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Episode 136: Exploring Direct Primary Care Models with Dr. Maryal Concepcion & Dr. Bradley B. Block

Host of The Physician's Guide to Doctoring Podcast



Dr. Bradley B. Block - Host of The Physician's Guide to Doctoring Podcast
Dr. Bradley B. Block

Get ready for a riveting episode that takes you deep into the heart of healthcare innovation. Join us as we venture into uncharted territory with the brilliant Dr. Maryal Concepcion and the insightful Dr. Bradley B. Block, renowned host of The Physician's Guide to Doctoring Podcast.


Today's conversation isn't just about Direct Primary Care—it's a journey through the evolution of patient-centric medicine. Listen in as we unravel the intricacies of my medical practice, and unveil the driving forces behind my transition from insurance-based billing to the groundbreaking realm of 24/7 patient access.


But that's not where the adventure ends. We'll also delve into the realm of patient service dynamics, uncover the unique patient profiles with an insatiable curiosity, and uncover the enigma of a seemingly ordinary weekday that led to my intriguing absence from the office.


Prepare to be inspired, enlightened, and captivated by this episode that promises to reshape your perception of 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 D P 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, Marielle 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.


In today's episode, we share a podcast recording from Dr. Bradley Block. As host of the Physician's Guide to Doctoring podcast. He asked me all about my favorite topic of conversation. D p c, enjoy.


What the heck is direct primary care or direct care? Actually, since there are other specialties that are trying this practice model other than primary care, it's a subscription service basically that gives your patients access to you 24 7. Uh, and it's disruptive sometimes. So we talk to Dr. Mario Conception, who is the host of my D P C story, where she interviews physicians on their direct care.


Journey. So we talk about her practice, her podcast, why she chose to stop billing insurance company and give her patients access to her 24 7. Let's talk about what happens when patients abuse this service, why patients tend not to do that, um, which patients tend to be interested in this model and why?


Earlier that day, a weekday, she wasn't even in the office. Dr. Conception went to Creighton Med School, completed her Valley Family Medicine residency in Modesta, California, and then moved to rural Northern California. She started working in the corporate model before starting her direct primary care practice, for which she's clearly an evangelist.


Welcome to the Physician's Guide to Doctoring. A practical guide for practicing physicians, Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Kreb cycle. The ideas expressed on this podcast are those of the interviewer and interviewee, and do not represent those of their respective employers.

And now here's Dr. Bradley Block,


Dr. Maryal Conception, thanks so much for coming to the podcast.


Thank you so much, Brad, for having me today.


This is super exciting. So we're gonna, we're talking about direct primary care. Mm-hmm. So that means, well, what does that mean? Let's start with that. What is direct primary care? What is direct primary care as opposed to like concierge medicine, as opposed to just like, just not taking insurance? Like what?


Yeah. What do these things mean? So I absolutely love this question, and I think it's super appropriate to start with this, um, especially for an audience of physicians on your podcast and on your YouTube channel who might not be familiar with the terminology. A lot of people assume that direct primary care or D P C is concierge medicine and where the line in the sand is drawn, so to speak, is that a typical concierge practice will take insurance.


While charging a patient, typically a very high fee for concierge style services. So, um, being able to text call your doctor is in concierge medicine most of the time, but you are still being billed and limited to what insurance says. You know, you, you have covered or not, but typically in, in practices where, A person is a direct primary care physician.


A direct primary care physician typically will offer concierge style services. So, for example, in my own practice, patients can text, call, leave me a, um, leave me a message directly in the portal that goes directly to me and not an administrative assistant. And yet, The average price per member per month for all Americans is on average 75 to a hundred dollars per member per month.


Um, there are some practices that charge children as little as $10 a month for concierge level services without saying, yes, I'm going to charge you your fee plus then I'm going to bill your, your visit to your insurance company. And then you might have to pay, um, the premiums on or. Not the premiums, but you might have to pay for your visit, um, through an insurance bill, plus the doctor's fee on top of that.


So that's, that's how I like to describe the difference between concierge typical practices and direct primary care.


Okay. Okay. I think I got that. Mm-hmm. And so what made you decide to leave? Typical medical practice. Yeah. And, and start direct primary care.


Yeah, that's a great question. So, um, I went from being trained at Creighton University, um, in a rural setting.


I did most of my family medicine, uh, rotations, and that was in superior Nebraska. It's a town of 2000 people that serves about a 6,000 people, um, radius in the middle of the geographic United States. And there I saw the power of being a family physician, being a, a generational family physician, somebody who knew, you know, kids all the way until they were adults, although way until they were delivering their own, or, uh, all the way until they were having their own grandkids join the world.


