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Episode 119: Dr. Nick Tomsen (He/Him) and Dr. Brandon Alleman (He/Him) of Antioch Med - Wichita, KS

Direct Primary Care Doctors



Dr. Nick and Dr. Brandon are co-owners at Antioch Med
Dr. Nick Tomsen & Dr. Brandon Alleman

Dr. Nick is a co-owner of Antioch Med and is originally from Nebraska. He graduated from the University of Nebraska with a BS in Engineering and subsequently from the University of Iowa with his MD. He attended residency at Via Christi Family Medicine where he was Chief Resident and then completed a Fellowship in International Family Medicine while serving at a hospital in Galmi, Niger. He continues to teach residents and students and is active in his church. Creating relationships with patients is life-giving to Dr. Nick and he is blessed to be able to serve patients through medicine. He is married to Michaela and has three children (Moriah, Charlie, and Daniel).


Dr. Alleman is a co-owner of Antioch Med and is originally from Michigan. He graduated from Hope College with a BS in Mathematics and a BA in Physics. He is a former Fulbright Scholar to Budapest, Hungary, and graduated from the University of Iowa with his MD and PhD in Translational Biomedicine. He is a graduate of the Via Christi Family Medicine Residency and was a Chief Resident. He enjoys helping people understand their health and uses his PhD training to assist in providing evidence-based medicine. Dr. Alleman is married to Becca and has four children (Jonah, Cora, Esther, and Levi)


 


Dr. Alleman talks about DPC and incentives to be aligned in healthcare




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Transcript*

 Direct Primary care is an innovative alternative path to insurance driven healthcare. Typically, a patient pays their doctor a low monthly membership and in return builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the My DP C story podcast, where.


You will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model. I'm your host, Maryelle conception family physician, D P C, owner, and former fee for Service. Doctor, I hope you enjoy today's episode and come away feeling inspired about the future of patient care direct Primary care.


 Direct Primary Care is a model of delivering primary care that aligns incentives between patients and their physician. It's allowed me to practice medicine at the highest level of my training and to develop meaningful relationships with patients making primary care life-giving and sustaining for the long term.


Direct Primary Care is a true medical home that is designed with the right incentives for both patients and physicians and it's also the only hope for achieving the quadruple aim in medicine, and that's better care, lower costs, and happier patients and doctors.


This is Dr. Nick, and this is Dr. Alleman and this is our DPC story.




 Dr. Nick Thompson is a co-owner of Antioch Med and is originally from Nebraska. He graduated from the University of Nebraska with a BS in Engineering and subsequently from the University of Iowa with his md. He attended residency at Via Christi Family Medicine where he was chief resident and then completed a fellowship in International Family Medicine while serving at a hospital in Gmy, Niger.


He continues to teach residents and students and is active in his church. Creating relationships with patients is life giving to Dr. Nick, and he is blessed to be able to serve patients through medicine. He is married to Mikayla and has three children, Mariah, Charlie and Daniel. Dr. Brandon Alman is a co-owner of Antioch Med as well, and is originally from Michigan.


He graduated from Hope College with a BS in Mathematics and a BA in physics. He is a former Fulbright Scholar to Budapest, Hungary, and graduated from the University of Iowa with his MD and PhD in translational biomedicine. He's a graduate of the Via Christi Family Medicine Residency Program as well and was also a chief resident.


He enjoys helping people understand their health and uses his PhD training to assist in providing evidence-based medicine. Dr. Alman is married to Becca and has four. Jonah, Cora, Esther, and Levi.


 Welcome to the podcast, Dr. Alman and Dr.


Thompson. Yeah, thanks for having us.


Yeah, we're excited to be


here. We were standing in front of the hotel at D P C summit talking about doing this, and we're finally here. So I'm super excited just because if, if anyone's been in the D P C space, they've heard your names before, they've seen your presentations at the, the different summits over the years.


But I really love that you guys are having the space to share your story. So I wanted to open up with the beginnings of Antioch Med and the beginnings of your, your journey into medicine. So how did you guys even start becoming family medicine physicians?


Yeah, so I initially thought I was gonna do ob and then figured out I didn't fit with the obs.


But still really liked doing obstetrics and loved relationships with families and saw especially doing medical school in the Midwest and seeing how a lot of Midwest trained family doctors do a little bit of everything. That was kind of what grew my interest and ended up coming from the University of Iowa to via Christi in Wichita to do residency.


So, that's a full spectrum residency where we trained to do about everything. Brandon and I actually started medical school together. Mm-hmm. , and Brandon took a little detour that I'll let him kind of talk about. So


yeah, I I did not know I was gonna be a doctor. I got degrees in math, physics, and then my senior years, like maybe I should go to medical school.


So not knowing if I liked clinical medicine or not. I, when I alluded to, I matriculated into an MD PhD program. So we did our first two years together, I kind of went off and did the PhD portion. That's really where I learned a lot about like health quality and the problems with just how medicine is practiced and that.


Led into my clinical years and I didn't, yeah, same thing. I liked lots of stuff. I liked Toby. I liked emergency medicine. I had these goals of running a business. I had these goals of like fixing healthcare. And it's like, well, how do I roll that into one? And it I knew I was interested in a direct primary care type of practice, even towards the end of medical school.


And so family medicine kind of brought all those things together for me.


Mm-hmm. . Yeah, I wasn't necessarily interested in direct primary care and the people that were talking about it in the residency. I didn't necessarily think that it was that viable of a solution and I was intentionally working towards trying to serve a more under pop underserved population here in Wichita.


And initially was planning to was bringing seven physicians in, in addition to myself to an F Q H C that were all from our residency to open a new practice with their Their outpatient clinic can also bring more expanded services to them. And that dramatically failed after three or four years of trying to get it started.


And that's a, a long story. But I think the, in the intro that I shared, the misaligned incentives with the patient and physician and the F Q H C system, really seeing the way that. The, the incentives that were at play that didn't involve the physician or the patient, and instead were government and insurance really were the thing that we're preventing people especially our most underserved from getting really good care.


So that fell apart. I was distraught and figuring out what we were, what I was going to do. And Dr. Alman comes and says, well, why don't you open this membership-based direct primary care practice? And I was like, you gotta be kidding me. You're not, you're going, going to come and tell me we should have underserved patients come and pay me money like that.


This isn't gonna work. And , but it got me thinking and it, it was really the start for me of really understanding what Direct primary care was. And it was really a model that could be about anything, but aligned the incentives between patients and physicians. And for us, it was something that we could do at a little bit more affordable rate and really offer great care to almost everyone in our community in a very comprehensive manner.


So that was the, I, I did an international fellowship, so an extra year of training. And then when we came back, things had fallen apart with F Q H C. and Dr. Alman and I decided to go into business together while he was in his, finishing his second year of residency and starting his third year. And then we planned for about six months and opened our practice in July of 2016.


I was the first one to start seeing patients, but we still were managing the business together, even while Brandon was in his third year. And he took a whole week of vacation to in, in residency to give me a week of vacation which was my only vacation for the whole year. So it was awesome. So that was kinda how we got started.


And I kind of knew that D P C was my, if I was going to practice medicine and not going to academia, like that was gonna be the type of thing That just resonated. Mm-hmm. , like I knew it was right. I didn't know why. And I think that's just been some of the probably discovery over the last six, seven years that we'll get into.


So


If that doesn't fire you up and feel so empowered to do D P C, I don't know what does because it's an incredible journey and it pulled two people together to create something where now you guys employ five physicians and multiple support team members.


So bringing all of your guys' experiences together, what were some of the first actionable steps that you put into place in those six months of planning to ensure that your practice represented what you wanted to bring to Antioch and to your patients?


I think the, the things that I would hit on is that we wanted it to be as accessible as possible. Mm-hmm. , so we, we actively kind of pushed against the concierge label, right? So we wanna be able to, to, to take care of as many people as we can, regardless of their running a company, they're working for themselves, they're uninsured.


We wanted to, wanted to be accessible. And I think continuing to do full scope medicine was a goal as well. So we started out doing obstetrics. We even started out kind of admitting our patients to the hospital and can go into that if it's interesting later. But I think those were the two goals.


It's like, how do we practice medicine in a way that we think it should be practice? And how do we do it in a way that's available to as many people as possible?


Mm-hmm. . Yeah, I think. Having it be something that even the, the folks that in Kansas and we didn't expand Medicaid, so there's a lot of folks that are underserved and but blue collar and working that still don't have access to care.


