DPC Doctor
John R. Jacobsen, M.D., a Board Certified Family Practice physician, is the founder and owner of Click Family Healthcare clinics in Kearney and Broken Bow, Nebraska.
John, who grew up in Merna, was an ag banker for 10+ years before applying to medical school. Coming from a small town, his desire was to practice family medicine in a more rural setting.
After finishing his residency, John was in private practice in Geneva, Nebraska for over 10 years caring for all ages including pediatric, adolescent, adult and geriatric patients. In addition, he provided obstetrical services including cesarean sections, upper and lower endoscopies, in-hospital and in-clinic minor surgical procedures, hospital in-patient care and emergency room services. John served as the hospital chief of staff, was medical director of a nursing home and was medical director of the hospital out-patient senior behavioral health program.
John moved to Omaha to become the Chief Medical Officer of a start-up primary care center, a role that was administrative in nature. After 3 1/2 years, the desire to provide direct patient care led him to decide to open Click Family Healthcare.
John has been active in family medicine organizations at both the state and national levels.
John credits his wife Janet for their success. They have 2 daughters and 3 grandchildren, the youngest being a few weeks old.
He opened Click Family Healthcare in Kearney, NE in 2017 and a second location in Broken Bow, NE in 2020.
CONTACT:
Visit the website at Click Family Healthcare HERE
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TRANSCRIPT*
Welcome to the podcast Dr. Jacob.
Thank you. I'm glad to be with
you. I've been to Carney. And what I thought was so amazing was that you had gone to medical school with one of my former attendings out in superior, Dr.
Julie Theis and so what a small world and what a way to celebrate, medicine and business and entrepreneurship, in Carney and now broken bow.
It's been a, it's been an adventure. I'll say that, you know, having gone from banking and then the medical school, and then into the fee for service world, where I own my own practice and then leaving that to become the chief medical officer of a, a new primary care startup center in Omaha, where.
Yeah, we had a 55 minute hour clinic, six story hundred 50,000 square feet where we wanted to be a one-stop shop. So we had our own pharmacy lab, all of the imaging you would want. We had, you know, behavioral health and optometry and physical therapy all within our building, just trying to improve the healthcare.
And it was mainly of people, 55 and older because we were going after the, the shared dollars, uh, you know, with the ACO and, you know, having done that for three, three and a half years and getting really, really burned out, coming back home, even the home is actually 70 miles from Carney, but coming back to central Nebraska, where it's a different pace, it's a different lifestyle, uh, was really, really good.
Let's delve into that a little bit more because you're from Myrna originally. So, can you please share a little bit about central Nebraska about, where Carney is in relation to big city centers and we're broken bow is in relation to those same places.
Well,
Myrna and broken bow are pretty much just geographically in the center of Nebraska. If you were to dissect north, south and east west, uh, we're right at the edge of the sand Hills. So people don't know what the sand Hills are. That's some of the best country, uh, for raising livestock and cattle that there are, is in the United States.
When you go south of broken bow towards the, what we call the Platte river valley, which kind of is what I interstate 80 runs. It becomes more farming. Central Nebraska really has a lot to offer, you know, from a tourism standpoint, uh, the cranes migrate through here, you know, we have the geese migrations, of course we have Nebraska football, which that's not anything to brag about the last few years, but overall there's so many things to do.
You know, a lot of people think Nebraska is just this desolate desert that you drive across when really there's a lot to do. And Carney is a, it's a college town. So there's, it's a university, it's a, it's a branch of the university of Nebraska. Um, and so they've got typically eight to 9,000 students. So there's always that those things that you can do if you want to go to college sports or college activities, but yeah.
Central Nebraska is, is unique in that it's just a little slower lifestyle for most people. Most people are very, very gracious. Most people are very humble and it makes it fun to be their friend and take care of them. Uh, when they come to see us in our clinics, broken bow specifically is a town of about 4,000.
Who or which has kind of gone through a resurgent the last number last few years. And we actually bought a old practice clinic building that had closed in July of 2016 and renovated it to fit direct primary care. Uh, you know, I always laugh. The rooms exam rooms are seven and a half feet by 11. So it was like a glorified closet.
So we took three rooms and made two, we opened it up. One thing I don't like coming from the banking industry is barrier. So you walk into a typical family practice clinic. And the first thing you see is this glass wall. And it's like, oh, I know you're sick. Come in, come in and come. We want to help you, but oh, stay back because we don't want you to close.
And so we removed all the barriers that were there and people who've come into our clinic that used to go to the broken bone clinic. Can't believe the transformation that we did. Carney itself is around 30,000 people. It's again in the center in central Nebraska. Carney is unique in that it one is a college town, but a two has a lot of small industry, uh, whether it be manufacturing driven from the ag economy, but the Carney economy is not directly tied to the ag economy like broken bow is so we get some diversity as far as not just seeing farmers, not just seeing ranchers.
We're also seeing people who are working in retail, people who are working in manufacturing, which, which makes it fun and adds stability to our business.
When you're mentioning direct primary care is a business model and you've so wonderfully highlighted the points of having value, accessibility, affordability, and having a product that's easy to use.
I want to delve into your history and your experience in banking. Can you share about your business background in ag banking and what lessons have you been able to pull from that have made you successful in DPC so far?
Well, I think banking in and of itself was a second career for me or what was the second thought process? I actually started pre-med right out of high school. Then I went to college for a semester and after a semester I quit because I went home and told my dad, I didn't know what I wanted to do. And I, you know, I just was struggling.
So I actually worked for a farmer for a year and a half and drove semi and planted crops and harvested crops. And in one of the, one of the best lessons I ever got life was I'd worked for him for about a year. And he was my best friend and my best friend's dad. And I said, you know, gosh, TYC, I've worked for for a year.
I really think I need to raise. One of the, the story about how he couldn't afford to give me a raise. And the next week drove up in a brand new pickup truck. So I knew right there where I was on the pecking order. And so that really motivated me to go back to school and I thought I always wanted to be a farmer, but I didn't marry it.
