All-In with Chamath, Jason, Sacks & Friedberg - #AIS: The Lanby's Tandice Urban on solving healthcare's customer service problem

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I’m going all in.

We’ll let your winners ride.

Rain Man, David Sachs.

I’m going all in.

And instead, we open sourced it to the fans,

and they’ve just gone crazy.

Love you guys.

Nice queen of Kinwan.

I’m going all in.

Please welcome Tandis.

Hi, everyone.

So what I want to talk about today

is the problem that I’m obsessed with, which is bad customer

service in health care.

So I’d like to start out by walking you

through a day at the doctor’s office.

It can look a little bit like this.

You have to start out by making an appointment.

So you call in.

You talk to someone very unpleasant on the phone.

They put you on hold.

You wait.

There’s bad hold music.

You’re waiting.

You’re waiting.

They come back.

You go back and forth a little bit on your calendars.

You get an appointment.

It’s in 21 days.

Now it’s 21 days later.

You go to the doctor’s office.

Someone very unpleasant checks you in at the front desk.

You sit down.

Super depressing waiting room.

Bad wall art.

Very old issues of Parenting Magazine.

Smells like Purell in there.

That’s fine.

This is your hangout for a little bit now.

And now it’s maybe 30 or 40 minutes later.

Someone calls you back.

As you may have guessed, they’re very unpleasant.

They take you back to the exam room.

It’s very small.

Blad fluorescent lighting everywhere.

They take your vitals.

They hand you, essentially, a sheet of printer paper.

They tell you to change into this.

Now you’re in sort of a secondary holding chamber.

Except this time, you can hear the doctor in the other room.

And they’re saying, hey, it’s so great to see you.

And so you know they’re just getting started in there,

even though your appointment was an hour ago at this point.

Pull up your phone.

You start to go through your little question list.

Got up the courage to ask everything you came in to ask.

And then finally, the doctor knocks like you could possibly

still be changing.

He comes in, does a little small talk with you.

He goes and sits down, starts asking you some questions.

You’re maybe like eight minutes into the appointment

at this point.

And you’re like, OK, also, I have some questions.

And you pull up your little question list on your phone.

And you get through maybe like two or three of these questions.

And then the doctor starts to give you a look

like, let’s wrap this up.

And so you wrap it up.

You ask three questions.

The appointment is over.

You go outside.

You check out.

If you’re lucky, they’ll tell you how much you owe.

If not, you will just find out later in the mail.

So my guess is that maybe many of you in this audience

have a concierge doctor.

But most of us have had some iteration of this experience

at some point.

There are a lot of terrible things about our health care

system, but the one I want to complain about specifically today

is why the customer service at the point at which you’re actually

consuming the health care is so appallingly bad.

And when I refer to customer service, that’s

anything that touches the patient experience

while you’re going to the doctor.

So a long wait time is as much bad customer service

as the unfriendly front desk person.

There’s this really great quote that I

love from Bill Gurley, prolific investor,

and my relationship hall pass.

Didn’t know he was going to be here.

The US health care market is the least customer centric

of any customer service industry.

We are so numb to the pain that we rarely object or complain.

So that’s part of what I think is so crazy about this,

is that we kind of just take it.

And so that got me curious to explore three questions

I want to go through with you here today.

Number one, why are things so bad?

How did they get this way?

Number two, why should we care that things are so bad?

And number three, what can we do about it?

What’s a little something we can do to make it better?

So let’s start with, why are things so bad?

A big part of this is our customer service problem

is really more of a consumer service problem.

And what I mean by that is patients

are consuming the health care, but they’re not exactly

the customer in the traditional free market sense of the term.

So who is?

The US health care system, as we know,

is an employer-sponsored model.

This was not very well thought out.

It’s more of a World War II relic

that came from a national mandated wage freeze in 1942.

And we kind of just kept going with it.

And now today, the doctor is not getting out

of bed in the morning for your $15 co-pay.

They’re really making their money off

of the major stakeholders in the industry who

are the employers and the insurance companies.

They’re the payers.

They’re the real customers in this story.

And doctors don’t love this either, by the way.

There’s major burnout in the medical community.

