Season 1: Episode 12 – Lobbying & Legislation: How Laws Affect Healthcare Innovation

Dear Healthcare It’s You: Episode 12

Elisha Yaghmai

Even from the questions being asked, the few questions that were being asked, it was very clear that the legislators didn't really understand the subject right here. Again, I don't mean as an insult. I mean, they had, you know, a thousand things they're trying to consider and think through. This is just one little tiny issue, and they don't really understand it.

Elisha Yaghmai

That then led to the well, okay, so maybe maybe, you know, we've tried talking to the insurance companies that hasn't worked. Maybe if we educate the legislators.

Jo O’Hanlon

Yeah, that.

Elisha Yaghmai

Will get us somewhere. Right.

Jo O’Hanlon

And lobbying is how you and.

Elisha Yaghmai

Lobbying is how you do that. Right.

Jo O’Hanlon

Welcome back to Dear Health Care. It's you.

Jo O’Hanlon

Welcome back to Dear Health Care. It's you. This is Elijah Yakima. That's with me. And I am Joe O'Hanlon. We are continuing to talk about issues, journey, becoming a doctor, and the cracks in the medical system here in America that he's discovered through that process. And now we're actually in the chapter of he had started a business and a talented business and, had a lot of struggle with insurance companies getting on board, even though their protocol said that it should happen one way, it was not happening that way.

Jo O’Hanlon

So it ensued in a legal battle and some lobbying. So we've touched on some of these pieces, but let's talk about specifically the lobbying. let's start off I know the very basics, but for our audience and for my own benefit, what do lobbyists do?

Elisha Yaghmai

What is lobbying lobbyists or people that are generally paid to advocate for a particular outcome or a particular position? Okay. they have a kind of sinister the word has a sort of sinister connotation, but you could think of them as people that go around to educate legislators that could be positively or negatively, but they go around to share information with them.

Jo O’Hanlon

From their client, from their clients, by threat, to give them education. Because these legislators are deciding on many things that they might not have any idea about or like they have some idea on the alternate side or.

Elisha Yaghmai

Yeah, it's that I mean, it's it's that we ask our legislators in our political system to make decisions about a wide variety of things. I would say they don't know much about the majority of those things. Right. Because if it doesn't happen to be in their particular area of work or expertise prior to ending up in the legislature, why would they know about that?

Jo O’Hanlon

And that it's not just part of their due diligence to do their homework?

Elisha Yaghmai

I think, as with anything, there are probably legislators that do a lot of due diligence and a lot of research and have an active staff, and then there are probably others that are less inclined to do that. Okay. You know, and so the lobbyists exist to provide an education and information, whether accurate or not, biased or not, as a different question.

Elisha Yaghmai

Right. But right information to those people to try to either teach them about it or to sway them from whatever their perspective is to some new, new angle.

Jo O’Hanlon

Okay. And you weren't counting such issues with private insurance specifically. Is that what this was about?

Elisha Yaghmai

Yes.

Jo O’Hanlon

Required lobbying.

Elisha Yaghmai

It did. Yeah. Because the private insurance was was in the state of Kansas, was regulated by the state of Kansas. Like, we couldn't we couldn't influence anything that was going on to Medicare because that's a federal program. Right. So you would need to go to the US Congress, which is a whole nother level of engagement and spending actually required to, you know, even begin to engage with that.

Jo O’Hanlon

Spending in terms of.

Elisha Yaghmai

Lobbying, in terms of loving. Yeah. And we did we did try I mean, for the for the for what it's worth, we actually did try to engage the Kansas, congressional delegation. So we tried to contact our senators actually a couple times. We got blown off most of the time. Okay. One time we got punted to their junior staff.

Elisha Yaghmai

you know who then who then sent us back to the exact same people that we had talked to at CMS before. We couldn't do anything. Right. So that was just a different level, basically, that we weren't able to execute at successfully.

Jo O’Hanlon

But for a state legislature, when did you like was it clear at a specific point of like, okay, we've tried these other things, and now we need to take it to this point of lobbying for legislature change?

Elisha Yaghmai

Yeah. The what actually what made it so what made it clear first was, I mean, initially it was just as we've described before, right, in private insurance that laid out there, this is how you get paid for doing virtual care, right. And we checked all the boxes. Then they made up some more requirements that weren't in those.

