Category: Uncategorized

Episode 45: Bundled Payment for Surgeries–with Mr Dutch Rojas


  1. Sano Surgery
  2. Article in Modern Healthcare about bundled payment
  3. Dutch Rojas’ Profile LinkedIn

In the advent of managed care, getting a surgery can often mean getting bills from many places. A single joint replacement can result in a bill from the hospital, the lab, the imaging company, the radiology group, the anesthesia group, the surgeon and potentially more. This can result in high costs for a procedure. While insurance may often pay these bills, for insured patients, the cost of a plan will go up as a result. Traditional insurance carriers have been loathe to change this, however, as they have a vested interest in keeping prices high, since they make more money when the premium is higher. For self-insured employers however, saving money on surgeries can translate to substantial savings on the price of the premium.

In comes Dutch Rojas, founder of Sano Surgery.

As a broker of bundled payments, Dutch Rojas brings together employers, brokers and surgical centers to negotiate a bundled price for a surgery. This can often yield considerable price savings. To give a simple example, a knee replacement when paid for by insurance can cost over $60,000. When paid for by a self-insured company, this can put considerable burden on the plan, especially with multiple employees per year that need a knee replacement. When paid for by a bundled agreement, many surgical centers will accept less than $25,000. As a result, the plan saves money.

In the interview Mr Dutch explains how bundled payment works, why surgical centers are willing to accept bundled payments, why health insurance plans are reluctant to negotiate bundled agreements and how to go about negotiating a bundled agreement.

Time Stamped
[3:03] So can you tell me about bundled payment? How does it work and how does it save money?
[4:20] Can you give some examples of how bundled payment has saved patient’s money?
[05:23] Why have hospital systems and traditional insurance companies veered away from bundled payment?
[07:17] Are there any surgeries that can’t be paid for with bundled payment?
[08:41] How can a plan go about getting a bundled payment contract?
[11:43] Why do both healthcare plans and surgeons/anesthesiologists/surgical centers prefer bundled payment?
[13:45] How can a bundled payment affect premium price?
[15:40] How does DPC fit into a plan with bundled payments?

Dutch Rojas


Mr Dutch Rojas is the founder and CEO of Sano Surgery. He has over 2 decades of experience in the ambulatory surgery market as a broker. Prior to that Mr Dutch was a US Marine.

Related Episodes

Episode 15

Episode 33

Episode 44

Episode 44: The Hint Summit Recap–with Dr Paul Thomas

Episode 44: Hint Summit Recap

Hint Summit

Hint Health

Health Rosetta

Plum Health

In June 2018, DPC doctors and industry leaders from insurance, IT, human resources and healthcare companies united in San Francisco at the Hint Summit to collaborate on direct primary care. How, they asked, can we work together to make DPC a cornerstone of the healthcare system? Bringing together thought leaders from different areas of the healthcare system, speakers talked about not only what is holding the system back, but what needs to happen to move forward. Dr Zubin Damania (ZDoggMD) spoke of the elephant-rider analogy, encouraging mindfulness about perverse institutional incentives that prevent doctors and hospital from doing the right thing; Dave Chase spoke about the waste and fraud that is happening as a result of our current third party payment system, and how that can change with transforming the employee benefits industry; David Contorno spoke of reforming healthcare brokerage practices to focus on the needs of employers and not carriers; Dutch Rojas spoke on focusing on value when negotiating for surgical services; Garrison Bliss, the founder of Direct Primary Care, encouraged DPC doctors to carry the baton, live their mission and develop lasting relationships with patients; and many more doctors & business leaders gave exciting talks about the transformation to health 3.0–what needs to happen to make a healthcare system focused on transparency, value and relationship.

In the interview, Dr Roussel interviews Dr Paul Thomas, founder of Plum Health in Detroit and Hint Summit Summit attendee, as he discusses key points from the major talks in the summit. In their discussion they not only review the major points from the speakers but also what their message means for the DPC movement.