But when you play this all the way out,

you’re left with misaligned incentives between physicians

and patients.

Physicians in the traditional fee-for-service model,

which is our predominant model today,

where physicians are paid per patient encounter,

they’re incentivized by volume and not by quality

and not by good health outcomes.

So it’s no surprise that practices are not designed

to cater to the patient.

And once that becomes the norm, it becomes the culture.

Every doctor’s office can get away with it.

And you’re left with these two really bad stats.

The first one is, in primary care specifically,

the average NPS for a provider is three.

That is so embarrassing.

Number two, 96% of patient complaints

are about the service itself.

Only 4% are about the care delivered.

So patients are really noticing how bad the customer service is.

And yet, to go back to our earlier point,

patients have this sort of Stockholm syndrome

when it comes to going to the doctor specifically.

We’ll request a non-talkative Uber

because we don’t feel like chatting with the driver,

or we’ll leave a very scathing Yelp review for a restaurant.

But when it comes to this service,

even though we’re not an easy-to-please generation,

we become very submissive.

And it’s the most important service

across any service industry.

So this is not a good thing.

Why is this happening?

And why should we care that we’re

having such a bad time at the doctor’s office?

It’s because bad service is bad for our health.

So good medicine is a partnership

between a patient who’s coming in with real information

on how they’re feeling and then a physician who’s

coming in with real expertise to bring to that information.

And they work together.

But if the patient is feeling very anxious and exhausted,

and the doctor is feeling very rushed and dismissive,

you’re left with losing a bunch of really important information

that you need to make nuanced diagnostic and treatment


So to give you an example, doctors

are far more likely to prescribe antibiotics in the afternoon

than they are in the morning for the same patient

with the same issues, because they’re just running late

and they’re dealing with decision fatigue.

If you leave with anything from this talk,

it should be to make morning appointments.

And then patients, on the other hand, know all of this.

And they’ve felt this before.

And so what many of them end up doing

is deferring treatment altogether.

So patients feel like it’s a hassle.

They’re not getting anything out of it.

They will just text their med school friend.

Health care has a patient buy-in problem,

because they’ve made the experience of going

to the doctor’s office so bad that we only go

when we absolutely have to go.

And what do we lose when we go when we only absolutely

have to go?

Preventive care.

And preventive care is really the reason

it’s so bad that we’re not going to the doctor’s office.

We lose out on going when things are early.

We lose out on all the upstream, life-saving, cost-saving

benefits of prevention.

So I’m going to hit you with three stats on that.

The first one is 40% of annual deaths

caused by the top five causes of death in the US

are preventable with good preventive care.

According to the CDC, for whatever that’s worth to you,

avoidable chronic disease accounts

for 75% of our health care spend.

And finally, on the other hand, patients

with a PCP, a primary care doctor,

spend 33% less on health care overall,

because they’re front-loading that spend toward prevention.

So bad service is bad for our health.

What can we do about it?

The good news is this.

We are starting to see more and more practices

shift towards models that incentivize physicians to care

about good customer service.

So there are two models we can use here

to change the compensation model to allow physicians

to have time and space to think about service.

So the first one is direct-to-consumer.

So that’s making the patient the customer again

in this scenario.

And the second one is leveraging value-based care models,

where the insurers are reimbursing based on quality

instead of over volume.

So in that case, the insurer is still the customer,

but we’re now rewarding a different outcome here.

So those are kind of the two options that we can leverage.

But as we can see, we have the tools that we need.

It’s really now about shifting norms in the health care


And the industry is very clunky, and it’s red tapey,

and it’s sort of crotchety at times.

And so the change might feel a little bit slower

than it does in other industries.

But we’re starting to see more and more companies push back.

And as they push back, patient expectations change.

We start to expect more out of our health care.

And now we’re starting to treat health care the way

we treat any other service that we interact with.

And we start to say goodbye to that Stockholm syndrome era.

But as we move towards these models that

change the incentives for physicians,

we still need a framework to think about, OK,

how do we get that good customer service?

How do we actually get the patient buy-in?

How do we get people to want to go back to the doctor’s office?

Because doctors and hospital administrators

are not used to thinking about this.

