Episode 50: Dr. Erin Kiesel and Dr. RJ Heck of St. Luke's Family Practice - Modesto, CA

Direct Primary Care Doctors

Dr. Erin Kiesel earned her BS from Santa Clara University in 1994 where she graduated Cum Laude and was part of the Alpha Omega Alpha Honor Society. She then went on to earn her medical degree from Midwestern University, Chicago College of Osteopathic Medicine in 1997. She completed her family practice residency in Modesto from 1997-2000. She went on to complete a fellowship in Faculty Development at UC San Francisco from 2011-2012. In addition to being awarded the Teacher of the Year Award by the Stanislaus Health Foundation in 2012, she continues to serve as a Clinical Professor of Family Medicine at the UC Davis School of Medicine since 2000. Her special interests include pediatrics and women’s health.

She is married to George and they have four children.

Dr. RJ Heck earned his BS from the University of Arizona in 1987 where he graduated Summa Cum Laude and was awarded the President’s Award for Excellence. He continued at the University of Arizona where he earned his medical degree in 1991. Like Dr. Kiesel, he too trained in Modesto completing his family practice residency from 1991-1994 and achieved the “Excellence in Resident Research in 1994.” He has two sons and has volunteered with Liga International where they do mission trips in Mexico.

Their non-profit practice, founded by Dr. Robert Forrester and Dr. RJ Heck, St. Luke’s Family Practice is a non-profit organization in Modesto, CA that bridges the gap of healthcare. The mission statement of the practice is "To establish a self-sustaining non-profit organization for the delivery of free outpatient health care, consistent with the Catholic tradition, to uninsured persons ineligible for government programs."

St. Luke's serves by providing primary health care to two very important groups — Benefactors and Recipients.

Benefactors are individuals and families blessed with the ability to support the work of St. Luke’s Family Practice. They receive their primary care from one of the physicians at St. Luke’s Family Practice.

Recipients are those less fortunate who do not have health insurance and do not qualify for government programs. They can also obtain primary medical care without charge from St. Luke’s Family Practice.

St. Luke's Family Practice addresses two main issues:

1. The deterioration of enduring doctor-patient relationships. Many patients today feel like their doctor is too busy for them. “Service” is a tired cliché. Choices are sharply limited by insurance. Rather than focusing on your medical concerns, doctors today spend too much time on authorizations and payment. 2. There are still millions of uninsured Americans. Worse yet, millions of Americans still have no health insurance. Despite the Affordable Care Act (“ObamaCare”) tens of thousands of Stanislaus County residents have no access to primary medical care. Most are “working poor” families. One in four Californians under age 65 is without health insurance for at least part of the year.

In today's episode, Dr Kiesel and Dr. Heck share more about the day-to-day activities at St. Luke's and how the practice was created as a nonprofit back in 2004 and how it continues to serve the people of Stanislaus County in alignment with its central mission.

A New Model of Charitable Care: The Robin Hood Practice

Here is the American Academy of Family Practice article about St. Luke's practice featuring Dr. Robert Forester.

Resources mentioned by Dr. Kiesel & Dr. Heck:

- Harrison's Textbook of Internal Medicine

- Essential Evidence Plus


- Cirugía Sin Fronteras - a surgery center for the uninsured in Bakersfield, CA

- The Gallo Foundation

- The Foster Family Foundation


website: https://www.stlukesfp.org

Dr. Kiesel: drk@stlukesfp.org

Dr. Heck: drh@stlukesfp.org


Episode 50! Dr. Erin Kiesel & Dr. RJ Heck of St. Luke's Family Practice - Modesto, CA

[00:00:00] Today's episode is the 50th episode of the podcast. When I created it, I had no idea that so many folks would be tuning in which to me is a great sign that people are wanting to learn more and more about the direct primary care movement. So in celebration of DPC and our 50th episode, I'm putting out a call to the authenticity.

[00:00:24] If you are a physician in the DPC ecosystem, and haven't gotten the chance yet to share your story on the podcast, go to speak pipe.com/my DPC story and leave us a message sharing your why. What made you think or decide to do DPC? How has it been going for those of you who have already made the jump?

[00:00:43] You might hear your story in an upcoming episode now onto today's episode.

[00:00:57] Direct primary care is an [00:01:00] innovative alternative path to insurance driven healthcare. Typically patients pay their doctor a low monthly membership and in return build a lasting relationship with their doctor and have their doctor available at their fingers.

[00:01:21] direct primary care means individual attentive care with longer appointments and better access to a provider than most people have in the community. And this should be offered in some way to all patients, no matter their ability to pay. I am Dr. Aaron Kiesel and I'm Dr. RJ, heck of St. Luke's family practice.

[00:01:39] And this is our DPC story.

