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'Possessed' woman was actually battling brain illness linked to growth on ovary
GSMC Weird News Podcast
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GSMC Weird News Podcast Episode 134: Internal Organs, McDonalds, and Celebrities
...tothePresbyterian hospital Napa know right now, you can get a twenty dollars prepaid visa gift card by mail with the purchase of...
GSMC Weird News Podcast
Aired 5 months ago 70:35
BCBC - Podcast - S3EP009 - Dr, Raj Purohit - Gender Affirmation Surgery
Welcome to the first podcast of October 2018. This is our month on topics around the theme of Gender Identity, the Gender Spectrum, and Gender Transitions. We have a really packed month - with 5 amazing Monday Mumblings, 5 podcasts, 5 blogs, and 4 nuggets. Make sure you stay tuned in to all of our episodes! In This Episode: Today Monkey and the Professor got to chat with Dr. Raj Purohit. Dr. Raj was born in Rajasthan, India (https://en.wikipedia.org/wiki/Rajasthan) but grew up in the midwest - he is a Michigander at heart. He left Michigan to study history and political theory in college - at Williams. He believes that background certainly informs many of his decisions and things he is very passionate about - he grew up in a family of artists and doctors. In medical school, he took a year off to apprentice with a painter in Rajasthan. He attributes his apprenticeship and painting to have a significant impact on how he views surgery. He came back to the US, finished his medical training at Columbia, went on to UCSF for his internship in surgery and residency in urology. He did a Fellowship in pelvic reconstructive surgery - this is where he developed an interest in cis gendered patients originally - in reconstructing the urethra from trauma and complications, and ultimately shifted his focus to developing the Gender Affirmation Surgery program at Mount Sinai a year ago. Dr. Raj made the decision to go into medicine because of his strong family background in medicine, where many of his family members are also doctors. His wife and sister-in-law are both doctors as well. You could consider medicine to be a family business. Even with that, something sparked within him when he entered the operating room for the first time - it was a sense of belonging and home and passion. He sees the surgical suite as a controlled environment, whereas a surgeon, he is an artist - painting the body and bringing out the beauty from within the canvas. Surgery is where he finds his balance in both art and medicine. We started off with a very high-level overview of what is involved in Gender Reassignment. To begin with, the preferred term is Gender Affirmation - because what is really happening is helping the person become externally what they are already internally - it merely affirms their gender identity. At no point are they really assigning a gender to the patient - that patient is already the gender they are on the path to appearing as. We really love that terminology and phrasing. As Dr. Raj states - the doctors are not assigning or giving the patient a new gender - they are only uncovering what is already there, the gender the person already feels exists. (https://amzn.to/2xOODmq) So - Gender Affirmation Surgery typically involves some level of reconstruction on the body so that the body will fit the gender that the person already identifies as. Patients have already gone through hormonal therapy and have had changes in their bodies to reflect the correct gender profile. These surgeries are broadly split into two groupings - Top Surgery and Bottom Surgery (https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries). For transwomen (assigned male at birth, but identify as female) the surgery may entail: facial feminization to transform the masculine features of the face to a more feminine appearance (https://www.healthline.com/health/transgender/facial-feminization-surgery) vocal chord surgery (https://health.howstuffworks.com/medicine/surgeries-procedures/transgender-voice-surgery.htm) breast augmentation to enhance the size and shape of the breasts to create a more feminine appearance to the chest Creation of a vagina through a surgery called vaginoplasty https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/vaginoplasty This typically includes removal of the testes as well For transmen (assigned female at birth but identify as a male) the surgery may entail: (https://www.ftmsurgery.net/) Breast Reduction/Removal includes bilateral mastectomy (removal of the breasts) and male chest contouring Hysterectomy removes the uterus, and may also include the removal of the cervix as well as the ovaries and Fallopian Tubes Creation of a Phallus and/or Testicles Through the implantation of a penile and/or testicular prosthesis to provide the ability to have erections. Dr. Raj stressed that this is really a continuum of options - not every trans individual will have all of these surgeries or go through hormones or have implants - it is a very individual decision as to what a person wants to do and go through. They may do one or two of these options, none of them or all of them. As a surgeon, he believes his job is the help the patient achieve a body that they are comfortable with, and who they want to be. Pre-Surgical Requirements: We spoke with Dr. Raj on counseling for gender affirmation procedures - what is involved, what is required. Keep in mind that different locations (states, countries) have different requirements on counseling and other things that must be completed prior to gender affirmation surgery can occur. All patients do require a psychiatric evaluation before being approved to move forward with surgery - this is very much the case when it comes to some of the more involved surgeries like phalloplasty and vaginoplasty. Most centers require that patients live in that gender identity for at least a year and that they are additionally on hormone therapy for at least one year prior to surgery. The delays before surgery are not really about ensuring people do not change their minds. Really, by living in the gender identity they relate to, it provides them with experience with the varied receptions within society, their jobs, etc. That may impact the medical care that is then available to them post-surgery. It is important that access to proper medical attention post surgery is readily available for the patient’s well being in the long term. Unfortunately many during this year of living in their gender find themselves ostracized, or being terminated for their place of employment - both scenarios having significant impacts on their lives overall. Hormone Therapy: The therapy treatments with transmen and transwomen are obviously different. The aim of hormone therapy is to make transgender people feel more at ease within their bodies, both physically and psychologically. Hormone therapy is usually the first treatment that trans people want to have and, for some, it may be the only treatment they need. