Meidas Health, Episode 12: Changemakers Take on Goliath (i.e., the American Health Insurance Industry)

Summary

Podcast Summary: The MeidasTouch Podcast – Episode 12: Changemakers Take on Goliath (The American Health Insurance Industry)
Release Date: July 28, 2025

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Introduction and Context

In Episode 12 of Midas Health, part of the MeidasTouch Network, host Vin engages in a profound discussion with two pioneering healthcare professionals, Dr. Elizabeth Potter and Dr. Waris Pokari. The episode delves into the systemic challenges within the American health insurance industry and showcases the innovative solutions these changemakers are implementing to combat widespread issues affecting patient care.

Guest Introductions

Dr. Elizabeth Potter is a board-certified reconstructive plastic surgeon based in Austin, Texas. With specialized training in microsurgery from MD Anderson, Dr. Potter focuses predominantly on treating breast cancer patients who require reconstructive surgery—a vital service often hindered by insurance limitations.

Dr. Waris Pokari brings a diverse background spanning clinical technology and entrepreneurship. As the founder of Claimable, Dr. Pokari is at the forefront of automating the insurance appeals process, striving to reduce the overwhelming number of unjustified insurance denials that plague patients nationwide.

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The Problem with Health Insurance in America

The conversation begins with Vin highlighting the absence of top healthcare leaders in governmental roles, emphasizing the necessity of bringing these experts directly to the public through platforms like Midas Health.

Dr. Potter shares her firsthand experience with the inadequacies of the health insurance system:

"Reimbursement drives access. Saying something's covered doesn't mean that a patient has access to it." [02:19]

She recounts a viral incident where United Healthcare questioned her professional judgment during a mastectomy procedure, leading to a broader conflict that underscored the systemic barriers doctors and patients face.

Dr. Pokari elaborates on the financial strain inflicted by insurance denials:

"With nearly 50% of cancer patients going bankrupt in two years... we've built a system that automated the appeals process... beating around 80% of these denials." [06:48]

Claimable: Automating the Appeals Process

Claimable, founded by Dr. Pokari, addresses the inefficiency and high denial rates within the insurance appeals system. The platform simplifies the process for patients to challenge unjust denials, significantly increasing their chances of receiving the necessary care.

Dr. Pokari explains the mission behind Claimable:

"We are prepared to actually start filing suits against the insurers on the basis of this." [06:48]

The platform not only automates appeals but also partners with litigators to hold insurance companies accountable, revealing systemic patterns of unfair practices.

Direct Care Model vs. Insurance Companies

The discussion shifts to alternative healthcare delivery models as Dr. Potter advocates for a direct care model. She envisions a system where physicians contract directly with employers, bypassing traditional insurance frameworks to provide more affordable and accessible care.

Dr. Potter illustrates the potential of direct care:

"Direct care is saying, okay, let's get real specific... let's tell Walmart to just contract directly with me instead of going through United or some other company." [26:51]

This model aims to reduce costs and improve care quality by eliminating the middleman—insurance companies—that often prioritize profits over patient well-being.

Dr. Pokari supports this vision by critiquing the current insurance model:

"There's literally no value add coming from these insurers. If anything, there's active value destruction." [28:40]

He emphasizes the need for innovative approaches like direct primary care to effectively manage community health needs without the constraints imposed by insurance bureaucracies.

The Need for Systemic Change

Both guests agree that incremental policy changes are insufficient to address the deep-rooted issues within the health insurance industry. They advocate for a paradigm shift driven by public pressure and grassroots movements.

Dr. Pokari states:

"The system will not self-correct. We have to change it." [19:36]

Dr. Potter adds optimism about public awareness:

"The market can change this more than government can." [22:19]

They argue that consumer choice and employer-driven contracts with ethical insurance providers can catalyze significant improvements in the healthcare landscape.

Success Rates and Process of Claimable

Claimable boasts a remarkable success rate in overturning insurance denials, often challenging arbitrary and unjustified decisions made by insurers.

Dr. Pokari shares impressive statistics:

"We've beat around 80% of these denials, which suggests to me that about 80% of these denials are inappropriate." [29:41]

He outlines the streamlined process for users:

1. Upload denial letters and insurance information.
2. Select the denied treatment category.
3. Detail the impact of the denial on their health and daily life.

This efficient system empowers patients to reclaim their rights without the traditionally high barriers associated with appeals.

Insurance Denial Rates and Transparency

The conversation highlights the opaque nature of insurance practices and the critical need for transparency.

Dr. Pokari reveals disturbing insights from insurance claim files:

"They described her as a cancer victim number one... they had a bariatric surgeon... it was improper in three dimensions." [14:18]

The guests advocate for publishing denial rates by plan and zip code to hold insurance companies accountable and inform consumers about the reliability of their providers.

