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Episode 76: Dr. Grace Torres-Hodges (She/Her) of Torres-Hodges Podiatry - Pensacola, FL

Direct Care Doctor

Dr. Grace Torres-Hodges in her white coat
Dr. Grace Torres-Hodges of Torres-Hodges Podiatry

Dr. Grace Torres-Hodges is a board certified podiatric physician and surgeon who started Torres Hodges Podiatry in 2001. She transitioned to a direct care specialty practice in 2017. She completed her undergraduate studies at Vanderbilt University and was pursuing graduate studies in sports medicine at the US Sports Academy prior to medical school. Dr. Torres-Hodges received her medical degree from the New York College of Podiatric Medicine and completed her post-graduate training in podiatric medicine and surgery at St. Vincent's Medical Center in Jacksonville, Florida. She maintains surgical staff privileges at her local hospitals as well as the Andrews Institute for Orthopedics & Sports Medicine.

She has shared her knowledge with the next generation of physicians teaching the medical students and residents at Florida State University College of Medicine and the USUHS programs at Eglin Air Force Base and Navy Hospital Pensacola as well as within the Doctor of Podiatric Medicine Mentors Network (DPM Mentor Network). Dr. Torres-Hodges has been named a Top Doc by HealthTap Online and was named the 2020 recipient of the FPMA's Podiatric Physician of the Year.

Dr. Torres-Hodges holds an executive MBA from the Quantic School of Business & Technology and promotes physician entrepreneurship. She is co-founder of D2P Medicus Consulting and remains a staunch advocate of preserving the doctor-patient relationship and the independent private practice of medicine. She has been featured on podcasts for Lean Frontiers, Healthcare Americana and the Benjamin Rush Institute and has been an invited panel member to Women in Leadership conferences.

Locally, Dr. Grace is still remembered in her hometown as a musician and cellist with the Pensacola Symphony and remains active with volunteer organizations in her community. She is proud of her family heritage, especially the traditions and values her physician parents taught her. She was honored to share their immigrant story as part of the compilation book Filipinos in New York City. Above all, her most treasured time is spent with her husband, son and daughter.



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Welcome to the podcast Dr.

Torres Hodges. Hey, how

are ya?

Thank you so much for being here. And it is wonderful to start with such an impassioned opening statement. I just, I absolutely love that and I hope that the listeners are just ready, ready to hear your story. So you are a podiatrist, you are a specialist who has been opted out of Medicare since 2017, but I want to take a step back. And if you can give a little bit more about your history as to after you graduated podiatry school, what, what did your, what did your world look like at the.

So after podiatry school, I did my residency in podiatric medicine and surgery in Jacksonville, Florida at St.

Vincent's medical center. I had a great opportunity there to learn about all aspects of pediatric medicine and surgery, because number one, we ran our own clinic. So there was something there to be said about actually considering private practice. So I was exposed to that. And then also we were the only surgical residents at the hospital.

So we scrubbed every case. I mean, I was scrubbing gallbladders and heart and everything. Never again will I did do that. But it was nice because, you know, you got to meet all different types of specialists. You've got to learn different techniques from other people. You just interacted with the whole system at at the hospital.

When it came time after, after graduation, trying to figure out where to live. My husband and I actually were separated our first two years of marriage because he was still working in Washington DC. And I was in Florida. Um, We racked up a lot of frequent flyer, mileage back and forth, and a lot of calling card calls all the time.

But it was going to be either around the DC area or in Florida. I had an inkling of wanting to come back home to practice in Pensacola, both my parents practice there also. So I kind of had a little bit of a leg up to, to come back home. it wasn't that difficult to convince my husband to move to Florida.

So, I'm very grateful that he obliged and, and we did. So I started practicing in Pensacola. I actually joined a group first and was employed and. You know, I remember my parents saying, well, why don't you just open up by yourself? And then both of them, they have a general surgery and internal medicine, clinical cardiology background.

And they wanted me to join them. Like, no, no way. I'm not going to do that. I grew up being a doctor, Torres kid all the time, and it was bad enough that I come home. And even as a doctor already, they were always knew me as, oh, are you Dr. Adelaide or Dr. Dewey's kid. So you always had to be kind of building up your own reputation on that, which again, that's another thing altogether, but it was, I think it empowers me, it empowered me at the time and made me, I have to prove I have to do this right.

And do well, but I joined a group practice and I learned the intricacies of insurance. Capitation and contracting didn't realize that at the time when I signed away everything that I was in that practice, actually, I didn't realize I was the one being assigned all the capitation stuff. So here I am working my butt off and was not getting a return because I had a an associate to partnership agreement that was going to be based on the revenue that I was making.