Not excluding those people, but also in the reverse, not also excluding high income earners and those that want really good, ar really good care and are friends that are also doctors that are getting bad care in other places and business owners. I think we, we wanted to be accessible to all of those people and then give a breath of care that came from a relationship and so time with patience really like.


Creating affordability through, wholesaling things and just like a lot of the other direct primary care practices do. But that was something that there wasn't as much available as far as just what resources were around and how do you do these types of things. And then that breadth of care, I think was important for us to not only just obstetrics, but even, surgical procedures in the office.


And more advanced medical care that usually would be referred to specialists. Like those were things that I think we really feel proud of the way that we started. But I think it really, for me, it really boiled down to do I have enough time to actually be a good doctor? And so that was probably the biggest piece.


And do I have somebody telling me the way that I'm supposed to do this or not? And I didn't really like the way that the last people were telling me how to do medicine. So, , and


especially when they're telling you, not because it has to do with anything related to patient care equality. Mm-hmm. , but because of codes and because of people who don't actually do the medicine, um Right.


Creating rules. So let me ask you there though, because, and, and Brandon, I love that you mentioned you guys were admitting your own patients to the hospital as you were, finishing your residency, Brandon, Nick, as you were, on your own, doing your thing outside of this F Q H C how did you guys, take call, how did you guys take patients? Did you limit the number of patients in the beginning, especially Brandon, while you were finishing residency? And were there any concerns because you were a resident while practicing at Antioch as well?


I think the, the stagger start was actually helpful cuz it was a, it was a pretty clean delineation of that, right? So Dr. Nick takes all the patients I help out if, like the vacation stuff and I can cover a little bit, but I'm not actively enrolling patients unless it's like somebody that they know wants to see me, in July of 2017 when I start.


So it was easy or it was easier for, hey, we know Nick's gonna build a panel. Hey, when I come on I'm gonna be building a panel. So, it was nice to have that clean delineation rather than somebody signs up and like, who do they go to? So, mm-hmm. .


Yeah. I think the the difficulty with that was the great part about it, the difficulty with it, was that we were blessed with really quick growth.


So the first year I had went from zero with like 10 pre-sign pre-nups when we opened in July. And about half of those were my family members and other physicians. That felt bad for me. But at the end of that first year, we, I had like 580 patients. And that had to do with a lot of different factors.


I think the the D p C realm was ripe in Wichita. Thanks in a lot in large part to Atlas. It's a family medicine friendly location, and we were underpriced which we've made some changes to over the past or in the, in the recent past. But it also, it was a wonderful thing to get so close to full, but it was also a really, our first years for each of us taking patients were pretty brutal.


And it was not a lifestyle focused practice at that point in time. So, and really was, I think we, we really worked hard to get ourselves as full as possible so that we could allow the next physician to take all of the patients and not, not feel bad about trying to siphon some of those to yourself.


So I think it worked out well for us. We would, I recommend solo physician just going gangbusters and never slowing down and working yourself into the ground in order to just get to a full level. I don't think I necessarily would say that, but it, it was the right thing for us to do at the.


fast forwarding a little bit, you guys are dads, you have other interests in addition to your D P C.


So how have you now looking back, been able to, like you said, Nick, you had your one week of vacation that whole year. How have you now built in time or balance into your practice so that you can do you can honor your careers as physicians, but also honor yourselves as people?


Mm-hmm. ? Yeah, I think this so after that first year and after some marriage counseling, which I'm not sad to say that I did and it was a necessary thing.


And still am married and still have a, I love my wife. But I think it, she loves, she loves him too. Yeah. And his wife loves him too, so, but I think it was, I think for me it was just an eye-opening thing that I, part of the reason why I did this is because this isn't the only thing that I am, and I wanted to be able to have a sustainable practice.


In order to do that, I needed to put some boundaries on things. And so I think some of that started even in the first year while we were open. So we initially were the free tech zone, 24 hours a day. I will meet and exceed any expectation you have for me, and I will go above and beyond to do anything, come to your house, what whatnot.


So, Some of that I started to put some boundaries on. In our practice, you only text us 8:00 AM to 5:00 PM Monday through Friday, and if it's urgent, you call and we're available, but I'm not at your Beckham call all the time. And so I think really starting to train patients and set some boundaries was really helpful.


Here now I take part of a morning on Tuesday to do things with one of the leaders for our church and so help with that part of life. And then on Wednesday mornings I do everything related to kids and get them to school and then usually have a date morning with my wife.


So I work the other days and then all the on-call and after hour stuff. But I think that's helped to normalize some of those other parts of. Parts of who I am, so, yeah.


Yeah. And I think that's, it's changed as we've gotten bigger too. Yeah. So, um mm-hmm. , when we started out, we started , we started, started out with like one number.


And so we all got everyone's texts and like we each got all the texts and calls for every, all of our patients, you know what I mean?


And it's like we had like a thousand some patients and we're getting all the texts for every person, including both doctors and nurse. Yeah. So it was


not wise. And so, yeah.


Part of it's just learning and then part of it's like growth affords opportunities to do that. It's like, well, it's easier to be gone on the weekend cuz you know, you have four other partners that can help you out. Mm-hmm. . And so, yeah. It, it's just evolved and it's been a learning experience for us.


It's been a learning experience for our patients and we're, we're still learning new stuff on how to, how to do it well. So, but yeah. I have, I have four kids. Dr. Nick has three kids and so b busy life outside of medicine too. Mm-hmm. .


I love it because, even though you guys are many years into practice, you are still very much in your business.


You're you're learning from your business and you're owning it. And that's how I think that all of the, the practices that have opened opened when you guys opened, opened just yesterday. This is how we continue to be with our patients. So I really love that you guys are, are sharing what you are.


Now, you know, Wichita is a, great area for a, a group of patients who value family practice and access to their doctor, did you guys have any hesitancies or fears when you were opening, given that you had never done this before?


I always, I always kinda say like, we will tell you the truth, but it's, it's kind of our like, retrospective on the path. So , so Jud Aska seven years ago, we'd probably say the same facts, but maybe in a different way, but Uhhuh . But I, I think the, the thing that made us successful is, is, we're, we're people with not a lot of needs, if that makes sense.


And if you, if you don't need a lot of things, you can do a lot of things. Mm-hmm. . And so, and having a partner that has a similar goals and outlook on life and things, it's like, I moonlet through my third year of residency to like half cash to, put into starting the business.


We didn't need to take out a loan. We had never taken out a loan on the business. And so, yeah, it's like, is it the questions isn't gonna work, but it's not like, are we gonna go bankrupt or are we gonna have problems? You have a very valuable degree , to earn money with.


Like, you're willing to work hard, you can do this. Which had kind of different stories around that. Mine took extra time, but the MD PhD program, like paid for all my tuition. I didn't come out with any debt, paid me a, paid me a stipend while I was in medical school and that was my path to like mm-hmm.


having financial freedom kind of leaving medical school. And Nick can talk about is, but yeah, the question is, is it gonna work? But it wasn't like we need this to work or else,


if that makes sense. Mm-hmm. . Yeah. I think now, man, you should have had a backup plan because , I, I mean, it could have failed, but I don't really remember myself thinking, this is gonna fail.


Yeah. Because I, I remember just like thinking like, there this is way better than all the other options that are available. And I really like, I think the biggest piece that made it easy to bring patients in was that it, we really believed in ourselves too. And so I think that was That's, that would be my, my answer to it.


But I think there, there was always that, especially the, the first little bit that you're getting going, the you watch the numbers and when you don't have a new patient sign up today or, or tomorrow or the next day, it's like, oh, what, what are we doing wrong? Like, where, where are we failing? And then you get a whole pile and it's like, well that was great.


And then you kinda live and die by the vine and that I think that was probably the hardest piece is that. You those first startup days, you're counting, okay, I need this many more patients to break even. I need this more, many more patients to actually have a nurse here and I don't have to draw the labs and do all the vital signs and send all the faxes and forward all , the patient orders and referrals.


Like having that day end was really nice. So , I think those were pieces that we could see that were like, oh, are we gonna get to that piece? And those were pieces that I sometimes questioned. Could we get there? So, yeah.


I definitely appreciate you guys sharing that and hearing that bit of your story that each of you shared there, it makes me think of having a scarcity versus abundance mindset, and I think that that's what we see a lot of in people who decide to do direct primary care is, Hey, it's either this or.