And so I loved that and I, I only sought out. Rural locations to practice family medicine after residency. My husband, who's also a family medicine physician, um, we had heard early on about this idea of job share and we're like, what is job share? That's amazing. And so, um, we had had this dream of having a family.


Being able to be home with our kids and not having to be a hundred percent at a job and have to employ, um, you know, a nanny or an au pair, um, while being able to practice in a rural, uh, position because he also trained in superior Nebraska. And so, That culminated in us finding a job that we thought was our dream job in, sorry, rural, sorry, Uhhuh.


Go ahead.


Job share. Yeah. What, I mean, it sounds like two people together are one full-time phy, one f t e, one full-time Correct. Employee or one. Yep. So, okay.


Yeah, that's it. Exactly. And so, um, you know, a little backstory, uh, there was a, an a lovely obstetrician who we worked with, um, at one of our rotations in, uh, OB and.


We asked him one day, we're like, oh yeah, how old are your kids? And he's like, I, I think 26. But they live in Chicago and I don't live with them, so I don't re actually remember. And that was one of the, you know, impressionable moments where we're like, we wanna have a family, but we want to be able to be there with our kids.


So a job share, correct. Is, is a, a job that is shared by two people to make one equivalent worker one f t e. Um, and so when we moved to, um, Northern California. We both did residency at the same location. Um, we chose to pursue a job in rural Northern California where we were able to do full scope care. Um, that was, that was what we thought was our dream job.


And then after the golden handcuffs of, here's your bonus sign on and here's your, um, here is your salary, then it was, okay, so now we're gonna go to rvu. We had to negotiate fairness of rvu. Um, for example, our RVU rates were being calculated at a 2017, 2018 rate, even though it was no longer 2017, 2018. And we had to fight to prove that.


Um, and the, the, the battle of being. Paid fairly while still being able to protect the time that we had with patients to maintain the quality we had with patients was just continuously, um, it was a, it was in a continuous battle, um, in terms of like how we felt the situation was going. So, um, it was September of 2020.


When I was 28 weeks pregnant with our second child, and negotiations pretty much stopped because there was a turnaround of, uh, admins at the company we worked for. And we basically both got a letter that said, well, you can either consider yourselves terminated unless you sign the R V U contract that we determine is appropriate.


And so, knowing this history of inappropriate contracts and inappropriate RVU U compensation, in my opinion, um, We were given this letter of you're gonna be fired or else, and I said, well, thanks, but no thanks. I can't be enslaved to take care of my patients based on how an admin, you know, dictates is appropriate.


And so, no, no, no.


Yeah. Maryelle if, if you really cared about your patients, Then you would take whatever they give you. Right. That's, that's unfortunately, I'm kidding. I'm getting, I'm kidding. That's unfortunately the, that's what they sell you and that's what we Yeah. That's what they make you feel. Mm-hmm.

Yep. That's how they make you feel. Yeah. And, and it's, it's so, and they're just gonna pocket the difference. Yeah. Yeah. And well, I, and that, that happened that, um, you know, the, the strategies of yes, c m s is going to increase your RVU rate for family medicine. However, of that increase rate, we're only going to give you X percent.


So, you know, the things that we didn't learn in medical school are this idea that, um, you know, We are, we are givers who go into medicine in general. Like we put our lives towards careers where we're taking care of other people. And yet too often, especially in primary care, we're made to feel like we are the bad people.


And so, With that feeling of like, you literally just gave me a fi like sign this or be fired letter and I'm 28 weeks pregnant, I'm gonna lose healthcare insurance for my child. Oh heck no. And so at that point, um, I was very thankful that an orthopedic surgeon two years prior had told me about direct primary care.


I'd gone to, um, conferences to learn about direct primary care, but I really hadn't wait. An

orthopedic surgeon taught a primary care physician about primary care. Because that would be, that would be the expect. I know. Yeah. But, you know, it's like, just how, because you, you work in the emergency room, you know, like I heard on a, a recent recording, you see 28 to 38 patients on one of your shifts, and it's like no matter who you are as a physician in emergency medicine, dermatology, it doesn't matter.


Orthopedic surgeon is just another example of this, that the, the, you know, devaluation of physicians, um, and the ability for us to be able to take care of our patients appropriately and needing the time to do that has become so bastardized in our healthcare system. And so an orthopedic surgeon? Yes. Um, Dr. Ariana Demers was the one who had said you're super frustrated with the negotiations that you're experiencing. Why don't you read about Direct Primary Care? And so, yes, she had told me about D P C, uh, about two years earlier, and she had left, um, our local hospital system to open up her own private practice.


So people are doing direct primary care as a business model, um, in their own specialties left and right these days. Um, But for me, when I was, uh, when I was a armed with the information of what is direct primary care, how powerful can it be, and arguably it can happen and, and be successful in any community that's rural, urban, doesn't matter.


