Latest / Becker’s Healthcare Podcast / Rethinking Healthcare as Technology Shifts Care to Consumers with Dr. Joel Selanikio

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Rethinking Healthcare as Technology Shifts Care to Consumers with Dr. Joel Selanikio · Becker’s Healthcare Podcast

0:00
This is Scott Becker with the Beckers HealthCare
0:03
podcast.
0:04
I'm thrilled today to be joined by a
0:06
brilliant physician leader who's also a technology leader.
0:10
We're joined today by doctor Joel Salonicchio,
0:13
and Joel's a speaker.
0:15
He's he he talks about GLP ones. He
0:17
talks about health care. He talks about women's
0:19
health. He talks about a lot.
0:21
Joel, can you take a moment
0:24
and and tell us a little bit about
0:26
your yourself
0:27
and your background?
0:29
I I don't know if you're a Georgetown
0:31
Hoya fan, but you'll tell us if you
0:33
are. But but tell us about you and
0:35
your career.
0:37
Sure.
0:38
Well, on a you know, the the easiest
0:39
thing when I meet people and they ask
0:40
what I do is I I say I'm
0:41
a pediatrician because everybody likes pediatricians and, you
0:44
know, that you don't have to explain any
0:46
further. But really my my although I am
0:48
trained, as a pediatrician and I do work
0:51
a couple days a week in the clinic,
0:53
most of my work for quite a long
0:55
time, for a couple decades, has been in
0:57
technology and health care.
0:59
Used to work for the CDC. I I
1:01
started with CDC after I finished my residency
1:03
and did a lot of work in international
1:05
vaccinations
1:06
by a
1:07
very indirect route that led me to,
1:10
focus on, data collection and data analysis related
1:13
to immunization.
1:14
That led me to
1:16
early technology work. This was back in the,
1:18
I know, Scott, you, of course, won't remember
1:20
this, but the the palm pilot days way
1:22
before your time, I'm sure. And,
1:25
I eventually wound up leaving CDC. And with
1:28
a friend of mine from the American Red
1:29
Cross, we started a company
1:31
that created data collection software that's, been used
1:34
for for quite a while now by Global
1:36
Health.
1:37
And
1:38
because of the work in technology and because
1:39
my background in in clinical medicine and epidemiology,
1:44
I've increasingly begun putting those two things together
1:47
for about the last ten years.
1:49
Because my work with the technology company, which
1:51
is called Magpie,
1:53
and this is unusual, I guess, for pediatrician,
1:54
I wound up attending a lot of meetings
1:56
and a lot of conferences
1:57
out in Silicon Valley and,
2:00
began to get some basic idea, again, unusual,
2:03
I think, for pediatricians,
2:05
at least maybe outside of the Stanford community,
2:08
of how technology works. And increasingly, I've been
2:11
trying to communicate,
2:12
my ideas about
2:14
what's happening with technology
2:15
and health and health care, and I I
2:18
definitely
2:19
separate those two, health and health care,
2:21
in in, you know, over the last ten
2:23
years and what's about to happen.
2:25
So, for example, looking at things like AI
2:28
in health care and AI in consumer health,
2:31
which I think is actually,
2:33
by far the more important
2:35
the more important topic and the the biggest
2:37
growth area.
2:38
But I think
2:40
lately, I've been talking to a lot of,
2:43
health care organization boards,
2:45
I've been talking to a lot of physicians.
2:47
I've been talking to a lot of technology
2:49
people about
2:51
a couple,
2:52
well, I I think
2:54
the a a couple very important statistics that
2:56
I think are,
2:57
almost entirely unknown within
3:00
health care. And one of them
3:02
is that,
3:03
you know, people always think of health care
3:05
as being this enormous, you know, it's $5,000,000,000,000.
3:08
It's, it's constantly growing.
3:10
And, you know, I started looking at that
3:12
because,
3:14
initially,
3:15
I had started thinking, you know, consumer health
3:18
technology seems like it it lets consumers do
3:20
a little bit of stuff on their own
3:22
that they used to do with the doctors.
3:24
You know, you can look up stuff on
3:25
Google, and doctors, of course, like to make
3:27
fun of doctor Google, but it prevents some
3:29
appointments. You know, some people who might have
3:31
gone to the doctor for that knowledge
3:33
get it from Google instead, or now they
3:35
might get it from chat GBT.
3:36
And I thought, you know, this must be
3:38
you should be able to see this in
3:39
the data. And I started looking into,
3:42
health care spending and health care spending growth
3:44
in The United States.
3:46
I went to the CMS website. First, I
3:48
started looking at health care spending. And, of
3:50
course, as we all know, it's gone nothing
3:52
but up for the last fifty years.
3:54
And then I started looking at the first
3:56
derivative of health care spending,
3:57
which is health care spending growth,
3:59
and I found that that's been falling
4:02
for fifty years. That the rate of health
4:04
care spending
4:06
growth
4:07
has been dropping for fifty years. Just to
4:09
give you an example,
4:10
you know, what would the the public spending
4:12
on,
4:13
health care in the sixties?
4:16
In 1970, if you look back at the
4:18
the previous ten years in nineteen sixties, you'd
4:20
find that health care spending had gone up
4:22
by 83%
4:23
per capita in The United States.
4:25
If you look twenty years later in 1990,
4:28
it had in the previous decade, in eighties,
4:30
it had gone up by 65%.
4:32
If you look most recently in the last
4:35
ten years, it's gone up by 28%.
4:37
And that was unexpected to me. It was
4:39
so unexpected when I was sitting there with
4:41
my Excel spreadsheet and looking at that data
4:44
that I,
4:46
contacted some economists that I know and said,
4:48
you
4:49
know, explain this. Like, did you know this?