They’re not used to training on customer service or bedside


So we need to look to another industry, which

is the hospitality industry.

So I brought you on this journey here today to tell you,

we need to be stealing from the hospitality industry.

They have figured this out already.

They know how to treat people like people.

They know how to provide human-to-human service,

which is ultimately today what health care still is.

So I really think this definition of hospitality

from Danny Meyer is really great.

Esteemed restaurateur, my other relationship hall pass.

Hospitality is present when something happens for you.

It is absent when something happens to you.

So we want health care that happens for patients

and not to patients, really Michelin-worthy,

or at least very effusive Yelp review-worthy health care.

And I want to share a few ideas on how

I think we can get there.

I’m the co-founder of a primary care membership

service called the Lanby.

And we do what we call a health care hospitality

training with all of our team members, all of our providers.

And I want to share a few central tenets

from that training with you that I

think are the ones that can be applied into any practice.

They can be implemented at very low cost

and can really start to shift the norms

and shift the culture, which is what we need.

Some of these may seem obvious, but they’re not in health care.

So here we go.

These are my top five.

Number one, follow the golden rule.

Patients are entrusting us with their most precious resource,

which is their health.

Treat them the way you would want

to be treated at the doctor or you’d

want your family to be treated.

Number two, set clear expectations.

This is not a subway track.

Nobody wins when we hold information

like running a few minutes late to ourselves.

Number three, be a good, active, empathetic listener.

Ask good questions to get good clues.

Treat every case like it’s a medical investigation.

If someone didn’t think something was important,

they wouldn’t have brought it up with us.

Another Danny Meyer line, be an agent, not a gatekeeper.

So an agent lets people in.

A gatekeeper builds up barriers to keep people out.

We don’t want to be that kind of practice.

If a patient has a good reason to be asking

you to break one of our rules and there’s

an easy way to break it within the bounds of the law,

then just break it.

Finally, for extra credit, surprise and delight.

How can we make this the best interaction of a patient’s day

even if they’re going through something really challenging?

I think that’s the fun puzzle of applying hospitality

into the health care context is finding a way

to bridge that gap.

How can we remember something about someone

and make them feel seen and make them feel like, yeah,

I want to come back to the doctor’s office?

All right, I don’t have a super punchy ending here,

so I’m just going to wrap this up with health care

hospitality treats patients the way

they deserve to be treated.

We’re all patients at some point.

And when that point comes, the stakes

will feel inherently high.

Too high to get worse service than you

would at your favorite restaurant.

Thank you.

I think the thing that struck me about our dysfunctional system

is the Bill Gurley quote, and then what you’re doing.

There is no customer.

And how does that change over time in America?

I know what you’re doing with your company is part of it.

So how do we change that in Americans’ perception?

Because I got my knee done, and I

didn’t know how much it cost.

And then I found out just cleaning up my meniscus

was $60,000, and that was like, how much?

$60,000 10 years ago for a meniscus surgery in New York.

And then somebody said, that should cost like $10,000.

And there’s no menu.

So we’re going to a restaurant.

You know when you go to the restaurant in Italy,

like the ones you go to, and there’s no prices?

Yeah, that’s when you know you’re fucked.

I love those.

Yeah, you love it, and then you hand me the check.

We were in Vegas that time.

So how do Americans start changing how they perceive this?

I think that’s part of the problem, is it not?

Definitely part of the problem is that we all are kind of just

OK with it and assume that this is this industry where we’re

not supposed to know the prices until afterwards.

No other industry works this way.

We don’t put up with it anywhere else.

And so I think direct-to-consumer models

play a huge role in getting patients to think,

oh, I can treat this like other services.

It’s not like we’re not annoying consumers in other ways.

We already are.

And so we just need to apply that same annoying attitude

to health care.

And then by leveraging direct-to-consumer models,

part of this is getting on higher deductible plans.

So we start to treat our dollars more like normal dollars,

putting money into HSAs and FSAs.

It gets us to start thinking more

like a traditional customer and think about where

we’re spending our money.

And we see that a little bit with direct-to-consumer drug

companies, HIMS, HERS, GetRome, and all the stuff

that Freeberg uses to get ready for battle.

