Direct Primary Care Doctor
Dr. Haden, a dedicated Family Medicine physician, is proud to serve patients with a rich background in healthcare, education, and business. Born and raised in Nebraska, he embarked on his journey in medicine at Nebraska Wesleyan University, earning his Bachelor of Science. He continued his academic pursuits by attending the University of Connecticut School of Medicine, where he completed a comprehensive MD and Masters of Public Health program.
Dr. Haden's medical journey included 18 months of residency training at Georgetown/Providence Hospital in Washington, DC, followed by specialty training in Family Medicine at the renowned Mayo Clinic Arizona. As a board-certified Family Medicine practitioner, he has accrued years of valuable experience in both urgent care and primary care settings.
In addition to his medical expertise, Dr. Haden is a versatile professional who pursued an MBA while working as a physician. His entrepreneurial spirit led him to establish MobileMDs, a groundbreaking on-demand service offering doctor's house calls to travelers at hotels and resorts across the United States. After successfully growing this venture, he redirected his focus towards the restoration of the doctor-patient relationship through Direct Primary Care (DPC). You can learn more about Matthew's work within the DPC space through his DPC network - PURE Primary Care.
Beyond his medical and entrepreneurial endeavors, Dr. Haden is a world traveler and a connoisseur of diverse cultures. He has lived abroad in Egypt and Costa Rica and explored various corners of the globe, including Rome, Casablanca, Malta, Gibraltar, Montreal, Ottawa, India, Nepal, Mexico, Trinidad, and the Dominican Republic. These experiences have enriched his understanding of how cultural influences can shape patient health and treatment preferences.
In his personal life, Dr. Haden is a well-rounded individual who enjoys staying active, spending time with family, savoring a good cup of coffee, playing the drums, and embracing eco-friendly transportation with his electric car. Above all, he cherishes quality time with his wife, daughter, and son.
Dr. Haden's commitment to community and personal growth extends beyond his medical practice. He was honored as a 2015-2016 Fellow of the Leonine Forum at the Catholic Information Center in Washington, DC and has dedicated his time to volunteering with the Order of Malta Federal Association Auxiliary.
Choose Dr. Haden for compassionate, experienced, and culturally aware Family Medicine care, and experience a unique approach to healthcare that prioritizes the doctor-patient relationship.
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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 the time. their fingertips. Welcome to the My DPC 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 Concepcion, family physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care. Direct. Primary care.
Direct primary care allows me to be the doctor I thought I would be when I wrote my medical school essays about being a doctor. I actually get to practice the way medicine should be and the way I'm trained to without the interference of all the other bureaucracy. I'm Dr. Matthew Hayden of Modern Mobile Medicine and this is my DPC story.
Dr. Matthew Hayden was born and raised in Nebraska. He completed his Bachelor of Science at Nebraska Wesleyan University and then attended the University of Connecticut School of Medicine for a joint MD and Master's of Public Health Program. Dr. Hayden completed 18 months of residency training at Georgetown Providence Hospital in Washington, D.C. before transferring to the Mayo Clinic, Arizona, where he completed his specialty training in family medicine. He is board certified in family medicine and has worked for several years in urgent care and primary care while working as a doctor. He also went to business school and obtained his MBA to help in his entrepreneurial endeavors.
He was founder and CEO of MobileMDs, an on demand service for doctor's house calls, serving travelers at hotels and resorts across the U. S. After several years of growing that business. He decided to return his focus to primary care and restoring the doctor patient relationship through the direct primary care model.
Dr. Hayden has traveled extensively and even lived abroad for a time in Egypt and Costa Rica. Over the past 20 plus years, he has enjoyed the opportunity to visit Rome, Casablanca, Malta, Gibraltar, Montreal, Ottawa, several parts of India, Nepal, Mexico, Trinidad, and the Dominican Republic. These experiences have helped him to better understand how one's culture can influence health and the treatment preferences of patients.
Dr. Hayden enjoys working out, visiting family, drinking coffee, playing the drums, driving his electric car, and spending quality time with his wife, daughter, and son. He was selected as a 2015 2016 fellow of the Leonine Forum at the Catholic Information Center in Washington, D. C., and has volunteered with the Order of Malta Federal Association Auxiliary.
Welcome to the podcast, Dr. Hayden.
Thank you so much for having me.
This is such a treat. Uh, I am just coming back from a conference where I was able to, you know, get an update on what's going on in the Hill and you are right by the Hill. So this is fantastic. With regards to modern mobile medicine, we've heard a little bit of the story from Dr. Marguerite Duane, who's no longer with modern mobile medicine, but this is going to be so amazing to hear from your perspective as the founder of the practice. And another thing that I loved learning about you. was that you were born and raised in Nebraska. Anybody who's born and raised in Nebraska is like my extended family.
And so thinking about, you know, my own experience in Nebraska, being a doctor in the Midwest is very different. I feel sometimes than being in more urban areas. So when you were growing up in Nebraska as a kid, what was your doctoring experience like? What did you experience as a
patient? My own experience probably wasn't that different than other places with kind of went to the pediatrician.
I didn't have anybody medical or doctors in the family. Um, but I heard stories, you know, my mother grew up on a farm in, in Northeast Nebraska. And I heard stories about doctors doing house calls and her family paid for births at the hospital in Sioux City with chickens. You know, it was a bartering system of, they would pay, I forget the number, probably, you know, a few hundred dressed chickens to the hospital that they would actually use them to serve the patients and staff in the hospital.
So, I knew of a different, you know, Midwest kind of old fashioned way, but my own personal experience was kind of the standard coming pediatrician and I. It was instilled pretty early on of sort of respect and appreciation and a bit of reverence for physicians. My pediatrician, I was frequently reminded, saved my life.
I was born premature, and this was right when they were developing artificial surfactants or using bovine surfactant experimentally. You know, I heard those stories of you were in an incubator and I saw the pictures of all that, even though I didn't see him that much, it was, I knew Dr. Fletcher was this important guy's life and made a difference for me.
And he was always this old fashioned, gentle doc took his time. It was a different model then.
And I think that's so cool because, you know, our generation, it's not all the time that people in our generation hear about the home visit, definitely not the payment in chickens for having a baby. Like that's definitely not a, not a common thing that we, we in our generation here, but.
You know, I love that you experienced medicine in a, you know, traditional way, so to speak, but you also got this, you know, this is, this is what medicine could be. This is what medicine has been up until the point that like you're, you're, like you're saying you were born. When we talk about you growing up in Nebraska and then you, you know, you went to Wesleyan and then you went to the East Coast for your med school training, you decided to do an MD, uh, plus a master's in public health.
So what led you to go to medical school and did you specifically plan to go to medical school? To also get your MPH, or was that something that happened along the way?
Yeah, it, it was not a direct route to that. I went into undergrad thinking I probably would, wanted to go to medical school, but it was one of those things where guidance counselors at the time were like, you know, you have good grades.
It's like, Okay. You're going to be a doctor, a lawyer, you know, banker. It was like five occupations, right? There wasn't this breadth of, you can do anything in the tech world yet. So they sort of said, you know, why don't you think about physical therapy or medicine and just do the prereqs because, because you can, you can handle that.
So I went in thinking I wanted. Keep that an option. So doing the prereqs, but then I kind of got sidetracked because I realized some other topics really interested me and the one that stood out was sociology because it just kind of put a name to what I was always thinking about and wondering about and reading about, you know, in my current events and stuff, just picking up a news week or something.
So I really was struggling actually to discern what I should be doing. I also had an early entrepreneurial spirit with my siblings doing a lawn business in our neighborhood. And so I knew I kind of liked business if, if, you know, if you know what that means in high school. And so I was, I was really torn.
I wasn't sure I was going to medical school. So I was kind of keeping my options open, taking lots of courses from a broad swath of things. And then I was very fortunate to get selected for a new program at Nebraska Wesleyan called Global Service Learning Program, and it offered an opportunity to volunteer on a local, national and international level.
And it was really just a small core group of students working together with the campus minister and organizing service projects on those 3 tiers. And through that, we went to the Dominican Republic and we were there working with a physician who was trying to build a new clinic and that's where it just clicked that this is how I can combine everything you have to know about your community and you can actually solve some of your community social issues If people can't keep their jobs or progress in their, in their family lives, if they're knocked down by, by medical conditions or ill health.
So that was sort of the light bulb that went off was, was, Oh, I can, I've always been good at science, but the way I can apply that as to medicine and I can make a difference in people's lives so that their medical condition doesn't hold them back economically and all these other ways. Right. So that's where it clicked.
And it really doubled down on, okay. Forget sociology. It's very fascinating, but I think medicine is the way to put all this together. And I had taken some business classes to just to make sure there wasn't something that really pulled me in and it just didn't. So that's where it clicked. And through those various volunteer experiences, then I also saw how you need to.
