Season 1: Episode 11 – Cost of Caring: The Personal Toll of Improving American Healthcare Innovation

Dear Healthcare It’s You: Episode 11

Elisha Yaghmai

It wasn't like, hey, you know, we're going to do we're going to go, you know, get ourselves into $500,000 worth of trouble, but we only have $70,000. It wasn't like that was like, you start off saying, how much is this going to cost? We need software that does this. How much is that going to cost? Right. Oh, you know, we'll put the whole thing together for $80,000, right?

Elisha Yaghmai

We'll get you we'll get you a basic, you know, working version of this, right? Yeah. $30,000. Right. $400,000 later, you still don't have it, right? You know, and so then you're like, you know, and as you're doing it right, one, you have the optimism of the venture itself, right? We're going to get there. We're going to get there.

Elisha Yaghmai

And it's always, okay. Now another month or two, we're going to get that. We're going to get there. and so you're spending and you're spending and you're spending in the hope that you're going to get to the to the goal, but you want and then you're going to be able to do all these cool things, right. So all these bills are accumulating.

Elisha Yaghmai

Right. And and while these are accumulating all, all your kind of savings, all our personal funds, everything else is going into this. Right. And disappearing in any number of ways.

Jo O’Hanlon

Welcome back to Dear Health Care. It's you. Welcome back to Dear Health Care. It's you. I'm here with Elisha Yang. My. And my name is Joe O'Hanlon. And we are continuing to go down the story of Alicia's journey through his medical journey, becoming a doctor. And then also, as we're in the story now, we're talking about as he was trying to start a telemedicine business and the hurdles that he's encountered.

Jo O’Hanlon

So if you haven't seen the past episodes, please feel free to catch up. They're all on YouTube and all podcast platforms, so subscribe if you haven't. And we're going to take a step aside today, actually from the, the actual like practical parts of the story in terms of how it all played out. And we're just going to talk about the human side of it.

Jo O’Hanlon

Alicia, you at this point, we've talked about the insurance battle and how long that went through so many hurdles that you had. you were not getting paid that whole time. You're just keeping this business afloat, basically. Is that accurate?

Elisha Yaghmai

That's pretty much right.

Jo O’Hanlon

Yeah. Medicare was starting to pay at some point when you got the workaround. But the private insurance. Yeah. Through how many years was it of like.

Elisha Yaghmai

Three from 2014 to 2019, there was basically no private insurance payment. And Medicare had some payment structures which they created, but no one for the first few years of the company, we had hired third party billing services. They couldn't figure out how to bill Medicare properly for telemedicine. So we would send them claims and they would be rejected.

Elisha Yaghmai

And the billing company had no idea how to fix them and would just dump it back on our plate and say, sorry, your claims are rejected. We don't know what to do. You know, it's your problem.

Jo O’Hanlon

And so the hospital was, we were the hospitals that you were working within during this time through the telematic process. Were they getting payment for these patient services? There were a.

Elisha Yaghmai

Variety of things going on. Some of them some of them were collecting a little bit of payment for what was called an originating site fee.

Jo O’Hanlon

Okay.

Elisha Yaghmai

So some of the insurers, Medicare at that point, mostly Medicare, had decided that there was some technology involved in doing telemedicine, so they would pay something called an originating site fee, which was supposed to offset the cost that the hospitals cost to have the technology to do a telemedicine visit, which you're already doing in in our case, right.

Elisha Yaghmai

We were paying for it. We were giving them the technology for free, and we were running it for free. We were sustaining all the expense of doing that. So they were just collecting originating site fees against nothing. and we found out, you know, some of the hospitals, for example, had started overcharging for the originator. So so they were they were charging they were charging the patient a fee to see the doctor.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So not not.

Jo O’Hanlon

Conversion.

Elisha Yaghmai

Not just paying as well. They were getting the original sexy but they would. So let's say the original site fee at that time was $20. So every patient sat in a chair. They get $20. They charge the patient $70.

Jo O’Hanlon

To sit.

Elisha Yaghmai

Sit in the chair to see the doctor, to then be billed by the doctor. Right. So yeah, you can imagine if you're a patient, you're like, why am I paying 70 bucks to see someone and then be billed by them, right? Not realizing this wasn't us at all. This is the hospital. Hospital? Some of the hospitals acting unilaterally.

Elisha Yaghmai

Yeah.

Jo O’Hanlon

And then would you try to build those patients like standard, you know, standard fee and then but I'm sure a lot of nonpayment because the.

Elisha Yaghmai

Vast majority was nonpayment. Yeah. It was just bills coming back unpaid. Yeah. Just denied. Just outright denied. And then and then the problem we'd mentioned last time, which was that with private insurance, we couldn't even bill them because they wouldn't acknowledge our existence. Right, right. By credentialing us to their panel. So we had no bill to send all the we could send them there just to say, we don't know who you are, right?

Jo O’Hanlon

Just straight back. Yeah. So in this time let's talk about just the stress on you. Obviously. we I had asked us before and so I know the answer is yes, but you took out your debt for this. I mean, was it did you start with medical school even? I mean, no, that's a place that a lot of people coming out of med school that I think a lot of us, we know that doctors have to charge a certain fee because it's like their education is so intense and requires so much payment for them to get that right.

Jo O’Hanlon

So you had medical debt to start this all? That's correct. And your wife is a physician as well. So did she have to? She had to. Yes. Collectively you guys had to doctors debt. did you have undergrad debt as well?

Elisha Yaghmai

I did not.

Jo O’Hanlon

Okay. Yeah. So had the medical debt. And then at what point did you have to start taking out a loan for the business?

