Direct Specialty Care Doctor
Dr. Andy Berkowski is a sleep neurologist at ReLACS Health, a direct specialty care sleep medicine clinic dedicated to the treatment of complex sleep disorders including restless legs syndrome through telemedicine. He started ReLACS Health in the spring of 2022. A Michigan native, Dr. Berkowski obtained an undergraduate degree in religious studies from Stanford University before returning home for medical school at Wayne State University in Detroit. He did his transitional year internship at Henry Ford Hospital and residency in adult neurology at the Detroit Medical Center-Wayne State University. He returned to Stanford for one more year of warm weather and sunlight to complete a fellowship in sleep medicine. After training, he was on staff at two of the largest academic sleep centers in the country along with an affiliated VA hospital for nearly seven years before making the jump into direct care.
In addition to serving patients in Michigan, Ohio, and Florida as part of his clinic work with ReLACS Health, he is the vice chair of the Clinical Practice Guidelines Task Force for the treatment of restless legs syndrome with the American Academy of Sleep Medicine. He volunteers on the Scientific and Medical Advisory Board of the RLS Foundation, writing a column in their quarterly newsletter and presenting patient webinars through the Foundation.
He also has the privilege to be a busy homemaker two days a week and homeschool his youngest son on those days.
LINKS/RECOMMENDED RESOURCES:
For the LATEST in DPC News: DPCNEWS.com
The White Noise Podcast, two parts on management of RLS for clinicians:
Appearance on Finance for Physicians Podcast:
How To Recover From A Life-Threatening Crisis with Dr. Andrew Berkowski
Podcast page: HERE
YouTube video: HERE
Five selections from A ReLACSing Blog:
A dozen selections from @andyberkowskimd YouTube educational videos:
Appearance on the Cleveland Clinic Health Essentials Podcast:
Or podcast home page: HERE
CONTACT:
Email: andy@relacshealth.com
Website: ReLACS Health
ReLACS Health Blog: HERE
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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 each week 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 Consumption 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 care is the old way of practicing medicine. Hearkening back to more than a century ago, in the days of walking to the doctor's office down the street or having the doctor come to your home, it was more of a personal relationship and you paid the doctor directly for their professional work. So for specialty fields, like direct care gives patients the ability to seek expertise or conditions on their terms and obtain the right treatment.
Patients pay the doctor directly so that the doctor works for them. This is particularly important for those with health problems left orphaned by the high volume procedure centered insurance-based medical establishment, direct specialty care. As resurrected my career in sleep medicine by allowing me to treat chronic sleep disorders in a way that works for patients without compromising my own values as a physician.
My name is Dr. Andy Burkowski of Relaxed Health. And this is my direct care story. Dr. Andy Burkowski is a sleep neurologist at Relax Health, a direct specialty care sleep medicine clinic dedicated to the treatment of complex sleep disorders, including restless leg syndrome through telemedicine. He started relax Health in the spring of 2022. A Michigan native. Dr. Burkowski obtained an undergraduate degree in religious studies from Stanford University before returning home from medical school at Wayne State University in Detroit.
He did his transitional year internship at Henry Ford Hospital and residency in adult neurology at the Detroit Medical Center, Wayne State University. He returned to Stanford for one more year of warm weather and sunlight to complete a fellowship in sleep medicine. After training, he was on staff at two of the largest academic sleep centers in the country, along with an affiliated VA hospital for nearly seven years before making the jump into direct care, in addition to serving patients in Michigan, Ohio, and Florida as.
Part of his clinic work with Relax Health. He is the vice chair of the Clinical Practice Guidelines Task Force for the Treatment of Restless Leg Syndrome with the American Academy of Sleep Medicine. He volunteers on the Scientific and Medical Advisory Board of the R L S Foundation writing a column in their quarterly newsletter and presenting patient webinars through the foundation.
He also has the privilege to be a busy homemaker two days a week and homeschool his youngest son on those days.
Welcome to the podcast, Dr. Burkowski. Thank you, Mario, for having me. This
is so awesome. I wanted to jump in with one of the things that really stood out to me when I was researching your history and your training and on your website, you had noted how you went to school at a high school where Jesuit values were highly valued and the idea of Keira Personalis.
I went to Creighton for my medical school training, and Keira Personnels was not something that at uc Davis I had ever heard of, but Keira Personalis. For those in the audience who might not know what it is, can you explain what Keira Personalis is and what it has meant to you throughout your years as a non-physician and then as a physician?
Yeah, so Keira Personalis comes from the Latin that means. Care of the whole person. And given that I went to a Jesuit high school, I know Latin and I know what Keira Personalis means, and my family's been steeped in the Jesuit tradition. My, my mother and father went to Jesuit schools. Even my wife went to a Jesuit college, and my mom's Jesuit college was in India.
So we have a whole variety of countries represented by our Jesuit institutions like yours at Creighton. And most people think of them as a lot of these sweet 16 basketball teams like Gonzaga or Xavier. But they're also great places of higher learning and some have medical schools. But the idea is that, and it fits along with the direct care model, is that we're not just diagnosis treatment, that when it comes to healthcare cure, personalis means caring about the whole individual.
Because no doctor would argue that spiritual, social, mental wellbeing is not part of the health condition. A lot of the worst patients are lacking in these areas, not just their biological disorder. It's all one whole person, and there's no separation between them. So this is a theme that has spanned my entire career, even predating medicine, and that's.
Part of the reason I'm indirect care is cuz I didn't want to compromise that value in my approach to patient care. That's awesome.
And I know that there's so many people in the audience who are just shaking their heads Yes. And nodding in agreement just like I am. It's amazing. Just literally before we jumped onto this interview, I was talking to this patient about how other diagnoses that this patient's received from other specialists are all impacted by what we were talking about today.
And not because she was talking to me about the particular issue, but because we were talking about her whole body when it comes to this issue and how it can affect her whole health. So I love that we have the time and we have these clinics that we've built. To serve the whole person. Every time somebody comes into our clinic needs our help.
So with that, I wanna highlight some portions of your past, which I wanted to give you the opportunity to share more with the audience about you had spent a summer in Uta Pradesh and the theme that you were there for was religion and healing practices in Northern India. So when you talk about your mom, when you talk about, this presence of Keira Personalis and the Jesuit teachings in your whole life, since you've been exposed to Keira Personalis in different settings, what did you experience in that journey to India in particular, and how has that incorporated itself into your practice today?
In India in particular, that region of Pradesh was a hill station country, so colonized by the British, but it had a wealth of religious groups in that area. They had, of course, Hindus and Christian missionary groups. But Tibetan, Buddhist, Sufi mystics, Sikhs so there was a whole array of different religious cultures that were built into this small Hill Station communities.
And what we went to do is to study that. There was almost no separation between the religion and the healing work, dating back centuries, Ayurvedic Lu Medicine, all of these, what we would call complimentary and all practices were being administered there in India. And it's very different than our very scientific allopathic approach.
But I think there's a ton that we could learn from those cultures. Separate from the American culture that. It can be part of our approach because it was not, again, diagnosis and treatment. It was really caring for the whole individual, whether it was Catholicism, Kira Personalis, it was these, all these religions had that incorporated into their religion and their healing practices were integrated into the family, the society, and the care of the individual.
And so it was a great opportunity. I was a religious studies major and one of the things I would recommend all medical, prospective medical students to do is to major in something that's not science. And really to develop something in the humanities because most people don't major in the humanities cuz they don't know what job they're gonna get when they come out.
But if you're gonna be a doctor, you're gonna learn everything you need to know in medical school. But I think it's more important to develop as a human being, develop that bigger picture when it comes to life and culture. And then you can apply that to patient care cuz you're not gonna see patients only like you.
You're gonna see a wide variety of people with different backgrounds, and you need to know how that interface with your healthcare.
I love that. And it's ironic because I was just doing a mentoring session with undergrads who are with my old group at uc, Davis Filipino Association for Health Careers, and we were talking about how when I was on the selection committee for incoming medical students at Creighton, we put at number one in our list of selection criteria, what's this person's life experience?
It wasn't, what's your major, what's your gpa? What's your MCAT score? It was What experience are you bringing to the table as a C Creighton doctor? So I love that piece of advice because I think that absolutely enriches our ability to adapt and to. Treasure all of our patients and their backgrounds no matter where they're coming from.