David, nice to meet you.

How are you?


Your hair looks great.

Just to prepare for war.

Those are a start, right?

People are now.

Just say nice things from now on.

Come on.

I love it.

But this is part of it that people are saying,

it’s so dysfunctional to go to the doctor.

It’s so dysfunctional to go to my insurance company.

For certain things, I’m just going

to go on a website and order.

That is part of the frustration, right?

Yeah, yeah.

That gives you a little taste of it.

And then alternatively, if you don’t want to go to the doctor,

you’ll go to Urgent Care, which has

much more of an easy pricing menu in many cases

that you can look at.

So again, we’re starting to get a taste of it.

And I think patient expectations will change.

And doctors will have to follow suit.

We tend to index the quality of American health care

when you look at the average life expectancy.

First, you do men, women.

And then you look at white men versus black men

versus brown men, white women versus black women, et cetera.

And white men have always sort of been the standard bearer.

And then this odd thing has happened

over the last three or four years

where their life expectancy has started

to get worse and worse as our percentage share of health care

expenses, as a percentage of GDP, have gone up.

And everybody gets up in arms because they’re like, well,

wait a minute.

Something is clearly so structurally broken

that we’re spending 15%, 20%, 30% a year increasing

And we’re dying now under the age of 80,

where this thing should be a thing where

we’re living to 100.

Why exactly is that thing happening?

I can understand where you could say maybe it’s segregated

to minority men or women or something.

But this is not.

This is basically everybody.

So why are we dying sooner as we spend more?

Yeah, because we’re also increasingly

spending on a lot of things that kill us.

And we’re overspending on health care

because we’re spending on things that kill us.

And then our health care gets very expensive

because we have terrible, terrible lifestyles.

And everyone is drinking way too much across all communities.

Everybody is eating totally processed foods.

These are becoming more and more readily available,

increasingly so every year.

And so, yes, in the very upper echelons,

there’s sort of a movement towards wellness and more

holistic lifestyle.

But that has not really swept the nation yet.

And so we’re all living really, really unhealthy lives,

not caring about our preventive health,

and then spending a lot on health care down the line.

So you’re saying it’s really not.

We just can’t outrun our lifestyle.

Exactly, exactly, which is not our fault.

I mean, corporations make it very, very difficult

to live a healthy lifestyle in the US.

And do you find examples of countries

that have gotten population-level health

issues right, whether it’s with respect to costs or outcomes,

where you say that is directionally something

that we can learn?

No, I have no good answer to that question

because every company besides the US

thinks it has the best health care system.

But then any time I talk to anybody in one

of those countries, like I was speaking to people in Canada

the other week, and they hate their health care

and think it’s the worst thing ever.

And they wait eight weeks to get UTI medication.

And so, A, I just think it’s too hard to compare

our unwieldy country to other systems.

And B, I don’t even know people who are

that happy with other systems.

So no, I don’t have a good answer.

How much of a role do you think Medicare, Medicaid, CMS

can do to break the logjam versus waiting

for politicians to pass legislation like Obamacare

to try to reorient what’s wrong?

I think it really is both.

I think that HHS is playing a huge role

in trying to get more and more value-based care

models through Medicare.

And they’re making a huge push to do that.

And so it’s slow and clunky.

But I think they have the right idea.

They want us to move towards a value-based care model.

I’ve been thinking a lot about mental health recently,

seeing what we’ve seen during the pandemic,

a lot of young people or kids having these two years alone,

and what the second-order, third-order effects of that.

And just trying to get consensus in America around health care

is very hard.

But I think since we’ve all suffered

some degree of mental health over this COVID break, which

I think drove a lot of people crazy

and created a lot of anxiety, is there any way for us

to think about universal health care

but not have to have this nationwide discussion of all

or nothing?

And I was just thinking, mental health

is something that everybody can appreciate.

It’s not that expensive to deal with.

It’s not surgery.

Why can’t we just agree as a country

that anybody who wants to talk to a therapist or counselor

will be able to do it for a sliding scale or a very

small amount of money and maybe be

able to just chip off one piece of the puzzle

and say, you know what?

Therapy will be $50 flat rate.