Elisha Yaghmai

Yeah. So there was a series of progressions. So initially, so to start with, at the time this started, I think we owe besides our house mortgage, which is already that's one debt.

Jo O’Hanlon

You had a mortgage in Seattle and Seattle.

Elisha Yaghmai

Yeah. So we had that. We had that debt. And then we had, a medical school debt which combined with between the two of us was over $200,000. I think it was two 3240 something like that that we owed. Yeah. and so the very first choice in launching this whole thing was we had been saving money. Yeah, for years, since residency, since we started getting any kind of payment, we'd been saving money and we'd saved up a certain amount of money.

Elisha Yaghmai

And the goal was to try to pay off these educational debts, right. To remove those things and just cut it down to just paying the mortgage. So the first choice was, well, we have this money in savings, right? Do we use this to pay down the educational debt or do we use it to fund starting this venture?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So, the, the vast majority of that money went to actually initially to fund the venture. So the very first thing that we blew through was just our personal savings, like it was gone. Right? That was all gone.

Jo O’Hanlon

And that was as the business was already up and running. Or is that to like.

Elisha Yaghmai

And just to get it just to get it running. Because in the beginning, right, we didn't have we didn't have anything. So all that technology we talked about right. Giving people devices for free, you know, that money came out of initially it came out of my, my individual pocket. And then also, you know, the other people that joined in early.

Elisha Yaghmai

Yeah, some of their money went into it to, the majority of it by along by wide margin was mine. Right. But we were funding all of that. Right. And then we started doing development of software. And the reason we did that was because the third party software was not doing everything that we needed it to do clinically.

Jo O’Hanlon

In terms of like the stethoscope and things like that.

Elisha Yaghmai

Exactly. Yeah. So at that time, like hooking a stethoscope into telemedicine software was not a commonly available thing at all, especially the types of software that are being used at that time. So we had to develop that. Right. So there were software development costs that went into it. Right. And in each situation, you know, it was like a lot of things.

Elisha Yaghmai

It was it wasn't like, hey, you know, we're going to do we're going to go, you know, get ourselves into $500,000 worth of trouble, but we only have $70,000. It wasn't like that was like, you start off saying, how much is this going to cost? And we need software that does this. How much is that going to cost?

Elisha Yaghmai

Right? Oh, you know, we'll put the whole thing together for $80,000. Right? We'll get you we'll get you a basic, you know, working version of this. Right. For $80,000. Right? $400,000 later, you still don't have it, right? You know, and so then you're like, you know, and as you're doing it right, one, you have the optimism of the venture itself, right?

Elisha Yaghmai

We're going to get there, we're going to get there. And it's always, okay, another month or two, we're going to get that. We're going to get there. and so you're spending and you're spending and you're spending in the hope of that, you're going to get to the to the goal that you want, and then you're going to be able to do all these cool things.

Elisha Yaghmai

Right. So all these bills are accumulating. Right. And and while these are accumulating all, all your kind of savings, all our personal funds, everything else is just going into this. Right? And it's disappearing in any number of ways. And it wasn't even just there. I mean, when we were starting out, for example, the legal structures surrounding all of this were very new.

Elisha Yaghmai

Yeah. Nobody knew how to how to set up. How do you do a telemedicine practice, for example? How do you do that? What are the stark laws related to this? You know, how does all the billing work? How do you structure these kinds of agreements with hospitals? Because it's different than what has been done before. So you're spending a bunch of money on legal trying to figure this out from scratch, right?

Elisha Yaghmai

All of these things are just you just hemorrhaging cash, basically.

Jo O’Hanlon

Because it's not just starting a new business, which is always a losing. I mean, almost always a losing venture at the start. You know, usually first three years you don't make a profit, but like, you're having to be a pioneer for a brand new type of business.

Elisha Yaghmai

That's exactly the thing. Yeah. It wasn't like we started a, you know, making selling sunglasses, right, where everybody kind of knows what selling sunglasses is. And you just another entrant in the market. It's like in a lot of cases we're going there and saying, you know, how do we structure this? Right. And the attorneys are like, we don't know.

Elisha Yaghmai

We never even seen this before. Right? We don't know. We have to do some research and figure this out. And then we're trying to create software structures in some cases which either didn't exist or, you know, pretty rare to find.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So then there's research and work that has to go into that. So it's a lot of that sort of startup and research and development cost. Right. That goes in that just vacuums up, you know, your cash.

Jo O’Hanlon

Were you anticipating some of that. All of that like was a shock to you at some point to be like, oh my gosh, I thought we'd be making money by now. Like was it. Yeah. What was that.

Elisha Yaghmai

Like? The shock I think was, as I kind of alluded to in a previous episode, was that I didn't go into this sort of Pollyanna style. Right. Like, oh, it's also going to work out. Right? Right. I went into it. I had set up pro for I had multiple pro formas, right where you lay out all which you think are all the details.

Elisha Yaghmai

Right? Okay. So I research okay. So what are all the codes? you know, how much is each one pay, right. how many, you know, how many of these should we expect a day? How many people are there, like in rural Kansas? How many actual people are there? Okay, what do we know about the need for this type of doctor relative to a population size?

Elisha Yaghmai

Right. So if I have 100,000 people, how many rheumatologists do I need for 100,000 people? Right, right. I had researched all of this stuff. Right. And I had it in these very extensive spreadsheets, which I did and then redid and then read it again and then read it again, you know, and I was estimating, you know, 0.1% growth, you know.

Jo O’Hanlon

Right.

Elisha Yaghmai

You know, per per the time period was several months or something. So I try to be as conservative as I can be. Right. And I was like, with all of that together, we should still make it. Like even with these expenses, we should still make it like all we need to do is just be able to send out our bills.