Understand the community's health and the community's needs and that's where I started exploring the MPH aspect of it back, you know, pretty good Internet. They had a Columbia review and a number of books. They would just review all the medical school curriculums in the country. And while I was on a. A college tour of India and Nepal, I took that with me and just read it cover to cover.
I just looked at every single school and kind of got a sense of like what they're good at, what they're not good at. And UConn really stood out for being an early adopter of, you know, the old model was two years of school. I'm sorry, two years of books and you don't see any patients and then you get two years of patients.
UConn was one of the earliest to switch to like patients the first week during med school. That stood out to me, and then they offered the MPH for no extra cost, um, at the same time. So, that was my top choice, and I got in there, and I was very happy with it.
That's incredible, and I, I did not know that that was, you know, included if you wanted it type of thing.
Like, that's incredible, and I, I don't know if that's still the case at UConn, or if there's other But I wasn't going to pass up a free degree and I was envisioning, you know, I thought of being like a mission doctor going international. So I was trying to prepare myself to like, how do you do in a community assessment and investigate the problems of the community, design an intervention and measure if you're making a difference, right.
It ended up just really flushing out my medical education. You cover a lot of topics that directly impact the history you take on every patient and thinking about different risk factors. And yeah, it was great.
When you're talking, it makes me think about my experience at Creighton where we had these breakout sessions where we would talk about things that weren't covered necessarily in the books, in the lectures, um, that weren't necessarily pertaining to physiology, anatomy, when you're talking about, you know, this, this idea that you were thinking sociology for a bit, but here's a way where you can combine medicine, combine, you know, things that you had been interested in, in sociology that determine a person's health access, health outcomes, et cetera.
Thank you. Even if a, if a student in your class did not pursue the MPH, did UConn still infuse your lectures and your learning with always thinking about the person behind the, the actual anatomy and physiology?
Yeah, for sure. I mean, some of it was direct lectures from the public health department professors.
And then. One of the other things that I noted when I was reading that book of curriculums of all the medical schools was this new emphasis on the biopsychosocial model. And so UConn was definitely at the forefront of that. And so it was already kind of baked into the curriculum and then augmented by the fact that they had a school of public health onsite.
That's incredible. And for those people who are especially wanting to do DPC while they're in medical school, if they don't have a master's of public health available to them. What are some recommendations that you can make in terms of, you know, ways to think about your medical lectures or ways to think about your rotations or even resources that you might have for people to do their own, you know, infusion of learning about a community that they might want to open DPC in?
Yeah, I mean, there's so much information available online now that it can be fairly self guided, you know, there's something. He said, if you, if you want to work professionally in public health, like in the local health department, state health department, things like that, you probably needed a degree. If you're really just trying to take good care of your community and understand it better, you can just turn to your health departments and look at their data and their stats.
Kind of fast forwarding to now with my practice, I actually just studied the map and figured out where there was basically a hole without primary care and just put a pin down and said, I got to find space around there and part of that's, you know, business too, you don't want tons of other options or competition, but you can meet a need that's not being met.
So you can't just research what, what problems are going on in your community. You can get all the socioeconomic information. You're all of your state and local governments have lots of databases. And you can learn a lot just that way about your community. And that's getting out there and starting and people in their training, just what you did mention at the beginning of the question about students kind of thinking ahead as you're treating patients in medical school and residency, think about the barriers, what are the barriers and what keeps people from getting the care they need at all or in a timely basis and an affordable cost.
Just think through those barriers. And not spoil the story, but that's how I wound up in DPC was where, why is this also broken? What is the problem here? What is the barrier of my patients being able to get the care I want to give them and the care they need? And for me, I always return back to insurance.
Everything circled back to, well, insurance doesn't allow it. You can't have more time. Insurance won't pay. You know, that was always the hindrance.
And I think it's, it's so ironic that, you know, you're practicing now in a time where back in residency, like you say on your website, like you noticed that insurance was not the way to guarantee people access to good quality health care, to a physician who knows them, et cetera, et cetera.
Like all the value propositions of DPC. We're now seeing medical students really questioning that, just seeing, you know, what they're seeing in rotations. Like we even before residency and definitely more residents asking like, seriously, this is it. Like how come we're only learning about fee for service?
And so I love that the trend has been shifting to residents, even having practice management experiences where they're seeing, you know, here's what we do in our clinic, but you know, send you out into the community and see what else is out there. Physicians who. Thank Own their own practice doing fee for service positions who are doing DPC positions who are working in a homeless shelter, whatever it is, I just love that, you know, we're seeing more in people knowing that there's other models than just.
I show up as an employee and process my magic codes. And, and I also wanted to, to make a note here about who you're talking about, you know, reaching out to your local, you know, public health department or your local government agency that might have data here in Calaveras County in Northern California.
We had a health summit that was put on by our county public health department. And it was insane. The, the data that they do have, like when we're talking about doing. Market research. I love that. That's how strategically you chose to practice where you are. Also, it's, it's backing up, you know, Dr. Felesky's argument that he mentioned in his podcast episode that, you know, you can open DPC anywhere.
And especially me coming from a rural environment, that's absolutely an area where you can thrive. Your, your interviews coming off the tails of Dr. Stephanie Phillips, who's practicing in the poorest. community in Georgia and she's thriving like crazy because people need access to good quality healthcare.
So with that, I want to go back to your residency years. You were at Georgetown Providence hospital for 18 months in DC and then you transferred to Mayo and Arizona. And I wanted to ask you specifically because that, that experience is fairly unique. Usually people like go to residency, they stay there.
Some people like Dr. Adam Schulte, you know, they, they switch gears. They weren't aiming, aiming towards family medicine. Some people like Dr. Jana Rebus, they're going towards surgery and they switched into family medicine. But for you, because you transferred in after already being in a residency program, how did you look at your experience differently?
Given that you were at another, the Mayo program. And you had experience under your wings, plus you were, you know, very aware of the social determinants of health care in both communities.
I really am grateful for that combined experience. I think it was a perfect kind of pairing to get inner city medicine with lots of pathology, low resource setting and learning how to work in that environment, low resource for us at the hospital and our clinic and for the patients.
So just how to get by when you don't have a functioning team of support team. Are really having to do everything yourself and then understanding how to work around people's limited options for treatment or even diagnostics all of that factor. So that was a great environment to start my residency in and then transferring to the middle clinic was sort of the other the flip side of that coin that it was extremely organized.
So I went from low resource disorganized, And I'm a very type A person, so that was kind of driving me up the wall a bit, um, trying to work with, for example, we just, in our clinic, we couldn't get a medical assistant, you're, you're waiting for your people to get rooms and you're sitting in the back in the conference room where all the residents are.
For, like, an hour, just waiting for your patient to get you can get started with your session and just being so mad about that, like, and not being not be able to really control the experience of your patient. You know, I had, I still remember a very, very nice elderly couple. Who were apologizing to me that they were going to leave the clinic because they were just sort of tired of all the delays and disorganization.
So we don't really want sort of the clinic experience anymore. We're going to go down the road, but we love you. We're sorry, but we're leaving. Going from that environment where you had really high quality physicians, really driven to helping people, but being sort of disabled by the system, you know, being inhibited by the system.
And then Mayo is like so organized, you know, to a point that some patients complain, it's like a cattle call or something that, you know, it's like here, here, here, here, here, but it does have its benefits of just making it very streamlined and efficient for people to get care. And having fewer chances for thing for communication to go wrong or handoffs and just the patient experience is actually much higher that way.
It was a 2 edge sword, though, because when you leave Mayo, nothing ever functions like that. And so you always had a benchmark. They're like, why can't it be closer to this? And it, you know, even my own practice, I'm like, why can't I get back to that type of efficiency? But yeah, I loved having both experiences.
I got tons of obstetrics in DC, not as much in Scottsdale. It just wasn't a high volume. So I had a very balanced experience that I'm super grateful for.
That's awesome. I think though, even, you know, with your experience in the two different environments, you mentioned on your website that within five years of completing training at Mayo, only one of your residency colleagues, and I'm assuming that's from your Mayo cohort remained in family medicine and everybody else.
Who was in primary care went to ACO management, bariatric medicine outside of insurance. They weren't doing true primary care, even with seeing what it could be at a place like Mayo. So tell us more about, you know, what, knowing your resident classmates and knowing like what they experienced, what was it that kept you in family medicine?
You know, at the time it was happening and, and I kept seeing my colleagues drop out of primary care. We, we talked a lot about burnout. That was the only term we could, we could apply at the time, but now we know it's moral injury. Right? And in, in retrospect, it was moral injury for all of them. That's, that's what happened is you had highly educated, highly capable, highly motivated physicians, straight outta residency, who can't do the work they trained to do.
They, you know, they invested their, their blood, sweat, and tears and time. Into that, and they really wanted to help people, but the system doesn't let you do that and it's that constant struggle of, you know, most people out of residency take a salary job, right? Because we have debt. You need to start making some money.