[00:01:47] Dr. Erin Kiesel earned her BS from Santa Clara university in 1994, where she graduated cum Loudy and was part of the alpha omega alpha honor society. She then went on to earn her medical [00:02:00] degree from Midwestern university, Chicago college of osteopathic medicine in 1997. She completed her family practice residency in Modesto, California from 1997 to 2000.

[00:02:12] And then she went on to complete a fellowship in faculty development at UC San Francisco from 2011 to 2000. In addition to being awarded the teacher of the year award by the Stanislav health foundation in 2012, she continues to serve as a clinical professor of family medicine at the UC Davis school of medicine.

[00:02:31] Since 2000, her special interests include pediatrics and women's health. She is married to George. Four children, Dr. RJ heck earned his BS from the university of Arizona in 1987, where he graduated Summa cum laude and was awarded the president's award for excellence. He continued at the university of Arizona where he earned his medical degree in 1991.

[00:02:55] And like Dr. Kiesel, he too trained in Modesto, California completing [00:03:00] his family practice residency from 1991 to 1994 and achieve the excellence in resident research. In 1994, he has two sons and his volunteered with Liga Internacional, where they do mission trips to Mexico together. They are part of the team at St.

[00:03:18] Luke's family practice and Modesto. Califia. Dr. Robert Forrester, who has recently retired and Dr. Heck opened St. Luke's in 2004.

[00:03:30] Welcome to the podcast, Dr. Kiessling. Dr. Heck, thanks for having us. I want to start by reading the mission of St Luke's and that mission. To establish a self-sustaining nonprofit organization for the delivery of free outpatient health care, consistent with the Catholic tradition to uninsured persons ineligible for government programs.

[00:03:52] Now that, with that statement, what does this mean? Or tell us about your practice. Yes. I will take [00:04:00] that one because I was around at the very beginning of it, but it's when Dr. Forester got this idea, it was really a gift of the holy spirit. And it was to take care of a small number of people who would be donors to a practice that then would allow us the time because it was just a small number of patients.

[00:04:19] It would allow us the time to take care of uninsured people. For free. And this was before the affordable care act. And so there were lots of people who were in that notch group who didn't have their own insurance. Didn't qualify for Medi-Cal. That number has dropped quite a bit with the affordable care act, but there's still a huge number, particularly in the central valley of people of human beings.

[00:04:44] Be they American citizens or not, who don't have access to healthcare. And so our goal has always been to reach them. And at the same time, take great care of a small number of people. We call them the goose that lays the golden [00:05:00] egg, the benefactors who contribute to the practice each year and keep us running.

[00:05:04] Thank you for explaining that. And on that note, can you give us a little bit of a breakdown with regards to your demographics? For the most part on our recipient side? I think we're probably in the range of about. Two thirds, Latino, maybe even closer to 70%. And of those, I would say. About a good two thirds of them are Spanish speaking only, or at least primarily on our benefactor side.

[00:05:33] Mostly people who are more affluent and older. So our uninsured side can be all ages, rarely kids, because most times kids, whether or not they have papers are eligible for some form of medication. But on the adult side of those uninsured patients, that was the demographic I was talking about with our [00:06:00] uninsured folks and for the benefactors, I would say people who are affluent and for the most part, my practice has matured more.

[00:06:09] And so all of them I think, are now. At least over the age of 40 and have kids. And I would say a huge number better than 50% of them are Medicare age and older. Can you explain to the listeners. What is a benefactor and what, is there a certain you want to do that or? Sure. So I would say a benefactor is a patient that comes to us and has the ability to pay for their care.

[00:06:36] We have an annual fee that they pay it's based on age to a certain extent it's based on how much care they need, patients that are older and that require care at home or care in a nursing facility or, or home care are going to be a little bit more expensive. But in any case, they pay an annual fee with the money that.

[00:06:54] Is leftover of what they're putting into their care. We are able to take [00:07:00] care of another subset of patients that are called recipients that are completely uninsured and are not able to pay. And for the annual fee, do the benefactors determine how much they donate to the practice as an annual fee, or there is a set fee and it's based on age.

[00:07:20] So I don't have the breakdown in front of me, but it is a set fee. So they know in advance how much they're going to pay. And as we take care of them through the year, we do keep an accounting of their visits and the time spent. And then at the end of the year, Those amounts, which are assigned a value, like an RBU value, if you will just like, as if we were billing insurance, but we don't bill insurance, that amount is subtracted off and whatever's left.

[00:07:47] The benefactor is able to write off their taxes as a donation because we are a nonprofit it's very unique in terms of how to approach it. Providing care for all in the DPC [00:08:00] umbrella, because St. Luke's has both benefactors and recipients. How do you guys get the word out in the community that you do have care for anybody who might need care?

