Episode 68: Dr. Tea Nguyen (She/Her) of Pacific Point Podiatry - Watsonville, CA

Direct Care Doctor

Dr. Tea Nguyen of Pacific Point Podiatry

Dr. Tea Nguyen is a board certified podiatrist with a subspecialty in minimally invasive surgery and diabetic wound care. Her extensive fellowship training at UT Southwestern in Dallas was the foundation for her passion in helping at-risk people prevent major amputations. She offers office-based surgery to prevent recurrence of diabetic foot ulcers, which reduces common postop complications associated with traditional open surgery. She opened her private practice, Pacific Point Podiatry, in Watsonville CA in 2018 and she is married to Dr. Paul Nguyen and has a daughter named Vylet.

CONTACT:

Website: Pacific Point Podiatry

IG: @drtea_podiatry

FB: Pacific Point Podiatry, Inc.

TRANSCRIPT*

So in your bio, you mentioned that you have the ability to have creative outlet time.

And so I want to start with that, especially because in this time where we're in the holidays and everything is so busy and we might have patients, trying to get ahold of us in mass right now because they're prepping for vacations and whatnot. I would love to hear more about how you spend your creative time.

The creative things that I think I've always craved doing something with my hands or with my mind. And so I'll a lot of my free time now has to do with crafting. And I feel like. My husband teases me.

And he's that's the old lady thing. Yes. I'm an old lady. It's fine. And I embrace it. Like I love crafting. I love working with my cricket. I love creating things, designing things, making gifts for friends. I designed t-shirts, I make the vinyl like cut it with the Cricut machine, iron it on, and then make it, sell it, whatever.

So I have the freedom to do those types of things that I never had time for before. And I think that creative outlet allows me to just unwind and relax and be in a different space. But I think ties in a lot to how I am as a physician, as a surgeon, because then I'm able to create things that perhaps I never was taught before or learned in the books.

A lot of times in surgery, I have to MacGyver my way around and how to troubleshoot a particular problem. So I think having that creative freedom really enables me to be a better surgeon.

I really love that though, because it makes me think about how on, football players will be required to sometimes do things like ballet as part of their training. And it just this idea that you are able to exercise all parts of your brain.

And then I love how you're able to also bring the skills that you have from doing things like crafting into the surgery room. I think that really makes you so flexible. And like you said, you're, MacGyvering it. Anybody who's seen MacGyver can understand exactly what that means, but everybody's body is different.

And so you have the ability to, pivot where you need to. That's fantastic.

So now I want to ask, because you have been opened since 2018, and as a specialist, where now we're seeing the creation of the drug specialty care Alliance, where we're seeing more action with regards to specialty groups on Facebook. I want to ask when you were starting out in 2018, the year that your daughter was born also your, the quote that you have on your website was I built this practice with the same attention to detail that I give to my daughter with my whole heart and soul and including that pun, which is awesome.

The statement really gets at the heart of the movement to go insurance free. So how in 2018, did you even come up with the idea of developing and creating an opening, your practice?

To be completely transparent. I opened my practice because I didn't have a choice in 2016, my husband and I came from Michigan to California to accept a job that was available for me and for him in the same community.

So I took that job as an associate and about a year and a half in, I became pregnant and I shared this with my employers. At first glance, they were excited for this new change. They were supportive. They said, it's great that you're pregnant. Just know that we support that pregnancy. And not even a month after that, my surgeries that were meant to be scheduled for patients, they were just getting canceled.

So I was really frustrated in the lack of ability to control my schedule. And I had asked why my surgeries were canceled. I just barely two months pregnant at the time two or three months. And the only thing they said was you're a little bit of a liability now, and we don't want to take care of your surgical patients in case you're not available.

So I was just flabbergasted. I felt like I got caught blindsided into this type of control. And at that point in January of 2018, I made the active decision to just create my own practice. I knew being employed just wasn't for me anymore. At the time, even though after fellowship, I had dreamed of having an academic position.

I had dreamed of being in a corporate setting. It was just something that was instilled in my education for so long. And now I have to pivot greatly because I'm introducing a child to the world that I want to be a part of. And now I have to build a practice that works for me. So I created this. Aaron honestly, thinking that I could do better.

And when I opened in 2018 in July, I did the exact same thing. My previously, my previous employer did, I got onto every insurance panel possible within the community, thinking that was the way to go. Not even a year in, I was thinking financially faster than I knew how to get myself out of, because I was waiting for pagans.

That was 90 days, late, six months late. And even today, this past week, I got a payment from an insurance company for a surgery that performed 11 months ago. And I just couldn't wrap my head around how I'm supposed to keep afloat with this mentality, with the traditional mentality of relying on insurance-based payments on top of paying for my lease, my business loan and all the equipment I needed to do my job.