But when you're cafeteria, you're not going to make the revenue on that. And I didn't know that long story short, the relationship there ended after a year. And then I opened up my own, my own practice and that's it did not have one HMO or competition plan in that, but one of the benefits of opening my own practice, I learned.

From my previous employer, how to run a podiatry practice. But I also had a little bit of a leg up because my parents both had had private practices already. They were actually in a joint private practice together. And so I got, I was free labor all growing up. I worked in that office. I answered phones.

I filed I cleaned, I even transcribed. So I learned how to, you know, I was doing a lot of the transcription over there. But one of the things that. It was a family business, not only where my mom and dad, the two principal physicians there, but my aunts actually where the office manager and the reimbursement and claims specialist and early on, I don't even recall them being too much into insurance things.

I remember when my aunt told me about the copay and how that was a different thing that they were doing. And, you know, I was probably in middle school when all that happened, but you know, so I got to see the practice from both ends from my mom and dad's side and also from my aunt's side to see all of that.

And so I had a little bit more business knowledge that I was able to take with me into my own practice. I successfully practiced from to 20. About 2013 when I was feeling, you know, the, the pinch of all the new regulations with, after having completed PQRS with Medicare, after completing a change up to, I mean, I started out with paper charts and then I had to switch over to EHR, I did the incentives with the. Electronic prescription because you know, none of us know that at the time that what you end up doing is you're given a, a directive and said you know, you can get an incentive on your Medicare reimbursement, if you Do this, this upgrade to e-prescribe without the knowledge, knowing later on that they're going to penalize you once you didn't reach or attain that by a certain date.

Um, But we were like conditioned to just do this over and over again. And one day my husband was asking me, what are you doing? Come on. Let's go.

And I'm like, no, I've got to do my charts. I've got to fit. I've got these audits to finish up. Cause there were probably some chart or audit and he goes and says, you know, what, what are you doing? You do this every night. And, and I said, but I had got to. And he goes, but is it helping your patient? And then that little question right there was the one that kind of got me thinking.

And then, you know, is it really helping my patient? No, not really was it was going to help me get paid for helping the patients that I already helped. And then, you know, it started the wheels turning a little bit on like, what am I doing? Why am I working so hard? And then each year up until 2013, I started you know, each of you had to see more people because your reimbursement rates kept them going lower and lower and lower.

I had all the insurance plans. Like I said, I had no HMO's, so these are all private pays and Medicare all PPS. And you could feel that that just overworked and it's like, why am I doing this? You were just tired. I mean, you, you love what you're doing, but you just hated all the minutia that was, was around it.

And then from that point, what happened was I got this email. How about this meeting called how to thrive, not just to survive from a group called the American association of physicians and surgeons. And it was a one day, a all day event and you can get CMS and it was over in Dallas. And I really didn't know what to expect.

I didn't know much about what the group was. And so my husband and I decided to fly out there to see it. And I get into this room. And the first thing that they talked about was opting out of Medicare and I'm like, wait a minute. Why, why would you do that?

You know, who can do that? Especially me as a podiatrist. Why would I want to do that? That's like 50 to no more than 50. It's about, it was almost 75% of my practice. You know, why would I want to do that? But then I got to thinking as they was listening to the lecture about all of the rules and regulations about the caps of how much you can charge about the reimbursements, the punitive, the punitive damages, or the punitive penalties that are there.

If you don't do something right. And I got to thinking, oh my gosh, this is. That. Yeah, they are right there. That's exactly what I'm thinking. Why can't. Yeah. And then, then they had a couple of other people come on and give basically a case studies on their practices themselves. Josh umber was one of them.

And you know, he, they to hear about Atlas MD early on in 2013 um, it was pretty, still new and it was amazing because these guys were young, they just got out of residency and they just opened straight up. And then ironically, I actually met three specialists at that meeting also Dr. Kathleen Brown dermatologist.

She talked about her practice, Dr. Gerard Ginoli an autoloader ecologist. And he talked about that and to hear it from a surgeon that was really interesting. And then Dr. Chris held who's an ophthalmologist To hear her. And then another doctor who's an emergency medicine doctor Dr. Beth Hanes went up and talked and she was very very passionate about explaining the importance of continuing on the noble profession of medicine.

Um, At the time she was very much involved in the Benjamin Rush Institute. And that was my first encounter with the Benjamin Rush Institute which for those who don't know, it is a nonprofit organization that is geared towards educating our medical students and residents about free market principles and honoring the doctor patient relationship.