So with that, you were in your dorm at Stanford and Dr. William Dement, the father of Modern Sleep Medicine, you've shared this previously and it's on your website, but he came to talk about sleep and from a perspective that was appealing to undergrads. So can you tell us about how you started learning about sleep medicine from the father of modern sleep medicine himself?
Yeah, and it really is an interesting story because I was in my freshman dorm and there was this talk on sleep at 7:00 PM in the lounge and it's this guy who tend, turns out to be he's known as the father of modern day sleep medicine. So he's the top. Sleep researcher in the world and he's giving, like talks to undergraduates at 7:00 PM in their dorm.
And in retrospect he, I think he gave us a little survey so I don't know if he was doing some research or whatever cuz he did survey us a little bit, but he was there to teach us about sleep and the importance of sleep for our own general wellbeing. He wasn't being paid to do this, he was looking out for undergraduates and not coincidentally, he taught the most popular class at Stanford University.
Over six or 700 students when I was there. Largest undergraduate course. And I actually didn't take it because I thought I might go into sleep medicine someday. So I actually regret not taking the course, but it was his work there that kind of got me a little bit interested and it created this whole culture.
Even my roommate took this course and he went into he was studying international relations and he took us a course on sleep medicine. So it was just really exciting. And then 10 years later I'm doing a fellowship at the same sleep center that he did most of his research and he's giving the lectures, some of the lectures.
He was more of a researcher but he and his partner, Chris, John Gimeno, they both unfortunately passed away the last couple of years. But they were both there and they helped train me to be a sleep doctor. And Dr. Dement is quite famous. He was on, I think the Johnny Carson show at one point, and he was even in a movie about 10 years ago by Michael Burbiglia called Sleepwalk with me and he made a cameo in the movie.
So this guy was, is a really cool guy, very charismatic, and it was a great experience to have him come to my dorm.
That's awesome. And when you took this exposure to sleep medicine and you ran with it, your training brought you to other parts of the country and ended up in you opening your own clinic. So can you share with the audience, what was your journey like after you left Stanford, you made your way back to Stanford, and then what led you to opening your own
clinic?
Yeah, so I was one of these five year olds to be a doctor, pre anointed into medical, sc medical school and the whole train. But I had always envisioned myself as an academic physician. I was really interested in specializing and also being a teacher. I loved to teach and I loved the influence of teachers within the medical field as I was training in it.
So after I completed my fellowship, I was really primed to, for what I thought was gonna be a long academic career. And then I got to my first destination, big research university, large medical center. And what I saw from training was starting to change that even the academic centers were becoming large businesses.
And the research and teaching had become a secondary or maybe a tertiary goal when the goal number one and number two was to make money for the institution. And I was put in these satellite clinics. I had almost no teaching time. I was seeing patients like I was a private practice doctor and then I was also not making any money because I'm in this academic center with a first or second percentile pay.
So it's not like I'm getting paid extra to do all this work. And I spent my Saturdays doing research and I thought I've got these young children at home and it's on a 70 degree day in Michigan, which happens maybe five times a year. I'm in this office with no windows doing my research on a Saturday morning.
That's not why I went into sleep medicine. Sleep medicine is the chronic laid back field. It's not trauma surgery. These are chronic lifelong diseases. And I'm working like crazy and not getting any of the academic benefit. So then of course a sentinel moment came in my life was that all of a sudden I had symptoms for a couple of weeks and it hit me that I was, I had cancer and I got that 9:00 PM call by my primary care doc at 9:00 PM I've got cancer and I'm gonna stop working now.
And so I was actually off for a total of nine months. So I had chemotherapy, surgery, more chemotherapy. I won't get started on the inner sides of the hospital system, which is a whole nother story. But I got to see that side of medicine and when I came back I thought I was given the second chance cuz I, the type of cancer I had, it was basically 50%.
Survival at five years that I'm at, five years now. So I guess God's plan was me to deliverers me to still be here today. But I thought what can I change in my life now that I've been given this second chance? So the first thing I did was I cut back on my work hours. So I cut back to 75%. There were other predominantly female faculty who were working 75%.
They had kids, so they were helping out at home. And I said I can do the same thing. I can help out at home and work 75%. But then as I got back into it, after six to 12 months, I decided that 75% of miserable is still miserable. Then I decided, now is the time to make a career decision. I need to probably move to a new location.
But I wanted to stay where I currently was. And so that's actually when I first had considered direct care. This was a few years ago, pre pandemic, and I had run into an individual named Dr. Taki, and she has a direct care practice in suburban Detroit. And I met her at this multidisciplinary c m E conference, and I, we were talking to her about lifestyle medicine.
I, I really had gotten into lifestyle medicine for my own health more than anything. And she said she'd practiced lifestyle medicine. I said, how in the world are you getting reimbursed from insurance for these like hour long visits? She said, no, I started a direct care clinic. And I said what's direct care?
And that was the beginning. She talked about the business. She had just started at that time and then connected me with other individuals, a consultant who set up concierge direct care practices, talked to him, and I decided not to do direct care. The reason I didn't is because, My financial house was not in order.
And in part cuz of a very low salary. But I also didn't do the things, and your audience should know this, that the time for life and disability insurance was yesterday because you could be like me, no chronic medical problems at all. And suddenly you could have terminal cancer, probably unlikely to happen, but something similar could happen to you.
And I think had I had that in place, like a private disability and life insurance plan, not dependent on the university or a medical center, I probably could have left and started my own practice at that point. So what I did was I doubled down and went to another academic center just before the pandemic.
And in, in that case it was, maybe this center's not for me, but if I go to this other place, things are gonna be different. And it was doubling down on the same situation, if not. Double the difficulties. So that was the turning point. And about six to 12 months into my new academic center, I knew that I either had to leave and do a non-clinical career.
And I actually was interviewing for non-clinical positions like I was gonna leave practicing active medicine myself, which a lot of people in the fire movement or some of these groups that are looking for alternative ways of practicing medicine or earning in a living outside of the insurance-based medical establishment are looking at these types of careers.
And there's nothing wrong with them, it's just that it's sad that, you go from career of academics to now not even practicing anymore. And that's when I got more into the direct care idea. And it was really interesting cuz I, I was in Ohio on one day, and a patient came and she was carrying a suitcase.
I said, what? Why do you have a suitcase? She's oh, I s I'm from Florida. I stayed in the hotel overnight to see you. And I said, huh. So if a patient is willing to fly halfway across the country or north across the country, book a hotel, maybe she's willing to pay me directly for me to provide telemedicine services in her home.
And the next patient after her was a patient from Milwaukee who drove by all the academic centers in Chicago all the way through Indiana, into Ohio to see me in person. And I thought if these people are driving places to see me, cuz I have something to offer them that they can't get where they're living, maybe they'll be willing to pay for that at a reasonable fee.
And so that was the reinforcement of this. And I should also mention the telemedicine aspect of my career was growing quickly. Prior to the pandemic, my first academic center, they were actually running out of clinic rooms. So they were actually Compensating physician departments to see telemedicine patients, even though the insurance would not pay for it.
By the way, and I know all of you direct care out there who had been doing telemedicine for 15 years, know that the insurance only started covering this until the pandemic hit, but I was already starting to do 15, 20% telemedicine cuz I was building a regional practice and people didn't want to drive four hours when I could do a follow up with them through Zoom and just before the pandemic hit, my second academic position was gonna be 70% telemedicine.
That was a, and I wasn't going to move to Ohio. I was gonna stay in Michigan and maybe go there day and a half per week to see people in person and teach in person. The telemedicine idea worked out extremely well and that gave me the idea I could do both direct care and direct a hundred percent telemedicine care all at the same time and start my own practice.
That's so incredible and I hope that there's people, especially the people who are on the fence about direct care, who have been inspired by what you just shared. And I am so glad, as I'm sure you and your whole family are, that you are in that 50% that with us sharing your story and inspiring people and educating people with your journey, that you are valued as a physician and you being able to remain as a clinical physician and not leave the clinical medicine is a gift to your patients as well.
