they do? They have to make it up elsewhere.

GW:

Yeah.

MC:

They have to increase their prices. They have to game the system as much as they can to overcharge,-

GW:

Everybody else. Yeah.

MC:

Where they can to make up for those losses. Those losses don't pay. Unless it's Medicare. That Medicare I think covers 65% of it. Okay. But you got to wait to get your money. So now you've got that issue. And so now the hospitals are playing all kinds of games in how they charge. So you've got facilities fees. Are you kidding me? I'll pay for what I got, what I need. Right. Had my hips replaced. Bam, hit me. A facilities fee? They start complicating, remember at the beginning, who's the bad guys? Right. Anybody who complicates the program, anybody who complicates the economics takes responsibility for at least at some level being the bad guy in all of this. And so hospitals find ways to compensate, but they're not even the worst of them all. The insurance companies are the worst of the worst of the worst, of the worst of the worst.

First of all, they're designing those plans and they're designing those plans with actuarial data based off the population that they're dealing with to figure out how to maximize their earnings. And they're figuring all that out not only by the premiums, and the deductibles, and the co-insurance, and the co-pays, but they're figuring out by having these subsidiaries, because they're vertically integrated, how they can game the system. You buy the physician's practice that's three floors up, and now because you're a hospital and they're part of yours, you get to charge the inpatient versus outpatient and the price escalates. And that's an arbitrage private equity place. Right. But wait, there's more. Insurance companies also use their PBMs because particularly for the ACA, they have to hit their 80, 85% medical loss ratio.

And so they run, especially medications at enormously inflated prices with huge margins. But then the PBM bills the insurance company at the inflated price, so they get to keep the margin as profit until once they do the roll up, right, if you're following me between the two companies. But as it applies to MLR, as best I can tell, that just jacks up the MLR and they're just gaming the system. And so you start seeing all of these things happening over and over. I talked to CFOs at hospital networks and I'm like, okay, let me get this straight. You have a contract with one of the BUCAs, one of the big insurance companies, right, and that contract for a hip replacement, to pick one out of left field, $15,000.

GW:

Yeah.

MC:

Yeah. And when you do the hip replacement, they don't just pay you $15,000, assuming it's just normal. They say, "Yeah, we're not going to pay you $15,000. We're going to pay you 13,000." And despite the fact that you have a contract, and the CFO is like, "Yeah, that's what they do. They just underpay and make us fight for it." Now, what does that mean in terms of the cost of the healthcare to this country? It means that hospital has to have lawyers, they have to have all these administrative people checking all the bills. And you can use AI or not, but you're going to have to have people there checking and reviewing. And when you hear all these discussions about the administrative cost as a percentage of the $4.9 trillion being anywhere from 20, 30, maybe 40%, that's where that comes from. And when you talk to these CFOs, they say that's three to 5% of their revenue.

GW:

Wow.

MC:

So you've got bad debt. You've got basically this underpayment, which is three to 5% of revenue, plus all the associated overhead of dealing with it. And then we get the pre-auth.

GW:

Yeah. We've only just now gotten to pre-auth. Yeah, yeah.

The problem with pre-authorizations

MC:

Yeah. Now, the thing about pre-auths, it's minimally designed to keep bad medicine from happening. Minimally designed. It's designed one, just to drive doctors crazy because they always hired the worst doctors apparently.

GW:

We think it is. We are absolutely. It's not paranoia when it's true.

MC:

But here's the real reason. It's for the time value of money. If you have billions and billions of dollars, a billion dollars a year, let's just say you work through pre-auths and you just extend them as long as you can. And at that average balance is $1 billion, 4% of that is a shitload of money. That's $40 million. If you're bigger as a insurance plan and it's 10 billion, now it's $400 million. So if I can keep a bunch of doctors pissed off at me, but I'm making an extra $400 million, what am I going to do? And so they're bad actor for complicating things and not trying to simplify anything. CMS enables all this shit by approving all the plans, knowing this stuff happens. CEOs of, even the CEO of your hospital for your own internal benefits, they sign off on these things knowing it's a clusterfuck, right?

GW:

Yeah.

MC:

They know all these things. This is not news to any of them, but they don't say, no, we're not going to sign a deal like that because they're afraid of getting kicked out of the network or not having that as a negotiation. They want that so they can better negotiate the fees that are agreed upon that are shown on the website as part of transparency that they really don't pay because they're short paying you, causing you to hire all these additional administrative and lawyers and sue each other, losing three to 5%. And meanwhile, while you're getting sued and everything and you're going back to the lawyers and doing all the extra paperwork for that, the lawyers can't do that paperwork and help you with that because they're talking to the committees who are denying them on their pre-auths so that they can make money off of the time value of money. It's just like Rube Goldberg would've just loved every minute of this stuff.