You'd have some benefits. That's the logical transition. But that makes you a cog in the wheel. And so you go from being protected in residency from most of the bureaucracy of insurance and coding and all that. You play your part, but you don't, you don't know the whole picture. You're sort of the. The frog in the pot that's being slowly heated up and then after residency, you're the frog out of the poppy and just thrown into the boiling water and it's an immediate shock of how broken the systems and people try as best they can to fight through it and provide the type of care that.
They envisioned they would provide and that their patients deserve, but they, they really can't do it. So within five years, they were essentially pushed out. And I'm glad they borrowed the term from the military of moral injury, because I think that's so much more suitable than burnout. Because burnout, you know, these managers at big institutions now just are trying to help doctors cope with burnout and be stronger and more resilient.
We don't need to be more resilient. We need to be able to do our jobs the way we want to and the way we're trained to. So yeah, that was the context was everyone was kind of dropping like flies. And these aren't weak people. You know, these are people that just. We're working 80 hour weeks and, you know, working 30 hours straight.
And these are not people that would cave. Right. So that was very disheartening. And I kept going because I didn't get into that system right away. I deferred joining the machine. I took a little sidetrack, I had taken a month during residency, just kind of created my own rotation going down to Costa Rica and learning medical Spanish, rotating through various medical departments in San Jose, at different hospitals, and just learning about their healthcare system, kind of from the public health side, but also directly clinically how they approach it, how different it is.
And door while I was there, doors were just sort of opening and I, you know, I wanted to practice internationally at some point. And when those doors were opening, I decided to pursue it straight out of residency. So, that was my little sidetrack was trying to open a clinic and I decided on HACO and being a tourist destination, I could have some tourist urgent care.
And then there's lots of expats that live around there, plus the local population. So that was a goal, never fully happened, but I worked on that for a few years and then realized I was being led in bureaucratic circles as a polite way of saying, you're not going to get a license here. They have great primary care.
They don't want competition. They have an excellent primary care set up in their country. If I was an ophthalmologist or neurosurgeon, I would have been working within a month, but they were, they are getting already getting primary care docs from Nicaragua and Cuba and other countries. So they didn't need an American primary care doctor, but that was, that was my little sidetrack.
So, you know, a few years trying to build that up and just working urgent care to, you know, going back and forth, work some urgent care. So I didn't get the moral injury that others had. It's so interesting because, you know, everyone has their threshold of like, I'm, I'm done and everyone decides, you know, whether they're done with medicine or they're done with fee for service medicine or, you know, whatever they choose to be their path.
But it's so interesting because. I think about how, as you're talking about, like you weren't exposed to the same level and extent of moral injury that your co classmates were. It really can make a difference. And I say that because as we're all practicing DPC, those who are like, sure, like I'll do a talk about DPC or sure, I'll, uh, I'll have medical students rotate with me, whatever, you know, it really can be like, it can make such an imprint on somebody.
And it can really be a, you know, a grain of hope in the hell that's out there when we're, you know, facing nothing but fee for service in a lot of clinical experiences. Now, knowing, because, you know, I'm, I'm cheating here, because like, I know more about you probably than a lot of our audience members, but You got an MBA after you had your MPH and just thinking about what you shared about, you know, you and your siblings have this lawn business, you liked entrepreneurial being entrepreneur, entrepreneurial, but it wasn't like, I'm going to do just business.
I, you, you lean towards medicine, you saw, you know, how medicine was done overseas. You saw how medicine was done in DC and then in Scottsdale. Why did you pursue your MBA and, and part of that question is, did you do it specifically so that you could open up a clinic in the States? So the answer to the last part is yes.
I didn't do it with international work in mind, um, although I'm sure it would help to agree with that. But when I, when I realized Costa Rica wasn't happening and I, all throughout my training, And maybe you heard this too, but I had heard from attendings or from legal, you know, when they have legal lecture and stuff that just doctors are not good at business.
And that was like a repetitious theme of doctors, not good at business, doctors, not good at business. But being good at business is what could allow us to deliver care well, you know, instead of having non physician MBAs setting up the practices and how they run and, and not understanding it. Thank you.
What we need is, is mostly time with patients, you know, that's a priority over all other productivity and measures. You may have patients want time with us and we need time to do our work. So, it just kind of made logical sense to try to shore up that side of my knowledge and I was getting a sense of. I don't have enough to go off right now to launch something to to do a well, I had looked into it with some residency classmates and it's a daunting task, you know, just.
Regulatory wise alone, I'm just trying to put all those pieces together, let alone trying to think about marketing and branding and messaging and how to price things. You know, there's so many factors to it. The AFP, I think, continues to have a manual about launching your own practice. Back then it was a little, a spiral bound notebook that was pretty good, but it was so focused on insurance credentialing regulatory stuff with Labs and it was sort of just molding you into what existed and I knew that wasn't going to work for me.
It just wasn't going to apply. I'm fairly entrepreneurial and and and risk tolerant, but then there's a there's a level where. You just want to be better prepared. So going to business school just makes sense.
So thinking about how resources are today for people interested in DPC, I think about how, you know, there's checklists out there where there weren't before, like you're talking about this little spiral bound notebook.
To which I laugh at because I'm like, we had so many paper based things before we had, like you're saying when the internet was not as it is today, but I digress when we think about the resources out there and that people are much more aware of, you know, marketing challenges, how they've overcome them, things to do to have a more successful marketing campaign, you know, ways people approach pricing, hiring other people, joining other practices.
Do you think that an MBA is absolutely needed for those who are interested in doing DPC? No,
no, not at all. I think, you know, for some, it's a good fit. I had a good experience with it and feel like it, it gave me what I was looking for, but you absolutely do not need an MBA. There's so many more resources now, like you said, that are free and you can start from from scratch or you have that foundation of what others have done before you to lean on.
And then I think the other piece of it you kind of touched on was like how to hire people or bring in partners and stuff that really is a lost art because private practice is dying. So trying to get information from older docs of how they set up their groups and how they had a partnership track and.
Just what the actual mechanics are, it's very hard to get that information out. Everyone who's, who did that has retired or sold their practices for the most part. I have been picking the brains of friends from medical school who went into other specialties, you know, ENT and things like that, but they are still in able to stay out of hospital ownership and they're not employed physicians.
So I think that's another piece of this that realized was going to be so, so like such an unknown and so closely guarded working urgent care. I got to take care of a broad swath of people. And some of those are old docs. And I would just try to hit them up for advice and say, Hey. You know, what would you mind sharing?
What's your partnership agreement? Like, how did you structure things? And the few times they said, oh, yeah, I can provide that. Just call our practice manager and let them know you talk to me and practice manager. Shut it down real quick. Did not want to divulge any specifics. We're not sharing documents.
So, anyway, a little side track, but that piece of it is kind of. Is touching because you want to be fair to your colleagues, but also there's a way to do it and doctors are not good at business. They don't understand overhead and all the things behind the scenes that are expensive and they don't realize how bad they were getting ripped off in the insurance world.
So, most stocks and stats I read were if you're in the fee for service insurance world. Your take home is about 5 to 10 percent of your bill of revenue. It's miniscule, miniscule, right? But you don't see the numbers for the most part. People have no idea.
So you totally don't. Like I, sorry, like I, I get, I was just having this conversation with somebody.
And, you know, there are some fee for service clinics out there that won't even let you know how many people you have on your panel. So you can't even, you can't even try to estimate sometimes what you're even bringing in. Yeah. And then, you know, the, the strategy that I love, I say that so facetiously where it's like.
CMS is going to raise the rates for primary care, and then the company is going to take their cut, which happens to be bigger than what they took before. And you come out as a primary care doctor making less than what you had prior to CMS raising their reimbursement for primary care. So please continue though.
Yeah, well, so all of those things just. Or are more readily accessible to people wanting to start now. So I would reassure people if, if you are considering going into direct primary care and starting your own thing, it's doable. It's not easy, but it's definitely doable. And you have a stronger, easier foundation now, and it's a very collaborative community.
Everyone wants each other to succeed. There's different ways to slice this and, and some different camps get very opinionated on. How it should be done, but you can make it whatever you want it to be for yourself and there's going to be people to support you. So it's all surmountable and just head and shoulders above and better than being in the insurance world, especially being employed by a hospital system in particular.
And I definitely would take a moment here to encourage people, you know, in California, we've brought to the CAFPs attention, like there's nothing on the website for people to learn more about the idea of direct primary care, the business model of direct primary care, who to connect with. If you're wanting to talk to someone about direct primary care, that's something that, you know, whether you're in Wyoming or Florida or wherever you're at.
You can reach out to people who are with potentially a bigger audience and ask them like, Hey, like, where are the resources for DPC? The AFP has had, I believe since 2013 stuff on their website about them. You know, the AFP supporting DPC and whether or not you're a member of the AFP. I just say that because, you know, there's some national recognition of what we're doing.