And then I'm not going to inherit it. So what a better way to work with farmers and get into banking. And that's really what I did. I started out in a small bank, up in the Sandhills, after about three, three and a half years though realized that's not what I wanted to do forever. And I had an uncle who was a physician in broken bow, and he actually got me connected with the Dean of admissions at the university of Nebraska medical center.
So my wife and I went down and talked to him and, you know, he said, you've been out of school for three, three and a half, four years. You've got two kids at home. There's no way you'd make it in. So, you know, we just put our head down and kept working in banking and kept working in banking. And the town I was living in with my last banking job, we, uh, had, uh, at a city owned hospital and they hired a physician and they guaranteed him.
I think it was 120,000 a year, but this was back in 19 89, 88 90. So that was really good money. And three days short of his contract, he left and I kept telling my wife that I'd really love to go back and be a family physician. I'd really love to be in a small town. And she finally, I always tell people, she gave me the ultimatum either put up or shut up.
And so we decided to move. I resigned from the bank effective on Friday. We loaded the UL on Saturday. We unloaded it Sunday. And I started classes at UNK here in Carney on Monday. And so through that two year process, that's what got me then where I applied and got admitted. But the thing about banking that I think has been so beneficial for me is one, it taught me the business side of things.
DPC as a business. Um, so you need to know the ins and outs. The what's a balance sheet, what's expenses, what's income, those kinds of things, too. I had got up to where I, when I resigned, I was the second in command to the vice president. So I got some experience managing people, you know, and I was, was able to attend courses on, on human resources and management.
Also, we were coming off the end of the ag crisis. So I actually had to deal with some, with customers who were financially insolvent and had to have hard, tough discussions with them about, you know, we may have to sell the farm or we have to sell equipment or livestock or assets in order to pay your loans back.
And that experience helped me, I think, become a better person. Being able to see both sides of the business, both the good and the bad of banking, both the good and the bad of people. And when I left banking to apply to med school, you know, I, my, some, a lot of my customers were kind of raspy. And I said, well, you know, I've told you, you should sell your corn above what we've put in the cashflow.
If you come see me as a doctor, and I tell you, you need to quit smoking. If you don't, you're going to die. So there's a correlation. You either go broke or you die. And so it was just, it was a blessing in disguise for me to go do something else for 10 years to learn people skills, to learn the financial skills.
When I got out of med school, And ended up in Geneva. There were three of us that own the bought two clinics immersion together. And I was the financial guy. Another one did the human resources and the other one did supplies and purchasing. So it allowed me to continue the financial side of things and kept me in the loop there.
Now there's a lot of things that I've forgotten about banking, uh, but it's allowed me to be and understand the business side of things.
what a rich history to bring to your clinic and to bring to your population because not only did you know. How to talk with people in difficult situations, whether it be healthcare or finances, but also the fact that you grew up in Myrna, that you are familiar with Nebraska, that, you know, the culture of Nebraska too.
Can you please share how you came to learn about DPC and how that transformed your, your plans in life into opening your DPC?
Sure. When I was in the P for service world, my first. Partner boss that I was with, I was 43. He was 83 and he got me involved with the politics, I guess, of healthcare. So he was a big advocate of the Nebraska academy of family physicians. So I started going through the leadership pass there, got to where I, I was on different committees.
And then I became president in 2014 and that allowed me then to go to a lot of American academy of family physician meetings, where I got to hear people from all over the United States, the so-called gurus talk about healthcare and. Then we had a guy actually from Nebraska, Bob Morgan, who was a family physician in Milford, got elected to the board of the American academy of family physicians.
And he prompted me to try to get onto the finance and insurance commission for the American academy. So I sat on that for four years and then I chaired it for a year. And so it allowed me to be exposed to a lot of different ideas. And I was at a meeting. It was, I think, around 2012, when I actually heard Josh umber and Doug nother maker talking about starting of direct primary care clinic or a cash pay clinic where they were just, they just got out of residency and they didn't want to work in the Obamacare type of clinic structure or reimbursement structure.
And at the time of that, yeah, that's kind of a cool niche market. You know, you could, you could move to Wichita or I could move to Lincoln or grand island or OMA. And I could probably do that, but at that time I was still had my head in the sand, I guess, about fee for service. And, you know, we've got to do this, we've got to do that.
And so that really was my initial exposure came about 2014 to 1516, somewhere in there. I, again, her Josh talking to meeting at an AFP meeting in the storyline, kind of changed that, you know, we now have small businesses coming to us asking us for how can we help you? Because we're paying so much for insurance or we can't provide a benefit to our employees that is limiting our growth.
And at that time, the bells kind of started to go off in the back of my mind that, Hey, this might be something that is growable or expandable. Not that you're going to be able to take care of every person in America. But at least it's no longer a niche market. And so I left Geneva in December of 2013. I moved to Omaha in our whole philosophy in Omaha was we wanted to get part of the ACO chairs, shared dollar saves savings dollars.
So that was our whole structure and did that for about three and a half years when I finally. Yeah. I mean, we, we decided to make the move in between there. My brother-in-law who is my best friend, uh, was diagnosed with a funky cancer to where they removed literally half of his skull, um, and said, you know, you do radiation, you've got a 10 to 15 year life expectancy and, and.
No 16 months, he was dead. And so my wife and I are driving home from the funeral and I looked at her, I said, all right, honey, where are we going? Because I quit my job the end of February of 17, because I was so burned out that I, I actually didn't work until August. I started doing some locums, but in may, the end of may is really when we decided that, you know, we're going to do direct primary care.
We started, we looked at Lincoln. Uh, we looked at Carney and we looked at broken bow and we ended up landing in Carney one because of the business environment there with small industry being ag, you know, an ag economy around it, But we also moved there because my youngest daughter lives there and that's where our grandkids are.
So that's really how we ended up, but the idea that coming from the business background of being able to talk to different people in their language. So I can talk to a farmer about their blood pressure, talking about the hydraulics and the tractor. I can talk to people who are in manufacturing. Based upon my experiences.