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery. Transmen (FTM) For trans men (FTM) who have been born into "typically female bodies" (i.e., bodies that have functional ovaries), as well as trans men who were born into intersex bodies, the goal of testosterone therapy is to induce and maintain the presence of masculine secondary sex characteristics. Addition of testosterone is the therapy - this is a very dominant hormone making it an easier treatment for transmen. There are many changes that occur almost immediately with the administration of testosterone. In FTM testosterone therapy, testosterone (often called "T" for short) can be administered into the body in a number of ways. The most common method is intramuscular injection with a syringe. Other delivery methods include transdermal application through gel, cream, or patch applied to the skin; orally by swallowing tablets (this method is uncommon as it has been shown to have negative effects on the liver); sublingually/buccally by dissolving a tablet under the tongue or against the gums; or by a pellet inserted under the skin. The T-delivery method used will depend on the type of medication available in the country of treatment, the health risks/benefits for the patient, personal preference, and cost. Testosterone is not stored by the body for future use, so in order to maintain healthy levels, it must be administered in timed intervals and in appropriate dosages. Injectable and subcutaneous T pellets remain active in the body the longest. Injectable T is typically administered between once a week to once every three weeks, and subcutaneous T pellets are replaced every 3-4 months. Transdermal T (patch, gel, or cream) is typically applied to the skin in smaller daily doses; oral and sublingual/buccal T are also typically taken daily. Transwomen (MTF): Transwomen have a more complicated approach to hormone therapy. It tends to be a combination of adding feminine hormones while simultaneously blocking male hormones. The goal of feminizing hormone therapy is the development of female secondary sex characteristics and suppression/minimization of male secondary sex characteristics. Estrogen is not a very dominant hormone - treatment with estrogen is combined with a testosterone blocker like spironolactone (this blocks the production of testosterone at a cellular level). There are many formulations of both estrogen and the testosterone blockers that can be provided to the person going through therapy - pills, injections, etc. With the combination treatment, increased fat levels in the body can be seen, reduced testes sizes and the growth of breasts, among many other physical changes. The transformation of the physical bodies with hormone therapy can start within a few weeks to months but will continue over time. The effects in a couple months may not give a complete indication of where things will continue to progress. The Challenges of Surgery for Transmen: Transmen do not typically go forward with the bottom surgeries - phalloplasty - at the time of this recording - the general opinion is that those surgeries are not very optimal. Constructing a new penis is a very difficult challenge - and functional penis creation is difficult and dangerous. The idea would be a penis that can experience erections, that can be urinated through (so peeing standing up is possible), and that can provide pleasurable sensations through touch. Broadly speaking there are two ways that a penis can be constructed. The first is clitoral enlargement (3 to 8 times) that occurs from the taking of testosterone. A new penis can be created from the enlarged clitoris. Additional skin flaps can be used to create a new urinary tube. This provides sensation and urination. The downside is that erections are not possible because the anatomy involved in erections cannot be created within this structure. Obviously, there is a small amount of fullness through stimulation but it is not really an erection. The second downside is that the clitoris can only enlarge so much - a couple inches at most, so you are left with a fairly small penis - and many are not satisfied with that size. The significant benefit is that the surgery is easy and has a high rate of success with low risk of complications. The second methodology for bottom surgery is the phalloplasty. This is where some tissues from another part of the body is used to create a brand new penis. You can create a tube within a tube - the first time is a penis, the second is the urethra. You can implant as well a penile prosthesis to enable an erection. You can have a penis with quite a good size. The downside is that sensation is very limited and not the same as the clitoris. The additional downside is a very high complication rate - scar tissue, infection, etc. At this point, the best way to avoid these is not figured out. Much debate and research is still ongoing. Dr. Raj believes a future possibility might be penile transplants. A number of transwomen are removing their penis - that might be one source for the transmen. That may provide a penis with all three criteria. There is, however, a very long way to go to get the immunology, sensation, and functions correctly. There is precedent in penile