{"id":14146,"date":"2026-06-26T07:37:00","date_gmt":"2026-06-26T07:37:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=14146"},"modified":"2026-06-26T07:37:00","modified_gmt":"2026-06-26T07:37:00","slug":"thcb-spotlight-warris-bokhari-claimable","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=14146","title":{"rendered":"THCB Spotlight: Warris Bokhari, Claimable"},"content":{"rendered":"

One of the most interesting follows on Linkedin is Warris Bokhari<\/a> from Claimable. He\u2019s a British MD, who has had stints not only as a doc in the UK, but also as a health tech and health insurance exec in the US. But now he\u2019s at war with the system, in particular working for patients to overturn denials from insurers using AI. But what exactly is the big picture aim, and how does Warris think that he\u2019s going to fix American health care? We had quite the discussion and we sort of agree, but also don\u2019t. Great discussion and transcript is below the video\u2013Matthew Holt<\/strong><\/em><\/p>\n

\n<\/div>\n

This was such a great discussion I wanted to publish the transcript. The way I do that is to copy the Youtube generated transcript and drop it into Claude to smooth it over. I then read it and if I think it\u2019s made an error, dip back into the video and listen to what actually happened and make a correction. This is all code therefore for me saying I think this transcript is pretty accurate but it might have a bunch of AI and human generated mistakes.<\/em><\/p>\n

THCB Spotlight: Warris Bokhari, CEO of Claimable<\/strong><\/p>\n

<\/span><\/p>\n

Matthew: <\/strong>Matthew Holt here with The Health Care Blog. Another THCB Spotlight and I\u2019m thrilled to be talking with Warris Bokhari. Warris is the CEO of Claimable and not so very long ago I had his co-founder Alicia Graham on a panel at ViVE, where she was faced up with at least one senior executive of a big health plan \u2014 although the other one didn\u2019t show up because apparently my questions weren\u2019t going to be nice or something like that. [laughter] So if you\u2019ve seen Warris around on LinkedIn, you know that Claimable has certain loud points of view. But Warris, why don\u2019t we start with what Claimable does. We\u2019ll get into a little bit about what you\u2019ve been doing before that and then we\u2019ll probably \u2014 the most of this conversation is how do we fix American healthcare, because that\u2019s what two British guys, as we both are, should be discussing.\u00a0<\/p>\n

Warris:<\/strong> I also \u2014 much to the annoyance of Anthem\u2019s PR person \u2014 would like to talk about that panel as well. I don\u2019t know if that\u2019s off limits, but we\u2019re [laughter] happy to talk about it. <\/strong>The good news is I remember what actually happened on it. [laughter]<\/p>\n

Matthew: <\/strong>And I think the only person who\u2019s ever found a recording of it was you,<\/p>\n

Warris: <\/strong>Why don\u2019t we start with \u2014 as you suggested \u2014 what Claimable is and does. The broad problem is: we\u2019ve in this country \u2014 and you and I, by the way, are not from here, but we live here, and I think that makes us\u2026.\u00a0<\/p>\n

Matthew:<\/strong>I\u2019m old, so I\u2019ve lived here more than I lived in England; I\u2019ve lived essentially my entire adult life here \u2014\u00a0<\/p>\n

Warris <\/strong>: depending on when you consider me to have become an adult the same could be said for me. [laughter] So the broad problem is that every year in the US there are about a billion denied claims across the entire healthcare system. That\u2019s when you think about Medicare Advantage, when you think about commercial \u2014 which includes self-insured and fully insured plans \u2014 the ACA exchange, which we\u2019ve been busy trying to kill (which is ill-advised), and Medicare, Medicaid, etc. So across all of those plans there\u2019s a billion denials out of the 5 billion claims filed every year, and really only about 1 million appeals ever get filed. Now when you think about how many humans this affects \u2014 obviously there aren\u2019t a billion humans in the United States, there are 300 million insured people \u2014 if you look at the latest data from the Commonwealth Fund, it backs into like a 1-in-5 denial rate, but that\u2019s as high as 1 in 3 if you have a chronic disease. So a third of America \u2014 quite a lot of Americans \u2014 have a chronic disease and they\u2019re battling denials. 50% of these denials are medication denials. And if you think about the few modes of health care \u2014 there\u2019s the stay-well mode, which is manage chronic disease well, and then there\u2019s get-care, which is normally when someone\u2019s acutely decompensated and needs to end up in a clinic or an emergency room \u2014 we\u2019re biasing toward people needing more expensive care because we\u2019re restricting access to things that keep them healthy, and those are medications that keep chronic diseases controlled. So we built a TurboTax of appeals, basically, for medications. So far \u2013\u00a0 it will be expanding to include investigations like MRIs and PET scans specifically for oncology pretty soon. And we\u2019re going to keep moving down the field. We beat around 80% of denials \u2014 I think the exact number across our entire platform is closer to 74%. But when you look in biologics, which are the expensive medications that are often restricted, we\u2019re beating well over 80% of those cases. There are a number of ways that patients can use us. First of all there\u2019s a direct-to-consumer door which will never go away, and that\u2019s particularly because most providers give up and don\u2019t appeal. And then there\u2019s also a door where we work with manufacturers and we support their patient assistance programs \u2014 where effectively we\u2019ve transferred the economic loss from the insurer (who\u2019s getting the premiums and should be paying for the care) to the patient, who then has to seek subsidy from a pharma company. But effectively the payer should be paying for it at least 80% of the time. And then we\u2019re increasingly starting to work with health systems. So those are the ways in which we work today.<\/p>\n

Matthew: <\/strong>And then for the actual consumer experience \u2014 I have a problem, I don\u2019t have anybody else to help me. I\u2019ve seen you appealing for people on LinkedIn on behalf of people and I know Mark Cuban is an investor and he joins sometimes. But let\u2019s say it\u2019s all normal. I come to the Claimable website and what do I do?<\/p>\n

Warris: <\/strong>Yeah, so there\u2019s a finite number of things that we support today, just to be very clear. We get people who come to us looking for all sorts of things which we don\u2019t cover. We cover a lot of therapeutics. Sometimes \u2014 like last week I had a mom reach out whose kid has osteosarcoma, which is a terrible bone cancer effectively, and the insurer\u2019s answer was: hey, amputate the leg versus get surgery at Memorial Sloan Kettering. And that was one which I did on the side. So we run a for-profit AI-forward SaaS company effectively on one side, and on the other side I run a pretty much 24\/7 advocacy business where I figure out how to help as many people as I can in the background whilst we\u2019re closing the gap on all the things we can automate responsibly. But say for example you\u2019re denied \u2014 a common example would be Zepbound, right? We get a lot of patients who are denied GLP-1s. They\u2019re extremely helpful drugs and they\u2019ve now been approved for more and more indications, including MASH \u2014 metabolic-associated steatohepatitis \u2014 which my dad died from. So the idea that there\u2019s a medication that actually could have prevented cirrhotic liver through that would have been very useful say 10 years ago. But like here we are. So you could appeal for that. We take you through a very simple Q&A of what you\u2019ve tried before \u2014 lifestyle measures, etc. \u2014 and then we\u2019ll ask you questions about how your disease affects you.<\/p>\n