So this is awesome that you are here sharing your story when it comes to you deciding to open, relax, health. When you left your former position, did you have any issues in particular with non-competes? Fortunately, I did not. The, my first academic center had a very strict non-compete one year, 25 miles, which part of the reason I left the state was it made it more practical to do that.
And oddly enough, my, my business address is literally on the floor above the sleep clinic I used to work in. So I guess that non-compete didn't work out so well for them. I'm not physically there, but that's where my business address is. It maps to the same location, but fortunately I did not have a non-compete with my second academic center.
So that was not an issue. But that is definitely something that all of you need to think about and maybe even need to hire a lawyer to see if that's something to be looked into if you do wanna start direct care where you live or where you currently are right now. So that is a good point. But fortunately, I did not have that issue.
And also I was never in that location to begin with. I stayed at my home in Michigan, even though I was working in Ohio, because I was doing mostly telemedicine and even the people, even some of my in-person days were half telemedicine visits. Anyway. So it, it was really building toward that to build a regional practice, there was really no advantage to being in person, particularly for sleep medicine.
Sleep medicine is really a symptom-based behavioral set of conditions. You do sleep studies, you might do some lab tests, but you really, the physical examination is more academic. You're really not diagnosing and managing a lot. It's very much history taking and talking with the patient. And so it lends itself really well to telemedicine.
That's awesome. And it's so interesting because when we look back on our medical school training, at least I can speak for the experience at Creighton, we were taught that 80% of what we're going to find out is really coming from the history of a patient. And so when people think about. Could I have more time in a direct care practice and get more time to figure out the history?
And the answer is, heck yes. It's something to think about if, especially people are on the fence about could this work better for me and my way of practicing medicine or my way of how I want to practice medicine when it comes to you having this amazing, I love that you dropped how your current address is aflo adjacent to your previous practice.
How did that work out for you? Because you are physically in Michigan, but your clinic address is elsewhere different from your physical location. Can you share with the audience how that's possible?
So if you're running a telemedicine practice through your home office, you're not gonna use your home address.
You might get a, the crazy paper, come, get you, so you really wanna protect your privacy. So you need to set up a business address that's a physical location and. Oddly enough, my wife's clinic was gracious enough to share their business with me, and they happened to be coincidentally, my wife used to work through the ceiling of my sleep clinic and still does my former sleep clinic, I should say.
So I used their business address and it happens to map to the same location. I used to see patients at. One of the locations at least. So it's ironic, but it's, I guess it's fitting with that 25 mile non-compete that I was 25 inches from the sleep clinic now. Oh man, I love that. And I think it's important for people to hear because there are more people who are incorporating telemedicine into direct care exclusively, or they're incorporating inpatient services for where they're physically located, but telemedicine exclusively for states where they might not be physically located.
So I think that's great for people to hear that. Now talking about other locations, you are licensed in Michigan, Ohio, and Florida. So as have experienced people with their suitcases in your clinic, can you share with the audience why these three states in particular and have you looked into getting licensed in other states going forward?
Yeah, so that's an excellent question because it's like the doctor's modern version of the doctor's home visit where you're coming directly into their living room, and it really has its pros and cons. Mostly pros in my view. That's why I'm doing it. But what happened was, obviously I had started in Michigan, so I had my Michigan license, and then I went to a Ohio institution, but I kept close to 10% of my Michigan patients followed me there.
Maybe not that many, but it made no sense to give up the Michigan license when I was seeing a variety of Michigan patients. And that's what I've maintained until I started direct care. Now Florida's a special case and they have a wonderful telehealth licensing program. It's three, four pages. You do have to get this registered agent, which is a physical address somebody to like, if you get served papers or something, somebody who could handle that in Florida.
So that was a little bit of a hassle, but otherwise you get this license. Now their controlled substance prescribing laws are very restrictive. So that's the downside because I'm prescribing a lot of controlled substances, it does create a bit of a hassle. But Florida has a dearth of specialists, particularly in my field.
I don't know if it's true in other fields. So I think they wanna make their state welcoming and I don't really understand why other states, maybe they're protecting their own physician health systems. But I think really this, with this technology now, we should be broader in terms of each state, allowing others their own citizens to access specialists out of state, because there are a lot of rare conditions out there.
And why should patients have to fly, take a plane flight to see a specialist at the Mayo Clinic for example, when they could just, somebody in Rochester, Minnesota could do it through telemedicine with them. So it really makes a lot of sense, and I think those laws will start to become less restrictive as people start to accept telemedicine.
But we're still a far pry from that. And during the pandemic, I had the privilege to see patients all over. I saw. An Illinois patient who was in California. I saw the patient technically in Ohio and I was in Michigan. So that was like a new patient visit for me. He's not in Illinois, I'm not even in Ohio.
And we're seeing each other through the same telehealth system. And then it, the restrictions started to come back and then you were limited to where you were licensed eventually through the medical center. So that's where I've stayed, I do plan to expand slowly. There is this state licensing compact that has been forming, particularly in states in the Midwest.
The issue is you have to have enough patience to justify getting the license because it's not just the hassle of getting the license, it's the fees and it's also keeping up with the laws. And you, there might be C M E you have to do for each state. So the centralized agency, I don't know if it's $750, but it's a centralized application process.
So you could apply to 15, 20 states from that. But you still have to pay each state fee. I'm starting to build up enough patients where I may expand to other states, probably through the Midwest, which would make the most sense, like Indiana would be the next state on my list most likely. But so far I've had enough busyness that I don't have time to get a state license.
And so we'll do that. If I feel like I can serve those patients better, I can do that. So right now people are actually still traveling to see me. So we, I do have states in the, across the border, West Virginia, Pennsylvania, Wisconsin, they will drive into the state, they'll go to a Starbucks or something and they'll see me it through telemedicine and I can legally see them cuz they attested that they're in the state of Ohio or they're in the state of Michigan.
But it's also sad because I could have seen them in their kitchen and they're driving four hours to get across the Ohio border. It still doesn't make any sense, but I'm just following the laws as best I, as I can in terms of understanding them. And so I am providing out-of-state care. I just. Would like to do that without restriction.
And some of the direct care allows that because, hey, if they send you a portal message, you're not seeing the patient in their state. They could be in the Bermuda Triangle and you're providing follow-up care for the visit that you established in your state where you're licensed because you don't have to bill insurance that lets you have all of this follow care.
You're getting your revenue through a monthly fee. You don't have to see the patient in person to get that revenue. And that's part of why telemedicine and direct care. Line up so well because of this whole billing structure more than anything.
That's awesome. And I'm sure that there are lots of people who are thinking like, oh, could I do that? Because I was wondering, when I was reading your website, it kept saying the patient must be physically in one of these three states to be seen. So I was wondering if people were traveling.
I cannot tell you how many people I've told about Dr. John Jacobson's partner in carne Nebraska who does carpal tunnel surgery under ultrasound as a family physician for a very reasonable price.
And I keep telling people, you return to full function with a surgery done by a family practice doctor under ultrasound in a clinic in carne Nebraska, three hours outside of Omaha, plus an airplane ticket, plus your hotel is still cheaper than what you are going to be paying with your insurance. And they're like, No comment, jaw drop on the floor.
So I think it's great that as physicians who are really saying, how can we serve our patients? We are thinking in ways that we were never taught in medical school. We did not, you and I did not go to business school, but yet we are thinking about how can we serve our patients in the best way possible. So with that, when you mention Indiana, when you evaluate Hey, which state would be the next state that I.
In expanding to medical licensure wise, how do you evaluate the threshold at which you'll say yes, this is for me. Are you getting a certain number of patients that you have specifically from Indiana, that you are looking for before you say yes, this is a reasonable venture for me to go get my Indiana license?
Yeah, that's a good question. Cause I, other than Florida, I haven't really expanded yet. And so that, those are questions I'm thinking about myself. The reason for Indiana is they have one major academic center and in certain areas of sleep medicine, they just don't have The specialists in that state.
So a lot of their specialty care, at least in sleep medicine may go to Ohio or Illinois or Michigan in the first place. So it's an area of need, particularly in my, I guess my academic interest, which is restless leg syndrome. I don't know that they really have a quaternary care restless leg specialist like me.