GW:

And Mark all of that swirl is happening way up here. And honestly, the doctor and the patient and the nurse are just way down at the bottom just trying to like,-

MC:

Just getting shit on every day.

GW:

Just trying to help somebody with their diabetes, or replace their hip, or get them a cath, or whatever it is. And it's So frustrating.

MC:

I can't tell you... You know what's crazier? I've talked to multiple CFOs of hospital systems. When I ask them, how much does a hip replacement cost you? How much does setting a broken arm cost you? Well, I don't know.

GW:

They have no idea. No idea. Yeah.

MC:

None. None. And what they do talk about is patient mix or payer mix more,-

GW:

Yeah, payer mix. Yeah, I hear that all the time. Yeah.

MC:

Right. Because we have X amount of Medicare patients, X amount of Medicaid patients, and we need all these other folks to get more, so. But what they don't tell you is unless you're in a non-competitive market, they're spending all kinds of money on marketing and specialists because they want to have the brand so that when you do need your hip replaced, you're the orthopedic destination. And now we've gotten to the point where there's no wards anymore. Right. And so everything's either private room or a couple people with a curtain, which is fine. Right.

And so the point being they've made everything more expensive because they think that's the way they have to compete. And because there's no transparency, that often is the way you have to compete. Now you're seeing more and more people, you're seeing apps pop up and other things where it's like, I'm going to get an x-ray or I'm going to a primary care physician. I'm going to shop.

GW:

Yeah.

MC:

And you're starting to see it's not prevalent, but you're starting to see more and more of that, and it may drive some doctors batty, but it's a right direction for everything. And where I think it goes and where I think there's a real opportunity for physicians that have their own practice is with direct contracting. And so I'll tell you what we do now with my companies, and it was a lesson I learned the hard way or expensive way.

GW:

Mark, is this the beginnings of Mark Cuban Wellness? I've seen a little bit about that.

MC:

Yeah. Yeah.

GW:

And I would, yeah. Oh, great. Great. Great.

MC:

Pretty much. Yeah. So we learned a lesson. My daughter broke her hand playing basketball when she was 15, 16, a couple years ago. And it was like, okay, I'm just looking at costs and everything because I had time. Remember I self-insure.

GW:

Yeah.

MC:

So it's either my left pocket or my right pocket, whichever credit card happens to be in whichever pocket, I'm paying it directly. I'm paying for it.

GW:

You're paying for it ultimately. Yeah. Yeah.

MC:

It was like a fourth of the price to just hand out my credit card rather than put it through insurance. I'm like, okay. The entrepreneur in me starts thinking, well, this way for this, what is it for everything else? And that's what got me to understand all these ancillary complications and costs that we just discussed. And so I'm putting my Shark Tank hat on and I'm like, okay, if a hospital walked into Shark Tank or a doctor or a practice walked into Shark Tank, how would I analyze their business and how would I redesign their business? I was getting accused at Shark Tank,-

GW:

Love it.

MC:

Of recreating someone's business. I'm like, okay, well, if on one hand the BUCAs are taking three to 5% for a negotiated price, if they're having this huge balance for pre-auth that are more about delay than really, I'm not saying it's 100% about delay, but there's some material percentage that's about that.

GW:

It's, yeah. Yeah, for sure.

MC:

And so that's just an additional cost. And then they have to take on the bad debt risk as well. That's another additional cost. That's 30, 40% potentially or more of their revenue. So I'm like, okay, let's go start talking to these hospitals to make sure what we think is correct, and let's just say to them, A, I want to trust the doctor. Now I'm going to play Ronald Reagan.

GW:

Thank you, Mark for just saying that part of it.

MC:

Yeah. Well, I'm going to play Ronald Reagan. I'm going to trust and verify because,-

GW:

Yeah, sure.

MC:

If all of a sudden it's 37 spinal surgeries out of 100 employees and their families,-

GW:

Yeah. We got to look into the, yeah, look into it. Yeah.

MC:

Yeah. So I said, okay, we're going to trust until you give us a reason not to. No pre-authorizations.

GW:

Bravo.

MC:

And on top of that, if you do a direct contract deal with us, there's going to be no deductible from the employee. We'll cover all of it. So you have zero risk associated with that credit.

GW:

So you now de-risked that entire interaction.

MC:

De-risked everything.

