Kaizen Health and Wellness
Spotlight Series
Spotlight Series Topic: Insights into the realities of healthcare behind the scenes, the flaws in the current system, and how direct primary care models are transforming patient experiences.
Guest Name: Dr. Jon Van Der Veer
Guest Credentials: MD
Discussion Details: In this in-depth interview, Dr. Jon Van Der Veer shares insights into the realities of healthcare behind the scenes, the flaws in the current system, and how direct primary care models are transforming patient experiences. Discover practical solutions for improving access, transparency, and quality of care.
Benefit of Watching
- Healthcare system flaws and behind-the-scenes realities
- The shift to direct primary care and its benefits
- The importance of transparency and access in healthcare
Address of guest’s business:
7300 Westown Pkwy #330,
West Des Moines, IA 50266
Dr. Jon Van Der Veer: Thank you very much. It’s a pleasure to be here today.
Dr. Bryan M. Ladd: Yeah, absolutely. I’m I’m super excited for this one mostly because myself and my family actually have experience using your services at Exemplar Care and so that’s not always the case when I get people on the podcast but we’ve had absolutely nothing but great experiences each and every time and so I don’t think yeah I was going to say I don’t think everyone can say that about their primary care and so and it really is true we we’ve loved it we try and tell everyone about it and so I just yeah thank you for taking time out of your busy schedule to to talk to us today so
Dr. Jon Van Der Veer: absolutely Absolutely.
Dr. Bryan M. Ladd: Yeah. So, you’ve worked in both clinical medicine and leadership. What’s something most people don’t understand about how healthcare actually works behind the scenes?
Dr. Jon Van Der Veer: It’s really slimy and grimy and gross in the background. That’s the That’s the part I’ve learned lately is, you know, healthcare is not a typical market. You don’t say like this physical will cost me $128. you know, this there’s there’s so many hands in the pot of how health care is delivered. Um, I mean there’s we always say primary care is really basic and and kind of straightforward, but you get into the layers of who’s the payer on the insurance side and then the specialty care and then who’s delivering that uh insurance product to somebody and everybody everybody’s kind of got their hands in the sticky pot and a lot of times I mean I think historically medicine was really good about patients are front and center and I think in the last oh 10 15 years kind of about the duration of my pra my clinical time you just see a lot of the focus going towards billing coding revenue and not just taking care of people I mean healthcare is a human interaction it’s a personal connection and a lot of that has just been squeezed out of transactions down into transactional things instead of relationships
Dr. Bryan M. Ladd: so what made you step into building a different model of care instead of just practicing inside the traditional system
Dr. Jon Van Der Veer: So, I did the traditional model for quite a while. I was seeing 25 patients a day or so. Average age was about 76. Um, incredibly complex folks with lots going on, lots of medications, lots of referrals and care that was needed and and the time was compressed down and I refused to have uh my computer open and and clickity clacking away on the keyboard like everybody does and ignoring the patient. So, I always did hours and hours of work outside of that. And I had patients who would ask me, “What’s this going to cost?” And I look at them kind of dumbfounded, like, “I don’t know anything about healthcare finance and how you how you as a consumer or a patient of mine is going to pay for this.” So, stumbled into an opportunity in leadership at a company called Caremore. At the time, they were they were partners with then Group and it was a really cool model of care that spent a lot of time with people. It addressed people’s needs, like their needs outside of the clinic. Where do people live? How do you get food? One of my favorite stories was a guy on insulin who continually wouldn’t have improvements in A1C despite insulin doses going up. And then a nurse I worked with went out and saw, oh, you don’t have a fridge, so you’re getting 3 months of insulin. And first couple of weeks, it’s good. And then you’re giving yourself expired insulin that hasn’t been refrigerated. So it’s you can take care of somebody by helping them get a mini fridge that keeps their insulin in them. I mean it’s you just you realize that providing care is different and that led to ultimately moving to direct primary care which was a a model that allowed for the same time the same type of care but a much less regulated insurance style of getting care. It’s you as a consumer or as a business. You pay a set amount and you get all the services that we provide or are capable of providing without getting nickeled and dime the rest of the way.
Dr. Bryan M. Ladd: Yeah, that sounds like it sounds like what it should be, right?
Dr. Jon Van Der Veer: Well, and it’s specifically it’s the way it was for most of medical history until you get to the mid 1980s and you start to see insurance start to pay for all sorts of stuff. the and I’ve given this example a bunch of times, but the most relevant is thinking of your car insurance. I’m assuming that you pay you and your listeners pay for car insurance and you don’t think a whole lot of it. Like, sure, you might see a Geico commercial and go, “Yeah, I could maybe get it a little cheaper if I switched up something.” You wouldn’t be able to afford your car insurance if you sent them every tank of gas and every oil change and every tire rotation. All that stuff that as a car owner, you know, you have to take care of and pay for. Insurance is there for when someone smashes your car, which would be equivalent to being in a crash or getting cancer, having a heart attack on the healthcare side. But in healthcare, we have every tank of gas gets build to insurance and they pan that out and the cost goes up only goes up. So just a completely different financial model allows for a completely different care model.
Dr. Bryan M. Ladd: Yeah. What caused that shift? Do you know like why why it started to move that way?
Dr. Jon Van Der Veer: A lot of things I mean over time the insurance companies could see that they were being helpful initially. If you look at some of the data in the 80s, insurance companies were starting to pick up additional pieces and they were starting to, hey, we’ll help with this and we’ll help you get this. And over time, they started to assist on a lot of things that clinics would have been doing, which was great. But then at some point, they turned around and said, “Okay, well, we’re doing all of these things, so now we’re going to start decreasing what we’re paying.” Cuz they were still paying really well. Then I had multiple older physicians I said that I worked with said, “Oh, you missed the golden age of medicine.” these early 90s everything was paying really well relative to the cost of living and everything else at that point. And they said you missed out on that golden age of medicine when you know and back then it there’s conflicts of interest in this in my mind but insurance companies were taking people on trips and it was really kind of a glamorous situation but then all of a sudden it said okay we as the insurance industry now do all these things for you and now we’re going to start decreasing what we reimburse. Okay. Well, they’re gonna cut they’re gonna cut reimbursement. What do I do to make up for that? Like, how do you keep yourself whole? And you’ve just seen the rat race ever since.