Future Outlook and Hope

As the episode concludes, both guests express hope fueled by growing public awareness and the emergence of innovative solutions.

Dr. Potter emphasizes the importance of storytelling in driving change:

"It's telling stories, telling the truth from across the country, from a million different voices." [33:04]

Dr. Pokari envisions a dual approach focusing on both prevention and accessible care:

"It is possible to have both a focus on prevention, but also making sure that care is truly accessible and affordable." [39:51]

Together, they believe that sustained public pressure and the adoption of models like Claimable and direct care can transform the American health insurance industry, making it more patient-centric and equitable.

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Key Takeaways

• Systemic Issues: The American health insurance system often denies necessary care, leading to financial ruin for patients, especially those battling serious illnesses like cancer.

• Innovative Solutions: Platforms like Claimable are revolutionizing the appeals process, significantly increasing the success rate of overturning unjust insurance denials.

• Direct Care Models: Bypassing traditional insurance frameworks by directly contracting with employers can lead to more affordable and accessible healthcare services.

• Transparency and Accountability: Publishing insurance denial rates by region and provider can empower consumers and drive insurers to adopt fairer practices.

• Public Advocacy: Grassroots movements and increased public awareness are crucial in pushing for meaningful reforms within the healthcare system.

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Notable Quotes

• Dr. Elizabeth Potter:
  "Reimbursement drives access. Saying something's covered doesn't mean that a patient has access to it." [02:19]

• Dr. Waris Pokari:
  "With nearly 50% of cancer patients going bankrupt in two years... we've built a system that automated the appeals process... beating around 80% of these denials." [06:48]

• Dr. Elizabeth Potter:
  "Direct care is saying, okay, let's get real specific... let's tell Walmart to just contract directly with me instead of going through United or some other company." [26:51]

• Dr. Waris Pokari:
  "They described her as a cancer victim number one... they had a bariatric surgeon... it was improper in three dimensions." [14:18]

• Dr. Elizabeth Potter:
  "The market can change this more than government can." [22:19]

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Conclusion

Episode 12 of Midas Health serves as a compelling exposé on the failings of the American health insurance industry and the innovative efforts underway to rectify these issues. Through the insights and experiences shared by Dr. Elizabeth Potter and Dr. Waris Pokari, listeners gain a deeper understanding of the challenges patients face and the transformative solutions that hold promise for a more equitable healthcare future.

Transcript

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[Vin]

Hi, everybody. Welcome to episode 12 of Midas Health. We have been talking about this from the very beginning, since we launched Midas Health as part of the Midas Touch Network back in April, that the very best healthcare leaders across the spectrum are not at the highest levels of government right now. And so what are we doing about it? We're bringing them directly to you through Midas health. And episode 12 is very much in keeping with that trend. We've had former FDA commissioners, we've had incumbent secretaries of health from major states across the country, we've had senior leaders at the WHO come here and they're coming here for a reason, because they know that we have reach, that we know. They know that people listen to Midas Health. They know that people are listening to the Midas Touch Network, arguably the nation's leading podcast based on some metrics. So thank you for being here. Without further ado, I have two colleagues, physician colleagues, who are making serious waves and really changing what's ailing the American healthcare system. And that's our health insurance system system. Dr. Elizabeth Potter and Dr. Waris Pokari. I'm going to bring them both on here. I'm so thrilled that Elizabeth and Waris that you're with Midas Health. Thanks for being here.

[Dr. Waris Pokari]

Thanks for having us.

[Dr. Elizabeth Potter]

It's great to be here. Thanks.

[Vin]

So both of you are clinicians by training. Dr. Potter, you're a board certified plastic surgeon that does kind of a lot, you know, across the spectrum, supporting patients with a variety of different needs. Um, wars. You have a very interesting background, spanning clinical technology, everything in between. And you're both entrepreneurs as well. I don't know how you found the time, but I'm gonna first kick it to you, Elizabeth, just tell us a little bit about yourself, the stuff that maybe people just don't know. And you know, how did you land up doing what you're doing, fighting the good Fight.

[Dr. Elizabeth Potter]

Sure. So I'm Elizabeth Potter. I live in Austin, Texas, and I'm a reconstructive plastic surgeon. So that means I did the traditional plastic surgery training and then additional training in microsurgery at MD Anderson to treat patients affected by breast cancer. So 90% of my work is treating those patients, and that's simply because there's not enough of me doing this work in the country. So I take care personally of about 40% of the women in central Texas, and also I take care of women from around the country who can't find access to breast reconstruction through insurance. Typically, you know, women drive from Mississippi, Alabama, across states because they can't find someone who's willing to take insurance reimbursement and. And perform breast reconstruction for them, which is provided for under the Women's Health and Cancer Rights Act. So, you know, re. Reimbursement drives access. Saying something's covered doesn't mean that a patient has access to it. And that's really where I started in advocacy. And then it sort of went to a different level earlier this year when I had a video go viral where I was called out of the operating room by a representative from United Healthcare to discuss some mundane details about a woman who was having a mastectomy. She was actually asleep on the table. And it was absurd. It was. And it was as absurd as it sounds. And I just posted about that experience that day and then unfolded a series of events which included United discrediting me in the press and saying that I had lied about that call, which I certainly did not lie about, and there was plenty of evidence to show it, and then a series of other events. So I'm just. I'm in the thick of it because I care about patients. I listen to my patients. I know what they need, and I'll take on anything that gets in the way.