\u00a0Because Matthew, the dirty secret is that insurers don\u2019t think of you as a person. They think of you as a membership card and a membership ID number. You\u2019re really a passive premium payer to them. But when you have a problem, there\u2019s no way that you can reach them. They sure as hell don\u2019t want you to appeal, because they never actually want to know what it\u2019s like for a patient to suffer from a disease. So we capture the information about \u2014 for example \u2014 \u2018I have severe rheumatoid arthritis. I used to be the person who did the cooking for my family on a Sunday and now I don\u2019t see my family because my disease has decompensated so much that I\u2019m in so much pain I can\u2019t sleep. I sleep upright in a chair in my living room every night.\u2019 And so patients become progressively socially isolated. We narrate that story in the patient\u2019s words back to the insurer, and then we combine it with the clinical evidence \u2014 the peer-reviewed studies, the clinical practice guidelines, and also cases where the insurer has been beaten before \u2014 to show them: hey, your decisions seem inconsistent with these other decisions that have been made for cases just like mine. Oh, and by the way, here are all the laws that mean that what you\u2019re doing to me is probably illegal. And we\u2019re going to send this to the CEO of a self-funded plan, because they\u2019re actually the fiduciary and they probably have no idea what you\u2019re doing. We\u2019re going to send it to the Department of Labor. We\u2019re going to send it to the C-suite of this plan to make it extremely clear that this is a real person with real needs.<\/p>\n

Matthew: <\/strong>So they are coming on board, they\u2019re getting some AI assistance. I mean \u2014 let me ask the scalability question. How are they \u2014 I know there are very few appeals \u2014 that very few denials that get appealed. I don\u2019t know how many are being appealed now and how many are you responsible for? Are you a significant part of the market now?<\/p>\n

Warris: <\/strong>Not yet.<\/p>\n

Matthew<\/strong>: As you said, the numbers globally \u2014 denials that get overturned on appeal is actually pretty high.So I don\u2019t know how good 80% is or 75% is compared to the average.<\/p>\n

Warris: <\/strong>The average from the Kaiser Family Foundation data is 44%. So across all \u2014 yeah. We\u2019re significantly better than that. I think currently \u2014<\/p>\n

Matthew:<\/strong> I assume these are coming from providers doing appeals or is it direct?<\/p>\n

Warris: <\/strong>If you look across the country, around 75% of appeals today come from the provider. The issue is \u2014 and this is the thing that people don\u2019t understand \u2014 the provider actually has no statutory rights to appeal. They actually borrow their rights from the patient. So providers have contractual rights with United and whoever, but the patient has federally protected rights under ERISA, which was the 1974 law that was set up to make sure that employers couldn\u2019t gamble away pension funds and things, but got extended into health benefits. And ERISA was built on top of \u2014 and this is probably more Chris Deacon\u2019s area \u2014 but was built on top of, for the Affordable Care Act in 2010, which basically stood on those provisions and extended them to include consistent rights of independent review, which basically every state other than Alabama follows.\u00a0<\/p>\n

And I\u2019ve had significant arguments with the state of Alabama over their lack of compliance, as you might imagine. And so what we believe is that your first appeal is your best appeal. We try to put as much forward in the patient appeals as possible. The first battle was convincing anyone that this problem mattered. No one believed \u2014 three years ago, when I posited that this was a problem, no one believed me at all. And it wasn\u2019t until after Brian Thompson died that suddenly the Overton window shifted. And initially it shifted in a really unhealthy way, which was a kind of morbid fascination about Luigi and other things. And then it shifted into like solutions \u2014 and I\u2019m here for that, right? How do we get patients\u2019 rights upheld? How do we get them access to care and not have them become progressively disabled? We\u2019ve certainly had cases where we\u2019ve intervened but it\u2019s been too late. And pretty much nothing is more painful to us as a team than winning for a patient but it being a completely Pyrrhic victory \u2014 the patient dies or comes to significant harm. It\u2019s probably happened four or five times this year.<\/p>\n

Matthew: <\/strong>Yeah. So the majority of cases \u2014 you mentioned GLP-1s, but the majority of cases that you\u2019re facing \u2014 how much of this is: people either change health plans or their health plan gets changed on them by their employer, and a new one has a PBM which doesn\u2019t cover the drug that they spent years figuring out actually works for them? Or in some cases the PBM changed the formulary on the drug. And a lot of this is not necessarily massively expensive \u2014 not the hundreds-of-thousands-of-dollar biologics \u2014 but some of them are serious. And obviously because one drug can work for one patient and another drug may not work for that patient, that\u2019s a big issue. We know the reasons why the PBMs are changing different brands for another, and even changing different generics for another. But give me a sense \u2014 how much of what you\u2019re seeing is that? The other one that has raised a lot of hackles recently \u2014 a lot of news \u2014 is obviously the nursing home\/SNF denials, rehab denials, especially in Medicare Advantage. How much of that are you seeing? Do you do that? Give me a sense of what\u2019s going on out there in the wide world of denials and which ones you\u2019re mostly picking up at Claimable.<\/p>\n

Warris: <\/strong>Yeah, so in pretty much all therapeutics. I have done rehab denials, just FYI, and the provider can be as much to blame as the insurer in some of the cases I\u2019ve seen. Some of that\u2019s about DRGs \u2014 disease-related groups \u2014 and not wanting to split them. In fact, the first case we appealed was a stroke rehab patient, come to think of it, and the provider was afraid to appeal because they were worried about retaliation from the insurer. And we got that one overturned. And then there\u2019ve been other ones. A friend of mine \u2014 her dad became quadriplegic after a fall and I had to intercede there because she was having a lot of issues getting his rehab paid for. But it was actually the hospital that didn\u2019t want to fight, and that actually ended up getting escalated to Kathy Hochul as in the Governor of New York to tell off the hospital, and that got overturned. Those ones aren\u2019t ones that we see commonly, but I see them and we\u2019ll try and help where I can. On the therapeutic side, we see a lot of formulary changes \u2014 a lot of \u2018if not Dupixent, then swallow this pack of steroids, good luck.\u2019 We see a lot of \u2018please don\u2019t take this biologic, take this biosimilar,\u2019 and the patient\u2019s been stable on the branded biologic for 20 years, then they get switched to a biosimilar and they start to decompensate and now need a way back onto the originator compound. Now in England, the way I was taught \u2014 we never learned brand names in medical school, we were always taught the systematic name \u2014 you think of it as a drug, not a brand. The issue here is that not all of the biosimilars are exactly the same. Patients may respond to them quite differently, and if they\u2019ve been stable. So there was a UC patient who was switched and ended up basically unable to eat, got admitted to the emergency room, needed feeding, needed a way back. There was another patient \u2014 a North Carolina patient, as I recall \u2014 a rheumatology patient who got switched from an originator to a biosimilar and developed rheumatoid lung, which is a really serious sign of not having control. I\u2019ve got to caveat all of this by saying that we see a biased selection of patients who have been denied and have problems.<\/p>\n

Matthew: <\/strong>just to interrupt \u2014 you are saying that some \u2018generic\u2019 biosimilar is not actually all that similar in some patients, right?\u00a0<\/p>\n

Warris: <\/strong>for some patients \u2014 there\u2019s a really good argument for saying that if you\u2019re starting someone on a therapy you should start them on a biosimilar because it\u2019s cheaper. Then the question becomes: cheaper for whom?<\/p>\n

And it becomes cheaper for the plan, not for the patient, because they end up routing the patient through either a white bag \u2014 which is more expensive for them, because then it goes from a medical benefit to a pharmacy benefit, they pay more \u2014 or it could be that their infusion center won\u2019t accept it because the infusion center\u2019s buying it differently, and then they lose continuity of care. Maybe a hospital accepts it, then it moves from being a clinic visit to a hospital visit, so it goes from a $50 co-pay to a $2,000 hospital visit. The patient then abandons care. So \u2018cheaper for whom\u2019 is the first question. But if all things were equal and there wasn\u2019t all of this chicanery, yes, it would be much easier to have patients on biosimilars to begin with.<\/p>\n