So it was January, 2020, where I got really serious about finding an alternative way to practice medicine. And as a surgeon, I didn't know that was possible that a cash practice as possible, because I didn't think people would pay out of pocket for surgery. They were already struggling paying for their copays.

So it was a fight like this is the negotiation you pay your part and the insurance pays the rest. So I had it in my mind, in my limiting beliefs that patients were just not going to pay. But I think I was in a point where I really had no choice. I was not employable. I had a newborn, so I had to make it work.

I was really persistent in trying to find a way that was going to make it work just for. So I started scouting around. I spoke to other colleagues who had cash practices. One was from my podiatry school. And he had told me he was cashing the get-go right after graduation. He made it work and he shared all of the benefits that he had.

He has a hundred percent cash practice podiatrists. And I thought that is incredible. If there's one of him, there's got to be more. So I kept digging. I kept networking and more and more people came to light. And then I just, in January, 2020, I made a decision that by the end of the year, I would have at least 50% or more patients as cash payers and the remaining insurance-based.

So right now, in the end of 2021, I've met my goal more than half of my patients are cash paying for surgeries and for conservative care, And I'm starting to dwindle the remaining insurance that have just been pissing me off. So that's where I am today. I'm a hybrid with the intention of growing at least 90% cash.

And then the remainder insurance-based,

It broke my heart. When you said the phrase, limiting beliefs. I, that is absolutely it in terms of, we go to training and I'm sure podiatrist is, school is the same as medical school.

And that you're taught, like you said, like your expectation was to work in an academic corporate setting and, to do codes and to do insurances, what was, what you knew. But that is it's limiting because we are not exposed to, even though it that's changing, but we're not exposed to the possibilities of independent practice as a way to do medicine passed our training.

So that is great that you. Are you are where you are at today, but it is heartbreaking to hear that, that, that phrase limiting beliefs, because that's something that I feel most people who have been on this podcast have been through. And, on that note, when we talk about our training, I want to ask, because you said that your friend had opened a direct practice, a direct cash pay practice, right out of residency.

In your curriculum, did you have business training in terms of if you wanted to open a bar, open up a business, this is, these are the skills you would need to do or did you also, figure that out on the fly?

Everything has been on the fly. The way I do surgery today has been on the fly.

None of this was changing residency or fellowship. So a lot of what I do is my brain. My whole business is just on the fly. The friend I'm talking about, he's a non-surgical podiatrist, more sports, medicine oriented. And I was curious too. I was like, how on earth did you have the imagination to believe that you can do this as a cash practice, as a podiatrist in the Midwest and for him?

He was just driven to make it work as well. Like he had a mentor I believe was a plastic surgeon who showed him the way to a cash practice. And it got me thinking it's really unfortunate that podiatry the profession itself is very small, that we don't have mentorship for this pathway. And so I'm determined to show people that if I can do it as a new mom in California, where everything is expensive as balls, but my community that I serve, the median income is $34,000 a year.

If I can make it work, there's got to be way more opportunities out there. That's being. In our education in a podiatry school, I hadn't asked this question. I said, why don't we learn about billing or what insurance is even what it's like to be contracted with them. And the answers were always the same.

It's insurance insurances change so fast. We can't keep up with education. So you're just going to have to learn on the job. I think that's so unfortunate because what is on the job? Does the job mean only insurance based or is there a non-insurance based way that was never even revealed? I've not thought of one podiatrist in my entire training that has a cash practice.

So to me that's wild and I'm so grateful for where I am today and for the people I've met because there is another path and I'm living it.

Especially for, that data where the median income is below $40,000. If you aren't aware Dr. Wynn is located around Watsonville around the Santa Cruz area.

So that's geographically where she's at, but it's just it's incredible because I hear people ask frequently, oh, that's like concierge medicine, paying cash out of pocket is only for people with means. I literally had this conversation with a patient during a home visit the other day.

And so that is definitely something that, you're proving is not, this is not medicine for bougie people for the rich people only. And I want to ask when you opened, how did you get to your community that you were open and how was that experience shifting from fully insurance-based to doing a cash practice?

Was it people were jumping on right away because you're the only the only surgeon of your type in the Monterey Santa Cruz area, or how did that go for you?

I think this was a combination of things that I just got really lucky with. The first thing was I was already established in the community for a few years.

And so people knew of me. The second is my husband's a general surgeon in the same community. So collectively, I think we had a power, couple status where if you knew, when you had to know the other I'm involved in the hospital I'm the only podiatrist that ever shows up on these hospital committees to speak on behalf of podiatry to speak on which board certification is appropriate for credentialing to talk about what our needs are as podiatrists in the community.

So I'm active in a lot of different ways so that I can connect with people in the community. So in 2018, I was insurance-based and a lot of people just found me because of the insurance networking. And then in 2020 I started opting out of the worst payer because I was losing more money than I could catch my breath.