Elisha Yaghmai

And we checked all those boxes and then they said, oh, sorry, we're still we don't care, right. You're not you're not going to get paid.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So we then went from that to, well, we just need to, you know, share data with them. We need to enlighten them more. They didn't even want to talk. Right. So that was the experience. And then actually what happened was in I think it was 20 early 2017, we found out that the rep, the state rep from independence, Kansas, had introduced legislation to the Kansas state legislature to try to get telemedicine paid for.

Elisha Yaghmai

I think, if I recall correctly, I think at that time it was a pay payment parity bill.

Jo O’Hanlon

and can you remind our audience what payment period of yes versus payment required.

Elisha Yaghmai

So payment payment parody. payment parody is basically where you say, if the insurance is going to pay for whatever it is, virtually, then they should pay the same amount of money as their, as they would pay for it if they, if they were doing it in person. Okay. So the concern for those that were trying to do anything until medicine at this point was they were worried that insurance was going to say, well, if we pay $100 to do this in person, we're only going to pay you $50 to do this virtually, right?

Elisha Yaghmai

That was their concern. And so, if I recall correctly, I think the bill was if you pay $100 for it in person, then you should also pay $100 for it virtually. If you.

Jo O’Hanlon

If you.

Elisha Yaghmai

Pay, if you choose to pay anything. Right. That was I think what it was. So we actually I can't remember now how we even heard about it, but we went up to the hearing in 2017. We attended that hearing. Oh, okay. and so in the hearing, you know, there was a committee meeting and it was a, an hour long hearing.

Elisha Yaghmai

more than half the hearing was spent on a very non-controversial, vaccination bill about something. I think the meningitis vaccine, if I recall correctly, really non-controversial. It took the bulk of it. And then there was this last little segment that was supposed to talk about this telemedicine bill that this rep had introduced. and in that hearing, there were, I think, if my memories characters like 13 parties testifying in favor of this bill, we were one of them.

Jo O’Hanlon

Okay.

Elisha Yaghmai

the parties there were, I think 12, mental health outfits of one form or another. And us. Right. We were the only ones that were doing anything other than psychiatric illness, and we were doing all the other kinds of medicine. Right. We each got two minutes to speak in favor. there were two parties that were opposed.

Elisha Yaghmai

They were both state insurance companies. Right. They got five minutes to speak against. Right. And then and then there were two parties that were testified as neutral, right. one of them was the Case Center for Telemedicine and Telehealth. Right. So there, you know, they were.

Jo O’Hanlon

Doing this.

Elisha Yaghmai

Yoga process as the EKU center for Telemedicine and Telehealth was neutral on whether telemedicine should be reimbursed in the state of Kansas.

Jo O’Hanlon

So they surely would have been having the same payment issues.

Elisha Yaghmai

Yeah, they're having all the same payment issues. Yeah. But their official position was that they were neutral. we.

Jo O’Hanlon

Are I mean, speculation.

Elisha Yaghmai

Speculate. Yeah. I mean, we never got a, like a, you know, a, state never got a statement from them on it, but it seemed to be that Ku in general has plenty of traditional insurance contracts and didn't want to jeopardize those relationships by by formally opposing the insurance companies. Right. In a public forum. So for.

Jo O’Hanlon

This one, small for.

Elisha Yaghmai

This one. Yeah. They're like, you know, telemedicine is like a tiny fraction of what they do, right? So we're not going to mess with all our other relationships and create a fight over this little itty bitty thing that we barely do anything with. Right. we're not going to we're not going to risk that. So it was an entertaining hearing in that, you know, we have people testifying in favor of getting almost no time.

Elisha Yaghmai

And then the neutral people who are the hilarious part about their neutral testimony was that it sounded suspiciously incredibly positive. It sounded like they very much favored. Legislation.

Elisha Yaghmai

But their formal position was that they were neutral on it. And then, of course, the people that were speaking against it. Right.

Jo O’Hanlon

And who was the other neutral party?

Elisha Yaghmai

Kansas Medical Society, if I recall correctly, I think I think that's correct. I think they were the other one. Right. So we have these, you know, all of this kind of going on, and, you know, and then the frustrating part about this hearing was that, the people get up to speak against it, and they stated some things that were just factually inaccurate.

Elisha Yaghmai

And I don't necessarily I don't necessarily know that they were lying in the sense of like, we know what we're saying is untrue.

Jo O’Hanlon

Okay.

Elisha Yaghmai

I, you.