[Vin]

Kind of love that. And, you know, for. For all our listeners out there, if you just Google Dr. Elizabeth Potter and that moment, you can Google any sort of prompt here, but viral video, whatever it might be, I've seen it. I'm sure many of you have seen it. It is compelling, and it's the reason why, you know, Dr. Potter is doing the work that she's doing. She really believes in it, and I thought that video was really compelling. Thank you for doing that. I want to dive deeper on all these things, but Boris, want to bring you in. Tell us about claimable and how you got to found it claimable and what does it do?

[Dr. Waris Pokari]

Thanks, Vin. So maybe I just start with this kind of assumption or this kind of assertion of what brings Elizabeth and I kind of into the same realm, which is at some point in your life, you realize it's probably easier to change your mind than change the system. But if you can't change your mind because you're not wrong, then you're left with the only thing to do is to actually try and change the system, because what else are you going to do? And it would be easy for us to say, actually we're wrong, maybe we should do things differently. But all of the evidence is actually not pointing in that direction. For me, this was born of a long observation of US healthcare over the last, I guess, 15 years, and seeing what was happening here with medical bankruptcy restriction, access or access restriction, sorry, meaning that even if patients were covered, they were left to have inappropriately high cost shares or driven to bankruptcy, and you would have medications that you just literally couldn't afford if you had cancer. With nearly 50% of cancer patients going bankrupt in two years, when you look at something like the rate of denials, you're looking at something like 850 million denials a year, of which less than 1 million of those denials are ever challenged. And the reason is because there's this absurdly high barrier that is put in place between the patient and the insurance company. And if you think about one of Elizabeth's patients, they're sick, they have cancer, they're dealing with a lot of uncertainty, and they're being forced to fight against these insurance bureaucrats. And their physicians are on their side, but at some point, there's a limit to what their physicians can do. So we built a system that automated the appeals process, and we started in immunological conditions such as Rheumatology, Crohn's, UC. We added in migraine, we've just added in GLP1s, we're adding in asthma in the next couple of weeks and really starting to bring better access to these therapies. And we're beating around 80% of these denials, which suggests to me that about 80% of these denials are inappropriate. And we've now started partnering with a litigator, which is interesting because we're finding systemic patterns and we're going to start bringing lawsuits against the carriers where patients have been badly impacted.

[Vin]

How do people find out and or intersect with claimable if they've been a victim or if they feel like they've been a victim of an unfair insurance, I wonder how they can work with your company.

[Dr. Waris Pokari]

Honestly, what we offer Online we've been very careful about qa, qc, quality assurance and making sure everything we do is accurate. We cite accurate evidence. So we really cater to some fairly specific conditions at this point. That is expanding quickly. That being said, I've been involved in everything from transplant to oncology. Whenever someone is at risk of serious harm, we get involved. Sometimes it's like an email from Mark Cuban at five in the morning saying, hey, have you seen this? And then we jump into it and try and help a family. And often these cases are extreme. We had a case here in California which was a double lung transplant that got denied. We've had two liver transplants that we got involved with both which got overturned. We had a case recently with a young girl who got hit by a truck where CIGNA were denying care. They were actually denying neuro rehab for this kid. And it goes on and on and on and on. And where we can't help in an AI driven fashion, we just get involved is good faith. We are actually looking at a not profit that we'll be talking more about in the coming weeks as well for families who are kind of at some multiple for federal poverty level.

[Vin]

You know, Elizabeth, just hearing Laura speak, I know that you are now also you're building on a lot of the, just the leadership and those moments that you referenced earlier. Can you talk to our audience about what you're doing now at scale or trying to sort of build organically in this space?