There needs to be more, for example, the AAP doesn't recognize DPC as an, uh, as a model of. Delivering equitable care. We've had that discussion time and time again with the pediatricians who've come on to my D. P. C. story, but. Um, you know, if there is, check your, your state website, whether your internal medicine or family medicine, et cetera, and see if there's any resources and reach out to the leadership and say, Hey, like there's, there's a whole bunch of us, you know, out here in the country.
I was recently looking at data that showed that, and this is just a subset of data that DPC practices had grown, I believe it was like over 800 percent in a very short amount of time. I would have to look at, I'll link that to your blog. That accompanies this podcast so people can read the data specifically.
But it's so interesting that we are definitely talking amongst ourselves. We are definitely supporting each other with that. And going back to this whole idea that, like, you were trying to get as much information from group practices and whatnot. One of your First entrepreneurial journeys in medicine specifically was opening mobile MDs.
So can you tell us about mobile MDs and also how you got people to join?
Yeah. Well, so mobile MDs kind of grew out of my Costa region, Costa Rican adventure. Because I planned to do house calls there. It just made sense to me to be able to go around that area and do house calls. And then I reconnected with a residency colleague from Georgetown who happened to be doing house calls in Washington, D.C. I told him what I was up to. We hadn't, we hadn't spoken for years. It was, you know, just a Facebook reconnection. And I heard what he was doing in D. C. was seeing people at hotels primarily. So just travelers health, but through house calls. And so that's interesting that I was gonna do the same thing, but in Costa Rica, it's not working out right now.
So I'm, I'm probably going back to Phoenix, Scottsdale. I would probably do the same thing there and just give it a try. And we stayed in touch the more we started talking about it. I was pursuing the MBA. I thought, you know, this. There's legs here, this can be something and basically kind of drew up the idea of.
Pulling in current house call physicians who are already doing this in major cities, and let's network together. So that we have a coverage in major cities for travelers. And then the trial insurers. We're not health insurance actually pay very well. They actually reimburse well, they're just generally happy.
You didn't go to the ER, so they actually reimbursed well enough to sort of compensate for that trade off. If you're not in a practice in an office, seeing, you know, multiple people generating revenue, you have to charge more for a house call that eats up that time, you know, or you're not going to get people to do it.
So it basically works. The foundation was, was reaching out to these travel insurers and letting them know we existed. And then every time I can say this now, because everyone does business puffery, right? You have to sort of inflate your abilities and embellish a bit to grow. So I was actually at AFP scientific assembly.
I don't think it was called FMX yet in DC in probably would have been 2012, 2013. I forget the year and Monique from Quebec, my main contact for these travel insurers called again and said, Hey, you have a doctor. In I think that time of San Francisco and then next to Chicago and every city, she would ask if it's a yes.
And then I frantically search on my phone and find a house call doctor and contact them and say, hey, will you take a patient from me? They're ready to go, just teed up and here's your fee. And it was universally, yes. I mean, all these household doctors want more business. So I grew it into a network that way, just by cold calling household docs and saying, Hey, I'm a doctor too.
This is what we're doing. I can send more patients your way. And so by the, at the peak, it was about, it was about a dozen physicians kind of scattered across the country. You know, low volume. It was, it was sporadic for them, but we, you know, rising tide lifts all boats. So we were all benefiting by just having a loose affiliation.
So they were 1099, just independent contractors. They weren't hired, but by having one contact with the travel insurers, then we can kind of negotiate rates because they like, you know, to call one number and not have to search themselves. That was, that was their priority was just make it easy for us.
That's awesome. And. Just thinking about the space of doctors working, you know, generally under the same model, but all over the country. How did you manage something like an EMR? Did you have one EMR that everybody would jump on to or?
They kept doing what they were doing. So they, they kept their own practice independent and had their own setup.
I think actually we did get malpractice to cover per visit, we had to get a specialty Well, practice policy, and those are hard to come by now that company actually has gone under. It was based in California and ran out of reserves and was shut down by the insurance authorities out there. But everyone was doing it the way they wanted to.
If we just kind of had a set template for. Specifics that the health insurer might want for like level of visits and, you know, things like that. Just a simple handwritten.
That's incredible. And just thinking about other doctors in the country doing this model, like I think about how DPC doctors, we all have our whys.
Did you pick up some of the whys as to why these people were not in fee for service? Why were they were doing the home visits before they even joined on with mobile MDs?
Yeah, most of them were mid career as opposed to kind of fresh out of residency like I was. And it was the reason why we all get into DPC, you know, the system doesn't allow them to practice the way they want to practice.
And it's just, you feel torn, like to take care of your own family, you have to move faster and have brief appointments and sort of be on that treadmill, but you don't feel good about that. At the end of the day, you feel completely. Inadequate is the wrong word, but ineffective at what you wanted to do.
Right? And it leaves you also a night worrying. Did you miss something? Is something to go wrong for my patients? Because I was moving too fast or I just couldn't take the time. And then, you know, I dabbled in the insurance world, helping a practice after residency. It was also just the feeling of like being pitted against the patients by insurance, you know, like we have sort of a set time limit for the appointment and the patient thinks that's driven by us that were money hungry or just don't care.
And it's just a necessity of how to keep a practice open, you know, you have to keep moving quickly. So, mostly, most of the people that are doing house calls are often. Mid career, had enough, want to get back to the basics and the doctor patient relationship.
So cool. And when you talk about that everyone was a 1099, I want to ask about how you helped everyone, you know, collectively get more visibility in their location.
So how did you, especially with your MBA training, look at marketing for everybody who was involved in mobile MDs?
Yeah. So we did a few things. One was. Requiring everyone to do a background check just so that we can sort of have that tag on our website that everyone, you know, if especially where we were catering specifically to hotel and resort guests.
And so to send someone into a hotel room, you know, they're a little skittish about it or hesitant and never had something like that. And we wanted just to have that reassurance that we can provide to them that everyone's gone through a background check. You're not getting any. You know, shady docs that are only doing this because they got pushed out everywhere else, you know, so that was part of it was like, we want to be trusted and verified.
And then for each practice, we offer them, you know, marketing sort of branding to put on their website that they're part of this network that they are, you know, have passed the background check and all this sort of criteria. That was sort of the main extent of it for them. And then otherwise it was working from the top down of just trying to get more travel insurers involved.
And committed that they knew they could rely on, on this network.
That's awesome. And in terms of trademarking, did you, like when somebody was working under a 1099 and then had like the copy for mobile MDs and the logo, was there any. franchising at all, uh, involved, or?
Yeah, we thought about that, but there weren't any existing, like, good models of successful franchising.
I think franchising just sounds like a dirty word to doctors. Like, it sounds somehow cheap, like it cheapens it. I don't know. People picture Denny's when they think of a franchise. We didn't go that route. You know, I thought about it, even with later endeavors, I thought about it, but It's, it's sort of a barrier, it's like a non starter for a lot of people.
Totally. Especially when you think about, you know, the big corporations that employ a lot of us prior to opening DPC, they have Super Bowl ads and billboards and you know, it's like they just pop up everywhere with these massive buildings and it's like the idea of being with something that's so impersonal, I feel also really impacts that word franchise.
So let me ask you now. Because you went back from, you know, the Scottsdale area to then going back to DC before opening Modern Mobile Medicine. So what was it that made you go back to DC versus practicing in Nebraska or the Midwest or staying in Arizona?
Yeah, well, so I was running the business side of mobile MDs and doing house calls in Scottsdale and the Greater Valley around Phoenix, but my co founder was out here in DC.
Time zone difference, trying to do meetings and stuff. It just was really slowing us down and making it hard to grow at the pace we wanted to. So I had always loved DC. I didn't think I was going to move away during residency. It just, it just happened that that was the best choice at the time. You know, I just grew up in the Midwest and went to the Northeast, down to DC or the Southwest.
I'd seen a lot of the country and DC was still one of my favorite places. I love the international aspect of our community traveled a lot. I've been fortunate to travel a lot in my, uh, even at a young age, just even through college. So I learned the value of diversity and just enjoy being around a rich environment of lots of languages and foods and all that, and I have, you know, political interests of current events and, you know, a growing awareness of how.
What happens in D. C. affects all of us. So, it was an easy decision to just come back. We needed to communicate better, I liked the city, it was just time if we're going to give this a go and really push it and try and grow it, I needed to come back. In the midst of that, however, the house calls we were doing, you know, it's sick visits at hotels and resorts, and there's no continuity.
So, On the one hand, it's interesting. You get to meet international travelers and people from all over, but the flip side is it's mostly after hours, people like save their complaints all day long, do their touring, do whatever they want to do. And then they wait till nighttime to reach out. And so it's, you know, lots of overnight earache evaluations and strep throat.
A lot of it was like flight attendants who have just gotten off of flight at late at night and. We're feeling miserable the whole flight and need to be cleared about whether they can fly or not the next day. So it was taxing too of just basically being a mostly a nighttime job and I missed the conduit.