Time Stamped

[03:35] Dr. Zubin Damania (ZDoggMD) talk on the elephant-rider metaphor, its relevance to DPC and on TurnTable Health

[05:50] David Contorno talks about the ‘old model’ of benefits brokerage and how his change of practices has provided more value to companies.

[07:30] Dave Chase talks on institutional waste and how to funnel dollars spent on healthcare to high value providers.

[09:20] Dutch Rojas talks about negotiating value for payment of healthcare services.

[10:36] Garrison Bliss encourages doctors to carry the baton forward in this movement to reform primary care.

[11:16] Joel Bessmer talks about how metrics can show that DPC saves money.

[12:42] Dr Jeremy Smith talks about his work providing a DPC-focused insurance plan.

[14:06] Zak Holdsworth talks about Hint’s vision for changing the status quo of healthcare.

[15:23] Jay Keese gives an update on HR 365/ SB 1358 allowing HSA’s to pay for DPC membership.

[16:34] Ryan Nuehofel talks about building an alliance for the future.

[18:19] Health Rosetta Micro-Summit focuses on bringing in key community leaders to the table to educate them on how to improve value and lower costs for healthcare.

Dr Paul Thomas


Dr Paul Thomas is a family physician from Detroit, Michigan. He graduated residency in 2016 and founded Plum Health straight out of residency.  He attended the 2018 Hint Summit and was gracious enough to share the product of his meticulous notes with the DPC Podcast.

Related Episodes

Episode 33

Episode 45

Episode 43: The Amazon Healthcare Venture with Chase & Berkshire Hathaway: What it Means for DPC


  1. Harvard Business Review Editorial on Amazon Healthcare Venture
  2. New York Times Article Announcing Amazon Berkshire JP Morgan Joint Effort
  3. Amazon Healthcare Venture Upset Healthcare Executives

In January of 2016, Amazon, Berkshire Hathaway and Chase announced the formation of a new  ‘Amazon healthcare’ company aimed at lowering the cost of healthcare and increasing value to their employees. Conceived as a joint idea between CEOs Jeff Bezos (Amazon), Warren Buffett (Berkshire Hathaway) and Jamie Diamond (Chase), the venture is aimed at bringing healthcare spending under control internally after the failure of the US government to find a meaningful solution to unsustainable healthcare inflation. In this episode, Dr Roussel provides his reflections on the potential disruption of such a venture for healthcare delivery in the US, including its potential to separate primary care from fee for service healthcare, to disrupt the current healthcare networks that dominate the market with a reference-based payment system and to push down prices for prescription drugs that have been inflated by multiple layers of intermediaries. Furthermore, Dr Roussel provides some reflections on the importance an ‘Amazon healthcare’ venture could have on the DPC community.

Last January Amazon, Berkshire and Chase announce the formation of a new ‘Amazon healthcare’ company to provide healthcare to its employees. I learned about this project from talking with Dr Garrison Bliss, and while at first the venture’s importance wasn’t quite clear to me, the more I’ve learned about it, the more that the venture has the potential to affect healthcare in a transformative way. The project is an effort by CEO’s Jeff Bezos, Warren Buffet and Jamie Diamond to approach healthcare the ‘Amazon healthcare’ way, lowering cost and improving value, in the wake of our government’s failure to accomplish any meaningful healthcare reform. Certainly many details are TBD, however the combined efforts of three talented companies—Amazon, who specializes in logistics; Berkshire Hathaway, who specializes in insurance; and Chase, who specializes in finance—along with the capital they have access to has potential to foster disruption on a large scale with a customer orientation not heretofore seen in healthcare.

While the project is early on, there are several likely outcomes of the project so far.

