interviews
An Introduction to Care | Part Two
by Dr. Kali Cyrus
February 13, 2020
Dr. Kali Cyrus is our February co-editor. This is part two of our conversation.
There is a lot of off the clock work happening, and out of pocket spending. So much of the care falls on staff after hours.
I would call it the out of pocket / out of office hours commitment. In terms of the costs to me, if I happen to be a doctor who gets bothered, a doctor who works in the public system, what ends up happening is most of my time is not actually spent treating the person's mental and physical health. It's mostly spent trying to figure out case management issues.
If we know this person doesn't have any food at home and they need to be taking their meds with food, or this person doesn't actually have a primary care doctor and they're smoking half as many cigarettes, which is usually the case, or their blood pressure is 200 over 120, or they keep getting hospitalized for medical reasons, if they're in a house dealing with trapping every night, they can't get sleep, it worsens their depression, and they're in a crisis and calling the cops, I can't do my job.
It isn’t really monetary, but as a team, we spend most of our time trying to figure out how can we get this person food when they may not be eligible to get free food from the state district, how can we actually try to get this drug dealer to forgive a debt – which is like, how can we do that?
What we end up doing instead of focusing on what kind of medications can I give you, or how can I meet with you on a weekly basis and talk through what you need to change, what is a path to recovery, is trying to manage the social stressors. It more so impacts social workers or people who've gone to school who want to be therapists, they end up being case workers. They end up doing these kinds of things, you can talk to them and use your therapeutic knowledge in that way, but it's a very different job that requires a lot more patience because you're dealing with systems that are so non functioning.
It's like going to the post office every day and getting in line for eight hours.
It's essentially what that part of the job has become. I think the other end of it, if you think about teachers who end up spending their money to buy supplies, that type of stuff, I don't necessarily end up in that position because I'm the physician. That's something a lot of us have very strict boundaries about. If I have a patient asking me for food, I'm at a clinic or I'm at their house, I'm not going to. No one would expect me to go run to the grocery store. That's going to fall on my staff. If my staff goes to see them three times a week, they're the ones who are going to get asked for money three times a week.
Think about people who work in group homes, where you have mental health patients with people who have other physical or mental disabilities, staffed by people who are not necessarily nurses. One, you're not making a lot of money and you're supposed to be in house with them all day, those are the clients saying, "I need a cigarette, I need a cigarette" when they've already used up all their cigarette money. But if they're going to flip, they're going to punch you in the face because they have a psychotic illness and they don't have the insight into knowing that you can't just give them cigarettes, cigarettes, cigarettes – they'll go buy them cigarettes if that's the thing that's going to keep calm.
Thinking through the costs in that way, is something I've learned from, and the way I've tried to help my staff out is however I can apply to services for them. I have some people in D.C., once I find out that they're at an age where they could potentially qualify from a home health aid, I apply to everything. I try to get them meals on wheels. I try to get them this thing, that thing. Many of them have been denied in the past, maybe they haven't really tried, or maybe they aren't eligible, but the main way is to try to get them as many services as possible, which then leads to complicating the treatment because you have four or five different agencies involved, and you're trying to figure out who's doing what, which is a different problem, but a better problem to have.
For the most part, the out of the pocket comes from my case workers. You end up spending a lot of money to help the system function to help your patient.
What needs to happen for these systems to work more cohesively?
I think about it as large group solutions and smaller more immediate solutions. In terms of the large overall solutions, I think crisis, I think crisis settings. I really believe in the urgent care system. If you're having a crisis right now people come to the ER and there's no beds to send them to. No long term hospital spaces. Not everybody needs to be in the hospital for seven days a week, 24/7 to be monitored.
We can move them to this middle unit where they can be kept safe for a little while. Some of them just need to get through the weekend. Observation units that aren't hooked up to all the expensive hospital bays are really great places, and then a lot of people can go home after that. They might not need the five days, they just need a couple of days. And I've found that that's a good workaround of not having inpatient beds.
I've also found that outpatient urgent care settings are good. It's a nine to five clinic, with staff, social workers, usually one physician, some peers. You can walk in off the street. It's an outpatient model, imagine how much money you save in that.
You can deal with the multitude of crises by having some place where you know you can go that's not waiting in the ER for eight hours.
In terms of the large system, it's groups. If you're not going to magically be able to reimburse every psychiatrist or every outpatient, why don't you have more groups of people, who once they leave the hospital just need something from six to nine. Think about AA in terms of mental health treatment, they need other people who are going through the same things they are that are staffed by social workers or staffed by psychiatrists who can provide ongoing care for them, in a model that's in a community center somewhere. That's not expensive and something the state can pay for.