Jo O’Hanlon

Know, but you knew what they were saying.

Elisha Yaghmai

Was is very clear to anyone that knew the field that what they were saying was decidedly factually untrue.

Jo O’Hanlon

Okay.

Elisha Yaghmai

But they were presenting it and there was no chance for rebuttal. So it was basically kind of the way our politics works right now. One side says something, the other side says something that completely contradicts it. Right. it may be factually, completely untrue. Nobody nobody knows. There's no chance for engagement. There's no chance for rebuttal. There's no chance for debate.

Elisha Yaghmai

There's no chance to say, let's like, look into the data and actually see what's true. Yeah, none of that was possible. And so that hearing just concluded with, Well, you know, this seems to be disagreeing about this. So we'll just table this and maybe we'll look at it next year.

Jo O’Hanlon

And this was not your hearing that you had instigated. This was the one that the state rep heads.

Elisha Yaghmai

Right. This is the one, the independence rep to consider his legislation that he'd introduced. so, you know, we finish that up, outside of the hearing, you know, we, we got some positive feedback from some of the neutral parties saying, hey, we really actually kind of support your perspective. It's just, you know, we're not we're not going to wade into that right now.

Elisha Yaghmai

It's politically it's not expedient for us to wade in. but y'all, you know, keep right at it. Right? And we're like, this is great. We're dying, you know? Hey, Frank, I'm.

Elisha Yaghmai

Glad to be the tip of the spear. so, so.

Elisha Yaghmai

so what we got out of that? I mean, what was very interesting to observe was, again, even from the questions being asked, the few questions that were being asked, it was very clear that the legislators didn't really understand the subject. Right here. Again, I don't mean as an insult. I mean, they had, you know, a thousand things they're trying to consider and think through.

Elisha Yaghmai

This is just one little tiny issue, and they don't really understand it.

Jo O’Hanlon

And it's it was a new thing that like, yeah, it's not like they could just dive into existing understanding of it. Right. Other people had that was very minimal.

Elisha Yaghmai

That's that's correct. Right. We had just spent right three years, four years. Right. Teaching ourselves about this. Right. So why would these people that weren't in this field and are not, you know, in this and don't have this background, why would they know all of this? Right. There's no reason they would. So that then led to the. Well, okay.

Elisha Yaghmai

So maybe maybe, you know, we've tried talking to the insurance companies. That hasn't worked. Maybe if we educate the legislators. Yeah, that will get us somewhere. Right.

Jo O’Hanlon

And lobbying is how you and.

Elisha Yaghmai

Lobbying is how you do that. Right. So one of the one of our partners, I forget how he met him, and it is maybe some random connection that he had or whatever. somehow or other connected us with, two guys that were had started a lobbying outfit in Topeka.

Jo O’Hanlon

Okay.

Elisha Yaghmai

Met with them. They, they listened to the whole ordeal that we were going through. felt some sympathy for our cause. And so they agreed to work at under their current market rate, you know, for so. So they gave us a discount. Yeah. Because we couldn't afford any more than that. We still don't have any money.

Elisha Yaghmai

Right? So what then? Once again, I just went and tried to, like, find more side hustles to, like, generate enough money to pay their fee. but what they did out of that was they got us a meeting with the chair of the of that of the health committee, or I can't remember exactly which committee it was. It was a health care related committee.

Elisha Yaghmai

So the chair that they got us a meeting with him over the summer, he gave us about an hour of his time, which was very good.

Jo O’Hanlon

I paused for a second. And so it's a health care committee. So they were familiar with health care in general in terms of the legislation around, specific topic. They're not just having to vote on.

Elisha Yaghmai

That's right, everything. This is not the general legislature. These are people that are on the health committee. Right.

Jo O’Hanlon

But they're starting a level of understanding that some people wouldn't have it. Right.

Elisha Yaghmai

Yeah. It's slightly higher. Right. Yeah. But again, I mean, you know, in American politics at this point. Right. There's lots of reasons people want to be on the health committee. Right. They may be there because they have concerns about, you know, reproductive rights. You know what I mean? Like they're in there with they their maybe they're with a, with a specific issue in mind.

Elisha Yaghmai

Okay. And all this other stuff is sort of peripheral to that. They're there for that. Right. Okay. And you pick your issues very well.

Jo O’Hanlon

A lot of is connected back into.