In fact, I think I'm the only one in the entire northern part of the Midwest outside of say, Mayo Clinic, Vanderbilt Hopkins, that does quaternary care for restless leg syndrome. So I could pull like a very large number of states in the Midwest who are lacking super specialists. But those will be decisions I'll make based on patient interest cuz people email me.
And then I do have patients in my panel who are from those states. So if I get to a certain amount where I could justify the time and effort to apply for those state and maintain a state license, I will probably do that. So when that point comes, I'm not sure yet. And I would think it has to be at least.
Half dozen, maybe 10 patients from one state, and maybe we're getting close there with Indiana. So I'm, that's why I mentioned Indiana, because logistically it makes sense. And then also the interest has been there from Indiana patients who want my services. But those are very good questions and I don't know if I have the answer to that.
And, but there's probably a certain number of patients you would need to justify a license. And hopefully that gets easier as these state compacts. Progress. It'll get easier and easier to get multiple licenses. I am glad though that you mentioned that because I know one of my dear friends, Dr. Haley Miller, who's in Montana, her practice is Montana State Diabetes.
She uses a centralizing service so that she can more easily apply to multiple states without having to go through all of the paperwork muck herself. So I think that's great that you mentioned that and when it comes to having an evaluation of, is this service right for me? It could be adding another service, getting another license, whatever it is.
But I think that, especially coming from a business perspective, if you have people showing interest, that's a great way, just like you did with like people showing up in your clinic with suitcases. Keep going back to that cuz it's incredible that. It really helps the confidence that we might be questioning or that part of us it might be questioning like, do people really need me?
And it's oh sure as heck they do a, as we see with all of these direct care practices thriving all over the country. So with that, one of the things that I wanna ask your opinion on is opting out of Medicare. Were you ever in a point where you were hesitant to opt out of Medicare, especially as a specialist?
And if so, why?
That's a very difficult decision, but it wasn't a hard decision for me because of a couple of reasons. Number one is my wife does work part-time as a pediatrician, so even if my income dropped to zero, our family income would not be zero. And some of you probably have spouses. Who might work full-time in engineering or as a physician.
So the more flexible you are financially, the easier this is to do, to be an entrepreneur. You have more resources and backup. But most of my patients, probably two-thirds, are Medicare patients just being these conditions I'm treating in sleep mass and it's just statistically over the age of 65. So I knew I had to do that because I couldn't really function the clinic when the majority of patients were gonna be Medicare.
And I wasn't going to do locum tenons. I was gonna start the practice and put a hundred percent of my effort into the practice and I knew I had a certain number of patients that were gonna follow me. So I had some kindling in terms of I wasn't starting at zero. I had patients who I knew were gonna start with me.
And then I also had a reputation. I, over seven plus years in academics, I actually built a subspecialty and it turns out a highly sought after one. Because of the insurance-based system. It's a neglected condition, restless leg syndrome, insomnia. These are neglected conditions in the insurance-based system.
So now I'm offering something that you can't really get through insurance, so there's a big market for it. So it really didn't make sense to me that I could fail and then it's a two-year optout. So financially I said I have to be making what's a, to support my family in two years, or I could get any number of fee for service jobs like I could have anyway.
So there's no lack of safety net for that. If I were dead, there would be a lack of safety net. But if you're still functioning, you could always just get a fee for service job anyway after two years and opt back into Medicare. And it does. Cause you to give up potentially working at other locations where you would have to see Medicare patients.
You've discussed with other physicians. There's some ways around that, including providing emergency services or working at a VA hospital is an option for people as well. Cuz VA loves part-time work. You could work at a va one day a week and make income that way and not you. I think you could probably be opted outta Medicare cuz the VA doesn't necessarily need to have Medicare patients that are internally insured.
So there are a lot of options, but I guess my opportunities were there to opt out right away. My hard part was just figuring out how to do the technical work of opting out. And unfortunately, a lot of the de the direct primary care websites have detailed opt-out, instructions, which worked beautifully.
It wasn't as bad as I thought it was gonna be.
That's awesome. I appreciate that. I am laughing over here because this is the conversation that we're having right now between myself and my husband. His position was recently eliminated from his clinic and because in the state of California, the laws make it such so you can have a non-physician led clinic.
So when we talk about Medicare, that's exactly like yesterday we had this conversation about it's only for two years. Can we financially make it through two years with neither of us working? And then, operate from that perspective, worst case scenario. And as people are saving money for six months of emergency fund or whatever, like thinking about financially How would it affect you, I think is super, super important.
And it can take some of that fear of the unknown out of it. Because if you can show book-wise, this is how we are protecting ourselves or how we can survive if I do and do not have Medicare, it's one way to concretely evaluate the, that question of can I opt out? So I love that you mentioned that and when it comes to other specialists who are at that point of, do I opt out or do I not?
One of the things that Dr. Grace Torres Hodges and Dr. T Wynn had shared, they're both podiatrists, but they had shared that once they made space for people who were not relying on insurance to pay for their services, their mindset opened up differently in order to be able to take those patients who value the physician for being the physician and not.
For do they take my insurance? So when you had patients who followed you, what was their reaction when you said Hey, yeah, I'm gonna be opening Relaxed Health and it's my own clinic and I'm not gonna be taking insurance. Did you have any pushback from those patients who loved you and followed you?
Surprisingly, no. I did have one patient who got mad. He's oh, you're like all the other physicians going for just the money without realizing that I'm gonna make a lot less money. I think doing what I'm doing, it's, I'm not making more money. So how is that going for the money? But I didn't get that one.
But most actually were very supportive. So some said, I probably won't be able to follow you for financial reasons, but a lot of 'em said that they were interested in the idea and they would follow and continue to see me as a physician. Now, some were doing well enough that they didn't really need to see me anymore, and I lo I probably lost those patients.
But some have come back like a year later now, they're like I don't know if my doctor's managing the condition. Can I come back and see you? And I said, yes, absolutely. I'm, that's what I'm here for. So there was some pushback, but very little. It was actually very supportive. And it's more of these oh, I completely understand why you would be doing that.
So the patients know the system too. They see that they're 10, the 10 minute visit. They see that even seeing me, they might have driven six hours to be put in a 20 minute return visit slot cuz it's a satellite clinic. And they know what it's like on our end too, cuz they see it from the patient side, that the doctors are rushed, they're unhappy, they're stressed out.
They're burned out. That's pretty apparent to patients as much as it is apparent to us in the, who have practiced in a, an insurance based environment. Crazy times. And I am glad though that the patients who are valuing us as physicians are figuring out ways to make it work. There were some comments that I had read recently about like, how do people make this equitable for people who can't afford it?
And there are ways that people are incorporating. Equity for anybody, no matter their background, whether they're in specialty care or primary care. And so just putting some episode examples out there, Dr. Aaron Keel and Dr. RJ Heck are doing a Robinhood model in Modesto. That was episode 50. There is an example where the doctors in St. Paul, Minnesota, Dr. Leslie Seck, Dr. Sherri Vang, and Dr. Anita McDonald have an example of how they help their community in need financially. The opening episode of this season, Dr. Jamie Glover, shared how she has a give back jar that she uses to pull from when there are people in need. So when it comes to equity and when it comes to offering services, there are ways to make your clinic work whether or not you are having patients.
Who are questioning if they can afford your services financially. So when it comes to valuing your time as a physician who has created a subspecialty and who is so passionate about providing the best level of care for your patients, I wanna ask now about pricing. Because when I looked at your website, you have very transparent pricing on your website.
How did you get to that point where you set a price for your services?
So the way I came up with my pricing, which I should say may change by the time that the podcast comes out, cuz I'm actually, I think undercharging at this point very clearly based on the amount of effort I'm putting in. And it's gonna be different than a direct primary care because you have to recall, I'm.
I'm really a ary specialist. Like I'm the person you go to if the academic center can't figure it out. And so I'm not taking people for mostly prevention. I'm hoping that your primary care panel, you have some healthy 35 year olds who just need, lifestyle discussion. They don't have all these.
End stage medical conditions cuz you, you wouldn't be able to have a large panel patients like that. So I'm the opposite. You're coming to me you're coming with an end stage sleep condition, so to speak. And I'm the last resort and so it's gonna require significant amount of time. So my average new patient consultation is 90 minutes and I spend probably close to three hours when it's to the interactions before paperwork, that stuff, and then follow up stuff, sending letters out to primary care doctors, ordering lab tests, maybe ordering medications.