And by doing that, someone told me, once you start getting rid of the lowest payer, you make room for people who will actually pay. And I could not believe him. I was. That doesn't make any mathematical sense. People are physically in my office right here right now. And you're telling me if I get rid of them, get rid of their insurance, not the people, but their insurance, I would get paid more.

So it couldn't, I couldn't just, I couldn't get my head around it. But I knew I had to do something different because it was that or filing for bankruptcy. That was where I was at. At the time I was completely desperate. I was depressed. I was like, I can't believe this is the business I'm running. So I made that decision to cut ties with that insurance.

Sure. Enough people who were willing to pay more, showed up. They started filling my schedule. Whereas my schedule was packed for an average day. I think I was seeing 20 people and I couldn't catch my breath. And I couldn't remember the people I saw. I couldn't remember their names. I felt like I was disappointing myself.

Cause I couldn't get to know my patients. On a deeper level because I was hurting to see the next person. So with all of that, I think it was a breath of fresh air to drop that one major insurance. I was taking to really come to a realization that all the fears that I had was completely false.

And so I started taking risks, one small risk after another, basically to prove myself wrong, like whatever it is that I was feeling, I'm probably wrong. Best case scenario, I make money. So I started doing things. I'd have a gut feeling against my gut feeling sometimes. And that's what happened there.

It was all on the fly I have, I had, there was no playbook. There was no one person that said to do it this way. Everybody was like, ah, you're on your own. You'll just learn as you go. And I think that really is the best lesson in business to be.

That is so awesome though. Again, just reflecting on what you've shared this idea that you're proving yourself wrong.

You've gone from a place of limited limiting beliefs to a place of unlimited belief in yourself. So that is amazing. And I love that you've shared, that, that gem about cut off the lowest paying insurer and then having that space filled with people who are willing to pay out of pocket.

That's amazing. I know for sure that it's, especially if my patients who, because I'm geographically close to you are able to do cash pay. I will absolutely be sharing your details with them. Do you have people because of your services, do you have people coming in from out of town or out of state?

I have initially had people at a state call for an initial consultation. With the desire to come here. So I think the furthest person was Washington and that was through Netflix networking with another podiatrist. So they kindly referred to me and the person happened to live in town part of the time, or grew up here, but lived out of state so that Arizona Washington, where some of the states where they came from, most people are local in Watsonville.

It's a small town. So I do draw people from Monterey Salinas, which is maybe 40, 50 minutes south. And as far as San Francisco driving a weekly to see me for surgery or aftercare,

that's incredible. Now I want to ask just with regards to the business side of your practice, because you are a hybrid, how are you balancing billing?

Like how do you manage getting the codes taken care of getting the insurers to pay you eventually and how do you manage the cash pay?

Oh, I'm somebody who maybe like most of the listeners is not a numbers girl. And I had learned to become a numbers girl in order to make this work out. So I had a wonderful biller, but she saw me transitioning out of insurances.

And so she has less work to do, and eventually she resigned, but I keep her close to me and pay her an hourly rate for questions regarding their remaining bills that I have. And I've had to basically learn everything on my own. With the remaining insurances I have, but it has been much more tolerable because I don't have 20 different insurance contracts to deal with.

Now, I think I have just three and that's more digestible. I'm able to understand each insurance a little bit better in detail as far as what the appropriate code is and what their reimbursement is. And the more I dug into what their reimbursement was because I was just billing blindly. I was like I charge my rate at the traditional 150% or 200% above Medicare only to realize insurance did not care what your rates were because they have what's called an allowable.

So you can say you want to charge 500% of a Medicare rate. They're just going to charge what they think is appropriate for your skill level. And since everyone else is accepting that rate you are to, or opt out. Saying that the numbers were never going to work for me at the rate that was being reimbursed.

I just started opting out really fast. And I think in the last month I opted out in another three or five insurances. And by January I should only have two panels left and I think just dumping everybody else out, made it easy for me to bill. And I have a really wonderful EMR system that has the billing side built in where I just put in a code, maybe a modifier and click submit.

And that's it

wonderful. And Dr. Shane Purcell had talked about this a little bit in his podcast interview and in your situation's very different because you are. Actively cutting out those insurance payers, but how do you go about, okay, this today, I'm going to be done with this insurance. How, what steps do you take to get out of these contracts?

Number one, I had to get it out of my head that it had to go because I was scared. I was like, I keep dropping insurances. That means I'm going to keep losing patients. But to think that way you're never going to prosper. So I had to reframe it. Once I dropped this insurance, I'm going to make more room for more people, more types of my people that I can actually care for.

That was number one, number two, I just started looking at their reimbursement rate and said, okay, who's giving me the worst time. Who do I have to keep asking prior authorizations for an x-ray they're going to go, who is not paying me within 30 days. They're going to go who Is threatening my business in any financial sense or telling patients the wrong information that the doctor didn't get the proper prior authorizations or didn't code correctly and putting the blame on the doctor.