transplants - a Massachusetts General trauma patient had their pelvis blown off. The surgery was successful there so that leads to possibilities in the future for transmen. Surgery for Transwomen: Vaginoplasty is a far more common procedure than phalloplasty. The complication rates are significantly lower than other surgeries - it is truly a technique that appears to have been optimized for success. These surgeries come in a few different flavors - the most common is the penile inversion surgery. The penis is inverted back into the cavity and the outer skin becomes the vagina inner walls. Sometimes skin grafts are added from the scrotum to deepen the cavity. The benefit here is that you have sensation. The former head of the penis becomes tailored into the clitoris. It is a functional and sensational surgery - providing transwomen with the benefits they would seek from a bottom surgery. The vagina must then be dilated for the rest of their life to avoid a long-term complication of scarring down but essentially this is a fairly optimal procedure. Additionally cosmetically this surgery looks amazing. What Dr. Raj finds most fascinating is that each center who performed these bottom surgeries historically had developed their own techniques but it is only in the last few years that there has been a sharing of the information so that the group knowledge can work together for better ways to treat patients, with fewer complications and more successes. It is also moving the industry towards a standardization in procedures that include what works. There is a fairly good overview with FAQs on this subject that you can download http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF The Cost of Transition: This is a question that comes up all the time. Unfortunately, there is no simple answer and it will often depend on insurance coverage and such. Many insurances will not cover all or any of the procedures, hormones, etc. Many will. In general terms, Dr. Raj suggested most insurances will cover hormones. Blue states tend to cover some or all of the surgeries - whereas many red states do not cover these at all. For patients that do not have insurance, cannot get Medicaid, or some from states where the insurance will not cover the procedures the surgical costs can range anywhere from $20,000 - $50,000 dollars. The cumulative costs of hormones can be expensive over the course of a lifetime but are not crazy on a monthly basis. The great thing about today’s world versus a few years ago is there is more and more of a push to include and cover these surgeries than ever before. Dr. Raj does not believe gender affirmation surgery as a choice - he believes it is a necessity to someone’s health and well being. This follows the way the medical and insurance industries are moving - these surgeries are no longer considered simply to be a vanity. Being in the wrong body has significant physical effects on health and well being. Doing the surgery results in a reduction of mental health issues that can also then lead to less physical health issues. “This is something as doctors we can fix, so why should we not fix it?” The Impact of Age on Transition: Currently, in society, there are seeing more children (pre-pubescent) and young teens moving towards gender transition. This is often done through postponing puberty through the use of drugs to suppress hormones. This is a very controversial topic - both in society and within the medical community. There is not great data on this topic and on the long-term effects of postponing puberty. What is known - many children under the age of 12 (puberty) may identify as a gender that they were not assigned to at birth. The majority of those kids will identify as the gender they were born with later in life. There is no real debate for these kids and doing hormone therapy - they are unlikely to continue on with the transition as they get older. The real debate is what to do about those kids who are 12 years and entering adolescence and entering puberty. There are studies that have shown that once puberty is hit and after, the gender is fairly fixed and is unlikely to change as they get older. That means that they are not likely to change their gender identity back to what it was assigned at birth - it is established in their identity. This is where the question comes into play - should puberty be stopped and/or should hormone therapy be initiated so that those secondary sex characteristics of the assigned birth gender do not develop. Questions around early surgery are also being debated. A lack of data makes outcomes uncertain - would they provide better outcomes with earlier surgeries or would there be additional challenges because of coming growth. For risks and things to be aware of for children, Dr. Raj suggested that parents should speak to an endocrinologist. This is their area of expertise and they can advise if there are and are not things to keep in mind. Resources for Parents: There are a lot of websites - but the best in Dr. Raj’s mind is the World Professional Association for Transgender Health (https://www.wpath.org/). This site is used by medical professions as well and contains accurate well-vetted information. Many other sites out there may be full of misinformation. It includes standards of care, risks, questions, and so much more. Other resources include Lambda Legal (https://www.lambdalegal.org/). This organization is geared toward LGBT issues and has a lot of amazing references present for parents. Transitions in Older Generations: The older generations - considered geriatric, are making a lot more of a splash in transitions. There are more articles out in the world about people in their 70’s, 80’s and 90’s going through gender affirmations and transitions. Dr. Raj notes he is seeing an uptake of people across all age ranges, but he is highly impressed by the older people who come in. They have lived with the social ostracization through their years. Now as the world is becoming more supportive, they seem to be able to feel safe in moving forward. The courage the older generations have lived with their entire