4:51
Does anybody know this? I I I was
4:53
surprised to find a graph that was going
4:55
down.
4:56
And, the economist I talked to said, oh,
4:58
yeah. Yeah. Everybody knows that. And I was
5:00
like, oh, everybody doesn't know it in health
5:02
care. What what's
5:03
what's
5:04
causing that? And no one really had a
5:06
satisfactory
5:07
answer.
5:08
And I thought, okay. That you know, that's
5:10
not that's consistent with, but it's certainly not
5:12
gonna prove that technology
5:15
is
5:15
pulling things away from health care and that
5:18
is, you know, materially affecting,
5:20
the growth in health care spending.
5:22
So that's sort of one mystery. The other
5:24
or one unknown within health care. The other
5:26
one that I I have found quite amazing
5:29
both in the content and in the fact
5:30
that it is
5:31
completely unknown within health care
5:34
is that a Harvard study that looked at
5:36
primary care
5:37
for insured American adults,
5:39
and this was published, I think, in 2020.
5:41
It looked at 2008
5:43
to 2016,
5:45
found a 24% overall decline in in primary
5:49
care visits for insured
5:51
American adults.
5:52
And the amazing thing to me about this
5:55
is
5:56
I have never found a primary care doctor
5:58
who was familiar with the study.
6:00
And having spoken to probably at least a
6:03
100
6:04
health care system
6:06
CEOs or c or c suite level executives
6:08
over the course of the last five years,
6:11
I've never found a health care executive who's
6:13
heard of it either, and I've never found
6:15
anyone who came up with a satisfactory
6:17
explanation for this. Now the authors of that
6:20
Harvard study
6:21
said,
6:22
well, we think that,
6:23
we can explain about 25%
6:25
of the 24%
6:26
decline
6:27
through,
6:28
things like urgent care, you know, stuff that
6:31
shows up in billing. You know, someone's billing
6:34
for something,
6:35
and it's just not the traditional health care
6:37
system that's billing for it. It's, it's urgent
6:39
care. It's things like that. Maybe direct to
6:41
consumer stuff. Someone generates a bill. But the
6:44
other three quarters, we're not sure, but we
6:46
think it might be because people are getting
6:47
more
6:48
comfortable, especially young people, with kind of taking
6:51
care of their self their their health
6:53
themselves more on their own. Yeah. This this
6:56
is back in 2020, and since then, that
6:59
sort of that sort of dropped. Everybody ignored
7:01
the finding. The the authors have apparently had
7:04
some new data that just kinda confirms that
7:06
the trend continues,
7:07
and health care
7:09
ignores that or is unaware of that of
7:12
those two findings.
7:13
And to me, I I you know, to
7:15
get back to your original question,
7:16
I I spend a lot of time now
7:18
thinking about why that's happening. I think it's
7:20
connected to technology and,
7:23
and talking about that with health care executives.
7:27
Thank you. And and talk for a second
7:28
about that. How much is that
7:31
primary care
7:33
changing in how people deal with primary care
7:37
is I'll give you three questions.
7:41
Technology, necessity
7:42
due to shortages,
7:43
and maybe this the third is sort of
7:45
combined with the second is access that that
7:48
by design,
7:50
it's harder and harder to get to a
7:51
true primary care physician. In some states, you
7:53
can't do it without paying paying tons of
7:55
yard trees. So how much of this is
7:57
due
7:59
to technology
8:00
and, by necessity,
8:02
people moving away from primary care physicians because
8:05
they can't get into them. It's almost why
8:07
you see somebody put the ER sometimes because
8:09
there's no other easy access point sometimes. But
8:11
but what do you think is driving about
8:13
what you're talking about? Because I think you're
8:15
the counterintuitive
8:17
stats that you have, I think, are actually
8:19
right on and really fascinating. Talk about what
8:22
do you think is driving some of that.
8:24
Well, Scott, I think you've hit on exactly
8:26
the question because, you know, one question is,
8:28
why is this happening? But here's a here's
8:30
a, I think, a more telling question.
8:34
Why don't we know the answer?
8:36
Right? You you raised, certainly, a great counter
8:39
possibility. You know? And people often in health
8:42
care, they assume
8:43
that this is because we need more access.
8:46
Right? We need we need more clinics. We
8:47
need more doctors, etcetera.
8:49
And that that's a a reasonable explanation.
8:53
It's also reasonable to say it's because demand
8:55
is dropping.
8:56
Now if someone found
8:59
that auto sales in The United States
9:02
over an eight year period
9:04
had dropped by 24%,
9:06
it would be all over the news. And
9:08
you know something?
9:09
Every car dealer in America would know about
9:11
it.
9:12
And the CEO of Toyota and the CEO
9:14
of GM would know about it. And they
9:17
would be finding out the answer to the
9:19
question that you just asked.
9:21
Right? They would they would be like, well,
9:23
you know, this might be because we don't
9:25
have enough dealerships, and we gotta build more.
9:27
Or it might be because, people are taking
9:29
Uber. Like, we need to put some money
9:31
and some time into finding out the answer
9:33
to this question. But within health care, that's
9:36
not what has happened. What has happened is
9:38
no one knows about it and no one
9:41
talks about it,
9:42
and and no one further investigates. It it
9:45
and the point is so well taken, and
9:47
I I've heard some discussions recently
9:50
along these lines.
9:52
One, I think you're absolutely right. I mean,
9:53
for example, just the beauty of health care
9:56
is every single one of us is our
9:57
consumers.
9:58
And while you can't extrapolate totally from your
10:01
own experience,
10:03
we do know that more recently,
10:05
many of us look at Chi ChiPT
10:07
Right. Go to the urgent care.