They've got to go. So I've been able to do that sequentially. I think I did it in a way that, it's going to hurt just rip the bandaid off and get going.

And in terms of the logistics, when you're canceling these contracts, do you does it work the same with each one to get out of the insurance contract?

Or is there a special site that you go to get the information that you need together so that you can cancel a contract?

Yeah. They're going to make you hostage. Most of these insurance companies. Somewhere in there 30 page contract, it tells you how to opt out. So it's going to be based on that particular insurance, some plans, some contracts that you have to give them 90 days notice 120 day notice.

I just try to get out of one. And they said, no tough luck. You're in a three-year contract with us. So guess who's going next.

I think that those are really big gems, especially for people who are in any fee for service type of medicine and are transitioning their existing panel of patients. So that's wonderful. And in terms of when you did sign up, because it wasn't, 15 years ago that you signed on to these contracts, did you know at the time that like, oh, I should, keep these in a certain place and where do you keep them?

So you can access these 30 page.

90% of my practice is digital. So everything was in Dropbox at the time or Google dry. My biller had her own file. So anytime she did the credentials for me, it all went in there. And to be honest, I just scan these contracts. I was so eager to just get on board.

I'm like, whatever their rate is, doesn't matter. I just need to get people in the door. And I don't think that was a smart move because now I'm having to backtrack. I think I am where I am because of my decisions and I'm learning from them. But if I can help somebody down the road, who's looking to open their own private practice.

I would probably say maybe just stick with one insurance and learn the billing really well, and then decide if you want to add more.

Great food for thought. Especially as people are becoming empowered to believe and know that they can do. Their own clinics out of residency and not have to join a corporate way of doing medicine. So let me ask you, when you talked about the market around you and the financial situation in your area I what types of patients do you see in your practice?

I see the whole spectrum. I have people a lot of immigrants in Watsonville area. They're farmers, they're seasonal, so they may have insurance, but it's for a season and then they don't have insurance. One of the more recent cases I had was a gentleman who had a toe fracture and he had went to a place and he didn't have insurance and needed the surgical correction, but because that.

Didn't give him a rate in time. The rate was dependent on the facility providing that rate. And so there was a bit of a lag time in giving him that information. He sought second opinion from me, and so I was able to provide them care immediately. The day I saw him, I said, we need to do the surgery and I can do that in my office tomorrow.

So already, because I do everything in my office. I have better control of my time and I can deliver faster service. And I told him, this is my rate. And there was no flinch. He was like, I'll figure out how to find the money. And he did, and we made payments and there was no contract needed because I trust my community.

They're all very hardworking. And if they don't pay fine, whatever, I did the best I could. They did the best they could. And I don't think you can do that when you're bound to certain contracts, because there's a particular insurance contract that says you cannot build a patient lower than the amount you bill us or higher than 15% of what you bill us.

So there's this huge constraint just being tied to an insurance contract. Whereas now if a patient can't pay fine, I'm not going to cry about it and they're going to be fine. Or if there's a patient who wants to pay more fine, you can do that too. I wouldn't happily accept. There's no issue with money.

It's just an exchange of service. And I think having that freedom empowers me to understand that money is just a thing that you use to get what you need.

One of the best books I've listened to recently was recommended by Dr. Julie Gunther. And it's, you're a badass at making money by. Jen Sincero and that idea that, your taking this you're changing your mindset and that is absolutely impacting the way that you do business. But having the James and Cheryl talks about being rich is not the amount of money that you have.

Being rich is the ability to do what you need to do to basically live the life you want to live. So that's amazing that you have learned the hard way and you were putting this into practice for yourself and for your family. That's awesome. Now, with regards to you talk about your surgery center is your office and that's it like, it's all, it's a one-stop shop.

What are your hours like

initially? I think during the pandemic I was part-time, it was like three days and now I've, I'm mostly three days, maybe four days that Melissa, but I built in a lot of time for business stuff, admin stuff, and then personal time. So my personal appointments.

So traditionally I'm open Monday through Friday nine to 12, and then one to four, because I take care of my daughter, drop her off at daycare, pick her up afterwards. And then I need me time for my doctor's appointments. So it's traditional hours, but I reserve, I put huge block times in my schedule. But I make it available so that if people do call if established patients call and they need, they have an urgent need, I'm readily available at the office.

I can take an x-ray and make sure the fracture, stable, things like that. Or if it's a new referral, a new patient, and they want to avert the ER or urgent care center. I'm right there. I'll fit you in. I'll go through my lunch break. I'm there from nine to four.

On your website, you have a picture of how it's your sign as well as there's a, an ENT and an endoscopy suite in the same building, but how how did you find your space and what does it look like when you are working in it every day?