So it, it's a huge time commitment and sometimes I spend as much as two and a half hours face to face through video with a patient. And there, there have been days I've spent a whole half day on one patient We're not talking about seeing 15, 20 patients a day, I have to probably charge more than say, a direct primary care is.
And you have to charge what you're offering. So if you're doing 30 minute consultations, you probably shouldn't charge what I'm charging at 90 minutes, because you probably should be doing, you could be doing three of those at the same time. So it really depends on your own individual model.
And is this the point in the program where I have to say, if you've seen one D P C, you've seen one D P C, but I'm really a unique practice. So I actually modeled myself after others who had gone before me. So one person who was very influential was Dr. Leslie Emer Buck. She has a direct care ophthalmology clinic in the Detroit area.
And you've pointed me to some of these specialty care groups that are out there. And you've had Dr. Diana Garita on early in the podcasts and Dr. Laura be Kelly, and then also Dr. Nicole Hartman recently she, they, they were all up on the Direct Specialty Care Alliance website. So I literally went to all these websites and looked at their rates and even though that wasn't my field, I did get some sense of what others are charging based, at least on time and specialization.
If you're doing more general stuff, you probably aren't gonna be charging as much, but the patients aren't gonna be as complicated. So it really is a little bit non-scientific. I will probably increase my rates cuz I'm probably not collecting enough for the amount of work I'm doing at this point, but it is a work in progress.
So I gave myself about a year bef I, you don't want to change your rates every month. You really want to give a large sample size. So I'm gonna give myself a year, change my rates at the one year mark coming up here in a few weeks. Very difficult though. I will say,
but I love that going into the future, there are more and more people, whether they're a ary specialist like yourself, a primary care physician in a rural area, an urban area, no matter what, there are more physicians choosing the direct primary care model as a business model going forward.
And so that allows more resources than we've ever had before for people to look at. I remember when I was creating my FAQ page, I texted Dr. Janine Rhodes and I said, Can I please copy and paste your faq? And she said, oh, sure, help yourself. So you know it, it's ways that we are able to learn from each other, but also network.
Because I feel that, especially as a specialist, if you're listening to this podcast and you're like, Hey, I wonder did this person think about, could you have done it this way? In every episode there is an accompanying blog with contact information. So please feel free to check out the specialist that Dr.
Burkowski just mentioned and others that are coming in the future because as this movement grows, there are so many people expanding their mindset as to, could I do D P C as a business model? Earlier we just had Dr. Eri Chung, who is an infectious disease doctor doing direct specialty care.
So the possibilities are out there and networking with people who are thinking in the D P C model space can really help open your eyes to what is possible that you haven't yet explored.
So I love that. Now, when it comes to pricing one of the things that I noticed is to do a meet and greet in your clinic, it's $35. So I wanted to ask you specifically about what was the thought process going into the $35 for a meet and greet versus a complimentary meet and greet versus something else?
It was a difficult decision cuz I, I didn't know what was the right thing to do in terms of a meet and greet. I was just afraid of some patients making it let's ask all the questions we can, but not really. It's a medical visit so I wanted to make sure that my time was compensated for that.
Now, people call me and I call 'em right back and I, it's essentially a meet and greet and I'm not charging them on the phone if they have 10 minutes of questions for me about the clinic. Cuz that's part of the practice you're building mostly a relationship. Some people do one-time consults for me, but it's mostly a long-term relationship you're building and they're making a financial sacrifice to do it.
And so I think it's important to talk to patients and. They're usually shocked that you return their call within a minute or two. And it's not the medical assistant, it's the doctor calling you and they feel, I, I have patients say, oh I am nervous. I didn't know that you would be calling me. I didn't know you'd answer the phone.
So the meet and greet is just, I guess to avoid it consuming time. And really, I think we need to change our mindset. We can't be volunteers for everything within this system because what happened in the insurance based system is every additional step got dumped onto doctors. Cuz doctors will just do it, this extra charting or this extra maybe this extra blood draw thing that, that we don't have a medical assistant to do that, so we'll just give it to the doctor or they'll do it.
They're professionals. We can't do that when we're not salaried. Every bit of my time is either spent working on growing my clinic prof. Or it's on patient care or it's with my family. So if I'm doing volunteer work, I'm gonna go to a soup kitchen and do volunteer work. I don't need to be volunteering to have patients spend 20 minutes time asking me questions that it's not compensated.
So I felt okay, 35 minutes for 30 minutes. That's not great compensation. But at least it'll get some of the kind of people who aren't really intending to join the practice out of. Cuz now there's skin in it. Now with that being said, I collect, it's virtual, so some people haven't paid me the $35 but most people who have done the meet and greet have, it's just I wanna make sure this guy's real, he's human.
I can talk to him and then I will book this more expensive consultation later on. So the vast majority of patients who do a meet and greet are gonna do the full consultation anyway. But I can see a reasonable, particularly for direct primary care where the cost is much lower and it's a longer commitment, you may wanna sacrifice with a free visit.
And many of the direct care physicians do this because you could have that patient for 20 years and sacrificing $35 to have a 30 minute meet and greet. I think it's worth the investment, but for me, I felt like it's probably not, cause I'm so specialized, I could easily get, 20 questions over 20 minutes about sleep disorders and not get any intent for the patient to actually come see me.
So it's a little bit different, but that was my logic behind it and I'm gonna stick with that. The one change I may make is to add an upfront charge. Maybe not increase my consultation fee, but add a hundred dollars chart review fee, whatever you want to call it. Not to keep, hide the raise of the rate.
But because I did have. Two patients recently who almost didn't pay me. And then I thought, oh my gosh, I spent four hours with this patient and their chart, and I did all this follow up, and now they're not paying me anything. And so at least maybe if I charge a hundred upfront, then maybe I get something out of it if they don't end up paying me.
But I don't wanna charge patients the full price upfront because they're taking a risk that what if I don't know what I'm doing? What if I don't know what I'm talking about? I just blew $475 on a one hour visit with somebody who doesn't, he's in some other state. I don't, there's nothing that I know about him.
So it's giving patients security that you're gonna pay at the end. I just had duct cleaning in my house last year. They cleaned the ducks and I paid, they said that we take check or charge and they charge me on the way out the door. That's how our profession should be. It's you provide the service and then you're, you pay for the service at the end.
I didn't bill my homeowner's insurance. So I think the direct care model, there's a lot of flexibility in how people should be paid or upfront costs or charging after the fact. But that's how I've done it and even my monthly membership fee, I charge at the end of the month, so for the previous month.
So if they leave 15 days into the month, I just bill them 50% of the month and hopefully they pay most of the time they will. And most of the time they have a card on file. But it has not been an issue so far the way I've been doing it. But that might be the one change is to put a kind of some skin in the game up front so I don't get stiffed at the end and lose all that valuable time.
I
appreciate that, and this is something that Dr. An Niti Kaur taught me that even if it's a dollar, if somebody invests financially in something, just the act of investing financially is making that value of time a person's expertise, whatever it is. It's taking it to a different level than if somebody had accessed it for free.
I would agree that the panels of patients who we are taking are a mixture of people who are young, healthy, older, and healthy, but not all chronically ill with multiple issues. Where they have to see a specialist of a specialist like your panel. So I think that is definitely something to think about.
And as other physicians have talked about, the paperwork review, like you point out, some people take registration fees because to spend the time to pay your virtual assistant or yourself do the faxing of the papers to get records, to review the records, that costs something. Also, people have used the enrollment fees or other fees to cover things like, I know that the credit card fees are gonna come from this patient every single month.
So how can we, as a business owner think about keeping our overhead low by incorporating, those expected future costs in how we charge our patients? And so I think that is really important for people to hear how you value your services and for people to think about how they're valuing not only the time that they're giving, whether it's for free or for a charge before and after a patient joins their practice.
So I love that. And when it comes to meet and greets and you having patients and multiple states and potentially expanding services into Indiana, how many meet and greets do you have on your schedule each week? And what information do you collect before a patient attends a meet and greet with you? So with the meet and greet, I would say I, I have, again, I'm very low volume cuz I'm spending a lot of time with each.