Matthew: <\/strong>Yeah. And I think that\u2019s one of the main ones. But there\u2019s also a lot \u2014 you mentioned changing PBMs and formularies. I know that for instance Jen Horonjeff used to be Savvy Patient; now it\u2019s Real Patients \u2013 she\u2019s just gone through this where even though she\u2019s as well known a patient as her, they changed a drug on her, formulary-changed, and she couldn\u2019t get in, has to go through all the denial process, can\u2019t get access, can\u2019t get a human being to call her \u2014 only robocalls and that kind of stuff. You see way too much of that. And there\u2019s now \u2014 a couple of things. One is that a lot of this is: who is to blame for the fact that these things cost so damn much money? [laughter] So let\u2019s talk a bit about that, especially on the biologic side. There have clearly been a lot of biologics invented which do great stuff and change people\u2019s lives, and there\u2019s been a lot of biologics invented \u2014 especially in the oncology space, a lot of cancer drugs \u2014 that extend life a little bit for a huge amount of money. And then wrapped up in this is the fact that somehow Novo Nordisk can sell Ozempic for 80 bucks a month in Denmark and seem to make a decent amount of money on it, and why they have to sell it for 1,200 or 800 or 700 or 500 \u2014 whatever the number is \u2014 here. So how much of this is a problem with pricing of those drugs? How much of this is a fight between the PBMs and the drug companies over who gets what slice of the margin for the drugs? And then I guess the last question is: how do we get to your ideal \u2014 what\u2019s the overall cost to the person who\u2019s paying in the end?<\/p>\n

Warris: <\/strong>Yeah. I mean there are way too many middlemen. If this business is ultimately successful, there\u2019s no need for us. And that\u2019s the future that we\u2019re actually quite happy with as a business. If we can get to the utopia \u2014 it\u2019s that the insurers realize that they can\u2019t deny via AI because it becomes so ludicrously expensive for them to have all of these appeals reflected back at them. Now, the reason why they deny is because they\u2019re looking for the more profitable route, which is either they don\u2019t pay out, or they route it through their verticalized infrastructure \u2014 they own everything. Their own specialty pharmacy, their own PBM, their own retail pharmacy. They literally own it all. And then there\u2019s an insurance company on the back of it that\u2019s issuing the denial and collecting the premiums. So the vertical integration is for sure a big part of it, and a big part of the waste and inefficiency. The other issue is that you\u2019ve got issues with how much the actual drug costs. Now, if you look at the dynamic \u2014 and I\u2019m sure if you got David Joyner (note\u2013CEO of CVS Health)<\/em>\u00a0 to put his hand on a Bible, he might tell you what\u2019s really going on \u2014 I\u2019ve had pharma manufacturers say to me that they would charge 5x less for a medication if the PBMs weren\u2019t rate-setting a rebate. Whether that\u2019s true or not, I couldn\u2019t tell you. But the rebate determines market access because it determines the formulary position. And if you\u2019re not on that list, your drug doesn\u2019t exist, because there is no other way of accessing the market in an organized manner than through your insurance mechanism today.\u00a0<\/p>\n

Matthew<\/strong>: Your argument is that it doesn\u2019t really matter what the list price is \u2014 there has to be a big chunk rebated back by the manufacturer to the PBM, or else they won\u2019t get on the formulary.\u00a0<\/p>\n

Warris:<\/strong> It\u2019s a mafia, right? They\u2019re paying a vig to the PBM to basically be considered. \u2018Nice drug you\u2019ve got there. Be a shame if something happened to its formulary position.\u2019 But ultimately the price does matter. And then your question also went to marginal benefit.<\/p>\n

\u00a0Now in England \u2014\u00a0<\/p>\n

Matthew: <\/strong>before we leave that \u2014 I kind of joke that the biggest pharma innovation these days is in the legal department, trying to figure out how to extend patents.<\/p>\n

Warris: <\/strong>Oh 100%, and the patent went on way way longer than it should have done because of all kinds of games played with formulation. I mean my inhaler \u2014 which is Symbicort \u2014 I think it was coming off patent and don\u2019t quote me on this, but I think they did something to keep it on patent by changing the delivery mechanism. I can\u2019t remember what it was, but it gave them another number of years. I mean there are generics for it, to be honest, but there are also FAERS reports with the FDA that say that Breo, for example, is ineffective \u2014 and that\u2019s Aetna\u2019s drug of choice for asthmatics like me, and they\u2019ll continually try to steer me to it even though there are reports that say it doesn\u2019t work, which is amazing.<\/p>\n

So the price ultimately does matter. And all of these companies are ultimately answerable to their shareholders \u2014 that\u2019s exactly what they\u2019re solving for. It\u2019s either volume of drug or unit cost. Now I think we can solve some of the toxicity if we actually were to clip the ability for these PBMs to earn rebates. There was a debate that went pretty viral between Mark Cuban and Patrick Conway \u2014 our neighborhood-friendly pediatrician as he describes himself \u2014\u00a0<\/p>\n

Matthew:<\/strong> who is I believe is the head of Optum altogether.<\/p>\n

Warris:<\/strong>\u00a0 I\u2019ve had some pleasant emails with him where I\u2019ve interceded for patients and he\u2019s promised to look at things, and that\u2019s been actually better than most, to give credit where credit is due. In that conversation you could see that Mark was visibly getting quite frustrated with the obfuscation of the answer to the question: what other charges are you not telling us about that you\u2019re billing for? Because there are a lot of bundled charges and a lot of things that employers are buying that they probably don\u2019t need, that are buried in the costs \u2014 including, you know, payers are starting to charge providers for challenging prior auth denials. So that gets passed on to the employer. There\u2019s a lot of buried costs in there. It\u2019s still non-transparent. And then there\u2019s gross-to-net as well.<\/p>\n

Matthew: <\/strong>Yeah. No, I think \u2014 AJ Loicano, who these days is at Capital Rx \u2014 I think Judi is the name of his PBM. He said to me at one point there were 27 or 25 different fee types attached by the PBM beyond the basics. And I think if you get rid of the rebate but you don\u2019t fix the contracts \u2014 and this is what you mentioned Chris Deacon has a lot to say about contracts that don\u2019t allow you to assess or audit the activity of the plan\u2013 f you put these people in the middle, they are going to figure out ways to charge you.\u00a0<\/p>\n

It\u2019s like buying a ticket for the World Cup and then the water costs you $19 or whatever. So where I\u2019m going with this: I think the only way you get to fix this is essentially what the Brits have done \u2014 you do some kind of NICE (note: the UK\u2019s National Institute for Clinical Excellence) <\/em>thing and say yes, this is a clinically acceptable cost, this is not a clinically acceptable cost. And then you say we\u2019re going to do price controls on all the drugs.<\/p>\n

I think if you did that, you would do two things. One is you would get a lot of unnecessary cost out of the pharma business \u2014 they are still spending more money on non-R&D than on R&D, if you add in stock buybacks and the vast amount they pay their executives. It\u2019s still an excessively lucrative business and they\u2019ve spent a lot of time and effort funding people atTufts & elsewhere to persuade people that drugs really do cost $3 billion to get to the FDA. I\u2019m not sure much of that is true. I think you can get prices down that way without impacting R&D.\u00a0<\/p>\n

And I think we also need to figure out how to make R&D better because we\u2019re spending more and more on R&D and getting essentially less and less valuable drugs out of it.<\/p>\n

Warris: <\/strong>There are a couple of interesting things there. I think it\u2019s easy to make a health economic argument for an expensive drug when the cost of all of the downstream care is even more expensive. And that\u2019s also the problem, because then everything\u2019s just really inflated. I was living in LA until quite recently and I remember getting into a punch-up with Cedars-Sinai for my neighbor who had been billed $70,000 as the total cost of an appendectomy \u2014 in a young, healthy person, uncomplicated basically appendectomy. The comparable cost was $10,000. So the question is: okay, they\u2019re charging 7x, and then the percentage of that is being passed on to the patient. That starts adding up. It\u2019s basically like having one gas station in a town \u2014 the price of gas is whatever they say it is. You have these monopoly providers, you\u2019ve got monopoly insurers, the prices go up in step. And then when you look at what NICE does \u2014 when they start looking at does this drug truly extend life, is this drug truly different to other things on the market, is the evidence solid, is the study actually rigorous \u2014 those things have to matter and they don\u2019t matter enough here.<\/p>\n