Um, I basically had the, you either do D p C or you leave medicine moment. And so it was at that time that I chose to do direct primary care. So that's the, the long answer to your question of how did I choose D P C? And then, and then come on. I feel like the story's rolling, and then what happened?


Yeah. So, so it, it is, I mean, honestly, I, I am, um, Every single day, I tell as many people, that's patients as well as physicians included about direct primary care because the model, in my opinion is really, um, at the crux of how we change the, the quality and the accessibility and the availability of primary care.


As well as, like I mentioned, you know, specialists are choosing direct primary care all over as a business model all over the nation. Um, this is really how we return healthcare to the people and, and give Americans the healthcare that every single human being deserves who happens to be physically in the United States of America.


And so when I say that, again, I go back to. People are paying $10 a month for their child to have access to their doctor. So for example, um, yeah, you have a rash that stinks. Go ahead and text me a picture of that and we can see what we can do. And if I need to see you in person, then we'll do that. But in general, direct primary care, um, is so.


Powerful in terms of reaching, again, accessibility, availability, and affordability to all Americans that I have this, uh, passion of continuing to share about direct primary care and highlight the physicians doing direct primary care. Um, as, as an everyday part of my life. And so in addition to seeing patients, I also host a podcast, and that's how, you know, we connected.


Um, and my podcast, or my d p c story is literally highlighting physicians all over the country who are doing direct primary care and how they're doing it. Because at the, at the root of it, it's not only education about D P C, but it's also a set of se. It was a, it's a series to. To give other physicians, no matter what, um, specialty, they're in the tools to say, oh, well they didn't go to business school either, but yet they own their own business and they're successful in rural urban settings.


It doesn't matter. Well, I could do that too. And so, um, For me, it's, it's my own little contribution to the movement that has really changed the lives of so many Americans already, so many physicians' lives already, and it continues to grow like wildfire, which I'm super happy to see. But also, um, I just feel like, uh, you know, it's almost like a, um, It's almost, it, it's so rewarding to my soul to see people making an impact in their communities and feeling that, wow, this is a, this is why I went to medical school.


Not because I needed, you know, to work for a system where I saw too many patients in a day, but I really actually got to care for my patients. And so, you know, this is going into the weeds a little bit, but um, like before we started recording, you asked like, oh, you know, you're at the end of your workday.


And, and technically yes, I'm at the end of my workday, but I. I've seen zero patients today. I've, I've had messages, um, virtually, but, but I've not seen any patients because my patients, um, in terms of that concierge style of care, but not at a concierge price, my patients are still able to message me directly and I get back to them, but I don't need to physically see them in person because I'm no longer working for the 9 9 2 1 3 1 4 0 4 0 5, whatever.


I don't care about those anymore because my patients understand the value of. Affordability, accessibility and availability, and they just message me directly. So I technically have been working, but I've taken care of my kid today, taken him to the doctor's appointment, took taken a nap. Like I've done lots of things today.


Um, and I, I feel so much, um, I, I feel so, so good inside because I'm contributing to care locally as well as contributing to the movement of D P C nationally.


Oh yeah. I mean, I, I, I get it. I mean, I can't tell you how many patients that I see in a given day that I could have diagnosed them accurately. Yeah.


And managed them over the phone. Mm-hmm. If they just told me their story, you know, I could have saved them the trip, I could have saved now, but I can't do that. 'cause billing, I, you know, I take insurance and billing. I just can't do it. There's also the issue of the liability, right? Like, let's say you're wrong.


And, but your, your patients, I would imagine also recognize that if you're not being seen, there's gonna be some, there's, there's room for error there and, but you're saving them the convenience of taking a full day off. And you know what, if this doesn't work and I don't get better, okay, now I will come in.


Correct. So yeah, that's ex, that's it. Exactly. And so there are direct primary care practices that do exclusively telemedicine, but in my practice I do have, uh, I just physically opened up a clinic. I was doing telemedicine and home visits previously because that's, that's correct. I, I mean, in terms of the physical exam that you need, you know, you can't, I mean, yes, there are tools where you can like, hear patient's heart or hear their lungs, um, virtually, but in terms of me, you know, like.


Seeing how the chest is rising, seeing those retractions, hearing all of the things, you know, being in the home to see the, the physical environment. The, the, the, the beauty of direct primary care to address that concern about liability is that it's relationship-based care so that people are, you know, they, they're plugged in with their physician for the long haul in most cases.


And so, you know, if, if there's somebody who never calls and you're like, Um, the fact that you're messaging me, I mean, like for example, I have this 90 something year old who, um, they put their weight in the, uh, in my electronic medical record, and I monitor that. And, you know, when I noticed the weight was going up, I, I reached out and said, Hey, Didn't know if you are having symptoms and they said, oh, I didn't even realize I was, but I was having some swelling in my legs and whatnot.