Elisha Yaghmai

But all of that kind of goes on. Right. So it doesn't mean that this is an extremely well versed person that really understands the healthcare business or how it all works. Right? They may have a specific issue that they're there therefore. So, but this this gentleman gave us, you know, gave us like an hour of his time.

Elisha Yaghmai

So we go through everything. We laid out all the stuff that we've talked about, what our experience had been, what we were doing clinically like, what kind of good it could do for the rural communities. And he ask this question, he's like, why are we not? Why are we not doing this everywhere in the state already? Right. You know, and you're like, well, funny, you should.

Jo O’Hanlon

So there we are. Right. Okay. All right.

Jo O’Hanlon

So what year was this?

Elisha Yaghmai

But this this is I think it's 17, if I recall. I think it's the summer of 17 when we had this conversation. So he said, okay, we got to fix this. So he said I'm going to get an interim hearing together, like in between the sessions of the legislature, and we get an interim hearing together with a joint committee with House and Senate members in it.

Elisha Yaghmai

And we're going to have committee. We're going to have a meeting and talk about this and is where he did. So I think I want to say it was November of 17, if I recall correctly. I think that's correct. he went ahead and got this, got this committee meeting together. So we did. so then I think if I recall, I think it was a two day hearing.

Elisha Yaghmai

so we went up there. And so this time around it was very, very different format. One, it was dedicated to the question of telemedicine. Okay. Right. So that was that was helpful. and then and then as much more time. so this time they had three parties speaking in favor. We had 30 minutes each. Okay. And then they gave the people speaking against which again, was all insurance companies.

Elisha Yaghmai

Right. And as all the Kansas based and, you know, the usual people you would think of, speaking against it. Right. But they gave adequate time.

Jo O’Hanlon

What was the arguments against it?

Elisha Yaghmai

The argument, you know, one of the arguments was you can't do very much with this. It's just not very useful clinically. Right? You can't diagnose things. You just can't do good medicine this way. That was not true. But that was that was one of the arguments. Another argument was it's not necessary, right. People in, you know, Royal Kansas and other places like they've got adequate access to care, like there's really not a need that you you don't need all this stuff.

Elisha Yaghmai

Like it's just not necessary. These are the types of arguments that are being made. Right. you know, and that was, I mean, these things were demonstrably untrue, right?

Jo O’Hanlon

So this is no not fair points in your mind.

Elisha Yaghmai

They were not. Yeah. You know, and then there was one point I think they'd made at one point, which was, well, you know, we are paying we are paying for telemedicine. Like, you know, if you submit the stuff properly, you know, we will pay. Right? So yeah.

Jo O’Hanlon

No. Are they paying?

Elisha Yaghmai

Well no, no. That's right. That's us. So and but they would.

Elisha Yaghmai

Use things like, well we're going to, we're paying the mental health people which at that point they were, they were paying some the psychiatric people. Right. So, you know, so we pay for this. Right. And we were like, you don't. Right. You know, and and here's, you know, 200 unpaid claims. Right, right. To show this. So again, the difference in that particular hearing was that there were different people there, some of whom had an actual professional health care background.

Elisha Yaghmai

So a different, slightly different audience in terms of just baseline level of not. And so in that one, after everybody made their statements this time around, there was time for questions and there was time for rebuttal. Okay. And so they asked questions. They would stand up and kind of give whatever their statement was going to be. And then in a couple of these instances, they gave us a chance to rebut.

Elisha Yaghmai

And that, I think, is when actual progress is made, because when there was a chance that we could have an actual debate and we could discuss what the issues were, and we've. Talked, we.

Jo O’Hanlon

Totally point out like what they're saying is not true.

Elisha Yaghmai

So one here's here's factual inaccuracies. Right. And this was actually one of the things that we came to in this hearing was, okay, if you you have legitimate concerns about utilization, about potential fraud. Right? It's not that your concerns. And this is, again, going to speak so much to our political process. It's not that your concerns about this are not real or legitimate, right.

Elisha Yaghmai

It's that the way you've chosen to go about this is through non communication obstruction. And in some cases what appears to be dishonesty. Right. Whether intentional or not I don't know. But it appears to be dishonest. Right. Why are we doing this right. We we know that there's a need for what we do. We know that there are concerns that you have.

Elisha Yaghmai

Can we please meet at a table and hash out a way that both parties can get what they want? We want to be able to provide better care to rural Kansas. You want to not have your budget blown by fraudulent doctors claiming all these visits. They didn't do right and all this kind of stuff, right? Fair enough. Right?