The building I'm in are a bunch of little sweets. So I have my own suite. I found it because it was the same community. I was working in one of the previous employers. So driving up and down, I just saw the lease available and I looked at it and I talked to the landlord and I said, there's a couple of things I'd like to change, which was basically everything.

And he did it. And I was like, that's pretty small. I don't want to work with this guy. So that's kind of serendipity. He did a huge renovation of the space, took out the floors, painted all the walls and cabinets, built up a wall to make, create another back office. It's 1100 square foot room with three exam rooms, a storage room and a room for an x-ray and a back break room and two bathrooms.

So I felt like that was pretty sufficient for my needs at the time. And now I'm feeling I need more elbow room. So the suite in itself accommodate all my needs. So yeah, so the space that I have is my own space. And then the other suites are the other doctors spaces.

So the endoscopy is their own office. There's a family doc with her own office, a GI doc in their own office and audiology, ENT docs. We don't share office space.

Gotcha. And with regards to being in a suite, I know Dr. Krista Springsteen had mentioned the perks of executive suites, especially in her area.

What about what types of perks do you get? Renting out continuously in this space?

The office space they have right now. I I have a wonderful landlord. So anytime there's the littlest thing, whether though the water faucets turning off a wonky way, he's there to fix it. He's very hands Kanzi. The AC wasn't working, he came out to fix that right away.

So I already love the landlord that I have other parks patients who walk through the unit. Let's say they're walking into the ENT office, they see my office name and knowing that it's podiatry, they often self-refer, or they were my patients from the previous practice. Then they have to happen to stumble on my name and, they'll just knock.

And they're like, Hey, can we be seen? And it's of course come in. So a little bit of traffic that comes through was very helpful. And the sign that you see on my website faces traffic. So when patients take the bus and they see my assign, they know they can walk through. So interestingly I've had patients who take the bus and to stop right in front of my office and walked in and was like, Hey, can I be seen for my foot?

When you left your practice, given that we don't have non-competes enforceable here in California, did your previous employer attempt anything to enforce a non-compete or make you feel the pressures of a non-compete?

No, I think we parted ways and it I'm a little bit sad that we had the part of it, because I felt like I got along with them very well up into a point and. When I separated, I think there was just an understanding that I was going to stay in the community because my husband works as a general surgeon there.

So of course I'm going to be around and they've not tried anything malicious against me by any means. And so it's been peaceful in that regard. My name there was a placard of my name. So I did request for them to remove that because patients assume that I was still at the facility when I wasn't.

And so when. We're within that practice. They were kept in that practice, not realizing I had left and to be on good graces. I didn't try to recruit patients to my new practice. I thought it would be obvious enough that I was in the community that know the referring doctors would know where I was at, if they really needed the service, but the people I was with before they provided an adequate service as well.

So I wasn't really in the the mindset that I had to take all my patients with me. I felt that people who were meant to be with me will find me. And there's plenty of people in the community where there's enough room for all of us to really thrive in the way that we wish for it to be.

I love that.

And it just is so freeing to think about, the people who are meant to follow you will follow you. I have absolutely experienced that in my own practice because. I didn't have a marketing strategy when I opened, because I live in such a small town and word of mouth is absolutely powerful here.

So I love that you shared that because when people talk about, how many percentages of people are gonna follow you? What's the, five to 10% rate. You can think about that. But while you're also thinking about what equipment do I need? What, what are my macros going to be on my EMR?

How am I going to do billing? How am I going to do lead management? Thinking about that number of patients who are expected to follow, you can definitely add some strain to those opening months of business. So I love that, like the people who are meant to follow you if you're known in the community, that's that I hope that provides some, calming relief for some people with.

Yeah, I feel I'm a strong believer of karma. Like you don't do the world dirty or it comes right back to you. So the energy that I try to put out as what I'm trying to attract, and if I put out shady energy, that's exactly, what's going to bounce back to me. And that is exactly what I don't want for me or my family or for my daughter to witness.

She, I don't want her to see that side of the world. I want her to understand that there's enough for everyone to succeed if they would just accept that to be

So powerful. I love it now. I want to digress a little bit with regards to your space, because you even said like how you have the break room.

You have three exam rooms, you have the x-ray room. So do you have staff or you talked about your biller, but do you have staff who are working with you in your office on an everyday basis?

Yeah. Since I started transitioning out, my staff went from four to one and a half, one full-time medical assistant, and one full-time virtual assistant.

I call her the half because she's not physically in the office, she's in Mexico. And so it's just me and my medical assistant. And so she is my right hand. I can't do a thing without her. She is my translator. She's my quote unquote office manager. Although she won't accept that position because there's a lot of responsibilities to that.

She's my everything takes care of it. Inventory cleans the room and make sure my schedule is full. And I just love having that level of intimacy with my office, because if I need to change something it's done quick, I don't have to ask for permission from anyone if I want time off, or if she wants time off, it's a quick text.