lives, to now come forward with the transition is a true inspiration to Dr. Raj. Later transitions have different risks than those done at a younger age. One the one hand there are social risks for gender transitions - groups of friends and peers may not support the transition and it may result in a loss of companions and loved ones in their social network. This can result in feelings of loneliness and feelings of isolation. There are also risks of hormonal therapy in older transmen versus younger men. Testosterone can increase blood count and the risk of high blood pressure and sleep apnea and cholesterol. This means these are things that need to be monitored more deeply. There are also concerns of prostate cancer for transwomen who are then put onto hormones. It is unknown if there need to be more screening, testing, and treatment around the prostate. Surgeries for gender affirmation are all serious lengthy surgeries with risks. Older patients may not be great candidates depending on their health - but as always, Dr. Raj does what he can to help his patients, young and old, do as much as they can to become the physical body they identify with. The patients often have to assess the risks for themselves as well. Long-Term Health Risks that May Result from Gender Affirmation Surgery: Unfortunately, there is not a lot of really good data on the long-term risks associated with gender transitions. A few things that are known however are the risks associated with the hormone therapy. Patients taking testosterone to run higher risks of increased blood count, high blood pressure, sleep apnea, and high cholesterol. They also tend to gain weight and may develop acne. For estrogen, there is a higher risk of gallstones, clots, cholesterol issues, cardiac disease, and high blood pressure. The things that are debated but there is no immediate proof is the increase in breast cancer for those on estrogen and progesterone. There is no data, yet, that testosterone can increase the risks of uterine and breast and ovarian cancer in transmen. Ultimately all these questions require more research and research dollars to look into. Pregnancy and Hormone Therapy: Following some of the conversations we had this month, we were curious as to known complications from stopping hormone therapy as a transman to get pregnant. Dr. Raj suggested a few things to consider - normalizing hormones to that of a gender female before getting pregnant and possible concerns for the baby from the additional testosterone in the system. These are also situations that do not have a lot of real research to understand what the possibilities are. Resources at Mount Sinai: Mount Sinai has one of the best online resources available to people. They have spent time and commitment in developing one of the best transition centers in the world. They have created a multidisciplinary team to ensure that they can work strongly in a coordinated care method on the patients’ behalf. They have also developed two Fellowship programs within the gender affirmation field. In Dr. Raj’s opinion, Mount Sinai is moving the field forward through training and procedure development. The research there is also pulling data together for long-term understanding and improvement. Parting Words: Dr. Raj likes to think about what appeals to him about the transgender community and the work he does. Some of the patients he has come from very supportive environments and can make the transitions easily. However too many others face ostracization, employment loss and os much more He inquires of each of our listeners - what are you willing to give up absolutely everything so that you can be true to yourself? Dr. Raj joins our barnyard today - he identifies as a pig in our barnyard. He does not mind to get dirty and to spent time flopping around in the mud. Pigs are also very intelligent animals and he believes that also indicates a part of his personality. About Our Guest: Dr. Rajveer Purohit is the Director of Voiding Dysfunction and Reconstructive Urology and Associate Professor of Urology at The Mount Sinai Hospital. He has performed over 400 complex reconstructive surgical procedures including urethroplasty for urethral strictures with grafts and flaps, surgery for complications of radiation therapy, treatment of mesh complications and complications of pelvic surgery such as incontinence and maintains a particular interest in transgender surgery. In addition, Dr. Purohit has continued to maintain an interest in general urology including surveillance for cancer, vasectomy, urinary problems, sexual dysfunction, and work-up for hematuria and elevated PSA. Dr. Purohit graduated Magna Cum Laude from Williams College and earned his medical degree (MD) and Masters in Public Health (MPH) from Columbia University before completing his surgical internship and urology residency at the University of California in San Francisco. While there he trained with one of the pioneers of male urethral reconstruction and then completed a fellowship with Dr. Jerry Blaivas in pelvic reconstruction and voiding dysfunction and was on the clinical faculty at New York Presbyterian for over 10 years before joining Mount Sinai. He has been listed in New York Magazine’s Best Doctors in New York City. He has been awarded the Pfizer Scholars in Urology, AUA/Praecis Gerald P. Murphy Scholar, Society of Medicine and Reproductive Urology Travel Scholar award, a California Urology Foundation Grant and an Arnold P. Gold Fellowship and multiple Patient Choice and Compassionate Doctor awards. Finding Dr. Raj! Mount Sinai Department of Urology: https://www.mountsinai.org/profiles/rajveer-s-purohit Twitter: @DrUroRecon Additional Resources and Links: www.wpath.com www.Lambdaleagle.com https://www.pinknews.co.uk/2018/06/26/starbucks-to-pay-for-all-transgender-staffs-surgeries/ https://nypost.com/2017/03/29/transgender-wwii-veteran-comes-out-as-a-woman-at-90/ https://health.usnews.com/health-care/patient-advice/articles/2018-05-25/what-is-gender-affirming-surgery https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries https://www.youtube.com/watch?v=EWdtByPm9a4 https://www.youtube.com/watch?v=zGkiC3Y8kk0 https://health.howstuffworks.com/medicine/surgeries-procedures/transgender-voice-surgery.htm https://www.webmd.com/women/guide/vaginoplasty-and-labiaplasty-procedures#1 https://www.ftmsurgery.net/ http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF http://transhealth.ucsf.edu/trans?page=guidelines-feminizing-therapy https://www.cosmopolitan.com/sex-love/news/a52196/what-its-like-to-transition-transgender-man/ https://www.healthline.com/health/transgender/bottom-surgery