I, I will find something else, but at least if I try this, I will know that I put my best foot forward in this type of care that is truly returning medicine to patients and their physicians. So, love that. Now, Brandon, you mentioned partnership and so I wanted to go there next. How is Antioch set up?


Are you guys an l l c an S corp? How is what is the legal background of Antioch? Yeah,


we're an L L C is kind of the, the simplest way to do that. And there's, depending on growth and goals and payment and stuff, there's different ways to be taxed, but we've been an l a professional L L C from the beginning and continue to be that.


Gotcha. And you guys are co-owners and so can you share with the audience how have you guys continued to be co-owners while bringing on fellow physicians to practice at Antioch as well as staff?


I, somebody, I think it was Kenneth Q at one of the, one of the events said, I think you guys are the only ones who are still partners in, in dpc.


And so I, I took that as a compliment. Yeah. And


Yeah, we're also neighbors, so we live 50 feet from each other. Yeah. So we're just kinda weird. But


that is what it is, I think. But I think that's, it's really that like, and, and a and we didn't do this at the beginning, but a book I always recommend to people who are considering partnership as the partnership charter cuz everybody has a plan till something goes wrong, , right?


So like mm-hmm. setting out the plan beforehand it's like kind of taken on a second marriage and so you should mm-hmm. know the person that you want to do this with really well and like, know how they're gonna handle adversity and who's gonna be doing what, those types of things. So, partnership's awesome because you can leverage each other's strengths if you don't spend time.


Planning and communicating about it, it, it's going to, it's gonna cause problem eventually. So. Mm-hmm. , those, that's what people considering, taking on a partner and stuff, they. Spend time investing and knowing those things, so mm-hmm. .


Yeah. And I think that that's also changed for us over time too.


So we, initially started out and we both just did everything. Like, if there was a check that needed to be written, one of us would do it. If there was something from a, a business to go to, to pitch something for, we both were always there. And eventually you get big enough and you have enough things going on that that can't occur.


And so that I think those were also just like difficult but good parts of our developing partnerships. So we have we're both co-owners and equal equal owners as far as stake in our practice. But those roles have evolved over time. And so I, I'm primarily a physician and have some management roles, but Brandon takes most of the management.


Is is in charge of most of the management pieces of our business from a day-to-day perspective. And so we pay him an amount for that even though we're still equal co-owners at this point. So, and then those are things that also, like Brandon shared flow into our strengths and avoid some of our weaknesses.


Like, so I think it's just pieces that we like a little bit more about the business. Yeah. And that lets us run our business a little bit better. So,


and when we talk about this being like a second marriage , the question that I think of is if someone is. In a place where they're potentially going to join on with another physician to open a D P C mm-hmm.


what are some key questions that you guys would, would suggest they think about or they ask before going into that second marriage? Because mm-hmm. , it's not always easy to know who someone is or how they practice if you have not worked with them


previously. Yeah, that's a great question.


I think the first piece is you need to spend time with them both clinically and non clinically. And I think look at their notes, look at the way that they practice. Cuz if they practice in a, in a vastly different style than you do it's gonna feel uncomfortable when you begin to cover their patients.


I think that's part of the reason why we've hired all at this point anyway, all physicians that have come from the same residency that we're from the breadth of care and the type of care is pretty similar. And then I think too, spending, having an an ability to spend time with them non clinically just because the value systems that you have probably are going.


Be even more important than necessarily those differences between the way that you care for a patient, but the, the why behind what you do. That I think could be a lot more damaging as far as future problems that can develop in a in a partnership, especially where you are, both of you are at stake rather than an employed relationship where there's a hierarchy that's that's set up from the beginning.


So those are the two things I would say. Yeah.


I don't know that I have a ton to add, but it's, it's like, make a plan, , you know what I mean? This is, this is the type of marriage where you should definitely have a prenuptial agreement, right? . So this is not, this is not, marriage is an analogy.


It's not literal in this case. And so, mm-hmm. . Plan ahead for like, who's doing what and what are my responsibilities and these things. Mm-hmm. And like, that book I mentioned if, if, uh mm-hmm. If the other person not willing to read it, ah, we don't need to do that. Like, that's a red flag, right? So mm-hmm.


Yeah, take it. Take it seriously. Yeah. And


I think the other piece that I think has been really valuable for us, but has still, even though we know it's valuable, it has sometimes been a struggle to get it done, is just regularity in meeting and also scheduling longer periods of time where we can just do, bigger vision related things and talk through stuff that feels like conflict or feels difficult, that we have time to be able to deal with it.


It's not just a 15 minute sit down, here's the list of to-dos for the week. So I think that having those types of things and. Just relationship building activities and, and time together is probably also just super important for anybody that's wanting to have a partnership that's going to to last into the future.


So, yeah, that's a great point. I think people like, oh, we're gonna be working together. Like, we'll just talk about these things. Like, we'll, if you both have a busy clinical practice, like, even randomly find time, even though you're six feet away from each other, it's like mm-hmm. , those things, you don't have time for those things to come up.


So planning time to, to do that is important.


Mm-hmm. ,


How did you guys build that time into your schedules when it was the, just the two of you before you added on a physician to your.


Honestly, that was a little easier cuz that's like, well, we only have one staff and there's not other people's schedules to build around and you're not covering further physicians and stuff.


And so I think getting bigger makes it, makes it harder. And so it's like mm-hmm. getting it on the calendar, mm-hmm. a week in advance, or we're gonna do this at a recurring time. And that's, it's changed as like mm-hmm. as responsibilities to change and things. But the, the foresight to do it and trying to do something a little bit longer quarterly is something we've done and trying to get out of the office and do it, so.


Mm-hmm. .


Yeah. Love it. And in, when you guys mentioned team building, what are some examples that you guys have found helpful for your team at Antioch over the years to do team building with,


I don't know, and I, and I wish I had a good answer for this. I think the, I think most of this still is is trickle down from the way that we started truthfully.


And I think our, the other so I think just, just the way that our physicians. Act and treat people and enjoy being around each other and our good teammates and jump in and everybody does a little bit of everything. And those are just things that started as we started. And I think that that has had trickled down over time.


But I also think that part of that is because we ask generally our physicians to continue to do some of those things. Not everything, but some things. And so I think that that has helped to just be a culture of like, everybody's valuable here and everybody can do a little bit of everything and nobody's above taking out the trash


So, I think that that is a piece that we've maintained even though we haven't like had. Retreats to all spend time together. We spend, we do holiday parties and we've had kind of, non covid. We've had our anniversary parties that we invite patients to and those types of things. And I think all that stuff is fun.


But I think ev most of it's just an, an everyday type of interaction. .


And I think it's, it's learning over time too, because it's that's where I get we might need to do more of the future. Well, I get, I get nerdy, right? So I think of like culture as kinda like gravity. It, it decreases with the square of the distance, right?


And so two physicians, one nurse, not that hard to maintain culture. Five physicians, five staff. Still pretty okay. More than that man. You need to start thinking about these things. And so it is you know mm-hmm. , like we've started meeting one, one lunch a week with all our pro physicians just to talk through anything that's going on.


And that's, we don't, you, you, I don't think other of us think about it as culture building, but it's like, it's here and everybody, what's going well for you? Mm-hmm. , how can we help you? Do we need to change the way we're doing something to make this better for physicians, better for our staff? And then, starting to meet with our staff weekly too.


It's like mm-hmm. , they're on the front lines. They take all the calls. They're seeing patients when they walk in, Hey, hey, what do you see that we need to be improving on and stuff. And so, I never think of those as culture meetings, but but it certainly kind of d dictates the direction we go. And then it's learning the hard way too, of making some not helpful staff hires and that it is just way easier to work really hard with people you enjoy than to add more people that maybe are not necessarily helping you get to your goals.


And so learning the hard way with that stuff has been, has been mm-hmm. , we've made mistakes in that, so. Mm-hmm. .


when you talk about those mistakes, how have you gotten through those? Because I, I have definitely talked with some physicians who they've brought team members on, whether that be an office manager, an ma social media manager, and having that discussion of this is not the place for you, we're not a good fit.


Those types of discussions can be really, really uncomfortable for people. Especially I feel primary care doctors because that's I find a lot of people pleasing tends to come through in primary care doctors. ,


we're laughing cuz we both know the answer to this question. ,


please,


please. . Well, I mean I think that this goes back to our early discussion of like, what are the strengths of people?