Hey, I have to take time off tomorrow. Do you think this. Fine. We'll just organize it so that it works for the both of us. She had just purchased a home. So she had a lot of appointments to take care of her home for all the deliveries and things. And it was just like every last minute thing or her, her kids are sick or whatever it is.

And I try to be very present for her so that she can take that time off and commit to her time off rather than being on the clock 24 7. So I value her a lot. And so I make sure that when she's resting, she's rested and prepared to come back to work. So whatever time off she needs, even though it's not written in the handbook, if she needs it, she gets it.

If her kid, for some reason, needs to be picked up at school, they can come to the office, they can hang out in the back, they can do whatever. So I love that level of intimacy,

In fee for service, I would too frequently hear like, oh, you know, I can't get paid for over time or I can't get the time off.

So I'm just gonna call in sick. Those are two things that I heard too frequently. So such a wonderful culture that you are embracing at your practice

women get shafted just for having a uterus and that annoys the daylights out of me.

Like we need to make time to raise children for the world that we want to have. And if you don't make time for your children or make it accessible for women to work, the culture you create is not going to be powerful. It's going to be very toxic. And I made it a point that when I had my kid, that if she needed to be in the.

Fine. She's going to be protected. She's going to have people look after her. Patients are going to know who she is. And guess what patients now ask for her? For my daughter. They're like, how's your little one doing? Where in the conversation is always about her now it's never, my feet hurt. It's what, how old is your daughter now?

What is she saying? And I think that's the reason I fell in love with medicine in the first place was to build these relationships with people in a way that you can understand them as the individual and not a diagnosis.

It's so true and I'm laughing so much when you say, it's not even about the issue that they, waited three weeks to see you for it's oh, so wait before we start.

How old is Asher? How old is Nolan now? Legitimately in my last two home visits, I would say at least five minutes of sharing photos. And I was telling Dr. Wynn this before we started the podcast, but I literally was in her neck of the woods recently at Manresa beach. And I was just sharing beach photos with my patients.

And that's what they're interested in. Absolutely you mentioned now you have your x-ray rooms, so the equipment that you have for surgeries, your x-ray have you purchased those machines directly, do you lease them because they might change in the next few years? What do you do about your equipment?

Yeah, so I was not very smart about this.

When I opened the practice, I took out a bank loan because I wanted everything new. I wanted to have everything available because I didn't know what was going to walk through the door. So a couple of the equipments, like the x-ray and some of some bigger, like the sterilized. Which is really expensive, the chairs, equipment, stuff like that.

I, I purchased right off the bat because you can't lease on alone once the loan once I used up the loan, the bank loan and I decided to purchase like an ultrasound machine. I have a shockwave machine and now a mini, fluoroscopy, and mini CRM in the office for my live surgeries.

Those, I ended up leasing to better manage the monthly payments. So there's two ways you can look at it. If your business is profitable enough, in a way where at the end of the year, you want to claim deductions, you can lease or purchase and claim those deductions at the full amount for me, I was trying to retain more cashflow on those items.

And I wasn't sure long-term like if. I didn't wasn't sure what else I wanted to do. Then I started leasing things out. I probably should have leased out more, this thinking in the back of my mind, if you leave that you're actually ending up paying more, not realizing I should have leveraged that cashflow instead.

Like I could have been smarter with my equipment, but now I have everything. So hopefully down in 20 years, I don't have to fuss about what next to buy or what is next to lease.

And you'll be financially in a very different place than when you open. So that's awesome. Now, have you Because like it, to my knowledge, the only cash pay surgical center is pseudo, HIA seen from their us in Bakersfield.

Have you talked with physicians in your area or just in the direct primary care and direct specialty care network within California about networking amongst each other so that consult for RQ, you bet you can refer to each other if you need, services for other surgical specialties or other specialty

care.

Yeah. I, this is such a new concept to my community. There's only one other DPC, which has Dr. Janine Rodens, which was who I spoke with early on before I really dive deep into the direct care world. So between me and her, we're about 20 minutes apart. And as far as I know, we're the only direct care practice.

It's growing. And I know my community would benefit greatly from a cash surgical center. It's really convincing the providers that it's the log logical thing to do, because right now we're actually suffering from a shortage of anesthesiologists or even CRNs where I can't even book my cases at a facility because staff isn't there or there's not any enough anesthesia services or my time gets bumped because they have to coordinate time for my surgeries.

So I just know that in itself that the payer mix is it's so poor that we can't even retain talent. So I know that's a key indicator for having a. Surgical practice. I just not have the business savvy to figure out how to make it work and to combine heads with other people who think in the same way, because everyone at least anesthesia services here in my community, they're not just at this facility.