Imagine the quality of what you could have at that time. It's not one reimbursable, so it's not there. Obviously the other individual level solution, you need a meals on wheels program or functioning transportation to help people get to appointments. You could even put a psychiatrist or psychologist in primary care offices.
My simple answer is how do you incorporate mental health players in these spaces? Making sure you at least know there are places that you can go. That takes investing in social services not just mental health centers. It's investing in the community itself.
interviews
Crypto For The Cash Economy
by Daniel Polotsky
January 22, 2020
Daniel Polotsky is the CEO of CoinFlip, the leading Bitcoin ATM Operator in the US.
frank | How did you get into crypto?
DP | It was around 2013 that I found out about Bitcoin for the first time. It kept popping up in news articles. I wanted to buy some after it appeared on my feed for the fifth or sixth time. I thought, "I've read about Bitcoin, it seems like a cool thing, like a cool alternative money investment that's not issued by the government, decentralized, something that's never been done before," so I decided to purchase them.
I went to the first Bitcoin ATM in Chicago, it was at an empanada place called Cassava. I put in cash, received a coin, but I didn't like the process. The bills kept going in and out – it took a really long time to get the bitcoin. I didn't want to do it again when I bought it again. Instead, I went on a site called locabitcoins.com which back in the day, had these listings where you could meet people in person to purchase Bitcoin.
We met at a Starbucks. I'd put down cash and she would send me the Bitcoin. We kind of got to talking and eventually decided even though the Bitcoin ATM I had used back in the day wasn't super user friendly, it's still in theory a better idea than meeting people in person because it's not safe. It's not really scalable. A single person can't meet with 23,000 people a day. There's a limit.
So we decided to work on the ATM thing. I was a sophomore in college, I was 20 years old, I was at Northwestern and I kept working on it. By the time I was 22 and ready to start a full time job, the opportunity at CoinFlip was too good to pass up. We had just under 20 ATMs – that was two, three years ago.
Fast forward to today, we're the largest Bitcoin ATM company in the world by volume, with 420 locations across the United States. Obviously we're growing and I hope to be able to get Bitcoin in the hands of as many people as possible.
This is different from the other conversations we’ve had about Bitcoin so far, in that most people aren’t treating it like a currency but rather a stock, or investment. But a Bitcoin ATM is tangible, immediate, more cash oriented. Do you find that because there's a physical component to what you're doing it's easier to explain to people?
What you were saying about currency versus investment, I don't know if I agree with that. I think Bitcoin can be used as a currency eventually, but in first world countries like the United States, it is still more of an investment or means tool.
I definitely agree that the physical element makes it very easy to explain to somebody. Its familiar. Essentially all you're saying is, "Okay get some cash. You already have a phone number, download a Bitcoin wallet, you're going to put the cash in, you're will see the exchange rates, you're going to input your QR code which is that black and white square, and then you're going to receive the Bitcoin instantly."
That sense of instant gratification and the physical component definitely makes it accessible. Because the ATM is something in a convenience store that you see in real life. They're not just moving imaginary money around.
How do you interact with something like Coinbase?
Coinbase is an online exchange where the exchange actually holds your money. You wire money from your bank, they hold it, and then you trade on the exchange, using the dollars that you have on the account. We don't hold customer accounts.
So for example, we don't have an account where you can deposit money and then hold it and then trade it. You insert the cash, we immediately do a conversion of the Bitcoin and then you receive the Bitcoin, it's on your phone. You own it, we are not the custodians.
You're not a custodian or a wallet at all?
We are working on expanding into a wallet, but no, we are more like a currency exchange. You go to a currency exchange, you get quotes for an exchange rate that tells you, “it's this many euros for this many dollars.” That's more similar to the model I see us as, as opposed to a company with a mechanism that people use to trade and speculate with continuously on.
Other than speed, why would I do this in person and not online?
Not everyone has a bank account. It's 30 million people that can't afford bank accounts, don't trust banks, don't have banks, think banks are inconvenient, or say they don't want to use bank accounts. They might want to use cash. There's a bunch of workers that get paid in cash.
They only take a bank wire transfer or a ACH. So you literally cannot use cash there. It’s a quick, easy and convenient way to use a different payment method to get it.
Does it work in reverse? Can I cash in my cryptocurrency for U.S. Dollars?
It actually does. We have around 30, 40 units where you can do exactly that. You send us the Bitcoin. Once we get network confirmation, you scan your ticket at the ATM and then cash will come out. It does go both ways.