Dr. Bryan M. Ladd: Yeah.
Dr. Jon Van Der Veer: And then there are some some other legislative things components of the ACA that had good intent. Hey, we’re going to make sure that people with really bad diseases still get coverage. Well, that’s fine except for it still gets spread out across the risk pool and and that those dollars still get shared across the the space. So I always say healthcare works exactly how it was designed. Unfortunately, no one ever sat down and said how should we design this? Just kind of follow the follow the money, follow the the clinical strings and and so we ended up where we are without really saying this is where we should be.
Dr. Bryan M. Ladd: Yeah, sure. So where do you think the current healthare system fails patients the most right now?
Dr. Jon Van Der Veer: Um wow, lots of places. Uh, access, convenience, and transparency are probably my three favorite talking points, and those are kind of the ones we’ve targeted. Um, I I went and uh scheduled through the office uh of a gal I’ve trained with and known forever, and it was 4 months to get a uh an appointment. And I text her and she said, “Well, you know, you can be seen tomorrow if you on. I was like, well, yes, I know I can do that, but the typical healthcare consumer doesn’t get to text their doctor in a fee for service world. Now, in the direct primary care space, that’s part of the relationship through a portal, through a message, through a phone call. There’s more direct ways to to interact and and so we’re proud we’ve added that piece, but I have patients all over the place who say we just can’t get in. like our employer group gave us you guys as an opportunity, but we have our docs and our family practice doc that we’ve always gone to or a pediatrician and we’re never going to use you until they call and need something and it’s 3 weeks out and they need it in the next 48 hours. Suddenly that access and convenience trumps the relationship that’s been there. I mean, seeing your favorite person but not seeing them when you need them isn’t very useful. Then the the transparency piece, really figuring out what care costs. Care isn’t that expensive. Um, at least not on the primary care side, lab side. Sure, people can mark things up several hundred% and make things expensive, but the actual unit cost to do what we do isn’t exorbitant. Not to the degree that you would see when you’re looking at an EOB and a chargem result from from a visit somewhere.
Dr. Bryan M. Ladd: Yeah, that that last point about EOBS, that’s an interesting too because they insurance companies I feel like have kind of made it a game. Um, and I’ve had to explain this to people, you know, it’s like if I charge your insurance company exactly what I think it’s worth, but they’re just going to cut it and then I’m get paid way less of it.
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: Yeah. So now I have to overinflate it and it it does look ridiculous, but they’re going to cut it like you said and then I’ll get hopefully what I want.
Dr. Jon Van Der Veer: fun example. My mother-in-law had a bad bout of atrial fibrillation. ultimately ended up having an ablation uh to her heart and I think it built at something like $130,000 and then uh Medicare paid 225 roughly 22,500 of that and then her supplemental insurance paid another like 500 and she’s like my insurance is amazing I only paid 50 cents. Well, first off, I love that they left her with 50 cents to pay out of $100 bill, but again, that was what the company felt they needed to charge to make sure that they got the the 22,000 23,000 which would have had their cost plus some functional margin built into that. And I I just always say that price and cost in healthcare have zero relationship with each other.
Dr. Bryan M. Ladd: Yep. Yep. None. How does uh universal healthcare compare to this?
Dr. Jon Van Der Veer: I think it solves the cost component in that you as the consumer don’t have to worry about it, but it causes issues on the access side. Yep. Again, now everyone has access and there’s not really any incentive to compete on convenience. You might have you might have access to the first line, but to get that specialty care that you really need to get that ablation might be a year out. And that means you have to deal with stuff. And that’s that’s one benefit to our current health care system is you can get access to those higherend units of care. The real question though is why on God’s green earth do we need so much of that? When you look at the actual drivers of cost, it has very little to do with those procedures with hospitalizations. The big drivers are the metabolic disease, the cancers, the heart disease, all the things that if we were taking better care of ourselves, you’d avoid most of that anyways.
Dr. Bryan M. Ladd: Sure. Sure. Yeah. And that was my experience in the Navy as well. I mean, everything was free, right? For active duty, you didn’t have to pay anything to come see us. But access even for physical therapy, I mean, we were at times two to four weeks out just to get your first appointment.
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: And then and then hopefully you can get in the next week for physical therapy and get your treatment started. But even things like ordering MRIs. When I first got to Okinawa, for example, I mean, it was common for 4 weeks out to get an MRI from muscularkeletal.
Dr. Jon Van Der Veer: Well, I’m I’m not going to lie that it’s still not uncommon in a lot of our footprint and geography for Hy-Vee Health Exemplar Care is 2 to 4 weeks isn’t still uncommon depending on the year early in the year when no one’s met their deductible. Nobody’s out out trying to get any of these things. So, but you get to the back half of the year and things can start to log jam even in our current system and there’s there’s really, you know, there’s no reasonable explanation to a patient to be like, “Oh, yeah. I think you have a torn rotator cuff and in three and a half weeks you’re going to get your MRI of your shoulder to confirm it because uh the orthopedic specialist isn’t going to know what to do until they have that imaging. They’re not just going to cut you open and go digging around.” And even if you’re doing physical therapy in that time period, which you probably should be, you still don’t have a definitive diagnosis of what you’re dealing with. Yeah. Can I take a quick story on one of my early learnings on how the insurance side of healthcare worked?
Dr. Bryan M. Ladd: Yeah, absolutely.