They commute 20, 30, 60 miles to their job sites. And that is a huge problem. I don't know how they tolerate it, but they do. But that's because they say the community I'm currently in, they, it doesn't pay well enough for them to stay. So if I only book one surgery at their facility, it's easy for them to say, we can't do your surgery.

It doesn't pay enough. So my case gets canceled. Talk about loss of autonomy. So unless I booked two or three and makes ma and make it worthwhile for the anesthesiologist that I'm bounded by what works for them. And so those are one of many things that drove me to do my stuff. In-house and I know there's a lot that I can do a lot more.

I can do. I just don't know how to make those connections yet.

And for your services, do you ever have like locums CRNs or anesthesiologists come if you have particular cases or do you just manage everything yourself?

Most of podiatry surgery, surgeries are elective, and I can do everything under local anesthesia.

If a patient it requires anesthesia services. Then I go to facilities. So in this past year, I've only had to go to a facility. Two times. One was the patient was adamant. She was just nervous on wheels. And she just was like, not willing to be awake, to hear, to see, to smell anything. And another one, because her case was a little bit more complex.

I had to go through.

it's so eyeopening though. And I wonder, how the communities of the recently opened well bridge surgical center and how surgical center of Oklahoma, how their communities were prior to them opening and even I wonder, how that all came to be. So I hope that as the movement of, cash pay medicine continues that hopefully you'll get some answers and hopefully we'll be able to achieve some kind of network or something in California.

I would totally be in support of that. And so in my patients.

I hope someone hears this podcast and it's yeah, let's do it for Watsonville. Our farmer friends, like these are people who have cash, who have it on reserve. It's readily accessible and they're more than willing to spend on their healthcare if they knew the resources were there.

Otherwise they're just going to go to the ER to utilize services. And it's you lose that continuous care when they go to the ER urgent care center because they get turned over so quickly, we solve your problem. You're not dying by move on to the next doctor. Whereas if we can retain these patients have long lasting relationships with them, we can actually educate them on prevention.

We can teach them that they or their family members can come directly to our office for care, lacerations, ankle injuries, fractures, whatever that can be managed in the office. And we're available twenty four seven either by phone, our office. We could be decongestant thing, the ER, centers, urgent care centers, and utilizing our services to such a higher capacity that I think we can really improve the health of our community.

Amen to that. I am. I love when I hear physicians who are practicing at the highest level of their training, or they've gotten additional training to be able to function in capacities. They never could before compared to fee for service physicians. So I think that's awesome.

I will say that, this idea that you are. Available 24 7 and you are still accessible, very much so on the weekdays. It's not like people have to wait for messages to be returned, weeks later, how does that end up looking like after hours for you do patients frequently call you, do they not call you because you're open during the week and accessible.

This is something that I think is really important to understand. I think a lot of us physicians fear the worst a hundred percent of the time. So we fear once we give out our cell phone, they're just going to be nonstop calls. The reality is. At least a lot of my patients, they're very respectful of my time because I'm very respectful of theirs when they come to their appointment, they're seen within five minutes of their appointment time.

And then if not, they get a lovely gift card to Starbucks or something like time is very valuable to me. And I try to give that right back. So I've not had any patients abused my accessibility. They know that I will answer during normal business hours for normal things that can wait. And oftentimes they preface their message.

I'll expect a phone call in the morning. I know it's after hours and that's the relationship that we have. And I think that's so wonderful. And you can't buy that relationship in any way. So telling patients that I am accessible doesn't mean they're going to use. And just because I use it doesn't mean I have to respond at three o'clock in the morning.

I don't have that type of service and they know that. So I freely give out my cell phone and even my office line is tied to my phone. So every message I get is on my app on the phone app. And so I'm there. And oftentimes I have patients who show up and it's oh, I went to the urgent care, ER, last night and dah.

And I had a school that patient, I said, I've been seeing you week. And you're telling me, you went to urgent care because you didn't want to bother me. My job is to be bothered. What are you even talking about? So I had to re-educate him, what he's paying for is covered and he doesn't have to worry. And I tell him every week, even my elderly patients, they'll say, I don't want to bother you.

I said, you were never a bother. Actually. You need to call me at least once a week now, because I don't trust you having that judgment. And I've had my staff reached out to my elderly patients once a week to say, is everything okay? Did you fall and hurt yourself today?

That's yeah. That's that personable touch that we're able to do in direct care is just, it's so different.

I would've loved to, send a text to a person or, schedule a text knowing that they were going to have a a mammogram or whatever. But yeah, it's just that ability to provide. Personalized care or personalized followup to make a person feel like your doctor is not just the person you go to when you're sick, but the doctor is here for you.

When you need to ask a question, if you need something, acute, like you said, stitches or something, if there's a laceration, but yeah it's so different. And even just at the time of this interview I've been in practice in my own DPC since about two months now. And it's just a huge shift just within the first two months.

