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[EPISODE]
Christopher Habig
Hi everybody and welcome to Healthcare Americana. I'm your host Christopher Habig, CEO of Freedom Healthworks. Today we are exploring a very fun and fascinating topic. Our guest is Mario Miranda, a CPA based in South Florida, who brings very unique insights into some very different healthcare systems and hopefully answering the question of why aren't more physicians in the U.S. pursuing direct primary care practices?
We'll discuss obviously the DPC world, but Mario, again, being a very unique perspective, is going to talk to us about the realities of a nearby international neighbor, Cuba, the Cuban healthcare system, the burgeoning healthcare black market in Cuba, and examine why more US doctors aren't shifting towards the DPC models as I explained earlier. So without much further ado, Mario, welcome to the show.
Mario Miranda
Thanks Christopher, appreciate you having me.
Christopher Habig
Now, my introduction, I kind of try to try to leg into what we're really talking about here. But just to give some background, you and I crossed paths recently at a conference down in Orlando, the DPC Nuts and Bolts Conference. And you were one of those people that caught my mind because I'm always out here saying, it's great that I'm able to see old friends and talk to people who...
have already understood what we're doing for Freedom Healthworks and what the doctors are doing across the country, but you legged into this conference without knowing a whole lot about it. What was attractive? What led you to showing up at a relatively unknown industry conference in Orlando?
Mario Miranda
Well, I think the first thing, and I had mentioned this to you before, when I quote unquote met you at the conference, I kind of felt like I knew you already because I had been listening to your podcast for some time. So you didn't know me, you had no idea who I was, but I kind of knew who you were from listening to the podcast over some period. And why did I start listening to your podcast and why did I start investigating the whole DPC world? It's because as a physician,
I guess CPA, I'm gonna call myself a physician CPA, because I've been practicing as a CPA now for over 20 years. The bulk of my clients are physicians. As a physician CPA, I was noticing, and I'm sure that many of the people who are gonna be listening to this, my guess is that they would agree with what I'm about to say, we've been seeing the independent physician go the way of the dodo bird.
We've been seeing how physicians, the independent physician is just slowly but surely disappearing to the point where people talk about it like if it was a foregone conclusion. People talk about it like if it was just something that we have to accept, something that we have to just live with. And these are the guys and gals who are my clients. And to just passively accept that wasn't something that I was prepared to do, at least without finding out more about why, finding out...
if there was any way to counteract that. So I started listening to your podcast, I started finding out more about this stuff, reading a few books, I found out about this conference and that's where you and I kind of officially met.
Christopher Habig
I'm thrilled and honored. I really am. We've been doing this podcast for years and I kind of mentioned it's been a labor of love. It's a lot of fun. And just to be able to have a voice for the industry is very rewarding where we come from. Now, going back to you mentioned that you are a physician CPA. And just to be clear, you're not an MD or DO, but you're a CPA who specializes in working with physicians in South Florida. And I think that's what...
Mario Miranda
Yes, I'm not a doctor.
Christopher Habig
Me, I am not either, even though they say Dr. Haybank, and I say, please, that's my father and mother too. But at one point, I wanted to go into the family business of medicine, and it just didn't work out. But I think with the interesting conversations that we had and that you bring, and I love talking to people who are kind of behind the scenes and helping physicians who, by and large, are very high-income potential, but—
There's a lot of physicians out there who are living paycheck to paycheck and getting bad financial advice. And so what I wanted to get from this conversation, working in South Florida, you came up and said, Chris, I work with a lot of doctors. They don't know that this model is a thing. They just think they have to go to work every single day, beat their head against their desks or beat the head against the wall, and then go home and they're supposed to love what they're doing, and they don't.
So what is it when you're talking to your clients when you're saying, all right, doc, let's find out if there's a better way to go out and practice medicine. How are you having those conversations with your clients?