[00:08:10] We have some different approaches for that for the recipient side. Of course. Word of mouth is, has always been on our side. Local churches know about us emergency rooms. Urgent care centers, the Medi-Cal offices where patients sign up for Medi-Cal has our information as well. We're also starting a social media campaign, which of course social media is available to anyone.

[00:08:33] And some of the local county clinics also know about us. And so when patients come in and they have they're completely uninsured, they send the patients our way. I want to go into more detail with regards to when a patient, whether they're a benefactor or a recipient. Can you walk us through how it looks in your practice when they wish to join uninsured patients?

[00:08:59] When they hear [00:09:00] about us, it used to be, we'd have them come in and see us and we'd see them the first time, no matter what their payer status. Now with COVID, we're requiring everybody to call and make an appointment, but we will see them the first time and figure out what their payer status is ahead of time.

[00:09:24] What happens? The front desk nurse asks them, do you have insurance? And if they already have Medicare or Medi-Cal. And they want to become a benefactor. We will offer them that many people to choose to do that. Others don't. If a person wants to be a benefactor, we've found that our greatest source of referrals in the past has been other benefactors.

[00:09:57] We hope or anticipate that will [00:10:00] change with our social media campaign that will reach a newer, younger demographic. Up till now, if a person expressed interest, we invited them in and scheduled them for a meet and greet appointment where they just got to sit down with the doctor and talk about the philosophy of the practice and what would be done, what could not be done and all of the details a half an hour out of our day.

[00:10:28] Is it easy in terms of selling? It's an easy payoff because most of the time, when a person can sit. Face-to-face with a doc for half an hour and get details about a practice. They love the place. That's how we approach those two. And as Dr Keezel said, marketing. We had not expended a whole lot of effort into that in the past, because our greatest source of referrals for benefactors was word of mouth.

[00:10:55] But as we were trying to ramp up as Dr. Keezel joined our practice [00:11:00] and we had a third doctor, we discovered social media is a huge untapped area that we needed to get into more. And so just toward the end of 2020, we were starting. Actually the middle, we were starting to get into tapping into that resource.

[00:11:17] And so we'll explore that further and anticipate further growth in the future. When you mentioned social media, what avenues of social media have you guys targeted so far? We've mainly just started getting a Facebook page together and Instagram have been our two, our two main platforms. We've had a little Rocky start with that and we're going to get a little help getting that going, but, but that's where we're starting basically.

[00:11:42] And when you mentioned a little help, are you guys looking to hire a person in marketing or are you guys going to organize the social media campaigns? Well, we have a, we have a consultant right now. That's helping us with that, but I think they're going to help us just launch it. But then we [00:12:00] are myself and our physician assistant is pretty good at social media type stuff.

[00:12:06] And so I think the two of us are going to try it. Do it on our own or possibly use perhaps like a college student that's interested in marketing that might just help us with just putting content up frequently to keep up with it. If we get too busy. Absolutely. And that's actually at an untapped resource that a lot of, a lot of docs don't necessarily think about if you have a community college or university or something where you can reach out to a member in the community who might be interested in.

[00:12:33] Um, having your clinic or your DPC as their quote unquote project to work on, I've seen, yeah. I've seen doctors use that successfully to develop a marketing campaign that they may or may not continue on their own after it's fully developed. That's wonderful that you guys are, are building that from the ground up and it will be interesting to see, like you're talking about the targeting, the younger population.

[00:12:57] It'll be interesting to see how [00:13:00] that impacts your guys's demo. Because with the pandemic, it's, you know, it's our way of communicating even more so than it was exactly. It's become everybody's way of communicating. Even my, my 80 year old mother now is become an expert at FaceTime and zoom. The opposite ends.

[00:13:20] I have a three-year-old who knows what FaceTime is compared to zoom. So. I, I definitely, I definitely hear you there. Is there any other way that you guys have been affected by the pandemic because you were mentioning how the way patients are scheduled is different and that's absolutely seen in a lot of clinics where you have to call rather than sit in the waiting room or you have to be screened before entering the clinic.

[00:13:47] I think that we're lucky because we enter DPC when change needs to be made. We can. Do it quickly. It's not like we have to get permission or go through a lot of rigmarole to make [00:14:00] changes. And so we were in a really good position actually to offer. We never had to close. Really. We were, we continued to offer our patients service.

[00:14:08] We've continued to through this whole pandemic and we were able to make safety changes and get our PPE. Change the way we scheduled and the flow of the clinic actually really smoothly and easily to keep the patients safe, but to be able to continue to see them, we offer testing we're out in the parking lot.