And that was probably the biggest thing that you get out of that conference was that everything was geared towards the doctor patient relationship. And it was. Kind of what, like my husband, when he asked me that question is what are you doing? Is it helping your pay, everything kind of jelled together at that point?

You know, and then I made a, I made a commitment at that point to start really paying attention to my numbers. And we looked at the books, I looked at my payers, I knew who was paying well and who wasn't paying well. And and then unfortunately every year they got worse and worse and worse, but I decided to look at who was paying the worst and start weaning off.

A lot of it also was educating. There was a group there called docs for patient care. That was really good about. Giving material to their patients, because it's not just doctors that have to do this. We are the first ones on board, but you have to also educate your patients about it. And I think that was the biggest thing in my transition from 2013 to 2017, I took that time to really educate my patients about what insurance and third-party payers were actually doing.

Not only to me, but to them that they weren't being good stewards of their money. And by the time I dropped Medicare and opted out of Medicare in 2017, I had there's a method of doing it, but it was about 55% of my practice. I took a huge financial drop that first year, year and a half. But when you drop those people in there, a lot of them stayed on because they'd been with me for, for a long time.

And when I had already educated them about how the whole practice was going to run at that point a lot of them stayed on, but you know, when you did, you, you did lose a lot of those first timers that, that one, you know, you have to be ready for that.

If, if you're going to go this route. I think in retrospect, if I was coming out of residency, I would have tried to do it directly. It it's, it is difficult when you're already in, not, I wouldn't say difficult. I say that it, it's more, you have to plan it properly when you're traveling. Does that make sense?

It totally

does. And Dr. T wen had mentioned this in her podcast, but that you are so passionate about mentoring. And so when you mentioned, you know, just being ready, it's definitely something that, to be business savvy, you have to prepare for the future.

So I think it's very intelligent to, to mention that because people who are new to this world of what is direct care or could direct care work for me as a primary care doctor, as a specialist, that is something that they have to

consider. Absolutely. You know, and the thing is, is that we want to do it.

Well, those of us that are in direct care, you want. For personal reasons, selfishly, we all want to do well. One of the things, I think that's difficult for doctors, we're, we're naturally altruistic and we want to serve, people. But I heard a, um, I heard a great phrase.

I, I took the Hippocratic oath. I didn't take a vow of poverty. And that was awesome when I, when I heard that, because, you know, that's so true. We, we were running a business when you were running a private practice, it is a business and you have to start running it like, and thinking of it like a business, your patients or your consumers, but there's just an added bonus to it.

The fact that you develop a relationship with those patients. And that's the essence of medicine is because there's that personal relationship that you get with them over there. But Yeah, it, it, we want, we want this to do well. We also want to attract good people into medicine. That's the thing.

And the way that third-party payers and administrators have hijacked medicine by adding all these extra rules and regulations it's burning out everybody and you hate to say burn out because that makes you know, you don't want to be, the doctors should not be the victims of this, you know?

But it, it has his tainted it, and the beauty of all this right now is that we have a chance to make a difference. So, I'm hoping that my attempt in doing it by, by helping other doctors by mentoring our young doctors, because you know, when, when you get out and I'm sure the same thing, you'd tell me if it's the same thing with you when When you go through through school, particularly undergrad, you go through med school your four years, and then you do your three years residency, some five years to seven years, and then fellowship first off, you know, talk about just the undergrad through your first three years of residency.

You know, you're talking about your 11 years of indoctrination of academic medicine. That's only in the hospital. You're not learning a lot. I don't know of too many programs that do private practices. You know, that's why I was kind of fortunate with, with mine. We did have a clinic, we ran and but the majority of them now are all geared towards particularly surgery.

Residencies are all geared towards cases and in the hospital and, and trauma, but I'm sure also in, in the non-surgical specialties, it's , the same thing. but, again, you want to attract the right people into it. You want to make sure that you give them the opportunity to grow.

And when you have some third party stifling you the entire time that's, that's not going to be helpful, but they, the, the students getting out don't know that one thing statistic that I heard was that almost 61% of our graduating residents they get interviews because they are catered to, by hospital groups to join, you know, the medical group practices.

I don't recall that when I was going through residency, you had to find your job afterwards, but now they're actually recruiting them. Have you found that or heard that also?

So in family medicine, I I definitely would say that when I was graduating residency in 2015 most of the residents in prior years had all gone to Kaiser because in Kaiser, Northern California, as well as Southern California, there's a lot of Amazing deals like we'll pay your seven year mortgage, we'll pay your blah, blah, blah.