You know, I'm a family doc at heart. The urgent care is kind of gratifying to fix things quickly, but I missed the conduit. So before we shut down mobile MDs, I was actually starting. And we're, we had pretty far along the planning for having a direct primary care branch of that for local conduit starting to offer house calls for direct primary care.
It was nice to direct primary care. The membership model kind of just bubbled up around me, you know, during residency. As I've told you before, I knew insurance was not the way to go and that that's what was brewing this dissatisfaction amongst patients and doctors and just breaking primary care. I had explored lots of options of looking at whatever examples I could find, just hourly billing or there was actually a doctor in Phoenix.
Who had a chest timer in his room, so he'd walk in and hit things and start the start of the clock and you only pay per minute so you can, you know, that was his way of making it fair that you can have as much time as you want, but that's how we're going to do it. So, there was various things that I had lots of spreadsheets trying to map out, like, what would I need to charge?
What I do kind of mimic the level of visit. I was, I was exploring lots of just modeling lots of things, like, how could I make this a viable thing? And then. Suddenly, direct primary could load up that, oh, membership medicine like Netflix. Okay, that's easier. Let's do that. And then it's just a perfect, it's a lion's incentives, right?
So, and it takes that element. Patients have been, have grown distrustful about the finances of medicine. You know, I heard patients, you know, wondering if they're being called back into the office just so they can get billed for, but back then the answer was kind of yes, because we couldn't get paid to review labs by phone.
That's a lot of primary care. We interpreting and explaining labs is a huge chunk of what we do, but it's unpaid if there's no code for it. Right now, things have changed, but back then that was a huge. Investment of time for patients that was not paid. So we had to call people back in just to overlap or just to discuss things that have nothing to examine, like their insomnia or their mood, you know, so many primary care topics do not require in person care, but we had to do it to keep place open.
It was just an immediate gratitude for people coming up with this simple. Monthly subscription fee and then if I'm calling you in because you, I need to see you, it's, there's no additional pay. It, it just, it purifies the doctor patient relationship that you've put me on your little salary per month as your contribution and I just get to take care of you and forget all that.
And you're not wondering by voluntary motives, it's, it's just about what's right
for you. Love it. And let me ask you here. We're at the scientific meeting that you mentioned as you, you know, were involved in mobile MDS. How did you come to learn about direct primary care specifically?
I believe that's a good question.
I mean, the earliest summit was organized by FMEC. So I imagine it was probably from Larry Bauer. Or just online reading, uh, I'm not sure exactly where I first came across it, but I heard early on about that first summit and I attended it. We actually had a mobile. We were a sponsor. If you go back and look at the program, um, mobile was a sponsor because we were recruiting.
We had a booth at, um, scientific assembly in San Diego. And then had a booth at this at the 1st direct primary care summit, and I'm trying to. Convince people, like, this is a viable model and you should think about doing it with with house calls.
It just makes me so happy to hear that because that's years ago and you're still killing it right and we'll get into pure primary care because that is definitely, you know, something that I love has manifested I'm assuming out of all of the experience you've had already, but focusing on modern mobile medicine first.
I was going to ask you, you know, who, who is your ideal patient, but what it sounds like is that your ideal patient was the person who values you as a physician and values having a physician who cares about them versus like, I would like to take care of this particular demographic.
Right. And it's patients who really put a prioritize their convenience, you know, that's who's looking for a house call.
So, my sounding board as I was designing my practice was my sister who has 9 kids and constant rotation of running back and forth to the doctor, you know, whether it's urgent care or the primary care doc. So, I was really trying to make it super convenient for families as a family doctor, and I didn't want to be a geriatrician, you know, when people think of house calls.
I often have to keep explaining to them, it's not just for old people, this can be for everyone like it used to be. So I designed it with that in mind of trying to make it very convenient and economical and, and, you know, valuable for families with children. And then additionally, you know, anyone else who values that convenience, right?
So I strategically market to families, but I, like any other direct primary care practice, to attract people who value. The doctor patient relationship, the time they get with you, that you're not a referralist. You know, when you're in the insurance world, people come in with their list, and what do you, what's your first thought?
Your heart sinks, you're like, oh crap. There's no way. Or, or even worse, you do the whole visit, and you grab the doorknob, and they bring out the list. And then they're trying to start the visit over again. So, people who have, who need additional time, attention, and don't want to jump around the way you, you have to refer people in the insurance world, that's who comes out.
So, one hot button for me is the criticism that frequently comes out in JAMA and, and other articles criticizing our primary care is that we're going to cherry pick all the healthy patients. That is a farce. That is absolute fiction. We attract train wrecks. Because we can slow down and figure them out and provide them actually time and comfort and compassion, as opposed to someone who just says, Oh, crap.
Okay, go see nephrology, cardiology, endocrinology. You know, the radar system divides up their care, which is well studied to actually lead to worse outcomes versus having a core primary care doc handling as much as they can. So I attract train wrecks and I like it, you know, instead of cringing. It's super gratifying.
It's challenging. You know, you actually get to like dust off the cobwebs of things you studied years ago and, um, learn new things. I'm always learning. I have time to research things. I'm not up to speed on or or have forgotten. So I actually have that time to be, you know, the studious. Physician, but I think we all need to be, you know, continuing to continue an education continuously learning.
You're always assuming the regular system. There's no time to pause for totally. And, you know, I'm, I'm right with you because when people say, Oh, you're concierge medicine. Oh, you're, you know, you're cherry picking all those. It's like, you know, I, I give it. So much praise to Dr. Emily Silverman. She is the host of the Nocturnist podcast, internal medicine physician who wasn't really sure what DPC was.
She came to the conference and I want to say Kansas City in 2022, um, the DPC summit. And it's like, if you're, you know, if you're writing for these publications and you're like. But I, I also think the DPC is concierge and it's cherry picking come, come to DPC summit, come talk to any one of us in our clinics and you will see that everything that you just said is so true.
And it's like, where is the zooming out of, wow, when we really piecemeal everyone's care, just like you said, you know, you have to see that. Like, you know, I have to, and I'm sure you do too, we have to remind our patients, like, you actually don't need to see the podiatrist for your callus to be removed. We actually can do those sorts of things.
We can take care of a lot of things, like you said, though, when we have the time. So, yeah, I definitely challenge anybody who might be listening and writing for those journals, like, you know, check us up. We are literally breaking. All of those fallacies that you just said. So
love it. I frequently mentioned that my first patient to find me is still with me.
And she is by far the most complicated patient I've ever taken care of, both medically and socially and all the economic issues and everything going on. You know, there's definitely no charity picking going on in your primary care. People who are healthy and don't want to see the doctor don't sign up.
They don't come to us. It's people who need care, value care, and are going to use the service. So, I've devoted hundreds if not thousands of hours to my first patient at this point. And she pays me what she can. She sometimes pays me what she can. So, I'm a little sensitive to that criticism of cherry picking.
I think it's just garbage.
And like you're saying, you know, no matter what your patient is, what background they're coming from, and this speaks so much to your, you know, interest in knowing about communities and public health, but it's like, like you just said, like, you have a patient who might not be at the level of payment that other members are.
Or they might be healthy and want a doctor when they need that doctor who knows them, or they're a person who has multiple issues that nobody can figure out. DPC allows a space for every single one of those people, no matter, you know, who you are. Most of us on our websites, it's just like, this is how we practice medicine.
I mean, on your website, you said, this is our philosophy. It's like, if you understand that you understand. What dpc is and so again, I'm being that dead horse because I totally agree with you when you opened you were completely mobile and then you eventually got a space for patients to see you at so at what point because I have this conversation with Dr. Cindy Rubin over dinner and we were talking about how Like I also opened as mobile, uh, home visit and then telemedicine only without a space. For me, it definitely limited how many people I could see in my practice. And Cindy was saying the same thing. So when did you decide that a space was going to be helpful to your practice?
Not enough people knew I existed, so I'm kind of curious how you got started to and got numbers because no one was googling for house call doctors. Like, no one knew it was an option. If you're not on Google Maps or elsewhere with a physical pin that would come up and search for primary care or otherwise.
No one knew existed. So I was trying to build up not getting numbers. And figured, well, just having a place to hang my shingle and have a dot on the map would help. So I started off with just renting, it's a, I'm still in the same building for now. It's a wellness center that lets different practitioners rent suites.
And so we have like lots of massage therapists, acupuncture. Psychotherapy, colon hydrotherapy. There's a whole broad mix of wellness oriented professionals. Right? So I just rented like a half day once per week so that I can be listed there and then it started growing where people are signing up. There's sort of 2 drivers to getting the.
Adding more hours there and more, more availability was some people are signing up and didn't want me to come to their home for whatever reason. And that, you know, people's preferences are private or, you know, embarrassed how messy they are for whatever reason. They just only wanted to see me in the office.
So I went from 1 day a week to then 3 days a week. And then I also had a corporate contract and those folks can live anywhere and households couldn't be offered to. So they had to come to me or I do on site care. That was sort of the impetus to, okay, I need to have more availability. So first I started with every other day and that was working pretty well.