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Aired Last month 42:02
Improving the Patient Experience while Maximizing Payments with John Talaga, Co-Founder, EVP/GM at OnPlan Health
Welcome to the outcomes rocket podcast where we inspire collaborative thinking improved outcomes and business success with today's most successful end, inspiring healthcare leaders and influencers and now your host so Marquez. And welcome back to the podcast today. I have the outstanding John Tolaga. He's the executive vice president and general manager at fly wire. Most recently on plan health on plan health was acquired by fly wire. In two thousand eighteen Dan has been a long standing trust with customers through an unwavering dedication to delivering what they really need in two thousand John co-founded health healtHcom partners, a leading provider of patient billing software and services for hospitals and health systems health com. Pioneered the patient friendly billing concepts and consulted with the healthcare financial Management Association in the early stages of their initiative health come sold to McKesson, which we are all in two thousand six as their first acquisition to form relay health a revenue cycle services company. I really health. John led the patient billing and payment business for five years serving more than one thousand healthcare providers. For all you folks, listening revenue cycle in healthcare is a big big sticking point and an area of major improvement for everybody. So there's gonna be some great Pearl shared here by John, but after relay health John launched and led healthcare vertical for doc. So an award winning payment and document network that is transforming the way people connect with businesses to manage and pay their household accounts. So John overall has a keen understanding of finance within healthcare. And is a true pleasure to have him on the podcast today. John welcome saw. Thanks for having me. It is a pleasure. So John if anything at all that I miss that intro that you wanna fill in the the listeners on. Nah, I think you think you covered it pretty well south. Thanks, cool. No, I'm glad now what is it that got you into the healthcare sector. Well, like anything is not always something. That's planned. Right. So in the late nineties, and I'm aging myself here, we had co founded a a. Business with my co founders Paul Hoffman. Jeff porter. And my partnered Paul Hoffman will with worked with rush Presbyterian healthcare here in Chicago and really identified a need that was a long problem in healthcare of sending out bills that patient's simply didn't understand and came up with the concept in which we coined the term patient friendly billing to make it's much simpler for patients to understand what the relationship with their insurance payment was to their out of pocket and really would propel in our business, which we then incorporated as health com partners. We built the product called patient, compass, which was the first online account management tool in healthcare which allowed for the first time for hospitals to be able to transform the paper Bill into electron- ick account management experience. So that they can see updated information pay their bills online, and it may be hard to believe. But in the early two thousands on payments in healthcare is extremely novel. So that's really what propel there. Business and really would focus to get into healthcare. Was you know, healthcare was so underserved. In terms of the patient friendly billing in payments, part of the business in which we took advantage of the really serving patient hospitals that had the need to to make those improvements in in one of the things all that. I'll mention that's that's important is when we when we went into endeavour in building patient, compass, which was the online tool we met, David king. David king was at infinite solutions, and what they did was they're the first ones that to higher education for student tuition. Management's completely digital who. So when we were looking to build a online solution for healthcare, you're introduced David, and we essentially use David in his team to repurpose what they had done for higher education to apply to healthcare. Because of there is so many similarities in terms of highlight -bility, so the consumer and a third pair. There's. Financial aid and student tuition and there's insurance health insurance and healthcare. So kind of the marriage worked really, well, man, that's beautiful, you know, in a couple of things John thanks for the history there. And folks, you know, a couple of things that I want to highlight about what John just mentioned in a number one. If you look across the economy at different verticals, there's a possibility that a solution for a problem that exists is already there. So John could have Steve for seeing this, and you and your partner all and and just being able to unravel it put the team together behind it and execute the similarities are just drastic. And then the second thing that comes to mind from your experience there is this idea of the user interface of healthcare. I had a one of the guys that was a co-founder at singularity university. That said the opportunity to create businesses in healthcare just by improving the user, interface are just like innumerable, and you've done just that. So kudos to you. And your team John for being able to make this happen. Well, thanks for sheet that so you've obviously been successful at making billing friendlier for patients and helping providers inevitably help the patients pay. What would you say is a hot