  1. To start, the ‘Amazon healthcare’ venture is likely to have a heavy up-front investment in primary care. This is evidenced by the fact that they hired a doctor from Iora Healthcare to head the project. Also, these companies are likely well aware that heavy investment in primary care leads to better outcomes. Finally, in Bezos’ own words, they want the venture to be free from “profit-making incentives” that currently is the status quo of the present-day healthcare market.
  2. The venture also has the potential to dramatically alter the way that claims are paid for healthcare services. Whether or not they will construct healthcare facilities is unknown, but they will have to handle paying for services outside of their system. It is not inconceivable that they could create a reference based payment scheme that forces a degree of transparency not currently witnessed in our healthcare system.
  3. Finally, the venture has within it the potential to dramatically reduce the price of prescription drugs available to employees. Bezos has indicated his interest in selling pharmaceuticals independent of the venture, and certainly Amazon’s expertise in creating transparency in the retail market is likely to be exercised in cutting out much of the waste in prescription drug prices.

What this means for DPC is in some ways TBD but there are several potential outcomes.

  1. A major ‘Amazon healthcare’ plan that pays for primary care separate from the fee-for-service based payment could create a more favorable environment for primary care payment totally independent from the rest of healthcare services.
  2. This project has the potential to create a network-free means of payment for healthcare services. With a large company that pays for healthcare services independent of a network this could force other suppliers of services (eg mainly hospitals) to be far more transparent about their price for services as opposed to their current inflationary and protectionist modus operandi.
  3. There is much potential to cut out waste when it comes to prescription drug pricing. This can help lower premium cost and make payment for prescription drugs outside of premiums far more reasonable. PBMs and Retail pharmacies have much to fear in this venture.

I certainly recognize that these projections are quite speculative, but I do think the companies are onto something and their joint venture has the potential to have a substantive impact on DPC.


JP Morgan Chase
Berkshire Hathaway

Related Episodes

Episode 33

Episode 42: The DPC Summit Pre-Conference (2018)–with Bethany Burk and Larry Bauer


  1. DPC Summit Pre-conference
  2. FMEC
  3. HealthTeamWorks


Key among issues facing the Direct Primary Care movement is the ability for employers to find meaningful insurance options that pair up with DPC services.  The 2018 DPC Summit pre-conference deals with just that, making it not only a healthcare conference but in many ways a HR conference. This conference brings together employers interested in reforming their benefits offering to lower cost and improve value and DPC doctors interested in providing high-quality, relationship-based primary care to patients outside of the fee for service environment. By bringing together both stakeholders involved, the conference hopes to catalyze these relationships as part of the transformation that needs to take place to grow DPC. The more that employers can learn about how their healthcare dollars are spent and the more that doctors can learn about the needs of employers, the more they can work together to improve value and lower costs. In the Episode Mr Larry Bauer, Chair of the FMEC, and Ms Bethany Burk, Summit coordinator, talk about the details of the Summit pre-conference and its importance to the conference as a whole and to the DPC movement.

Time Stamped
[02:35] Larry can you tell us about the pre-conference? Where is it? When is it? What does it deal with?
[04:40] Is the format going to be talks, breakout sessions or both?
[06:18] FMEC’s previous experience facilitating HR conference with DPC doctors
[07:11] How will the pre-conference tie into the official DPC Summit?

Larry Bauer, FMEC
Bethany Burk, AAFP


Larry Bauer is the Chair of the Family Medicine Education Consortium. A staunch supporter of Direct Primary Care, he has played an integral role in organizing previous DPC Conferences.


Bethany Burk is a quality specialist with the AAFP and is the current 2018 DPC Summit coordinator, a role in which she has served for the past 5 years.

Related Episodes

Episode 7 (link on its way)

Episode 33

Episode 41

Episode 41: The DPC Summit Healthcare Conference 2018–with Bethany Burk and Dr Kylie Vanaman


  1. The DPC Summit
  2. AAFP


Every year Direct Primary Care doctors from around the country come together at the annual DPC Summit to support DPC doctors—present and future—as well as to grow the DPC movement. It is now in its fifth year of operation and is now likely the fastest growing healthcare conference 2018 has to offer. The 2018 DPC Summit will take place in Indianapolis, IA on Jul 13-15. In this episode, Dr Roussel interviews Bethany Burk, DPC Summit coordinator, and Dr Kylie Vanaman, DPC doctor and DPC Summit steering committee member, about the 2018 summit. In particular they not only discuss the summit logistics but also new focuses on this year’s summit including an increased focus on collaboration with employers and employee benefits consultants. Finally, they also discuss the importance of the summit to the state of the DPC movement, which continues to gain traction.