[Dr. Elizabeth Potter]

Sure. So, gosh, I, I just have to say WARS is doing amazing things. And you know, I had seen him from afar online and watched how he was making waves and making things happen for patients. And yeah, I, I honestly think that that's sort of, that's the spirit of where we're all engaging. Right. The system isn't working for patients. And if we ask for permission constantly to help patients from entities that really aren't interested in delivering care, then we get held up and we don't wind up delivering what patients need. So all I'm doing really simply is just getting patients what they need and exploring options that aren't the traditional networks. Right. And I'd say that I'm, I'm shedding light on the problematic system. So, you know, I feel that, I know that folks have wondered how bad it is in insurance and how bad it is in health care. And what I'm doing is sharing the actual experience of someone who has been a good actor in the system. Right. So I have tried to provide cancer care and reconstructive care in Network in communities through insurance. And I set out to do that to prove that case, that it could be done. I did not intend to tell the story that it would be extremely difficult or that the system would work against that. I thought I would demonstrate to my colleagues that we could, in fact work within the system and do good things for patients in the cancer world. And what I have found is exactly the opposite. So, for instance, I mean, I. I took out my own personal loans, I built a surgery center to deliver excellent care in network through insurance. Because I saw women driving to me from around the country trying to get this care, and they couldn't get into the big centers if they didn't have great insurance, right? So, you know, if you've got Medicare or Medicaid or tricare or some. Some insurance that, you know, isn't really robust, you're denied at a lot of the big cancer centers. So I said, I can do this. I have all the skills. I've got my hands, I've got my skill set, I've got my team. We can deliver this care. Let me build this center and do it, and we'll be cheaper and better with outcomes that we can, you know, demonstrate. And what I found is that the insurance companies don't want me to do that. They don't want to contract with me. Just this morning, I operated on a patient already today who wanted to spare her sensation after mastectomy. And she was having mastectomy removes, the sensation to your breast. She's a really, you know, very smart woman. Researched all of her options, knew that there was an option out there, nerve grafting. And we discussed that, and we tried to get her insurance company to cover that. And they, they said no. They said no again on multiple appeals. So she said, okay, well, what would it cost me if I wanted to pay for that myself? Because I really want to do this. And I. It's my one chance. If I don't do it today, I won't ever be able to do it. Okay. So we went to the hospital and said, okay, hospital, what will this cost for nerve grafting? And, and some or time we're already going to be there doing mastectomies and doing reconstruction just to add this on. And they came back with $80,000 for this woman with breast cancer. And then they said, we'll. We'll do you a solid. We'll let you have it for $42,000. So I said, okay, I own a surgery center. It's me and you. That's all it's Me and you, whether it's at the hospital or the surgery center, what would it cost me to do it? So went to, went to my place and asked that question and it was less than $20,000, less than $20,000. And she ended up actually paying out of pocket because she wanted to preserve her sensation. So I'm fighting every day to make a business case for better care outside of the current systems. And what I'm finding is the work isn't just in making the case for it because I've got lots of data to show many stories just like that one. It's in telling the public that the system doesn't want to save them money and provide better care.

[Vin]

So you know what's interesting about that Elizabeth? And worst I want you to react to this but one, what Elizabeth just said is so compelling and I thought that was so well stated, but it feels like the conversation we've been having about insurance amongst the public has not been that Elizabeth and the stories that you've been telling making it real. It's been when we talk about it vis a vis health policy, it's who's not covered, why are we not covering them? Every two to four years it's we're going to incrementally draw back Medicare or Medicaid or commercial insurance for a certain sub segment of the population. And that's the conversation that gets had. These macro statistical based conversations not really focus on storytelling and it also feels like it's the type of conversation that a lot of people hear and look at and say well that doesn't apply to me. And yet here you are telling the story that I think is broadly applicable to anybody likely with good insurance is that this can happen to you. And Morris, I'm wondering to your. I wanted to pose this to you. Do you feel that there's an every every person and I was going to say every man but this is an every man, every woman, every child experience that this the things that you and Elizabeth are fighting for on behalf of patients. This is an every person problem. No.

[Dr. Waris Pokari]

Yeah. I mean I get the claim files back on cases. Right. So I actually see what the insurers say behind patients backs. So there is a woman in California who we fought to get a lung resection for stage 4 non small cell lung cancer. The only available care that actually did that surgery was MD Anderson in Texas who passionately believed that she was a great candidate. She'd responded really well to chemotherapy, almost no detectable disease anywhere else. The insurer based in California denied The care. And we got a claim file back and what they described her as was a cancer victim number one, which I thought was horrifying. The second thing that they said is any surgeon, any thoracic surgeon can debulk a tumor. And then the third thing that they did is that they had a bariatric surgeon, which to your listeners is an obesity surgeon, actually review the case. So it was improper in three dimensions. Right? My own case, which was in the New York Times last week for my inhalers. I'm asthmatic and I fought Aetna to get coverage for my inhalers. Trinity LA wildfires, they said that they granted me a courtesy exemption. And I found out about this, I guess in the Times, or maybe I just wasn't paying attention. But breathing is not a courtesy, it's actually a necessity. So I found that to be a staggering admission and also completely ignored the law, which was actually under California and New York law, like New York law, where my plan was purchased, they had exactly three days to respond to what I put in as a formulary exception, after which it would have been considered self executing under law.