And eventually I just booked a suite for every day of the week and then added a 2nd room when I got medical assistance. We have a triage room and can kind of start the process there. So, that was my story. How did you gain awareness and get patients when as house calls and telemedicine only?
Yeah, I definitely love the question and I am very grateful and very lucky that I had a presence in our community, a small community before I opened.
And so the people who joined, you know, I, I say 80%, but I, I should go back and look at, you know, the, the people who joined in the first 3 months, how many of those were my former patients, like, Majority, if not 80%, maybe more than joined my practice because they were like, we can't lose you as our doctor, like you specifically we need.
So what is the investment that we need to make so that we can continue having you as our doctor? And then I've shared this in, in other podcasts, but I literally like had a patient who was Shouting from my porch in front of the post office to people in the town about like, joining the practice. So it's like we, it's a very different situation than like, I think about, you know, your, your locale, the direct primary care physicians of Pittsburgh.
Like they're, you know, competing with the billboard, uh, companies. Like, it's very different, Arnold, California. But I will say that in terms of, You know, getting the word out there, especially in rural America, like, if you don't have a presence and you're wanting to move back home and your home happens to be rural, you might be known because.
Everybody in the town knows that you went to doctor's school and you're coming back, but it also, you know, it also matters like how you're talking about relationships and building practices, the relationships. It also matters how you're building relationships within your community. So, like, Dr. Leah Gupta really highlighted that I love, you know, um, she went out to restaurants and would say like, hey, I'd love to, you know, post about your offerings at the restaurant on my.
On my socials and she would, you know, build relationships like that. And so there's, there's, like you said, there's many ways to skin the cat. I think that it definitely also is a different world now because I have people who they'll, my patients will tell their siblings and like, you know, citrus heights.
Like that was a case that I had. My 80 something patient told her sibling about, you know, what she was getting. And her sibling was like, What? What the heck? What? Why don't I have that? And then I gave my sibling the contact information for Dr. Zinmarmar, Zinmarmar, who's in Citrus Heights, and miraculously, she had a patient.
So, even when our patients are talking about us, I feel that that really also is helping us push this rock uphill. So, but yeah, that's a little bit about how I started.
Yeah, that's definitely an advantage. If you can, if you can start your practice where you did residency and already have patients who are attached to you, that's a huge difference.
You know, I had just moved across the country and no foundation, 0 patients and just trying to gain visibility and of course, you know, being away for, I guess it was. 5 or 6 years, you know, I wasn't in touch with the specialist or anybody else to have referral network of them being aware of me anymore. So it's definitely a challenge.
I wouldn't, I wouldn't recommend moving to a whole new place and starting if you have no connection or no, no foundation. They're moving back to your home state is different. Like you said, if people are just aware, I think that can work, but, um. Yeah, so that was my process starting from zero and trying to grow it.
And definitely, you know, if you know that you're going to move to a particular area, because like your spouse found a job there, whatever the case may be. I mean, you can, if they have a, like a UPS store, we don't because our UPS store is like 45 minutes away from us, but like you can establish that dot on the Google map.
Before you even move. I mean, Natalie Gentile, who's, who's one of the, uh, direct primary care physicians of Pittsburgh, she did that while she was in Mayo in Minnesota. And even though she was from Pittsburgh, she started posting socials, you know, in Pittsburgh, you know, you can tag your Instagram, your socials in a location that you might not be physically in.
And so, you know, having that SEO building as much as you can before you start definitely a thing you can do. And then. Like what I did is I had my arnolddoctor. com would not suggest that to people because I had so many people say like, is it D R or D O C T O R? Like it was very confusing. So that was lesson learned on my behalf.
But when I switched to BigTreesMD, I just switched where the link would take them to. And so even though, you know, they were, they knew me from arnolddoctor. com, I had not committed to BigTreesMD is the name, but that's another way that you can just. Continue to build leads and build SEO while you are not open, so to speak.
That's great advice, actually. Yeah. A lot you can do to sort of get a little bit of momentum going even before you launch. So that's a great point. Everyone should know a little bit about SEO and there's definitely much better options now for reasonably priced, uh, help with that. And you can start a wait list.
You can definitely start building some. Visibility.
Absolutely. And when you opened, you described how you started incorporating physical space into your practice. But I wanted to ask because going back to building relationships, learning what you did from people who were in, you know, specialty practices or group practices, you eventually brought Dr. Marguerite Duane onto the team at Modern Mobile Medicine. So how did that happen? Because she, my understanding is she was formerly your professor at Georgetown.
Yeah, so she was one of the attendings when I was at Georgetown and we didn't have all that much interaction. She was, she was one of the community attendings that would come in and precept and make rounds with us on a rotation.
So I happen to be on inpatient, you know, I'd see her every few months, maybe for like 1, 1 day of weekend rounding or something along those lines. So I knew of her, but we didn't know each other well. And then fast forward, you know, I transferred and then. Was in, was in Phoenix and I was pursuing training in the Creighton model of natural family planning.
So, the courses are taught at Creighton, it came out of Creighton, so they're held in Omaha. So, it worked out well for me, I could go to class and then see my family in Lincoln. So, I had done the first half already a few years prior, I think this was the second half, and I walk into the conference room of the hotel and who do I see but Dr. Duane. So, you know, I went and reintroduced myself to her. And we got reacquainted, and So, when I was finishing residency, she actually reached out to me to see if I, she was a Catholic charities clinics at that point in Washington, D. C. she was a medical director. So, she reached out to me to see if I'd be interested in being a medical director at a new location.
They were opening and this was right at the kind of Costa Rica moments. And so. Low pay for a charity organization versus trying out Costa Rica. I had to tell her no, thank you and get Costa Rica. Try it, but we stayed in touch. And then, as I started doing the house calls under mobile fees for the hotels and resorts.
I reached out to her to see if she'd be interested in being 1 of the DC physicians and taking some of those. And then I let her know that, look, I really want to get back to primary care and she had stepped away from clinical care to raise her children. I kind of pause your clinical care and was looking to return.
And so I said, look, I'm going to rather than do it under mobile. And he's going to spin off and just do. Direct primary care under a new practice, a standalone. Give me a little bit of time to set that up. And when I have the organization and everything ready to go, you can just be independent and take care of your neighbor.
Take care of your community. We're not physically that far from here. We're not far from each other, but with DC traffic, you know, it's like. It's impractical to share office space or anything, you know, it can take forever. So she was based up in in North DCC and Brooklyn and. Around Catholic University, if you're familiar with that area.
I just wanted to take care of her community, so it just worked out well, and I could set up an umbrella organization for her to do that. And that was the model I launched with was based on my experience of all my residency colleagues leaving primary care. I wanted to make a good job opportunity for docs who just wanted to do what they're trying to do.
So, from the start, I set up everything to be nationwide with national accounts for malpractice. Our lab accounts were nationwide negotiated and are investigated to get as low cost EMRs and just trying to make it an umbrella organization that anyone could just sort of come join under and not have to start from scratch.
It's hard to start from scratch and not everyone wants to be a business owner. So that was the model. She was the first one to join. And so I was doing it down here in Alexandria. She was doing it in D. C.
I love it. And I love that you said, like, give me some time to just set that up. Like, give me, give me a few and then I'll have a new business tomorrow.
I'll look at you. I had, I had practice. I'd already done it. I knew, you know, I knew what the check boxes were and I can, I can crank it out pretty fast. And then we just had to, you know, she was a sounding board and I wanted to make sure she'd be happy with the end product. So asking what were her must haves or deal breakers or, you know, what did she want her practice to look like and what does her community need?
So just. Figuring out pricing to cater, you know, we're in different communities, we got to sort of bridge her neighborhood versus where I live, like, where can we find a price that works in both places. So all those kind of conversations, then we can launch. I love that. And, you know, I think about the amazing physician recruiter that, uh, my, the company that I used to work for had.
The. Let her go after 12 years, uh, you know, without any reason, in my opinion, and I remember that when she started talking to my husband and I, before we moved out here, the conversation was very much around, like, what, what are you looking to do? And then, like, you're talking about that frog in the pot. I see lobster in the pot.
Everybody's in a pot, some kind of animal, you know, it's like we go in and then nobody ever asked. What is it that you're wanting to do? Like we had, I, for me, it's like I had to ask that I would like to get colonoscopy started. I would like to be able to, you know, do X, Y, Z, but it wasn't ever past that position recruitment conversation set.
What do you want to do? And are you achieving that? So I love that you had that conversation. And I think it's important for people to think about, you know, if you're bringing somebody on, especially like a clinic that you opened, you, you're bringing somebody on. Culture matters and culture definitely feeds down or it trickles down into the patient experience.