You'll get this amount of money. But in terms of recruitment, I feel that recruitment was not that aggressive when I was in residency, but I definitely know that having seen the recruitment side of things and heard the recruitment side of things in my local community after residency, I know that it's very, very competitive to try to get people, especially to certain regions where there could be lack of care in all specialties.

Yeah. But it it's interesting because when you mentioned this idea of That you know, that a person should be able to continue to grow after residency and how you, you also mentioned the very regimented, , we go to undergrad, then we go to medical school, then we go to residency. Then we go to fellowship if we so choose.

We're conditioned to just follow the rules. Our pathway is not designed for us to really think about how do we grow as individuals, not just in our skillset, but as making careers and choosing positions that allow for us to feel fulfilled in our, in our souls and for us to be able to have that freedom, to develop the relationships that we want to build with patients.

So I think it's so interesting how it all goes together. And I want to ask there when you went with your husband and cause in what profession is your husband in?

My, my husband actually has a health insurance background. Okay. The funny thing is that he actually. he's going to love this.

He predicted this. He predicted a lot of this because he has a background in health insurance having worked in the federal government before, and then also working in the private sector having his own brokerage firm too. So, he sees it from the payer side. So he, and, and he was my office.

He still is my office manager. He does it more part-time and away from it because he can do it remotely. But yeah, so he can actually see, see everything. A lot of what he did in my office was actually the follow-ups for reimbursement. And then when I say. Doing insurance. He didn't have a job. And with that, which was, I think maybe part of his plan in his head also, but uh, no, but in all seriousness, he, his, his background is in that.

He actually understood it. And he, he looks at it from an employer's perspective and how the employer's money is being spent properly and how the patients money and their premiums are. Use or not used properly. So, yeah,

when you mentioned though, that your husband was in, was on the opposite side of things in the insurance world. It's so interesting. Cause I, my question not knowing what your husband did for a career was after you guys left that conference, the APS conference in 2013, what sense of value did you have and how did it shift by hearing these words about.

Wow. There's people, specialists, dermatologists, ENT doctors, people who are doing specialty care, who are also probably very dependent on Medicare is as the reimbursing insurance that they're able to do. Direct care. What was your sense of value after you went to that meeting?

Oh, it went up, you know, for the longest time you think that after spending hours at charts spending late, late days, seeing 30, 35 patients a day, you know, realizing that the return on each patient was so minimal compared to the actual care that you gave many times not being paid for your service.

Three six, even, almost a year after, because of all the appeals and everything. You know, the, the patient probably has already been discharged at that point. And you still haven't been paid. patients didn't know that. And unless you see the behind the scenes of it, unfortunately, a lot of doctors don't know that also, you know, and that's another aspect of my mentoring is, is always trying to not teach just new doctors coming in.

But doctors currently what's going on in your office. And if, if you're working in the hospital or employed, you don't know what's going on, but that's the problem is that your. Uh, You know, if you don't know what the prices are of what you're doing how is it that you're kind of contributing to the system also to the broken system?

Unfortunately, you know, one of the things I've I've recently started mentioning to patients is you know, cause they say, well, why can't it just be like car insurance? Why can't health insurance just be like car insurance and, you know, and in a sense that people get it, people get it with car insurance, it's for major medical for accidents, you don't see any of your car insurance folks paying for gas or for the car tire rotation or oil and filter changes, which are your maintenance things yet when.

And this is going back to when my aunt was telling me about the copay and what was covered you know, automatically your annual checkups and everything. The fact that all those, it just got lumped into one copay. They think it was like a prepaid type thing. That's not how the system works.

You know, and that the cost of the visit was only $20. I, I, I know, I think might be jumping a little bit around here, but as I'm thinking about what, what we're talking about, what's interesting is that the patient base that I had when I was still on an insurance tended to be a lot sicker than the patient base that I have as a direct care doctor.

And the reason being is because you're giving the patient onus on their own health. They have to maintain and stay healthy. Otherwise they are having to come in more often and pay more often. And there is, they're getting value on what they're getting their treatment, but look at the ones that I only have to just do copays all the time.

You're not, you're not, there's not a, there's not an incentive, I guess, for them to, to, to get better because they're going to be taken care of. Anyway, it doesn't, you know, I don't know if you've seen that in your own.

Definitely. My practice at this point is, is, you know, a few months old, not a few years old yet, but it's definitely that the people who came over from my previous practice really understand the value of.

Health and the value of prevention. And so it's, it's very different when in my previous panel of patients, the people who would not consider a direct care practice are the people who are more so in the. I'm not going to do anything. If my insurance doesn't pay for it. Right.