Key Questions for Discussion

[02:22] To begin, Bethany can you give us a run down of the DPC summit healthcare conference 2018 agenda? Where is it, when is it and who’s invited?

[3:37]  Can you tell us some of the highlights of the healthcare conference?

[04:55] Dr Vannaman, as a steering committee member, what are you trying to focus on in the DPC healthcare conference 2018 that distinguishes it say from 2017 or 2016?

[06:46] I noted in this year’s agenda a focus on DPC as an employee benefit. Can you tell us about some of these talks that deal with the HR side of DPC?

[09:41] Do you see attention to DPC as an employee benefit as a sign of DPC’s growth?

The DPC Summit Healthcare Conference 2018


Bethany Burk is a quality specialist at the American Academy of Family Practice and is the coordinator for the DPC Summit.

Dr Kylie Vanaman is a DPC doctor who has a practice in Kansas City, Missouri and sits on the steering committee of the DPC Summit Healthcare Conference 2018.


Related Episodes

Episode 7 (link on its way)

Episode 33

Episode 42 (link on its way)


Episode 40: The Surgery Center of Oklahoma–with Dr Keith Smith

Episode 40: Bundled payment & The Surgery Center of Oklahoma–with Dr Keith Smith


  1. The Surgery Center of Oklahoma
  2. Time Article on The Surgery Center of OK
  3. Business Insider Article on The Surgery Center of OK
  4. Dr Keith Smith on Fox Business
  5. Dr Keith Smith on CNBC
  6. Dr Keith Smith on ReasonTV
  7. Dr Keith Smith on Capital Account


For most healthcare procedures, the markets have been marked by obscurity and dramatic overpricing. Separate bills from the anesthesiologist, surgeon and hospital combined with extreme price exaggeration often leads to sticker prices for procedures far above fair market value. This leads to increased premium prices and unaffordable procedures for the uninsured. The Surgery Center of Oklahoma is changing all of this by bundling payment to the surgeon, anesthesiologist and facility and kicking out insurance companies. In this episode Dr Keith Smith, co-founder of the Surgery Center of Oklahoma explains how bundling payment and not taking third party reimbursement has allowed them to lower prices for surgeries sometimes by a factor fo 10. As a consequence they’re now forcing other hospital systems to follow suit and be more transparent and fair about their prices. As well, Dr Roussel and Dr Smith also discuss how DPC and the Surgery Center of Oklahoma can collaborate to lower cost and improve value by focusing on transparency and relationships and minimizing third-party involvement in healthcare.

Time Stamped

[02:52] What was your inspiration to start the Surgery Center of Oklahoma?

[05:05] So the Surgery Center of Oklahoma has really been a trend setter in terms of cutting costs. Can you give us some examples of how you’ve been able to save people money on surgical services?

[07:45] How are you able to cut costs for these services?

[10:57] How do patients pay if no insurance is accepted?

[14:50] So this podcast is about DPC, which is somewhat distinct from ambulatory surgery, but I find your work very relevant to DPC. DPC lowers costs by breaking down the barrier of 3rd parties and restores the doctor patient relationship. How can DPC and Surgery Center of OK, or other surgery centers who are interested in adopting a similar model, work together to lower costs and improve quality?

Dr Keith Smith


Dr Keith Smith is an anesthesiologist who co-founded the Surgery Center of Oklahoma after seven years in private practice. He has been featured on Fox Business, ReasonTV, CNBC and many other major media outlets.

Related Episodes

Episode 15

Episode 39: Q&A: How Rural is Too Rural for DPC?


  1. Dr Roussel’s Presentation at the DPC Summit 2017 on DPC in Rural America
  2. DPC: A Consideration for Rural Health
  3. DPC: Improving the Doctor Patient Relationship


As many doctors in rural communities consider closing up shop or selling out to major hospital systems, some are considering a third path: Direct Primary Care (DPC). Yet as a new model, DPC also carries with it uncertainties of sustainability and viability, especially in an unpopulated area. In this episode, Dr Roussel discusses key factors to consider when operating a rural area. In particular he elaborates on the question of what population size is needed to sustain a rural DPC practice.