So having, you know, the discussion about, like, what does it look like to join the practice? Like, what are you wanting? What is the, the person you're joining wanting? And seeing if there's, you know, a place where everybody agrees, that would be beautiful. And we, we are seeing that more and more, like. You know, I, I say this because I recently was at their clinic, but Dr. Emily Scott and Dr. James Gohr, they have two physicians who are 1099s at their practice who've joined on and they weren't necessarily wanting to open up their own, but they joined because Halcyon Health was open. So I love that. Now, when you talk about how there was already autonomy and this feeling of autonomy going into joining the practice, how did you have practices that were similar and how were they different?
So, we were similar in that we catered to families. We had a lot of families with young kids. It was, we still, it's 1 of our frequent signups is parents who have a new baby. You know, we get newborns all the time because it's so preferable to take care of them by house call and not be in a journey environment, you know, in a waiting room ever.
So, we had a lot of overlap of just the demographics of taking care of families and. You know, trying to sort out the whole vaccine issue, which a lot of DPCs kind of struggle with. So we had a lot of overlap with that. I'm sure talking about, you know, I took the crane model fertility awareness training for physicians and medical staff.
To be able to apply it to medical problems and use it and assist with diagnosis and treatment. She really is 1 of the leaders, maybe she didn't toot her own horn, but she's really 1 of the leaders in the country. It's not the world on educating. Medical people, you know, nurses, doctors, pharmacists, everybody about these different methods, advantages, disadvantages, and incorporating them into medical practice because it's a lost art and it's been modernized.
Right? So it used to be standard training for nurses when I was flying back from with my creative model manual open the middle age, late middle aged lady next to me. Looked at the diagram and said, oh, sphinc mycartin, or whatever, it's just, it's a German term for cervical fluid stretch. She just called it out.
She's like, oh, yeah, we learned that in nursing school. It used to be a part of curriculums and then it just faded away. So Marguerite is one of the most knowledgeable people and a leader in our field. And so her practice was very heavy on fertility treatment. Fertility awareness, workups to diagnose infertility and treat it, PCOS, any, any hormonally related GYN issue, these methods can be extremely helpful.
So, she was heavy on that and I had dabbled in it. I, in retrospect, I took that training too early in my career because I didn't have patience to practice it with, you know? So I should have done it later to be able to actually have a panel to work with. So I had a foundation. She was the expert in that.
And so we sort of diverged there where I would just defer or refer people to her. And that's ultimately why she left because she really, that's her focus. And that's who everyone finds their tribe. And you figure out what you're really known for and what. what your passion is. That's clearly she's a standout.
She broke off to do a really fertility focused practice and just maintain some of her previous primary care patients.
Absolutely. And When you talk about what, when she broke off from the practice to open up her own, how did your practice adjust in terms of, like, I think about, you know, when my husband was told that they were, the clinic was going to non physician model, like, here's all these patients, especially in our area, we're like, what are we going to do?
And then, you know, not all of them were able to stay at the clinic, is my understanding that he worked at and. So I, I think about asking this question because seeing what's happening in my community when a doctor is no longer available as an option for people to access.
Yeah, 1 sort of 1 thing that made it a little easier to transition was that she had a small panel, so it wasn't a lot of people affected.
And basically, I gave him the option of. Transferred to me for office only because they're too far for me to realistically get to for house calls. They had the option of a virtual primary care only, which was starting to come up more and more at that point as a proven old, you know, has its critics, but it was an existing model already, or just transitioning to another practice.
There was a few families that were close enough in the district that I could take on for house calls. And so we had a mix of all that. So a few people moved over for house calls, few people switched to office. I don't think we had any takers on virtual at that point. People didn't necessarily understand what that could be.
And then we just had attrition, but people decided they didn't want to drive to Alexandria. They just found other care.
It's interesting because, you know, I was just talking with somebody about how there's a difference in numbers. Like you just pointed out, you know, there, Her practice was not 4, 400 people trying to find a doctor where there is no care.
So I, that's, that's really great. I, I'm glad you, you know, shared what you did just because, you know, especially if somebody, you know, they. They decide that a life change is going to happen, like they, something happens, they have to, like Dr. Sharon George, she had to go and take care of her family member and that's, you know, around the time that she closed her practice down in Southern California.
So there's always, things are coming down the pipeline always, like our lives are usually not stagnant and the same every single day and same thing with our practices. So let me ask you now. With regards to pricing, because like you said, you know, you, you had your spreadsheets, you're trying to figure out pricing on your website.
I, you know, I was looking at this before our interview just to, to really get a good feel of the different options. And I think that. Again, it's like you, DPC allows anybody to come and get a doctor, you don't have to have a seven figure salary to access a direct primary care physician, but you have your standard, your plus, your premium, you also have options for after hours calls, you have options for non members in the office, and then also like thinking about your sister and her children, like you, you say, you know, if you're wanting a vaccine, like a flu vaccine, like, and you have multiple people, let me know so we can, Arrange that differently than you would like a one off visit, but how did you work through all of your knowledge and your training, um, your education as an MBA to come down to your pricing?
Sure. The first thing I started with was. You know, everyone else was doing office space, unlimited visits, and I, that sounded like a bad idea for house calls because people could be calling you back very frequently. And the time invested, you would just not be making enough money per hour. Bluntly, you know, just would not be worth it.
So going off of that sort of premise, I just researched the frequency of visits by age and other demographics, and you can see it's, it's a bell curve, basically with high utilization for infants and elderly, and it just drops precipitously in middle age. Right? So, but still the average for most people is 4 visits or less per year.
So that's what we started with was let's have a basic 1. I think the actual number is 3 visits or less. So I added an additional 1 to make it forward and a little cushion to give people that reassurance. And I can tell them like, look, just data wise, you're not going to see me that much. Here's sort of the basic bundle of house calls.
If you need more, it'll be discounted. You know, we just had another individual one, but I'm fairly confident you won't need that. Versus maybe people on the ends of the bell curve that are very sick and maybe actually homebound that may need more frequent check in. And so I wanted to have these tiered options available where they would meet their needs.
So that allows you To keep a lower entry level costs, you know, you sort of businesses are always trying to divide up the market to get as much of the market as they can. Right? So there's like a stair step model of pricing. And that's that's why cars are priced with these different packages and stuff because they're trying to divide up where where's people's limits.
What motivates people to maybe go up to that next. Price here, and how do we bring in people who maybe are a little more price sensitive? What can we have for a base model? So it's sort of that line of thinking of, I want to have at least a basic membership, but it covers the vast majority of people and what's viable and then go from there.
So the premium, the original premium is not what you see now on the website, that's a, that's a recent revision. The premium really wasn't being used. Originally, it was basically just 16 visits. It was like, the other ones kind of set up 16 visits. When I was using it, it was just taking up space on the website.
So I revamped it, I think, last year to have it kind of like a concierge approach of like, just bundling everything. So there, if we do mobile phlebotomy, there's not going to be a charge, your flu shots are wrapped in. No on call triage fees, and I can speak to that later too, but I'm one of the few DPCers who does charge a little speed bump fee for after hours calls.
I just recently revived the premium, but it includes health coaching. It's for people who really are trying to make a major shift in their health, trying to get their diabetes under control, their weight. You know, they have a project in mind. So now the premium really speaks to that. And I don't have many people go for it, but it.
The family membership, we had standard and they just share the house calls. So, again, it was based off of how many visits are they going to likely need and had a premium 1 as well. Nobody ever touched the premium for 6 years. It just wasn't needed or just recently had someone request something along those lines.
We revived it last week. I don't think it's posted yet. It was sort of coming up with a custom plan for a family that wanted more all-inclusive. I try to give it as simple as possible, but also you wanna meet different tiers of needs, right? So the mantra is keep it simple, but sometimes it doesn't meet everyone's needs or the practice needs.
As you work towards building out options to get as much of the market as possible, like you're saying, or to appeal to as much as the market as possible, how did you look at, you know, what is the maximum that modern mobile medicine can carry in terms of patient load, because you might have people who are accessing, who are wanting to access one off visits versus your members.
So I think about that in terms of. Providing quality access to care without recreating the hell that we left in fee for service. How did you think about balancing numbers that go along with your pricing, that go along with the number of hours you have in the day to doctor? Right.
Even as I was launching, it was already a fair amount of data DPC.
You know, with at MD and, and Brian Forrester and, and some of the earlier adopters, we knew what was manageable and they were recommending, you know, a thousand, maybe 1500 max for an office-based practice. And I knew house calls was, was going to need to be half or a third of that just to account for time on the road.
So I had that cap kind of in mind of. 400 500 is probably the most we would ever take on when the office side suddenly spontaneously came in demand and I grew that side actually allows more capacity, you know, I can, I could probably take 600 even 700 if it's evenly split between office and house calls, but I'm sorting it out, you know, it was, there wasn't anybody doing it before me that I can look to or just still kind of feeling out as we go.
The one offs. So. Other I've heard other docs and lectures and summits and stuff say you shouldn't do those. That gets back to the fee for service and the transactional nature of medicine. But when you're starting, it's why leave revenue on the table? People are looking for a sick visit in various, like, nursing home physicals, or there's different things that they don't have a doctor, they have a need.