And so, oh, it's, I didn't know which direction you were taking that. Yes, I saw their weight going up and I was like, So the sandwiches. It's the sandwiches again. Yeah. And so No, no, no. Someone with congestive heart failure. Okay, I get it. Yeah, exactly. And so, um, in, in my world, in the world of a direct primary care p physician who is or direct care physician, because again, specialists are choosing this as a model, um, where you.


Have a smaller panel of patients and are able to, to monitor them in different ways, whether that be via telemedicine or via in person. Um, you can also proactively say, Hey, I noticed an issue about you, or, Hey, it's time for your skin cancer screening. Let's go ahead and schedule you. Because you're not, you're not reactively waiting until like, oh, they got seen in the emergency room, or they got discharged from the hospital.


Now they need to see you within a week. So it, it's no longer like that. Um, so it, it, it's a very different way to address that liability issue. But it's, it's because it's, uh, and I, I. I pull this quote from Dr. Jake much who's in, um, Williamsburg, Virginia Defiant d p c, but he calls it small batch medicine.


And that, and that I absolutely believe really represents what we do because it's like if you have even. A hint of something is off, or you are trying to be proactive about something, you have the time to go after that and not just like, let it go. So, yeah, that, that, to me, that addresses the, the concern about liability, which is very, very reasonable and very, you know, we, we, it's, it's a real thing as a physician, especially with me being in California.


Yep. So how does the, you, you touched on it when we were comparing d p C to, to concierge, but like, how does your compensation work? How does your mm-hmm. Business model

work? That's a great question. So in terms of business model, um, the, the business model at a high level zoomed out view is we are like a Netflix, uh, or gym membership subscription.


So for example, um, you know, you pay 8 95 or whatever the rate is for Netflix and you either watch it or you don't. The same thing in direct primary care. So a patient pays a set rate per member per month depending on what the doctor sets or what the, the direct primary care company sets. Um, and then that's what the, the patient understands is their share per month.


Um, and to, to have, as a result, access to their doctor when they need them. Um, and so that, Allows us to not have to worry about, well, shucks, I only saw, I only, you know, I, I had five no shows and only two showed up. And I had got 2, 9, 9, 2, 1 threes today, and that's all I brought home. And it's like, no, we don't have to do that anymore.


Because like I said, you know, I, I have technically been working today, but I have not been working to see patients in the office because I'm addressing their needs without having to see them in person. And so, so that's the.


Income is from the subscription.


Well, so that, that is how some people do their direct primary care, um, membership.

There's a saying that I absolutely love. If you've seen one D P C, you've seen one D P C. So that's the zoomed out level of membership, which is, uh, is in most cases the typical direct, primary care, um, value proposition to patients. But then other people do, and like I'm one of those people I charge, um, Extra for if there's procedures.


'cause lidocaine costs a ton more than it used to. Um, you know, for different procedures, for skin biopsies, for doing skin cancer screening, um, for doing, uh, you know, non-member services. I do offer because my community is so. It is such a medical desert, and it is so in need of basic things like availability for pap smears.


Like people can't even get in to see a gynecologist. Um, and so, and there's very few primary care physicians in my area, and so it's like, yeah, if you are at college and you can't. Forward or the time to go to an obstetrician, you can't wait and you need something done. I offer non-member services. So there's different ways to, um, to generate an income.


And then also in terms of, you know, but again, you're not billing that through

insurance. I. So that's a good question. You're not billing the biopsies through insurance or do you bill them and then they can go after the insurance company for the, for the difference?

Yep. That's a perfect question and I really appreciate you asking that.


So, um, and that's actually something that I am working to clarify in my own, in my own area. Um, so if a patient comes in who's not a member of my practice, but they need something like a pap smear, I will charge them a rate. And so my rate is $50 for me to do to perform the pap smear. And all the services, there's that, it's a transparent price, um, in terms of what happens with the pathology sample that is billed to insurance.


And so a patient typically when they, when they're like, oh, that's it. I can get it done this day when it's convenient for me, and then you bill the insurance for everything else. Like that is a, a, a like no brainer in my area. 50 like, yeah, that's the copay. Yes, exactly. And so, um, that's, that's how a lot of, um, a lot of direct primary care practices who offer non-member services will operate.


And then even for members, members can have the choice whether, like, for example, labs so transparently, you know, a correct. Uh, C B C is less than five bucks, typically at a national, um, lab service, uh, company. Um, and so a patient. Can be told by their D P C physician. Um, if they're a member, typically your C B C is either $5 if you go here and you pay directly, um, or you can use your insurance and magically in the black box it will be translated to whatever the insurance company wishes to value that C B C at.