GW:

Yeah.

MC:

Right?

GW:

Yeah.

MC:

Now in exchange, I want a better price. I want a better price than you're giving the biggest insurance company because you're already giving the cash person who walks in the door, and when I ask you why you're giving them a better price, it's because you don't have all the administrative headaches.

GW:

Yeah.

MC:

And so I want a better price than that because what I'll do is I'll personally guarantee it. If you need me to, is depending on the number of employees in that region, I'll even put a debit, an account for you. So you just credit it as you provide the services. So you have no cash issues whatsoever. But we started off at 100% of Medicare, and that worked for a lot of practices, and now we're up for some of the hospital networks. We're about 120% of Medicare on a fee-for-service basis and 150% for more advanced things and for specialties too.

GW:

And that's enough?

MC:

Oh, yeah. Because they know.

GW:

Wow.

MC:

I mean, I had one hospital network, say, 120% of Medicare, let's go. I would do that for everybody all the time with your scenario, right, where it's prepay cash.

Money in healthcare is going to "all the people who complicate the system"

GW:

Mark, so where is all that money going then? It's going to all the people that complicate the system? Everybody's taking their little slice of the pie.

MC:

Yes, everybody takes as much as they can get. Then you have your chief revenue officer who has 16 revenue consultants who try to then go back and out of that three to 5%, they go and analyze those and then go and sue the BUCAs to try to get that money back. That's more overhead. And so all these complications. Now, if somebody pitched to me a business using AI where they analyze millions of claims so that they can anticipate what each of the insurance companies is looking for when they do a pre-auth denial.

GW:

Sure.

MC:

And so they then use the AI to actually write the response. So it already does. So they tries to reduce. What the fuck do you need that for? Just do it right the first way. And so when I hear hospitals say, "Oh, we lose 8% on Medicare." No, you don't. You spend your way into a deficit.

GW:

Wow.

MC:

Because of all the ancillaries and all the growth you're trying to create and all the Super Bowl ads you're trying to buy.

GW:

Yeah.

MC:

And so those are the complications. Those are the bad guys. If it was 1955, if the government just says, you know what? We're going to guarantee everybody's medical bills, not pay for them like single payer, but guarantee them. Because effectively, if you're under the federal poverty level, you're on Medicaid anyway.

GW:

Yeah, sure.

MC:

It's guaranteed. If you're above that and you're older, you're on Medicare. It's not fully guaranteed. And there's a lot of out of pocket, but there's a lot guaranteed. So now the question is if we did a means tested that said, if you make twice the federal poverty level, up to three times the federal poverty level, we're going to just deduct 2% of your paycheck,-

GW:

Sure.

MC:

Every paycheck until it's paid off.

GW:

Yeah.

MC:

And then after some period of time, because if something horrific happens after 15 years, we stop deducting. Right. You lose your job, we put it on hold. But then you have the government guarantee. Now all of a sudden, you may be able to charge just straight up Medicare.

GW:

Yeah.

MC:

Because across the board, you don't have to worry about payer mix. And for the super-duper superstars, the heart transplant that can do the heart transplant while playing the guitar with his eyes closed, right, and for the people who want that, okay, charge a premium for that and make that outside the program, but you just check the credit worthiness of the person making that decision. If it's some genetic scenario and you need some special care that's involved, well, okay, we'll pay some amount plus a markup so that it's worth your while. But if you don't have 600 people working at the hospital that are just working in administration and legal.

GW:

That's a lot of savings you can pass along to, yeah.

MC:

Not just for you, not just for patients, but for taxpayers in the entire country.

GW:

Mark, let's say it is a trillion dollars, if it's like 4.5 trillion we spend right now, maybe five in 2025, maybe a fifth of that is just to make the numbers easy, it's a trillion dollars. So is that money that is going into healthcare workers' pockets because they're able to make more money? Is it going back to,-

MC:

Oh, you mean if we save?

GW:

Yeah. If we're saving that. Is that money that,-

MC:

Yeah.

GW:

I'm making more money?

MC:

You make that choice, right?

GW:

Or is it that employers can now pay their employees more because there's less waste in the system and so our raises go up?

MC:

Hopefully, right? Because the more time you spend doctoring and the less time you spend administering, the more valuable you are.

GW:

Sure.

MC:

And because trying to do that seven minute churn thing, that's because those numbers, that analysis includes all that overhead.

GW:

Yeah. It's like the system is feeding itself.

MC:

Yeah. No, it's eating itself. Yeah, it's eating itself.