So it does, I think, make me a better physician because I can build that relationship, which I was able to do in Geneva because I inherited Dr. Ashlyn's population to where I, you know, I had mainly 30 minute appointments, but my population was actually 70 and over the bulk of them too. So. That whole background, listening to Josh.
And then, and, uh, and then when I decided that this is something I wanted to do, I actually went on the trail and I went and talked to shadow. Doug and Josh, I went to I'm drawing a blank. Ryan knew Hafele and I went to his clinic. I went to Jennifer hairdryers clinic. Uh, at that time, I didn't know Vance Lassies or I don't want to his clinic, but I made that loop down and spent two days just gathering information of how does this work, the ins and outs of it.
Um, I, you know, I, I I've always felt like I had the business sense to do it. It's just the other things and yeah. Direct primary care is not without stressors. It's just a different kind of stress.
Yeah, absolutely. Dr. Nestor Mohammed put it beautifully. He's never worked so hard in his life, but he loves every day of his work.
And it's very different than showing up in a fee for service clinic where you are, like you said, you're burned out and burned to a crisp, in some cases to the point of quitting.
I always ask my customers how you doing, or I ask friends how you're doing. And I always love it when they say, well, I'm living the dream.
Because most of the time when people say that they're being a little bit facetious and my, my immediate Lurie's response to that question, when they say that is, are you living your dream or somebody else's dream because if you're living your dream, it's not a job. You do you work? I mean, I work more hours.
I last night, the last three nights we've had our grandkids and we handed them off to my son-in-law's parents last night and at eight o'clock they called wondering if we forgot to bring over the kids' clothes. It's like, well, no, we're still at the clinic. I mean, I was finishing up notes yesterday, how to be a day.
I just really got bombarded and it's like, oh really? Well, they, both of them had only worked eight to five jobs, their whole lives in, medicine's not an eight to five job people don't get sick between eight and five. And that's what I really like about direct primary care is people can text you as, you know, people text you at eight o'clock and you take care of it in a heartbeat instead of them fester and, and worrying all night or fussing all night.
And you know, my friends who I talk about direct primary care said, oh gosh, I'll be on call 24 7, 365. And it's like, you are, but you aren't because. People know you're going to, if they call at five o'clock on Friday, you're going to take care of it. If they call at Wednesday, you're going to get it taken care of.
So they don't wait until the last minute, because gosh, if I go to the doctor or the ER, I'm going to drop a grand or, you know, whatever the cost is. And that's really what I, I like about direct primary. I have one patient that about every three months, I'll get a call about eight o'clock on Friday night and I'll pick up the phone and say, Hey Jacob, what's going on?
He goes nothing. I'm just sitting there with some friends. And I just bet him 20 bucks. You'd pick up the phone if I called you. And I said, okay, so now I've started saying, okay, we'll drop 10 off with the clinic has that tool. And that's the thing we do. And it's not work when you love what you do. Yeah.
It's so true. It's so rewarding. I had a patient call me at 10 30 at night. Yeah. this person, they never call, for acute issues. And so when I saw their name on my, caller ID, I picked up and I was able to go to their house, do an EKG, you know, figure out what was going on.
Provided this person with reassurance. Um, save this person a trip to the ER, and within an hour I was home. And so for the people who are really thinking about, oh, this 24, 7, 365. You're so right. And so many people have said that before that your patients know that they can get ahold of you when they actually need you.
And if this goes back to that, ease of use in the four prongs of that value proposition for DPC, that you are mentioning that when they know, and they develop confidence in that you are accessible. And it's very easy to get ahold of you, that frantic state of what am I going to do?
What am I going to do? I got a call last minute. It really, really does go down. So I hope that the people who are in that space of like I had this 24 7 is a deal breaker, do reach out to people like yourself. Um, you know, other people who have accessibility after hours and ask them what it's really like in there are communities to serve like that.
And
I
think it's really funny when we first opened, you know, we, we do callbacks, you know, the next day or either the following day or the next day. And when we first started doing them, you know, people would pick up the phone, I'd say, Dr. Jake, just want to see how you're feeling. Why are you calling and make sure you're feeling better?
You know, I was a little worried that, you know, make sure things are going better. And one of my nurse does that and now if I don't call them or she doesn't call them, it's like, well, you didn't call me last time. I'll just joke. Say, well, you weren't that sick. So I wasn't worried about you, but, but people that, it, again, it's another layer of the relationship.
And then if I correlate it back to banking, if we could get you Marielle to open a checking account and our bank, the next thing we did is we tried to push you to get a savings. And then we tried to loan you money for a car. And then we tried to say, at sea on the streets, say, Hey, when you and your husband going to be buying a house, you know, we're here to help finance that house because we knew the more products you bought from us, the more likely you're going to stay with us.
That's the customer service part that most physicians in the fee for service world who are in. Don't even think about, you know, the last thing, when you, when you tell a physician they're a salesman, you know, the most of them put their hands saying, no, I'm not a sale. We're salesman every day, you know, we're selling our knowledge, we're selling our diet, a diagnosis, we're selling a medicine, we're selling whatever lifestyle changes, those kinds of things.
So. That that's the fun part of being in a direct primary care practice. And, you know, you mentioned Amber, when I was in Geneva, Amber actually did a couple months with us. She was a resident. And so she was actually the third clinic in the state to open. I was the second and Todd Johnson and Lincoln was the first.
And then you'd mentioned Dr. . My daughter, my 38 year old daughter, our oldest girl just had a baby last Tuesday. And she called me and said, Hey, I, I found this guy that does DPC pediatrics. And he's just like five blocks from where I live. I said, go for it. I mean, and she has, she works has got a job that she has pretty decent insurance, but they're going the DPC route just because of what she's seen our customers get that benefit.
And then they've joined his practice.
That's amazing. So amazing. And he's actually going to be on the podcast in a few weeks. So that's awesome.