Dr. Jon Van Der Veer: Related, it was actually a rotator cuff tear. I saw a guy who I saw, I did the exam, I said, “You clearly have a rotator cuff injury. We need an MRI.” I ordered it and it was denied and I appealed. And then I got to talk to a 70-year-old retired gynecologist from United Healthcare. And he said, “Well, you didn’t get this cuz you didn’t do the X-ray.” And I said, “Well, if the X-ray is normal, I get the MRI.” He’s like, “Yep.” And I said, “If it’s abnormal, I get the MRI.” He goes, “Yep, that’s right.” I said, “Do you see why I’m confused?” He goes, “Yep. The protocol to get an MRI, though, is you have to have a plane film first.” I mean, it’s built in.
Dr. Bryan M. Ladd: Yeah.
Dr. Jon Van Der Veer: Time, waste, cost, and inefficiency. And that that kind of summarizes how healthcare felt to me before I moved into the direct primary care space.
Dr. Bryan M. Ladd: Sure. Yeah. Yeah. I always try and warn people like, “Hey, they’re going to order an X-ray. I know you need the MRI, but just it’s the protocol. Just don’t question it. You’re getting
Dr. Jon Van Der Veer: That’s what I really like is I can now skip that step for a patient we have and we have good partners in getting imaging and I can pick up the phone.” But it’s amazing how when you as the provider pick up the phone, the front desk of most places that I call are usually excited to talk to me. I give them all the information they need. And I almost always get faster care than if I just send the referral through and hope that it goes through a queue. Now, I start most of my phone calls with uh so are you in uh the miracle working business today? And you you start off with like I don’t want this to be 3 weeks from now. Can you do this in 3 days? And and it’s amazing how when you call and treat people like humans again, those things make a big difference.
Dr. Bryan M. Ladd: Absolutely. Yeah. Back to the the universal healthcare thing. I want to talk about one other thing that I think will resonate with you and I I think it’s one thing that consumers probably don’t think about because they’re thinking about themselves and that’s fine. But when you’ve got all those access to care issues and I know like for me when I was in the Navy like our schedule is full every day and you know as a provider you’re kind of it’s unfortunate because you kind of get to the point where you’re just hoping someone cancels like you just need to catch your breath go eat some food or something but it’s every day all day every day and that wears you down and so providers start to get burned out. They’re not delivering care that they want to be delivering and so the the consumer on the back end is getting the run into the deal there.
Dr. Jon Van Der Veer: Yeah.
Dr. Bryan M. Ladd: And so yeah, well people don’t think about that side of things is it’s providers get burned out and then they wonder why there’s not as many physicians in the area or access is is even worse because people are I mean I’ I’ve had so many classmates get out of physical therapy. It’s like you spent 120,000 or more to get your doctor of physical therapy and now you don’t even want to be a physical therapist anymore and your life dream like you spent your entire life moving towards these things and we see it in medicine and
Dr. Jon Van Der Veer: I I had a couple presentations really early on about direct primary care and why there was starting to be this momentum of of providers physicians moving into direct primary care was the burnout piece and I said you know when you describe the same thing you did when you’re burning out. You don’t you don’t enjoy these things. You don’t do as good a job. You’re not as engaged as you should be. And I had a guy in the audience raise his hand and go, “So what? You guys don’t like your work now, just like the rest of us don’t like our work.” And I said, “Well, there’s a caveat with that. And the data shows that you as the patient, your morbidity and your mortality go up if I’m burnt out and I don’t want to see you. If I don’t if cuz burnout includes dehumanization. I mean some of the worst qualities we talk about in society. Like I remember looking at my schedule and going why on God’s screen earth is that person coming in tomorrow and you just loathed the thought of seeing them which is terrible to say and that’s why I always say direct primary care kind of saved my career because I was at that point and I know I wasn’t practicing my best medicine then. I tried but you just had to slog through to get it done. And I understood the sentiment that yeah, a lot of people don’t like their work, but you don’t get sicker. I don’t miss your cancer and you don’t die from it cuz you didn’t like flipping burgers that day. I mean, there’s a difference in the process.
Dr. Bryan M. Ladd: Right. Right. Exactly. Yep. Now, you mentioned using EMRs and and research to drive better care. So, how should data actually be used to help patients and not just track them?
Dr. Jon Van Der Veer: Well, I think there’s kind of on the front end of all of this and it’s starting to get really exciting. I think clinically having the data and tracking it is beneficial, but them understanding the data that you’re getting and tracking plus data that they’re now generating with devices is really interesting. You look at some of the precision medicine environments out there and the different things that they’re testing or the studies that they’re going off of which are used in other industrialized countries, we kind of have just ignored. So starting to get like a fasting insulin level with someone’s fasting glucose can be indicative of if there’s insulin resistance earlier than you’re ever going to see an A1C start to move. It’s the lagging indicator. So how do you get some of these initial things? So you have a conversation and you can say, “All right, I’m seeing these things change and now is the time to fix your diet and your exercise routine and really start to impact those things and make sure you’re managing your stress and you’re sleeping adequately. you can get out in front of all those things and then they can have the step counters and the calorie counters and the various data that they can generate on themselves and they can see the impact that it’s having. So, they’re getting a real-time feedback instead of me checking blood work again in 3 or 6 months and saying, “Okay, well, your A1C hasn’t moved. Okay, well, I don’t have to change my behavior.” But if they can see the other things that the scales going down, your pants fit better. like if they have that real-time feedback, it makes a heck of a difference on how they behave.
Dr. Bryan M. Ladd: And do you use some sort of like remote monitoring yourself?
Dr. Jon Van Der Veer: We do not right now as a clinic, we’re not doing those things. The biggest thing I I hate to say it, but I’m still old school on the blood pressure. I still want people to text me at those things. A lot of people on Whoop Rings, Apple Watches, and oh, what’s the other one I’m missing? Oh, the Oura Ring. There we go. But it’s interesting. In the last couple of weeks, there’s actually been some data out that shows people using all of the devices to measure their sleep quality, etc. versus placebo. If you tell them that their data was bad, they feel worse even when the data was really good and vice versa. So, the data could show, hey, I you could tell them your data was really good and they would feel better all day, even if it was some of the worst data they had. I mean, it’s really amazing the placebo effect on these things.