And so, you know, I've had a lot of patients who chose. Oh no, I'll just, I'll just do the insurance. 'cause that's our culture is just like charge that insurance card, just like a credit card and then magically. There's a number at the end, like a flu shot costing $184 for my son one year. And, and so we learned the hard way, like, well, we're not gonna do that again.


But for labs, again, going back there, um, my patients now are like, oh yes, vitamin D not covered by Medicare. I'm gonna go ahead with the less than $20 option for that one. Thanks. So it's, um, there's different ways to, um, Address that value proposition. But in terms of going back to the question of how do we make our income, there's ways to charge through membership, which is you have X number of members per month paying you on average this amount of money, and that's your take home minus your overhead.


Um, super simple, high level, you know, math there. Yeah.


Okay. Um, how does your patient population differ from your experience with taking insurance to D P C? Yeah. You know, are they, are they more or less educated? Is it higher or lower socioeconomic status? More or less demanding? More or less medically complicated or?

Pretty similar. Yeah. So what I would say is that that is exactly, I think the reason why Direct primary care is able to thrive in any community because the direct primary care physician, I. Their value proposition, no matter how they, you know, um, per how they personalize their D P C to their community, that will attract certain people.


So in my practice, a hundred percent of my patients are insured. In terms of my education level, it's all over the board. But in terms of the people who believe in my practice and who have joined, They understand that the nearest urgent care is 30 minutes away and you can't get there on Saturdays and Sundays 'cause then they're not open.


Um, and so there's practices who are in, you know, very, very heavily, um, corporatized. Uh, urban settings, but the availability of having a transparent rate and an, and, and an affordable rate for a college student or for a, you know, a parent who has multiple children. Um, the, the, the people who join. Really depends on who understands in that community the value of the direct primary care physician's model.


So there are practices where 60% are uninsured, there are practices where 60% are employed and it's their employer who provides a direct primary care membership for them. Um, it, it very much differs all over the country. And that's why in every episode that I feature a physician in, um, on the podcast, People can say, oh, that community's just like mine.


Wow. I didn't think that it could work in my community because of, you know, I have, uh, undocumented members in my practice who, you know, don't have health insurance, or I have, everyone has health insurance and they all have their, you know, I have really good health insurance plans. But yet they can't get into the doctor.


So that, that, again, that's the beauty of if you've seen one dpc, you've seen one dpc, and that definitely impacts the people who understand and, and believe in the model. Yeah.

I was thinking about the undocumented population because Right, they, they, they're stuck getting. Because they can't get insurance.


They're like stuck in what seems like an untenable situation. Yeah. And nowhere to go. And, um, and it, it seems like it would be a great, a great model for them in particular.


And I mean, you, there's, there's examples like Dr. Wendy Melaca in Wisconsin, Dr. Bena Mott in Michigan. They are taking care of undocumented, um, uh, you know, people in this country.

And there's situations where it's like, I. Well, I ran out of my insulin. How, how am I supposed to get insulin? 'cause I don't have insurance. When they, when their patients have come over from different countries or, you know, there's people like Dr. Dipti Mour who takes care of people who for six months they're in India and then when they come back they need, you know, somebody to take care of them.


And, um, that, that type of service is offered. Um, and then when you talk about. Just undocumented people. The other thing too is that even if you have, like in California, we have Medi-Cal, not Medicaid, but it's like there's, there's no access. I mean, like for example, even like in the summer of this year, if you're over 50, no matter who you are in the state of California, you can get access to Medi-Cal.


However, it's like, okay, you're over 50. You have Medi-Cal now as a benefit, whether you're documented or undocumented, but. You need a rheumatology visit, and the rheumatology visit is three hours away. You don't have the gas nor the car to get there, and it's also six to eight months away. So that's your healthcare because you're 50 and you now are a beneficiary of Medi-Cal.


So even with insurance, you know the, and I, I pointed this out to a patient. Even on the back of the insurance card, it says, this card does not guarantee healthcare. Because it does not, insurance is not healthcare care from a physician is healthcare care when you actually need it is healthcare, but care because you carry a card that we use, like a credit card is not healthcare unfortunately in this country.


How did you grow your practice? Like how did you get the word out? For people. Right. As you said, people have it in their minds that they just use their insurance card, like a credit card. Like of course I'm gonna run it through insurance because it has to be run through insurance. Like how did you start reaching out to people and going, Hey, hey, hey, this is a thing.


This is the thing that you will really. Appreciate if we do this together.


Yeah, that's a great question. So in terms of how a physician grows, how I grew my practice, one thing I will say is that no matter where you are in the states, you definitely have to be aware of non-compete and enforceable non-compete laws in your state.