I'm connected with him. So introduce myself. Absolutely
absolutely grow that network in Nebraska. I love it. When you made the decision that you're going to be in Carney, what was the planning process like in terms of starting to plan to actually opening and seeing your first patient in terms of, um, your building?
How did you choose it and how did you get your staff lined up prior to opening?
So when we decided to make the move again, our youngest daughter was living here. So my wife and I made multiple trips to Carney looking to rent. And we actually struggled to find what we felt would be a small enough space, but in a good and not, I won't say good enough location, but in a location that was, I felt was appropriate for healthcare.
And we finally ended up putting an offer on a Saturday morning on a building that was $625,000. I'll never forget the offer because I said, I told the bank, you know, I can Moonlight. Forever to pay for this. But that night I was going at halftime of the first Nebraska football game, 1997. I was going to the grocery store for something for my grandkids.
And I drove by this building that had assigned for rent. And so I pulled in and looked in this, it was, uh, it was wide open. And so I called my realtor and said, Hey, why haven't we looked at this building? And she goes, well, I don't know. So after the game at 10 o'clock, we've got our eyes against the window.
We got the headlights shining in and I actually withdrew my offer on the building called the good that they called the people that own, this sat down and met with them the next week and actually designed our clinic the way we want it, because this building was pretty much wide open. So we, we, we laid our building out, um, and very fortunate we just pay a, a per square foot fee rent.
Um, but it includes utilities. There's no triple mat. 'cause there. They built it out. They own the building. So I felt like when they, you know, I didn't want a triple-net to be stuck in there and they were willing to negotiate that with us. So that's how we got into Carney. And, uh, we actually, when we started, we had a young lady, a friend of mine, actually, he used to be my boss in banking.
His daughter, uh, went to massage school. She wanted to do, she was going to do yoga. So she, we actually designed space for her in our practice as well, because I wanted to use her. If I had somebody with chronic pain. Let's go, let's go get a massage. Let's get a physical therapy. Cause I'm not a, uh, a narcotic person at all.
So we, we started out and that's how we work when we first opened, it was just my wife and I, um, we were open about two months when I finally, you know, we had seen, we opened November 15th, November 17th, you know, by the January one, we had like 85 people signed up and then we were continuing to grow. So I went and hired a, um, an RN who actually was, came to me from the psych world.
So in Carney, there's Richard Young hospital, which is a psychiatric hospital. And so she joined us and she allowed us then that I could leave the clinic and she could answer the phone and I could go out and start knocking on doors and meeting with business people and promoting what we did. When we went to broken bow, um, I had no intention of expanding.
Absolutely none. I was at a, at a bank open house here in Carney, and they have a branch in broken bow. They have a branch actually down by Fullerton where I used to live. And one of the girls was on the economic development board. She goes, oh, you should come. You should come look at this building. We've got, you know, it's still Dr.
Books is old clinic. And I said, you know, I know I, you know, I'm by myself, I'm getting busy. I don't really know. And so I kept telling her no, but then we went and looked about four weeks later, we drove up and looked at the building. Um, and I just told him, no, we're not, I'm not ready to expand. And then about two, three months later, she called me again and said, look, we.
Well, economic development owns a building. We're tired of paying rent. We're tired of paying the taxes. We know it needs some work. Just come look at it and make us an offer. We've had a lot of people look, but nobody can figure out how to modify the building for their particular business. So my wife and I went back up and, and we looked again and just kind of had this epiphany that there's a demand here.
There's a need here. Um, we can get somebody to come join us somehow some way, you know, just kind of prayed that God would lead us down that path. And. I made an offer and they accepted it, you know, and everybody thinks that I got a great deal on the building, but then I follow that up with the first thing I did was spent $33,000 on four new furnaces and air conditioners.
So it was a good deal. The bones of the building are really good. It's a nice brick building, but it just, it had sat empty for four years. If it hadn't had a lot of done, it was built in 1970 and 1979. So furnaces, air conditioners, all those things, but we were able to modify it to where we have our space and then we've, we've renovated.
One other hallway to where the economic development actually now rent space from us. And then we have a mental health clinic that runs an office from us. So we have that right in the building that we can refer to them. And they're very, they've been very helpful with our customers getting them in, in a timely manner.
So I still have a hallway to renovate and run out, but you know, the good thing is it's cash flowing, the rent, paying all the bills. And so we're doing.
I want to take a step back because you mentioned, you opened in November, by January, you had about 80 patients with you being the second DPC and the first one being, you know, all the way in Lincoln.
How did you generate your patient base, to get those 80 so quickly?
Well, we started out, we were on. On the local radio state or new TV. And we, we did some radio things. And that really is what jumpstarted us after that initial rush, because it was the end of the, you know, open enrollment's open, people are losing their insurance or whatever, you know, things slowed down a little bit.
So we saw this kind of peak and then things kind of tapered off. We've really focused on social media. I hired a college kid, uh, to do a social media for us, and she did a pretty good job, but then she got other things going on in her life. And we now, since we've opened our second clinic, we are now actually working with a local company called control yours.
That that's what they do, their internet marketing company. They they're managing our Facebook. They're managing, they're running all of our ads and our nurse practitioner. She does quite a few posts, but they're the ones managing all that for us. So we're really trying to drive people to us. We're also in the process of modifying our website.
You know, we open our website, we opened, I had my, uh, nephew out of Minneapolis. Who's does marketing and brand development. He helped us develop our brand help and he did our webpage for us. He did our initial marketing for us. And really we need, when you start to build a business, you really want a website that looks pretty, that looks nice and explains things well.
But when you get to the point where you want to really focus on growth, you need to modify that webpage to where now it's driving people to sales. So we're now we have a new landing page on our website. And so, you know, you can click on something in Facebook and it takes you to our landing page. And then we'll be in the process of renovating the backside of our website with all of our products.
You know, now that Dr. Peterson's on, we're doing PRF PRP, we're doing some microneedling, um, along with Dr. Peterson who will be adding obesity medicine, and some ultrasound guided procedures.