It's not that's I don't, I don't pay for healthcare. My insurance does, but you know, Dr. Jeff gold is famous for talking about the, the credit card analogy, how, you know, we use, we just swipe our health, insurance cards, like credit cards, and it's like, it doesn't actually work that way because you know, Medicare, premiums for month or I'll over $170 this year.

What's interesting is that a lot of those patients and also the doctors don't understand how this works. You know, insurance will say I'll pay 80% of your, of your visit. Well, what's the cost of the visit because if the cost of the visit is $10, that's great.

Okay. But if the cost of the visit is $1,000, They're going to pay 80% of that. You're still that there's a hidden, you know, that whole thing with price transparency and everything like that. When you don't know what the actual cost of the stuff is you, you, you don't even pay attention and people wonder why are the premiums kept going up or keep going up and everything.

Now I want to ask about. Your actual transition to you. You've mentioned it a little bit. You, you went back from the conference in 2013, you started paying attention to your books.

You started paying attention to the reimbursement rates that insurances were providing you. And you started on this pathway of I'm going to work towards not accepting insurance at all. And in 2017, you finally, when Medicare free you took a hit, you said, but I want to ask when you knew that your practice is around 55% Medicare at the time that you decided to opt out, what did you do financially to plan for that hit?

So, you know, at that point then 45% of the practice was all cash already at that point. So, you know, as you build the practice up and a insurance patient doesn't come in, there's a, another patient that comes into that slot. And, and keep in mind that your reimbursement on that cash patient now is better than what the insurance one was before.

Because you're getting paid for the full amount of your visit rather than. You know, the worst pair I had was down to 52%. You know, if you can't, you can't run, run an office. in 20, 20 14, 20 15 our staff changed also because as we started dropping insurance my staff now consists of my husband's offsite.

So I don't count him. He's like half, half there. But I have two staff members I have a front and a back office assistant. So your overhead, the things that you can control you control we, I got really, really picky about how. I started paying attention to the ordering, making sure that we recycled all of our paper because despite the fact that we had switched over to an EMR, we still use paper.

You know, but I really got strict on, on expenditures. I took out a line of credit. You have to, you have to be realistic with that. You also have to look at niches that you can do and look for non. Visit type of things. Now, in, in podiatry, we have a lot of options. Number one, we do surgeries and a lot of procedures in our office.

Niches in there can include, I do minimally invasive procedures. I do small, a lot of nail surgeries we do in the office, obviously a lot of excision, excisional, biopsies you know, do it both in office and outpatient as well. You know, I, my I've always had an interest in and I think it's because being a mom myself Poteau paids, you know, so there's a lot of that.

And you start to market in that realm. And I didn't really do much marketing as much as word of mouth. I would show up at a lot of. You know, my, my children's baseball games and their basketball games and everything like that, I'd sponsor the teams, you know, I would check on the kids afterwards and everything.

I would go to the preschools to the daycares. I drop off flyers and introduce myself to the OB GYN staff. You know, you have to do a little marketing on your own. So you'll find your niches. Uh, With that I had I offer other modalities in my office that were already cash based that were never covered by insurance.

Ironically Medicare helped me a lot because they stopped covering a lot of services, like routine care for, nails, corns and calluses. And what's what has always amazed me is like, The will will take, for example, the diabetic shoe program which Medicare has as a good, good program in the sense that it's there to protect the diabetic from developing pressure points with accommodative in lace and proper shoes, proper examination and everything like that, so that they don't develop an ulcer eventual infection that could lead to an amputation, good premise and everything like that.

And that works. Medicare will cover that fully for the diabetic one pair of shoes, three pairs of in lays. We're good. Now what about if you have a rheumatoid patient that has severe arthritis with calluses on the bottom of their foot, that patient with Medicare does not get any kind of reimbursement for a shoe.

It does not make sense to me. And it didn't, and, and things like that, you know, like I said, there were a lot of little rules and regulations that had nothing clinically to do with caring for a patient that it made it very clear that you could transition. And the more I got into doing more cash things private insurances are notorious for a patient comes in with bilateral or both sides, toenails ingrown and infected.

They will pay for one and they will deny the second one, unless you bring them back in for another procedure, you know, I never did that. I never brought them back. You just swallow that because you don't do that to your patient, you know? the most convincing one for me. And that led to one of my most vocal advocates for direct pay was a gentleman.