GW:

Yeah. Yeah. Yeah. Yeah.

MC:

And it's not virtuous. It's the opposite of a virtuous cycle, right?

GW:

Yeah.

MC:

It's a horrific cycle because every cycle just makes it worse.

Creating transparency in drug pricing

GW:

Mark, with Cost Plus Drugs, you have a very transparent markup. You talk a lot about, you're selling trust and trust is through transparency as well. Why was it 15%? Is that just an easy number? I mean, should that be the number of the markup for an ER doctor or an orthopedic surgeon? Should that be a fixed number or?

MC:

No. Basically we just pulled it out of thin air. It was like, okay, if we can get to certain volumes given that we're lean and mean and automated a lot of respects, how low can I make it and still make money at scale?

GW:

Yeah. And try to keep as few complications and as few people dipping into that bucket as possible?

MC:

There's nobody dipping in at all, right, other than the pharmacists that we're working with to do all this, and then we're trying to make sure they get paid what they deserve. The key is my mission, we're a public benefit corporation. I don't need more money. I'm a lucky motherfucker. I've got as much money as I need, but when it's all said and done, if I can save lives, and you wouldn't even believe the emails I get. I mean, I got one a couple weeks ago where, "The medication I was prescribed was going to cost $903 at the local pharmacy. I couldn't afford that. And I made the decision that my family couldn't afford it, and I didn't want my wife borrowing it. And then I saw in Cost Plus Drugs, it was $73."

GW:

Wow.

MC:

Now, the other ones, "Hey, I was getting ready to pay $2,000. You guys were $13," especially generic like Imatinib.

GW:

Yeah. And the data's very clear that patients, especially on fixed or lower incomes will, they're choosing between medicine and food or they're rationing their medicine. They're taking half a pill.

MC:

All the time.

GW:

They're, all the time.

MC:

Right. One of the great lies of the PBM, the pharmacy benefit manager world, is that specialty drugs are special. And because they're special, they want you to buy it from their pharmacy at a high price, huge markup. And so people think, okay, it's on a tier six, it must be special. It must be unique. And we literally now have Medicare patients who of part D, and their co-insurance for specialty medication is so high that they come to us and they're stunned that we could be under $25 for something they were looking at spending a fortune on. And so it's just such an opaque industry. And the pharmacy side isn't as convoluted as the healthcare side, but it's just as bad. And so by being transparent, it just changed the game. And literally, one of the smartest things we did was we published our entire price list.

We have 2,500 medications, not all, we don't have as many brand drugs as we need, and that's for a whole other reason with the PBMs. But we published them, and by doing so, researchers were able to say, okay, compare this to Medicare, compare this to what this hospital is charged on these bills to et cetera, et cetera. And the FTC sued companies and used our numbers. I saw something. It was or I heard it on a podcast, actually, it was fascinating, where they talked about trust. If you were trying to make it an equation, it effectively was transparency divided by self-interest.

GW:

Oh, yeah.

MC:

In other words, the more transparency you have, if it's on a scale of one to 10, if you're a 10 in transparency and you're a one in self-interest, you're doing it for the right reasons. You've got a trust level of 10. And if that happens, which we think we've got, people are going to want to come buy. We spend no money on advertising or marketing.

GW:

Yeah.

MC:

Not a nickel. Now, I got a big mouth and a platform, but it's still, it's insane that we don't spend a penny, and we've barely been able to keep up with our growth. And you alluded to Cost Plus Wellness, and I started talking about what we're doing. Well with the members we have, the lives I've covered, we're direct contracting, like I had mentioned, and where we've been able to do direct contracts, that's in-network. And for anything in-network for our members, because we want them to stay in-network, it's free. Now you pay premiums, but it's free. And a lot of people actually don't even pay premiums anymore because we saved enough money, so it's free.

GW:

Wow. That's incredible. Well, I think you're also just gaining trust in the medical community too. I mean, I've been following you for a while. You're now doing some IV sterile injectables. I mean, that's mostly what I use in the ER.

MC:

Good.

GW:

And those are constantly going on shortage as well.

MC:

Yes. How insane is that? How insane?

GW:

And not just for medicines, Mark, like for salt water.

MC:

For sterile water. Yeah.

GW:

Yeah, for normal saline.

MC:

Yeah. Yeah. No. So we build, Alex, my partner, Dr. Alex Oshmyansky, who's our radiologist as well, smartest guys I've ever met. This whole thing started because he sent me a cold email and he wanted to build a compounding pharmacy in Denver, Colorado that only did sterile injectables that were in short supply. And I'm like, how are generics on short supply? And then we also have this thing called Cost Plus Marketplace, which is business.costplus.com. Just as obscene in pricing for patients for specialty, the pricing that hospital networks, big hospital networks pay is ridiculous.