Elisha Yaghmai

And then the problem came about because we couldn't figure out how to bill Medicare, decided that for, telemedicine, billing was the exact the way to build them was the exact opposite of how every other Medicare bill was sent. It meaning you normally would bill, by where the where the patient was.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Like where they were located and Medicare cited for telemedicine. You bill by where the doctor is. No one knew this. No one knew this. So they're sending the.

Jo O’Hanlon

Claim is one standardize for one hospital.

Elisha Yaghmai

They're sending the claim and doing it the way they've always done it for Medicare and getting denied. And not understanding why they're getting denied. It's because the procedure by which Medicare is chosen for the to to pay these was different, or the information they were requiring was different than anything that had previously been done. So that was one.

Elisha Yaghmai

And then on the other side was like I said, before you research out the private insurance policies and you said, you know, okay, we check all the boxes, right? We should be good. And then you go there and then they're like, now we don't want to talk to you. And we're not paying you.

Jo O’Hanlon

Right, right.

Elisha Yaghmai

So then all of a sudden it's like, oh, okay. So we're seeing these patients and then there's $0 coming back. And then we have committed to the physicians saying, yeah, you know, how.

Jo O’Hanlon

Am I going to pay you. Right. How many physicians did you yeah.

Elisha Yaghmai

I think at that point we I think we started we had 25 specialties when we started. Right. So there's a lot of people. Yeah. Right. And what we were doing was we had said, hey, this is a startup venture. We don't, you know, it's going to take a while for people to adopt it. So give us availability. We will pay you to be there.

Elisha Yaghmai

We're not paying you per click, which is what a lot of services do. We're not paying you per click. We're going to pay you for your time. So if you sit there for hours and nobody shows up, we will pay you for four hours, right?

Jo O’Hanlon

Like a clinic model?

Elisha Yaghmai

Basically. Yeah, it's a clinic model. This is what we went with, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So so here again right. We're rolling this out. And then, you know, some people are coming and then we can't get paid for any of that. And then you know, then the hospitals are doing their high jinks with whatever the fees to see the doctor. Right. And trying to exploit that. And then fewer people are, you know what I mean?

Elisha Yaghmai

All of this is happening, things that you couldn't necessarily anticipate.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

and, you know, and you're just and so the cash is just flying out the door, right, with no revenue coming in against it, even though theoretically there should have been.

Jo O’Hanlon

And you were working in this venture full time at this point as well, right?

Elisha Yaghmai

No. So to start it was to start it was a side. So I was still working a medical job. I was working employed medical job. What happened was as the savings all went away, right then what happened was all basically all the money that I was making from my real job. Right? All of it was going not to not to the family bank account, not to anything.

Elisha Yaghmai

It was all going into the business. Right? Yeah. so all of that was there. And then on top of that, that still wasn't enough money, right? So then I was moonlighting, right? So I was I was basically taking up side jobs, like side hustles on top of my medical job. Right? I was doing all this.

Jo O’Hanlon

Stuff on top of your medical job and your other.

Elisha Yaghmai

Job. So I'm doing the administrative side, trying to run this business. Right. I am, I'm doing all the sales calls. I'm driving all over the place, flying all over the place, trying to sell this thing and demonstrate the.

Jo O’Hanlon

And while you're still in Seattle, you're flying to Kansas and then driving all around.

Elisha Yaghmai

Flying back and forth, recruiting, driving all over. Yeah. Doing all this kind of crazy stuff. I'm doing all that working my full time job also have side hustles going on. And this went on for years. Right. And all of all of that money.

Jo O’Hanlon

All those years.

Elisha Yaghmai

So I flew back and forth. Yeah. So we we came back to Kansas in 2015. Right. So 2014 into to to the last quarter of 2015. Basically we're still coming back and forth from Seattle.

Jo O’Hanlon

Right?

Elisha Yaghmai

Right. In 2015 we were we were living in Kansas again. Okay. So at least I didn't have to do the flying right. But I'm still driving all over the place trying to run the business, trying to set up all these other structures that you need to run a business, trying to set up all the clinical aspects of what's going on.

Elisha Yaghmai

Right. doing all of those things and then also doing a full time medical job and then also moonlighting on the side and all that cash is just dumping into the, into the, into the money pit of the business. Yeah.

Jo O’Hanlon

Are your partners in similar positions where they also like just not profiting off of it at all and just giving everything.

Elisha Yaghmai

They want to profit? Yeah. So they had foot in. Each one of them had put in a fixed amount at the beginning. Yeah. The ongoing cash outlays basically were mine. Like that was that was my responsibility. So they had I think different they had different situations. So each one was in kind of a different place in terms of where they were in life.

Elisha Yaghmai

But long story short is they kind of put money in. And then that was more or less the end of their financial contribution. They were still helping out in other aspects of the business. There were lots of other things were going on. There was quite a bit of work that was going on, particularly the technology side.

Jo O’Hanlon

Right? Yeah.

Elisha Yaghmai

things like that sometimes on the sales side. Right. So people were putting in effort in those ways. but, but financially, you know, the, the bulk of the weight of that sled was made.

Jo O’Hanlon

Yeah. Did you feel alone in it initially?

Elisha Yaghmai

No. Initially, no. as things got worse and worse and worse. Yes. Yeah, I would say, you know, certainly, you know, we got to kind of the worst times in it. Yeah.

Jo O’Hanlon

That time, I mean, like you were doing so much to which even for just one physician job, like we've already talked about often, it sounds like there's overwork involved. Yeah. To do it to the due diligence point that you like to do it to and feel compelled to do it too. So, like, how much were you sleeping?