Patient when I first see them. So I'm seeing maybe one to two meet and greets per week and maybe one to two consultations and maybe half of the consultations have started with a meet and greet. And then the consultations is the following week. But the meet and greet, a lot of them are out of state because they don't understand how are these laws gonna work, what do I have to do to see you?
It's almost like a practical visit because they can actually do that from home because I'm not doing medical care. They could be in New Mexico or somewhere and I don't have a license there and I, but I could still do a meet and greet cuz it's, I'm not doing any medical care at that first visit.
But then they can, we can discuss, hey, you could drive to this state, or I'm gonna, I've got this in-law in this state where you're licensed. I could fly there for Thanksgiving and I'm gonna be in Ohio for Thanksgiving. And so we can discuss some of the practical aspects. And then I also explained the system and some people are not, obviously not going to be familiar with the direct care system and some are definitely familiar with it already.
And just explaining how it works. Cuz I have. I've got that kind of dual model where I do one-off consultations, but I also do consultation and then membership, like a direct primary care would with the monthly membership. And it really depends on the patient and what they need, whether it's just direction I equate it to, am I driving the car or am I in the passenger seat navigating?
And some people just need navigation. They have good doctors, they just need to see the specialists for their opinion. And then the rest they need me to drive the car. Really, they shouldn't. I took, they need the cars taken away from their doctor. So that's where it comes from in terms of the combination of meet and greets and consultations.
It's really more, I think people want to see you in person. I know I post lots of videos so that there's some of that, but they want to talk to you in person, see, get a sense of what you're gonna be like to talk to and. I think I'm fairly similar on my videos as I am on a meet and greet as I am in the clinic.
So that's the good news is I'm fairly consistent, I think through this process. So it's just a consistency of this is who you're gonna work with. If you're gonna pay money to see this person he probably is gonna be okay for me to pay this money for. He knows what he's talking about. So that's the idea.
It's a salesmanship in some ways or reassurance to the patient.
And speaking in that thread, when you go to your website, you have a whole page on media where you have journal articles or you've been featured, webinars that you've hosted, research articles that you've been featured in as well where you've been the primary researcher.
So when it comes to a specialist highlighting their services, I really love that you have that, because again, I always think about you never know when patients are looking for help, for whatever. Ailment they may be having whether that's a primary care issue or a specialist issue. So when you were putting together your media page, what were your thoughts about I would like to highlight X because of y?
I think it's really important and one of your colleagues, Dr. Unna talks a lot about this, is that you're not doing these things in a vacuum. It's actually you're teaching patients or you're providing information, but you're also marketing yourself. And most of my patients to this point, almost a hundred percent are self-referred because they're coming to me because they saw something, I wrote, they saw a podcast.
I was in a video I was in where I looked like I knew what I was talking about. They're like, I've never heard anybody say that about this condition, and you seem like you knew what you were talking about. And that's the idea, is that they can go and read what I've written. They could see videos, they could listen to me before they even come to see me.
And part of that is. Advertising yourself. Hey, I'm out here. I ca I'm here to help. Cuz if you're in Florida, how are you gonna know this guy in Ann Arbor can help you with your sleep condition? So that's part of what I'm trying to figure out. But if they hear me on the, on a podcast, which is a national audience, they might see, hey, oh, he's licensed in Florida.
I can see him. He's 1500 miles away, but I could still see him as a patient. And so it, it really gets your name out there. And I really haven't curated any of my media. I pretty much put in everything that's in there and as it comes on, I'm gonna hopefully keep it up to date and is something that's really important, particularly to the direct care field is because.
We've now reversed course, we've flipped it. It used to be you are so overloaded with patients, you don't want anyone to know you're even a doctor because you're, you've got a backlog of three to six months. And now it's Hey, I don't care if I get people interested in the practice cuz I do wanna have patients who are interested in coming to see me.
So now I'm taking all of the opportunities that I used to try to avoid maybe I shouldn't do that. I don't wanna really be known for that. Now it's Hey, I'll do that. Because now it's getting education out there and it's getting my name out there. And there's a dual mission that I have on the micro level.
I'm treating a handful of patients in person, not in person, but virtually I'm treating them one-on-one. But my media tab shows what I'm doing on a larger level. And that's been the research and work I've done either with the Restless Leg Syndrome Foundation, educating patients themselves.
Or on the national level in terms of the committee work I've done putting out the American Academy of Sleep Medicine's clinical guidelines. So I'm not only gonna be influencing the patients I'm seeing tomorrow, but I have the ability to influence doctors and all of these hundreds of patients who are going to see the doctors and read the guidelines that I'm helping to write.
So one, one thing I haven't mentioned is that I've done more academic work this past year after leaving academia than I had in seven plus years of academics, cuz now I have got the flexibility and the autonomy to actually get things done. So I've got a poster that was an abstract accepted at the National Sleep Conference, which I haven't had done in seven or eight years.
And I'm working on these clinical practice guidelines and I'm gonna be publishing a large paper by the end of the year on treatment of restless leg syndrome. So all of those things are coming together after I've left academics because I actually have the time to do that now and the autonomy to set aside time.
To do that and then it's gonna come back to me as well, because that's putting your name out there. That's advertising. I guess if you publish something, it's not to get academic promotion anymore, but now it's, Hey, I can reach these patients who saw that I published this journal article, or I could just influence the people who are reading the journal article so they can learn about the conditions.
So it's a win-win in two different directions. And that's the beauty of direct care is the autonomy is probably the biggest thing, is you can decide what you want to do with your clinic and you can do it. There's nobody who tells you what you can or can't do with the design of your clinic.
Such a freeing experience, especially for medical school trained physicians who have been so regimented in, you do this and you do that, and this is how many minutes you have. This is the code you need to use for this particular diagnosis or whatever. So I absolutely love that and I think it's absolutely important for people to think about that wherever they're engaging, whether it be social media or research journals or mentoring or what, whatever, to always remind yourself also that like you've done a ton of stuff in your lifetime, Jessica, by going to medical school and then all of the stuff that we're doing as physicians beyond medical school.
Everything is important for our careers. But then when you throw in, Hey, autonomy is included in the direct care model like you've experienced, allows you to expand to what you love, and it makes us happier as physicians and happier physicians, you can't really argue the importance of being a happy physician when it comes to your patients and the care that you give them because, Like we all, I feel have we have a shared trauma of how we were not given the autonomy that we needed to be able to practice as the physicians that we were meant to when we went into fee for service for those of us who have gone in to that system.
So I love that. Speaking about your expertise and you, we have definitely established that you have expertise via expertise. I love that you have been able to talk with patients via, the Restless Leg Syndrome Foundation, as well as writing guidelines for sleep medicine nationally and internationally.
I'm sure that other people are referring to your research. So when it comes to your expertise and it, when it comes to the people who you are seeing in your clinic, I wanna jump to the primary care level because typically when we see a workup for whatever disease it is, diabetes or chest pain, whatever it is, In fee for service medicine, there are particular algorithms that drive the fee for service medicine compensation.
And so when it comes to restless leg treatment and even, collecting the history or when it comes to sleep issues and collecting the history for sleep issues, what are major differences that you see in the typical fee for service workup versus the actual workup that's needed for those two diagnoses in particular, from your perspective?
This is a very important point, particularly for other specialists who want to go into direct care because sleep medicine is technically not a procedural field, but it relies on the holy grail, which is the overnight sleep study. And for comparison, An insurance company might be charged the same amount for one overnight sleep study as the number of entire patients I would see in a full day.
What they, the insurance is charged now, whatever they pay, it's crazy, but they're charged the same amount for an entire day of clinic visits for one sleep study, and that's just unacceptable because most sleep conditions do not involve a sleep study. A sleep study is really to diagnose obstructive sleep apnea, and there's a couple of other conditions that it's helpful for, but the vast majority of conditions, restless leg syndrome, insomnia, those are two of the top three sleep conditions that are treated in a sleep clinic or should be treated in a sleep clinic, I should say.
And those are mostly behavioral counseling, educational, those are time consuming conditions. And restless leg syndrome, it's really a primary care condition because it's, most patients would be treated with lifestyle modification and probably iron levels and iron supplementation, so it shouldn't really even reach the desk of a physician who needs to do any type of medication treatment at any point if it's properly managed from the beginning, which is primary care insomnia.