And so, when you mentioned peace pleasing that may, that that is why Nick grew so well initially is cuz when you were taking awesome care of people and you're great to be around, it's like, well, people are gonna sign up fast to have you be their doctor. Confrontation has never been something that's been a problem for me.


And so and so tho tho those two days are, are fine to come to me and, and I, we've never like fired anybody. There's no, not of any like blow up and like get out, but it's like we communicate the expectation. You document the ways you've communicated, the expectation, you give the feedback that like, this is the expectation you haven't met at.


And then people have just self-selected, Hey, this isn't the place for me. Mm-hmm. . You know what I mean? So that's, that's, I'm glad we've come to the same conclusion. So that's the that's the way to do that. And it's. trying to take really good people of, once you realize they're part of your core, like mm-hmm.


see what they need, yeah. My favorite story to tell on this is like our current one of our current MAs, and she's kind of taken on some of the administrative roles with me. She mm-hmm.


she started out as a 19 year old cleaning her office. Right. And so then she, well, you can come in and, do faxes for us one day a week, and do, then do those things and well, you can, make sure our medicine, medicine inventory is correct and like, oh, you go to MA school and, she's just kind of grown from there.


And it's like, you want those people to like, retire from your office, not hit a ceiling and be stuck there. So. Mm-hmm. , the, the way you cultivate people like that is, is important, so. Mm-hmm. .


Yeah.


as you guys are talking about the, the staff in your office, can you give the audience a feel as to what your space is?


Like, how big is it, how many offices how do you use your patient rooms? All of those details. Mm-hmm. .


Yeah. This has really changed over time just because the, so we started out in an 1100 square foot that was 900 900 square foot kind of dump of a place. So we're in an underserved part of Wichita, but we're right next to the hospital, so that was super easy.


And I think we started out at like. Nine bucks a square foot, 10 bucks a square foot, something like that. So it was very affordable for us as well. We did all, it was essentially like one exam room that was anywhere usable and two that were like micro exam rooms that you couldn't actually get anything done and the walls were so thin that you could hear everything through them.


And there was like a pass through cabinet between two of the rooms in one of them. So it was, we, we made it nice. But it was not ideal. And that was where we started and


we, you couldn't schedule two pap smears at the same time. Oh no. It was like, we don't have the space for that. You know what I mean?


So it's like we only have one room that we can do a real exam.


Yep. And. I put up all my art in the room and Dr. Alman was not super, super pleased with the art that I had, which is mostly multicolored cows. And so, that was a point of contention until we got more rooms. So we that office space was actually in kind of a strip mall space of outdoor offices.


And there was an opportunity for us to be able to renovate into some of the open spaces that had been there. And so we moved, we actually have now renovated four different times in. Almost seven years, six and a half years. And so that we always thought we were getting enough space and then we would just barely get in there and realize we'd need more room.


So our last renovation was about two years ago or so. Mm-hmm. . And so we've been in pretty good shape at this point in time. So we have about we now actually own our building and our. Essentially in three of the office spaces that out of the five that are in our building, but combined all of those into one office space.


It's kind of a long track that runs all the way down. We have a very small but living room, like waiting room and room for three nurses there, and then a separate room for our nurse manager. We have one vitals area, and then each physician pretty much has one main exam room that they see all their patients in.


And then we pretty much have two overflow rooms or three overflow rooms, a procedure room, and then an X-ray room. And we have a, a mobile X-ray group that comes every day to our office that's available. So we have about. 12 rooms. And then we have a full-time therapist that's an independent contractor with us who has a room in our office as well and a meeting room.


Okay. And then we, all of our physicians, you didn't, we didn't hear anything about physician offices, so we actually have a full basement in our whole place and so we renovated a big open area and we have kind of cubicles, but mostly open air. So we can get a little work done, but it's a very collaborative space, so, yeah.


Very cool. And in terms of tips that you guys might have, given that you've been through multiple variations of your clinic and the Buildouts what tips might you have for other people who are considering a buildout in the future or are actively going through one right now?


I think if you're starting out, like we kind of joke about the space we were in, but it, again, it's like, it's, it's mm-hmm. , we didn't need more than that. Or at that point, right. And like mm-hmm. , I think the danger would be spending a bunch of money and doing the My Dream office before I'm ready for that.


So we've always erred on the underside of that. I would say probably the biggest thing we learned is we like cash flowed our first build out, and that that was fine cuz we could do it. But then come to find out like, well you can't, let's, none of that's really a business expense and you only only get that back like amortized over 30 years.


And we're like, well this is terrible. Why did we do this ? And then the second one it's like, we worked with our landlord. It's like, well, we'll roll this into our rent and pay it over time. And then rent is a, rent is a business expense.


But yeah, , I think about this as fragility, right? So taking out a loan, spending a bunch of money, renovating a huge space makes you fragile. Working in 900 feet with two physicians and one nurse is a little cramped, but you're also more robust than you would be if you take on debt.


So, mm-hmm. .


I would say from a practical standpoint I think having an office space that represents you is what patients really want. They want to know that this isn't sterile and isn't a place that feels like it's generic. It wants, they, I think patients want to know about you, especially when you're a smaller office.


They, they want it, they want it to be, they want to feel like they're getting the, the the specialized treatment. And so having things that are a little bit about you, we have a bookcase that we take books that we're, we like as personally, we like not just medical books and put those on there.


I think having customized art or things that are meaningful to you is really important. Very good lighting I think is important. And that just makes spaces look way better. So getting good lighting and then lots of storage. So we have, we are pretty much the entirety of our more or less 3000 square foot area is open underneath, underneath of us and outside of the about thousand square feet that we have for our physicians, most of that is filled with stuff that we use for storage.


The more physicians you have, the more services that you offer, the more redundancy that you need in. Okay? We don't order one box of band-aids at a time and then get to the last five and then order it in the last minute. We order 10 boxes of bandaids cuz now we can afford it and we don't have to worry about not having enough money to buy more bandaids.


So those, those things all need more storage, but, Increase the efficiency of your time in ordering and inventorying and all of those types of things. That's especially true with pharmacy. And we run a big dispensary, whatever you wanna call it. The, we run a big one of those.


Yeah, a different one of those. So, yep. Not


specifically cannabinoid products, but a dispensary of dispensary, , , prescription medications. Love it. So let me ask you there, because that is clearly a value proposition that your patients love. Can you tell us more details about your patient population? You, you shared that you're in a low income area of Wichita next, the hospital in a place that loves D P C as a culture, but who has joined Antioch over the years and who has.


Yeah, I think this really has evolved a lot. So my patient panel was probably, especially with the first members that joined I pretty much had one business that joined with us during the F one or two. So they were, smaller. They were just paying a membership.


It didn't involve any type of insurance product or those types of things. And it was mostly the owners that liked what we were doing and wanted to give it as a good benefit to their employees. The, I would say it was probably 50 to 60% of my initial patient panel were either uninsured or on a cost.


And I speak Spanish proficiently. It's not perfect, but I have a I had of about between 30 and 50 primary Spanish speakers that I take care of and have had those patients here long term. Now most of the folks that that came and saw me initially were folks that either couldn't afford the F Q H C across the street or had some relationship to me through connections that we had in the, in the community, whether that be through, churches or other other physicians and I'll let Brandon kind of give maybe a current physician view,


so. Sure, yeah. Yeah. I, I think um, I'm gonna use these terrible terms just cuz they're used, but like the, the, at least what I hear keep people talk about is like retail patients, so patients that are kind of paying their own membership fees.


Yeah. When we started out, that's, 90% of who we took care of with a, with a heavy bias towards some people that don't have something to look like traditional insurance. Mm-hmm. , we kind of like started to grow with small groups and I don't, I don't feel like we have like, oh we have this only focused, like we're all, we're becoming an employer clinic.


But I think the, patients in that kind of retail bucket, they may love you, but they also respond to incentives. And so if somebody, gives them a free, insurance card or they get a new job and it's like, wants them to pay for benefits, if you look like a cost to them, they'll, they'll leave.


You know what I mean? And so I think that's painful when, when you spent two or three years with people and it's like, oh, see. And that's kind of pushed us to think like, how do we solve these, we're delivering great primary care, but can great primary care solve some downstream problems for things?