Mario Miranda
Well, the first thing you'll find as a CPA, if people trust you with intimate knowledge of their finances, of what's going on intimately with the economics of their house, if they trust you with that, they're going to trust you with a lot of things. And if you're perceptive and if you're open-minded and if you're not just focused on doing their tax return or doing their books,
and you listen a little bit, you're gonna sense the frustration. It's palpable. It's something that you can really, really feel. And then when you dig a little bit deeper, if you care about your clients, you're gonna find that they're frustrated. And they're frustrated because they're overworked. They have panels of 3 ,000 patients, which means that if you have a panel of 3 ,000 patients, you're typically seeing 1 % of your panel on any given day if you're a primary care physician, that's 30 patients coming in.
to your office every day. And when you have that many patients coming into your office every day, and you have to do that because it's the only way that you can survive. You sign on with these big health insurance companies and they give you 500 patients and that's great, you're off the ground running, but you sign on with another one and with another one because they're only paying you so much per patient. Before you know it, you're seeing 30 patients every day. You can't, there's no way that you can.
take care of these patients in the way that they need to be taken care of. In effect, what you become is a referral machine. And that's what I keep on hearing from some of these guys. They're just referral machines. They're just a wheel in the car, you know, a cog in the system to just spit out referrals for the specialists and for the big hospital groups so that they can make money, right? So that the big pharma, you know, they can make money. And the primary care guys are just overworked and just...
fed up with things. And that's what comes across as a person who's just there to do their taxes, but hears a lot more than just tax stuff. Right?
Christopher Habig
Right. They kind of say, well, what's going on here? They want the whole picture. And you're like, well, there is actually a better way to do this. Now, like I said in the intro, you bring a very unique perspective to South Florida. You were born and raised in the US, but Cuban parents. And so you're very integrated with the Cuban community, the expat community, dare I say refugee community, down in South Florida. And...
One of the things that got my brain kind of working when you and I were chatting before the show was saying, Chris, it's unbelievable that doctors in the US are practicing a model of medicine that is very reminiscent of a country that people are fleeing like crazy, yet this DPC model is completely legal, is the way that...
you know, capitalism and the US should be functioning healthcare system, yet nobody is doing it. I'm curious, just kind of recap for our audience, share your experiences along those lines, building really that dichotomy between what you've experienced, your family's experience in Cuba along with your clients, and then what is possible in the United States.
Mario Miranda
Well, the first thing we need to remember, and for a lot of people this isn't going to come as a surprise, but maybe for some it will come as a surprise, so it's good to mention, Cuba is a communist dictatorship, right? So there's tons of elections, but only one party can field candidates, the Communist Party. There's one official newspaper. There's one official union that everybody has to belong to if you're a worker. It's a totalitarian state. It exerts total control over the lives of its citizens, and within the party, everything outside of the party, there's nothing.
That's the political part of it. Economically, it's organized along socialist lines. There's very little private property. There are no property rights. There's some private business, but the government can and will intervene if it sees fit, leaving the business owner, quote-unquote, business owner, with no legal recourse.
So the Cuban system is organized along those socialist lines I just mentioned, the healthcare system. On paper it looks fantastic and they're going to pitch all the quote-unquote gains of the revolution, right, healthcare-wise. No health insurance premiums, no copays, no deductibles, the number of medical providers is amongst the highest in the world, high life expectancy, low infant mortality, but...
But when you scratch the surface, and this is what you get when you speak to people who were medical providers in that system, people who have recently arrived, in addition to the people who were practicing 20, 30 years ago that have been here for some time now, a lot of those statistics with the low infant mortality and the high life expectancy, that's all statistical sleight of hand. Those statistics can be easily manipulated and they absolutely do that to make their system look better. It's all about propaganda, remember.