[00:14:27] Every day, swabbing people we're helping to screen. We initially we helped quite a few of the recipient patients who really didn't know what to do. A lot of them, the migrant farm workers. Yeah. And people that were coming down with COVID didn't know how to access disability benefits, and they didn't know how to get back to work and with notes.

[00:14:45] And so we were really able to help them navigate things right from the get-go. So I feel pretty lucky that because of our DPC status, we really were able to just do it the way we want it to. For those who might be early [00:15:00] on in their DPC journey in medical school or residency or exploring the world of DPC.

[00:15:06] I hope that they take that to heart, right? Because not only are your patients, I'm sure, so grateful and they are absolutely blessed to have you. In existence and to have you guys, as their doctors, but also the fact that you were able to help them navigate through things that you would never get help with in a fee for service clinic, the doctors don't have time because there's no code for, I helped a patient understand or get to a particular page to download an application.

[00:15:34] Right. So I that's incredible. And like, Everybody in this country, no matter who they are should have. I think the other advantage of a democracy is the same day scheduling module, where people are not scheduled way ahead of time. Interestingly, the pandemic has that's. Something that has changed for us is that our uninsured patients are now scheduling in advance.

[00:15:58] But previously it was [00:16:00] same day. Scheduling benefactors would rarely be scheduled out a few months, but most of the time they make an appointment for two tomorrow, today. And so we didn't, as that Kiva said, we didn't have to close, but even if we had been faced with that, we wouldn't have had to call six weeks worth of scheduled patients to, to let them know everything was delayed so that the DPC.

[00:16:24] Scheduling kind of thing is just incredibly advantageous, which is the reason I wanted to go into it in the first place was you're your own boss and it's so much easier, so much more time with each other. And so much easier in terms of the administration part. Yeah. I think a couple other things that I thought were awesome that we, we were able to get FaceTime.

[00:16:46] We have, of course we have that on our phones, but we were able to set up a station with, with Skype. To offer that to anybody recipient or benefactor that wanted to do a virtual visit. If they, or over the phone visit, they didn't want to come to [00:17:00] clinics. We were able to mobilize that we already were doing that a lot actually as well.

[00:17:04] So it wasn't hard to get that going. And I think the other nice thing has been is that both Dr. Heck and I have quite a number of patients that either are homebound or in some kind of a facility. And we have the, have the unique opportunity to be able to go in at the beginning. We were actually testing some of those patients because some of the places didn't even have testing supplies yet.

[00:17:27] But I think also just some of these people are so isolated. They haven't been able to see their families, the places around locked down and to be able to go in and see a patient and call the family and say, Hey, I saw your mom and she's okay. I saw her and I examined her and she's fine. It was really, I think that the families really appreciate it.

[00:17:46] And when in, in a regular fee for service model, if a patient is being seen in a nursing home or in a facility, they, in most cases don't know their doctor. Like you guys know your patients [00:18:00] right. With the way that your practice has pivoted with the pandemic. Do you guys maintain a limit of how many patients you take and has that changed because of that idea that we're limited in terms.

[00:18:14] The number of patients, we limit the number of benefactor patients. And primarily because they require that individual attention, they tend to be people who need more time than, than people out in the community who aren't necessarily mean somebody who's paying that kind of money to be able to have better access, wants more time with their physician.

[00:18:39] So that's the number that we seen. But on our uninsured side, we'll see as many people as we possibly can. We, for a while, actually, I remember in 2012, that right, 2012 or 13, right before affordable care started, we did 5,000 free visits that year of uninsured [00:19:00] patients. And we had two full-time doctors and.

[00:19:03] One full-time PA and another PA coming in part-time so we don't limit that except for availability. If there's a lot of benefactors scheduled on a given day, we may not have as much access for uninsured patients. But we don't necessarily limit that number. It's just, we see as many as we possibly can.

[00:19:25] When you talk about your schedule, I'm assuming that there are time slots that benefactors have to choose from how does that work for the recipients in terms of scheduling and how long are their appointments set for benefactors do have access to our portal, which allows them to schedule their own appointments.

[00:19:44] And they. Can schedule as long of an appointment as they want. Honestly, most people don't schedule. They schedule somewhere between 15 minutes and an hour, depending on what they want to come in for. Sometimes we will choose the time if they, for example, call or text and they [00:20:00] tell us what it is we guess how long they're going to need.

[00:20:02] And so most of our schedule is open for that. The recipients, we try to put them into our schedules same day, if possible, wherever there are openings. It's a similar idea. The appointments are probably 15 minutes to a half an hour, depending on what they're coming in for. And we just decide that based on what they tell us they need.

[00:20:24] Gotcha. You guys mentioned that you're using FaceTime and Skype. Do you have that running through your EMR and what are you doing, which is out of Austin, Texas, and the, we have to docume