We look at that. So if we\u2019re going to work with a manufacturer \u2014 by the way we say no to people a lot \u2014 we actually look at the studies and whether they\u2019ve been rigorously conducted and whether there\u2019s a basis for this drug being on the market. We had a manufacturer with an absurdly inflated price \u2014 it was effectively a marginal benefit over a traditional steroid and only in one circumstance would it be considered actually appropriate \u2014 and we told them to pound sand. We\u2019re not going to help ramp healthcare costs on the basis of this. It\u2019s just too marginal. We see this from time to time and just say not for us. But where you get to biologics \u2014 take a rheumatology patient: I remember when Cosentyx was first coming out, there was a patient in Chicago who needed to be on it because she tried and failed everything else and had incredibly poorly controlled rheumatoid disease. For that kind of patient, yeah, it\u2019s appropriate. And you know, that\u2019s not where it is on the label anymore \u2014 it\u2019s now approved earlier than that. The point is that yes, an expensive therapy could be justified if a patient\u2019s gone through the requisite number of cheaper drugs. We saw this this morning on a new patient. A patient who had failed a medication previously, had been stable on another medication for 7 years, was then directed by CVS to go try the medication they had previously failed \u2014 again \u2014 and was now on six medications to control all of the side effects of the medication they\u2019d been put on. At what point are we now doing more systematic harm?<\/p>\n

Matthew: <\/strong>That\u2019s exactly the point. I mean there are two things going on. One is the issue we\u2019ve talked about: how much damage do you cause by changing somebody\u2019s medication? Not to mention the bureaucratic fight they\u2019re having back and forth with CVS. You look at Jen Horonjeff and her attempt to get a human being to call her. And then the issue is: what\u2019s the cost downstream? Now as you raised, the problem with the cost downstream is no one knows what the hell the cost downstream is, because it varies so much. And I\u2019ve looked at my bills and said, you know, Blue Shield\u2019s been paying a huge amount more for some providers than others. I\u2019ve seen UC versus some private guy for the same thing. And you\u2019ve got a lot of just not knowing. And I\u2019m now at the point \u2014 policy-wise, not everyone\u2019s agreeing with me \u2014 that you give a bunch of money to primary care doctors, tell them to look after people, and then everyone else gets a global budget and gets told to figure it out, or else a fixed price.<\/p>\n

Warris: <\/strong>Look, I can give you a window into this. There\u2019s a guy in Missouri, his name\u2019s Ed Stratton, and we put his story on the front page of the Wall Street Journal \u2014 which I\u2019m sure Anthem really loved, especially as I used to be an executive there, but oh well.<\/p>\n

Matthew: <\/strong>You\u2019re probably not going to be invited back.<\/p>\n

Warris: <\/strong>Probably not. I actually had this idea of just applying for some really low-level role at Anthem \u2014 just doing it for a laugh. Like I wonder if I could get hired as a call center worker, or someone in med policy who just approves everything. But anyway \u2014 there\u2019s this patient called Ed Stratton who had been denied a liver transplant. We\u2019ve talked about this one quite a lot. But what was interesting is that we have his EOBs for all of the care he was getting whilst being denied his transplant, and it added up to hundreds of thousands of dollars over I think about 6 months, which his employer was paying for. Now if you think about the transplant, it probably costs a million dollars all in. If you were to just say, \u2018Ed, you can\u2019t have a transplant, you\u2019re going to keep being admitted in and out of hospital for infections to your necrotic liver, and we\u2019re going to keep having to drain this using CT-guided drainage, and he\u2019s just going to continue to get worse\u2019 \u2014 the employer\u2019s on the hook for all of that. They\u2019re going to pay way more over the odds than if he just had a transplant. Which he has now had, and to my knowledge he\u2019s doing great. So that to me is where it starts becoming a false economy. Because palliative care in America \u2014 dying in America \u2014 is an extremely expensive proposition. It\u2019s also not cheap. So if you\u2019re going to die slowly from cancer in America, someone\u2019s picking up that tab \u2014 either the family or the employer \u2014 and when you withhold treatment, that\u2019s the only path you leave open.<\/p>\n

Matthew: <\/strong>Yeah. And actually you go down that path \u2014my favorite fact about American healthcare is that the biggest palliative care\/hospice company is owned by the same company that owns Roto-Rooter.<\/p>\n

Warris: <\/strong>[laughter] Right. Right. Right.<\/p>\n

Matthew: <\/strong>And you know there\u2019s been a lot of expos\u00e9s about the hospice industry \u2014 poor care but also very expensive care out of that. Similar things are happening now in the home care industry. I\u2019ve just run into this lately where there\u2019s been an expansion in what home care should be paying for under Medicare, but in fact companies are not delivering that.<\/p>\n

Everywhere you look there is some kind of \u2014 whether it\u2019s for-profit or nonprofit \u2014 highly incented bad behavior. And I think the only way we get rid of that is to put a combination of patients and physicians back in charge.<\/p>\n

Warris: <\/strong>I would agree.<\/p>\n

Matthew: <\/strong>\u00a0I don\u2019t think value-based care the way we do it works. Capitation \u2014\u00a0<\/p>\n

Warris: <\/strong>no, it\u2019s nonsense.<\/p>\n

Matthew:\u00a0 <\/strong>I think Jeff Goldsmith, on The Health Care Blog, has said that we spent 40-50 years putting these controls in based on the fact that we thought physicians were cheating people, and the way you get rid of that is you get rid of fee-for-service and pay physicians a salary \u2014 and pay them a damn good salary, because they\u2019re very expensive people who learned a lot, and by the way you\u2019ve made them pay well over $300,000 to get through medical school and be bankrupted during residency and all that stuff. But that\u2019s where I think you fix it.<\/p>\n

Doesn\u2019t get over some of these problems, right? What do you do about very expensive people? So let me slightly shift the conversation. At some point \u2014 we mentioned palliative care, we mentioned hospice \u2014 the argument about the denial is that if you get over the bit which is clearly \u2018we put this other drug on formulary and we make more money if we steer it this way,\u2019 which is BS \u2014 and if you get over the fact the drug costs too much \u2014 how often do you run into something where it looks like somebody is trying to do too much rather than letting patients die\u00a0<\/p>\n

Warris: <\/strong>a quaternary prevention type situation?\u00a0<\/p>\n

Matthew:<\/strong> I mean historically there\u2019s a lot of ICU care of people who are going to die anyway. How much of that sort of comes into the claims?<\/p>\n

Warris: <\/strong>I think most of it\u2019s in hospitals. I rarely see it. On the therapeutic side, the patients who are appealing are really hurting. I\u2019ve seen a couple of cases where families reached out looking for compassionate access to medications where there was no basis in science for the use of that medication in the therapeutic mechanism that would be understood for treating that cancer. And that\u2019s one where you have to draw the line and say: I\u2019m not sure you actually have a chance of getting this approved, and also you should probably talk to your physician because it sounds like there might be a misunderstanding and it would be good for you to understand what your options really are.<\/p>\n

I\u2019ve run into that maybe twice. And I\u2019ve run into cases where physicians are adapting to step edits in maybe an overzealous way \u2014 trying to figure out the easiest way to get something approved by using a vague code, but then the patient doesn\u2019t fit the criteria of that vague code, and that creates a problem for us because then we can\u2019t support it.\u00a0<\/p>\n