Elisha Yaghmai

Right. There's ways we can we can do this, right?

Jo O’Hanlon

It's not cutting insurance out. In fact, it is factoring insurance. It's factoring.

Elisha Yaghmai

In. Right. And we can actually I mean ironically, right, by doing this the right way, we can we can improve the quality of care. We can improve the accuracy of what's going on over what's done in person. Yeah, right. And we can save you money.

Jo O’Hanlon

Doing all that I say at less expense. Ultimately to them.

Elisha Yaghmai

We can save you money, you know. You know, kind of as mentioned before, right? We weren't coming in saying you need to pay us more for this. We had come into them saying, pay us less, right. We'll give you a discount off of our. No, we don't even want payer.

Jo O’Hanlon

Parity, right.

Elisha Yaghmai

We just want you to pay for it in some form. So we have some. When we go to our pro forma, we can plug a meaningful number into that and then figure out what we need to do in response to that. Right.

Jo O’Hanlon

But it doesn't even have to be.

Elisha Yaghmai

A 1 to 1. We recognize our expense to do virtual care is lower, right? So we can save you money.

Jo O’Hanlon

So you already conceded what had already been a dilemma. Exactly.

Elisha Yaghmai

We conceded all this. So where this where this ended up was after that hearing, or the lobbying firm told us it seemed like the opinion in the legislature on this issue had changed. Right. and, with a majority of the body now in favor of passing some legislation. And the difference in the legislation that was proposed this time around was that we had asked for guaranteed payment.

Elisha Yaghmai

So we didn't specify how much had to be paid. Right. We just said, if you're going to pay for it, let me rephrase it. We said, if you would pay for this in person and it can be done virtually, you must pay something. If it is, if it's done virtually. Yeah, but we didn't. We didn't because.

Jo O’Hanlon

They were just saying if it's the payment parity pieces, if you would pay, then you have to pay the full thing. And so they would just say, well, you're not.

Elisha Yaghmai

Paying exactly right or they would do. We also added in language that you can't not you can't refuse to credential somebody because they want to offer virtual work, which is the loophole they were using for us. Right? So yes, in the places that had done payment parity, the loophole which people had used to get around this was, oh, you know, we would pay the same, but, nobody wants to offer the service, right?

Elisha Yaghmai

Well, they didn't mention well, no, we want to offer a service because if they want to offer the service, we exclude them from. Them for that. All right. We to let them in.

Jo O’Hanlon

So nobody in phone. Yeah. So. Exactly.

Elisha Yaghmai

Right. So this is this was the way around. That was mandate payment. And you see explicitly by law you cannot exclude us from credentialing just for this reason.

Jo O’Hanlon

Right.

Elisha Yaghmai

So that legislation went through.

Jo O’Hanlon

Was that this all happened on one day. No no no.

Elisha Yaghmai

So no. So then after the after that, so that hearing, all that hearing did was establish a change in the mood. And it's probably how describe that right now the information's out there. We've had some actual engagement on the issues. The legislators, as again as we were told we didn't go poll everybody, but as we were told by the firm we were working with, had changed their opinion.

Elisha Yaghmai

Right. And so it became clear that something was going to happen. Okay. And then once again, speaking of American politics, right. We had been one of the main drivers of getting this thing to this point. We were completely cut out of the process. Whatever happened after that, in terms of negotiation, we had nothing whatsoever to do with we were not invited.

Elisha Yaghmai

We didn't know anything was. All we knew was that when the bill went, I think, into the Senate hearing in the winter of 2018.

Jo O’Hanlon

So a full year.

Elisha Yaghmai

Later, not not a full year later, like 4 or 5 months later, three, 3 or 4 months later, maybe, by the time that bill came up for discussion, their insurance was suddenly firmly on the side of telemedicine. So they had been adamantly opposed to it before, in a very short period of time, one eight they were completely in favor of telemedicine all the way around.

Elisha Yaghmai

It absolutely supported the legislation and everything that had to do with it. And, and it just.

Jo O’Hanlon

Passed. So it just passed.

Elisha Yaghmai

Yeah. Passed through. Yeah. So again, you know, what happened was the real power brokers in this state, right? Which was not us. Right, right. SAT down with the insurance companies and they hammered out whatever arrangement was going to work for all of them, since nothing had to be done. Right. And they and then everybody was on board with it.