Elisha Yaghmai

like during workweeks? Two hours, two hours a night.

Jo O’Hanlon

Two hours a night. Yeah.

Elisha Yaghmai

Yeah, I would work.

Jo O’Hanlon

How are you functioning?

Elisha Yaghmai

I mean, it's a good I mean, optimism and.

Jo O’Hanlon

I really like that. Was it?

Elisha Yaghmai

No, it was challenging. It was not.

Jo O’Hanlon

Easy. Like, would you have a day off and then just have to sleep the whole day, you know, or.

Elisha Yaghmai

No, there were no, there weren't days off. It was just you just grind it out and you grind. And I mean, the motivation at the time, thinking back on it, besides the general insanity of it was, hey, we have a goal. I mean, you know, like I mentioned before, right at that time, we were looking at it like, hey, we solve this access thing, right?

Jo O’Hanlon

I was going to say you felt very, very convicted that it was it was for the better good of the whole system. Yes. You were working for it.

Elisha Yaghmai

That's correct. Yeah. And that I mean, that is I think anybody that's been in that position, I think can testify to it. It's very motivating. Right. And you find out in those situations what you're capable. These are.

Jo O’Hanlon

Like.

Elisha Yaghmai

When you're really motivated which capabilities are right. And it was that kind of thing where it's like on the one hand it's miserable. It's horrible. On the other hand it's like, well, I'm trying to drive toward a goal that I think is useful, right? And that will get you through a lot. That will get you through a lot.

Jo O’Hanlon

Which, as you've talked about in many different forms throughout our time together, is so far like doctors in general, many of them, a stereotype that you've put forth is that, you know, there's a there's an, a level of achievement like that's a thing that you chase. And I think that that's a true thing for our human capacity is that many of us don't know how much we can achieve, because we won't push ourself into the discomfort or the extreme.

Jo O’Hanlon

I mean, the extreme realms that you're talking about. So I do understand that, that it can be quite compelling to those that want to see how much they can accomplish. And is that somewhat like you started your journey wanting to go into international medicine based on your time that you had in West Africa? Yeah, and I don't know much about your chapter in West Africa.

Jo O’Hanlon

How extreme and extreme your, circumstances were there. But obviously in many, you know, foreign settings for medicine, there's a lot of need and a lack of resources. So there's a lot of stretching. Yeah. Is that something that was it, like, fulfilling something in you that had been there this whole time that you'd wanted to stretch yourself since then?

Elisha Yaghmai

I think the, I think on a, on a personal basis, I, I have always been a, I'm not motivated. I'm not motivated by fear.

Jo O’Hanlon

Yeah, right.

Elisha Yaghmai

So I'm more motivated in a positive way. Right? I have to love the thing. Right. And so on a personal basis, I think it was so much of medicine prior was, obligatory. Right? It's obligatory. And it's,

Jo O’Hanlon

And what do you mean by obligatory?

Elisha Yaghmai

You have to do this, right. You have to take this test, okay? You have to pass through this rotation. You have to do this thing. You have to do this to get to the next thing. Then you have to do this to get to the next thing. Right? And then suddenly, you know, in this period it was like, you don't have to do this.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

But you want you I wanted to do this right. And I want to do this because I feel like it actually makes a difference. Right. So it's kind of taking all that problem solving impulse. Right. This is this is in a lot of ways, this is kind of a tragedy of modern American medicine, right? We take people that on average, you know, reasonably intelligent people.

Elisha Yaghmai

They like to try to solve problems. Right. And we paint them into these really tiny boxes, and we put all these constraints around them. Right. And then we're like, why are you unhappy?

Jo O’Hanlon

Right. You know.

Elisha Yaghmai

Like your joy is to go fix things. Yeah. We're not going to let you fix anything really. Right. You can only do it within these kind of these limits and at these times. And these were and this was like, hey, all that, all that's off, right? This is we're trying to do a thing that is not not really been done.

Jo O’Hanlon

Right.

Elisha Yaghmai

We have to figure all this out from scratch.

Jo O’Hanlon

Yeah, right. So in itself, I think to you sounds like it was exciting at the onset. It was. Yeah. And then now when we're talking about, you know, in the midst of it, you're getting two hours of sleep, I'm imagining your health was declining in ways that you maybe could notice, maybe couldn't. Yeah. Some like where you eating health healthy stuff to help you sustain.

Elisha Yaghmai

Was I eating is probably the question. Yeah a lot of times no no I mean I go in all day and not eat anything. I mean there is no time.

Jo O’Hanlon

Because like, that sounds so much worse objectively than some of the things that you have rightfully so, labeled abusive tactics or expectations that you experienced prior in different settings. And then this was you imposing this need on yourself in some ways. But and that's where it sounds like, you know, you you found something you believed in enough to make you want to push that hard.

Jo O’Hanlon

Yes. And to make it worth it. But, was there ever a point that it felt like it was not worth it?

Elisha Yaghmai

There were times when I think the question, the question I had was, I think I to this day I'm like, I think this is the right thing.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Maybe I have just come too early.

Jo O’Hanlon

Yeah. You know.

Elisha Yaghmai

Like, this is just weird. And that happens. Right? Right idea. Wrong time. Sure. the problem and in the funny thing is, like, you know, you read business literature, right? You know, market product, market fit, timing, the smart thing to do from a business perspective was to look at it and say, yeah, we're a little early, let's cut our losses, right?

Elisha Yaghmai

Just go back and wait.

Jo O’Hanlon

Right.

Elisha Yaghmai

Maybe we'll reincorporate something in a few years and try again.

Jo O’Hanlon

Yeah, right.