A vague code \u2014 like, we see this with PANS\/PANDAS, which is a rare disease. The treatment is IVIG. It\u2019s off-label. The American Academy of Pediatrics don\u2019t believe in it, but there\u2019s a lot of politics in how that clinical report got written, it\u2019s a shit show \u2013\u00a0 and in the interim a lot of kids are in bad shape because they become acutely psychiatrically unwell and the insurers use the AAP report \u2014 which says it\u2019s not a clinical guideline \u2014 to deny these patients. Every now and again what we see is providers who sometimes put the patient in as autoimmune encephalitis. And the problem is the patient often hasn\u2019t had an EEG, hasn\u2019t had an MRI or a lumbar puncture or the other things that would qualify them as actually having autoimmune encephalitis. And so then we can\u2019t help them, because it\u2019s not a true appeal. We only want to support cases where the evidence is really on the side of the patient.<\/p>\n

Matthew: <\/strong>So yeah. It seems to me that what you\u2019re saying though is: overall, if the doctor and the patient have followed the right protocol, most of the denials you\u2019re seeing are not about end of life where the patient will die anyway. Most of them are about: can we pay once upfront for something which will save money later? Which by the way will save money for probably another insurance company later,<\/p>\n

Warris: <\/strong>Yeah, totally. But there\u2019s no collective action solution in this country. United is going to look 18 months into the future, which is the average time they\u2019ll have a patient, and that\u2019s how they set their actuarial payback. When we\u2019re talking about whether GLP-1s are worth it and David Joyner is saying it\u2019s not, that\u2019s based on the price of a GLP-1 and then probably the downstream occurrence of an avoided cardiovascular event, which probably wouldn\u2019t happen in 18 months but might happen in 5 years or 10 years depending on the average age of the person taking it. So you\u2019re never going to see it. We\u2019ve moved into a risk-shifting business, and people change employers regularly and change plans regularly.<\/p>\n

Matthew: <\/strong>Absolutely. And even now in Medicare, right? You go into Medicare Advantage and people start to change plans.\u00a0<\/p>\n

Warris:\u00a0 <\/strong>And you know, the way I thought about this \u2014 I did Eisman\u2019s podcast in December and I actually haven\u2019t been back to rewatch that one because \u2014\u00a0<\/p>\n

Matthew: <\/strong>I saw it the other day, it was actually pretty interesting. This was Steve Eisman, the guy who was played by Steve Carell in The Big Short.<\/p>\n

Warris: <\/strong>Yeah. I was super bummed because I had an Anthem patient who died a few days before \u2014 a transplant patient. The daughter of a liver patient reached out and said her mom needs help, she needs a transplant, and no one would accept Anthem\u2019s Medicare Advantage contract in LA. This was a patient in a hospital in Orange County. I managed to get her accepted into a bed at UCSF, but by the time I got her accepted, she died. She had been languishing on that ward for about 10 days, and days really matter when you\u2019re that sick. I was bummed. So if you watch it and I seem really depressed, that\u2019s why \u2014 because I was really bothered and I hadn\u2019t slept in about 3 days. And a lot of it was also just preparing to go up against Eisman because he\u2019s so smart that you have to actually know your numbers.<\/p>\n

Matthew:<\/strong> You don\u2019t need to on this podcast!<\/p>\n

Warris: <\/strong>Well you prepped me to be fair, so that\u2019s helpful. But Steve has the recursive \u2018why.\u2019 And you have to have really thought about what you\u2019re about to lay out.<\/p>\n

And I put together a thesis of where this goes \u2014 I think these insurers are vulnerable, and they\u2019re vulnerable in their insurance business. All of the other stuff, all of the unregulated revenue and that kind of thing, is going to start looking really attractive to split away from the insurance business over a period of time. Because if you look at the long history of conglomerates, it doesn\u2019t end well. They will naturally want to unlock more value for shareholders by breaking them up. And so our incentive is to drive that narrative for activist investors to go into the boardrooms of these companies and actually break them apart. And then you\u2019ve actually got a shot at free market behavior, if that\u2019s actually the answer. Beyond that, what you need is a risk transfer mechanism from insurer to insurer, which solves this 18-month problem, which then allows people to actually take the bet on paying for more expensive care earlier \u2014 so then it isn\u2019t futile. The other mechanism I\u2019ve seen is manufacturer warranties for very expensive medications, which are starting to become a thing \u2014 where manufacturers say we\u2019ll warranty some of the cost of this medication if survival isn\u2019t XYZ months minimum.\u00a0<\/p>\n

Matthew:<\/strong> Which is interesting, and it kind of goes against 200 years of drug company history.\u00a0<\/p>\n

Warris: <\/strong>They\u2019re taking bets on riskier disease, and if you go off those narrower indications, you have to be able to underwrite your benefit. I kind of like them having skin in the game there as well. And then the final thing is you just need an insurer of last resort, which is the federal government, who can take a longer horizon across everybody. Because ultimately we pay for this anyway. You stop working \u2014 guess who pays? The taxpayer pays.<\/p>\n

Matthew: <\/strong>I mean, so you\u2019re getting to where I\u2019ve been for a little while. I used to think \u2014 you know, it\u2019s America, you could figure out some kind of free market solution. I sat in front of Alain Enthoven in the early 90s figuring out how could you create five competitive Kaiser-type organizations and then have people buy into the more expensive plan if they wanted \u2014 with their own cash, therefore you drive the market down to a level, and then everyone does a sort of Kaiser-type thing where they figure the money internally. All sort of privatized British NHS.<\/p>\n

Warris: <\/strong>Yeah.<\/p>\n

Matthew: <\/strong>And great. My problem is that when you actually look at what happens in healthcare in America, there\u2019s always some open field where someone can get away with something for a while. And then if you try to fix an individual thing \u2014 like out-of-network surprise billing \u2014 now there are people who\u2019ve figured out how to game the arbitration system. If you put in a massive fee and choose the right arbitrators \u2014 I don\u2019t know how the arbitrators have figured out that something should be $1,400 but they\u2019re going to pay $28,000 or whatever \u2014 and now half the insurers are not paying up and there\u2019s generalized chaos. Someone was complaining that Blue Cross of Texas wasn\u2019t paying their arbitration bills and I said, \u2018Well, is Blue Cross the only organization in Texas that has to obey the law?\u2019 I didn\u2019t understand.<\/p>\n

Warris: <\/strong>[laughter] I mean they have the biggest penetration in Texas, I believe.Yeah, they\u2019re the largest payer there<\/p>\n

Matthew:<\/strong>. Anyway, just to finish my point: if you look at what the big players do \u2014 the pharma companies benefit from unregulated pricing. There\u2019s some attempt at drug negotiation for Medicare, and there\u2019s Medicaid and VA, but in general they can charge what they like here and charge way more than they do abroad. You could argue Europe should be paying more, but that\u2019s a different argument.\u00a0<\/p>\n

The hospitals have all consolidated and they\u2019re all sitting on massive reserves and charging as much as they can. Dave Chase will go on about this \u2014 a big hospital system gets somewhere between 65 and 80% of its money from the government anyway. It might as well be a public utility. I don\u2019t know why we\u2019re paying the top 200 people at UPMC $500,000 a year plus, you know, $12 million to the CEO and $12 million to the former CEO who was still getting paid even though he left three years ago.\u00a0<\/p>\n

The last group are insurers. A lot of their business comes direct from commercial employers, who are theoretically out of the tax base other than those employers are not paying tax on the benefits they\u2019re giving their employees \u2014 that\u2019s a massive subsidy from people who don\u2019t get taxpayer-funded insurance to people who do. And then number two: their profits in recent years have all come from either Medicare or Medicaid. Some plans are entirely Medicare. That\u2019s the taxpayer as well. So essentially this is all a wealth transfer to private healthcare companies. We should be able to do something about it.<\/p>\n

Warris: <\/strong>But we\u2019re seeing more and more of this. With ICHRs we\u2019re basically shifting the risk back to individuals \u2014 \u2018the employer\u2019s going to give you a stipend, go buy a plan, but you probably can\u2019t buy a plan that\u2019s worth a damn for $500 or $300 a month.\u2019 The president has mentioned getting rid of the ACA and is doing a good job of defunding it effectively.<\/p>\n