The country will pick up the other $50 or $150,

whatever it is, to get this done.

And maybe you could just speak about mental health

as a larger issue, because it does

seem to have so many downstream effects in terms

of our physical health.


We’ve thought about this a lot at the LAMBEE

because we’ve tried to figure out

a way to integrate mental health in a way

where we would be able to make money and we can’t just yet.

So yeah, there have been a lot of models that came out

during COVID that allow for you to text with somebody

and do virtual therapy.

There are a lot of therapists who offer a sliding scale.

But part of the reason it’s a little bit more difficult

is that the patient panel size, the number of people

they can take on, is so much lower

because it’s such a higher touch experience.

And so it’s hard to integrate it into the traditional primary

care model where across the US, one physician

has a panel of 2,300 patients on average.

And so you just can’t do something

like that for mental health.

Are there large population health issues

that you’d love to just get on the radar of folks

in this room that are poorly understood?

I’ll give you an example.

Like there is somebody I follow.

She’s a writer, I think, for the,

I can’t remember if it was the New York Times or something.

And she said her best friend died of a heart

attack in her 40s.

And then she had some stats about the incidence

of heart disease amongst women versus men.

And I had always assumed that it was largely

a male predominant issue until I saw those stats

and I realized, my god, this is a broadly pervasive issue.

Maybe it’s because of lifestyle, et cetera.

So I learned something in that moment I didn’t know before.

But any broad population level issues

that you think are really important

for folks here to know about?

Yeah, I mean, sort of related to that,

I would say nutrition label literacy

is so hugely important.

There’s so much scary marketing that people

have to educate themselves on.

And it’s such a part-time job to have to learn

about why this product that looks extremely healthy

and is like using the new brand colors

that are not Dorito-y, that looks like it should

be vegan and organic, is actually really bad for you.

So having more education on what makes for good food,

I think, would cut out a huge, huge portion

of our preventive lifestyle.

How can people find out more about the,

it’s Landry, L-A-N-D-R-Y?

This is the nightmare of my life.

It’s the Landby, L-A-N-B-Y.

It’s on the big screen, Jason.


It’s just right there.

Yeah, I’m sorry.

How can they find out more about it

if they wanted to become a member?

How do they become a member?

Are there membership available?

It’s just right there, L-A-N-B-Y.

There’s gotta be a website, I’m assuming,

or you have an email or something.


But the website is actually L-A-N-D-Y.

Yeah, it’s the Landry.

Mostly people call it the Lamby, like a lamb.

So the Landry is.

I keep hearing people mispronounce it.

I’ve already lived a lifelong Candace life,

and now I have a mispronunciation

with the Lamby all the time.

So you can just go to

You can apply for membership at the top of the website.

It’s in New York.

Can it scale?

And are you gonna raise money for this?

Is it gonna be a venture-based investment?

Because it sounds fascinating to me as a business model.

Yeah, so we’re actually raising our seed right now.

We predominantly raise money through our members so far,

which has been really nice,

is having our consumers as investors.

But yeah, it can reach a venture scale

because the way we’re doing it,

not to get too in the weeds,

is through a three-person care team model.

So we’re able to take on more patients per panel

because you’re assigned not just a doctor,

but also a nutritionist and a concierge manager

who does all the patient homework for you.

So raising a seed and, yeah,

let me know where to send the check.

Sounds great.

Let’s thank Tandis for taking the time.

Thanks, Tandis.

Thank you, guys.

Thank you.



We’ll let your winners ride.

Rain Man, David Sackman.

I’m going all in.

And instead, we open sourced it to the fans

and they’ve just gone crazy with it.

Love you, Wesley.

I’m the queen of quinoa.

I’m going all in.

Let your winners ride.


Let your winners ride.

I’m going all in.

Besties are gone.

That’s my dog taking a piss in your driveway.

Oh, man.

Oh, man.

Oh, man.

My avatar will meet me at the place.

We should all just get a room

and just have one big huge orgy

because they’re all just,

it’s like this like sexual tension

that they just need to release somehow.


You’re the B.


You’re the B.


You’re a B.



We need to get merch.

Besties are gone.

I’m going all in.

I’m going all in.