GW:

So the hospitals aren't even getting the best rates?

MC:

No, it's not even close. Look at some of the press release, like from Penn Medical, CHS.

GW:

Yeah.

MC:

MultiPlan, like we're saving them millions of millions of dollars because the whole supply chain was complicated again. Just in healthcare, that 4.9 trillion, wherever anybody can grab an arbitrage, whatever they can out of the system, that's exactly what they are going to do. I read this book, The Hospital, and it was an okay book, but the one thing that stood out to me was the small town Ohio Hospital when they were buying for hip transplants, right, the actual implants, right, the devices, they were paying two to three times as much as a little bit bigger hospitals down the street. That makes no sense whatsoever. Right. So we'll get into those things as well.

GW:

Amazing.

MC:

And we'll start to take all the mishegoss out of the system, right, the things that just don't add value, where people are just trying to extract margin and there's just a shocking amount. Now, obviously, the competitors are going to react to us, just like the big PBMs have. The price of specialty generics has dropped like a rock for self-insured companies.

GW:

Because you're introducing competition into the market.

MC:

Yes. Yeah, for sure.

GW:

Yeah.

MC:

They come up with, their cost plus plan, that's literally what they call it, our cost plus plan. Now, they won't publish their price list and they game it and play these other games. And what they can't do in margin on a product, they make up in fees. I mean, the fees that PBMs charge manufacturers and self-insured employers are insane.

GW:

Wow. Mark, it just really feels like there's no transparency, even with physician salaries. I mean, it's a total black box. We started to just get physicians like, hey, upload your data. Help us compile something to figure out what people are seeing. And it's grown like wildfire because we're seeing discrepancies in departments where someone like,-

MC:

Oh, yeah.

GW:

Somebody accidentally gets the HR thing emailed to them and they're like, wait, I work the same amount as this person. They started at the same time. I'm making $100,000 dollars less than them.

MC:

Yeah, for sure. Look, as an employer, I'm not going to lie and say, I haven't done that for programmers back in the day, Hey, I can get you for 100, but this person's good and they're asking for 200 and I can't lose them. That happens. But at the same time, the less transparency, the more control.

Restoring trust in doctors, aka "the people who save lives and make other people feel better"

GW:

Mark, let me just ask you this, why do you trust doctors? Because you seem so pro doctor. And honestly, we don't hear that much anymore. I think there's really been a loss of trust and expertise. But you are like, you say, doctors should be paid more. I think you trust us, and I really appreciate that about you. But why?

MC:

Yeah, I mean, I happen to be a fan of people who save lives and make other people feel better. Call me crazy, but I look at that as a good thing that's good for society and good for my family members and people I know, my friends, you guys bust your ass. You guys go through a whole lot of shit to get where you are. And it's so stressful just trying to keep up, especially now, right? Because with AI and everything, you got to be smarter than the AI, but you know you can't be smarter than the basic AI. So you got to know how to use all the tools. And not only do you have to use all the tools, you have to know which tool to use and how do you take the best out of the best because all it takes is one good idea from an AI model, and you saved a life, and that's always a positive. But you guys have to know how to stay ahead. And I respect that. Most doctors I know are competitive like that.

GW:

Let me ask you, I'll ask you for some free advice here. If you were physicians, what's the move that doctors should be doing to disrupt just the same way that Cost Plus Drugs is disrupting pharmacy, like to fight against the payer challenges. Most of us are now employees of another, of a health system now, 80% of us just in a decade. So what's the move that physicians should be doing?

MC:

So first of all, for those of you who have your own practice, I'd align all together. I don't know if there's organizations of doctors who have their own practice. I'm guessing there are.

GW:

Yeah.

MC:

And I would hire a salesperson, right, and set up direct contracts instead of just being in the networks. Because a lot of people, when you go on your own or stay on your own, you try to be a concierge doctor and you try to do capitated payments, and a lot of doctors don't want to get into sales side of things and don't want to deal with all that. They just want to be doctors. And so I would organize and take that as far as you can. Beyond that, I would identify the hospitals that really simplify things, that are being innovative with payments, because as long as there's a shortage, you're going to be in demand and you know you're in demand. But it's just the switching costs are high, really, really high. And that's always the challenge. And so there's no simple answer, but at the same time with what you're doing with your company, I would try to look for ways to meet patients where they're at, to meet companies where they need to be and provide those solutions. So I would think like an entrepreneur.

