Future of Healthcare / Membership Program Overview



so I'm dead Carlin and I'm a relatively new president when I return we met in a conference it was a little bit like gasoline in the match about kidding can I say that because we're in a very interesting age of medicine and healthcare right now it's a neat characterized by a lot of money a lot of profit in a lot less care so when a guy country doctor running a really interesting medical practice and what let immediate call the same passion in the same graphics same commitment it is it's like gasoline in a batch so we just start talking and now we put something together between our two practices that are going to talk about the rate and I'm really going to talk about a couple things beyond just how Rebecca and I work with I want include a minute on what's coming I'm going to tell you about the next 10 years and I'm not making it up websites and I want you to know what's coming because it's not in the same breath there's unbelievable opportunity so let me give you some background about me I'm a 59 year old physician country doctor I've had an extraordinary past since medical I went to radio in two years we profile to be like tycoon class hunter submarine we're waiting for essentially a mutual killer the president says shoo them you're going to shoot them but when they hear you shooting that they think they shoot but it was to each other those Stinger missiles I knew you guys are all community I didn't know are you after the fact but is it working radically and once the Russians lost control again they started calling attention places the nearby colonies were so Spelman experience so imagine I plan to come over from all of this in 30 years old we go to Colombia to become an emergency physician with a little residency business something's off you boarded this so a certain ethical practice for ships I was the first time use the internet to save a guy's life he was a solo sailor in 1998 I needed him to operate on themselves our hero what happened I thought everyone would be really excited about me saying the Internet is important it's good to be really important in health care but I couldn't have been I was like hopelessly naive no one cared Bennet it didn't have anything to do billing codes reimbursement and it was so far off the reservation so to speak it wasn't gonna happen on a Broadway but the notoriety from that surgical case may be the darling of the superyacht community so you started getting super Leonsis clients that is an interesting world that's an interesting and I became a village doctor to the world series all the while figuring out how to use the internet and simple stuff like taking pictures and had lots to do with the taxes we have a feeling some of their super yoga in a short time came to me and said they did get rid of the yacht but we like you and your partners and we like the fact that we just make one phone call and you take care of us everywhere we are in the world so tell us any product it's just the family there's 11 of us we're in seven homes in four countries but we want one phone call thank you organize our medical records and make sure we get those physicals what if something bad happens we're gonna call you you tell us what to do you're going to treat us on a miniature version by then it was like I started with super yachts with these big suitcase medical kits now this is one of our medical kits this little guy here but the idea was I'm talking to you I'm an old ER doctor diagnosed is going to treat you the emergency room in Kuala Lumpur is quite expensive actually right so that was the beginning of world clinic these it was actually kind of a challenge to take care of it one they operated globally so I end up building a database to nine thousand english-speaking doctors and modern credential hospitals around the world I figured out what should be in this kit that will cover 99% of emergencies right I figured out how to organize all their medical records from all of their doctors which in many cases were in two or three or four different locations but about 30 percent of our practices snowbirds so you're getting records from Florida Arizona you're solving all this stuff and the Graduate recording you know I started using software to do that and built a platform now I'm gonna tell you I'm not a code writer I designed it with an excess writer 1998 I was our first version by 2013 we I think we're out of eighteen thirty at which point we had built a pretty big house as possible it just wasn't a bus was strong and we brought in a CTO to put our turnip popsicle sticks to concrete and now we have this it's really exploring there just to finish the story very quickly billionaires cents and millionaires unbelievably wealthy people now started telling their friends about us in the practice group five years ago we started getting higher needs of their portfolio companies to take care of their c-suite executives the periods of risk management life like sitting in boardroom with the 12 most senior executives to a fashion house of review wearing clothing unseen in mom and dad said we want to retire here's the Empire sell us a new product that you can't ever let anything bad happen to these folks and then we got a new product meanwhile the price is falling the billionaires of 50 60 