Elisha Yaghmai

And then suddenly the problem was solved. And so then in May ish spring of 2018, the Kansas Telemedicine Act passed, and it got held up for a couple of months because they wanted to add language that had to do with abortion, the abortion issues. And, you know, it was the I'll spare everybody the details, but that that kind of held everything up.

Elisha Yaghmai

But it finally got passed as part of another bill which called the Kansas Telemedicine Act. And then it went live January 1st of 2019.

Jo O’Hanlon

Wow. Okay. And then Covid comes March 2020, right. And then was it all did everything change at that point. And for everybody state like, yeah. Nationwide. Yeah. Yep. Comparable to what we already gained in 2019.

Elisha Yaghmai

So in 20 2019 what Kansas did was relatively out in front of the curve compared to most of the country. It actually was, but it was like it was game changer for like.

Jo O’Hanlon

One of the first, if not the first states.

Elisha Yaghmai

Of that type of legislation. I think. So, a payment guarantee legislation, if we were not the first, we were among the first to do that. We may have been the very first, but just in terms of everything that we had done with that, it was it was out in front of a lot of other places which were way behind, and then in 2010.

Elisha Yaghmai

So ironically, we had that environment that that was what that's probably the reason we made it. Yeah, it was because that changed. And then, 2020 Covid hits and then all of a sudden all this stuff that we fought so hard for, they changed it all overnight. So CMS, we talked about previous episode. Right. They tell us we love what you're doing, but, you know, no one here knows how to change any of this.

Elisha Yaghmai

They figured out how to change it and they changed it for Medicare. Yeah. For Medicare. So they went from being unable to figure out how to change their manual and the rulebooks to being able to change it within the space of a few weeks. All of a sudden they figured out somebody in that organization figured out what lever to pull to change everything.

Elisha Yaghmai

So they open all the doors, all the rules were gone, all the restrictions were off. Anyone, anywhere could do anything they wanted, basically. And that continued through the entire Covid pandemic and that that in turn now. So now telemedicine people hear it and they're, you know, very familiar with it. Everybody knows what it is. They very experienced it.

Elisha Yaghmai

But we went from the complete opposite of that to having all of that within the space of a very short period of time.

Jo O’Hanlon

Because, yeah, I mean, it's hard to even I mean, in a lot of ways, it's hard to think back pre pandemic life. but telemedicine is such a large component of our conversation now. It's very regular for anyone to be talking on the phone to their doctor or something like that, that, I mean, we really was that even a thing like in terms of direct not having to go to the hospital for telemedicine, like patient direct to provider on your phone or something like that.

Jo O’Hanlon

Prior to 2020 or 2019, there was.

Elisha Yaghmai

There was a little bit of it going on. there was not as much as not nowhere near as much as there is now. Sure. Yeah. So like there were there were two companies at that time that were trying to do this on a national level. They had a bunch of money behind them. they'd raised tons of tons of funds, but their actual utilization numbers overall were low.

Elisha Yaghmai

So to give you an example, like even for video call, one of the largest was just a company called Teladoc. they were still doing, mostly telephone telemedicine. They had been doing that actually for several years back in the 2000 zero as a very concrete. They were doing it for employers, but it was a telephone call. Yeah, that you would do.

Elisha Yaghmai

And even up until like close to that time period, we were talking to people that were familiar with their operations. They were like, still, the bulk of what was going on was telephone based calls. Yeah, not this like video calling and everything else like that. So that really kind of blew up in much more recent times.

Jo O’Hanlon

was it was there any sort of like did you feel a little like jaded ness or jealousy of everything going into effect so easily all of a sudden that you had worked so hard for?

Elisha Yaghmai

Yeah, I would say the feeling jealousy, maybe the wrong word for. But it's it's like that. it's like getting out of the front end of any sort of meaningful movement. You know what? I'd say it to some degree. You kind of empathize, like people. Maybe they're on the front end of, like a social movement or something like that.

Elisha Yaghmai

Right? Or it's like you push and you push and it's so hard. It's so hard, it's so hard, it's so hard. And you just keep getting punched and punched and punched and punched and then like something happens that's external to all of that. Right? And then all of a sudden it's like the whole the wall falls down right?

Elisha Yaghmai

Right. And you're like, I have been chiseling at this thing with my little tiny. Hammer, my chisel for so many years. Right.