GW:

Mark, why are more employers not stepping up and talking about this or fixing this? You talk about this all the time with people, but why is it you and not the rest of the Fortune 500s?

MC:

Because that's who I am.

GW:

Thank you. Thank you.

MC:

No, I look at things entrepreneurially. A CEO just got to run their business.

GW:

Yeah.

MC:

It's not their core competency to think about their healthcare budgets, and that's why I can walk in and give them a ton of shit. Right. I understand. Look, before we started Cost Plus, I had my guy, a broker, a benefits broker who had been my guy for 20 years, and then right when we started, I had to fight, but I finally got our claims for the Maves for just generics that cost over $30. That's it. For 18 months. We paid $169,000.

GW:

Wow.

MC:

Our out of pocket with Cost Plus, and we had only just started, and so we only had 111 drugs, $19,000.

GW:

More than 10 X difference in generics?

MC:

Yeah.

GW:

Wow.

MC:

Just about, yeah. I said to my guy, "Guy, you are no longer my guy." And what they were charging us per month and how much, like there's literally brokers that'll do deals where they're getting seven to 10% of the premiums and they're getting paid per script that's written, that goes through the pharmacy. I mean, it is bonkers, but I didn't know. I was just trying to run a business. I was trying to, you see that gold thing back there, win another one of those. Now I'm not in charge of that stuff anymore. I did not make that trade, but you get the point.

GW:

But Mark, it's really interesting because the corollary between the CEO just trying to run the business is the same with the doctor. I'm just trying to see the patient, and so it feels really hard that the people on the front lines are doing the work, and I worked overnight on Thursday night. I'm shortening my life by working overnights and weekends and holidays, and then you see the BUCAs and you see pharma just printing money out.

MC:

Yeah.

GW:

And doctors are not seeing that same level for us.

MC:

When you have an industry that goes through a transition, you're seeing the consolidation, the vertical integration, things change.

GW:

Yeah.

PE understands how to do arbitrage

MC:

And PE understands how to do arbitrage. That's what they do. And so they come in and they buy everybody up. When that happens, that's where there's opportunity. Where there's change like that, that's where the... It's like when we came in, everybody was like, talk about printing money. Just like, Hey, I don't care about that patient. We'll charge them $2,000 for Imatinib. We'll charge them $30,000 a quarter for Droxidopa. Now, Cost Plus $13 and $43 or whatever it is. I mean, you know why they charge that? Because they could.

GW:

Because they can. Yeah. Yeah.

MC:

Yeah. And so here you guys are, physicians and you are where you are. The industry has changed because of the vertical integration and PE coming in where they're trying to extract every nickel, but you look for the vulnerability points and you look for the things that they don't want to do, and you look to see if that's an opportunity. That's how you guys have to look at it. It's really hard for doctors in particular. I mean, my first company was a company called MicroSolutions, which was a system's integration company. And the one thing about doctors, they all think they're entrepreneurs, right, and they all want to be entrepreneurs, and they're all going to start a business because their doctors. They're smart. Right. They figure they'll figure it all out.

They're not great business people because again, I've been looking at businesses my entire career. When looking at the hospital business isn't a whole lot different than looking at 50 other businesses that I've already looked at before. So I can see the similarities, I can see the patterns, I can see what needs to change. That's hard for doctors to do because they haven't had that experience. Whereas you can look at symptoms and say, oh, yeah, I've seen that shit 50 times before. Bam, bam, bam, bam, bam.

GW:

Mark, if you look at hospitals all the time, have you had thoughts about buying, acquiring, partnering with a hospital yourself?

MC:

I looked at it, but the hard part is the flow of patients. You got to work with the insurance company to be your sales organization. That's the challenge. If I can ever get to the point where there's enough businesses, self-insured employers doing direct contracting, then you can look at it because you can say, okay, I'll be a virtual hospital. I'm going to simplify everything. And you can have the private room or you can have the double or quadruple room. You pick, your choices, but we're going to only design plans that are with you in mind, not that we're selling to 20 other or 100 other companies. We're going to optimize all these variables so that everybody's interests align. We'll save the employer as much money as we can. We'll keep the as healthy as we can for as little money and hopefully no money, and we'll make money as a hospital. Because once you get to the point of trust and transparency, radical transparency, like for Cost Plus Wellness with these direct contracts, we're going to publish the contracts.

GW:

Amazing.