80 thousand bucks a year and more down to executives 24/7 every wearing a little kids liable honestly and we're now at a point where it's a fully mature practice and it's completely what the software people would say a distributed medical practice we're leveraging connectivity to diagnose and deliver care wherever the patient is in fact the location is irrelevant you know what's relevant my life signal strengths claim about the endless and of a hog for bandwidth we did separate shortwave radio do you know how long it takes to send a picture now it's unbelievable we have a tendon is the central highways here live within 10 miles of the central power you've got 4G in the bush and I mean the bush as in like Daktari wild animals we have four gene we don't have clean water okay so this is one coming from coming from a place of evolution science digital science digital enablement right at the same time I'm a doctor and okay like that right and I don't like what I've seen so I'm gonna talk about the back and then we keep it really brief but I want this to sink in the healthcare system you knew ten years ago is well on its way out the window so you buy it's moving fast Medicare is now it's actually 52 years old the original intention Winston flipped me a few bucks to cover an expensive procedure it was really well-intentioned but that became the focus of the program it paid for expensive procedures and they didn't pay for prevention of primary care we'll come on I'm not an economist what happens if you drive an entire system revenue around the expensive procedures our system is built around expensive procedures and you know the most efficient way to get a lot of expensive procedures right coronary artery bypass stroke extending its to ignore the primary care let me wait until you suffer a crisis and then that becomes my revenue event it's a paradigm of today's celebration ignore the primary care the way to the house of cards fault because it creates a money event that sounds simple yeah I love my dealers as much wake up I'm coming at this from I'm 59 I've watched this whole thing of them it gets worse I'm also baby boomer I'm sort of a channel a million so what are you doing a country that only has 340 million people in the whole damn population and 90 million of them are heading into retirement and their health carriers probably six the doctor probably two ways we'll hire foreign bring in from other nations hopefully certified information but we're probably going to use a lot more intermediaries nurse practitioners and physicians assistants FYI physician assistant has two to four years of Amiens put into practice well that's one and hardworking now I'm not seeing is not any of those things but seriously twelve is better than the fourth and 12 us wait but you are going to be dealing with some standard practitioners here's relative to what you know now okay on top of all this and this is gonna kind of lead us out of the bad stuff every day I see an ugly little thing called conflict of interest going on in medicine especially in vertically-integrated no fear citizens where the slightest pretence of a diagnosis for example they have a sore throat I had a sore throat for 12 hours I went to an urgent care center that is hosted by a huge credit wall array that owns a vertical vertical integration meaning all goods and services are within the system so 2,200 bucks how good screening screening any guesses 3,600 bucks yeah now why is this going on I'm like oh my gosh how did this go crazy so fast well your insurance company put you or your employer to provide you with health insurance give you a high deductible plan the hospital that is going to the end of your life it's collection agency I was like I got to take my insurance yeah the insurance just adjust the price down to five thousand two hundred and forty dollars that's the benefit view insurance because you know I didn't have five thousand two hundred forty dollars that's what's going on and you're gonna see a lot of Americans Bank especially Americans are naive enough to trust the health care system to be my father they're not gonna do any funny right now Medicare pays 66 cents on every dollar cost being an older person is it's true it's a big deal okay you're in the hospital they're in the I saluted survived the event the Medicare into the days three to six cents the true dollar awesome take care me well really helped me make up the other 34 cents you make it up on the people who have insurance and have deductibles cash that's what that's how we're gonna balance books this is the most sophisticated taxation thing I've ever seen in my life it is like a shell game in constant motion and you're the pigeon the show pretty doctor I'm making it up so let me get to the good stuff I want the bad stuff to sink in for a second though you guys know there's a thing called the physicians in the Wall Street Journal like this is like a you know like this is like kind of social metric that's now being tried the physician misery index the percentage of physicians and different specialties that given the opportunity would chop their own career and it's like clicking up about 4% every year it's just hovering north of 50% right meaning 50% of dachshund given the opportunity across the board we're chuck it and do something else