Before we talk about Dr. Peterson, because he just, he just joined your practice in that last month three, you said three weeks ago before we started the recording, which is so exciting, because like you said, you know, you put that out into the universe.
Like somebody will join us. Somehow some way as this movement continues, like wildfire, people are joining and somebody joining. So, let me ask you though, because you dropped some great pearls with regards to how you negotiated out the triple net. And so I wonder, just with your history in banking and with your history of getting two buildings under your belt and having the space be used for not only your practice, but other uses as well.
What are some tips that you can give to people who are contemplating? Do I buy a building? Do I rent a building? And at what point do you suggest people start looking before they have patients or doing a little bit of funding before they jump into something like a three.
Well, everybody's situation is different. You know, I, I said I was 57, so I had some financial resources that a lot of people didn't don't have, you know, when they're just coming out of residency or been out three or four years, my student loans are all paid back a number of years ago. I think initially renting a space is always the best because that's a short-term commitment.
Even if it's three years, that's still a short term commitment versus buying space with our economy. The way it is right now with inflation, the way it is right now. I mean, if you can lock in a three year, three year, I mean, we actually did a five-year just because I knew I wasn't going anywhere. I'm 57.
This is, this is what I'm doing. Being a banker. I always look at the negative side of things because that's what I always had to do, but I've never had a doubt that direct primary care would work. And so we went, we signed a five-year lease. Going all in at that regards. But if I was younger and didn't have financial resources, there's an old adage.
Why buy what you've been rent or why rent, what you can steal. So I would definitely tell people to rent initially. Now, if you can walk in and you can negotiate with a private land or building owner that you know is maybe older and wants to supplement their retirement by maybe doing a 10 year or 15 year contract, Neil didn't look at the option of doing that as well.
As far as renting space, like with our clinic, with the massage therapist, the yoga w she actually just sub rented leased from us. So I rented the space. We had a sublease with her. We've we've had two mental health providers. Who've come into our clinic. I've just paid them a per visit, you know, or they've paid me.
So, you know, the first guy I charged him five bucks an hour, just because I didn't want to make any money on them. I just wanted them to take care of our customers. So there's lots of options that you can do. If the one thing I, that I think people really have to understand is with any kind of ancillary service you're going to provide, you want to make sure you keep an arm's length because you want to make sure that people don't perceive that they're under your care when they're seeing this other person, that they are separate from you.
I think there's some medical liability issues. If you give that perception. So we have a deal with a physical therapist here in town. They do the first visit free, and then they charge $45 a visit cash. After that. That's a third party transaction between my customer and that we have nothing to do with that.
Uh, when we refer to chiropractor, refer to the dentist, we refer to the optometrists. Those are all arms linked transactions. So people, a lot of times try, I think, overthink things and just like DPC. When you're talking to customers. Now, this is really simple. That's what you want to do when you're thinking about opening your business less is often more so when we opened, you know, I went and I, I ordered way too many pharmaceuticals for me at the end of the first year, I was like, oh, I'm throwing this bottle of 500 lisinopril away.
You know, instead of just buying it as I added those customers, which is what we do now, you don't need to have. Everything that you had in your fee for service world, because you're not going to have 2,500 people out of the gate. You're not going to have, you don't have three other partners. So you got, you know, 15,000 people you're serving, you don't need 10 or an eight, eight or $10,000 EKG.
You don't need a procedure room. That's set up like the Taj Mahal. I mean, I bought things off of eBay. I bought things off of, uh, off of Amazon different just medical instruments that I'm not going to use a lot. I did buy an autoclave from a business that was going on that closed. I bought a, a used EKG from him that just crapped out on me last week.
So I just ordered a new EKG for both of our clinics. Uh, but buying things, you don't have one, you don't have to buy new. And to buy them as you need them telling somebody, Hey, I'm sorry, I don't have an EKG, but I can get you one at the local hospital for 50 bucks. That's still way cheaper than if they go to the local hospital on their own or they go to the ER.
And so I think people need to focus on less is more when you're first starting out.
But keeping the overhead low is, is so important, especially as you're evaluating your financials, especially if you do have school loans, et cetera. Starting DPC.
I say that with tongue and cheek, because the advice I give is not the advice I took.
So when we opened our clinic in Carney, you know, it was a brand new facility top to bottom. It was empty space, brand new. And my wife said, you know, you don't want to play old used equipment for exam tables. You don't want to buy, you want to give, you can only make that first impression once. And what we're trying to do is show people, healthcare can be different.
So our lobby does not look like a medical office. It looks more like a lounge. You walk in and there's a buffet buffet. There's big chairs, but when you go back to the procedure room, I didn't buy it. Box tape what I call box tables. I bought procedure chairs. So I spent a lot of money on those. I bought procedure carts because I don't like things hanging on the wall.
So I didn't want otoscope up DAMA scopes hanging on the walls. So we bought procedure cards. You know, there were $1,800 a piece. When I opened broken bow, I went and bought $400 craftsman toolboxes. They do the same thing, but they were $1,400 cheaper. So we went through a local company here where we bought our cabinets, broken bow.
We went to Menard's and bought our cabinets. You know, so learning in, not that they're that that's not okay. It's just that our cabinets in broken bow look really nice, but they were $3,500 versus 28,000. You know, and so those are the things that people just need to keep in mind is you can buy things that are really nice, which you don't have to spend huge amount of dollars to get them.
And so don't be afraid to shop around it's it's no different. I tell my wife all the time, we're no different than our customers when we tell them, okay, you're a cash pay customer. There's nothing that says we can't go negotiate when we're buying something for our clinic. And so that's what we do. I mean, my wife's a great negotiator.
She makes me, you know, she makes a salesman pride. I know we're going to get a good deal.
High five to your wife for that, because that's a great,
I tell people all the time, sometimes I don't show her, but, uh, if it wasn't for her, I wouldn't be here because when I left banking, she worked two jobs while I went to undergrad.