Do you have competitors? Are there other ATM options?
Yes, there are other Bitcoin ATM companies. None of them have the volume and the low fees that we do, but they do exist. Like I said, we're the number one Bitcoin ATM company by volume in the world, but we do have competitors and they tend to be in the United States, but there are probably in the world 5 to 6,000 Bitcoin ATMs.
Are most of them in the U.S?
A pretty big chunk are in the United States. That's typical. The United States is often a leader in emerging technologies because we have systems in place where people are entrepreneurial and whatnot. Plus we have a large cash economy.
What is the sale for the convenience store? Why would they want them?
The convenience store gets the best deal of anyone. I mean, they get a check, our ATMs are really small. They're probably one and a half or two square feet by five feet. So it's really easy to place them inside a convenience store. The convenience store is not going to be able to monetize that square foot any meaningful way other than receiving rent from us, and we also give them the option for a profit share. In addition, we bring in around 1,500 people a year to any given location. So it's absolutely free advertising for them. It's not like you just see a Bitcoin ATM and you use it. You're literally searching for it and then you go to where it is. So we drive traffic specifically to that store and they can always buy something when they are in there, chips, soda, whatever it is. So there's absolutely no drawback for the convenience store.
What excites you about Bitcoin?
The thing I like a lot about Bitcoin is, you know it's deflationary, right? I love Bitcoin because of that. The U.S. dollar loses 1% to 2% of its value per year because of inflation and the government printing more. Bitcoin itself is limited in numbers, so it's a better way to keep your money long term. The blockchain it's built on is fraud proof. It's public, everyone sees it, it's fast. You can send money halfway across the world in 10 to 15 minutes, it's borderless, it's cheap. The average fee to send is probably $2 to $3. What's cool is that there's no one single issuer.
So you can't turn off the coin.
You can't sue Bitcoin. There's no company responsible for Bitcoin. It’s all around the world. It's very resistant to being able to be stopped. It's kind of like digital gold I would say. That's what I like to say about Bitcoin, it combines characteristics of a commodity and a currency. It’s something that's never been done before. And I think it's very important to keep the centralized entities like banks and governments in check. If they ever go haywire, which they have in the past, there has to be some alternative. Some digital alternative that isn't as cumbersome as gold to obtain that the average person can get.
This decentralized economy is what I’m excited about. My goal with CoinFlip is to get Bitcoin into the hands of as many people as possible so that people see what is really so cool about this Bitcoin and why it really is the future.
Is your prediction that this becomes a widely used and accepted form of currency in the US?
Yeah, I could always see it in unstable countries, it could even be the number one currency. In stable countries, it might be number two currency or it could just be used as an investment vehicle. But I do see it as being perhaps the global reserve currency, within 10 to 20 years as people build trust on it. It makes sense for the countries of the world to not want the global reserve currency to be issued by one country. It used to be the pound, now it's the dollar, it makes sense for it to be decentralized and not one entity responsible for it. It makes a lot of sense in my opinion.
If it does go that direction what policy will come form around it or do you think it can exist as free as it is now?
I think it's actually one of the biggest myths that Bitcoin is not regulated. That's what everyone loves to say, but it's not true. Pretty much every applicable brand in the U.S. Government has come up with regulations regarding Bitcoin. The IRS came up with guidance for how to pay taxes on it. The SEC declared it as not a security and also declared guidance on how to determine whether or not projects that are Coinbase, like blockchain-based are securities or not. The CFTC has also regulated Bitcoin as a commodity and FinCEN, which is our regulator, is the financial crimes enforcement network and we're definitely heavily regulated by them. We're treated as a financial institution.
It's a great system and I think that it's come far from it's early days. But now I think that you still need some regulation, some basic rules to follow, even if it is a borderless, permissionless system and there are those in place in the United States.
I want to get Bitcoin again into the hands of as many people as possible and lead the financial revolution. I want to place 1,000 ATMs by the end of this year and hopefully 3,000 at the end of the next year. In addition, we're working on having an OTC desk. That would allow us to actually trade Bitcoin and other cryptocurrencies in exchange for wire transfers and vice versa, so that's something I want to expand into. And we're also working on a wallet and an app.
What is the app?
The wallet is the main component of the app but it's basically going to be an easier version of our website. You know, just the main parts, probably the map, customer service, or awards program, and obviously the wallet. So we're going to have our own wallet where people can purchase Bitcoin and that's something that's really cool because it's an additional service we can offer to our customers, an additional way we can communicate with them.
Amazing.