that's not today because when this when the providers lose heart they know a lot of them their capacity for compassion and caring is diminished because they bury they have very accurately interpreted situation where no one has compassion for them and no one cares about that in fact they're routinely identified his physicians an easy target they making two hundred twenty grand a year sixty grand a year and he's seeing a patient every seven minutes and he's so far where he or she started mentioned wanting to do right by the patient so I say that because it's a risk factor for your lives an uncaring physician came to me a physician who doesn't connect the dots doesn't bother to get the old MRI find that Haskins and two years ago so having her medical records to find out yes indeed you are allergic to that drug think you might have just been put on a diversion because no one could find your records and I want you guys to look I need you dolts up in 10 years maybe 12 you're lucky but I need you here in 10 years let me tell you why for all that darkness there are some unbelievable stuff going on right now in medicine that has gonna radically radically effect on my life status we just touched on a few but really quickly I'm sure you've heard about stem cells right and unfortunately we got a lot of charlatans in the stem cell market right now then they're doing stupid things like why but there's honestly real science and stem cells and it's working I like company does a post surgical follow-ups on the stem cell clinic of Americans in the Freeport Bahamas we we touched our patients in the three ten fourteen so how you doing what's going on you just got stem cells for tremor just not central core subpoenaed injury that sentence up for dementia parkinsonism about half these patients at sixty days are saying I'm better wish if you've dealt with parkinsonism is nothing short than nothing short of a miracle since those are going to completely change how we think about repair and cure they're being actively resistant at the FDA and fully bought we didn't funded by pharmaceutical industry which is pretty unhealthy and I don't blame them they've to pony up 1.2 billion dollars to get a drug need to market a couple million stem cells and mine is a permanent cure whereas yours is a yearly injection of that cure I just completely destroyed that business so it's gonna take a little while to get to stem cells but there's more good news it may not be about to themselves in fact stem cells probably to get what they call small molecules or messenger hearted a decisive injury and cellular depletion okay so let's go back to parkinsonism within five years we're gonna be able to deploy the molecules we have identified that can encode proteins that replace what you lost in terms of neurotransmitters that caused your parkinsonís we don't have a means of placing those small molecules and our enemies the basal ganglia of your brain they will take up residence there and they will turn on the residual cells to replicate and get back to work this is going to happen I look around the room there's a bunch of young people here Rebecca for example – you guys you will see this in your lifetime you will absolutely see this in your lifetime it didn't become like I'll get antibiotics on one side I'm into the small for small you know the one they use for chondrocyte regeneration inside the children near of neurodegeneration it's like Perkins's or dementia dementia this is going to happen they stay ahead of the curve and a lot of them have taught me and what to be watching and staying ahead of the curve right so any well what about stem cells like so so passe it's already going it's gonna be about small molecules and the tricky part is how do you deliver them to the right spot because that's what really smart they're really good at pulling in on where the injury is and then they show up like a bus parking they distort this discourse that passengers which are them over ahead of those stop next to the door oh we haven't figured that out there but we also know I can give you a lot more small molecule messenger RNA and thus I can turn on a lot more tissues back to recovery back to the generation so I need you to be here in ten years you're gonna get smaller this will probably be the end of a lot of our neurologic diseases like Parkinson's in creation what they call Korea essential tremor how many people here have essential tremor you know I guess my motor strip is 59 years old it's getting tired I know what its gonna look like in ten years can it hold a cup of coffee but it kind of social embarrassing I'm already teaching my left hand how to hold the coffee how to pick up the fork it's gonna be doing this I don't do the Foley optimism stuff I know what this gonna look like so I'm hanging my hat on small molecules insensible and I don't want you guys to be thinking you know story there's another thing cool thing that's going on it is for my immunotherapy for cancer cancers cancers are real rat bastard of a disease State do you know what cancer is no like we used to think give the person a chemo will kill all the cases cancers are in many ways they're living organisms they will actually secrete proteins to hide themselves really really hard with conventional to no but we have watching the chemotherapy