Can it affect the total cost of care? Can it affect the cost of insurance? And so with TA tackling some of those problems, it has been a growth in, , employer, customers where we take care of close to 60 small businesses, and then a couple medium to larger size businesses as well.


And so it's not like, oh, we, we don't care about retail anymore, but it's diversifying the population of people we can take care of. And, Giving, giving them access to additional benefits as we grow, whether that's, how do we know how to work well with cost shares for our individual patients who are self-insured?


Or how do we know how to work well with a, a differently designed health plan? Those are all things we've had to learn, so. Mm-hmm. ,


As you guys have grown the population of businesses that have become members at Antioch mm-hmm.


how do you guys reach out to new businesses if they're not familiar with direct primary care? .


Yeah, I think most of it has been word of mouth and people that we've taken really good care of. Here locally, there are a few kind of smaller business groups and there's a business group on health that is run in our local area that Brandon is very active in.


And we've been to different business related insurance meetings that have all the big Blue Cross and the local. Kind of physician-led group in our in our area that has kind of an insurance add-on and have talked at those types of meetings that involve HR and financial people and CEOs and that, that type of thing.


Mostly from uh, here's how we think about all of this and here's how we can answer some of these problems and then have had people kind of trickle in over time. So, I think the, the business community in Wichita is relatively insulated, and that's a, been a great thing because we're not so big that nobody knows what anybody else is doing.


And a lot of the businesses, especially bigger, bigger ones that Brandon's now working more in depth with as far as creating more kind of specialized and, and more comprehensive insurance products that include D P C as the centerpiece. Those people, when they see. Their employees are getting good care, their employees are staying with them because they don't want to lose their care because they love the stuff they're getting at their D P C and it's saving them money.


Like that is something they want to tell all their friends and all their friends or the other business people in Wichita. So you have more to add to


that? Yeah, just that we haven't really, we haven't really like, oh, we need a vision, this retraction strategy. It's like we have a form on our website and we get people that email situation


It's like, okay, well this is how this works. So that's been, it's been good. And it, and it, I think it stems from taking great care of people. You take great care of people and they tell their, they tell their boss and they tell their friends and stuff, so, mm-hmm. , it's been, it's been good from that


aspect of it.


Yeah. I would encourage people not, especially those starting out, you don't want to start out with like a monster business. , it just brings. A ton of complexity and a lot of extra work. And a lot of it, you don't know what you n don't know until you get going. And you learn a ton of that with those individual patients.


And then they also act a little bit as a diversifier, so that way you don't have all your eggs in one basket. And so I think that's something that we've grown into, but I'm glad it didn't, it didn't all start that way for us. So,


Nick with you sharing that Brandon, is the person really, helping build in the more complex plans that incorporate D P C at its core.


Are you working with any brokers in particular in Wichita or are you doing this all yourself to build DPC into insurance plans as you approach business? ,


I'm working with a broker and he's sitting right next to me in that . It's a, it's a bad word. I'll tell you what, Yeah.


I'm not a broker , I, I help consult and yeah, I, I think we've met with lots of people in Wichita.


There are some people in Wichita that are kind of learning how to do this. The default for people in the Wichita, it's like, well, you have your plan over here, and then people need care here that here's this DP C option. And that's kind of as the extent of it's been or the, the extent of people in Wichita.


We've had a couple groups that saw a broker outside of Wichita, a consultant outside of the Wichita that knows about D P C that is willing to consider doing these new things. But we're only a couple months into that. And so, the next six months will tell, we'll have some data to show how this is working.


It's exciting. It's also a lot of new learning. It's something that I'm interested in just cuz it's like, system change interests me, but it's also like, I don't want to have physicians who aren't interested in this, having to jump through a bunch of hoops.


Like, we want it to look as, as little like the old system as possible. . And so fine for fine for me to be, to figure that stuff out with a lot of help. I, I certainly haven't done this on my own, but figuring out how to do that is, is a learning process. And we're only, six, seven months in, so.


Mm-hmm. .


Yeah,


I think it's, I think it's so important though, as you talk, it makes me think about what Garrison Bliss said. If, if we're gonna do this, the physicians who are doing this we need to be the people writing the story of D P C, the policies, the, the way that it's built into plans and whatnot.


Um mm-hmm. like you're doing, because if we don't have any say in it, we get into a lot of the problems that we see nowadays with healthcare outside of D P C.


Yeah. Yeah. And I think that that's Brandon's just done a really good job of that. But it's not a simple. Problem to fix. Just because the more you, the more you dig into it, the more you find that the majority of the system is messed up , and we're about the only ones that are working well.


So even, even the well-intentioned people are just, it's like, there's, there's, the way it's used to be being done and, and direct primary care is just new. And it's like, well, how much latitude do we give this new thing? Like, mm-hmm. , do we just pay for all the lisinopril? Cause almost lisinopril is only $4.


Or do we like, how do we think about that? So, mm-hmm. , it's just it, it is, yeah. It's a reinvention process that to me is, is fun and interesting, but it's. . It's a lot of new stuff that I never, never thought we'd be dealing with. So, yeah.


And I think that you're right in that that is best done with a physician at the table because nobody, the other groups are not going to know, well, why would I pay for Lisinopril when it's $4?


Like maybe the, the, the patient can just pay for that. Well, it's like, well just pay for it cuz it's like one, 1000000th of your total spend. Hmm. So, that, I think those types of things we can put into perspective and also can just open the eyes as to like what things need to go through your T P A versus what things can you just pay cash for.


And when cash is king, especially when you get a lot of independent physicians like there are in Wichita, especially independent phy in independent specialists. So that's something that we're excited about and I think Brandon's doing a great job of kind of spearheading that part of it. So,




So we've talked about your patients, we've talked about how you are incorporating businesses into the diversity of Antioch. I wanna talk about OB patients. Last week we were able to hear from Dr. Esther Kabi and Corpus Christi about how she is a full scope family physician, able to do OB c-sections high-risk pregnancy management.


I wanna hear from your guys' perspective how are you guys still incorporating OB into your practice? And how many patients do you have at one point who are expecting mm-hmm. ?


Yeah, so this is something that changed over time too, and I actually, I delivered a baby at 1:00 PM today, so it was, it was good.


The ideal patient for us in our clinic is mostly younger families and or has been anyway. Traditionally. I think that that probably is changing a little bit, especially as we get more variety coming from businesses. But the main decision makers are.


In, in large part females in the household. And so being able to offer really good comprehensive primary care to that main decision maker and not having to send them to the OB down the road just was really an enjoyable thing for us to be able to do. And I think it's just an area of medicine that is like, has the highest highs, but also has some of the lowest lows.


And being able to be having that relationship to then weather the really high highs and the really low lows with patients was something I didn't want somebody else being able to do. So we kind of knew it was something, it was a non, a non-negotiable for us when we were starting our practice. On average, I think we Brandon and I probably averaged about between 12, 15, 18 deliveries a year, somewhere in that range.


Dr. Elson, who's with us, is one of our female physicians and she delivers closer to 25 a year. So we're not super high volume. And we have some things I think in Wichita that play to our favor in this. We have the residency program that helps to kind of manage our laboring patients. We're like three minutes away from the hospital so we can pop over there and pop back to clinic afterwards.


And we have, we have a very supportive laborist group that's made up of OBS that we actually trained under in residency. So there are no OB residents and the OBS actually train the family doctors in Wichita. So all those pieces kind of came, are a little bit of a perfect storm to allow a family doctor with lower volume to be able to continue practicing.


I think they're, especially with businesses who have kind of non-traditional insurance products that are looking for ways to contain costs, I think that's a piece that, that is very intriguing to see how, especially businesses that have a larger number of younger females who are childbearing age, being able to say, Hey, you don't have to put this through your, blue Cross plan and be charged $15,000 and we have a cash price with our local hospital for a vaginal delivery and a C-section, and here's our delivery fee and we'll take care of your patients and you pay cash for all these things and save X amount of dollars on every patient that delivers.


And they get really good care and they love it because, Very personalized. And your physician is gonna deliver you and they're gonna see your baby in the, in the clinic. And it's the same person that you see for all those things. I think those are pieces that we have really loved and have worked well for us.


I don't think we've ever cracked the nut on how to make OB profitable. And we're we essentially cover our malpractice with the price that we charge patients for additional pregnancy services. And I think that mostly was because we were looking to mostly make money on the membership and we knew we weren't gonna have huge volumes of obs and so we didn't wanna make that a barrier.