Dr. Bryan M. Ladd: Yeah.
Dr. Jon Van Der Veer: But that’s in both the positive and the negative way. So I think there’s we’re all still coming to grips with what this data is going to actually mean and tell us versus your body still knows best how it’s doing and you have to pay attention to the the physiologic data that your body’s telling you.
Dr. Bryan M. Ladd: Sure. Sure. We’ve started uh just recently started doing some remote therapeutic monitoring al it’s all through an app. What does it look like? What are you guys doing?
Dr. Jon Van Der Veer: Basically what it looks like
Dr. Bryan M. Ladd: for us is like our home exercise program gets put in this app. And so every day, you know, when the person logs in, it’ll ask them to score, I don’t remember what it is, 0 to five or so, like how do you feel right now? So it’ll give us that data point. Um, and if it’s below, you can you can change what it is. I think for me, I’ve got it set at two. If it’s two or below, it not it notifies me.
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: So I know, hey, something’s going on. But then they can go in track their exercises and I can see what day, what exercise they’ve done. They can comment on it.
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: It’ll actually they can turn this off, but you can track step counts with that as well to see how much activity they’re getting throughout the day. And then the other side of it, there’s, you know, there’s a messenger feature. So they’ve got questions, they can shoot us a message, get us as quick as we can get to it. It’s it’s been really really handy and and patients love it, too. And one of the things we wanted was just from a compliance, you know, get people actually excited about their physical therapy and their exercises and and the objective data does matter.
Dr. Jon Van Der Veer: There’s they they respond to seeing the improvements which absolutely again this is I had day veins tennis of my left wrist and I’m left-handed and doing hand therapy like okay I was a I was a constant six at rest and now I’m a four and you could see okay these things that we’re doing are making an actual impact instead of I think I’m getting better you could actually objectively see these things
Dr. Bryan M. Ladd: right and it motivated me to keep wearing a wrist brace I had no interest in wearing, but
Dr. Jon Van Der Veer: but I’m like, “Okay, it’s working, so I I can stick with this a couple more weeks till everything’s back where it needs to be.”
Dr. Bryan M. Ladd: Yeah, absolutely.
Dr. Jon Van Der Veer: Very surprising.
Dr. Bryan M. Ladd: Yeah, for sure. How do you balance evidence-based medicine with treating the individual in front of you?
Dr. Jon Van Der Veer: Well, that’s a good question. So, first off, I think we use evidence-based and guideline based medicine kind of interchangeably here. Right now, I believe the study shows if you practice full guideline based medicine on a full panel of people, you’ll spend 26 hours a day doing that, which is not feasible. So, evidence-based medicine is a result of you really measure or you get what you measure. So, what are you paying attention to? It’s it’s really interesting. I always reference as like 1998 or 99 uh study that showed that the amount of time spent face tof face having uh thorough history and physical performed uh was directly correlational to the correct diagnosis being made and the correct uh treatment plan being implemented. And I was like it’s weird we never quote that evidence-based study that shows that uh time actually matters in how you do things.
Dr. Bryan M. Ladd: Yeah.
Dr. Jon Van Der Veer: But I think I think there are like anything there are priorities that matter more than others and you try to get through them all and the better the relationship you have the easier it is to check off more of those evidence-based and guidelinebased models because if you have a relationship you don’t have to reprove your trust every time well I’m recommending well why are you recommending that doctor and you have to go back and forth instead of having that relationship like hey I’m telling you these things I’m going to let you have a shared decision and and decide whether or not you want to want to move forward with it, but here’s the recommendation. Here’s why. And then I have to also be okay that people have autonomy and can make the choice not to get a test or not to get a vaccine or not to go to physical therapy. I mean, the number of times that you recommend what is recommended, people are going to make their own decisions and you just have to make sure you’re comfortable addressing why it’s important for them to do it. And then you have to be okay with people making those decisions.
Dr. Bryan M. Ladd: Yeah, absolutely.
Dr. Jon Van Der Veer: It’s hard. I mean, there are times I I had one guy who always told me, “Oh, I’ll get a colonoscopy the day I have blood pouring out of my rectum.” I’m like, “Well, that’ll be too big.” I mean, yeah. So, you have to you have to educate people when they’re really off base. But, I mean, back to physician being a teacher was kind of the beginning point is it’s our job to educate people, but we don’t get to make decisions for them, right?
Dr. Bryan M. Ladd: Yeah. You can lead a horse to water.
Dr. Jon Van Der Veer: Yep. And you shouldn’t dunk its head under it.
Dr. Bryan M. Ladd: Bad for the horse, right? What what’s an appointment look like? You know, if I were I were to walk into Exemplar Care today, like can you walk us through the process? How much, you know, what’s an appointment look like? How much time do you actually get to spend with your patients? Things like that.
Dr. Jon Van Der Veer: So, that’s one of the big differences. Try and we’re always working on trying to figure out how we streamline the check-in process. We aren’t trying to gather tons and tons of extra data. Depending on the clinic and the time of day, you might start with a nurse, you might start directly with the provider, and you go into you go into our office, which is also the exam room. And I’m actually down in a a different office today, but typically you would sit at a desk across the across the desk in a chair, and you would sit and have the conversation portion of a visit. Then once that was done, you would move over to the exam table that’s in that same office. So, my old world it was office, exam room, exam room, exam room, and you’re just kind of running through them all. This is all done in one location. You’ve got the time to sit there and have a conversation, make sure everything’s addressed. Our typical average visit is scheduled for 30 minutes. We do have some longer or shorter depending on needs. And I always tell people just cuz we have a 30-minute slot, if you have a cough and a cold and you want in and out in 4 minutes, I’m not going to I’m not going to make you sit here and talk to me for the next 26 just because I want to because we have longer visit types like right your convenience and happiness as a consumer still matters. When I get in and get out, then that’s what we’re going to do. And then after the visit, after the exam and everything, you may get your blood drawn. You may get an X-ray on site at the facilities. We have that. And depending on the state and the dispensing rules, you may even leave with a medication in your hand. So if you have uh acute bacterial sinusitis and you’re past the the 10 days and you meet all of the criteria, you may leave with Augmentin in a bottle, which is amoxicillin clavulanic acid and off you go. You get your 10 days of medicine. Doesn’t cost you anything extra as a member. All the things we do on site are built into the model unless we’re sending you somewhere and then we’re going to tell you, hey, there’s going to be a cost incurred. here’s where we think you should get it, here’s where it’s most cost effective, and we can have those conversations.