So for example, um, in New York, there might be a different non-compete than there is in California. In California, they're non enforceable, so that. Impacts how a patient can learn about direct primary care from their physician if, if their physician is going to be going into direct primary care. So that is something for especially those early on in training medical students, residents, to keep in mind if they can negotiate out of their contract non-competes, um, or if they're in a state that's not enforceable or that where a non-compete is non enforceable.


It, it's, it's null and void doesn't matter. Um, in terms of. When a patient is learning about direct primary care and is attracted to and then joins a direct primary care practice, that's gonna differ depending on the patient and the location and the offering of the D P C physician. But in terms of, typically what happens is there's usually this threshold of a direct primary care physician will either open like Dr. Kissey Blackwell in Wichita Falls, uh, Texas, who opened 200.


How do you remember all these people's names? You've name dropped so many people from all of your episodes, like, I can't keep a person's name in my head for more than 30 seconds, and you remember everybody's first and last name and pronounce it impeccably.


I think this is, you could also be making all these people up. Are you making all these people up?

I, I definitely am not doing the latter, but this is how much. How much each one of those people is really impacting healthcare in America. Right? It's like they mean so much to me because they are doing this basic healthcare right?


For, I mean, not, they're not, they're that they're doing, but they're providing this basic human right is what I meant to say to people in their communities. Making such a difference every day and for a primary care physician, it just makes me so happy that I am able to be in the space with these people.


So that's for me, that's how I remember. I. Not only their, their names, but their stories. And so she opened Dr. Kissy Blackwell with 278 people on her waiting list before she opened her doors. And then there's people like myself, I opened with zero and grew from there. But in terms of how people grow, usually there is this threshold of word of mouth and around 50 patients, a hundred patients, then everyone's like, oh, everyone's telling other people about.


Oh yeah, I just texted my doctor no big, like, sorry, you had to go to urgent care for, you know, a strep swab when you could have done that for like $15 or something, or included in your membership. Um, and then people start, I. Be becoming the value proposition and the, the, uh, advertisement for your practice.


And so it, it really allows, again, it, it allows that autonomy from a physician, but then it allows the physician to just do what they need to do. Now there are markets like, um, the direct care physicians in Pittsburgh. It's a group of people who are physicians currently. They're all females. Um, Where they each have their own practices, but together they're collaborating to have a marketing campaign to, to be seen and heard above the offerings that are corporate in Pittsburgh.


But in terms of, you know, that, that word of mouth, that is typically how a direct to primary care practice will grow. And then how to get that word of mouth going. People do it all different ways. Um, they go to b n I meetings, they go to ch um, chamber of Commerce meetings. They just. Go into the local subway and tell the owner, Hey, like, if you're looking for healthcare, I'm open.

Um, in terms of my practice, I was very fortunate because I practiced for almost six years in my neighborhood. And so being again, in a medical desert, my patients who joined immediately, I'm, I, it was, it was very humbling because my patients all who joined in the first year were just like, I, I can't lose you.


Like I, I have, I have very much, um, valued our, our relationship as a physician patient. And I can't lose that because there, there is nothing else like this up here. And that was when I was in fee for service, which makes me so happy that they understood that this is even better than that. Um, at, at my private practice.


Yeah.

Have you had any proceduralists that you've encountered, like, like surgeons, like you mentioned the orthopedic surgeon, right? And you, you said not direct primary care, but direct care uhhuh. So can you, I know it's not in, in your practice per se, but what about some of these like higher cost?

Procedures. Yeah. Right. Do you, do you know how any of that works?


Yeah, that's a great question and so needed. Um, so the first example I love to say is that, you know, a family practice doctor, primary care doctor can be doing procedures left and right because you know that that might be within our wheelhouse in our training.


So, for example, circumcisions, biopsies, um, you know, colonoscopies, those types of things, even. Um, deliveries, like people in c-sections, people in primary care do those things still. Um, when it comes to specialists who are doing procedures, um, I like to highlight options like the, uh, surgery Center of Oklahoma and the Well Bridge Surgical Center in Indiana.


Those are places where literally you can go on the website and say, I need a. Colonoscopy or whatever it is, and you can get an estimate as to this is how much it costs. So when a person is open to, okay, my plane ticket on Southwest, plus the hotel on hotels.com, plus the surgery is still less than what I would've paid through using my insurance benefit.


I have the time to take off of work. Well, I'm gonna do that. Sure. So there are places where physicians are getting together and collaborating to say Yes together as specialists, we can offer a whole surgical center, uh, even as an option. So different types of surgeries happen at those surgical centers.


People who are doing things like neurology, endocrinology, um, rheumatology, dermatology, uh, let's see, what else? Uh, gastroenterology. Um, there's so many examples of where people are saying, okay, um, this portion of my practice, I can have either an insurance rate or a cash rate, or they're just saying, no, I just do all cash.