And that is leading to patients going bare. I\u2019ve had two patients in the last 2 weeks reach out. One is in a catastrophic amount of medical debt because they ended up uninsured and then got very sick. And then the other one did a health ministry, and the health ministry does not cover cancer within the first year of being in the plan \u2014 and unfortunately this person got cancer. So we\u2019re going to see a lot more of this.\u00a0<\/p>\n

And the other sort of wealth transfer is high-deductible plans, which also shifts the risk onto the patient. You\u2019re covered but not covered.\u00a0<\/p>\n

Matthew:<\/strong> And to give you a personal example: I\u2019m about to have my knee surgery, as I think I mentioned the other day, and had I stayed on the exchange plan \u2014 and if my wife didn\u2019t actually go out and get a job, which has its own problems, because she went out and got a job and was covered by Cigna, which is about to break up with UCSF.. So I had to have the date moved up so I\u2019m in the coverage window, which is nuts, but there we go.<\/p>\n

With Cigna the out-of-pocket max is going to be like $4,000 as opposed to I think it was going to be $14K or $12K on the exchange plan. And how many Americans who, by the way, are scraping together to get on the exchange in the first place, can afford $14,000 additional out of pocket? There\u2019s no reason. We had this massive underinsured class, and the ACA was never supposed to be like that.<\/p>\n

And don\u2019t forget the ACA came from a huge amount of stories exactly like the ones we\u2019re talking about \u2014 people who couldn\u2019t get coverage, people who bought shoddy insurance that went away, people who couldn\u2019t get insurance because they had pre-existing conditions or had their insurance taken away. All that was going on in California back in the 2000s. There was a term called rescission, where in fact Blue Shield was one of the worst offenders \u2014 \u2018You didn\u2019t check that box in the form and you did have this condition and therefore we\u2019re taking it back.\u2019\u00a0<\/p>\n

Warris:<\/strong> I\u2019ve seen a rescission case in the last year where the patient was stuck with like a million dollars in retrospective claims. I mean, look \u2014 this system is a catastrophic mess. It is not fit for purpose.\u00a0<\/p>\n

The problem is that everybody\u2019s pretty much on the take. And as a result there\u2019s low incentive to fix it. Right now we\u2019re celebrating deregulation like it\u2019s going out of business \u2014 you see whichever wearable executive posing with RFK and Marty Makary because they\u2019ve decided they\u2019re not going to weigh in on algorithms. But who bears the cost? The health systems do, when there\u2019s all of this utilization full of false positives. It\u2019s not going to be Oura or whoever else. Everybody\u2019s just in it for themselves right now and nobody\u2019s really thinking about the collective action problem we need to solve to make this system more sane. This is going to have some very negative effects in the coming years. I\u2019m hoping for 2028 to restore some sanity. But who knows if that\u2019s possible. And I really hope whoever runs actually understands that empowering Blue Cross or United or Cigna to go solve a problem on their own isn\u2019t going to happen \u2014 unless there are real penalties that are enforced. They will never arrive at a solution themselves.<\/p>\n

I very much doubt this solution is political. I really feel it\u2019s going to be economic before it\u2019s ever political.\u00a0<\/p>\n

Matthew: <\/strong>Say one more thing about what you mean by that, because I actually think I\u2019m about to disagree with you. What do you mean by economic?<\/p>\n

Warris: <\/strong>Well, feel free to disagree. For the 2024 election, we decided to make an explorer for OpenSecrets to see who was actually taking money from PBMs and it was basically everyone \u2014 and it was really in local races. This had been on the back of a punch-up I was having with Blue Cross Blue Shield of Alabama over recovering a woman\u2019s breast reconstruction, which they have a mandate to do on the state that this patient was on a union plan. And we actually ended up paying for it ourselves, because we were not going to let this woman suffer \u2014 it was before Christmas and we were feeling like we should. But the fact of the matter is everyone\u2019s on the take. And when you look at how long it\u2019s going to take to get beyond performative sessions in Congress where we sit all the executives up and make them answer awkward questions, followed by no change, no enforcement, no bills passed \u2014 that\u2019s an extremely long arc.<\/p>\n

Matthew: <\/strong>I don\u2019t know if there\u2019s an economic reform. People have talked for years \u2014 my friend Brian Klepper told me 25 years ago, \u2018Don\u2019t worry, employers are going to sort this out. They won\u2019t put up with this much longer.\u2019<\/p>\n

Warris: <\/strong>That\u2019s actually not what I mean. I mean that we <\/em>are the economic reform. If we can get enough patients to appeal, we actually change the economics of these insurers. If we can stimulate this enough, it really impacts their bottom line, which actually impacts their top line. The revenue replacement is a real problem for them at that level. And then more patients get care and their model of denying by AI effectively becomes completely untenable because you start having investors really paying attention to the line item that\u2019s failing.<\/p>\n

Matthew: <\/strong>So that happens and the insurance companies get sort of sliced off by outside activist investors or hedge funds or whatever. Doesn\u2019t that mean essentially \u2014 what\u2019s left just becomes more expensive, more people become uninsured?<\/p>\n

Warris: <\/strong>Not necessarily. I think what you do is you actually break up the verticalization. You allow more companies with a genuine value proposition into the market. The products are expensive because they have no idea how to price anything because there\u2019s no collective action solution. But you allow new models to exist. And the other thing is you remove their bargaining power with the federal government to some extent because they\u2019re far less powerful. They\u2019d be diminished.<\/p>\n

Matthew: <\/strong>Maybe. I have so many things I\u2019m depressed about. One of them is I met with Natalie Davis from United States of Care, which is kind of supposed to be the moderate but sensible pressure group that Andy Slavitt set up some years ago. I talked to her about:, what are you pushing for in 2028? She told me\u00a0 \u2018I don\u2019t think we can get anything done by 2028, but in 2032 we might be able to get \u2014 we\u2019re going to be launching something which is going to help, hoping for more transparency in the system in general.\u2019 I\u2019m thinking: 2032 means it\u2019ll get passed in 2033,which means something will happen in 2034. I\u2019ll almost be dead by the time this problem gets addressed.\u00a0<\/p>\n

And the other thing I see is: People are mad, but I don\u2019t know how <\/em>mad people are. I think we need a total revolution. Because if you do something that\u2019s not a total revolution, you end up with somebody figuring out a way to make money out of every little piece. And the only way you can do it is to essentially abolish the insurance function.<\/p>\n

Warris: <\/strong>Hey man, I\u2019m there for it. Well, the point is the second you make these guys vulnerable, I think new solutions start presenting themselves. Some of it might be that it\u2019s just cheaper to actually have the federal government pay for it \u2014 you actually shift the Overton window in that direction. Because it\u2019s kind of what they\u2019re doing in England. There\u2019s a really great book by Walt Bogdanich called When McKinsey Comes to Town, and it is completely horrifying. It explains a lot of the crap I lived through when I was actually in the NHS \u2014 McKinsey were around like messing with the dials of how the NHS was running, and you\u2019re like, \u2018Oh, this is why it was all getting worse.\u2019 And the idea has been to intentionally break the NHS and make it so unpalatable that people say, well, we would accept anything other than this model. Little do they know that a model like we have is unbearably worse. [laughter]\u00a0<\/p>\n

I think people in England think it\u2019s bad there, but until they\u2019ve come here and had the pleasure of paying for private insurance that then denigrates you through denials, they haven\u2019t lived it.<\/p>\n

Matthew: <\/strong>You\u2019re right. And by the way, that is an argument that gets used here all the time \u2014 how terrible it is in the NHS \u2014 whereas if you actually go to Japan, Germany, Holland, Spain, France, there are a bunch of perfectly acceptable healthcare systems out there which don\u2019t tend to involve massive delays to get care or massive prices. I was talking to a shoulder surgeon in Japan last year and said, \u2018If I hurt my shoulder, how long would it be before I got on your operating table?\u2019 And he said four to six weeks \u2014 not so bad \u2014 and it would cost me essentially nothing.\u00a0<\/p>\n