My diabetic patients, come in regularly for a bi-annual checkup. So I know them, they are very, very proactive. This gentlemen was very proactive. Had Nick to shin, had a gash on his shin that had a little bit of an exposed tendon. I looked at it and wanted to I said, you know, this is not looking like it's healing.

Well, you should've come in sooner, obviously, but what's done is done. Let me I'm going to bring you to the operating room. We need to delineate this and I want to find out how much I might need to debris on also double check and make sure it's not into the ball. And. I was going to send him for an outpatient MRI to check this, but the insurance company denied it and said that, no, you need to do local wound care and put a cast on it.

And, and I said, forget that. So I played the system, I sent them to the emergency room. I told him this also. And he was like flabbergasted. And he goes, what? I mean, they, they denied it and they go, it's a stat. I need it. And they go, well, this is how we're going to do it. Go to the ER, I give you, I gave him his note.

I wrote a note to the ER, physician gave him a heads up. They ran the MRI at the hospital. They admitted him, consulted me, brought me in. I did the procedure at the hospital, but you know, it got paid by his insurance, but even him, he looked at it. It could have been a lot cheaper, done it the other way.

And As time went on more and more of those types of things kept on showing up. And by the time, by the time it was a 2017, the drop everything we were ready and it, like I said, it took about a year you're you're you're in two months to build back up. And then since then it's been good.

The pandemic ironically showed how viable the direct care model works because when everything else shut down, direct care, Because we're still accessible to our patients. Whether, you know, I had an opportunity for them to come in and see me, but even before the pandemic, I was doing telemedicine because that's just it's for me, it's not a visit.

It is an extension of the cell of the telephone call. It's the next phase up. I use it as follow-up for wounds. I use it for follow-up for nail surgeries for trio. Also with the patient home visits, I, started doing more of them because my patients were scared to come in. That's fine. You know, I can, I can do that.

There's no one dictating us. And then I remember early on in the pandemic that a lot of, a lot of other doctors were, how do we get reimbursed for the telemedicine? How do we like not an issue for us? You know? So that was actually a good thing, but it, it, I think COVID, and the pandemic shutdowns all really did open up a lot of awakening with regards to direct care.

Yeah. And

when we talk about patient awareness, I definitely would say, and we've said this on the podcast before, but it's so true that patient. We're sort of forced to see the ugly side of healthcare and when they couldn't access, physicians by their cell phones, their zoom calls, whatnot.

It made it very difficult for people to get care and thus more people went to, at least in our community, local, urgent cares, local emergency rooms for things that could have totally been taken care of in the clinic. But you know, this idea of like how do I get reimbursed it makes me think about how.

My husband who is still in fee for service. He had, you know, three, no shows on his last day of clinic this week. And , I was talking with his mom and saying how like, oh no, he doesn't get paid like that. They don't show up. There's no codes to, to build, or he doesn't get paid versus in direct care for physicians who are paid on a monthly membership basis or an annual basis or whatever, the agreement is there's no, oh, because the patient didn't show up, you don't get paid.

And so, you know, it's, it's so interesting. How, if someone, if you could only talk to a person by telemedicine and fee for service, you may or may not get paid in the future. But with direct care, it's like, that's just included in the membership. So.

Bringing up the whole thing with that, that made a lot of patients aware, you know, in the midst of all of those shutdowns, a lot of people lost their jobs and lost their insurance.

Now, what do they do? You know, and I was, I was available for those patients because I didn't take insurance so they could come and see me directly. And I think they were surprised to see how much, you know, for a consult with a specialist it's not as expensive as you think it would be. You know? I, it, everything is so inflated and their mindset is so inflated because they don't know what the prices are.

And the whole thing about price transparency that became very apparent with it. And that's, you know, the fact that, that their insurance was tied to their, to their job. This is where the beauty of direct care actually in the free market works. Because if you are the owner of your own. Destiny, I guess, particularly not just from the doctor perspective, but from the patient perspective, you have the opportunity to go to who you want to go to and when you want to go to it.

So, it's the three A's accessibility, affordability and availability.

yep. And I love that that's legit on my Instagram page where my clinic is as the three A's, but when you talk about that people, that patients, people who are in need of care can choose to, to go to anybody who is doing a direct care practice, because we, we don't discriminate against, what insurance do you, or do you not have?

I go back to your mentoring and the fact that we need more quality physicians doing this so that people have access to, to people in their local communities, no matter where they live in the United States. So I want to ask about your mentoring because people clearly have have talked with you about direct care, direct specialty care, direct primary care when you as a practicing direct care specialty.