And I think ob the difficult part with it in D P C is that there's a lot of places that you're going to save patients money in direct primary care. Ob, especially for those that have traditional insurance, probably isn't a place that you're gonna make a ton of money. Mostly because the patient is expecting usually to meet their deductible and when they've met their deductible, they by all means want to use their insurance.


It's awful hard to submit are pregnancy services as an out of network claim to an insurance product and to do all the paperwork and those kind of things. And so we just haven't done any of that and said, that's up to you. You, you figure those things out if you want to do them and have really not had patients generally desire to do that.


But I think the growth piece largely comes from employers that have larger numbers of childbearing age women. So, yeah. Do you have thoughts on it?


Yeah, I think it's been important cuz it's something we've enjoyed and it's also Wichita is a place that trains.


People to do full scope family medicine and we don't, we don't want that to die out in the community, right? Mm-hmm. so we can, if we train people in residency, but no, they don't really see any examples of family medicine physicians doing it, then it seems less realistic and so, mm-hmm. , we want it to continue.


We wanna use it to, attract physicians that want to keep doing that. And D P C is a place that you can do that in, not like, well I have to go to the middle of nowhere if I wanna deliver babies as a family medicine physician. So those have been the goals. And then, yeah, it's It is, it's very rewarding.


And I, I think our practice looks a little different. So you'll hear like, well, how many, what percentage of your patients are pediatric patients in DP C in the numbers of 10%, 12%, 15% get thrown out. And like, we're about a third in our practice of, of peds. And so having a place where families feel comfortable is, keeps your practice young.


So it's, it's fun to be able to do that breadth of things.


Very, very cool. And how about in terms of hospital privileges? I know you guys shared how you have the laborist group, you have the residents. In terms of hospital privileges, are you guys on staff or how does that work for you guys to actively do medicine in the hospital?


Yeah, we have just privileges at our local hospital. They don't require, they don't require a whole lot at our hospital. So we don't have to take like hospital call or ER call or any of those types of things. Um, Able to be active members of the outside staff at our hospital. And the privileging pieces were easier for us since we had all the numbers coming directly from residency.


And the people who were going to approve us were people that we trained with and already knew our skills and abilities and those types of things. And it's also not a place where it's unusual for a family doctor to deliver a baby. And so I think all those pieces were a little bit easier for us. inpatient wise we just have stopped admitting patients, mostly just because I think we do too good of a job keeping people healthy, that we, I, I mean, I think I averaged like three patients a year that needed admitted. And we also have a, generally a little bit younger practice skewed that direction.


And so three patients admitted to the hospital a year probably isn't quite enough to continue admitting them. And so that's something where we, when we admit people to the hospital, we just have a hospitalist group that we work with see them and then we come and kind of social round. So, Gotcha.


And what about in terms of courses for like N R P or also because you guys are working in the hospital where your residency is, do you have any way of getting access to those courses through the hospital or do you pay for those separately?


The residents we trained at, we, we want to stay in good, good relationship with. So we're actually volunteer to be also instructors. So we teach also to the incoming residents every year. And so that, keeps us credentialed and also, is a way to meet the incoming residents and they're gonna be the ones laboring our patients mm-hmm.


And doing things like that. So we, we all have privileges at the hospital. We trained at, I, I got privileges at the other hospital and it's, it's just way harder to learn a new, new system. And so, um mm-hmm. , I think a lot of DPCs that'll be facing, well, I'm going to start my DP C in a new city.


Well, that's a, that's a much different battle than we faced where it's like, well, we're just submitting our privileges right after residency to the hospital we just worked at for three years.


Mm-hmm. . I think it also, it also helped that while we were preparing to open our practice, I was also part-time faculty at the residency.


And so I did a week of inpatient and kind of our ob OB panel for family medicine. I did a week of coverage for that once a month and then continued for the first 18 months that we were open, taking night call with the residency intermittently to help give them extra coverage. But it also allowed me to keep numbers up and kind of advance some of those relationships as we were growing.


And so that was a useful thing I think for us.


And when it comes to maintaining full scope Nick, especially you, you've paired up with Dr. Van Lassi in 2018 and in 2020, if, for those audience members who have not seen check out Dr. Allman's and Dr. Thompson's blog accompanying this podcast I have both of those videos linked, but you, really highlighted that a family doctor is able to do lots of things and mm-hmm. , you focus on how to expand your outpatient scope of medicine when it comes to things like procedures. There might be those people who are in a residency in an opposed program, um mm-hmm.


versus something like, versus somewhere like via Christi or someone who's been out of residency for a few years who hasn't had a lot of experience with procedures. Mm-hmm. , how do you talk to those people when it comes to their hesitancies to expand their full scope of practice as an outpatient D p C doctor?


Yeah. I don't, I don't think everybody needs to ev every family doctor needs to go and deliver babies. I don't think every family doc doctor needs to remove massive lipomas and to do vasectomies and to like, do some of these things. But I think as as physicians who are, I mean all of.


Have the A license that says Doctor of Medicine and Surgery. And this is something where you are free to do things that are within that scope of care, which includes medicine and surgery and what your malpractice says you can do. And so, . I think finding ways to advance those skills not only is wonderful for your patients, cuz they don't wanna be sent anywhere else and they trust you more than they will trust any stranger.


But also I think it's just really a way to remain to have medicine remain rewarding over time. And this is something that, I think is really, is valuable to me. So, and I think I, I get lots of enjoyment out of this, so, I think that that's an area that is a, a strength of mine and that's something I kind of try to bring to our group as far as just ultrasound and skin procedures and surgical options and those types of things that we do in our practice.


And sometimes there's things like, so I don't do coposcopy, but we have. Two or three physicians in our group that do colposcopy. And so I don't have to do everything. But I'm the one that does vasectomies in our practice and we'll do those for other, other people's patients. But I think continuing to grow both in that scope and just figuring out what's the next thing that I could do.


And I think some of those videos from Vance and I They're helpful. If you do no procedures and have much more narrowed scope of practice or, or wanting to enter back in, they show a few basic things like how do you inexpensively add cryotherapy or think about finding an autoclave if you want to get some reusable tools, like how do you practically do some of those initial things rather than here's how you're going to do a vaginal delivery in a second degree repair.


Like, we're not teaching those things. So th that's stuff that takes more, more work. So, but I think finding that next thing to keep you going and to keep your patients having options to have stay in-house care that's really, I.


And diversifying that amongst physicians too. Dr. Cooper does, skin prick testing for allergies and sublingual drops.


And Dr. Elon's always done N F P and she's like, well, I can learn transvaginal ultrasound so I don't have to, my patients don't have to pay for pay for an ultrasound and colposcopy and those things. And so when you get more physicians, it's like, what are you interested in? Is it a useful skill? Okay, let's help you develop it.


If you need to go to a conference, let's have you go to a conference to learn how to do it and keep your skills up. So mm-hmm. , it's exciting to have a group of physicians that is, is oriented that way, like. , what, what additional benefits can we add?


So you, you guys are leading me to my next question, which I love, and it's, it's about your team.


When you were mentioning how you guys have been so lucky to be around via Christi and to have people from via Christi understand full scope family medicine, join on at the practice, how do you guys bring these physicians on? Are they employees? Do they get a percentage of the members monthly fees?


And Brandon, when you were mentioning going to courses, do you guys cover things like benefits including payment so that someone can do C M E or get a 401k?


Yeah, yeah. Again, it has been a, a learning experience and things have gone well and haven't gone well. We've, we've never really I mean aside.


At this point we're search, searching for our next physician more actively. It's mostly been running across people. They know what we do, and, we're kind of, we're kind of hitting the right spot at the right time. We, we've done compensation differently depending on the situation. So some people it's, well, we're kind of.


They want some sort of salary advance. It's cuz I'm coming outta residency and I, I'm, I wanna figure out how to build my panel, but still, feed my family great. We can figure out how to do that. Other people, it's like, figuring out how to salary advance and pay back and do that.


Some of that sacs more confusing. I'll just eat what I kill from the beginning. So we're flexible enough where we can figure that out for new physicians. Mm-hmm. and then yeah. A adding benefits. So at first it's like, well you'll, figure stuff out on your own as far as what you do for insurance and things like that.


And well now we, we have a cost share, a, a medical cost share available that we pay all of for, for our employees and physicians. And for the first several years it's like, wow, doing a 401K sounds confusing. Well, actually it's very valuable to both owners and employees. Mm-hmm. . And so let's start one.