Elisha Yaghmai

But the problem with it was that mixed into that and this is this is the soul of the issue, right? Mixed into that business imperative was the medical imperative. We know that we can fix a serious problem in health care.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

We know this. How do we pretend we don't know?

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

So how do we go back? How do we go back to the line?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And keep doing what we've been doing when we know that we could be doing better than that and that there are real people who will be harmed by our failure to stick this out, that's. You know what I mean? That's just a psychologically, it's a very different position to be in.

Jo O’Hanlon

Right?

Elisha Yaghmai

And that was part of the problem here. Right. So is how do you quit that.

Jo O’Hanlon

And pretend like you don't know it and.

Elisha Yaghmai

Pretend you don't pretend you don't understand what you have done.

Jo O’Hanlon

Right. Yeah. I mean, can I ask this question and you can feel free to say no, but, did you deal with depression during this time?

Elisha Yaghmai

No. no, I wasn't depressed. I was angry a lot. But at the circumstance, you know what I mean? At the this just very, you know why? Like, why is this so hard? It shouldn't be this hard. It shouldn't be this, you know, why are we having to fight? So fight these people to try to help them, right.

Elisha Yaghmai

Save money. Right? Right. That those kinds of things were going on. But no, it wasn't it wasn't a depressing thing. I mean, it was again, that's sort of.

Jo O’Hanlon

Like you had that mission that.

Elisha Yaghmai

There's a mission inside of you. Yeah, yeah. Which I think people need, you know, that's. Yeah, that's one of the things I realized from this. I was like, you need it. You need some kind of meaning in your life. Right? And this, this supplied that to some degree.

Jo O’Hanlon

Yeah. Which is really interesting to hear because just on a on a side note, I mean, you started this saying that you didn't really have much thought about going into medicine. It was just kind of like the hierarchy of education. And so you just went went that way. You wanted to help in some way, and that was a practical way you could help.

Jo O’Hanlon

And then through this chapter, it sounds like that's really what helped solidify was like you pushing yourself or, and, or being pushed to such a far extent of just stretching yourself. So then. Yeah, but you needed to find that thing that you were like, yeah, passionate enough about to do that for.

Elisha Yaghmai

I mean, it would to kind of go sort of back to what that drive was. So at one point I realized, okay, we we're not we're not making any we're not able to make any money doing virtual visits. Right. So but they'll still pay us to do in-person care.

Jo O’Hanlon

Yeah. The traditional.

Elisha Yaghmai

Model. So one of the problems which we talked about in a previous episode, right, that a lot of the little rural hospitals had was, trying to transfer patients out. Very difficult process, lots of phone calls, lots of phone tag, waiting around, getting punted, getting excuses. Right. So I came up with the idea of something called the Rural Transfer Service.

Elisha Yaghmai

And the purpose of that was basically to make it easy for rural hospitals to transfer patients. And the reason was we had admitting privileges at some of the hospitals in Wichita.

Jo O’Hanlon

so what does that mean? Admitting privilege.

Elisha Yaghmai

We have the ability to admit patients to the hospital and care for them there. We didn't have to ask someone else to do that, right? The rural hospitals, the providers out there don't have those privileges, so they have to call the big hospital and say, Will you please accept my patient? And they can say yes or no, right?

Jo O’Hanlon

And just because of your former relationships and or we can.

Elisha Yaghmai

We're living in the town, right? We had all the qualifications to be able to do this. Right. So we have those privileges. So the thought I'd had was, well, wait a minute, you know, why don't we just start doing this like, rather than when we were caring for people virtually, sometimes they would need a bigger hospital to do whatever was going on, and we would have to call and we'd go through the same song and dance and games that we had already experienced.

Elisha Yaghmai

So I had the thought, well, you know what? We need money. We need to get some revenue in here. And seeing patients in person, they'll pay us for that. So why don't we start taking that taking that on. Right. So basically, rather than having to call the hospital and go through all the stuff, just call us, tell us about the patient and we'll handle it from the we'll we'll get them admitted.

Elisha Yaghmai

We'll do all the backend work for you, the rural hospitals. So you don't have to do this.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And that worked.

Jo O’Hanlon

Where many of your doctors.

Elisha Yaghmai

Actually, you know. No, none of my partners were here. there were a few other docs that were working with us. That's not correct. I'm sorry. One of my partners was here. The rest were not. Okay. but there were other docs that were working with us at that time. One doc had recently joined us to do this.

Elisha Yaghmai

so this process starts, we start bringing in patients this shortly after this, we had one of the worst flu years that we'd had in in like a decade.

Jo O’Hanlon

Right.

Elisha Yaghmai

And so tons and tons of people were sick. Hospitals were full. It's crazy high volumes, and high acuity. So during that period, I mean, again, it was getting increasingly difficult to get much help. Right? So I was doing the bulk of these. So these admins would come in, I would go round in them, see them, you know, take calls, do all these kinds of things.

Elisha Yaghmai

And, you know, we have patients in the hospital, right? If you don't have coverage, you take the call 24 hours a day, right? No matter what's going on. So there was one period where I had, I did 72 hours straight right of just like, no, of just new admissions coming in. Right. And it was like.

Jo O’Hanlon

Two hours straight.

Elisha Yaghmai

I would finish one and then another one would come and then another one would come. And like, as I finished each one, the next one would come and the next one would come in, the next one would come and I just went for 72 hours like nothing. I was just clinical care for 72 hours all the way through.

Elisha Yaghmai

And over the years, you know, you know, after that, I mean, I had I had runs of 60 hours, I had runs of 50 hours, right where I was just doing this stuff. you know, and here I.

Jo O’Hanlon

Feel like that was.