It's incredible to be in that world. And I love sharing this space together on this interview. Now, when you talk about your practice and how it's evolved, I want to ask, because even though your direct cash price pro part of your practice has been more recent. You've still been in business since July of 2018.

And so have you experienced. Any challenges that in addition to ones that you've shared that you have overcome, that you would like to share with other podiatrists who are thinking of direct practice or direct cash practices or even primary care practices who are thinking about going into a cash based system?

I think it's really important to adopt a mentor who has already done it. I don't think this is something that you should go into blindly. Like I did. Now that the resources are there, because there are a lot of hardships that a lot of us don't share publicly, because what for right when I opted out of my biggest payer Medicare in, I believe it was March or April of this year, I had a significant drop in revenue over 50% because that was supplying my income at the time.

So that had been drawn out for where are we now? November. And it's only now in November that I'm starting to pick up again. And I think it's really important to understand what the financial impact you're going to have when you make these decisions. I'm fortunate enough to have a secondary income.

My husband's a primary income, so he takes care of everything else. Outside of my business is my responsibility. He's there for everything else. I've personally have been afraid to even ask him for financial help, because then that I felt like I would have been a failure in my own mind, of course.

Just getting out of my head and saying, look, my business is not going in the direction. I want it to, I had to have that open discussion with my husband and talk about the, what if the, a, B and C plans, if my business has to shut down, what is our plan? Can we continue to live here in Santa Cruz?

Do you have to pick up more shifts? What do I need to do? The pressure was on me because I had my daughter violet at three years old right now. And she's in daycare. Do I have to pull her from daycare? Do I have to be a stay at home for a period of time to make this all work out? I haven't had to go in that direction, like I said before, we like to think of the worst case scenario and live it, but not actually, that's not our reality.

So getting a mentor, who's doing what you're doing in your specialty is critically important for me. I had doctor. In Florida direct me almost hand in hand. And so it was like, there was always a little bit of a safety net with her cause she had done it for several years, even before me. And she's been in practice for 20 plus years.

So even though our business pathways are different she, I think she gave me a lot of comfort in allowing me giving me the space to know that this is going to work out exactly how I designed it.

That's awesome. And I think it's so ironic because Dr. Torres is going to be on the podcast

so that is amazing that she was your mentor.

She's incredible because her point of view, she has so much wisdom to share. And for me, I'm so new in what I'm doing, what we do is so different. Her focus is in educating the new residents of options. And I'm just starting to understand how valuable that is.

Whereas my focus is in healing, chronic patients with diabetic foot ulcers that deal with legs that are about to come off and I'm trying to save those things. So even though we're both podiatrists, we have very unique pathways that make direct care very valuable to our.

When you are talking with Dr.

Taurus or when you're doing your own re-evaluation of your business, are there certain things that you follow? Like you mentioned time blocking in your schedule for admin time, but do you have this is the, this is my plan that I do every week for, by balancing the checkbook or this is my plan every week for making sure that my, my schedule is balanced out appropriately for my family time and my needs.

Like, how do you work the business of your business?

I don't have a schedule. It's very hard pies. I have a three-year-old she's number one. So if she lets me sleep, I can get work done. And let me tell you, the past three years, I've been trying to create a schedule where I wake up at four or 5:00 AM, workout journal.

That sounds a little dandy and stuff, but the reality is. No she traps me in the bed and she holds me there she'll hold me hostage until 7:00 AM. And once I get out of bed to go to the bathroom, she's screaming her eyeballs out. And that is the start of my day. And so I do what I can with what I have, knowing that my priorities are always going to be her number one.

I need to be emotionally available for her and then the businesses number two.

Awesome. When it comes to, this podcast and I'm sure that just on so many levels have connected with people already, just hearing your story. What is the best way for people to reach out to you after this podcast?

I am on Instagram. My tag is my handle is at Dr. T D R T E underscore podiatry. But I agree. I'm chronically there. Like I need to get off of there as what? So that's a good place. Facebook I'm there frequently. I'm actually on Facebook to network more than anything. It's my name T when DPM and I check all of my messages through my website.

So if you contact me as a, at, if you're a patient, I'm answering those messages as well. So it's not, it doesn't take a lot of effort to find me. So please connect with me. I would love to share what worked, what didn't keep in mind that what works for me may not work for you. And life is fluid. You're a dynamic, everything is evolving.

So my story today may be different 10 years from now, just like yours. But I think just having those early connections, they opened some doors for you that you never knew existed.

Fantastic. Thank you so much for joining us.

Thank you so much, Marianne. I am so in awe of what you do, I've listened to every single episode and I'm going to listen to myself because that's just what I had been doing.

And I want to make sure that you get to interview yourself with your DPC practice someday.

It's coming soon. I will say that

I look forward to it

*Transcript generated by AI so please forgive errors.