strategies going on we make antibodies to a very specific tumor just like 15 seconds bare with me I take the genome from a healthy cell 3.2 billion genes thank God I take the genome from a cancer cell 3.2 billion genes by maximum there's some weird defects in there in the cancer cell there are coding proteins i make antibodies to those particular proteins encoded by the cancer cell DNA and those weird proteins which are currently estate in detection actually get found because I can make antibodies to them outside your body Sylvia for those data points and I'm sure you those antibodies will find those cancer cells and white blood cell will come along find an antibody attempts for cancer cell and save your chest it's happening now in the pumpkin and the energy it's super effective when stopped circulating cancers liquid in slow-mo in leukemia it's not so great with solid tumors like pancreatic cancer but we'll figure that out something Hey okay a third of us you're gonna die of cancer this is how it goes two-thirds are gonna go from vascular stroke and heart disease now one-third or going from cancer that's how this breaks out that's how the human genome ends itself the thing will probably cure most cancers dependent I don't know pancreatic cancer and there's some other weird ones but the you know the usual early killer to breast cancer so here's my last point gave you the bad news the good news I'm gonna get their produce to know we're all here right you are today you take a three prong attack and I'm not going to go into insane TJ I'm just gonna give you their faces a healthy life you're gonna get your genome done or at least look at your family history and figure out what you're probably gonna die some and you're gonna create a plane around what your probable risk is for that particular things for that yes like I know I'm a vascular guy I'm gonna probably definitely dad yeah they've got a little plaque in my heart so try to eat healthy exercise Mediterranean diet low carb take a stab check a couple numbers every six months you know HDL particle size and once here they image my heart to see how much like I've gained or lost a molting study three years into this six because of this fear and deliberate plan in my world my CTA was bugging the hell out of me to reduce us to algorithms we call it nineteen numbers basically six numbers on the lifestyle side six numbers on the screening side and then you are six numbers the numbers when we did your genome I looked at your risk said oh you're a cancer guy you're a bracket to mutation closet okay here's your six numbers the other numbers you're important and need to live a healthy lifestyle because that was an issue cancer but here's the numbers I got a tag you twice a year to see what's going on with your evolving cancer risk and to pick off tumors before they get big okay I also know what I should be testing for to alert me that the cancer has emerged because your survival is a lot of your survivors relate to how early we find this thing while it's hiding I want to kill it okay so now think of these ideas nineteen numbers if you will a dedicated action plan that's calendar miserable put evenings of reality that's how you're gonna be here in ten years with me okay and now I'm gonna tell you is why I'm working with Rebecca okay the most perfect health care system in my opinion is an awesome bricks and mortar office based primary you're a physician who wants to prevent disease instead of treatment that's that's really where you start right now I also know that our system is not very kind to that bricks and mortar for service anymore so there's emerging models membership medical practices concierge medical just prior to medical practice but I tell everybody they tell people across the entire United States if you were north of 50 you better get a primary care doctor right now who cares about you who and who is hopefully a little younger I hate to be reality that I won't might not to be 40 right cuz I'm gonna be sick 175 pink of your career one other the peak of my illness that's part would someone who cares and the focus is prevention part two is what I do I take a very data-driven approach to your life span I create a system that's so insanely easy to use and for demonstration purpose it is open your eyes phone tap the app that says world clinic tap the button that says call doctor and in 35 seconds you're talking to me on one of my partners I have all your medical records I know all your medications you've got this kit and I'm gonna treat you right now because you know what I don't want you waiting an hour and a half an emergency room for deeper because it's Sunday afternoon 15 drugs the green ones the blue ones are yours I give you a seven-day supply because I don't want you to miss your blood-pressure medicine yeah nitroglycerin keeps you having enjoying them chewable aspirin beta blockers or your heart Kevin arrhythmia this kid picks up 90% of the reasons people call it and allows us to deliver the relationship that Rebecca and I put together is pretty interesting and you open that app if you're in inside this combined program we put another you open the app and you get to call dr. button and here please forgive my bad knowledge of California geography but we're attempting to create a 100-mile