And we've had fun for the last three, four years at least. Mm-hmm. , So, yeah, we try to just paying for those things through the business has, has been the way we've gone about it. So we pay everybody's malpractice through the business. We pay up to date for all physicians through the business.


We you know,


licensing and all of those, all of those pieces Yeah. Yeah. Are paid.


So the local CME events and, one CMA event, we've, we've paid for physicians and so we want our physicians to enjoy it here have mm-hmm. , half perks and then be competitive. Cuz again, people, people love the concept of DP C, but if it's a this's, an enormous sacrifice to practice a little differently, while you're not, you're not gonna be competitive for talent.


So, mm-hmm. .


Definitely. And Nick earlier you mentioned how in the living room feel, waiting room, you have the space for three nurses and then your, your separate space for the nursing manager. How did you guys determine how many support staff you needed as you grew the practice?


In terms of physicians joining


mm-hmm. , we've always been a little bit behind , . And I think I think in general, if I were to summarize, I think a, a new starting physician in our practice needs a full-time staff um, physician that's full and maintaining a practice needs a little bit less than a full-time staff.


And then we, we have some just administrative needs that we also have that are, are done through staff. So essentially we have we have. Three and a half full-time, three and a half full-time equivalents of nursing staff. One of those ends up working remotely. Is that true? Mm-hmm. . Yeah. One of those works remotely and does all of our referrals and faxes and, and sorry, four and a half.


Four and a, yeah. Yes, four and a half. But then one of those nurses also is halftime administrative and halftime nursing. And so we're probably on the borderline of being a little bit understaffed for what we could do with our practice. But it works great and it works fine. But I think we're always also trying to think about like physician quality of life and also quality of care.


And I think starting to consider rather than every nurse taking, touching every patient when they come in the door and having everybody do a little bit of everything. How do we create kind of care teams that work a little bit more efficiently with each type of physician and their preferences and also know those patients a little bit better because our patients really loved when it was one nurse and two doctors and, you know, everybody like, and so that felt like home.


Now they still know about everybody, but it's like, oh, what was that nurse's name? And so sometimes there's a little bit less of that. And I think if we are, we're figuring out how to get to a patient home that involves a care team, that it for us probably involves a physician and an rn. We've had more luck with having RNs, not necessarily because they need, we need their.


Clinical abilities at this point yet, but more so they have been the, the reliability factor has been wonderful with them. So yeah.


Yeah, they're just great to, if you want to start an IV and run fluids or if you want to draw blood on a three and a half year old, so they're, they're great. Yes.


I love hearing this and it just makes me think about how you guys shared about family, doctors in the Midwest in particular that tend to do everything and in, in my experience in superior Nebraska, it was all about the care teams. It was the physician with their nurse or nurses backing them up for those reasons.


So I absolutely love that you guys are, talking about your teams like this and in terms of your staff. You've also brought on Kelly who is doing mental health in your practice. And so, one of the things I learned from social media was that she filled up very quickly.


So how did you find Kelly and how did you bring her into the.


Yeah, she was actually in training and then one of the businesses that has been with us for a long time one of the employees there knew about her and knew she was looking at this. She had worked in a facility that I think was working fine, but you know, she wanted to have the freedom to do something new.


And so, yeah, I, I just think, mental health is obviously a mm-hmm. a much talked about topic and a much like, how do we get access? But you can hand out a lot of cards to patients and say, counseling would be beneficial to you. But if you say, actually, her door is right down here and our nurses can schedule you, and by the way, we've, we've found a way to like, make this as affordable as we can.


You get lots of people getting the help they need. Mm-hmm. . And that's been just very rewarding. And so yeah, when we talk. Our DP C being a medical home, it's their physical health, their mental health, their spiritual health. We wanna be able to touch all of these pieces of their life. And if we can be, if we can be a net positive, we wanna get them access to the care they need.


So it's been great. I would encourage DPCs to think about how to do that and mm-hmm. , there's, there's no one model that'll work, but it certainly does. Allow you to give better care when you're giving access to, to mental healthcare as well. Mm-hmm. .


Yeah. And just because Kelly filled up quickly, are her services incorporated into plans when you're talking to employers, Brandon, or is it, do you mention that if they do see Kelly, it's at a discounted rate compared to other services that might take cash only around the, area?


Yeah. Every business kind of decides what they wanna do. And so, the vast majority, it's like, well, we pay for the membership and all ancillaries are kind of on the patient. The ones that are, truly kind of putting primary care at the heart. It's, we're never saying, oh, you have to include this.


You don't have to include this. Like they may choose to pay for allergy. Allergy resources are not right, but we're saying, Hey, here are the things available. If you find it a value, use it. And then, yeah. So the, I think the, the wise ones are saying Yep, that, that makes sense. Like we know, we know we will have happier, more productive employees when they're mentally healthy.


So it's say, it's an investment willing to make, so they're willing to pay for strep throat, strep throat visit and test like, well, paying for like, you to not be anxious and not be depressed at work is an important investment as well. Mm-hmm. ,


absolutely.


It's just been a great, great resource for patients and I think there's a lot of there's a lot of consternation that physicians go through, especially in that early stage of I have to be everything to every patient.


And the very most helpful referrals that we do are to physical therapy and to mental therapy . And so, I think having, having really good resources like those, especially if you can bring them in-house to your most common referrals, ends up being the best way to get patients really good care, and also to offload some of that off of you.


and with all of the, the things that Antioch brings to your community, I wanna ask about onboarding because you, you guys have talked about how people have, have have migrated towards you in terms of physicians who understand what you're doing and who wanna be a part of it. But how do you bring on staff members and or physicians, even if they know about the practice, so that they understand the workflows and that they understand all of the things that you guys offer at Antioch?


Mm-hmm. . Yeah. The, the nice thing is we've had kind of, we've, we've had staff come through and people have been here, for, for the duration of ancy. So they've been here three years. We've never like completely turned over where there's no, no institutional knowledge left, if that makes sense. Mm-hmm.


so we've always had somebody that's been trained by the last person. And so the staff, it's, well, we have this core team that's gonna. I'm gonna show them the ropes. And it's honestly, very little of a physician showing a staff other than like, well, this is, this is this physician's preference.


Next time do this. Hey, if you get a phone call like this, you can handle it in this way. So the staff trains the staff at this point. The physician doesn't, doesn't do a lot of that. And then the, the physician onboarding it's, it's it's getting everything in place. We have a check. We made a checklist probably the second time after we did it.


It's like, oh yeah, we should actually, we should think about all these things, . And so it's, it's the same thing, like, you don't start out by scheduling them six new patients a day. They look at their schedule and they're like, well, I have one patient in the morning, one patient in the afternoon.


It's like, it'll be okay. Like, you know what I mean? Like, there's lots of, there's lots of stuff that's different than residency and different than your last job that you're gonna have to learn. So, but it's not, again, it's, it's just. Them using the skills that they have just in a new setting. We order labs differently.


We order medications differently. But it's, it's, once you've done it 10 times, it become, it starts to become second nature and you just start asking yourselves questions. It's like, oh, this person needs, an echo. I don't really just reflexively refer them to cardiology. It's like, I know the price of the echo and I know I can get it and I know I can get them in with cardiology.


So it's just once you see it done a few times and then the, the physician meetings, it's like all questions are open. Like our physicians just add stuff to the agenda and we, we can go over how to do it, how to do it best. So


you guys have touched on pricing and made a comment about how pricing has changed over time. So can you share with the audience how has pricing changed over time and how do you go about changing prices at anti. .


Yeah, so we started out probably less, less than half the average price per member per month compared to national average.


Part of that was a little bit of a miscalculation, I think for us where there wasn't as much there wasn't as much information about how to start a direct primary care practice as there is now. And so we kind of used maybe 10% peds, 15% peds rate, but when we ended up having like 35, 30 7% peds, we were, we just couldn't couldn't continue at the rates that we had four peds at that point in time.


And initially we started out with reductions in price based on family size. So if you had this many members, your prices went down. Over time we um, Done two price increases. Both of them have been about the five to $7 range per patient per month on average. And we've simplified things drastically.


We have one adult price, we have one peds price, and that's the same for everybody. And it, I think for us the simplicity of it is probably key. And there's already enough things you really have to describe and explain and reexplain and reexplain to patients in direct primary care complexity and how much it's gonna cost is not one of the things you want to have to re-explain.