topic that needs to be on every medical leaders agenda today? And how are you guys addressing at flywheel? Yes. Fly wire. Fly wire Yang. Oh, no problem in this. It's a great segue to this because kind of going along sort of the the story line in about two thousand seven as we all know before ability of forcible care ACT's really started making the affordability of healthcare a topic. Whereas in the past when we launched patient, compass patient responsibility was about ten percents of the net patient revenue at hospitals. The other ninety percent was collected by from insurance companies and with the shifts in high deductibles from the Affordable Care ACT's slowly of. Surely it made that ten percent increase to twenty five and sometimes it's highs thirty percents. So the old practices of sending a statements trying to collect in wait for payments, and then Senate to bad debt collections was no longer sustainable when the hospitals were only collecting about forty percent if they're doing really well. So the it's really become a crisis in terms of the affordability. Not only for the patients who are having difficulty paying their bills. Fact, sixty five percent of the bankruptcies in the US are caused by medical expenses. It can't be paid. So it's a patient problem patient, certainly patient affordability medical debt problem, but it's also a problem for the hospitals because if they're not collecting thirty percent of the revenue than you can imagine what that does their bottom line. So really the hot topic that we really kind of focused on with the launch of on plan health and twenty fourteen was really serving once again underserved need. So it wasn't so much the. Y improvements that several could businesses had made, you know sense, the really health patient compass days, but it was more now about how do we leverage analytics to be able to help hospitals identify patients that can't afford their Bill up front and then being able to take that. And automate that process to give them an offer upfront. Visit you may pay us thousand dollars in what you owe. Which is about the average patient balance after you know, with their deductible or you can pay us hundred dollars a month for ten months, and allowing that patient to self activate those offers by writing a check or going online to do it. So by doing that, we're able to really help focus the hospitals on automating and reducing their administrative costs and collect more and at the same time. Help patients pay them out that they can actually afford without having to call and ask for estimating gas. It's the other end you Dismore looking at analytics to help them maximize collections. And then it's that user friendliness for the patient as well that they could actually feel okay with going with whatever option they want to. Yeah. That's right. Like in the old days. It was about taking something that was essentially unreadable and make an readable. And now it's about changing the contents to say, okay, understand that I owe a thousand dollars and I can't afford it. So it's really the patient friendly to Daito if you will now transforms into giving them content that's tailored specifically to that patient's willingness and ability gosh, that's beautiful, man. And you guys just layered on sort of the learnings from what you've done and just consistently tweaking it to make it even better year. So give us an example of how the organization year part of now as created results by doing things differently. Yeah. For sure. So the process that we ended if you take an example of our hospitals that were working with one of them is one hundred hospital system. Catholic health initiatives based out of Denver, and one of the things that they were struggling with was as many hospitals. Do they use early out to help them? With the increase in patient. Responsibility comes more phone calls, more credit card payments, and these hospitals. Typically, don't have the resources or funds to go. Hire a bunch of people. So there's a lot of the early outs or extended business office companies that allow that relief through call centres and being able to manage some of the administrative things of this this higher volume of transactions. The downside that comes from. That is is hospitals can sometimes lose control over that patient experience because they're outsourcing so much of it to a standard process that they may not agree with. So what we've done at Gye and Munson healthcare and rush Copley medical center here in town as well as presence health and others is we've been able to give them control of their patient exp. -perience while they still use the benefits of these outsourced extended business office companies, but what we'd help them do is direct those accounts to be able to turn over the early out companies after they've run it through automation techniques. So they can place less as you would guess when you place accounts with these early out companies, they're expensive answered to percentage or everything that's collected. So by driving the automation, we've been able to drive a seventy percents on average payment plans that are self activated by patients. So that means there is no phone call. The patients are getting what if we're doing our job rates with the hospitals were getting it rights by giving them offers. They can afford and then their self activating. So we're not only driving that automation that results in less placements that early outs which is a direct savings and then less phone calls that come in. You can always tie patient complaints in satisfaction to how many phone calls come in. Ms patients will call when they have a problem. So by reducing those phone caused by almost forty percents is a direct tribute to how much we've been able to drive that patient satisfaction. Definitely a testament to how well it's working if your provider exempt listening to this, you know, that you have your expertise, and there's things that you outsource. And it's interesting today the opportunity to outsource business -sarily mean you're outsourcing it to an outfit you could outsource to software, and I