Dr. Bryan M. Ladd: Love it. One thing I want to touch on that you you talked about streamlining the check-in process, and this will kind of segue into another topic. I have with my EMR right now, I have the capability to hand someone an iPad and they can take care of the check-in process themselves.
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: I’ve purposely avoided that because I like that human interaction and I, you know, it’s you’re taking care of the person in front of you like we’ve talked about before. So I guess my my question with that is you know there’s so much push for AI nowadays and automation and I think there’s a a place for that and a role but where do you see that in the direct primary care?
Dr. Jon Van Der Veer: So I think as we move towards that AI automated piece I think it’s best for data collection data manipulation but it’s not for that facetoface interaction. We still have people who answer the phone. we haven’t moved to an agent doing that and we don’t really have any intention right now to do that. Same thing with check-in. And I I’ve always said it doesn’t matter if the relationship if you were coming in if is the relationship between you and me? Is it between you and the nurse? Is it you on the front desk? It doesn’t matter who that relationship is formed with. The relationship has to form somewhere. And if you don’t feel a connection from anyone, nobody has a a side conversation, you don’t feel like we’re people interacting with you as a person, you’re not going to stick around very long, especially in in our model. So having that human interaction and we want it to be efficient. We don’t want to ask you questions you’ve already been asked 100 times. We want to try to make it efficient because the more efficient the necessary parts are, the more times available to have real human interactions. So long answer, do I do I love my Care Pilot AI ambient uh documentation? Absolutely. We walk in, I say, can I use this? They say yes. I hit start recording and then I hit stop and I send it to the EHR and the notes 98% done. I just have to read it and make sure it didn’t do anything weird. So, and now it’s less intrusive. So, you and I get to have a better conversation in that case.
Dr. Bryan M. Ladd: Yep. It’s it’s really those are the pieces it should be fixing is the tedious stuff, not the pieces that impact the human connection.
Dr. Jon Van Der Veer: Yeah.
Dr. Bryan M. Ladd: Yeah. I was going to ask you about the documentation piece of it because we’ve been using that here for probably a year or so now, maybe longer, and it it really has been a gamecher for us.
Dr. Jon Van Der Veer: It’s night and day different.
Dr. Bryan M. Ladd: Yeah. Yeah. I don’t know. I I was going to say if if someone has a note left over to the next day, that’s that’s pretty rare. Like our documentation is almost always done.
Dr. Jon Van Der Veer: You got it. We had one physician who she tried it for the first time and she sent me a text. She goes, “This is terrifyingly amazing.”
Dr. Bryan M. Ladd: Yeah. I was like, “Yeah, yep. That that’s pretty much it.
Dr. Jon Van Der Veer: It literally and I always tell my patients while I’m sitting there with it recording, I’m like, “We can talk about your kids. We can talk about sports. We can talk about fishing. You name it. It’ll only pull out of this conversation what is clinically relevant to you and that’s all put in there.” And they’re like, “Really?” And then I show them the like, “Here’s here’s the transcript of it and what it’s going to look like.” And they’re like, “Yeah, wow. Yeah, that’s a lot than you used to write.” I’m like, “Yes.”
Dr. Bryan M. Ladd: Right. Yeah. I recently had an attorney compliment me on my subjective note takingaking and I was, you know, I didn’t have the heart to tell him like that was AI. You know,
Dr. Jon Van Der Veer: I had a condition and Yes. Right. It’s crazy. Yes. Exactly. So yeah, those are the things that I think AI can help in healthcare. If if it I mean if it’s a prime robot or whatever having a conversation, it’s probably not what people are wanting out of the system.
Dr. Bryan M. Ladd: Sure.
Dr. Jon Van Der Veer: I I you know, you can argue the physician to NPA financial arbitrage is about 2 to one, like oh cool, we can get robots and get rid of people. I’m sure there will people who will think, “Oh, there’s there’s a financial benefit to having robots do this instead of people, but obviously the care connection will never be there.”
Dr. Bryan M. Ladd: Yeah. Well, and I think some insurance, at least from the physical therapy standpoint, some insurance companies have already tried to do that. And so, yeah, you know, I I’m sure there’s a small percentage of people and maybe there’s some issues that that’s fine. They can handle it with that. But that human interaction I think is such a big piece that I don’t I don’t think we can ever fully replace that.
Dr. Jon Van Der Veer: No, there’s I mean there is without a doubt healing qualities just from that that human interaction. And you know that if you hug your kid or your your loved ones like those those things impact you in ways that nothing nothing automated will ever do.
Dr. Bryan M. Ladd: Yeah. Yeah. Absolutely. Well, Dr. Van Der Veer, uh if you could fix one thing in healthcare tomorrow, what would it be?