10:09
We think we have a better sense, and
10:11
we often do, of what's wrong with us
10:13
unless it's something that's really serious,
10:16
and and we take care of it through
10:18
the
10:19
practice assistant, the PA,
10:21
the nurse at the urgent care versus what
10:23
would have been a one way ticket to
10:25
the primary care doctor years ago.
10:28
And part of its necessity, we're in we're
10:30
in our country creating 200,000 nurses a year
10:33
where we're creating
10:34
maybe eight to 10,000
10:36
primary care physicians a year while we're losing
10:39
almost that many per year, and the numbers
10:41
just don't work in terms of long term
10:44
single primary care physician for a lot of
10:46
stuff. But but what are some of the
10:48
things that you sort of believe
10:51
may be causing the change in how people
10:53
see physicians?
10:54
Well, I I don't think it's just how
10:56
people see physicians, but I think that
10:59
over the course of our lifetimes,
11:01
we have seen
11:03
a variety of tasks that used to be
11:05
done by doctors or used to be done
11:06
by the health care system
11:08
move into the consumer space.
11:10
And, you know, we're all very familiar with
11:12
that. I mean, Google, of course, you know,
11:13
in terms of knowledge, I I usually think
11:15
of this as sort of five categories or
11:17
five migrations out of health care. And, you
11:20
know, in terms of knowledge, obviously, you know,
11:22
twenty years ago, all of a sudden, you've
11:23
got all kinds of websites,
11:26
designed specifically to help people and doctors
11:29
to look up information,
11:31
beneficial to the consumer, beneficial to the doctor,
11:33
and, of course, Google, probably the most important,
11:37
knowledge tool up well, maybe up until recently
11:40
ever developed,
11:41
you know, you know, post printing press.
11:44
And, you know, as I said, you know,
11:46
if you go to Google and you look
11:47
something up, you might not go to the
11:49
doctor.
11:50
We haven't really quantified exactly what happens with
11:52
that. If we look at diagnosis rather than
11:55
just knowledge, well, you know, we've had home
11:57
pregnancy tests for a long time. Nobody thinks
11:59
of home pregnancy tests. No one ever asks
12:01
the question, will home pregnancy tests replace the
12:04
doctor? But the fact is the 20,000,000
12:06
home pregnancy tests that are done in The
12:09
United States every year, and this is, you
12:10
know, this is not some up to date
12:12
technology. Right? Those are 20,000,000 visits that don't
12:15
happen. That's 20,000,000
12:17
visits that don't get billed.
12:19
If you look at treatment,
12:22
over the counter drugs
12:23
I mean, over the counter drugs are specifically
12:27
designed
12:27
to replace the judgment of a doctor with
12:30
the replay with the judgment of a consumer.
12:32
Right? That's the whole reason for over the
12:34
counter drugs is to replace doctors for certain
12:36
health interactions.
12:38
That is what they do. That's what they're
12:40
designed to do. And,
12:42
you know, estimates that I've seen, and I
12:43
think these are pretty rough estimates, are that
12:46
we would need tens of thousands more doctors
12:48
if we didn't have over the counter drugs.
12:50
I think the current FDA,
12:53
is very, very interested
12:55
in trying to figure out
12:57
what can the consumer of today equipped with
12:59
chat GPT, equipped with an Apple Watch, equipped
13:01
with a a smartphone and a and a
13:03
computer. What can the consumer of today with
13:06
all those knowledge sources and all those resources?
13:08
What can we make over the counter today
13:10
that maybe we couldn't make over the counter
13:12
when people had to go to the public
13:14
library to learn about things? Now the answer
13:16
can't be, well, it's just the same. Right?
13:18
The answer has to be, well, yes. Of
13:20
course, people have many more knowledge tools now
13:23
than they did, say, you know, thirty or
13:24
forty years ago. So surely, we can move
13:27
more drugs over the counter. Again, that's a
13:29
process that's been going on a long time,
13:31
largely unnoticed.
13:33
Monitoring, I mean, monitoring has exploded. I'm, you
13:35
know, I'm wearing an Apple Watch right now.
13:37
Many people wear some similar things, Oura rings
13:40
and and Whoop and all these other,
13:42
different devices designed to monitor stuff. I mean,
13:45
monitoring used to be used to be a
13:47
big thing that you had to go to
13:48
the doctor for, except you only monitored certain
13:50
stuff once or twice a year.
13:52
That's not only allowing people to see things
13:55
and understand them at home that they didn't
13:57
used to,
13:58
it's allowing them to see things that they
14:00
could never understand at the doctor. Right? The
14:02
doctors doctors were never measuring,
14:05
for example,
14:06
let's say, heart rate variability or v o
14:09
two max.
14:10
I mean, I think the American Heart Association
14:12
came out. This must have been ten or
14:13
twenty years ago with a statement saying that
14:16
that we should measure v o two max.
14:17
It's a it's a more potent,
14:20
predictor of a future health than I I
14:22
can't remember, you know, than than any of
14:24
the things that they that they were doing
14:26
currently in the doctor's office during a checkup,
14:28
and that doctors should do it. Now, of
14:30
course, doctors didn't do it because it requires
14:32
a lab and exercise test and all the
14:34
rest of that stuff. So that metric
14:36
would never even done. I think the thing
14:38
that's new I mean, all that stuff that
14:40
I'm talking about, this is, you know, decades
14:42
old. I think the thing that's really new
14:44
is the interpretation
14:45
layer,
14:46
right, that we never had before.
14:48
So, you know, we've got the knowledge, the
14:51
diagnosis, the treatment, the monitoring, and now
14:54
technology that can actually interpret that stuff for
14:56
us. All those things, you know, they're not
14:58
destroying health care. They're not eliminating health care,
15:01
but they are removing tasks out of health
15:03
care.