was talking to John before the podcast today. And you know, I saw him one of the things that I enjoy is being able to create a forum were great ideas can be shared because oftentimes you don't know what you don't know. And today, I hope that through my conversation with John you get to learn about a new opportunity where you can actually outsource software. What you're currently outsourcing to an outfit, and you know, what try it because it might be better today might be that idea that gets you from to. Be in a more efficient way. So John can you share with the listeners a time? When you had a setback that made the product even better, and we learn more from our mistakes. I'm interested in hearing about that. Yes. So, you know, it's interesting. I think anyone that's has been in business, not even businesses. They've started you realize that isn't always one big setback, right or a failure. It's a lot of little failures little setbacks that make you better. And so I could probably list in take up the rest of the time listening about fifty things that we've experimented with contested with and things that it worked. So well in we we came back and change it. Most of our ideas over time have come from customers. Right. So we've always been extremely customer sensitive in terms of what their needs are. They're the ones that know the problems and oftentimes no this solutions, or at least how they'd like to solve it. And then coming back and putting your heads together to figure out the right way to solve it. But if there is one that I'd probably point to which is kind of a broad concept is. When after McKesson, I started the healthcare vertical for doc. So that you mentioned in the in the opening and one of the things that I envisioned is that at some points hospital payments, patient payments, like any other household payment. She really should be aggregated in made in one place. Right. So you can manage everything together with your finances. One of the things that I learned is you really can't. There's one thing about healthcare. You can't do as you can't speed it along with other industries, and I don't think healthcare is ready for that. While we've made some incredible strides with some large health systems that are are still moving towards aggregation one of things that we did in on plan is we kind of went back to basics and focused on solving the direct interaction engagement that hospitals want directly with them. They want that loyalty they want hospitals to patients to becoming to them for their clinical questions in care at the same time of being able to to make payments in an easy way. So. So that was something that I learned kind of in a broader, you know, rather than the small setbacks was one large one that can remind me of how we really need to approach healthier because it really isn't industry. That's like, no other. Yeah. For sure I think it's a great call out. So what would you say the other side of the coin is John? What's your proudest medical experience leadership moment that you've experienced? Well, you know, I don't think I have one to be honest with you. It's sort of the every day one of the things they were doing on planet fly where that gets me most excited, and I think most proud, you know, my partner David king in I really bringing together higher education and in healthcare. It's you know, Healthcare's always searched for other industries in terms of how it can learn from other industries, and you hear Amazon lots and that online experience in here other things as well. But higher education and healthcare, probably the two that are are most closely, aligns wise, I mentioned earlier with highlight ability and the third payer that so. Financial aid insurance, and we built one platform to serve both markets, and what we've been able to gain from the higher education side to be able to ply to healthcare such as students being able to set up in automatic payment plan over there semester. We brought that to health care to be able to offer financial incentives as well as automating to the patient. So us being able to drive you can't go to sleep at night in you bounce off your pillow in the morning, and you get excited because we're helping patients that can you know, neighbors that can't afford their bills when they get the average consumer cannot afford a four hundred dollar unexpected Bill and the demographics have healthcare is the world Irish -cations, very focused on students in eighteen to twenty two year old range, but the demographic for Healthcare's the world, so there's a real need of unexpected expenses that can devastate a family, and it really excites me to work with a team that is. Israeli folks, I'm proven that as beautiful it's a great mission. And I could hear the passion in your voice to tackle this challenge and very insightful. You know, this connection between academia, and and health in that it's that third party payer, and since you guys are adding value here in the in the financial aspect of it. It makes much sense. Can you tell us about an exciting project or focus that you guys are working on that fly wire? Yes. So we we are bringing together. So as as you just mentioned in the there's academic medical centers that are all tied to universities. So of fly wire offers international cross border payments. So if you imagine you have these, you know, in terms of patient volume, which is what every hospital's trying to increase the more and more hospitals that are looking overseas to pull in patients that need experts. Specialty medical care that are able and willing to travel into the US. So what you can imagine the problems with making payments in terms of the financial inner change and. Sending a wire in how difficult it is for a patient to pay overseas in cross-border in how expensive it can be for providers. And they need that experience to be smooth for the patients. So that they don't have any barriers to come to their hospital for care, and they got a managed cost because whenever a patient comes from outside the US they're paying the full balance up front. So they have to have the money. It's not