There are clearly American-specific issues: the level of violence, the level of addiction, maybe mental health. There\u2019s a bunch of stuff going on here that\u2019s different from other countries. But I think we could get to somewhere that\u2019s rational and American \u2014 but it would require a kind of FDR-level New Deal hit. Unless you get \u2014 I don\u2019t know \u2014 an AOC or whoever the guy from Maine is now called \u2014 you need a president who\u2019s got the Donald Trump level of \u2018I don\u2019t give a damn\u2019 but actually wants to enforce something good.<\/p>\n

Warris: <\/strong>I know one guy but he says he\u2019s not running.<\/p>\n

Matthew: <\/strong>Who\u2019s the guy that\u2019s not running?<\/p>\n

Warris: <\/strong>Mark Cuban said he\u2019s not running.<\/p>\n

Matthew: <\/strong>Oh, yeah, he would be great. Still \u2014 scratch him hard \u2014he believes in a free market. He thinks if we got rid of all these conglomerates and got to real pricing and transparency, we would fix it.<\/p>\n

Warris: <\/strong>I think it would certainly be more functional.\u00a0<\/p>\n

Matthew:<\/strong> But the question \u2014 my point is that there are so many places you can\u2019t see where somebody will pop up and start making a fortune in two years and then be gone.\u00a0<\/p>\n

Warris: <\/strong>But the NHS \u2014 when I was in the NHS, blood services were privatized, so that was spun out. Hospitals used to manage their own transfusion services, that got spun out. Diagnostic testing used to be done in-house, that got subcontracted. Ambulance transfers, MRIs were all run by private companies and then leased back to the hospital, which is why the hospitals were in such a dire financial mess. You couldn\u2019t get an MRI in daytime hours, you had\u00a0 to transfer your patient across town. There were a lot of dreams of free market within the socialized model which actually broke the efficiency of that socialized model entirely. And then the constant pressure for ward closures as well, which endangered patients. I was there during Cameron but before that it was Gordon Brown. The same shit from prime minister to prime minister. So the idea made sense in the abstract \u2014 where it is today I don\u2019t think necessarily makes sense because they\u2019re trying to intentionally break it. And you\u2019ve got people waiting in the wings like Optum and Cigna who are in the UK probably looking to pick up some type of contract somewhere. No doubt. But read the book \u2014 When McKinsey Comes to Town. It is interesting.<\/p>\n

I would be remiss if we didn\u2019t briefly touch on the panel.<\/p>\n

Matthew:\u00a0 <\/strong>All right. I\u2019ve forgotten about the panel. Actually, I forgot about it three months ago. I\u2019ve forgotten about it from the start of this hour.<\/a>\u00a0 OK, your complaint about it. I thought Alicia did a great job. Bunch of different issues and, to be fair, she did not get a lot of reply back.<\/p>\n

Warris: <\/strong>No, she was basically like dealing with a mannequin who was preloaded with three PR-approved statements. Anthem\u2019s chief digital officer \u2014 no matter what the question, he had to say one of three PR-approved talking points. And then the CVS person didn\u2019t show up because I guess they were worried that anything they said could be used as evidence against them in a court of law.<\/p>\n

Matthew: <\/strong>. The excuse they gave me was \u2014 and I\u2019ll show you the correspondence, I may never be invited back to HLTH or ViVE again \u2014 I had a pre-chat with everyone\u2019s PR agencies. They said to me, could you write up some questions? So I banged out a bunch. Normally I wouldn\u2019t write out questions, or I\u2019d use them and realize they were the stupid questions. But I banged out some questions and the CVS PR people \u2014 it wasn\u2019t even CVS, it was their separate PR firm. And I forget who was the chief officer of Cigna \u2014 Michelle Gordine.I don\u2019t know if she ever saw this, I don\u2019t think it got as far as her.<\/p>\n

Warris: <\/strong>Oh, I tagged her into my post-review of her non-performance.<\/p>\n

Matthew: <\/strong>Well, what happened was that I wrote out these questions, which I thought were sensible real questions. I also said: \u2018We\u2019ve had a fee-for-service system forever in America and we can\u2019t just do everything because we know what happens to medical inflation.\u2019 And they came back to me and I said \u2014 if she doesn\u2019t like that question, tell me and I won\u2019t ask it \u2014 and they wrote back to HLTH and said \u2018No, we don\u2019t accept this, we are out.\u2019 No discussion<\/p>\n

Warris: <\/strong>\u00a0It\u2019s because they can\u2019t say anything real. If you\u2019re in a large company, it\u2019s actually quite hard to say anything that deviates from the company line and speak extemporaneously. They really don\u2019t like you doing that. Which is why I was probably not allowed to speak on behalf of large companies for that reason. But it\u2019s interesting. I would welcome a debate with them, because I think there\u2019s a really good argument \u2014 for example, I spoke to one of the insurance execs afterwards and said: please stop denying cancer and transplant, and you guys will be heroes. Just remove prior auth in oncology and in transplant \u2014 things where patients really could come to harm or die. You\u2019ll have far fewer angry patients and I guarantee you\u2019ll save money. You\u2019ll save money on the admin side and I think over time you\u2019ll save money on the cost of care side. And the answer I got back was: \u2018Who would pay for all of the additional care?\u2019 And I\u2019m like: there\u2019s an inbuilt presumption there that the care is medically unnecessary. But if you think about what it takes to get approved for a transplant \u2014 these patients have been seen by a transplant ethics board, rigorously assessed, there\u2019s a ton of imaging \u2014 on the oncology side, these patients are often desperate and increasingly they have curable disease if you get them early enough. The question is what care do you want to pay for versus are you going to pay for it? Because you are going to pay for it. Do you want to pay for something curative or something palliative? I would love to have that debate with them \u2014 genuinely in good faith, all day. And I would encourage them to ask the Wizard of Oz for some courage.\u00a0<\/p>\n

Matthew: <\/strong>But they can\u2019t do it, because by the time it gets to the court of public opinion via the Luigi situation and whatever\u2019s happening \u2014 the answer is you\u2019re cutting somebody off, you\u2019re going to kill them. We had this with death panels back when the ACA debate was happening.<\/p>\n

I think you were just arriving in the States at that point. Sarah Palin talked about death panels, and the US Preventive Services Task Force \u2014 USPSTF \u2014 was putting together at the time some completely apolitical thing about mammograms and got completely railroaded. \u2018These are the death panels we\u2019re going to have.\u2019 And they\u2019re now being shut down \u2014 I think RFK Jr. fired everybody on the panel and closed it down when it was trying to be an apolitical scientific body doing guideline treatments. It seems to me that as soon as you put the big insurers in that bucket, they cannot win in the court of public opinion\u00a0<\/p>\n

Warris: <\/strong>because they\u2019ve become the death panels.\u00a0<\/p>\n

Matthew: <\/strong>Well, they\u2019ve become the death panels and people are now noticing. And the reason I think there might be a big political shift in 2028 \u2014 I put it at maybe 2-3% probability that somebody would come along and say \u2018I have a better way of doing this in healthcare.\u2019 I mean 2028 is going to be so hard because it\u2019s going to mean recovering from all the crap that Trump\u2019s pulled. But at some point we\u2019re going to have to get to healthcare and say this is an amazing show that we have to fix. And I think it has to be a radical fix. The ACA dont forget \u2014 massively fought over, a complete war about extending insurance to not very many people really \u2014 got us from like 84% to 93% insured, for 10% of the population. And we went to death wars about that forever. If you\u2019re going to do something, you might as well do something big \u2014 say I\u2019m here to take out the big four insurers, reconstitute how the big health systems behave, and price-control the drugs.<\/p>\n