15:03
And interestingly and importantly,
15:06
those we we never hear of a task
15:08
that is dealt with on the consumer side.
15:10
They never move into health care. They only
15:13
ratchet
15:14
out of health care.
15:16
And so, again, you know, when you think
15:17
of, like, why this might be happening,
15:20
that's why I think it's happening.
15:22
A a bigger picture is we need a
15:24
lot more information, and an even bigger picture
15:27
is why is it that we're not getting
15:29
that information. In fact, no one's even looking
15:32
at the question. As I said, no you
15:34
know, with the the example of the car
15:36
dealerships, I mean, literally 24%,
15:39
and you and I are sitting on a
15:40
on a podcast. Hey. Saying, yeah, I wonder
15:43
why. Scott's got one idea. Joel's got a
15:44
different idea. Do we have any data? No.
15:47
No one's looking at the question.
15:50
And and and talk about this because two
15:52
things that you mentioned resonate so well. And
15:55
I know you do a lot of discussions
15:56
and speaking and TED Talks around GLP ones
15:59
and other evolutions.
16:01
But the GLP one area is a fascinating
16:03
area
16:04
to the point that we're talking about
16:06
in that in the old days, anybody that
16:09
wanted to get a GLP one would
16:11
go see their their primary care doctor or
16:13
some doctor or specialist in weight management.
16:16
And now
16:18
we've taken so much out of the system
16:21
by going directly to whether it's Hims and
16:23
Hers or Rose Sparks or one of the
16:24
other telemedicine
16:26
or
16:27
online providers,
16:28
and and that would be a huge burden
16:30
on the system if not for these companies.
16:32
Is it
16:34
is that a fair assessment? I can't even
16:35
imagine how overwhelmed our health system would be
16:39
if all of that went through the traditional
16:40
health system versus some of these online retailers.
16:43
Can you talk about that for a second?
16:45
Sure. Well, I mean, I think, to me,
16:47
this, the term I usually use to describe
16:49
the effect of these on and some other
16:51
things on the health care system is demand
16:53
elimination.
16:55
Right? So, you know, there is, as you
16:57
point out, tremendous demand. Although, one thing I'd
16:59
I'd you know, one
17:01
quibble I'd have is I wouldn't say that
17:03
previously anybody who wanted to get a GLP
17:05
would go to their doctor. Previously, anybody who
17:07
wanted or ought to get a GLP
17:10
didn't go to their doctor because as we
17:12
pointed out, there's not enough capacity to deal
17:14
with that. So, you know, the the unmet
17:17
demand
17:18
for those medications
17:19
is huge. And, obviously, this is why you
17:21
see companies like like the ones you mentioned,
17:24
like, you know, HIMS and HRS and Roe
17:26
moving into the space to do that. So,
17:28
you know, this, I think, is a little
17:30
bit different from the migrations that I talked
17:33
about because in that in that case, what
17:35
you're seeing is,
17:37
the disruption of health care. Right? In the
17:39
kind of, you know, Clayton Christensen's sense of
17:41
disruption
17:42
where
17:43
there is a, you know, a new technology.
17:45
Let's say, the Internet has been developed or
17:47
the smartphone has been developed or the smartwatch
17:49
or, you know, all those things have been
17:51
developed.
17:52
And those things are providing
17:54
perhaps a lower quality,
17:57
but a much more accessible and much cheaper
17:59
version of something that you previously got in
18:02
the health care system. Again, classic kind of
18:04
low end disruption going on, and you can
18:06
look at that from over the counter drugs.
18:08
You know, getting going to the the drugstore
18:10
to get, Claritin is not the same thing
18:12
as going to see an allergist by any
18:14
means, but it's good enough and it's a
18:16
lot cheaper and so people do it. With
18:18
the GLPs
18:19
and another example of that, I think, would
18:21
be the,
18:22
with the GLPs is is a great medication
18:24
example. Another example, I think, is is gonna
18:26
be autonomous driving, and I'll I'll touch on
18:28
that in a sec. But with the GLPs,
18:30
I think what you're talking about is, you
18:32
know,
18:33
these companies are not disrupting health care. They
18:35
haven't invented a new technology. We're just talking
18:37
about people who have different business models.
18:40
Right? So it's not a new technology that
18:41
has somehow made it
18:43
that has disrupted in the Christiansen sense. You're
18:46
talking about just companies that are doing that.
18:47
Now
18:48
how long, I wonder,
18:50
until these GOP medications
18:52
wind up being you know, the pills particularly
18:54
wind up being over the counter.
18:56
You know, we we have you know, in
18:57
The United States, tons of people are on
18:59
statins. They're not over the counter. In The
19:01
UK, they are. Right? There are versions of
19:03
statins that are or one version of statins
19:05
that is over the counter in The UK.
19:07
They've looked at that equation and and decided
19:09
differently. But I think
19:12
one crucial point about the the hims and
19:14
hers, etcetera, is at least
19:16
that stuff
19:17
is to some extent trackable.
19:19
But it points to the it points to
19:21
the the
19:23
the lack of integration or lack of aggregation
19:25
of the data around this. Again, GOPs, as
19:27
you point out, this is an enormous thing,
19:30
an enormous,
19:32
need. Or I should say obesity is an
19:34
enormous need in The United States, not to
19:35
mention all the other things that the GLPs
19:38
may, in fact, have a beneficial effect on.
19:41
But
19:42
where's the data for this stuff? Well, we
19:44
know the stuff that happens in the health
19:45
care system. We can look at billing.
19:48
Some of the stuff that happens in the
19:49
over the you know, in the in the
19:51
direct to consumer stuff, some of that is
19:53
is billed in a way we can see
19:54
it. Some of that stuff is locked away
19:56
in the records from those different companies.