Elisha Yaghmai

Wise. No, it was terrible. It was terrible. Yeah. And I mean, there's there's periods of time where I can't I can't quite, you know, like thinking back on it, like it's hazy, like my mind was hazy.

Jo O’Hanlon

So, I mean, they say that sleep deprivation, as I say, at some point, it has the same effect as. And yes, it does. Yeah.

Elisha Yaghmai

Yeah it does. that research was less, less well known at that point. But I mean, I could have told you subjectively, I was like, yeah, this doesn't, you know, don't feel good. Right. So, so I had, you know, episodes like that, I was having chest pain, like, you know, all this stuff is going on and I'm trying to, you know, do all of this.

Elisha Yaghmai

And again, why am I doing this? Right? It was not because, oh, you know, it is like I'm making tons of money and I love making money, right. It was like, because we need this to be able to keep, to buy another device to send out to whatever place. Right. But we need this to be able to pay our staff for another month.

Jo O’Hanlon

Right.

Elisha Yaghmai

You know, this was the this was the motivation for that kind of insanity. Yeah. which, you know, I think thinking about it now, I probably would try to find another way to. But it wasn't like I didn't it wasn't like I was asking for help. I was trying to find other, other things. And there was there was no help coming.

Elisha Yaghmai

Right? So it was like, either you do this or you don't, but but either you're like, it's on you, right? Know you're going to do it or you're not. And if you don't do it, then this is over, right?

Jo O’Hanlon

Yeah. So that was that was that thing with your partners where it was that they were drawing boundaries for themselves.

Elisha Yaghmai

Correct? Yeah.

Jo O’Hanlon

And you could have drawn those boundaries, but it would have meant the closing of the chapter.

Elisha Yaghmai

That's right. That was it. Yeah. This was going to be the end. Right. And there were a lot of episodes I'd say even. I mean, here again, why did we continue? besides, besides the sort of the mission and the stubbornness, there were just weird things that would happen. Like, we would get to. We would get to, like, the end.

Elisha Yaghmai

Like the end, the other, like, there's no more cash.

Jo O’Hanlon

Yeah, there's.

Elisha Yaghmai

You know, the debts are too high. and then something would happen kind of out of the blue, like there was one. We were about. We were about dead. And I met my friend at a some event. I met, a doc that was working. He was working in rural. He's, like, managing rural hospitals. Right. And we just.

Elisha Yaghmai

I forget how we even started talking. We struck up a conversation. He was like, you know, this sounds really interesting what you're doing. You know, maybe, like, you could help us out. Right? And this ended up leading to an agreement. Right. And that agreement came like within within like a week or two of when it was like this, this was going to be the end.

Jo O’Hanlon

Right. Well.

Elisha Yaghmai

And that that kind of thing kept happening. And the way I described a lot of times, it was like it was like it was like we were, you know, we were kind of code blue, right? And we were about to call it and say, this is the end.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And then, you know, all of a sudden, like the pulse would come back and that happened 2 or 3 different times, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So again, you know, you can kind of, you know, call it what you want. It it was like, this keeps almost dying, but right about not dying, being resuscitated. So maybe we need to keep it going. Right. We need to take this as a sign that we're doing something that we should be doing. You know what I mean?

Elisha Yaghmai

Yeah. Get it interpreted in whatever way you want to. Or maybe just random random luck, whatever it was. Right? Random bad luck, actually, given how it went. But, but that was that was part of it also. Yeah. So anyway, so all that's going on, within. Oh go ahead.

Jo O’Hanlon

Can I ask I mean, to about like, you're married at this point and have a child, right? And now have another mortgage. Oh, a second child by then. Yeah. And you're living in Wichita. Another mortgage here, then all this debt, and you're sleeping two hours. So I'm guessing that there's not a ton of family time.

Elisha Yaghmai

There's not? No, it was terrible.

Jo O’Hanlon

I mean, that's a huge component when we talk about, you know, mission versus like what's most important in this life. And I think that there are people that feel such a vocational calling so intensely, or it's that the circumstances demand it for a time. And we understand this won't be the time this way forever sort of thing. And the sacrifices given, but also, we know the early years of development for kids are something you can never get back.

Jo O’Hanlon

Your relationship has strain. Debt and overwork are two of the biggest factors of divorce. Yeah, and you're still married to the same woman. You still have these kiddos, like, is there a personal side that you regret in this chapter?

Elisha Yaghmai

Yeah, I would say. I mean, there were I mean, the space of a few years, I mean, I was more or less absent.

Jo O’Hanlon

Yeah. You know, I mean, that's what I'm assuming had to be.

Elisha Yaghmai

Even more absent than, you know, during residency or whatever. You know what I mean? Like, I worked harder on this than on anything ever.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Anything ever, which includes all the medical training, everything else that was it didn't even come close. Actually, residency wasn't even in the same ballpark of severity as what went on with this.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So, I mean, during the worst of it, 110 hour weeks, probably something like that, you know, that's just the work, right? Never mind whatever else you have to do at home. And all the kinds of things are easy, easy. That much time. and that went on and on, you know. And again, why did it go on?

Elisha Yaghmai

In part because there was always this what, like tomorrow is better, right?

Jo O’Hanlon

Right.

Elisha Yaghmai

Next month will be better.

Jo O’Hanlon

Yeah. And then those little glimpses of hope, you know.

Elisha Yaghmai

Yeah. And you have this right. And you're right. Okay. You know, just push it a little bit longer. Right. And then you look back and it's been three years. Right?

Jo O’Hanlon

I mean, and then ultimately five years is a long time to hemorrhage money and life. Like, was it worth it?