So use your time and energy on other parts of that. So, that's where we've landed right now. I don't, we don't have plans that's, so that's almost seven years that we have had essentially two price changes. But I don't, we don't have plans at the moment for price increases. But I think those are things that we're.


W being able to hire adequate and excellent staff, being able to bring on excellent physicians and have them paid competitively while also, having a nice office space that's inviting for patients, but also not making our prices so high that the, those people that are just above that, the government related resources that are around who have who are kind of our working poor.


We don't want to alienate those groups either. And so we're always trying to find that balance with where is it worth what we do to about everybody that wants to access our services. So,


yeah. I mean, we love making ancillary services inexpensive, but you know, if you're gonna employ an RN to draw labs, we never want.


Hey, we make money by ordering CBCs, so let's like draw labs on everybody. Right. We never want that to be our incentives. Mm-hmm. And we don't, we don't pay our physicians off lab production. Right. But it's like, Hey, how much time does this take a staff member that we to pay? We need to recoup that cost in the lab while still saving people money.


So mm-hmm. Figuring those things out is a continual learning process, especially with doing medications like that is a mm-hmm. , it's a awesome thing to be able to do. It's also a a big staff investment to be able to do


mm-hmm. .


I wanted to highlight your guys' social media on LinkedIn, on Facebook, on Instagram, because it's, it's always about Antioch in terms of patient testimonials or one of your staff members will talk about one of the value propositions that you bring to your patients.


So how do you guys go about strategizing your social media presence in a community where you're already well,


I think this is something that's changed a lot over time too, so,


so the things, the, so the theme things change .


Yeah. No, and I think we're not changing. We're probably not learning. And initially all of our social media stuff came from me.


And it was pretty much, I mean, I started our Antioch page and then I invited every single person that I was friends with on Facebook to like our Antioch page. It was like thousand people. And I, I mean, some of the people I don't even know anymore., I went to college with them. They're nowhere near So that was where it started.


And it was more or less an extension of who I was as a physician. And I think that that really helped us to grow that social media presence. Initially that was also seven years ago. And so, Facebook was king at that point in time and you post something on a business page and it just gets spread to the random city of Wichita and you don't have to pay for anything.


And it just randomly goes and it shows up on all these people's pages cuz they might like it. And so it's a, it's a different world now compared to then. But I think the pieces that we learned were that people really want a physician that they can relate to, a physician that. Is more than just knowledgeable, is personable.


Somebody who has a story to tell, somebody who wants their patient's stories, told somebody that that can do more than just save you money. I think those are like pieces that connect some way to a patient and our biggest. Our biggest marketing ploy to date has just been posting pictures of babies that we deliver.


And that's like the best, I mean, they get like a hundred likes every time. We don't even do anything with it. So, those I think tho seeing where we connect with patients on Facebook and then kind of, really trying to. Prioritize those types of of posts was helpful initially. As we grew to five physicians, having a Dr.


Nick Facebook page isn't that helpful anymore cuz I'm not taking any new patients. And so, we really, we kind of had to pivot our social media strategy. Some of that was me do, continuing to do some of that. We've hired a couple different advertising agencies that are kind of one that was a little bit bigger, one that was a little bit smaller and one kind of individual to work through those things.


And I think we're still figuring that out. But, and a lot of that's, I'm not the most, like I, I was most Facebook savvy, but I'm not Instagram and TikTok savvy and so, Once again, it's finding the people that help us tell those stories in the way that patients are wanting to hear them. So I think that's um, and then involving our staff, involving our other physicians, not having it all be let me teach you this thing, but more, let me help you feel this, this thing about our, our practice.


Or let me share this story, or let me help you understand how you fit here. So I think those are the pieces that work the best for marketing.


Some of your posts, they feature reviews or testimonials from your patients. So how do you guys go about getting those reviews or testimonial.


Initially we patients just put 'em up. And so that was very nice of them and I'm very thankful for that because we didn't think that that would be that big of a deal. But then we started realizing after the word of mouth, like entered all the, the word of mouth areas that we had and didn't have as many circles that we were entering into new patients.


We started having people show up and they're like, I just read your Google, Google reviews. That's how I found you. And so I think we've started to prioritize especially it's hard to sell yourself, but. One easy way, I think to sell yourself that doesn't sound self-serving as much is, Hey, did you love the care that you got here?


And if you did, then it'd be really awesome if you left a review telling about it so another patient can find our care. And that's the way I love taking care of patients and I want to be able to continue offering this care to others. And that's a great way for them to find it. So that's the way when I have somebody that is in here and they're like, that was awesome.


You kept me outta the er, you did this thing to me. And it was, it saved my life. And it's like, that's awesome. Like, would you tell somebody else about that by leaving a review? So I think that not being a ashamed to ask for that is one. . And then two, we have a, a part of our website that we don't use very often that we've kind of used a little bit as a review funnel.


And that's something that is less used, but I think could be more utilized in the future. So yeah.


And involving our, you know, nickname involving our staff when they're younger and cooler than us. So , they, they know how to do this. And then two, like, we will have an encounter where a patient will leave.


They may need to schedule, they need to pick up a med. And our staff is hearing the outcome firsthand. Mm-hmm. . And if the staff know like, Hey, that's a great thing to do, just post, because if we grow, we get to add stuff, like we've started doing vaccines and we've been able to add these services.


So growth isn't just for the sake of growth, it's like mm-hmm. , we get to do, we get to offer more benefits to our patients that come along with membership. And so, having staff involved in that has been probably the, one of the better things that, that has happened with our kind of advertising and reviews.


Awesome. So in closing, I wanna ask one more question, and this goes back to Culture Brennan, especially for you. I, I would love to hear your answer on this. When we look at direct primary care as an option for primary care doctors and direct primary care as a model for people like specialists to adapt to and practice under,


when you were speaking at the Hint Summit and you were, you were highlighting family medicine. I kept thinking about how do we bring more doctors into believing this model can work and giving them the confidence that you guys now have six, seven years later to do this model?


Yeah. I, I think it's, to me, it's just continually pushing against misconceptions and so, it's like, well, you're contributing to the shortage, and so it's like, well, let's turn that into a numbers problem. If you have 2000 patients and you take care of 20% of their medical needs, and I have 60 per 600 patients, and I take care of 98% of their medical needs, like, who, where's the shortage, right?


like mm-hmm. . And so I think pushing back on the, the narratives that are, that are not true is important. Mm-hmm. , and then, and then it, and again, it, I think there's different ways to join the fold and mm-hmm. , they don't have to be the same for everybody. You can have a one doctor, 400 patient, one ma Micropractice, and if you're taking great pair of those 400 people, awesome.


If you don't want to grow like that, that's okay. But I think, I think some segment of TPC has to grow into becoming the default, right? Like if, if primary care is going to be the solution to some of these problems, like the type of care D P C provides has to become the default and patients have to be given the incentives to choose that.


It can't. pay a lot for your insurance that you really don't want to ever use. The costs keep going up. And oh, by the way, also choose DP c i, I don't think that's a, I don't think that's a sustainable way for, for the movement to grow. And so if that's a question you're interested in, there are ways to join the fold with practices like ours and practices that are growing, growing regionally, eighth.


And so that's a legitimate way to, to do this. And so, I gave a talk a couple years ago about starter join, right? Starting a practice is definitely possible, but joining a practice is now a legitimate, legitimate option. And so, yeah, look at those. And, the road's still bumpy. It's not like it's this perfect thing and it's gonna be easy and you just join a D P C and you're full in two months and you make the salary at once.


Like, it, it's, it's still, we're still kind of, I like to think that we're still kind of trailblazing and, and we wanna figure out how to make it mm-hmm. less less bumpy for the people coming after us. Mm-hmm.


Yeah, I think I think having. Having different options for different people is probably the main, the main thing. And, seven years when we opened outside of a very few practices that even had more than one physician, it was pretty much just, one pop shops.


And so now having places to join places that are much more corporate style or catering only to employers, places that don't do anything with employers. Different parts of the country, different patient populations, different kind of more specialized care or even specialists in, more direct patient care rather than direct primary care.


I think there's just lots of opportunities. And I think, as we, as we start to. To think about, especially where the vast majority of people are, are thinking they're getting care, which is from their business related insurance product, but they're not actually getting care. I think as we start to answer some of those questions it makes D P C a lot more valuable rather than just an add-on.