Supply shortages, basic things like sutures you can't get. Outdated equipment in dilapidated condition. Rundown facilities that experience frequent electrical outages, have plumbing issues. Oftentimes if you go on YouTube you will find a video that a fed up nurse or a fed up doctor who just can't take it anymore anonymously posts where you see people in a surgical room.
that's flooding because there's a leak in the roof and it's just falling apart because nothing's been invested back into the facility. And all of this leads to disincentivized medical providers leaving the country, mostly to the US and mostly to Miami, leading to a brain drain there. So the problem gets worse and worse and the guys who do decide to stay.
the medical providers that do decide to stay, they have to end up working because they get paid in Cuban pesos, right? And now with inflation, inflation doesn't just affect us here, it affects them worse. The exchange rate, the exchange rate officially is 20 to one, I think for the Cuban peso to the US dollar, unofficially, which is the one that really matters. The black market rate is like 400 to one. The average doctor might make 300 or 400 pesos a month.
That's what they get paid. Like the equivalent of a dollar or two. It's crazy. And then a sandwich will cost you 200, 300 pesos. So basically your salary is...
spent on a sandwich. These guys, because they can't make ends meet, what they do is they go to work in hotels as piano players, as bartenders, they drive cabs, because they can make money from tourists in euros or dollars and that goes a much longer way than the salaries that they get paid in pesos. So all of this stuff is just, you know, it's just a complete nightmare, the system, and that's what you would expect to find
from a communist system that doesn't address the needs of its consumers. It's just there, very top down, as opposed to bottom up. That's what you get. But here's the interesting thing, Chris. Even in a communist country like Cuba, that is proudly communist, it's not like we're...
Denigrating them or saying something that they don't themselves proudly say right because they people throw that communist term out very loosely They they're the ones who are saying that they're communist. I'm not saying that they're communist even in a country like Cuba The free market finds a way it just finds a way example Cubans on the island they receive every year around four billion dollars From in remittances from family that they have mostly in the u.s.. But all over the world
Now with access to these US dollars, they will approach the medical providers at upscale healthcare facilities that you find on the island. Because I was talking to you about the facilities that the average person has access to. But if you're a Communist Party official, or if you are a tourist, you're not going to go to the same place that the regular people go to. You're going to have a really nice hospital with really nice equipment and really nice, you know, so everything that you need is there.
and now armed with US dollars, they will privately contract with some of those medical providers who are getting paid in pesos and need help themselves to buy gauze, band-aids, antiseptic, medicines, other supplies. They'll schedule at night, in the middle of the night, procedures ranging from just getting stitches to open-heart surgery using the good facilities that you find there. So even in communist Cuba,
the free market finds a way and people get what they need by engaging directly with their medical providers, with a medical provider there, which is how everything since time immemorial has ever gotten done, by doing it just like that. You know? So that, that, yeah.
Christopher Habig
Now, Mario, yeah, I got a question for you. I mean, you threw a lot at us, right? But the one thing that kind of gets in the back of my mind, connecting with how the Cuban healthcare system works, how it treats its physicians right now, and then what you're saying is, well, there is a black market for these healthcare services. And you brought up an interesting point that says, you know, the government lets the party, I guess is a better way to put that, lets these things kind of happen.
until they reach a certain point, until they become too successful. So where I think you're going with this is saying, if you're a Cuban physician and you're getting paid quite literally pennies a day in our world, but yet you have the ability to take care, be a concierge physician, in other words, but you have to do it in the middle of the night and you have to do it for high ranking party officials or European or American tourists. In the back of my mind, I'm still saying,
Yeah, but that is almost somebody doing something underneath the party's nose, which could change tomorrow. And then what happens if you fall out of favor in something and all of a sudden, boom, there's a crackdown because you're out of favor or you cut somebody off in traffic or anything of those things could happen, right? That's what worries me when you're talking about the plight of these physicians down in Cuba.
Mario Miranda
And that absolutely does happen to physicians and to anyone else who's trying to... The government there, and we're not having just a political discussion here, but the government there wants you to depend on them for everything. That's what big government does. It wants you to depend on them so that the solutions come from them, the money comes from them, the privileges come from them. They...
Big government communism thrives on people who just depend or are dependent. The antithesis of communism is independence. Because if you're independent and you don't need the government, you're a threat, right? You're a threat. So you're absolutely right. From one day to the next, that can change. That can change.