19:59
So we don't actually even have a real
20:01
idea
20:02
of what the extent of this is.
20:04
So, you know, okay. We we've already looked
20:06
at well, there seems to be a hemorrhaging
20:08
of people out of primary care.
20:11
No one's looking at it. There seems to
20:13
be
20:14
a hemorrhaging of people or at least a
20:16
movement of demand from health care to these
20:18
nontraditional
20:19
providers for the GLPs.
20:22
Who's putting all that data together? And, I
20:24
mean, it would be a job, Scott, to
20:26
put all that data together. You've gotta go
20:27
to a lot of different sources.
20:30
Health care seems to be focused in both
20:32
instances
20:33
only on looking at things
20:35
that that generate,
20:37
you know, a a code and that can
20:39
be measured within the traditional billing system. They're
20:42
not really looking at these other things. I
20:44
think health care is also
20:46
they're also biased toward looking at things that
20:48
involve a provider.
20:50
So I would say the difference between
20:52
the technology stuff I talked about at first
20:54
and the GLPs is or let's say looking
20:56
at direct to consumer stuff.
20:58
Health care is aware of the direct to
21:00
consumer stuff.
21:01
I think that's because it involves a provider.
21:03
Health care
21:05
can pay attention to something where there's a
21:07
doctor. Even if the doctor's over the phone
21:09
or the doctor's over a video consult or
21:11
even the doctor's doing something asynchronous,
21:13
there's a doctor who's gotta be involved to
21:15
make that decision. There's a white coat someplace
21:18
that's involved in health care gets white coats
21:21
and stethoscopes.
21:23
The stuff that's happening with the technology,
21:26
doesn't involve that and isn't measured, and nobody
21:30
pays
21:31
any attention to it at all. So, again,
21:34
we get back to this issue of, there
21:36
are so many important questions,
21:38
that no one appears to be making any
21:41
effort to answer.
21:43
Your question, this question of exactly how big
21:46
is the the direct to consumer,
21:48
exactly what kind of a threat does it
21:49
pose
21:50
to the traditional health care system, you know,
21:53
how much of it is need that health
21:54
care could never have met and, therefore,
21:57
you know, it's not a big deal because
21:59
we weren't meeting that anyway?
22:01
What will the direct to consumer companies do
22:03
next? Will it then become a dis will
22:05
they then become disruptors because they'll start to
22:07
do more stuff and pull more stuff out
22:09
of the health care system? You know, these
22:11
are all important questions that nobody seems to
22:13
really have a very good handle on. I
22:16
think another thing
22:17
another thing that health care
22:19
really doesn't have a handle on is
22:22
what happens when obesity
22:24
is drastically reduced.
22:26
The the only thing I've gotten in talking
22:28
to to executives about this in the last
22:30
year or two as the direct to consumer
22:31
stuff has really, you know, blossomed
22:34
is the effect on bariatric surgery. Like, hospitals
22:37
are already seeing,
22:39
an effect, you know, decreased scheduling and bariatric
22:41
surgery because people are losing weight in another
22:44
another way.
22:46
What no one seems to be discussing, I
22:48
mean, at all,
22:50
is all the other stuff, all the other
22:52
activity, all the other billable revenue that occurs
22:56
within the hospital
22:58
that is related to obesity. Right? We're talking
23:00
to everything from, you know, kidney issues, dialysis,
23:04
you know, hip replacements,
23:06
cardiac evaluations,
23:08
you know, all those different things. What is
23:10
gonna be the effect on health care if
23:12
obesity drops by,
23:14
let's be conservative, you know, twenty percent
23:17
or twenty five percent?
23:19
Another big question,
23:21
no one seems to be paying any attention
23:23
to looking at that question or or modeling
23:25
it. Again,
23:26
I'm talking to CEOs.
23:28
People are like, wow, that's really interesting. Oh,
23:30
you guys working on this?
23:32
Who's got the time?
23:34
But but isn't that the truth on so
23:35
many things? We're just on a discussion about
23:38
the one big beautiful bill, you know, OB
23:41
three, and
23:42
and and we hear so much from CEOs
23:45
and leaders of health systems and and physician
23:47
leaders.
23:48
They are dealing with so many different things
23:50
right now
23:52
that actually
23:53
taking a longer view of some trends or
23:55
trying to figure out exactly how to prepare
23:57
for o b three or for something else,
23:59
almost takes a a back seat to trying
24:02
to make sure that you're taking care of
24:05
patients, filling your work needs, handling things,
24:08
then looking at some of these bigger questions
24:10
as to where might things go.
24:13
And how much do you see that, doctor
24:14
Seleneckio?
24:16
And and also, let me ask you a
24:17
second time question.
24:19
When you look at all this, are you
24:21
optimistic about the future because some of these
24:23
changes, or do you think it's a scrolling
24:25
mess or both?
24:27
Well, one, I I'd say, you know, who's
24:30
who's future?
24:31
This future of the health care system, the
24:33
future of, people's health,
24:36
the future of these, you know, of direct
24:37
to consumer companies. Right? These are all different
24:39
these are all different questions with different answers.
24:42
So, you know, I often will say that
24:44
I look at the future of health care,
24:46
and I see it as being better. I
24:49
think technology tools like AI, etcetera, are already
24:52
and will continue to make health care better.
24:55
No question about it. There are big advances
24:57
that are barely deployed, and I think they'll
24:59
have that they'll make beneficial changes within health
25:02
care. I also think that health care will
25:04
get smaller.
25:05
And for the reasons that I mentioned, it's
25:07
gonna get smaller because
25:08
a lot of the stuff that we do
25:10
right now, because we had previously been unable
25:12
to successfully address obesity,
25:14
all of that stuff is gonna go away.