I, you know, I, that way I could be home for our girls who were, you know, um, Fourth grade. And first grade, when I came, when I left the bank, when I started med school, they were seventh grade and fourth grade. So, um, she, she's the one that allowed, uh, allowed me to do and follow my dream. And she's been the one you want to talk to somebody at DPC, she can talk to you about DPC inside and out from working backwards.
She understands it and she loves it as much as I did. And we're, we've been really fortunate that the staff that we've hired. So our second nurse, I've Chris, our first nurse, she ended up moving away. We hired a lady, uh, who actually came to us from. Home health. And she had called one day and it was really a weird deal.
We're looking for a nurse and she had called one day about one of our patients who was in their home health. And Janet was talking to her about, well, do you know what we do? We'll know. And by the end of the conversation goes, are you best looking to hire somebody in Tennessee? She goes, well, I'm kind of thinking about getting out of home health.
Well, come see us the next week she comes in, we loved her made after a position. So she came from surgery and then home health. So her learning curve in clinical medicine is been steep because she never was exposed to that. But she's been with us now three years and she does a fantastic job.
Okay. And you alluded to the fact that Dr.
Peterson has joined your practice and then you also have, Ann Llano, who is a nurse practitioner so, with the addition of those two to your practice, how do you guys, arrange coverage for the two clinics
so initially. In the spring of 2021 and was in nurse practitioner school.
So she had called up in the previous summer and wondered if we would, if I would mentor her. So she could do her last semester of her, of her training with us as a student. And so I did that and I told her I'm doing it reluctantly, but I'm also doing it because your husband and you are customers of ours.
So her husband. They have the company that we're doing the internet marketing through. They have been customers of ours for a couple of years. And so she understood direct primary care. So then she came and was a student with us and then about halfway through the spring. Well, and when we opened at broken, but we'd actually hired another nurse practitioner, but our numbers just didn't take off in Brooklyn that I could justify her salary.
So I had, uh, I had to cut her loose, but when Anne came on and then about, oh, was about March, she said, we know UMC has a residency program that I would really like to do that I would be with you for the next year, the caveat or the good part is they'll pay half my salary. It's like, oh, well that sounds like a win-win, um, you know, like cut your salary in half, but train you the way you need to be trained to do family medicine.
And so she came on board and has been with us full-time since July. And then she'll be, uh, the end of June. Should we? Don't the residency. And then she'll, she'll stay with us. And then. Last fall. Jacob reached out to me, Jacob's been out of residency about three and a half years. He started actually in the fall of 2018 in a town about 40 miles away.
Holdridge might be familiar with that if your superior ties. Um, and you know, he, he had gone out and talked to some people on his own vans, Lassie, for instance, and, and really when he came to me, it was like, well, what do you think about if I would be interested in joining us? Like, you know, I'm, I'm willing, you know, I'm now I'm 61.
I was starting to think about a transition plan out of direct primary care because I want to retire someday. Um, and he said, well, I went and talked. Eric was the, one of the questions he asked me was, well, if you had the opportunity to open a clinic, Or join somebody, what would you have done? I said, I'd absolutely.
Would've joined somebody. I wouldn't have gone through and spent expended all the energy that we've expanded the last four years to grow this, to get to where we are today. And so he goes, well, that's what told me. So that was kind of the impetus. And then, you know, we, we met with him and his wife. We took them out for dinner.
We met with Jacob a couple other times. And the beauty of Jacob is he understands he gets it. So he's got a wife. She's actually a family physician as well. She went to she's a Creighton grad, but Jacob already has been doing some moonlighting. So he has a locums gig already set up that he's going to be doing here for the.
Four or five, six months. And hopefully, you know, he's grown enough that he doesn't have to do that. But a lot of times when you talk to physicians about direct primary care, and you say, well, you may have to do locums until you get your numbers up. That can be a turnoff for a lot of people. But Jacob embraced that and said, oh yeah, I've already got this lined up.
I've been doing it one weekend a month. And I would continue to do that. And it's like, okay, you understand what it's going to take? You know, he's a small town kid. He grew up by acting. So, which is a ranching farming community up in the Northern part of the state. So the work ethic is there. Yeah. So it's been just a really good, so far, a really good relationship.
You know, he's at this point he's a 10 99 employee. So we will just pay him a percent of what he brings in and then the rest of it would go to cover his overhead. But again, I'm looking to the future. So. I'm not really too hard on him when it comes to what we're going to charge him, what that percent is, because I want him to stay.
And I've told him if you feel like at some point you want to leave, just ask me and I'll step out and you can take this over because we need more direct primary care physicians in Carney. And we actually have a physician that just opened one, a female physician. Um, I've been told there's a nurse practitioner that has just opened a direct primary type clinics.
So there people are getting into it and growing it. But Jacob Ward is absolutely floored that he decided to join us because one he's got great skills. He actually did the primary care program at the university where he did internal medicine and family medicine. So he did a lot of internal medicine, but he's boarded in family medicine.
He recently got boarded in obesity medicine. So. And we've seen since he's opened. I mean, we, this past week I looked at the schedule for this next week. He already has five or six obesity appointments set up just to talk to people about what he does. And so I don't think it's going to take us long to get him busy doing that, but he also does primary care.
So, you know, he can, he can do the toddler up to the, the 80 year old that we have in our clinic. Yeah.
Oh, wonderful. And let me ask you, because going back to the fact that he's a 10 99, what models, especially from your business background, would you say would be models to think about if a physician is looking to bring on another physician to their practice in addition to a 10 99.
Well, I think it really depends on the number of patients you have in your panel. I mean, if you, if you've got a thousand people in your panel, you know, you've got cushion there that you could say, okay, I'm gonna I'll guarantee you four thousand five thousand six thousand a month. And then we'll take a percent of what you bring in and I will pay you that.
And I think that's more of the Josh number models that that's, or I think actually Josh, they just start them out at two 20 or something a year. But I know there are some other physicians who've done, we'll give you a base. And then a percent above that, you know, with, with Anne coming on with Jacob, joining us was like, you know, For us for me and you, I think the most fair thing is less just do a 10 99, but there it's like stepping out of the fee for service world.