Dr. Jon Van Der Veer: brutal. I think I think the first key to unlock is price transparency and not in the machine readable file posted 27 pages deep on a health system website. Transparent. Here is the price of an office visit. Here’s the price of a PT appointment. Here’s the complexity levels. So, you might see there’s three codes that we commonly bill. You’re going to be one of these three codes. and you’re going to see the top and the bottom price. I think once you have that, you can start to have competition off of not only cost, but quality and access and other things that matter to the consumer. As long as everyone goes, “Well, I have a $15 co-ay.” Well, you don’t know what’s behind that. And then the deductibles, you’re always getting a surprise cost. My example of that is if you and I went into Walmart. I use Walmart cuz everyone knows their TVs are hanging in the back. and you go out and you pick you and I find the exact same 65 in TV. You walk up front and they scan it and you say you owe $200 for that TV and you’re like, “Awesome. That was a good deal.” And then you take your TV and you move along and I scan and they say, “You owe $4,000.” I go, “But why? Why do I owe 4,000? I just watched him pay 200 for that.” Like that’s what your arrangement with Walmart is today and you owe two or $4,000. Well, I don’t want to pay for it. I’m going to bring it back. No, you already touched it. It’s yours. That’s how healthcare is consumed. It’s consumed and then build on the back end. So, okay, now I can’t leave Walmart without this EV that I’m paying way too much for. And we were I was having conversations with CEO of an orthopedic group and we were talking about you could you could arguably set up having travel for orthopedic care similar to the surgery center of Oklahoma for general surgeries. Um, if you had a $25,000 uh joint bundle and you were in California and your uh plan was paying $120,000 for that same procedure, you could fly in, stay in the nicest hotel, have the best dinner, have your uh physical therapy brought to a hotel and and delivered for still a fraction of that cost. I think until we know pricing, you can’t fix any of the other flaws in the system because then people would actually see sight of care differences. Uh that’s why surgery centers keep popping up. You can have a a surgery center procedure or the exact same team surgeon staff in a hospital and have it cost three times as much just because it’s build out of a hospital and they get to add in the facility fees that go with hospital care. I mean once transparency comes in that uh light becomes the bleach to all the darkness.
Dr. Bryan M. Ladd: Yeah. Yeah. It’s that like surprise bill 3 months later too that you know people thought their care was paid for already and then bam they get this massive bill and they’re like what is this? Where’d that come from?
Dr. Jon Van Der Veer: Our first onestar Google review. I still laugh about it to this day. Had a gal in. I had nothing to do with the care, but she came into our urgent care, which we were uh still doing fee for service in at the time. Daughter needed a sling, and we said, “We’ll sell you the sling we have here, for $20.” And she said, “No, I have the best insurance in the state. I want it to go through my insurance.” It was early in the year, so she hadn’t met her deductible. And our one-star Google review was her saying, “I got a bill for $197 for a sling that I could have bought for $15 at Walmart.” And in my mind, I was like, Walmart gets uh has better buying power. So 15 versus the 20 we offered it to you because you wanted to use the best insurance that you had. You got the privilege of paying $197 for that sling. Um and yet you still think it’s our fault because we sent the bill off like you asked us to and that’s just how healthcare works. Appreciated rate of what they pay for a sling. So that transparency breaks down all those barriers and then you could actually have people make informed decisions. You know, that’s what HSAs were supposed to be. Oh, everyone will go out and shop those dollars. Well, they didn’t because there’s no way to do it. When we first opened, we tried calling five or six different locations to see what an X-ray cost. Like, where are we going to price ourselves? No one could tell us what an X-ray cost. didn’t matter who we called, front desk, some of our colleagues, some leadership, nobody knew what the X-ray actually was going to cost. So, we had to come up with our own pricing. I think that that’s another powerful example where the the power of transparency would allow some of these things to to get all of this waste out of the system.
Dr. Bryan M. Ladd: Yeah. Yeah. And we try to be totally transparent here as well. I mean, we have our cash rate. This is exactly what it’s going to be. But even for insurance, it’s like, okay, you have Blue Cross. Well, these are the four codes that we generally bill during a 40-minute session here. And we know based on previous patients.
Dr. Jon Van Der Veer: Yeah, exactly.
Dr. Bryan M. Ladd: Look, this is what we’re going to get paid or this is what you would owe from that. And so, you can expect roughly this price here. And we’ve got it. I mean, it’s our front desk has a little cheat sheet, desktop sticky note cheat sheet that has all those prices listed out. And so, there’s no surprise. I don’t want to be surprised. And so, why would I want to surprise my patients? And correct, we’ve got all that listed out. You know, we’ve got a sheet even where our front desk will like we had a a Tricare patient the other day and she’s verifying benefits. It’s like, well, it’s not real clear. It could be this price, but worst case scenario, it’s going to be this price here, but it’s listed out. So, at least, you know, like, hey, hopefully it’s this price when it comes back. It might be this price, but I just want you to know, you know, and they we’ve got this sheet that they can sign, so you know, they’ve seen it. We know they’ve seen it, and so there’s no surprises then when that new comes back.
Dr. Jon Van Der Veer: It’s crazy. I remember I’ll never forget this conversation when I was doing fee for service. A guy came in and I learned later in life he was a a broker and I still know the guy and he’d come in every year and be like, well, I know you want to do all the annual wellness labs, but uh what are they going to cost me? And I’d look at him like bewildered. I’m like, I have no idea what this is going to cost. Yeah. Um I don’t know first off what the labs actually cost. I don’t know what your co-ay or deductible structure is. like I I mean he goes, “Well, this is about what it costs. The last time I did all of them, this is” and I was like, “Okay, well that’s three 400 bucks.” Okay, that’s a lot. Well, then I move on and I I started directly contracting for lab services. And I’m like, “And annual wellnesses lab wholesale.” And I’ll let you guess. What do you think the cost for us to send labs out, get them done, and result it is for a CBC, a CMP, a lipid, an A1C, a PSA or a urine, depending on gender, and a thyroid? What do you think the what what’s the actual cost? Yep.
Dr. Bryan M. Ladd: Versus three or 400 he was paying when he hadn’t met his deductible. Same test.
Dr. Jon Van Der Veer: Yeah. What do you think?
Dr. Bryan M. Ladd: Is it Is it 50 bucks?
Dr. Jon Van Der Veer: 9 to 11.
Dr. Bryan M. Ladd: Wow.
Dr. Jon Van Der Veer: And people are getting charged three 400 bucks for this stuff. Oh, I had a guy who did one of the testosterone replacement clinics and he’s like, “Well, I spent $400 and I got all the testosterone stuff.” I was like, “Yep, testosterone test costs $4.” Wow. There’s It’s just crazy. I get it. As we we talked about, the prices kind of compressed down on services. So, fine, then we’ll make it up on ancillary stuff.