For example, the first line treatment for chronic insomnia is cognitive and behavioral therapy. If insurance paid the same for a sleep study as they did for cognitive and behavioral therapy, you'd have more than like 10 providers in the entire state of Michigan doing cognitive and behavioral therapy.
How could the first line treatment not be offered by any sleep physicians? I, there are only a handful of physicians in the entire country that do cognitive and behavioral therapy for insomnia, and that's a first line treatment. So most people are not getting a first line treatment. It's done mostly by psychologists and social workers now.
So from a primary care perspective, these are examples of conditions that could be primarily addressed first by the primary care doctor and may not need to go to the level of a sleep clinic. But then when it does get to the sleep clinic, a patient ends up getting a sleep study, but they never get their condition addressed.
I had a restless legs patient and I saw him after one year within the system. He's You're the first doctor who's actually tried to treat my restless legs. I originally came for restless legs and they did a bunch of sleep studies. I do have sleep apnea. I'm glad I'm treated, but you're the first doctor to actually make a change in my restless legs treatment.
And that's why I came in the first place. And you get that story over and over again. It's because there's no procedure. There's no procedure to diagnose restless leg syndrome, and there's no procedure to treat it. It's time consuming. Patients are not doing well currently, and it's one that pretty much most insurance-based systems want to avoid, which makes it a great system for direct care because you have 5% of the population with the condition and nobody wanting to treat the condition.
So you have a market there. Even if a primary care doctor wants to treat restless leg syndrome, that's a great area to treat cuz it's in such high demand wi with restless leg syndrome. The biggest problem has been pretty unique to the condition in that the historic first line medications for restless leg syndrome called dopamine agonist.
This is your Prima Paxil Rol. They were shown to cause this phenomenon called augmentation. And augmentation is a destruction or disruption of the dopamine system of the brain where the condition actually gradually gets worse over time, and so much so that they develop these severe symptoms that could never happen naturally.
So it's this really bad phenomenon where the treatment is actually causing the condition to be extremely severe. And the guidelines had changed at around 2015, 16, but as of right now, 70 to 80% of doctors are still prescribing dopamine agonists. They probably should be taken off the market to be honest with you, but they're still being prescribed as the majority treatment.
And why is that? It's because doctors see restless leg syndrome. It's the eighth thing on their list, and they have eight minutes with the patient. Heart failure, diabetes medication referral. You get to restless leg syndrome. All you remember from medical school is prima pex. Hey, I'm gonna give you prima pexels.
See you in six months for your next 10 minute visit with me. So that's how patients are being treated. Nobody knows about the condition cuz there's no incentive, there's no money being made by the condition. And that's reflected in the professional societies. So the American Academy of Neurology has no lectures on restless leg syndrome.
At their annual meeting this year, the American Academy of Sleep Medicine, in their preliminary program, they have one lecture on restless leg syndrome. So what field is giving lectures on restless leg syndrome? Nobody. And why aren't they? No fancy drug. No, no drug company pushing the condition, no diagnostic test, no money, nobody cares.
And it's really sad cuz it's greatly affecting a significant number of people cuz they're on a drug. A lot of these patients are on drugs making them worse. And you can't just stop the drug cuz it causes severe chemical dependence. So you go through a miserable withdrawal period. And that's my program.
I have a five month program just to get 'em off the drug that they were on for the condition to take 'em off the drug is a five month program. So that's the situation we're in the field of sleep medicine. And I really think it's driven by the insurance industry. So in terms of good practice, restless legs, patients should have iron levels checked at least once a year, maybe every six months, because low iron levels in the brain are the biological cause of restless leg syndrome to the extent that we know.
And you wouldn't, you believe it, but the insurance doesn't. Reimburse. Even the iron lab test. You have to put it under another diagnosis code to get it paid for. And then the main first line treatment, it might be an iron infusion. And that's not even on the radar for any insurance company right now. So the first line treatment's not even covered by insurance, the first line test for the first line treatment's not covered by insurance.
So everything pushes itself toward poor care in this particular condition. And it's really sad and that's why we have this array of patients that are much more severe than you would actually see maybe 20, 25 years ago before these drugs came out.
That's incredible. And I'm so grateful that you mentioned, your experience and what you are seeing and how we can think differently as primary care doctors, especially when it comes to evaluating someone who has.
The complaints or concerns about restless legs? I was reading on the Restless Legs Syndrome Foundation page about the basic things that you can do symptomatically to try and help your symptoms at home. But even just reading that article took me longer than I would be given in a patient visit to address, like you said, like the multiple issues with restless leg at the bottom.
And I think that also even the diagnosis of restless legs, very often people who are saying, I have any issue with my leg at night are just diagnosed with restless leg. And sometimes that will follow them. And I've seen people put on those medicines even though their symptoms weren't even consistent with restless leg.
So it's so interesting to hear that. And when you talk to like you said it, and I love that you said it, when you spend the time to communicate with a person's primary care physician, which should happen with any specialty and any specialist who is taking care of a patient who has a primary care physician, I just, I love that you said that.
When it comes to communicating with a primary care physician about their patient, if they've been diagnosed with restless slag syndrome or they've been diagnosed with a sleep condition that requires ongoing care or ongoing support from their primary, like an iron infusion, how do you talk to primary care physicians about getting their patients treatment that you are finding helps patients based on evidence and based on being able to have the time to explain that evidence to
patients Well, yeah.
The key is to get them to understand. A lot of doctors don't even know iron is a part of restless leg syndrome when it is the part of restless leg syndrome. And again, that's again, lack of time to read about the condition like you, you did. It's, it is time consuming to learn new things about new conditions and some of the direct care model will allow for that.
But then there's actually the administration of the treatment. So hopefully as the guidelines keep coming out, that insurance will have to support this type of treatment financially. But until then, I'm actually strategizing with the patient as to how can they get, let's say they need an iron infusion.
There's an issue, there's multiple issues. One is who's gonna do the infusion? The infusions are done oftentimes at major medical centers where you need privileges. It's not a dr, it's not a prescription drug, it's a procedure. So if I don't have privileges, they may not let me order the infusion. Sometimes they order it and they'll have another doctor co-sign and that works.
But then the independent centers don't make enough money. They come out negative on the iron infusion, even when they are reimbursed for it. So a lot of them will not do an iron infusion unless you're also getting chemo on top of it. So you actually have to have a fancy infusion to get the iron infusion at these independent centers.
So it limits the locations that I as an independent physician can order these. So I have been able to work with some of these medical centers and some of the primary care doctors and here are the diagnosis codes you need and this is what you need to do and these are the formulations of iron you need to order.
So I spend a lot of time looking into that cuz it does make a huge difference and a lot of particularly primary care, they're very afraid of iron. They think of iron as oh, I'm gonna get called in the middle of the night with an infusion reaction, which is completely not valid. It's minor reactions happen 11 to 22% of the time statistically.
But there are no major infusion reactions with iron. It's just they don't exist. But there's this fear of iron. There's this lack of knowledge of iron. It's something the hematologists do. So it's getting them educated. First iron's important. We need to get an infusion. An infusion is the treatment with the fewest side effects in this condition.
And then I do have other places where I have been able to work with independent centers. I know their cash prices. If the insurance is not gonna cover it, I can predict which insurance will cover which infusion at this point. So patients are prepared. I'm going to pay, no, I can't pay. They'll tell me upfront about whether that's an option for them.
And then I've been able to work with at least one direct care physician, Dr. Phil Hellman. At Paradox Health in suburban Detroit. He has a spa infusion center. He did iron infusions. So he talked, I talked to him and he's yeah, we could do it for restless legs. It's a higher dose, but we're already doing iron infusions.
So he got me a reasonable cash price where the patient pays on their way out the door, so I don't have to guess. It could, they're gonna charge you 3000 and then the insurance is gonna pay 50% and you're gonna have this we don't know what's the charge is gonna be if they go to a medical center for this infusion.
And now I have a place to do a cash price. And I would encourage a lot of the D P C community to consider adding an iron infusion if they're doing infusion services or home infusions. This would be a great thing to add. Not just for restless leg syndrome, but because there's a lot of people walking out there who are anemic.