Christopher Habig
Now, and again, what sticks out in my mind is I appreciate the kind of quick yet deep dive into Cuban healthcare because, I mean, gosh, there was a couple of documentaries out like 10, 15 years ago that papered over a lot of the problems and when it comes to health insurance and all this kind of stuff. And I think now we're reaching a point where the Americans are more educated in understanding that health insurance does not equal healthcare.
And I think that's the number one thing to kind of get across to people in everyday life. But from your perspective, understanding how Cuban physicians have to make ends meet, becoming bartenders, playing the piano or doing a lot of business, healthcare services on the side, it's not exactly on the up and up. When you look at the US healthcare system, are you kind of saying, Docs, what are you doing? You're kind of acting like Lemmings here, working for...
big hospitals that are functioning very similar to the Cuban government when there is a free market healthcare model out there that no one's going to come raid your home in the middle of the night if you do this, yet people are not flocking to it in droves.
Mario Miranda
Right, I think Chris, we've been so conditioned as a society to accept the current state of affairs in healthcare. That's kind of rained for some time now. If you go back to ancient times, the physician-patient relationship, it's ancient and it's sacred.
And it's really what we need to get back to. It's just, it's difficult to kind of, again, get out of the conditioning that we've been accustomed to for decades now. And it's ironic to me that the black market that's emerged in Cuba that we were just talking about in some ways is even more capitalistic, if we want to call it that, than the restrictive arrangements that you find in the US, brought down by big private equity groups, big hospital groups, big pharma, big insurance companies.
You know, they have their own restrictions, just like you find in a communist country, you know? And if we just let the market find its way, which is, I think, the natural state of affairs, the reason why capitalism works is not because someone discovered it, it's because it's in tune with how human beings, with human nature and how human beings think and work and act. If you got, you know, four sticks and I got four rocks and I need a stick and you need a rock,
You're gonna, it's just natural. We're just, even if we can't talk, even if we don't speak the same language, I'm gonna point to your sticks and you're gonna point to my rocks and we're gonna like, okay, here's two of my rocks and you give me two of your sticks. Now I got sticks, now you got rocks. It's just nature. It's just more in tune with how things actually work. The reason communism doesn't work, the reason big government and big healthcare doesn't really work, I mean, it works in the sense that it works for the people who are...
engaging in it and they're profiting. But the reason it doesn't work for everyone else, for the majority of people, is because it's something that's imposed that's unnatural. The natural thing is for us to engage directly with our physicians and for them to get paid by us for the stuff that they provide. Not some middleman to get in the way and to determine how much the service that was provided for me is worth. That's why it doesn't work for the majority of people. Again, it works great for the bigs.
It works great for the people who are profiting, but not for anybody else.
Christopher Habig
I like your example there that the Cuban black market and healthcare might be even more capitalistic than the U.S. healthcare system because you quoted out a black market exchange rate. You did it. You're like, I can put a number on what the black market Cuban peso to U.S. dollar exchange rate is. You can't find anything like that when you go to a hospital and ask the damn price. So I'm kind of laughing about that. God, that is so true that...
We can put, or you can put on, somebody familiar with it can put on an actual exchange rate to black market services and goods, yet we struggle to find transparent pricing and transparent costing as well, there's two sides of the coin, from pretty much every single major hospital out there, let alone the insurance contracts and super bills, all that kind of fun stuff that just drive people absolutely bonkers. So with all that said,
And with your career of having intimate knowledge of how to do things in a couple of different ways, the kind of the polar opposites of each other, or have enabled the polar opposites of each other, I guess I go back to my original question. Why aren't more doctors flocking towards a transparent, free market business model when it comes to seeing patients?
Mario Miranda
There's one word and only one word to describe why and that's fear. There's a lot of fear. And I think the fear is born, if we scratch the surface of that fear, we drill down a bit on that fear, it's born out by or comes about as a result of ignorance.