The direct primary care world allows you to do anything. So think outside the box and you'll be surprised. If you ask a young physician, how do you think you ought to be paid? They probably have two or three ideas that they've already thought about. So what a way to build a relationship is let them tell you what they think.
You know, just like we tell our, ask our patients what they think. Um, but I think you're really, you're either going to pay them a flat salary. Um, you're going to pay him a smaller guarantee plus a percent, or you do a 10 99. Those are the three ways I would, I would look at the initial thought process of adding someone now with Ann she's, she's an employees.
So she's just employed by the, you know, I've took a, we'll look at an hourly rate and then we'll, we'll figure that out for a salary. And that's what hers, her basal.
Gotcha. Now you mentioned how Jacob's bringing a bunch of new things to the clinic . you mentioned, that he is board certified in obesity medicine, but can you tell us about procedures that you have been offering and that now you are going to be offering with Jacob joining your practice?
Sure. We do. You know, I, I was been trained that I, you know, I do vasectomies. I, if there's something I can cut off, I'll cut it off. I'll biopsy anything, unless it's on your face. Um, you know, so we've been offering a pretty wide variety of joint injections. We're not doing PRP and PRF. We've had a lady that, uh, has had this wound that I am amazed at how PRF is healing.
But what's one of the things. And Jacob does those things too. One of the things he, he has some experiences with ultrasound. So when he joined us, we went out and bought an ultrasound. Um, not a butterfly. We went out and spent 25 grand on an ultrasound machine, but it allows him to do. Ultrasound-guided carpal tunnel surgery.
So he works with a company that with their device, he makes a four millimeter incision, puts the device in and Arabs. I mean, first the criteria of what do you have carpal tunnel, but then the procedure average recovery back to work is 1.6 days. And he's done over 70 of them so far. You know, the device itself is fairly pricey at about a thousand bucks.
So we're pricing enterprise had probably a two for one and three for both sides, but that's still 40 to 50% cheaper than going to the local or local outpatient surgical center. You know, he does this Actimize he does. Um, I, and D's all those kinds of things as well. But the ultrasound is one thing that he's, you know, he feels comfortable, you know, even, uh, like he looked for a young girl that, and saw that couldn't find the strings for ICU.
So where's the IUD, you know, so he did an ultrasound of her, of her pelvis. I mean, didn't do a trans badge, but did also have her pelvis and could see that the IUD was in her uterus. So we at least know it hasn't migrated outside of, outside of her uterus. So there are things like that, that he's had enough experience and had training on that.
You know, we're not going to do it and read it in-house but he can do it and we can make the decision. Okay. Do we need to have you go to the hospital and do more screening? And you know, we're lucky here in Carney. I'm not, have you ever heard of MD saying yes. Yes. So we're lucky that CHF both hospitals here, but Chi was.
The leader in that. And so, you know, we use MD save a lot for all of our imaging, whether it be ultrasound, mammograms, you know, CTS or, or MRIs. And so we can use the ultrasound as a screening tool before we make that decision. Yeah. We need to send you down to the hospital and get a definitive dumb. This is what we think is going on.
But, you know, in Carney with two hospital systems, when it comes to medical malpractice, you have to look at what's the standard of care in your community. And unfortunately that would be the standard of care is to send them to the hospital. But I'm, I'm thinking about, and Jacob's thinking about actually getting a VPN set up with a radiology company in Lincoln that we could capture those images, send them down, but then you, you really, what images do they want?
You know, from a, um, sonographers standpoint, are we doing the right images that the radiologists want? So that's kind of up in the air, but that's, those are two of the really exciting things on top of ISIL based medicine that I think we're going to add people to our practice, that it's a service they're not getting anywhere else for, for a price that they can afford.
You know, they can go get a couple of local fee for service clinics, but you know, our labs are 44 bucks. The local clinics are two 50 to 600. So
when a patient hears that or when a potential patient hears, um, what the cost of, uh, you know, CBC is, if you do it with transparent wholesale pricing versus what they got billed, you know, with their surprise bill a year after they actually had the labs done, they're just like, Wait, what, well, why would I use my insurance and they're blown away?
So yeah, I definitely would
say that. And I had a lady yesterday that we do some hormone testing. I use Amber some to do, to help me with some of that. And you know, her saliva hormone testing was $150. She's been the only two, a nurse practitioner that has her blood tests has been costing three 50 to 400.
And I said, we really need to get a baseline. You know, CBC CMP, lipid panel, TSH free four. And I'd do a vitamin D on everybody because over 70% of Nebraska's about to be deficient. And I said, you know, it's 44 bucks. We charged $10 to draw your blood and you pay a sense of what I paid for the lab test. She has her lab.
Does she had done in November at our local clinic in Holdridge, which is where Jake, the clinic Jacob used to be at. And she goes, I paid $1,200 cash for these labs. And I said, well, welcome to our world.
Yeah. Welcome to DPC. Absolutely. Oh man. Now I want to take a step back in that you were mentioning how involved with AFP you were and with the Nebraska family medicine, organization.
And so I want to ask do you see DPC really getting a national spotlight as more and more physicians are really wanting a different way and a better way to do medicine?
I wish I could say yes when I was doing my term on the insurance and finance commission, um, you know, it was, oh, it was, and it continues to be all about, uh, payment reforms, map, MACRA, MIPS, all these little acronyms. And as I, as I was finishing my time on the AFP finance insurance commission, I really started thinking about where family medicine was that today.
And I actually asked a couple of the executive leaders of AFP. Do you feel like the AP as an organization has put us where we are today because you haven't really helped us from a physician burnout, you know? Well, yeah. They've started a program of physician wellness or whatever. Yeah. That's a way to make money.
Yeah. But I do not feel like they have. I think they've, they're the ones that have kind of led us down. They're the ones that have, have bout the insurance companies and said, oh yeah, we'll do this. They're the ones that have said bowed to Medicare saying, oh, well, yeah, we want this reform and payment. And then they argue, well, that's the best option we had at the time?