25:16
You know, right now we see with bariatric
25:17
surgery, but if I say, oh, I think
25:19
that, you know, I think knee replacements are
25:21
gonna go drastically down, people look at me
25:23
like I have two heads.
25:25
But it's the same thing.
25:27
I think that the stuff that's being pulled
25:29
out by, you know, all the the sort
25:31
of low level stuff that's being pulled out
25:33
by consumer health technology, that's obviously not gonna
25:35
slow down. That's just gonna you know, all
25:38
that technology right now is, as people sometimes
25:40
say, is the worst that it's ever going
25:42
to be. Right? This snowball just
25:45
keeps rolling.
25:46
I think, you know, you make a great
25:48
point, and it's one that I've heard, as
25:50
I said, from the CEOs, you know, who's
25:52
got the time? We don't have the time
25:53
to look for this. You're a CEO of
25:55
a big health care system. You're a busy
25:57
person.
25:59
I think
26:00
health care, though, as a whole has got
26:02
to start thinking about,
26:03
is there anybody
26:05
that can look at this? Because otherwise, you
26:07
know, otherwise, you're you're Blockbuster.
26:10
Right?
26:11
Otherwise, you're Blockbuster, you're Kodak. You know, you
26:13
are having your lunch eaten
26:15
by these up and comers or by these
26:17
technologies,
26:18
and you're too busy to pay attention to
26:20
these things that, again, will materially affect
26:23
your results.
26:25
You know, I I read I read some
26:26
of your newsletters, your many newsletters, and, you
26:28
know, a persistent theme, of course, is hospital
26:30
closings
26:31
and hospital financial problems.
26:34
I I have never ever seen any of
26:36
the financial problems except more recently with bariatric
26:39
surgery
26:40
attributed to any of the things that we've
26:41
been talking about.
26:42
And we haven't talked about, for example, autonomous
26:45
driving. I, you know, my wife's thinking about
26:47
about buying a Tesla. I went,
26:49
I've been in the Waymo taxis, but I
26:51
never actually this seems remarkable to a guy
26:53
who, you know, thinks about technology a lot.
26:55
I'd never actually driven a Tesla before, so
26:58
we went and did a test drive yesterday.
27:00
And, you know, you think to yourself,
27:02
right now, I think Waymo and, some of
27:05
the insurance companies, I think Swiss Re had
27:07
said, you know, that roughly they see 90%
27:10
fewer accidents with Waymo than they do with
27:13
human driven cars. You know, let's suppose they're
27:16
way off and it's only a 50% reduction
27:18
in accidents.
27:19
What's the amount of revenue in the hospital
27:20
system that that happens from
27:23
accidents?
27:25
What percentage of that revenue is simply going
27:27
to disappear? Not because it's a a disruptor
27:30
or a company that's doing it better or
27:31
that's pulling accident care out of a health
27:34
care system.
27:35
Right? Just like with the GLPs, you know,
27:37
nobody's it's not like somebody's pulling, you know,
27:39
all those
27:40
downstream from obesity cares out of the health
27:42
care system. They're just making them disappear.
27:46
So with all these different things, there are
27:49
I there was, I think, an enormous potential.
27:51
I mean, I would say it's
27:53
it's a certainty
27:54
that there will be some drastic revenue reduction,
27:57
drastic
27:58
activity reduction in health care. I think that
28:00
health care will deal with the stuff that
28:02
it continues to deal with in a better
28:04
way because of these technologies. So, again, better
28:06
and smaller.
28:08
But, if I could do something about this,
28:10
the thing I'd most like to do is
28:13
find out how we can get some,
28:15
you know, third party organization,
28:18
to you know, or academics or something to
28:20
be looking at these questions and getting better
28:22
answers
28:23
to what's gonna happen. And you've got this
28:26
great challenge, doctor Zelenikyo,
28:28
between sort of the cortex and block versus
28:31
the world
28:32
versus
28:34
this massive health systems and massive health care
28:36
economy
28:37
that shifts a little bit slowly based on
28:40
how many people and how many payment systems
28:42
are part of it.
28:44
And so when you look at these overall
28:46
overall issues,
28:48
you know, they talked about how airlines are
28:50
gonna need less fuel
28:52
as we become skinnier through GLP ones.
28:55
Yeah. But but but, again, it's it's a
28:57
cascading time frame and seeing whether these predictions
28:59
actually happen or not. And so you're stuck
29:02
as a leader between
29:03
all these predictions of the future
29:05
versus sort of the old adage if you're
29:07
a carpenter and you see something, you'll hammer
29:10
it, you know, versus a knee surgeon who
29:12
says, well, this is what I do. Right.
29:14
And I'm not seeing the impact on me
29:15
yet, whereas the people that are doing,
29:19
obesity surgery are already seeing that actual impact
29:22
that the weight loss surgery people that that
29:25
that do that are already seeing a real
29:27
impact. Yep. And it it it's a matter
29:29
of how much this cascades when enough people
29:31
actually get
29:33
lose 10 pounds and stay skinnier and where
29:36
that
29:36
you know, you we you and I are
29:38
of the age, at least I am, of
29:40
the age where plenty of friends have had
29:42
knee surgery or knee replacement.
29:44
Some of them had been in involved with
29:46
fitness for life and kept us of a
29:48
good shape. Some of them had not. It's
29:50
all over the board quite frankly. We do
29:51
know if you have more weight, you're more
29:53
likely to need a knee replacement. No question.
29:55
But but many other people still need it
29:57
because they just were very athletic for a
29:59
very long time and they just knees can't
30:01
take it.