I think people need to find out about these options the same way that I found out about it because it was frustrating me to think that there was no solution out there. I mean, this is a, to me, it's the greatest country in the world. And it just boggled my mind that there wasn't something out there that could counteract the adverse effects that I was seeing on a lot of my clients. And when I did a little bit of searching, I found out that there was something like that. It's called DPC. But to answer your question, it's fear.
Doctors are afraid and they're afraid of the consequences if they don't successfully navigate the transition to independent DPC practice. That's the main thing. Even if they find out about DPC, they're scared. You know what? I don't know if I could do that. I don't know if I could pull that off. I mean, I've done medicine and science my whole life and I don't know if I can do that. I don't know if I can manage that transition and if I don't, then what's going to happen to me? What's going to happen to my family? You know?
They're also afraid, not only of not navigating that transition successfully, but they're also afraid of the repercussions of going down that route. We talked about the bigs, big pharma, if you're a local pharmacy. If you take that big pharmacy group, that big pharma group on, what's gonna happen to you? If you're a physician and you take on that big hospitalist group, hospital group, if you're gonna take on that big private equity group.
You know, what's gonna happen to me? These guys are huge, I'm small. What can I do compared to what they can do to me? You know what I'm saying? So they're afraid of that and they're also reading from tons of medical school debt. I mean, you come out as a doctor, you finish your training, you might have deferred your student loans for a few years, and then now you gotta start making those payments. They are significant. And you just need to hit the ground running. You don't have time to think. If you think,
You feel, you think you're dead, right? You gotta just hit the ground running, you gotta take on whatever anybody throws at you and if it's ridiculous what's being thrown at you in the way, not just of overwork and underpay, but also in the way of restrictive covenants, restrictive non-competes, you're signing whatever they're putting in front of you because you know that you just, you need to get out from under this mountain of debt. So it's fear.
Christopher Habig
I'm curious when you talk to clients and friends and family down in your area who have left Cuba, and I'm assuming that you're going to have, look, I have a lot of doctors, clients who used to practice down in Cuba who came over to the US. What's their reaction when they start living and breathing, being a physician in the US from where they came from?
Mario Miranda
It's like, it's really hard to explain. It's really hard to explain. Even if you're not a doctor, they post videos. I go back to YouTube because it's what, you know, it's easy and readily available for everybody to see. They routinely show videos or post videos on YouTube where there's someone who's lived in Cuba all their life, then now all of a sudden they go into a Walmart.
And they see the plethora of products and the plethora of things that they can buy and they just start crying. They start crying because they cannot imagine that they were living the way that they were living. And now this was always there. So the same thing happens with physicians. A physician comes here and they're like, my God, you know, I was satisfied with just getting by and scraping by and just accepting this as just the way that things were going to be.
and I come here and I can make all this money, you know, whatever. But that's the thing, the good is sometimes the enemy of the great. They'll come here and after a few years they'll be frustrated, even though it's great initially, they'll be frustrated too because the same kinds of frustrations that lead other physicians to wonder, man, is there another way that I can do this? Is there a better way of doing this? Is this the only way that we can practice? Am I...
kind of a, I call it indentured servitude, right? You know, you're getting paid, but you're basically at the behest of whoever's paying you. And they make it abundantly clear, this is just my opinion. They make it up, they being the bigs, right? The big private equity groups, the big hospital groups, they make it abundantly clear to you that if you cross them, it's not gonna be pleasant for you.
So they're initially they're very happy, they're ecstatic. But within a very reasonably short period of time, they're just as frustrated as anybody else who's lived here all their life and had to navigate this this labyrinth and healthcare system that we have.
Christopher Habig
Now I'm going to assume that there are different solutions to both sides and I'm not saying, hey, you know, in order to overcome the Cuban economic system and political system, I mean, that sounds like it's going to be a full on revolution. For the U.S. system, what do you see in as far as here are the little things we can do to make sure that the kind of nascent movements of direct primary care and, you know, that you talked about the local pharmacies, what do you see in that
they can do to overcome that inertia or really the oppression that big pharma, big healthcare systems have over them to control them. What are you telling people to say, hey, look, this is how you're gonna fight back here in the US?