radius so if you're beyond 10 luma call comes to me and my guys if you're south of Petaluma it goes to Rebecca if you're on this side of the Sierra Nevadas it goes to Rebecca if you're on the other side it comes to me I don't know what the southern boundary is yet we figured that out yet maybe it's like Monterey Carmel but you get the idea if you're within shooting distance of Rebecca the system is actually smart enough to route your tap which initiates a phone call to Rebecca if you're beyond that it's smart enough to send it to me and in my world if it gets to me and my partner's we open an iPad our iPad and inside our own software I see you I see where you're calling from I see your entire summarized medical record and then I open the map and where you're calling from and thanks to our good friends at Google and other contributors I can then map where you're standing the distance to a 24-hour pharmacy a quest labs for a blood draw a cardiac lab for a rescue angioplasty that used to take me 20 30 45 minutes and now it takes me four seconds this is what health care is going to look like in ten years there'll be a lot less bricks and mortar it's going to be a lot more virtual kind of virtual triage figure out a problem assign the right resources right now there's no economic incentive to do that hospitals like it when you get sick and show up in their emergency room again in 3,600 bucks for a sprained ankle that's good money I'll take that actually it wouldn't but this is where this is gonna go so we're back and I put this together not just as a trial or pilot we're way past that we're way past proof of concept it's like you care I care you're good I'm good we're gonna create something really special it has been priced for you guys way below our market rates I think it's five thousand bucks for the double program after February first it's ten thousand dollars for the double program after February first I should explain to my board what the hell for why are we doing is such a discount right now I can say it's because we're doing a pilot there do some some integration challenges with medical records hey we're gonna get some killer patient feedback but after February first this goes back to where we started so I'm gonna stop talking right thank you for being patient with the bad news thank you for embracing some of you I can tell we're embracing the good news thank you makes me feel better but if you take anything out of my words get a concierge doctor get a plan serious plan to be here in ten years and then we'll talk again I'm done [Applause] I tend to be the more diplomatic Mary sunshine um first of all thank you all for coming it is incredibly humbling to see all of you here at least willing to explore these different paradigms and where we're headed and some of you are here because you beating your head against the wall of health care and some of you are here because of our personal history and and all of those things and and I certainly take your trust in me exceptionally seriously and to be able to I kind of joke and it's okay to joke with my husband's here I joked like oh we've been dating for you know it's like we've been constantly interviewing each other right and what I find interesting is that all of all of our conversations really center around ethics and how we practice and why we practice the way that we do and I have very few I I feel safe in saying that I have very few mentors that I feel like reflect the values of what I think medicine should be so it's been really nice to see and work with Dan who's 20 years ahead of me in this process and realize that there are still out there I don't want to spend too much more time talking specifically about me I think that many you are familiar with my history I kind of called this my career midlife crisis because I had to decide I felt like I had to decide a couple of years ago I had to choose between being effective or sort of beating my head against the wall for 35 more years and pretending that I was doing what I was supposed to be doing for people and it's certainly been a learning curve I am NOT a business person as many of you know but I really do enjoy being able to be the effective advocate that I feel patients need and one of the things that I find so appealing is that this isn't about telemedicine this isn't about having a doctor in your pocket this is about having your doctor in your pocket and this is about long-term relationships and all of the improved health outcomes that we know come from those long-term relationships that have just been devalued over time we can get into specifics but then I wouldn't really never stop talking which but I I just want to thank you for coming it's not my intention to lead any of you down a certain path I certainly don't want to lead anyone into sort of a direction that they don't want to go what I think has been very interesting about the past few years in medicine is that there's not necessarily a rhyme or reason to how people prioritize their their time their money their what their goals are I mean none of that is uniform and and there is no right answer I don't believe people are coming from a lot of different directions and I'm proud that with my colleagues you know we we've worked very hard to structure this in a way that we want to be able