a collection effort like it is in the US. Right. So to make that process, clean, and inexpensive. In smooth is is really important. So what we're doing it fly wire on and they do that for students is they as well as patients will we're doing it. Fly wearing on plans bringing together one experience for at an academic medical center, where you can be a student coming in overseas, or you can be a patient coming in overseas in paying cross-border and be able to pay from one one place, and they're still separate because you know, hospitals will still manage their collections differently from students. You know in economic medical centers what managing those from a single platform single experience in a single pay partner like fly wire Ma is critical. And we're so that's something that is not every medical center. Still doesn't see the connection. But that's what drives us as well. As to say, hey, there is connection. And we're working that with a few academic medical centers right now that we think will be really exciting Mets fascinating in kudos to you guys. For seeing where the puck is going not just working where the puck is super exciting work that you guys are up to in in you know, that mission of of alleviating those families from that financial strain is is a big big motivating force. Let's pretend you and I are building a leadership course on what it takes to be successful in the business of healthcare and finance. I've got five questions for you lightening round style. Followed by a book that you could recommend the listeners ready ready. All right. What's the best way to improve healthcare outcomes? That would say personalized digital patient engagement. So. Again, this is focused on financing in revenue cycle. But I think if you can personalise that engagements of nets would consumers expect, and I think that's probably the best thing you can do to get a better financial outcome. What's the biggest mistake or pitfall to avoid? I think number one with any businesses trying to avoid boiling the ocean. Right. So don't try to do. Too much be a specialist and be the best added healthcare is is so big and leaders need to stay focused. Stay with it and avoid distractions of that how do you stay relevant despite constant change. That's a great one. Right. It's always the constant challenge. But I think if anything it's very decisive than confidence in adding new innovation and not everything is gonna is gonna work right away, but sticking with it. So I don't think you should seek perfection. But you know, get results out there refined seek feedback and refining. Again, great advice. What is one area of focus that drives everything in your organization? That's an easy one solving problems for your customer. So I mean, our focus is always. Where customers are identifying the challenges in pain points that they have and everything if you talked to anyone in our business, it's really gonna be customer first beautiful. And finally, what's your number one success habit by number one success habit will some people that know me my save, you know, working late at night when there's no distractions. So I'd have to say, you know, I wouldn't recommend it to people because everyone has early mornings and everything, but you know, I have four kids and lots of activity going on after work as well. So I've got my time ten thirty to twelve register focus on things and I'm not able to accomplish during the day. So I actually cherished at time. So that's probably my success habit. Love it gotta have that block time. It's awesome. Yeah. That's right. And what book would you recommend to the listeners? So this may be surprising. So I'm a self admitted a non prolific book reader, I read a lot. And it's nice about things that are journals in keeping up with what's going on in the markets and things like that. But there is a book that I always recommend to any age and any business person or not business person because it's called the way of the peaceful warrior by Dan moment. It's a book that came at a critical time for me in terms of helping me find my direction new I just spoke to me in terms of how to live life creature. Own meeting and opportunities, and I think a lot of that sort of thing has continued to drive me in my business my business life as well. Love the recommendation hadn't heard of it before. And we'll definitely put it on the list for sure John and listeners the way of the peaceful warrior add that two years as well. Dan millman for all the show notes as well. As just full transcript of our discussion links to companies, we've mentioned as well as this book, go to outcomes, rocket dot health slash fly wire, that's F L Y W IRA unified, everything there, John this has been a blast. I've really enjoyed our discussion if you can just leave our listeners with the closing thought, and then the best place where they could get in touch with or follow you. Yeah. So I guess a closing thought, you know, it was like the dimension. Is you know, you see more and more capital being invested in healthcare than ever before? So anyone healthcare you're in the right place. Right. People want in and with with that comes a lot. Out of noise, and it makes it difficult for leaders to sort out what's important in. What's what's not my co founder, David king in? I we always remind ourselves and our team of the y you know, why are we doing what we're doing? And at the end of the day. It's the reason people buy from you. It's the the reason employs feel sense of purpose. So if there's anything I leave that that would be an if people wanna get hold of me, a very happy to respond. You can Email me to my Email address, which is John J h n dot Tolaga TA L AGA at fly wire dot com. Outstanding John, hey, really appreciate your insights today is just definitely a fascinating discussion. And so folks appreciate you listening as well. John thanks again for being with us. The pleasure south, thanks for having me. Thanks for listening to the outcomes rocket podcast. Be sure to visit us on the web at WWW dot outcomes. Rocket dot com for the show notes resources inspiration and so much more.