Elisha Yaghmai

And then this bomb just dropped in this whole thing and it fell. And now it's all over, right? It's like that, right? And it's like I. We did all this work.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

To get incremental, tiny little progress. And then with.

Jo O’Hanlon

So much effort.

Elisha Yaghmai

So much effort and so much suffering to do this, and then now it's all over. And everyone else that didn't do anything during all of this right now has access to all of these these benefits, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Without without ever lifting a finger. Right, right. It's just the way, you know, it's it's like how life is. Right.

Jo O’Hanlon

So for you in terms of you've been fighting so hard for this thing once it passed, I mean there was a year until there was such broad stroke change everywhere. Yeah. But like what changed for you in 2019 besides getting paid? What did that end up changing in the trickle down effect of it all?

Elisha Yaghmai

The trickle that what we're getting paid helped a lot. Yeah. but enabled us to start to distribute our services more widely because people started to become more open to it. hospitals began to understand better how they could get paid for it. And actually, there was a guarantee that they could get paid for it. Right? So patients, the.

Jo O’Hanlon

Understand.

Elisha Yaghmai

They started.

Jo O’Hanlon

To understand that just because you had talked to them long enough at this point.

Elisha Yaghmai

Yeah, we kept we kept the conversation going. We would notify people what was going on. And then they began to follow. Right? They were aware of these things. And so so that opened up a lot of doors. Right. The fact I think that we had participated in that, like within our state was some people knew that. Right? So that also helped open some doors because we yeah.

Jo O’Hanlon

That's a big credibility point.

Elisha Yaghmai

Yeah. So you know, it's kind of we we were here from before this was cool. You know, that kind of thing.

Jo O’Hanlon

Yeah. The original. Doctor. That's right. That's right.

Elisha Yaghmai

So you know, so all those things helped. Yeah. And helped us gain some traction.

Jo O’Hanlon

Did it decrease the amount of stress that you were holding?

Elisha Yaghmai

Yes. At that time it did. Yeah. It did. it was still I mean.

Jo O’Hanlon

You're still having to run a business that was still a pioneer in business.

Elisha Yaghmai

Oh, and we were still I mean, bear in mind, right, it wasn't like 2019 or like, you know, snap. Now you're like, debt free.

Jo O’Hanlon

And, you know. Right. That's why we we're in the hole.

Elisha Yaghmai

Where we. We were way in the hole.

Elisha Yaghmai

Like. Yeah. So it took us I mean we didn't we didn't have our first I think, I think our first year of profitability barely profitable and not like actual profitable just for that year, like not losing money, right? Yeah. 2019 was the first year we closed a tiny percentage above even. Well, you know, ever so from 2014 until 2019, I was just lost like every just lost lost lost lost lost that accumulation loss.

Elisha Yaghmai

so 2019 we finished our finished slightly above water for the first time.

Jo O’Hanlon

At what point did you say it started as for profit. And the last episode we talked about that just briefly. and then at some point it became a non profit. Right. No no no no it never did.

Elisha Yaghmai

Don't we've added and we added a nonprofit entity later.

Jo O’Hanlon

Oh okay I.

Elisha Yaghmai

See. Yeah.

Jo O’Hanlon

But this component it was your goal was still to get to the point of making something.

Elisha Yaghmai

And it was at the time. Right. This is a thing that also shifted. Right. It did shift over time. So initially right. Bear in mind the beginning of this was supposed to be a staffing issue, right? It was. We're just solving a little tiny staffing problem in rural. We're gonna make it cheaper, right? Yeah, that was about it.

Elisha Yaghmai

So we just got through to get this company. Didn't really think much about it.

Jo O’Hanlon

Right.

Elisha Yaghmai

All the things learned over, over this entire process, right by the end of it really, really made me question, actually, that whole the whole concept of kind of for profit. Yeah. No, it wasn't for profit in the way that some of the for profit entities in health care operate. And we operated effectively as a nonprofit almost our entire existence. Yeah. I mean, my circumstances, right, by choice.

Elisha Yaghmai

But that, but that. Yeah, but my, my concept of sort of what health care economics and motivation should be changed more from the entire experience.

Jo O’Hanlon

Yeah. That. Yeah. well, I think the unless there's anything else about the lobbying process specifically that we want to talk about, I think we'll go ahead and wrap up for this week. Thanks for being with us and join us next week.