Well, no, the best option to say, you know what? We have 110,000 members they're going to quit taking care of Medicare patients. So we need to change the way the system is. We need to break the system. We need to start from scratch. The other thing that I think people don't realize is when you start talking about the amount of money that, that follows, um, fee for service to the two biggest lobbies in Washington, DC, The hospital association and big pharma.
So it's hard to get a Senator or a Congressman to think outside the box when they're getting money pushed in their back pocket from a healthcare organization, like a hospital, you know, if you're familiar with them, do you save, you know, if you walk in and use your insurance card in Carney, it's going to cost you 22 to 2,600 bucks to get an MRI without contrast.
But if you buy it up front, it's $436. Well, to me, that's a travesty, there's 75% fluff in the cost. If you have insurance and why, why are, why are we doing that? Or why is that a, an option? And so I would love to say yes, but unfortunately, uh, I don't think so. I backed out a little bit of the API. I was on the board of the NFP.
I was an older to delegate to the AFP. Um, but I resigned from the. Two and a half, three years ago, because when I went to the last Congress of delegates for the AFP, there was nothing there about direct primary care. It was all things that I didn't even deal with. And I went back to the leadership. They are, they in AFP and said, you know, you really need to get somebody here that lives that world.
I don't live in that world anymore. Now I feel your pain, but I don't live in that world of having to worry about payment reform and how am I going to get reimbursed?
Um, so short answer is I wish, but I don't think, I don't think we were ever going to get that push. And that's where I think the DPC Alliance has been good. I mean, the AFP is, has thrown a little bit of money out there and has helped with, uh, what's not the nuts and bolts con it's not symbols. I mean, they have helped some, and I can't, I don't want to say that they haven't.
Um, but just, I don't think we'll ever get their full support
With that said, as this movement clearly is growing whether or not the larger organization support the movement with money, with visibility, et cetera. what are words of encouragement that you have for people who are really on that cusp of, Hey, should I do this or not?
Because you made that decision even at a later age than most people.
Well, I think the, the first question is, are you living your dream? You know, and that's the sad part is people who go into family medicine, don't go into family medicine to get rich.
We go into family medicine to take care of people, to build relationships and, and feel like we're doing something worthwhile people who are burnout. When I got burnt out, um, I wasn't helping anybody. You know, I wouldn't help him myself. I wasn't helping our customers. I wasn't helping my, my relationship with my wife.
So I think that's the first thing is, are you living your dream? If not, then we all have to look and make up, make decisions. You know, it doesn't matter if you want to lose weight, you want to quit smoking. You drink too much, you know, you want to make a change in your life. You've got to look at the pros and the cons and personally, I'm a list writer.
So I, this is the problem. Here's the pros. Here's the cons of all my. The explosion that we've seen in the DPC, I think is because more people are, are getting more burnout, but are also building relationships with people who are in DBC physicians who are actually practicing. And then hearing that, Hey, this can work that it's not gloom and doom, uh, is not con being on call 24 7, 365, that you can set boundaries.
You, you know, you, you can do what you want to do. You know, the old adage where you always hear a DPC meetings, as you've seen one DPC been seeing one, you've seen one family practice clinic. You've seen every family practice clinic fee for service. And I truly believe that that's true. I remember in the fall of 97, I went to a meeting in Florida, Amber and I went to that doc, uh, something foundation, but it was a DPC meeting in the first night.
There were like 380 clinics represented. And like, we hadn't even opened yet. There were 60 or 80 of us that were just looking. And I remember calling my wife and saying, it's the first medical meeting I've ever been at where everybody's happy. There's nobody complaining about their administrator. There's no way to complain about the hospital.
There's nobody to complain about fee for service or Medicare reimbursement or a lot of out and out and out. Nobody complained that they got disgruntled employees because the only typically have one or two employees. And if you don't like them, get rid of them. It gets me in there, your life. And so I can still remember telling her everybody's happy.
And that's the juxt of it. Is it do what you want to be happy, but realize the direct primary care has different stressors. There are, you know, I remember when we first opened, we would sign up 10 people in a week and then we wouldn't sign anybody up for two weeks. It's like, oh my God, we're, we're good.
We're golden. And then it's was like, oh, we're going to go broke. And then we're golden. Now we're going to go broke. And so, you know, when you look at all the financial charts, it's always a straight line. It actually should be a zigzag line going up or going down because you don't add people in a linear fashion, you add them in, in fits and starts.
And the big thing is one, believe in yourself too. You have to have the support of your partner, whether whoever that is. But three, are you living your dreams? And if you're not, it's time to make a change anyway, and going from one healthcare system to another healthcare system, unfortunately, it's not going to change how you feel or how you practice medicine.
Well said, well said thank you so much, Dr. Jacobson for joining us today.
I'm glad to be here. I, uh, I love what I do. I love direct primary care. I love what you're doing, getting everybody's stories out. I, when I drive to broken bow, I usually have headphones on and I'm listening to your podcast. Um, just because everybody has such a unique story.
And if you listened to your, to all of your episodes, There is such a diversity in what people are doing and how they're doing it from your type of practice to I'm more of a traditional family medicine practice to somebody who's focusing more on women's health to somebody who's really focusing more on internal medicine as an adult population.
So follow your dream. If you're not living your dream, look in the mirror. And the hardest part is looking in the mirror and being honest with yourself and say, "I need to make a change." If an old fat guy from central Nebraska at age 57 can do this and be successful, because right now we're about 850 customers in a little over four years, anybody can do it, especially if you're young and you've got more energy than. Go for it. Live your dreams.
Next
week. Look forward to hearing from Dr. Bolina mock of direct primary care in west Michigan and grand rapids, Michigan. 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. Leave a five-star review on apple podcasts and on Spotify now, as well as it helps others to find all these DPC stories.
Lastly, be sure to follow us on social media. If you're wanting to continue learning more about TPC, check out DPC news.com until next week. This is Marielle conception.
*Transcript generated by AI so please forgive errors.