MC:

In a hospital, like for the insurance companies, a lot of the contracts get really complicated. It's not just a matter of this service or this procedure has this price. It's if your overnight four days or three days, and then you have surgery, then if you have to stay another two nights, your rate goes up by 90.

GW:

It's a double multiplier or something.

MC:

Yeah.

GW:

Yeah.

MC:

Yeah. Yeah. Yeah, there's all these complications that nobody gets to analyze and really understand. And so we're looking to try to overcome that so that once we get to a point of transparency, I mean, hopefully it'll all change. If you can make it work with Medicaid on a virtual basis with little capital out of pocket, you get to be the doctor you always wanted to be. And then that transparency, if you're transparent about, Hey, it's our new virtual hospital, here's everything that we do. Here's our price list. Here's how we work virtually with other hospitals. Here's where we use this surgery center's room. Here's where we use this 24 hour emergency thing. I'll meet you there if it's this or that, right, and we'll pay them some percentage that we negotiated with them. Great. But just make it all transparent, and now all of a sudden you'll find yourself making more than you are now because you guys don't get paid shit.

GW:

Yeah. Yeah.

MC:

Particularly surgeons, right? The surgeons get paid primarily, if I understand it right, on a per surgery basis.

GW:

Yeah. For a lot of it. It's all RVUs.

MC:

Yeah, the RVUs, that stuff's insane. Yeah.

GW:

Well, Medicare's been dropping RVU reimbursement rates for years, and so if you're paying 100% or 120% of Medicare rates, if Medicare's paying us less, then that's a problem too.

MC:

I forgot about the RVUs.

GW:

Yeah.

MC:

You're getting paid based off of an RVU that's going to the hospital who then has to pay you. If all that came to you,-

GW:

And then, yeah.

MC:

If you need that. You might not even need the hospital.

GW:

Yeah, yeah, sure. Yeah. Well, it's another complication. It's just the expensive,-

MC:

Sure. Sure. By the way, if you guys do do this, I want to know about it because the more,-

GW:

Okay.

MC:

I think about it, literally if you got paid the Medicaid prices and you didn't have all the overhead associated with it and it all went to you because you can only do, it's like any other specialty in any other hospital. If the hospital doesn't have an oncology group, you're referring it out. Right. If you don't have orthopedic surgery, you're referring it out. And so if you just do the things that you want to do, but has enough volume to pay your bills, putting all that money in your pocket.

GW:

Yeah. Well, and you're virtual, which is just a better, I mean, that's the other thing that I think physicians are challenged by, is a lot of the stuff we do is in person, but if you can filter out using AI or something, you can filter out and say, yeah, this person's appropriate for, yeah. Yeah.

MC:

Yeah. And plus you'll do telehealth, right? Right. You'll be sitting on the toilet with your phone and your hand, hi, Mrs. Doe. Tell me about your hemorrhoids.

GW:

I'll tell you about mine. Yeah. All right, Mark, for every resident, the residents just matched. As a technologist as well, what's the number one thing you think they should be doing to prepare for the future of technology and AI in medicine as well?

MC:

Learn everything you can about AI, period. End of story. So there's going to be, we all think of ChatGPT, Gemini, Perplexity, and we try to know the big name models. The reality is there's going to be millions of models.

GW:

Completely agree.

MC:

Millions of them.

GW:

Yeah.

MC:

And there's going to be branded hospitals or research centers, universities that have their own model because there's no way that Mayo is sharing their research and everything they know with MD Anderson or Stanford or brand, you name it. Right. Because that diminishes their brand. If you can just go to ChatGPT, no. If it's MD Anderson and it's oncology, whatever their specialty is, you better come to my model. Right. Because that's the only place. So understanding all these elements, part one. Part two, understanding how to communicate with patients and families of patients as it relates to AI, because people are going to trust AI more so than they do the doctors, because AI is literally going to talk to them as many hours as you want it to.

GW:

Yeah. They could talk infinitely,-

MC:

Because you can literally have a conversation just like this.

GW:

Ask infinite questions to the AI about your hemorrhoids or whatever it is.

MC:

Right. Right. Whatever it is. Right. Or I got this feeling, I'm at that age. Okay, my left side. Oh, shit, I felt something. Is it going down my arm? No. You get old. This shit happens.

GW:

Yeah.

MC:

And so being able to connect, again, just thinking off the top of my head, there are these things called agents and agents are going,-

GW:

Hey, agentic AI's going crazy. Yeah.