30:02
And and so trying to predict these things
30:04
and making decisions based on them
30:06
is still really challenging, isn't it? Well, it's
30:08
really challenging if if no one's out there
30:10
trying to trying to answer it. Right? I
30:13
mean, I've had I've had many discussions, you
30:15
know, many similar discussions with folks. And, you
30:18
know, again, get back to that that
30:20
decrease in the per capita
30:22
health care spending growth over the course of
30:25
fifty years, you know, a very, very consistent
30:27
decrease over the course of that time. Over
30:30
that same period of time, the country got
30:32
older and much, much fatter.
30:35
And health care, you know, health care spending
30:37
growth
30:38
still went
30:40
down
30:41
per capita. Right? They got older and fatter,
30:43
and it still went down.
30:45
Nobody is working to explain that. And, you
30:48
know, in fact, actually, in the last, I
30:49
think, in the last twenty years, health care
30:51
spending actually
30:53
the absolute spending, not the health care spending
30:55
growth,
30:57
the absolute spending went down four times. It
30:59
has that has never happened before since CMS
31:02
started collecting data in 1960.
31:04
So not only I mean, what would you
31:06
expect if you saw a graph that showed
31:08
the growth going down over fifty years? You'd
31:10
expect, wow. That's pretty consistent. I guess, at
31:13
some point, absolute spending will also decrease.
31:16
Right? I mean, at some point, it's gonna
31:18
hit the it's gonna hit the x axis.
31:19
Right?
31:20
Well, it did four times in the last
31:23
twenty years. It never did before.
31:25
Is anyone paying attention to it? No. And,
31:27
you know, it it's also interesting that we
31:29
I think we
31:31
the the sort of the bias in the
31:33
information that people look at. You know, I
31:35
I I think I've lost count of the
31:36
number of times I've seen newspaper,
31:39
you know, news articles or or,
31:41
or people speaking at conferences talking about,
31:44
you know, well, we got the silver tsunami
31:46
and,
31:47
you know, we've we've really got to,
31:50
get,
31:51
more doctors. You know, this we're gonna have
31:52
a shortage of this many tens of thousands
31:54
or hundreds of thousands of doctors.
31:56
And I have tried
31:58
to trace back where those estimates come from.
32:01
And in every single instance, those estimates come
32:04
down to one organization, which is the what
32:07
is it? The American College of
32:09
Medical
32:10
Schools. I I can't remember the exact
32:12
organization, but it is the trade organization
32:14
of
32:16
companies, of of organization, schools
32:19
that train more doctors.
32:21
So
32:22
See.
32:22
But but don't you think, doctor Seleneccio,
32:25
to an extent,
32:26
you know, it is is
32:29
we I I think that you're you're
32:32
agree with a a ton of what you
32:33
say,
32:34
and and some of these numbers are just
32:36
a way in how we're gonna change how
32:37
we do business. For example, if you look
32:39
at the shortage of primary care doctors, it's
32:42
based on the concept of all of the
32:43
primary care doctor like like I did through
32:46
my adult life where you had an actual
32:47
primary care physician.
32:49
Right. You saw a couple times a year
32:50
and so forth, and that that model is
32:52
just gonna is just changing.
32:54
And and we're never gonna get back to
32:56
that model with 350,000,000
32:58
people here.
32:59
But but I do see in the specialist
33:01
area you know, I'm I'm of an age,
33:03
and I hate to keep on saying that.
33:04
It makes me sound so old. We're we're
33:05
we've had so many people that we know
33:07
have died of pancreatic cancer, brain cancer, disc
33:09
cancer, neck cancer.
33:11
And what I have found
33:13
in in following close colleagues and family members'
33:15
cancer journey
33:17
is how short the bench gets in certain
33:19
specialties
33:20
in in subspecialties
33:21
really quickly throughout the country. You know, at
33:24
some place might be known as the best
33:25
oncology place in the country, and you get
33:28
past, you know, doctor number two in the
33:30
area, and they're lost. And that and that's
33:32
not that just is what it is.
33:34
So it seems like so much of the
33:36
guidance on where we're short physicians
33:39
has been narrative driven towards primary care when
33:42
at least in my own experience where we
33:44
seem to be the most short
33:46
is in all kinds of subspecialties,
33:48
and
33:48
that's an unpopular thing for the, medical establishment
33:51
to say, but that's where I see the
33:53
bigger gap. I I'm I'm curious as to
33:54
your thoughts.
33:55
Yeah. I I mean, I think that's a
33:57
I think it's an interesting point, and I
33:59
I I definitely think that a lot of
34:00
the primary care stuff,
34:02
you know, well, again, a 24% decline. Right?
34:06
That wasn't really surprising to me when I
34:08
saw it. It was only surprising that no
34:09
one was talking about it. I think,
34:12
you know, if we say, okay. Well, we
34:14
don't need the primary care physicians.
34:16
We're gonna have the same number of doctors,
34:18
but they're gonna be specialists
34:20
instead. You know, well, then you have the
34:22
issues of, well, you know, what's the cost
34:23
of that gonna be?
34:25
In terms of cancer, and particularly, as I'm
34:26
sure you know, the rate of cancer in
34:28
The United States has actually been going down
34:29
pretty steadily from the you know, since the
34:31
eighties or the nineties.
34:33
I think it's down by about a third.
34:35
So, it's not gonna be cancer specialists.
34:38
It's not gonna be obesity specialists.
34:41
You know, so the the the thing is
34:43
if we're saying, well, I think what's gonna
34:45
save us is we're gonna,
34:47
we're gonna move those doctors. They're gonna graduate,
34:49
and they're gonna go into to specialties instead
34:51
of going into primary care, which, let's face
34:53
it, they're already doing.