Elisha Yaghmai

Was it worth it? That's, you know, I think in the end that'll be that's more of a long term judgment. Yeah. even to today, I don't know. Yeah. The only the value that I see on a personal basis was learning. Learning what my own limits and capacity are.

Jo O’Hanlon

Yeah. how much sleep do you think you need now?

Elisha Yaghmai

Less than I thought. I. So, but, I mean, all of that, I mean, it it it had additive effects, like, you know, you don't go through even physically. You don't go through that. I wouldn't recommend it like you don't you don't go through that without there's a toll to pay.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

You know, which I, you know, to, to a large degree, I mean, I experienced, you know, it was like that.

Jo O’Hanlon

Because, I mean, we can jump to the, to the current 2024 is when we're filming this. And, you know, you recently not to be the spoiler alert. We'll talk about it in a, in a later episode. More in depth, because we're still talking about the story of how this has gone through. But first, a clinic that has been a physical clinic here in Wichita is closing.

Jo O’Hanlon

And your letter that you sent out to patients announcing that earlier this year, you mentioned still pulling like 19, 20 more days.

Elisha Yaghmai

So that had that had improved. And then and then it went back to that. Right. Yeah. And this time around, I think I learned something from the first one, which was that I can do this, but I but also I need to I need to be sure that what I'm doing is the right application of this amount of effort.

Jo O’Hanlon

Right.

Elisha Yaghmai

You know, and and we can talk about the reasons why this time around. I did not think that that was true. Yeah. But at that time and at that stage of life, I thought it was to give another example, just from the physical perspective, like when I started, my hair was brown, right. It got like this in the space of about three years.

Elisha Yaghmai

Really.

Jo O’Hanlon

Yeah. During that. Yeah. Yeah. That's interesting. Yeah. I mean we see that in presidents all the time in the four years.

Elisha Yaghmai

Now when I look. Yeah, the before and after photos. Yeah. And I'm like that's real like it. Yeah. Because that, you know I wasn't running the country but but I had the same.

Jo O’Hanlon

Know I mean yeah the same.

Elisha Yaghmai

Physical.

Jo O’Hanlon

Effects of yeah. You know an extended period of time with. No. Yep. Yeah. do you have a savior complex?

Elisha Yaghmai

It's an interesting question.

Jo O’Hanlon

Like, have you ever. That's not a I don't mean that to be a gotcha question, but do you feel like that's something that you, like, have to battle and, like, be aware of in yourself for.

Elisha Yaghmai

I think it's the, What do you call a savior complex? I don't know, I mean, it's a it's an innate need to solve issues like, I, like you would be.

Jo O’Hanlon

Open to dealing with a team, though. It doesn't.

Elisha Yaghmai

Yes. Oh, no, no, no, it doesn't have to be me. No no, no. In fact, in every case, actually the I try.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

To mobilize a team to come in. Right. The difficulty is that not everybody has the same personal motivation. They're not the same circumstance of life. Right. Yeah. I've a different philosophy about how they want to do things. Right. Right. Increasingly, I'd say people have ideas about what their boundaries are and what they're willing to do, and they're not willing to go beyond that.

Elisha Yaghmai

Right. Doesn't matter what it's for. They're not willing to go beyond that. I mean, all those things are there, right? But no, it didn't have to be that to be me.

Jo O’Hanlon

Okay.

Elisha Yaghmai

and it wasn't,

Jo O’Hanlon

Do you ask yourself sometimes like, why is it at the end of the day, just you?

Elisha Yaghmai

Yes, I have, I have asked those questions and I think, you know, there's different, different reasons for that. I mean, I think it's, For I think in the case, in this specific case, I think the issue, the issue was this the the task was difficult. It was increasingly hopeless. Like, in other words, you know, when you start a business for most people, you go to command and you put something into it.

Elisha Yaghmai

You do some work, right? Eventually start seeing a return right, or you don't. And you say, okay, right, I'm done. It's not necessarily there's not a philosophical component to.

Jo O’Hanlon

It, right?

Elisha Yaghmai

You know, I mean, like, it either works or it doesn't.

Jo O’Hanlon

Right.

Elisha Yaghmai

And the and.

Jo O’Hanlon

I think cut your losses and.

Elisha Yaghmai

Then you move on. Right. Yeah. And I think to some degree psychologically, I think a lot of the other people that were involved kind of got to that. Right. This is not going to go anywhere.

Jo O’Hanlon

Right. Yeah.

Elisha Yaghmai

So we'll cut our losses and move on. I think that was part of it. Right. So it's that.

Jo O’Hanlon

Did they did they not feel the same, compulsion that you did about like not returning to the way things just were?

Elisha Yaghmai

No. And I think that even even in the, in the ranks of medicine. Right. That's not a uniform feeling.

Jo O’Hanlon

Right.

Elisha Yaghmai

my problem is that I like to try to get to the essence of things. Yeah. This is, you know, this not just medicine, anything. I try to get to the as. Like what? What? Really? Right. What is this thing? What are we all doing here? Why are we doing it? What's the point of all of this? And so the problem that I had was that as we got deeper into it, epic, like my level of horror began to increase because every layer down we would go, it got worse.

Jo O’Hanlon

Yeah. You kept uncovering more and more problems.

Elisha Yaghmai

Yeah, yeah. And then it's like, oh, okay. So these problems are more extensive that we do a lot more. Oh wow. It's even worse than that. I mean to do a little bit more right. And I think here again it's a difference of personality. My approach to it was as things got worse, it's like, well but we have to we can't just abandon this, right?

Jo O’Hanlon

We we have to.

Elisha Yaghmai

Keep chipping away at.