[Dr. Elizabeth Potter]

So.

[Dr. Waris Pokari]

The little that patients understand about how their plans operate is staggering. And this happens all the time.

[Vin]

I invite our listeners. I know we get a lot of feedback on social. I get it often direct via email. I'm getting to know Dr. Potter. I've known worse for a little while now, but I do know that the two of them just comes right out when you first interact with them, that they are willing to help anybody. And so if you are a loved one or somebody that in your neighborhood is experiencing one of these insurance denials, let me know. I'll share it with Elizabeth and Morris and we'll see what we can do. But tell us these stories because again, you know, Elizabeth, this is an every person problem. Know you could have Cadillac gold plated insurance and yet this could still happen to you.

[Dr. Elizabeth Potter]

It is an every person problem. And I think even just the fact that I'm sitting here with you says something. I'm a full time reconstructive surgeon. I operated this morning. I'm gonna go to clinic later today. I did not plan to do this. You guys are amazing and I love talking with you, but I'm a doctor. Doctors are having to engage with media to tell the public that there's a big problem brewing. I mean, the. It's just, it's appalling to me that medicine has gotten to this point. The number of times that patients reach out to me and tell me that they've had difficulty just getting basic care, basic cancer care. The number of times where I have had to fight for a patient to get, you know, routine cancer care, for patients to get mammograms, to schedule cancer surgery, when I have to justify my plan to a pediatrician on an, a phone call with an insurance company, it, it's completely upside down and we're not going to be able to fix it from the, from the inside out. Right. It's clear that insurance companies aren't, aren't self regulating to a better course. Right. So yeah, it's, I'm, I don't, I don't mean to be dramatic, but I am sounding the alarm. I'm sounding the alarm. I'm saying I have doctors reach out to me regularly who say, okay, Elizabeth, you're in private practice, so I'm my own practice, I'm my own boss and that's why I can sit here today and Talk with you. 70% of physicians are employed and many physicians who are employed are not free to post on social media or take interviews or say anything that could be deemed as critical of their institutions, including their hospitals or their group or the insurance. Right. So I'm speaking for, for a lot of people saying this doesn't feel right to doctors in America. And you know, even if that's, even if that's the only thing that the doctors are able to say like, hey, help me, I'm trying my best. And the system is at odds with providing great care. It's that intersection of, you know, doctors who want to take great care of their patients and the industry which has a fiduciary responsibility to their shareholders to maximize profits. And we have met in the middle and things are just dissolving.

[Vin]

What is, Go ahead, please, Morris, please.

[Dr. Waris Pokari]

Things haven't improved, right? So the three of us have a background in science. So if you were to take a scientific approach to this, we've run the experiment for a long time. Nothing is getting better. So as Elizabeth's saying, the system will not self correct. We have to change it. And it is really up to our generation to change it one for ourselves when we actually become fully reliant on the system to look after us, but also for the generations behind us as well who are going to need it. So that to me is incumbent upon us and brings urgency to my work and our work every day to show up for patients. So that's really interesting to me. And the second thing is that every single defense of insurance is in defense of a Payment model. The payment model doesn't serve patients, it doesn't serve providers. And right now it's not even serving the shareholders. You look at what's happening on Wall street and you're getting CEOs from these insurance companies being turfed out like Karen lynch from cvs. She got removed and replaced. Andrew Weddy stepped down. This isn't an accident. This isn't coincidence. It's because these companies are not doing well or what they're meant to do. Something has to change.

[Vin]

So what do you think? What has to change? And I say that because, you know, all of us. Elizabeth, your point on independence and being able to speak freely, I couldn't agree more that I wish more of our colleagues had freedom to do that. And you're right, a lot of them don't. And a lot of them would probably want to be in a forum like this talking about these issues. They just can't. And that's a version of sort of corporate suppression of freedom of speech. And it happens all the time. I, but, but I do I. Posing the question of both of you and Elizabeth, perhaps you can begin. What, what needs to change? And, and I, I'd love for you to be specific in this world in which we just saw that one big beautiful bill quote, unquote, come out and do all the things that, you know, we've seen now every four to eight years, incrementally claw back things and coverage and access make things worse. I, frankly, I feel like that's dumbed down these nuanced conversations and giving cover to what commercial insurers are doing to every person across the country, which is the things that you guys are fighting against. You know, these, these policy debates distract us. And at least that's my opinion. And so, you know, what are the things that you think we should be doing now? Having you've been at this now for a while wondering what have you noticed certain trends or things that we're not talking about in our public discourse?