34:54
Okay. But
34:56
I I think we we have to health
34:58
care as a field
35:00
has to move beyond
35:02
the hypothesis stage
35:04
and start looking at the, let's get data
35:07
that enables us to determine to what extent,
35:10
one of these things is happening
35:12
versus another thing is happening.
35:14
Again, but mind blowing that that no one's
35:17
really followed up that that 2020 study looking
35:19
at the 24% decline, and that the primary
35:21
care docs don't even know about it.
35:24
No. I think it's it's actually
35:26
absolutely.
35:27
I I I know we've gotta wrap up
35:29
in a second, doctor Solonikio, but it is
35:31
brilliant to visit with you. It's such a
35:33
brilliant sort of different perspective on some of
35:35
this, and it's so helpful because it it
35:37
helps me also see, like, talking to you
35:40
gives you some of the sense of sometimes
35:42
the errors in my own thinking.
35:44
Because
35:45
if I predict from my own personal experience
35:47
in watching this as a consumer
35:49
that somehow or another we need more rare
35:52
cancer specialists because
35:54
when I'm seeing colleagues pass away, it's pancreatic
35:57
cancer, brain cancer, melanoma, the eye cancer, different
36:00
things that have happened more recently.
36:03
You know, you give that against the backdrop
36:05
of the increase in colorectal cancers and other
36:07
cancers.
36:08
So I immediately go towards, we gotta figure
36:10
out more specialists because so much of our
36:12
primary care is getting taken care of in
36:14
different ways. And you say, well, Scott, by
36:16
the time we change that,
36:17
you know, if we don't study this very
36:19
carefully,
36:20
there might be dramatic differences in the numbers
36:22
of cancer. So by the time it's almost
36:24
like the Maginol line thing in France, we
36:26
will be solving the last generation's problems,
36:29
particularly when we're trying to develop specialties ten
36:32
years out. And and it doesn't even if
36:34
we ten years develop a specialist,
36:36
it actually takes longer to get the pipeline
36:38
going correctly too. So you're really looking a
36:40
long time in the future,
36:42
and and you have to be careful and
36:43
solve the wrong problem. But I think your
36:45
point is
36:46
that there's so much anecdotal hypotheses
36:49
going on
36:50
that that someone's gotta do a deep dive
36:51
into where this might be going,
36:53
and and I think that's a brilliant thought.
36:56
Yeah. I think and the question is the
36:57
question only becomes, you know, who? I mean,
37:00
you know, Scott, you know, you're a guy
37:01
who obviously spends a lot of time thinking
37:03
about health and health care.
37:06
You know, you don't know the answer. I
37:08
don't know the answer. Why don't we know
37:09
the answer? We don't know the answer because
37:10
we're not collecting the data for that. I
37:13
mean, that's not that's not our job.
37:15
We have other things to do. It turns
37:16
out that everybody's got other things to do.
37:19
And and so, again, nobody's actually
37:22
getting the information that's gonna let us you
37:24
know, we you and I have had again,
37:25
we pointed out a couple different possible explanations
37:28
for some of the things that I've raised.
37:30
We don't exactly know what's gonna happen with
37:32
the GLPs. Maybe it'll somehow it'll be a
37:34
bust.
37:35
And someone
37:36
someone has to be tasked
37:38
with identifying you know, actually going out and
37:40
saying, we we need to find the datasets,
37:42
you know, with the GLPs.
37:44
We need to have some perhaps government organization,
37:48
that can go to these these direct to
37:50
consumer companies and get the data on exactly
37:52
how much are they serving. You know, we
37:54
wanna know what that is.
37:56
So is is any does anybody know how
37:58
many times somebody,
38:00
got some information from Google or chat GPT
38:03
or their Apple Watch
38:04
and chose not to go in to see
38:06
the doctor as a result? No one has
38:08
that data. No one's collected that data.
38:11
Or or any real sense of it. We
38:12
we all we all know anecdotally how many
38:15
times we've not gone to the primary care
38:16
doctor because we end up going to the
38:18
nurse practitioner or so or the urgent care
38:20
or CHAT GBT.
38:22
But we also know how many times in
38:24
the last few years family members have gone
38:26
to the ER
38:27
for different reasons that we couldn't get the
38:29
access through a telehealth visit. We couldn't get
38:31
the access through primary care visits, so I
38:33
ended up rebounding back to the ER, and
38:35
that's what ERs to be crazily full. But
38:37
I think your point is well so is
38:38
so well taken. Doctor Selenicchio, I know we've
38:41
gotta wrap up.
38:42
Joel Selenicchio,
38:44
brilliant pedia pediatrician,
38:46
but but more technology and futurist and thinkers.
38:50
Joel, tell us about, doctor Salenichio, the name
38:52
of your
38:54
company. I I know you've got a company
38:55
called FutureLive, I think it is, but tell
38:57
us about that for a second.
38:59
Well, I mean, the the company the company
39:01
is just me. Future Health is just me.
39:03
That's that's the
39:04
the consulting
39:05
and, public speaking that I do,
39:07
under that label, under that website.
39:10
I had a technology company that made software.
39:12
We recently had shut down that software
39:15
a year before last.
39:17
Basically, just a there was when we started
39:19
it, nobody else was doing it, within the
39:21
international public health community in terms of the
39:24
mobile data collection. When we finished it, you
39:26
know, we had 200 competitors, and we just,
39:29
decided to, to sell the the
39:31
sell the technology base, sell the stack, and
39:34
get out of that. So the only company
39:36
I have right now is a company of
39:37
one.
39:38
Well, plus plus my system.
39:41
Well, god bless that. Nothing wrong with that.
39:43
I love that. Doctor Silaneckio, what a pleasure
39:45
to visit with you. Absolutely brilliant. Thank you
39:47
so much for taking the time. My my
39:49
pleasure. Thanks, Kyle.