Jo O’Hanlon

This. Yeah.

Elisha Yaghmai

And I think for others it was more like, oh, this is, this is even worse than we thought. Okay. Well that's confirmation, right? Right. Time to get out of here. Like, you know, I'm not going to I'm not going to kill myself for this. Right? I'm just going to go do something that is good for me or good for my family or financially better for me.

Elisha Yaghmai

You know what I mean? I'm going to salvage myself, right? Right. I'm not going to sort of set myself on fire so that, you know, we can try to warm up this.

Jo O’Hanlon

Problem, right? Like you had found that I think in finding that mission, it sounds like there are people that we read about in history and there's many that we don't ever know their names of, but they're the ones that like work life balance is, for most people. And then there are those that have a vocational or other calling, I don't know, a better, you know, a better term for that.

Jo O’Hanlon

But it sounds like that's really the essence of like you really discovered and converted to your mission, almost like your calling in this in this chapter. Yeah, I would say, oh, it's true.

Elisha Yaghmai

Yeah. As we ran out of money, we did two things. one was we tried to raise money, so we talked to, investors and people put in about 600,000 at the time.

Jo O’Hanlon

Was it a nonprofit to start?

Elisha Yaghmai

It was not. No. It was started for profit venture. So we went to try to raise money from investors. This was kind of the early stages of this. Almost all that money went to just pay accumulated. That's right. And so then it was necessary to take out a loan, a small business administration loan. And probably the first serious fracture that occurred with the partners was we needed we needed actually about $900,000.

Elisha Yaghmai

We could only get six. We could only get six because I was the only one willing to sign for the loan. If the other docs had signed on it, we we could have gotten the money we needed. So we got 600,000. So to do that, I had to sign. I had to sign away everything we owned as collateral.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So that was, you know, that was an experience. So I went to that banking meeting. I had my newly born daughter with me, and I was like, signing an agreement saying, basically, if we fail to pay this, like, y'all own everything we have, and I did that there by myself, right? Knowing that there were other people that could have signed on to this thing who refused, right?

Elisha Yaghmai

Who refused, even though I had I had I had actually said, look, I'll sign a side deal with you that I'll pay I'll pay the payments on this. I will pay your portion of the payments if you'll just sign out of this thing so that you so that we can get the capital that we need to actually do this.

Elisha Yaghmai

Right. So we couldn't get all the capital we needed, couldn't get that amount.

Jo O’Hanlon

That amount. Was that what you needed to get out of debt at that point?

Elisha Yaghmai

No. But the 900,000 that we needed to to, to get us to pay our debts and also enable us to do the things we needed to continue to grow the business. Right, so we weren't able to get all the way there. So it was a weird feeling of saying, I'm signing for an amount that I know is not enough to get us over the top in our life is still going to be very difficult.

Elisha Yaghmai

I'm having to sign over everything I own solo to guarantee this loan. none of my partners are going to help me, even when I've agreed to pay their payments for them.

Jo O’Hanlon

was that a hard asked? like I said, maybe we don't want to put this in there, but, like, as far as your marriage. oh. To ask your wife to do that.

Elisha Yaghmai

My wife was, like, amazingly okay with it. Yeah. And and, you know, here again. So for people that, you know, so my wife is a physician. Right. So then a lot of people's response. Oh, well, your wife's a doctor and everything's fine. No. So I all my money was going into the house and then on top of like the don't have any money left to pay the loan payment.

Elisha Yaghmai

Right. So so then what was happening was money that she was earning, which was supposed to cover family expenses, was also going to be the payments on this $600,000 loan. And this isn't $600,000 back.

Jo O’Hanlon

And for also partner.

Elisha Yaghmai

That's right. You know, this is $600,000 back in 2016, right? In 2017. Right. That's a substantial amount of money, right at that point in time. And this is, you know, and all of this was going to, you know, try to fund this, you know, fund this whole thing.

Jo O’Hanlon

Yeah. So does she does she believe in it as much as you do?

Elisha Yaghmai

I, I don't know, she I could say she believes it. No, she's she's less sort of idealistic I think that I, I think I think she just viewed it as like, this is the thing that I'm working on. And she was offering support. Yeah.

Jo O’Hanlon

And so she's supporting you as a person?

Elisha Yaghmai

Yeah. She's there to support you, offering support for me to do this thing that I felt was very important. And I was putting all this energy into.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And and as often happens in these situations. Right. She was carrying a lot of the load, right, in terms of the kids and various other things that are going on and also working. Yeah. Right. Well, I'm, you know, burning myself to dust trying to do this at the same time, but I don't think I could have done that if she wasn't if she wasn't stepping into that role, it was not possible to do.

Jo O’Hanlon

Yeah. Yeah. You could have had a lot more, personal struggle and, I mean, suffering. Yeah. In this chapter without a, supportive partner in that, in that mix, for sure. And it's not a rosy story. We don't have an ending. Like, it's not solved. All the things that you were trying.

Elisha Yaghmai

It's not solved it all.

Jo O’Hanlon

It's been. You know, we're farther down the story, but that's a unique part of our, our story right now as where we're not trying to just tell your story. And then there's a nice ending or even just a tragic ending. There's not an ending. Still, we still don't know what will happen next. So, well, we'll get back to going through the story and the plot kind of points that we've been doing.

Jo O’Hanlon

And we're going to dive into lobbying, what that lobbying process looked like next time, because you guys were doing lobbying with the insurance companies. And that's something that, you know, I don't know that many of our audience or myself have a ton of knowledge around. And so we'll dive into that some more of the specifics next time.

Jo O’Hanlon

But thanks for talking candidly about just the struggle. Of it all.