Have people approaching you, how do you start the conversation? The reason I like asking it, like this is because I want to, you know, I want to also plant seeds for people as they're talking to other people as to what you found is helpful. When you have a conversation with someone who's interested in direct care medicine, so that, you know, we don't scare people off from that first conversation.

Right. Right. I think it comes down to first remembering why you went into. Okay. You know, again, we are naturally altruist. If you will, on the medicine, you do not go into medicine, do not go into medicine to make money. That is not the reason why you go into medicine. You go into medicine because you want to help somebody, you know, and that you want to make a difference in their life.

And it, you know, to give is better than to receive. And that, that is that's the underlying premise behind it. So don't forget your, you know, I guess it's Simon, Sineck always says, , don't forget your why. Um, Know your why. But that's that, that is the first and foremost. And what's going back to the fact that the indoctrination after

11 years of undergrad graduate and residency, at least for the first three years. What it took for us to get into medical school required all free market principles. We had to sell ourselves. We had to have that initiative to, to rise above. We had to know our worth and we had to explain that to people.

We had to show that to people we had to see one, do one, teach one. We had to do all that. We have to remind people that we knew how to do that. We just forgot how to to do that. And then, You have to be realistic. You can only see so many people in a day.

You're only going to see who you, you know, you're only going to make money of the people that you can actually see, but don't work yourself to death about it. Be realistic. We get, I think a lot of doctors in their head get spoiled because they get enticed by these big. And I th this is where I have seen some issues where it's been harder to transition out doctors who have already gotten on board um, big clinics or big like hospital groups.

They had those big six figure salaries and almost seven figure salaries in some cases. But that they got used to a certain level. And you, you have to be, you have to be realistic. You have to just go back and realize that no, you work for each one and just like balancing a checkbook, knows your ins and outs that it comes down to a lot of, a lot of basics.

It's a lot, you know, it's not a harsh reality, but it's a reality that you have to I try to be gentle when I explain that to, to people. You know, cause what, what everybody's different. And I think my, my, one of the key things that I do when I'm talking to doctors that ask me about direct pay and either primary care or specialty is that there's not a magic formula to do this.

You have to figure it out yourself, but you have all the tools I will help. I will guide and I will be your sounding board, but you have to do it yourself. We all have the capability of doing this and you know, Look at other industries, my aha moment. Was when the plumber came to fix our toilet.

What was so funny was that the whole way that, that came about made sense to me, why can't a doctor do that? You go to your friends in this case, I went on Facebook and I wanted to find out who do they recommend as a plumber? So you ask your friends, who do you recommend it as a doctor?

they come over, they examine, they diagnose, they give you your options. That's exactly what I do. I examine, I diagnose, I give the patient their options. I let the patient decide just like the plumber made the client decide. You can either go with me or you can go to somebody else. It's always their choice.

And that's a key thing. You do have to remember. It's the patient's choice they're coming to you. And at that point, when you decide, when I decided, okay, you fix it, you're the expert. Go ahead and do that. The amount is transparent already. We pay at the end of the the service, the transaction's completed.

I'm happy. The plumber's happy. The same thing happens with a doctor visit. It seems so simple with it that way. And when you put it in terms like that, people get it. So I think it's just a matter of, we maybe may have overcomplicated so many things with, with the way that medicine is right now.

But it was John Josh, Amber reminded me of that. Pavlov quote, you know, if you want to learn a new idea, read an old book, this is, this is an old book. This is the way that medicine used to be done. You know, this is the way that my mom, my mom and dad practiced also, you know, and it's ironic. I had a conversation with my mom today about about this and, you know, one of the things that she's so grateful for was that I had lunch with both my mom and my aunt, the aunt that was the office manager.

And so, you know, she was so grateful for the fact that she got to just concentrate on medicine and didn't have to worry about the business end. And my aunt was the one that did all the business end stuff. And, and she goes and says, and I think what happened was the, the business people took advantage of you guys.

And she goes, yeah. And now you're going to fix it. And I'm like, well, I guess so maybe I'm trying. That's really beautiful

though. it's full scope in terms of, your parents now seeing you be part of this movement, to take it back to how it used to be.

So I think that's so beautiful. Now when you talk to people about direct care, Part of this is being an entrepreneur. And part of it is, you know, the, the language of business and the language of owning one's own business. So how do you talk to people who might not have an MBA or might not have business training or who might not have been in a previous profession where they were responsible for their own books?

When you talk to physicians about doing direct.

Going back to w we have the skill set, it just needs to be refined. Everybody learned how to balance a checkbook. So you have at least a hope um, you know, you know, so you, you, you know, it w you know, what's the funniest that you can relate it also to medicine, we understand ins and outs when it comes to volume in a patient, and, you know, well ins and outs of your, of your practice, the same thing, you know, you have to, everything has to balance in there.