[Dr. Elizabeth Potter]

I love that question. And I'm all about some practical advice. What can Americans do right now? What can businesses do right now? And the number one thing is, okay, open enrollment periods coming up. Okay, so let's, let's challenge the insurance companies out there to demonstrate who the good actors and the bad actors are. I would say if you've been hearing a lot about an insurance company as a bad actor than for large employers, reconsider who you are contracting with. That, that level of pressure will act more quickly than government ever could. The market can change this more than government can. If large employers around the country say, I will not contract for my employees with a company who is consistently seen as a negative actor in the healthcare community in America, that will move the needle, that will drive change. So open enrollment's coming, I would say do that. And I would say, if you're a company out there that feels like, I don't want to be thrown in the mix with bad actors, okay, come to the public. Come on this show. Send your CEO, talk about what you're going to do different for the American people quickly. That means they should buy your product and be in your network, because we can drive network change. We can. I also think let's start talking about the direct care model. I mean, fee for service worked for a long time and there were problems with it, but we can get back to something like that again through employers. Not through, you know, patients having to pay out of pocket for cancer care, but through networks of doctors contracting directly with employers, bypassing insurance completely and saying, like, I can. I can price out breast reconstruction for Walmart. If they would like for me to perform all of their breast reconstruction, I'm happy to do that and I will save them, I bet over 50%.

[Vin]

So, Elizabeth, I'm going to interrupt you that when you say direct care, can you speak a little bit more about. So does that mean for our listeners out there, physician practices, however big or however small, directly contracting for payment with employer entities, as you just mentioned?

[Dr. Elizabeth Potter]

Sure. So you might have heard of concierge care and, you know, concierge care, when someone decides they want to pay a certain doctor, you know, to provide care for them, and they don't want to go through the insurance network, I think we all kind of know what that is. Right? So I live. I live in a world where that doesn't really work because people are, you know, inundated with these. This devastating financial situation when they have a cancer diagnosis. Okay. So all of a sudden, coming up with the cash to pay for cancer care doesn't sit well with me as someone who takes care of patients with cancer. So I walk that back and I say, what do we really need? You have a patient who needs a doctor and a facility and treatments. You don't actually need an insurance company. So what direct care is. Is a way of putting those things together outside of the insurance company. It takes some forethought and it takes some willingness to change. It takes. It might seem like it's going to take risk for a company, but honestly, companies like, I know Mark Cuban's company is doing this. There are companies around the country who are exploring direct care because it makes, makes more sense for their patients, it saves them money. And you know, I, I think that it's, it's better for the health of the physician system. So if, if we can empower physicians to know their value and I think a lot of physicians don't to know what they're, what they're bringing to a patient and put a value on that and then take that value to the employer and say, you know, I see, for instance, my EOBs, my explanation benefits for breaststrig instruction when my patients have microsurgery. And some of them say, you know, that the care that we delivered cost $250,000 for a three day stay in the hospital. And I am positive that that is not anywhere near the cost and that's why I built the surgery center to show it. So direct care is saying, okay, let's get real specific like Americans are when they have to write their budget. Let's actually talk about how much does anesthesia cost and a surgeon and a bed for 12 hours and the medications and let's add it all up and then let's come up with some, some markup that provides me to the ability to make some money, keep my doors open and let's, let's tell Walmart just to contract directly with me instead of going through United or some other company that's taking a piece of the pie like an atm, like it's just like an atm.

[Dr. Waris Pokari]

There's literally no value add coming from these insurers. If anything, there's active value destruction. And also because of the way self funded plans work, which means a large employer, typically a thousand employees or more, the employer is actually on the hook for the liability. If the insurer does something wrong, right under erisa, the Employment Retirement Investment Savings act, the employer becomes liable. I would contend that none of these employers actually know what these insurers are doing to operate their plans. Because every time we've involved an employer in one of these complete nightmare cases that get sent to me, the employer says, yeah, sure, I want to help, how can I help? And they overrule the insurer. I've seen it time and again. So I think there's something there for sure on direct care. I think direct primary care can really work for sure. You know, I tried imposing, I tried exploring that when I worked in insurance and the idea of there not being any claims coming from primary care and managing risk in the community and keeping things out of the hospital. I think it blew the tops of their heads off. I don't think they could actually understand it that, you know, there was another way of doing this. And now if you could actually say, like, look, we know what's needed in a community per capita, so we know that say, for example, Boeing is in this community and there's a lot of people doing airplane manufacturing are going to need orthopedics, physical therapy, or if you happen to work in Silicon Valley and then it's mental health, primary care, pediatricians, et cetera, you can actually coordinate what kind of care exists in a DPC model, direct primary care. And that would be very, very effective. We need something like that. I actually don't believe the insurers have any purpose. And the pharmaceutical benefit managers for sure have no purpose.