Time Stamped


[0:56] Last week I received a question from one of our listeners who asked:


  1. “How rural is too rural for DPC?”
  2. “Is there a suggested amount of eligible people in a certain radius [needed to start a DPC practice]?”


[1:07] These are interesting questions and I think ones which many docs in rural areas are asking more and more right now as they either close up shop or sell out to a big hospital system.


To start, just looking at Dr Phil’s mapper, there are many rural DPC practices in small towns throughout the US, not to the point of finding any in rural AK but certainly in rural towns to the likes of:


Kamuela HI, pop 9200

Emerald Falls MN, pop 6k

Garden City, KS pop 26k

Sandpoint ID, pop 7900

Cortez CO, pop 9K

Nashville GA, pop 4600

Ketchum ID, pop 5500


And many more.


[2:00] Now just because a town has a DPC practice isn’t necessarily an indicator of how well the practices are faring in terms of enrollment, but having spoken with many DPC docs who have rural practices, eg Dr Vance Lassey.


And having a rural DPC myself


[2:17] DPC is certainly possible in rural communities, but how rural likely depends on several key factors;



  • [2:27] Proximity to other healthcare providers


      1. If a DPC practice is the only show for 100 miles. It doesn’t matter who or how the payment model is, patients will find a way to pay.
      2. On the other hand if there’s multiple other options for primary care within driving distance, the population may be less willing to go to a DPC


  • [2:48] Position in the community


      1. The rural doc who’s been there forever and is trusted by the community is simply going to have a much easier time than the doc who is starting from scratch
      2. I learned this having been the doc who started from scratch.
      3. Not to say that it can’t be done, just takes longer to grow


  • [3:10] Insurance status of people in the area


      1. If the population is predominantly Medicare/Medicaid it’s going to be harder. Not impossible, just harder, based on what we’ve learned from other DPC practices


  • [3:29] How big a DPC practice needs to be to break even.


    1. Even in the best case scenario, only a fraction of town members who have healthcare needs will sign up.
    2. Certainly possible in a town of 1000 that a DPC doc could make it work if he or she is the only doc in town.
    3. Going to be much harder if there’s another doc who takes insurance in a town of <5,000.


[3:53] The point is that DPC is certainly possible in many remote situations, and certainly with Medicare/Medicaid pilots on the horizon, is only likely to become more likely that rural America has access to a rural DPC, as more docs and patients realize the beauty of going direct.


Related Episodes

Episode 23

Episode 3


Episode 38: Iora Health–with Dr Rushika Fernandopulle


  1. Iora Health
  2. Iora’s collaboration with Humana Medicare Advantage
  3. Iora raises $100M to expand

Iora Health is a company based out of Cambridge, MA that provides DPC services to larger companies. Starting out seven years ago as a DPC practice serving individual pateints, Iora has since moved to focus on employer groups to the likes of Boeing, Dartmouth College, casino workers of Atlantic City, Medicare Advantage patients and many many more. Dr Rashika Fernandopulle is the founder of Iora and now serves as their CEO. In the interview they discuss how Iora got involved in serving employer groups, how going direct has allowed them to improve quality and lower cost for their clients, and howe their collaborations with employer groups can serve as a model for other DPC practices and businesses to form partnerships in the future.


Time Stamped


[2:54] So, to start, can you tell me about the name Iora. Where did it come from?

[3:47] When did Iora start? And how did Iora get involved in employer contracts?

[6:17] What’s the average number of lives covered in a contract? What is the scope of the services in the contract?

[7:39] As mentioned earlier, for many Iora would not pass the litmus test of DPC, but there are many ‘direct’ elements of the care you deliver that differs markedly from the status quo. How does Iora consider itself similar/different to/from DPC?

[9:14] Importance of what Iora is doing to the DPC movement.