MC:

Right. And it's just sending, like DMing other models, right, or DM, making yourself available as the output. And so hey, if you're coming to, well, you're a resident, but if your plan is to have your own practice and understanding this stuff, because doctors like to think they're programmers too. They all love to program. Right. They all learned Python and everything, but being able to send and received agents. Okay. Ms. Doe, I appreciate you going on ChatGPT or Gemini to understand more of your hemorrhoids. And you're telling me that because it was bright, it was a hemorrhoid as opposed to something else. That's great. But let me just tell you something. Follow these instructions and every time you look something up, it'll automatically send it to me. And since this is my practice, I'm charging you $1,-

GW:

Sure.

MC:

For every one you send to me, but I'll respond or my model that I've built, learning from all these questions,-

GW:

Will give you the best advice and, yeah.

MC:

Right.

GW:

Yeah.

MC:

And you never know what the best advice is, but you can set up scenarios where you know Ms. Doe, the more she sends you, the more you can enable a model to learn more or work with programs that enable your model to learn more. So Ms. Doe with a hemorrhoids, she's got to decide on surgery or not surgery or whatever. You've already got a base of information that you can then pull just by talking to it. Ms. Doe, how many times have we talked? Dah, dah, dah, dah. And so being able to leverage AI not just as a tool for information for you, but recognizing that it's going to be a tool that will be used by everybody. Nobody's not going to use it.

GW:

It's like cell phones or the internet or, yeah, electricity.

MC:

Exactly. Right. And so before email, doctors didn't take emails until they did. Before text, doctors didn't take texts. Before apps, doctors didn't use apps until they did. Now that's what's going to happen. So with the agenetic AI, being able to accommodate patients in ways that make you smarter and more efficient and make them feel more confident and comfortable, that's what you want. Because think about your hassle phase right now. That's doing everything for your EMR and Epic.

GW:

Yeah. Yeah. And having the agentic AI handle it for you saves you a ton of pain and time.

MC:

Yeah. And just who knows where it goes. But I know it's not going to go backwards. It's only going to go forwards. And I can't predict when all this will be prevalent and common, but I can predict it will be. And I can tell you that the more your model talks to my model, that's going to be like, oh shit. And particularly for young people who are more confident with this stuff. You're 24, you're working, you're hung over. You think you hurt yourself, right, and instead of having the embarrassment of calling your doctor or whatever, calling your mom, it's just like, okay, ChatGPT, dah, dah, dah, dah, dah, dah, dah. Send to my doctor. Bam. There it is. The doctor's agent says, you're fucked up again. Okay.

GW:

Come get an X-ray or, yeah. Yeah. Yeah. Yeah.

MC:

Yeah. Or whatever else it may be.

GW:

Yeah. Mark, last question. We've skirted around it a little bit. Doctors unionizing, good or bad?

MC:

I mean, fine if you can make it work.

GW:

I'm seeing it as a response to the health system employee issue and the grind and getting work to the bone. I'm not sure that it's the best, but it is like a response.

MC:

It is a response. And it depends on the employer because they're all going to have different responses to it, but to me, it's a sign you don't have leverage yet. If you get to the point where you have more leverage, then a union can be great. I mean, I can see both sides. I think what at Kaiser Permanente is unionized and,-

GW:

Some of the residencies, the residents are, but the attendings are not. MGH at Harvard, there are a bunch of doctors just picketing just a couple days ago. So there are little pockets around the country where people are,-

MC:

Yeah, look, I'm not against unions at all. I can make you a ton of arguments, but to answer your question, I think that's a response that says, I'm stuck.

GW:

Yeah. Yeah. I totally agree. And yeah, I don't know another way out. Mark, last thing. If every physician in America could hear you say one thing to us, what would it be?

MC:

Thank you. Thank you for all the blood, sweat, and tears you put in to keep us healthy, to keep us alive, all the time you put in learning everything that comes up all day, every day, going through the anxiety of dealing with your family when you have that push and pull of what your family wants and you know what's right as a mom or a dad that you want to do, or as a son or daughter, and just feeling that pull to take care of a patient. Thank you. I know how hard it is. I can't imagine the stress it creates. Thank you.

GW:

Well, Mark, and that is why I wanted to talk to you because you are just so real and appreciative of the work that we all do.

MC:

Absolutely.

GW:

So thank you for saying that.

MC:

My pleasure. I meant every word of it.

GW:

Mark Cuban, thank you so much for joining us today. It's been an absolute pleasure. Thanks for joining me today. If there's someone you think I should interview for How I Doctor, drop us a line at podcast@offcall.com. Make an account on Offcall to confidentially share your details about your work and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well, stay inspired, and practice with purpose.