Dr. Bryan M. Ladd: Yeah.
Dr. Jon Van Der Veer: is the way that dollars have always shifted and the maze always has cheese somewhere and it’s somebody’s job to go find it. I mean, we just think it’s a lot easier to be like, well, here’s the cost and this is what we’re going to charge you and here’s what’s included. So, you make your own value equation of whether or not we live up to the price point.
Dr. Bryan M. Ladd: Yeah. Well, it’s so much easier to build trust with people when you’re upfront with them and you’re telling them exactly what
Dr. Jon Van Der Veer: Yep.
Dr. Bryan M. Ladd: going to be.
Dr. Jon Van Der Veer: One of my favorite things, and it it took me a little while to get comfortable saying this, and now I I say it to people all the time, in a membership model, subscription-based primary care, like direct primary care, you have our list price is $89. So, $89 a month for an individual to come in off the street, have access to labs, meds, imaging, discounted contractor rates we have with other folks for other services, and you get to make that decision. So you okay you decide it is then I’ve made the decision that that’s enough for me to be happy and your goal as a consumer is you want to be healthy. That’s why everyone does these things. So if you’re healthy and you’re paying me an amount I’m comfortable with. My goal then is to make you as healthy as possible. So you need my services as little as possible. And that’s the opposite of the fee for service world. like, ooh, the more you’re sick, the more you’re coming in, the more the system gets to bill you. And I said, so if you’re happy trading money for being healthy and not needing my services, except for when you do need them, like this is a really good arrangement for you as the consumer, as a patient, for me as a physician and the business side of it. Like, our incentives align versus the sick care system where I can make more money off of you if you’re sick. I mean, it’s it’s just a complete 360 of how uh the system works. And yeah, and I started saying that to patients like, “Yeah, I agree. If I pay you and and I don’t need your services and you’re doing what you need to do to keep me healthy, I’m thrilled.” And it’s a really easy business model. People are like, “Well, this seems really complex.” We’re like, “Nope. This is really, really straightforward.”
Dr. Bryan M. Ladd: Yeah. Yeah. That’s awesome. I’m going to put you on the spot a little bit here. I’ve never asked I’ve never asked someone this, but what what is Exemplar Care’s mission and core values?
Dr. Jon Van Der Veer: Our mission is to solve healthcare challenges for members. And I’m going to quickly go through that. That’s kind of strange sounding for a primary care clinic. We want to help solve different health care challenges in whatever shape they come in. That can be getting you an image or a lowerc cost version of a medication or we have examples when COVID was still going on. We started doing COVID testing for employer groups who wanted to make sure they could keep people at work. We moved the the cash pay market was between $250 and $300 a test for PCR down to 89 and we watched health system move to that price point as well. Uh so we brought the cost down. We did the testing and then we stumbled across the uh Des Moines International Airport was going to do COVID testing and we did an RFP there to make sure that travelers could get results and we went and partnered to get uh PCR results in under 24 hours which at the time uh was unheard of. Another example, Central Iowa Shelters and Services downtown shelter had a cold freeze and their previous provider wasn’t returning after the pandemic. They had a cold freeze coming and they knew they were going to have frostbite and we said, “Well, we’ll go in and we’ll start taking care of folks.” And we were in that clinic for three years. So, and then on a behavioral health hospital, they were having problems getting adequate coverage for their medical HMPPS opposed to their behavioral health ones. And they partnered with us on a set fee to make sure that we provided histories and physicals within 24 hours of admission. So, weird things we’ve done, but we’re always looking at those things. So that’s why the mission is solving healthcare challenges from Epers. So then for the core values we have first is fiercely care. That one’s self-explanatory. Care about the patients, your colleagues, the community. Then next is do right by people. So that’s taking care of them. That’s making sure if a for us if a if a patient needs something extra, you’re going to figure out how to do that. If a colleague needs off, we’re going to figure out how to cover that shift and move things around so they can go be with their kid. Uh that can look like a lot of different things. The third one is do whatever it takes. And I did have an employee once say, does that include things that are illegal? No. Uh do whatever do whatever it takes within legal bounds. That’s that’s doing the the stuff that’s above and beyond. You know, you’ve you’ve all you and all your listeners have had uh experiences where customer service isn’t very good. It’s something as little as we had somebody who sent us a thank you just for turning the TV on at 2:00 in the morning in the urgent care waiting room so that the little kid could watch Bluey. It’s not a lot, but it could also be it’s 4:29 and you were leaving at 4:30 and someone walks in and needs something. doing whatever it takes is yes, I’m technically done, but you take care of them. Yeah. A fun Hy-Vee story before I get to the fourth one. Ron Pearson was a longtime CEO of Hy-Vee and I had the pleasure of meeting him and had a conversation with him and his known phrase was I’ll do anything for a customer, which is along the same lines as do whatever it takes. And I met him and he said, “Everyone can say that they’ll do anything for a customer, but really doing it versus saying it is where the difference is.” And I’ve always said that from the patient care standpoint, if it’s your mom or your dad or your kid, you would bend over backwards and you’d want someone else to as well. So yes, this isn’t your your family member, but it’s somebody’s family member and you take care of them the same way you would yours. And it’s it’s really been powerful and we always hear about the times where it goes right and uh people rave about that attitude. And then the last one is always improve. We started off with me doing things by myself. Added in a full uh leadership team, full clinical team with no processes and we had to start making them all. So you go from no processes to what we have today and there’s hundreds of iterations throughout there. Sometimes you look at a process and go, “Well, that one really didn’t work out very well.” But you get to you still have a chance to improve it even though it exists now. Yeah. And another example would be the ambient AI for notes. There’s there’s lots of different things that we feel like healthc care is so broken. There’s always something to be fixing and we’re no different. We have things we can always be improving on. So those are our four core values.