to accommodate different people in different situations with different needs I am most excited about the central and sole purpose of patient advocacy with this system we don't answer to anyone but the patient and it has not felt that way for a long time for me it's also more about alignment of incentives you know we all have to share risk in healthcare and what we've been doing is we've been generous with our healthcare insurance company and that hasn't actually worked out particularly well for most of us so shifting that paradigm sharing risk with the person that you're actually working with who is caring for you and working with you maybe we give that a try and I just the the closing of the loop and the safety factor to me is huge the fact that this is all one record this is all you know this isn't 50 million doctorates right this is five doctors who will talk on a regular basis about every single person that's involved in their care and that's one of the things I'd like so much about comprehensive bonuses going up to stocking it's we need to rely on each other nobody knows everything in the added value in terms of the ability to be effective for people is something I'm very acutely aware has changed the whole way that I can practice for people I don't have anything else specific to say besides a poem if you anyone has any questions I also were happy to answer questions individually you know sometimes this healthcare stuff it you know it can be sometimes one on one is better so we're happy to answer any questions yes so I don't know because I'll tell you why seriously in my world it was all about doing the right job your brand strength to use a business trip it's all around reputation to go to great time so for here for right now this is when start over with Rebecca she's gonna over the Bay Area that's all she'll find that if I find any Google if I find a Rebecca International Athena by Washington Philly I know you're in New York I can see the day could come well a lot of concierge practices around the country will set up such a licensing operation with us footprint for their snowbirds and that kind of stuff I should mention one of the things we're really good at the methods 20 years patients that are not employers over how I'm 20 years older right we're really good at finding if you have something weird at work II we're really good at finding the best person in the country for it we look at the scientific literature and another doctor so he come out with a great you know stage 3 retinoblastoma back to when you're I know the guy or I can find a Gallup insurer can get the employee they organize the records a 35 we probably got seven times a year and this is not a patient base about a thousand patients we're not actively doing that we got Australian so we did you next time fourteen of these executives so about nine months ago this one group came to us and said hey we love you guys you're wonderful would you consider taking care of our employees we mean we want you to be their village doctor for our fund here in Midtown and so we think that's what the market is actually it's somethin sure corporations are currently getting crushed by health care systems that would become expert at aggressively you stop that your company's meaning they're they're paying their employees health bills they look to make look toss to be the perfect client because we disintermediate the emergency room because they come right to us first and we decide oh I asked you another questions the right to face time don't go to the emergency room I will call the specialists the medications we do include a group of six specialists and then we use a special statically clinic in Boston that's about six hundred doctors so many neurosurgeon with no IVs who flipped your Jeep in the Congo or New Mexico I can get that to you so there's is a pretty burden if I may be from the pharmacy to the specialist connection to for the corporate folks crashing we actually well they put all my loyalty in that sense no I'm vertically this is how to find the right specialist wherever they exist so I'm thinking vertical in terms of expertise you're thinking terms Berg internal internal recite rod revenues no senior side lesser degree with UCSF you might see technology are you looking more at wearables that your clients can wear for heart rate you know yeah we are again it's 20 years later I've been 93 year old patients who flew a dive bomber at the Battle of Midway it's chronic congestive heart failure five years ago I convinced his sons let me take care take care of this guy and it's just as harsh legs all by weight and if you gained three pounds overnight I guarantee you it's water weight so now you're in fluid and you're going to tip them to congestive heart failure that fluids got to go slower I don't get it on your kidneys fast it's going back she looks so the scale he wasted self a greedy gets up here Nate's steps on the scale scale scared to his wife's iPhone and the weight comes to my office the magic number friends 143 pounds the bad numbers 147 pounds but we never get there he gets 146 we didn't eat 40 milligrams more lasix any urine aids out the fluid overload we just started the patient like he just did good stuff my waist is secured it simple compliant so we use it a lot we've got me the