And so that really depends on how a person is, you know, using their skills in specialty care and where their patients are able to get access. If they, if they are finding that a cash price is what. Allows them to fill their practice, then they'll do that. If they're finding that, you know, because there are some hybrids out there that a patient will want to use their insurance for, um, for, uh, services.


They can be apart from a corporate, uh, location, but still offer insurance-based care. Um, oh, I, and I'm, I forgot to mention cardiology. That's also a big one where people are doing, you know, All, um, outpatient cardiology, workups, visits, all of that stuff. 'cause there's no accessibility and they're just paying cash.


So there's so many options and the the options are, um, are out there for any specialty. I mean, even vascular surgery. I was talking to somebody who's a dear friend and they were saying, Even if I just did the ultrasound review for people, just that portion I could be charging a cash rate for and have, you know, a, a very quick turnaround versus if they had to see me in the office.


And because that, uh, person is, you know, licensed in a state rather than. A county that service could be helpful for people all over the, the state that they live in. So there's, there's so many options. And this is where I really appreciate like you asking these questions because again, like your audience is the, the same type of people that we went to medical school with and it's like, we didn't learn this was an option in medical school and residency.


It was just, this is, this is your chart now you code it and then you go to work for a coding. Employer that that's the, this typical, um, the typical pathway that we take as physicians, especially in primary care these days. Well, and, and for that vascular surgeon doing the ultrasounds, you know, in a, in a large state or mm-hmm.


Maybe even not in a large state. Um, you know, you health insurance is local. You can really only take care of, like if you're reading ultrasounds for people that live far away, like I'm on Long Island, I can't be. I don't have any contracts in Buffalo, but I'm licensed in New York State. So really the entire state now becomes my catchment area in, in that situation, so, correct.


Really, uh, you know, it. It could work. It could work. Um, so you're available to your patients 24 7. Mm-hmm. Yeah. So how do things like vacation and getting drunk work?


Well, so I definitely am not a ladder. I, I the, uh, in the ladder group often. I, um, I don't think I've ever been drunk technically because I like will sniff alcohol.


I, it's so funny. I was with, uh, with a group of physicians doing a direct primary care, you know, um, Themed retreat and I sniffed the wine that they had at their wine, um, tasting, and I was, my eyes shut and I was talking like a sloth. So I don't do alcohol. But in terms of the 24 7 and vacation and just, you know, the idea of not creating another burnout situation, the beauty of Direct Primary care is that because it's a relationship based practice, patients.


For the, the majority of the time, and this is all over the nation, because I often ask this question of my own guess is that they don't, my, the patients do not have the anxiety of, oh my gosh, I'm not gonna get in for six months, so I have to ask all the questions right now, or I have to ask after hours because that's when I remembered.


And it's like, no, the, you. You actually have access to your doctor when you need them. So they are, they are very mindful and respectful most of the time that it's like my doctor, we gotta take care of our doctors so that they can take care of us. So they typically will, you know, like Dr. Julie Gunther in Idaho.


I mean, they're cheering her on if she needs to take vacation. My patients were like, oh my goodness, I'm so excited you get to go to Legoland. Because we were, we were go, we were gone in Legoland in August with my now five-year-old and now two year old, but they're very supportive. And then after hours in my practice, which has been open, open a little over a year, I've gotten three calls after hours.


One was for a cardiac concern, one was, excuse me, two were for cardiac concerns, and the third one was for, um, Something that was non-acute. But what we tell our patients is, if you don't know if you're gonna go to the ER or stay home, that's a great way, it's a great time to contact your doctor if you're like, this is, I'm having a cardiac arrest.


You know, we're not, some people do hospital medicine, but typically, um, The, the, the, the verbiage to patients is if it's a medical emergency, dial 9 1 1, like it is on any medical, you know, uh, reception line or message machine. Um, and the same thing holds for direct primary care, but it's if a patient is seeking guidance as to, is this acute or not to the point where I need to drive 45 minutes to the emergency room.


That's a great time to ask, you know, your physician, but that doesn't happen thankfully too often. And then even in things like covid, we saw direct primary care thrive as a movement because there wasn't the limitation in the, you know, spring about, oh, there's no coverage for telemedicine services. Direct Primary care is always incorporated telemedicine.


And so, um, we kept as, as a movement, we kept so many people out of the hospitals because we were able to say, Here's the pulse ox. It's like 16 bucks. Go ahead and here you can buy it, check it out, whatever. And we're gonna help watch you over telemedicine if we need to see you in person, whatever. But they kept people outta the hospital for covid.


Not to mention, like I, I mentioned the C H F, um, you know, example. But there's so many things because it's a longevity relationship and not just. Periodically, every few months you get seen. Um, that it, it's so powerful to have access and that's where patients don't typically abuse the 24 7 aspect because they can reach their doctor the next day if they needed to.