[Vin]

Morris. You know, it strikes me that every entity in healthcare, but just across the spectrum that's making money, that's, you know, as profitable as an insurance company is across the spectrum, that they are most interested in self preservation and they don't want anything to change, they don't want a bad breath cycle. All these things, none of these things are good to self preservation. Why is it, you know, I've seen already, you know, the video of Dr. Potter that went viral that I thought, you know, spoke for itself. All the great work you're doing at claimable, why are they creating an opening for the two of you to be successful? Why not just acquiesce? And so I guess said another way. Are you noticing that when you put the two of you collectively, that worse up to at first to you that when you were pushing back as claimable more most often successful. I mean, how often are you successful? How often are you not successful when you're pushing back on behalf of your clients in the cups?

[Dr. Waris Pokari]

It depends on the therapeutic area, but like around, let's say 70 to 80%, I would say that we win cases, which suggests that 70, 80, 70 to 80% of denials are total nonsense.

[Vin]

That's remarkable.

[Dr. Waris Pokari]

GLP1s, we've seen a lower success rate right now, but we think that the denials are completely improper. So it's going to be interesting when those go to independent review and we're sending all of those denials to independent review on behalf of patients.

[Vin]

Take us back. Take, go back. The curtain did. So somebody comes to you or you hear about something that shouldn't happen and then how does the process work? Just curious.

[Dr. Waris Pokari]

So if you go to getclaimable.com, which is our website, it Basically laid out in easy steps. You upload a copy of your denial letter, a copy of your insurance card. You select what you've been denied for. So rheumatology, Crohn's, UC will be asthma, migraine, host of other things. It's all therapeutics right now. And then you answer simple questions. How does this disease impact you? Like, what are the symptoms? Like, so, for example, when I get migraines, sometimes I have to pull over on the side of a road because the headlights basically give me. I just can't focus. Does it impact your ability to work? Does it impact time with your family? We find that, for example, in rheumatology and, you know, conditions where there's a burden of chronic pain, families, people get isolated. They get isolated from their families, they get isolated from their friends. They don't see their kids, they disengage from their community. There's real harm. And then we also document what treatments they've tried and failed, because oftentimes the insurer will push someone onto therapy that doesn't work. And that decision is based on preference for their formulary, not based on anything that's actually good for the patient. So we've seen cases where, you know, the insurer has completely invented criteria which are actually not in their printed criteria. So they'd said, you need to try three medications and fail it. Patient tries three, and I say, just kidding, it's five. Patient does five, and they say, just kidding, it's seven. Then we appeal it, and we beat it in a day. Then I've got the other channel, which is basically my side job, which is like another 80 hours a week, let's say, which is helping families. And that arrives anytime. So, like 4:00am Someone calls me and says, hey, my dad, husband, wife, daughter, whatever, is seriously sick and needs help. Will you help? The answer is pretty much always yes. And then we just get to work as a team and we fight. And now we brought on an attorney who helps us basically find all of the ways that the insurer is violating the patient's rights and the law. And we're prepared to actually start filing suits against the insurers on the basis of this.

[Vin]

That is remarkable. Wow. That is, I mean, 70 to 80% success rate. And, you know, Elizabeth, I'm just, like, putting it all together and thinking about the future. I wondering what the next six months have in store for you. What are you hoping to achieve? Sort of as we approach 2026, as these health policy debates seem to kick into gear, but again, on a different so again, what we talk about at the federal level feels like a distraction from these really intimate, compelling stories. Wondering what the next six months have in store for you.

[Dr. Elizabeth Potter]

I see a different level of understanding among the public, like a heightened level of understanding of the realities of insurance and healthcare. I see the next six months as a time when we can really increase the depth of understanding and the mindfulness across just grassroots America about the realities of healthcare. And that's really the work that I feel like I'm centered in right now. It's telling stories, telling the truth from across the country, from a million different voices, so that people start to develop their own opinions about, about the system that we're, we're living in. Right. I think that that pressure in terms of public opinion applied to companies is going to be far more powerful than anything that's happening in Washington D.C. right now.

[Dr. Waris Pokari]

And it'll be faster.

[Dr. Elizabeth Potter]

Yeah, I just think, I think public opinion is, I feel the temperature rising and I want to channel that energy towards, towards those individuals and those companies that can actually drive change by forcing insurance companies to do better. And again, that's if we have enough individuals talking about it, then the companies that they work for, small or large, if they start listening to, and we have a deeper understanding that companies can drive this change, individuals can drive this change just by, you know, running the bad act out of town or supporting a different player. So again, open enrollment's coming. Choose a good actor, choose the best actor you can find. And if there's, you know, maybe ask your employer for a direct care option. Not just, not that they do it, but just have an option for direct care and let's see what happens.

[Dr. Waris Pokari]

Elizabeth, let me ask you, can I ask a question to Elizabeth?

[Vin]

Oh, my God, please.

[Dr. Waris Pokari]

What do you think would happen if we started publishing denial rates per plan by zip code?