Dr Rushika Fernandopulle


Dr Rashika Fernandopulle is a primary care doctor who completed his training at Harvard Medical School (HMS) in Boston, MA. He started Iora as a way to offer high quality, relationship-based primary care free from the constraints of fee-for-service based care. He now serves as the CEO of Iora in addition to being a primary care doctor.


Related Episodes

Episode 35

Episode 36

Episode 37

Episode 37: The DPC Friendly Broker–with Mr George Claassen


  2. Gold Direct Care

Mr George Claassen is one of those exceptional insurance brokers who not only has come to embrace Direct Primary Care (DPC) but also to focus on DPC as the target market of his insurance firm. Self-titled the “DPC Friendly Broker,” Mr Claassen found in DPC a solution to the unsavory options he had available to offer his clients for healthcare coverage. Starting out working with Dr Jeff Gold of Gold Direct Care in Marblehead, MA, Mr Claassen has come to work with many DPC doctors throughout the Northeast. He now focuses on direct primary care patients and doctors, working together with them to find insurance options that can supplement DPC practice membership. In the interview they discuss how he works to pair DPC with wrap-around insurance coverage, what kinds of plans he offers and how DPC doctors can work with other brokers to provide primary care and insurance to pair with DPC membership.



Time Stamped

[2:15] Mr Claassen can you tell us a bit about how you got into being the DPC friendly broker?

[4:51] What types of options do you offer to pair up with DPC membership?

[6:40] What DPC doctors have you worked with?

[9:15] For patients and/or doctors who are looking for a DPC friendly broker in their area, where would you suggest they look?

[12:36] For brokers who want to learn more about DPC, where would you suggest they look?

[13:37] Why the ‘old way’ of offering group plans as a broker doesn’t necessarily serve the needs of the employer.


Mr George Claassen


Mr George Claassen is an insurance agent who lives in Maine. He works with DPC doctors to help them find small to medium sized businesses who are interested in pairing DPC with wrap-around coverage. He can be found at the


Related Episodes

Episode 35

Episode 36

Episode 38

Episode 36: DPC as an Employee Benefit–with Suzy Johnson and Rachel Miner


  1. Employee Benefits Advisors of the Carolinas
  2. Employee Benefit Advisor Magazine
  3. Suzy’s article on why benefits advisors should offer DPC as a benefit

As the Direct Primary Care (DPC) model takes off, many in the employee benefits world are continuing to grapple with Direct Primary Care as an employee benefit. While many brokers struggle to find a place in their offerings for a benefit that (usually) provides no commission, some benefits advisors have fully embraced DPC, recognizing the value it provides to their clients. Suzy Johnson and Rachel Miner are two such brokers who have embraced DPC as an offering to their clients and have worked to adjust their insurance plans to pair with DPC. In the interview, Suzy and Rachel discuss how they learned about DPC, how they’ve come to embrace DPC as a model for their clients and how other brokers who are interested in learning more about DPC can follow suit.

Time Stamped

[2:25] Suzy, to start out, how did EB advisors get involved in working with Direct Primary Care as an employee benefit?

[5:48] How has your experience grown with direct primary care practices?

[8:02] Now Rachel, you have worked with self-funded plans that pair with DPC for some time. Can you tell me about how these plans work and how they pair with DPC?

[13:01] A reference-based self-insurance plan paired with DPC has considerable potential to lower cost for premiums. Why is this?

[16:24] Now, as I’m sure you’re both aware, DPC is very novel and many advisers don’t understand it well enough to know how it fits into the whole picture of health insurance. How would you advise a benefits adviser to learn more?


Suzy Johnson
Rachel Miner


Suzy Johnson is the President of Employee Benefits Advisors in Charlotte, NC. In addition, she serves as a Senior Benefits Specialist and an author for Employee Benefit Advisor magazine.

Rachel Miner is an Employee Benefits Strategist with Employee Benefits Advisors in Charlotte, NC. She has experience facilitating DPC membership as an employee benefit and in crafting wrap-around plans to pair with DPC membership.


Related Episodes

Episode 35

Episode 37

Episode 38