And so part of it's meeting the community, and part of it is if they don't, if you don't accept them, they're going to go somewhere else. And you have someone willing to hand you money to do your job, why would you turn that away? So after I heard someone mentioned that in the lecture. It was probably my second or third year of practice.
I actually calculated how many, what the annual fees were for non member visits. And it was like 5, 000, I was like, that's not nothing. That really helps when you're getting started, you know. So I still offer it. We started kind of restricting saying I shouldn't be doing your checkup. If I'm not your primary care doctor, first of all, it's too much time investment.
I don't charge enough for that. If I did, no 1 would do it anyway. But also, if you're not, if you're not in it for continuity with me, you should be with someone else. You should be with a doctor who's going to know you and work with you moving forward. So we don't really allow. One off checkups because it creates tons of work, lab orders, lab results, referrals, all that stuff, and just building a chart from one time visit, you know, if you're flushing it out.
So it's more for. People are sick and they can't get into their doctor, you know, meeting those needs of their doctor tells them to go to urgent care and they don't want to go to the urgent care, especially, you know, that really grew in the pandemic as well. Just lots of virtual visits, giving people reassurance or guidance on what to do.
And then the goal is, if they have a good experience, maybe they'll become a member. So, I don't think you should be shooting people away or refusing. You know, one time visits, just have parameters that you're comfortable with. Absolutely. And there's some services that are great fits for one off things like circumcisions.
Like if you offer them for anybody, you know, but there's also a discount for your members, it definitely encourages people to look at what, what is a membership mean, and especially if you're taking care of a baby for a procedure and that baby joins, how wonderful is that? Like you get a baby, you know, who.
We'll know amazing primary care from day one. So I think that's awesome. Well, the first time you see him, it might not be day one, but so let me ask you here then because you also allow people to pick appointments. So some people are like, no, no, no. Some people are yes is yes. We'll allow our patients to pick.
How do you build your schedule on the back end such that you don't have? Our favorite double booking, triple booking that we experienced in fee for service, but also that you have time to, you know, have longer visits scattered with shorter visits.
Yeah, that was, that was one thing I really insisted on with scheduling was self scheduling.
I always thought it was ridiculous for people to be on the phone on hold and doing the back and forth of does this work? No. Does that work? No. How about this? Just completely inefficient if, if we could all book our flights online. People are so used to doing everything themselves, it's literally just clicking on a calendar.
There's no reason to have that whole process of tying up a staff member and wasting the patient's time. Just let them pick. So, I sought out a scheduling system that could allow for that. It's, you know, when you're slow, it's not a problem. Your schedule is wide open. It's not an issue of double booking or people not having availability.
What I've moved to as I've gotten busier is not allowing checkups on Mondays or Fridays without permission. So those appointment types are just not available because Mondays and Fridays are so busy with acute care. You know, everyone's been sick for the weekend, holding, holding your breath, waiting to talk to me or get an appointment.
So Mondays are crazy busy. Friday, same thing. Everybody's trying to squeeze in before the weekend. So there's things you can do just with your template of making it. You're not rationing care. You're rationalizing the care. So keeping appointment length, what you want it. I just linked in mine because I realized I'm running out of time.
Every time, because I'm thorough, maybe I document too much, I don't know, maybe I talk too much, but I just linked in my standard appointments because I was tired of feeling like I'm running behind, like I'm rushed, I can't do my notes, I have that flexibility, there's no administrator telling me the appointment length.
Love it.
Now talk to us about pure primary care, because like, I love that throughout your journey that you've shared here, you've, you've kept pulling and pulling from your previous experiences. So especially with mobile MDs, and then going back to DC opening modern mobile medicine, what is pure primary care and who's a part of it?
Yeah, so pure primary care is basically a spinoff from my practice to handle the employer sponsored. Direct primary care, so, you know, I set up modern medicine as a nationwide network and was doing some employer contracts under that. But, you know, then you talk to other docs, lawyers. And it was advised to have it as a separate legal entity.
And it really is more of a management process, an administrative role than the practice of medicine. So, 1st, 1st, it was just a brand or a line of service in my practice. So, I launched that way and operated that way for. Maybe a year or so, and then I formally split it off and got the separate tax ID and all that.
So, it's really to handle the employer side of things. And it just came out of sort of organic demand as well. So. The house call network really wasn't growing. I interviewed and had a lot of people. Say yes on board and then not sign their 1099 contract. They were just picking my brain to figure out how to do it and go do it themselves, which is fine.
We're trying to grow the movement, but that's all that was happening was like dozens of phone calls and interviews of people. Telling them how it works and then the network, you know, the, the Pete's with, I guess, 3 of us, not including the employer side. And I started adding some independent practices to help with employer contracts.
And so, you know, all told, we were, we're still less than 10 docs just sort of affiliated together. So, I just spun it off into a standalone and there was pre pandemic. There was cold calls from brokers from employers and. The final tipping point was a university out here. The provost was speaking at a business networking event, and I just didn't chat with him afterwards and told him what I do.
And has he ever thought of it for the employees? And he said, I love this. I want this for employees. Look, you need to talk to HR and it should have known better than the HR recommendation because they're never open to it. They don't understand it. You have to talk to the CFO. Don't don't bother with HR.
So, he really wanted it for the campus. Um, all the staff and HR shot it down because we didn't have enough dots on the map basically is where it boiled down to. So, that was sort of the tipping point of, okay, I need to it. Instead of just spontaneously affiliating, I need to proactively try and get other docs and practices to just work together because we can all take patients from these contracts.
And we need, it's like a chicken or the egg. The businesses don't want to sign up if there's not enough doctors or practices to choose from. The practices don't want to sign up if there's not a guarantee of patients. So, it's been a lot of that sort of, you know, back and forth. So, yeah, I set it up for that and it was more of a, you know, a lifestyle business.
It wasn't like I was going all in. I was declining investment offers. I still get emails of there's tons of private equity. That's just pursuing health care and direct primary care specifically. So as a lifestyle business, and it kind of got tabled too with my own life and my family life, the pandemic, it was just on the back burner, but it's there to meet those demands or those opportunities now as they come up.
So the opportunity still exists for anybody, you know, who's out there and wants to be an affiliate. It was a godsend to me when I was getting started that I got some patience from employers through NextEra. You know, you get a nice little lump sum instead of trying to recruit one patient and one family at a time.
And then it's less risky for an individual practice to not have all the employees there because as that contract goes away, you suddenly lose a big chunk of income. It's built from that. For that purpose, because we can all kind of benefit together if we're affiliated and it looks better to employers to have more options and we can all get a little tranche of patients and not be tied in for like 100 or 200 patients all at once.
Awesome. So in closing, I want to ask one fun question. When people are thinking about opening their practices as a home visit model only. What are some of your favorite tools that you would recommend the must haves to have in your bag? Man, I mean... The beauty of starting mobile is, is it can be very minimal, you know, you can actually just go out with your set scope and things to measure vital signs.
It can be that simple. That's not necessarily the fun part. I'm kind of a gadget guy. I like trying out lots of things and a lot of them don't work that well, but I like to give them a try. You know, I, I like my really compact EKG that connects to an iPad or an iPhone. That has no stickies on it. Patients love that it just wraps around them and you're going to put any pieces on them.
It's perfect for house calls. It's that's 1 of my favorite toys just didn't have this originally. Um, and actually I should say I didn't have the originally. You don't need to spend money on that when you're 1st starting. That's a later on when you have some revenue, but like the cardia patient oriented little rhythm checkers.
That's perfect for a quick rhythm check. I mean, when I didn't bring my EKG and I spontaneously hear an irregular heartbeat, that's great to just say, look, it seems like you're an AFib, let's do a quick check. So I love that, you know, it's a credit card size device you can keep in your bag. I try it out. a sonic height measure that you would put against the wall and it would use like actual like ultrasound and it just was not reliable.
So I had to give up on that. My kid's pediatrician has a new one in their office that is a newer, more reliable version, but I got the cheap Amazon one. Didn't work so well. Yeah. I mean, you don't need a lot of Tricks up your sleeve though for house calls. It's, you know, give vital signs and have some, you know, a primary bag, maybe a backup bag for procedures and extenuating circumstances.
That's the beauty of it. Thank you so much, Dr. Hayden, for joining us today. My pleasure.
Next week, look forward to hearing an update from the doctors who opened their DPCs right after residency. Dr. Deepthi Munkaur of My Happy Doctor, Drs. Christina and Jake Mutch of Defiant DPC, and Dr. Lauren Hughes of Bloom Pediatrics and Lactation. 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 DPC.
We have a five star review on Apple Podcasts and on Spotify now as well as an album. to find all these DPC stories. Lastly, be sure to follow us on social media. If you're wanting to continue learning more about DPC in the meantime, check out dpcnews. com. Until next week, this is Marielle Concepcion.
*Transcript generated by AI so please forgive errors.