Mario Miranda
I think the first thing they need to do is inform themselves. To find out about what's out there, what's being done by direct primary care to counteract the effects of the bigs. That's the first thing, you need to inform yourself. You need to find out, to educate yourself about what's out there. Podcasts like this go a long way, I mean it informed me. And it led me to do extra things like go to that conference where you and I officially met.
enough people start listening to podcasts like this, enough people start reading about going to some of the websites that are out there, DPC Frontier and other ones that really explain what is being done. If they hear enough about success stories of people who have successfully navigated that transition, if they see that it can be done, that this is not just a one-off or a one in a million kind of thing.
like running the gauntlet or something like that, that you can succeed, that there is a formula, there is a way of doing it successfully. It's like anything else, like you have the early adopters in any kind of innovation cycle, you have the early adopters, the pioneers, the people who are really the frontiersmen, right? The Davy Crockett and the Daniel Boones who are going out there and they're doing whatever they can to just survive and seek out an existence.
But as they become successful, then the other people who maybe aren't as pioneering as those guys, they'll want to start doing it themselves. So I think it's a slow grind, it's been a slow grind, you had mentioned that to me at the conference, but I think to the extent that we get enough people finding out about this, taking a chance, finding out that there's a method, a formula to succeed, and utilizing those formulas that are out there to succeed, and transitioning successfully, more people are going to want to do it.
Christopher Habig
Do you think that, this will be my final question for you here, Mario, do you think that CPAs and financial advisors are in a special position to talk with physicians and clients about a little dose of reality of, hey doc, this is what you're doing and you're doing well financially, but this is what life could be like over here. And that's where I can tell you can be really happy with you and your family.
Mario Miranda
I mean, I think so, I'd like to think so. I know that personally, ever since I came back from the conference, anybody that I hear complaining or, you know, whereas before I would just kind of listen passively like a psychologist and just kind of let them vent, now I'm a bit more proactive because now that I've informed myself a bit about what's going on and I've found out a bit more, I'm more proactive. I'm the one that's telling these guys, hey listen, you may not know this,
But this is an option for you. And even if you don't think that it's going to be for you, before you decide definitively that it's not for you, inform yourself, educate yourself. Read the books by, like the one that was put up by Paul Thomas. That's an excellent book, DPC Startup. Engage with companies that can help you transition. Run that gauntlet. What you feel is a gauntlet. It's really not a gauntlet.
But if you feel that it's a gauntlet, then engage with companies that can clarify that process for you, make it more transparent for you, let you know what you need to do soup to nuts. Because there is a formula, it's not rocket science. There's people who have done it, there's ways of doing it. So I think that's something that I'm doing and I think that to answer your question, CPAs, CFPs, financial advisors in general can absolutely bring
Let people know that there's a light at the end of the tunnel if they choose to turn that light on.
Christopher Habig
Mario, I appreciate you coming on the show, sharing your insights. I knew that when we first met, I was like, this is somebody that I want to chat more with and dive into some of these fun subjects. So Mario, again, thank you for joining us here on Healthcare Americana.
Mario Miranda
Pleasure Christopher, take care.
Christopher Habig
That's going to be it for this episode. To our listeners, thank you for tuning in to Healthcare Americana. As always, we hope today's episode provided you with valuable perspectives on really some different healthcare systems out there and how different countries are treating their physicians and kind of a warning that, hey, the U.S. isn't too far behind of really treating our physicians like commodities rather than the experts and really people that they are.
We touched upon the evolving model of direct primary care and trying to encourage more doctors to really take that first step, work with people, find the resources, educate themselves. Because as I always say, remember informed choices are the best choices when it comes to healthcare. Once again, I'm Christopher Habig. Thanks for listening.
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