Yeah. But have you had any patients or even heard about patients from other D P C physicians that, 'cause some patients don't understand boundaries, like it's not even that they're pushing the boundaries. Mm-hmm. It's that they, that it's just something that they just don't understand and you can often see that when you're interacting with them.


Oh yeah. And especially in fee service, because too many times it was like, And I have my list of 52 items that I'd like to cover in my eight minute visit with you. And it was like the boundaries there. That was an exercise for me in boundaries when, when I look at direct primary care models all over the nation, yes, boundaries are absolutely something that a physician has to address.


Whether that be, um, you know, Boundaries where they're, uh, the number of hours that they're checking messages or how they're checking messages. But when it comes to patients who are quote unquote high utilizers, that's what we typically call a patient who is, um, really not respecting the boundaries set forth by the practice.


Um, a physician, you know, we are. As Dr as direct primary care and direct care physicians, we have chosen a different path than the typical going into employed medicine. And so with that, we have, um, we have an air about us in terms of we. Value ourselves. And so when it comes to patients who are, you know, making us feel uncomfortable, stressed out, overworked, all of those things, when we have a community where direct primary care physicians, I mean, if you go into a room of them, it's like, Where, like what Kool-Aid did people just drink?


Because this is crazy. Like everyone's so happy and the way that people protect that is one, seeking support from other people and saying, Hey, how do you manage this situation? If a patient will, like, if they're a night shift worker on the OB floor and they text at two 30 in the morning and they don't understand that, like, that dings your phone, then you know, typically the, the recommendation for most of us would be, yeah, and you gotta talk to that patient.


Say, hey, I am. A single show here, or I'm, you know, taking care of so many patients. Yeah.

Um, so you draw, so you draw that boundary, but then, um, ha have you been in a circumstance or have you heard from one of your colleagues where they've had to let a patient go? Oh, absolutely. Right. Like, okay. Absolutely.


So that's, that's another, okay. So it's, mm-hmm. Like, it's not like you've paid your money and now you can do whatever you want. No, correct. It's, I'm gonna warn you. And then clearly we've had this conversation if we have to have it one more time. Mm-hmm. Yep. You're off the panel. Yep. I'm sorry. It's just not working.


Yes. And people protect that in their patient contracts when they sign a membership saying that, you know, if these things happen, if abusive language is is happening, if you know, um, if. Whatever the physician sets forth is being done and you've, you've had a warning, then this is not gonna be the best fit for you.


Um, there are some physicians who, and they, they've shared this on the podcast, they'll, they'll say things like, alright, and so going over the patient contract before you sign onto my practice. You need to understand, I have two children and I go to bed at seven 30. And so if you contact me, you better have a darn good reason for contacting me after.


And that's how you know this is, uh, this is how one physician, she manages her, um, patient onboarding. Um, At the beginning of her practice, before the members sign on, because she is saying right from the beginning, this is my practice and this is how I run my practice. If you cannot respect that, you cannot be part of my practice.


And so that, that is very common how people, um, are setting those boundaries. Yeah.

Fantastic. Fantastic. Mm-hmm. So where can people find you? Let's say, let's say we have a listener who, who wants to be on your panel, uh, or they wanna listen to your, your podcast, they want to connect with you on, on social media.


Where do we find you? Yeah, so great question. Um, so the most common things would be, uh, with the, at my DPC story handles. So Instagram, I, it's at the. I guess generally my dpc story.com would be, uh, the, the branching point as to where to hear, uh, physicians from all over the country. Um, I have a mapper where people can click on their area and listen to episodes in that region.


Um, I also have a resource page where people can download completely free, you know, checklists as to how to open your direct primary care practice. This from nothing. Um, and then on the bottom of my website, I have all of the social handles. So just at my DPC story dot or at my DPC story would be, uh, where all of the social media lives on any platform pretty much.


Um, but my dpc story.com is probably the best place to start out. And then if people are podcasters, um, on all major podcast platforms, uh, you can find my D p C story, the podcast.


Fantastic. Fantastic. Well, it's really exciting stuff that you're doing and it clearly, you're an evangelist for it. Um, and thanks for all the work you're doing for your patience and for

medicine.


Absolutely. Thank you so much for having me and for helping spread the word about Direct Primary Care.


Next, we look forward to hearing from Dr. Mina Julip poll of Bluebird Dermatology in spring, Texas. If you've enjoyed the podcast and you haven't yet done so, subscribe today and share the episode with a 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 D P C stories.

Lastly, be sure to follow us on social media. If you're wanting to continue learning more about D P C. In the meantime, check out DPC news.com. Until next week, this is Marielle conception.



*Transcript generated by AI so please forgive errors.

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