Dr. Bryan M. Ladd: Love it. I love it. Off the top of my head on the spot. That’s awesome. That’s leadership right there. All right, couple more questions here. So, if someone listening feels like they’ve tried everything and still they still don’t feel well, what’s their next step?
Dr. Jon Van Der Veer: So, give me some context. They’re not feeling well. They’ve tried what is trying everything? Have they been in to see us yet? Um cuz that would be one thing. Uh, and I I’d say that partially tongue and cheek, but I’ll bet out of our net promoter score surveys, the most common theme we have is I’ve been to four or five other people and this the first time I feel like I’ve been heard, not just listened to. So, um, I think that’s the first thing is have you as a patient really felt like they understand what I’m experiencing? is physiologic feelings, pain, emotional distress, all of that stuff is something you as the patient are experiencing and you’re communicating that to someone who then has to interpret what that means to then make a diagnosis and come up with a plan to fix whatever the problem is. So, back to that time is important to make sure you’ve experienced that. And if you say yes, I’ve had that and no one can do it. I would challenge you and say they aren’t listening enough or they would know there’s another layer of assistance that’s needed. So let’s say you go into your primary care provider two or three times and you brought this up and they haven’t said, “Gee, this really sounds like it’s a rheumatologic puzzle and I can only peel the first layer or two of the onion. you need to see a rheumatologist and we need to get through those next couple layers so that they can find out what’s wrong. Very, very rarely are things unsolvable and unfixable or at least improvable. So, I would always say first off, don’t give up. And most importantly, in today’s healthcare environment, you have to be a fierce advocate for yourself or for your loved ones if it’s them going through this. Yeah. And you just have to keep kicking down until you know that someone’s heard you and that they’re actively trying to find things. Now, you might still run into a dead end and not find that, but that’s really pretty rare.
Dr. Bryan M. Ladd: And what’s one thing you wish every patient understood about their health before they walked into your office?
Dr. Jon Van Der Veer: My favorite lately is um stepping back for a second on all the the peptides that people are learning about the GLP1s.
Dr. Bryan M. Ladd: Yes. Yes.
Dr. Jon Van Der Veer: All these measuring devices we talked about earlier, all these things are there. And one of my former colleagues says it best. If you haven’t fixed the foundation of nutrition, exercise, stress management, and sleep, then all the fancy fun things that we can do aren’t going to actually move the dial forward until you take the accountability to deal with those kind of four pillars of the stool and make sure you have your ducks in a row and then we can start to build on that foundation. But if I could have every patient come in and the first thing they said is, “All right, I’m eating whole foods, fruits, vegetables, lean meats, lots of nuts, and I am dialed in there, and I’m sleeping between seven and eight hours a night. I wake up well rested. I put in my 30 minutes of cardio five or six days a week, and I lift weights three times a week.” Like if you get all those pieces in and I’m turning my phone off at night and I’m turning stress levels down and I’m managing my workflow. If people showed up with that, then it’d be like, “All right, now we have somewhere to really start. Now I know that there’s a real problem because the problems that most of us have are self-inflicted.”
Dr. Bryan M. Ladd: Yeah. I love that you guys talk about that because the pillars of health is something we talk about all the time here as well. We’ve got whiteboards in every office so you know our providers can sit down at the end of every visit or at the end of every initial eval anyways and and kind of map out exactly what’s going on with you. Here’s what I see. You know, here’s what the process looks like and here’s how it pertains to you. And then we kind of map out those pillars of health. Here’s your tissue capacity. Here’s where you know your these are all stressors. This is going to add to it. And so yeah, that’s that’s amazing that you guys talk about that.
Dr. Jon Van Der Veer: And just as a sidebar, now that you mentioned that on what I what I try to do for my physical therapy colleagues is I always tell my patients that if physical therapy gives you an exercise, you should probably do it for the rest of your life. Cuz the number of times it’s like, “Oh, I had back pain. They fixed me. I had back pain again. Did you stop doing all your exercises?” Well, yeah. I was better. Go back to them. Try those first.
Dr. Bryan M. Ladd: Yeah. It’s amazing how the little things really are the big things, right?
Dr. Jon Van Der Veer: Yeah.
Dr. Bryan M. Ladd: Yeah, we always tell people like, hey, you know, we’re going to get you feeling better, but life happens and when it happens and if this flares up again, you’ve already got the tool, so you know exactly what to do. If you need to come and see me, that’s fine. But you’ve got that tool and try it out first.
Dr. Jon Van Der Veer: Yep. It’s great advice.
Dr. Bryan M. Ladd: Awesome. Dr. Van Der Veer, this has been great. Is there anything we haven’t talked about that you want people to know?
Dr. Jon Van Der Veer: Just don’t ever be satisfied if you’re not getting the care and the the experience that you want, the convenience, the access. Don’t assume that all of health care has to be broken. You can always look at other alternatives and there’s plenty besides us as well. I really think that you all need to be consumers of health care. I know it’s hard. I know it’s opaque, but taking the time and energy to really make sure you’re making the best decisions for you and your family. There’s better ways to do things than just saying, “All right, square peg is going in this round hole one way or another.” Look around. You’d be surprised how many square holes there are for that square peg. I think you guys would probably echo the same thing.
Dr. Bryan M. Ladd: Absolutely. Not everything’s one sizefits-all, right?
Dr. Jon Van Der Veer: Agreed.
Dr. Bryan M. Ladd: Awesome. Now, if someone wants to learn more about you or uh how how can they do so and how can they find you or Exemplar Care?
Dr. Jon Van Der Veer: [www.exemplar.care](http://www.exemplar.care), which is what most people do. That’s the best place to start. You can always email me at [join@exemplar.care](mailto:join@exemplar.care). Uh if you have questions, there’s my email. Fire away. And make sure you reference the podcast so that I know where you’re coming from.
Dr. Bryan M. Ladd: Awesome. Thank you so much for your time. Appreciate it. You have a good one.
Dr. Jon Van Der Veer: You do.