[Dr. Elizabeth Potter]

Oh, yeah. I mean, it's. Every time the denial rates come out where KFF publishes a study and says, oh, the ACA plans and you know, Blue Cross has this 40 denier rate in Alabama for whatever. It's appalling. And those are the specifics that America doesn't know. So I say let's do it, let's, let's publish those and, and then let the chips fall where they may.

[Vin]

You're all, you know, worse. I, and I know we're coming up on our last few minutes together, but I, it strikes me that so many of the things that I think Americans are interested in, curious about, let's say, their favorite wearable to help them stay Active or to gamify the idea of fitness. There's supplements that people believe in, whether or not there's scholarship behind it or not. There's so much out there in this new fad of wellness prevention longevity, I think accelerated by some of the Maha doctrine. But I think a lot of it has been far, has been in there for, you know, far longer, for decades now. You and I had the chance to work on a wearable together briefly, and I'm always amazed that in most cases none of this stuff is covered by insurance companies. These are things that people want, generally speaking. These are things that people say might or studies have shown will help people stay more engaged in their healthcare. And yet a company, an insurance company says, you know what, I'm largely not going to want to have that against my profit and loss margin. Why would I cover something like that, like a device or a wearable that might help somebody gamify fitness or might detect sleep apnea. I know I need years and years of clinical trials data to justify the expense. And it just feels like the way they think about this incredible world of persistent medicine, new digital tools available to us at our fingertips is, is. I know it's a different side of the coin than what you and Elizabeth are focused on, which is claims for, you know, critical care. But this prevention area as well seems, it seems real. And I'm wondering how you, how you think about that.

[Dr. Waris Pokari]

I, I thought about this basically for the last 10 years, as you well know. Just this week, maybe it was last week. Now there was a study published in JAMA Open, I'm an author on that, showed the value of the, the Apple Watch specifically in reducing asthma symptomatology. So that was a lot of work. That was a randomized controlled trial. It was 900 patients. That was a joint effort between numerous companies. And it's probably some of the best evidence to show that you could do this. And particularly in low income, which is great. And that's where my heart has been, partly because I grew up in a low income family in England, secondly because I am asthmatic. So it matters to me. This is never far from me. So how do I keep people who grew up like I grew up out of the emergency room? And you can do it, you can get ahead of these things. It took a lot to get that program instantiated and actually funded at an insurance company, but I got it done. The question is, what happens now? And I just hope that someone picks up that research and really deploys it. I know Care Evolution have built a tool that's, that's kind of similar. There's a great piece in stat on this. It is possible, I will say that it is possible for someone to care enough to do it. And we have shown it. The problem for me is that so many people say to me, and we've had this, certainly this conversation with investors is like, I'm going to wait for a world without denials. I'm going to wait for perfect. Perfect isn't going to happen. And meanwhile, there's all sorts of people suffering the ill effects of the healthcare system today. They have no opportunity to get healthy enough to kind of prevent an emergency admission, prevent unexpected costs, to prevent needing being on a biologic for rheumatoid arthritis. That may not be something they could have prevented, but it is something they need access to. So I think it's possible to have both kind of a door focus on prevention, but also making sure that care is truly accessible and affordable. So that's, you know, I've worked in both fields. Right now, this is where I am, which is like stopping, stopping this insane system from metastasizing fervor into American society.

[Vin]

Elizabeth, I'm going to give you the last word here. I know we had to wrap up, but what gives you hope? Elizabeth?

[Dr. Elizabeth Potter]

Oh, gosh. I mean, I'm just, I think just the truth does, right? I mean, when you see a problem that's really seems like a bad problem, I just know that there's a huge opportunity there and there's an opportunity for personal growth, but there's also an opportunity for, you know, for business, right? Isn't that, isn't that when people really succeed, when they see a problem and they fix it? I'm hopeful. I'm hopeful because we're all talking about this and we're, people with different skill sets are coming to the table and saying, how can I make America healthier? How can I do that? And I think it's actually good business. I do. And I'm excited to see how the American market pushes us towards healthier. So, yeah, I think we've all got the, we have permission to speak out now. We have permission to have this conversation. Let's, let's see what happens.

[Vin]

And with that, thank you. I love that. I love that ending. Both from both of you, both your Last comments here. Dr. Waris Borkari, Dr. Elizabeth Potter, thank you for joining Midas Health. We really appreciate it.

[Dr. Waris Pokari]

Thank you, Vin. Thank you, Elizabeth.

[Dr. Elizabeth Potter]

Thanks.

[Dr. Waris Pokari]

Can't get enough Midas. Check out the Midas substack for ad, free articles, reports, podcasts, daily recaps from Ron Filipkowski and more. Sign up for free [e-mail] Mama Papa.

[Vin]

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