chronic atrial fibrillation reasonably well controlled but we're moving in we have another technology called a life court which look like a piece of government to ECG be telling into that and now I go right to the I watch the latest I watch an old version it is for where you know I'm pretty good we're noticing that if they use the I watch something actually put their hand down on the TV and the other hand is steady on the table you completely eliminate the motion which rendered it useless if you try to do while you're standing there's a lot of motion repent but if they get the patient just sit at the table put their hands on the table the motion artifact goes away which is like that's gold fur for me and my colleagues like I get to see richer every day and again the net effect is I get a lot of data on you incrementally tweak the medications or I call the Rebecca of the world and say yeah this guy's not controlled anymore that's offices metoprolol or Rebecca his heart rates 50 and he's like edited because he's over medicated I see that all the time but so I'm loving that I'm absolutely loving those things because he did a ton of data and you get to do little little incremental management weeks as opposed to they just go off on their own how the crisis end up in the emergency room and it was totally preventable if you got enough data right that sort of passion where do you see physical therapy running tomorrow most people while people they'll be reality right right so look I'm a really big believer in two things pills in physical therapy and/or massage no seriously there's the pills are a really cheap way to manage a serious condition like each other in relation right I'm the only kid you know where we grow old we actually die very gradually right like first you get the back pain no you don't move a lot now you gotta take the golf cart is you backwards so you're not walking 18 anymore right and we slowly turn to stone and as we do so we're not talking as much without it's physically interactive we should go dancing don't burn it anymore it's actually an exercise for your brain and your muscles so I'm a huge believer in deep tissue massage and physical therapy because honestly the first thing to go is your physicality so if you can do low intensive things low intensity interventions to to restore or maintain physicality that's what we would be better than having a hip replaced or a knee replaced because if this if you have like I see this a lot into your back now you're tilting the pelvis now this ship is getting ground to stand with us right like this these heels piece was your name they didn't say weeks replace your yet and so in my world we do a lot of revolver physical therapy deep tissue massage range of motion really basic stuff right and what a shocker if you it's like everything to pick it off early you prevent that very expensive painful intervention down the getting this it's like it's like those it's cheap deliciousness does that mean around the world they use for consul it's a segregation 7-inch mobile network where the patients live so a physical therapist and not surprisingly the West Palm Beach by a bunch of them down there New York Chicago Washington Delhi is here I was thinking of but then renamed Jeremiah boil candies there's some experience but the one of the things that I'm excited about is the virtual access to anyone you know it within our team with whom you get care not obviously you know we can't do for example never the internet you know the world kaneki's continues the CW's continues to whatever extent the situation allows that's a clinically appropriate I'll take a direct step I don't care where you live so you leave town you stay in touch with my team tonight we still want to keep continuity with Rebecca's practice but it is like I'm moving permanently the Texas and I needed a rebecca equivalent in Texas we don't you find that person that would be a very very clean handoff meaning all of these records and all of this input would follow with you and if you said well you know I just got a primary care doctor but I want to stay in touch with Rebecca's practice that could set it up technologically that you guys are never gonna touch but as far as I'm concerned with your ability sir questions so if you're on Medicare benefits honestly I think it's the prevention side because if you get hospitalized you work you're gonna blow right past your Medicare benefits muscles are getting better and smarter again it's a building game so Medicare's gonna cover some stuff I'm sure you've got supplemental insurance that's gonna cover some stuff and they're still gonna find a way to screw you I'm sorry right so probably you've not end up in the hospital by being super aggressive about your prevention and primary care and having a response mechanism when you just have a question when you're on the road outside the Bay Area or you do get something seriously we want to know who's the best person in the country to do this tell Rebecca she tells me my team will find out if you're gonna get pillaged from Medicare your bodies will get pillaged by the best hospitals to prevention expertise a lot of this again so in Mabel's around as a chat with you and see bell rings thank you very much [Applause]

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