Warris:<\/strong> And I\u2019d love to pour energy into helping whoever comes up with that plan.<\/p>\n

Matthew:\u00a0 <\/strong>Right. Because I came up with this plan. I wrote it up. I\u2019m very happy for AOC to plagiarize it with my name.<\/p>\n

Give everyone fantastic primary care, give the primary care doctors a lot of money, and figure out a way to take it out of everybody else. We\u2019re already spending 18% of GDP \u2014 6% more than the Germans, the Japanese \u2014\u00a0<\/p>\n

Matthew: <\/strong>in England they had quality outcome frameworks, the QOF points. You might remember: docs were paid for asking about smoking cessation, blood pressure, etc. They actually improved outcomes. The problem was they made primary care relatively so well paid that people went into it for the wrong reasons. In my cohort, the people who went into it really didn\u2019t go into it for the love of patients. They went into it because they didn\u2019t want to be in a hospital doing on-calls for 72 hours across a weekend. You have to find a way of finding people who genuinely love working with patients and have a genuine sense of empathy. I don\u2019t know how you select for that, but that\u2019s really what you need. When I was practicing, 20 years ago \u2014 I was an ICU doctor, attracted to the fast-paced part of medicine. And now I spend all my time talking to patients; it\u2019s basically like being in primary care. And I often do the thought experiment of: if I was to go back, would I go back to ICU? And I think the answer is I\u2019d be a primary care doc, actually, because I care very much about that.<\/p>\n

Matthew: <\/strong>You have to do some measurement but I don\u2019t think you have to do the pay-for-performance measurement that the Brits introduced or that people tried to do here. I think you have to trust the doctors more. And in this country, the pediatricians and the primary care doctors, the family doctors \u2014 they make a pittance compared to the surgeons and the radiologists. And that\u2019s why you don\u2019t have enough people going into those residency programs. That\u2019s also why all the prestige and money goes the other way.\u00a0 You could fix that with money \u2014 just pay the primary care doctors more. You\u2019d have to pay the other people less, but that\u2019s not a big drain on the system. Where you\u2019re going to save the money is on hospitals that are now incented to have primary care doctors referring people in for stuff that may be of marginal value.<\/p>\n

It\u2019s usually orthopedic surgery. [laughter] Speaking of the guy getting his knee replacement \u2014 If they have an incentive to fill hospital beds \u2014 and that\u2019s why hospital systems across America have bought so many primary care docs. And you\u2019ll see these big fights now and again with primary care groups that got bought by a hospital trying to get themselves out of it.\u00a0<\/p>\n

Warris:\u00a0 <\/strong>I just moved to Miami and two of our friends who are primary care docs quit taking insurance and now they are either concierge or DPC.\u00a0<\/p>\n

Matthew: <\/strong>I\u2019m fine with people going concierge and DPC. I think the government should pay for it. I think if you managed everyone through that \u2014 if you paid the concierge docs very well for 600 patients to manage their chronically ill patients \u2014 I would force everyone to go into it. I wouldn\u2019t let people not have a primary care doc.<\/p>\n

Warris: <\/strong>I would agree with that too.<\/p>\n

Matthew:<\/strong> And then I think it would save so much money on the back end.\u00a0<\/p>\n

Warris:\u00a0 <\/strong>If you have a competent, incentivized primary care doctor it goes a long way. DPC can really work. Concierge \u2014 I have mixed opinions on, for reasons. There\u2019s some quackery that gets stuck into high-price concierge\u00a0<\/p>\n

Matthew:<\/strong>\u00a0 It doesn\u2019t have to be $20,000 or $50,000 or whatever private medical insurance is charging. You could do it because you could have a government-paid voucher which would be pretty decent \u2014 not that much. I was spending about 7-10% of the healthcare \u2014 the $15,000 per person \u2014 where I would spend 20%. It\u2019ll be fine.\u00a0<\/p>\n

Warris: <\/strong>Where I would have gone with that \u2014 I actually thought about this prior to starting this company \u2014 was to take a DPC chassis and power it with claims data. Then you\u2019d know which services to put into DPC, and could pull clinic-based specialties that otherwise live in hospitals into kind of a multi-specialty clinic effectively. It\u2019s really per-capita based on where you live. And you\u2019d effectively have far less care going to hospitals because all of those specialties could manage things at the primary care level.\u00a0<\/p>\n

Matthew:\u00a0 <\/strong>There are bits I hadn\u2019t figured out. I don\u2019t quite know how you get mental health there. I don\u2019t know what you do about dental \u2014 which seems to be a weird thing that\u2019s excluded in most countries for no particular reason.Apparently your teeth are not part of your body.<\/p>\n

Your brain and your teeth have nothing to do with your body, which is fine. But in the end you\u2019ve got to say: how do I reliably manage the chronic disease of the massive population? That\u2019s half of it. The other half is what do I do with very expensive people \u2014 which is what we\u2019ve been discussing the whole time. And with both of them we are doing terribly. I don\u2019t see any reason why not have a revolution.<\/p>\n

Warris: <\/strong>Yeah, god-awful \u2014 I mean absolutely. I\u2019m here for it. I want to see it happen. I want to have enough data on the bad behavior that we can drive that change. Maybe start working with some analysts to actually help them change their ratings on various insurers. I would love to be able to do that.<\/p>\n

Matthew: <\/strong>Well, that maybe is where they end up. All right, so we\u2019ve had a great chat. I\u2019ve been talking with Warris <\/strong>Bohkari\u00a0 He is the CEO of Claimable \u2014 Somewhere if you go back to the start of this conversation, we\u2019re discussing what Claimable actually does in terms of helping people who are denied by insurers.And you can go to getclaimable.com. I assume, on the internet, if you have any issues with claims denials. And there is a policy where \u2014 is there a consumer fee? There is, right?<\/p>\n

Warris: <\/strong>Yes, it\u2019s $50. It\u2019s getclaimable.com. And it\u2019s $50 whether you win or lose. The idea was to charge a low flat fee \u2014 we\u2019re not incentivized by what the care costs. It\u2019s purely to allow anybody who has a denial the ability to come and appeal.\u00a0<\/p>\n

Matthew: <\/strong>And then you\u2019re making it up \u2014 hopefully \u2014 on the back end in work you\u2019re doing with the patient access programs and others with the pharma companies.<\/p>\n

\u00a0Check it out if you have any issues. And otherwise if it\u2019s something urgent, reach out to Warris \u2014 turns out he\u2019s very contactable. And you will find Warris on LinkedIn, almost all the time, lighting into some innocent insurance executive who\u2019s giving their opinion about oncology in a bit.<\/p>\n

Warris: <\/strong>[laughter] I was lighting into the SpaceX IPO yesterday. I\u2019ll leave it there.\u00a0<\/p>\n

Matthew:<\/strong> But I\u2019m looking forward to almost all of my index fund being put in there. [laughter] And zero. But speaking of wealth transfer \u2014 as long as Elon Musk can get a bit richer off all our backs, I\u2019m much happier.<\/p>\n

Warris: <\/strong>It\u2019s good to see you, man. All right.\u00a0<\/p>\n

Matthew: <\/strong>Thank you, Warris. Great to catch up with you. Great discussion. I look forward to doing this again. And we will figure out how the two Brits are going to fix American healthcare eventually.<\/p>\n

Warris: <\/strong>I love it. Take care.\u00a0<\/p>","protected":false},"excerpt":{"rendered":"

One of the most interesting follows on Linkedin is Warris Bokhari from Claimable. He\u2019s a British MD, who has had stints not only as a doc in the UK, but also as a health tech and health insurance exec in the US. But now he\u2019s at war with the system, in particular working for patients…<\/p>\n","protected":false},"author":0,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-14146","post","type-post","status-publish","format-standard","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/14146"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=14146"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/14146\/revisions"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=14146"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=14146"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=14146"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}