They're inflamed, so they don't have the ability to absorb iron. And they could have a boost of iron. We treat anemia when it's end stage, but we could be treating it a lot sooner with iron infusion if people really understood it. So I would encourage more direct care with iron infusions because it's definitely, it's not a very expensive one.
Now, getting into like specific forms of iron I particularly like iron Dextran, or Infe is the brand name because it's the most cost effective of the high quality infusions. So this is maybe on the order of a couple hundred bucks. So you could probably do an infusion between 500 and a thousand dollars depending on, what the administrative charges would be.
So it's actually within reach of many patients are willing to pay $500 or $750 to get treatment of the restless legs without all these other side effects of these other drugs for the condition. So it's really a great opportunity that we're gonna have as a direct care field moving forward in over the next five years in order to provide this service where people really are desperate for these infusions and they can't get it elsewhere.
And when it comes to sleep issues, you spoke about sleep studies and what they're good for and what they're not good for, and how the data can be used to treat patients when it comes to sleep centers, I'm like, I know locally it is very difficult to get into a sleep center. It takes months to get in.
Sometimes it's very inconvenient for patients. And then they tell me afterwards very frequently, oh, I didn't sleep a wink in the sleep center, blah, blah, blah, blah. You offer evaluations where patients can get sleep studies at home. So can you touch on that as well, please?
Yeah. So it's important to note which conditions require sleep testing and the vast majority of a patient in a primary care, it's gonna be for obstructive sleep, aptio and in general.
The people with insomnia, which probably is the second most common insomnia, is not diagnosed or treated with a sleep study. It's really behavioral modification, things like sleep hygiene and other higher level treatments, which is C B T I or cognitive and behavioral therapy, which might have to be done through a referral, but they now have apps and other ways of getting that treatment that are almost as effective as seeing a psychologist or a physician who does this treatment.
But for sleep apnea, number one, you have to know how common it is in the American population. It's probably one in three adults at this point, who has it to some degree, just statistically. We really, it's mostly driven by obesity primarily. So in an obese population it's gonna be somewhere in the order of every third patient, which means it's also on the level of diabetes.
So you're not sending every diabetic patient to the endocrinologist. You should not be sending every sleep apnea patient to a sleep doctor. So becoming familiar with the basics, number one is home sleep apnea testing. Probably directionally 80% of patients could get away with a home sleep apnea test. I work with a company that it basically, they ship it to their home, they do it overnight, and then it gets shipped back.
They don't even have to go into a sleep center. And I can interpret a score and interpret the study myself, but that plus an automatic C P A P machine, if you just understood that amount, that could probably get a primary care doctor, 70, 80% of their patients treated without ever seeing a sleep physician.
So that's your, like initial Metformin or ozempic, for patients with diabetes or, Hey, how about lifestyle for diabetes? But lifestyle modification is really gonna be the big solution for insomnia and also for restless life syndrome to a lot of extent. But to know where the patients are more complicated, where they have severe heart failure, maybe they're on chronic opioids they have arrhythmias.
Those are the patients that might need. Evaluation at a sleep facility because they might have central sleep apnea, which gets into more complicated sleep issues. Most people are sleepy, not because they have narcolepsy. They don't need a sleep study. They are sleepy cuz they're not getting enough sleep.
They're sleep schedules irregular. They're drinking coffee at bedtime. They're on an irregular sleep cycle. So just the basics in terms of sleep hygiene and good lifestyle habits. Cutting down on alcohol, cutting down on caffeine. These are things that actually help people with poor sleep quality.
Good mental health, stress reduction, those are all things that you all are doing in terms of lifestyle modification. That's what helps with sleep. But that stuff is time consuming, even at a sleep clinic. And those are the things that are often ignored cuz somebody comes to the door, you want to get 'em that sleep study and get 'em in and out and get that sleep apnea treated.
If it's anything beyond that, you don't wanna see the patient again. That's the mentality in our field right now, but that's because of the insurance reimbursement. It's driven by that system. I think everyone likes these other sleep conditions, they just don't have time to deal with
them. It's amazing when you have the time.
The outcomes that you see with our patients. I feel that I'm a much better doctor now than I was in fee for service because, just because of the time, you throw autonomy and control of your schedule and control of the way you want to practice. It's just, it compounds and compounds as to the benefits of direct care and direct primary care.
With that, I wanna ask you, when you look back on your years in fee for service, as you've shared already, you've had more time to do, to be involved in academics than you were in the last seven years, but what's your worst day at Relax like compared to your a typical day in fee for service?
My worst day at Relax Health is where I have overscheduled myself with things I love doing.
So now the problem is not all of these things I'm forced to doing, like unnecessary sleep studies where 70% of them are medically unnecessary, but I'm spending all these hours interpreting sleep studies. Now it's, oh, did I schedule, too many am I spending too much time recording this video or working on this article or on this research paper?
And then I have the patient care on top of that. So with all the autonomy, there are decisions to be made that now it's, you're, it's on you. So I have complete control over my schedule. If I over, I've overscheduled, I can't blame anyone but myself. So that's the miserable part of it, is that now I'm responsible for doing too much.
It's not the system did it to me, it's I did it to myself. And that's where you do need to set limits in terms of. Deciding upfront, when are you gonna talk to patients? Are you gonna be available Saturday, Sunday? Are you available in the middle of the night? How many days of the week are you gonna work? I put all my clinic work into three days a week.
The reason is, cuz my wife works the other two days of the week, we have a child who's being homeschooled. I gotta do dishes. I, there are other responsibilities I have that are non-clinical. And guess what? I have the ability to do that now because I have autonomy over my clinic. And probably the most exciting thing was I was my fifth and sixth grade son's basketball team, assistant coach.
They didn't have an assistant coach very hard from three 15 to four 30 every day, four days a week. What person who's working is gonna be able to just leave work during that hour. Hey, I can block off my clinic from three 15 to four 30 and I was the assistant coach of the basketball team. Never would've happened in an insurance-based system where everything is dictated to you.
So that's the worst day, is that you overschedule yourself. And sometimes you have trouble setting your own limits, but at least you can set the limits, you can change that, and it gives you this sense of liberation really is what I would call it. And I feel liberated. My career, I thought I would work till age 70, then I thought, I'm gonna leave the medical field and now I'm gonna work till age 70 again.
That's my goal. I don't plan to fire financial independence, retire early, and then just leave medicine. That's no longer the goal anymore. And so that's exciting to me that the job that I thought I was going into, I could actually do. And it was what I thought it was, but it's just in a different way than it was before.
That's so
inspiring. And with that said, when you think about the people who have come before you and the fact that you have joined this movement of direct care physicians, direct specialty physicians who will continue to inspire other physicians to choose direct care and direct primary care as a business model, what.
Other words, would you have to say to them if they are considering D P C as a business model in the future?
Particularly for specialists, it's think of all of the areas in your own specialty that are not favorable to insurance, whether it's. I don't want to do 20 endoscopies today. I want to treat irritable bowel syndrome or chronic constipation.
So think of the things that the major medical centers are not doing well and that you're interested in, and whether you think you, there's a business plan for that. Cuz if I'm gonna just do a bunch of sleep studies all day, I don't know that I would be surviving in direct care, cuz you can get that through direct or through the insurance based system.
But if you can offer something to patients that they can't get through the standard system, then you have a business idea and people will come to you because people are affected by all health conditions, not just the ones that are covered by insurance. And so that's what you have to think about is it's not for everyone, but it's for a lot more people than you think, including a lot of specialists.
Amazing. Thank you so much Dr. Burkowski, for joining us today.
And thank you Mario particularly for the work you're doing. It's influenced me tremendously and coming on as a specialist. I hope to inspire other specialists in addition to primary care doctors to keep choosing the direct primary care route as they go through training and into their career.
That is a guaranteed going to happen, and it is happening right now as people are listening to this podcast.
Next week look forward to hearing from Dr. Jennifer Allen of New Freedom Direct Primary Care in Herman Washington in O'Fallon, Missouri. If you've enjoyed the podcast and you haven't yet done so, subscribe today and share the episode with the physician. You may know who needs to hear about D P C. Leave a five star review on Apple Podcast and on Spotify now as well as it helps others to find all these DPC stories.
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*Transcript generated by AI so please forgive error