We're, we're all

Making sure that everything has informed consent. So I think that's important understanding how insurance contracts work and how they have not worked read your contracts because you don't realize what you signed away, what you signed away for. One of the things that I mentioned to them is.

Just start slow, starts, start small. And I actually have had a problem trying to teach business because it came naturally to me and, and there are some people that are like that. It just comes natural to them also. So as a matter of fact, I just, I went back to school because I actually had time now because my, the way my schedule is I was actually able to go back.

Because I wanted to learn the pedagogy of how to teach business concepts to people. I have a better understanding now in the midst of all of that I think it's important that doctors that do understand business or have business degrees really speak up also because it gives credibility not just within the physician world, but also in the non-physician world.

I'm able to talk to two other business entities, business heads about this, that we understand, I understand where they're coming from with it. You know, the, the thing is also this, this, the whole idea of free market. It's going to take a community involvement. The physicians have to take the first step in this, but patients and their employers also have to, to understand that they're part of the whole.

Ecosystem as well. But as more doctors become empowered and they break away from third party payers and administrators, and then they open up their direct primary and direct specialty care practices. We'll have more people to, to educate. And then as employers find alternative ways to offer benefits that allow their employees to use direct care, that's going to be important.

And not to be just going to just all the, the, the regular the regular players the, the major healthcare players and then as patients, as they recognize and realize that the current health insurance industry, there are just not being good stewards of the money that they put putting their premiums and so-called investing in it.

And they'll, they'll find alternative ways also. But I think until. It's going to take an effort with all of that. Like I said, with trying to teach the business aspects of it it just, it starts with.

And when you have conversations with people, whether they be in primary care or specialty care, what are some of the biggest fears that you hear people talking about? You've mentioned, how to prepare if you, if you're going to take a hit, if you're going from insurance driven care to insurance free care, but what are some of the things that you hear from the people that you are mentoring

Like, I can't do direct care because

I can't do direct care because I won't be able to, you know, I have too much students. That's a big one. Again, that goes back to our conversation about, I think they get, they get spoiled with the bigger salary and then they got used to that lifestyle. You have to be frugal again.

You have to live the life of a resident again, you know, I don't know what it was for you when you were in residency, but we were making less than 30,000 in residency. So, And that was before all the time restriction things also,

And are you hearing any other major fears that come from either primary care or specialty physicians?

You know, from the specialist depending upon the specialty, I think with the DPC and your membership model, that's that's a little bit more financially secure in the sense that you've got that recurring stream of income for specialists.

That's where I was mentioning the fact that you have to find other, other niche services for it. Because it's hard to do. A membership in some of our specialties, you know, I could talk about doing a membership for diabetics, but, you know, that's just kind of routine maintenance care.

You wouldn't want to do that necessarily for wounds cause you want the wounds to heal, you know? So it's, it's a little bit more difficult with that. And, and you know, one of the phrases that I always say is that I didn't change how I practice medicine. I changed how I interacted with the system. So, you know, when you put it a little simpler in that regard, I think that will help with the idea of, switching.

That is an amazing quote. I I'm big about writing quotes, things that are very meaningful and that, that is one that I wrote down just now that's dust just beautiful.

Resources. I want to ask because with you having, your MBA with you, having been a physician in fee for service direct care practice, what are some of the resources that you love recommending to other people when they're interested or thinking about.

You know, nowadays compared to 2013, social media probably is one of the biggest ones.

Your podcast is a big one. And there are several others also healthcare Americana is one entrepreneur MD, another one you know, there, there are organizations, the free market medical association the association of American physicians and surgeons and the hoping that they're gonna have more meetings I would highly encourage everybody to go to those.

And then now I think a lot of them are doing virtually too. So there really is not an excuse for that. What's so beautiful about the community of direct care. Everybody wants to help because it's a win-win for everybody, you know, ultimately we're all going to be patients too.

So we kind of want to see this work, you know? There's no reason why we can't, we can't keep this going.

No reason at all. I'd love it.

So as we close, I want to ask, do you have any other pearls of wisdom that you'd like to share with people as they're, you know, jumping into the strict care space?

So one big one would be don't get upset, particularly those that are transitioning. Don't get upset. If a patient doesn't follow. Or says something, something mean about it.

A lot of times I've I had a couple of my patients tell me, you must be just doing this for the money. That must be all it is. You don't care about taking care of old people or anybody. Well, so what, to a certain extent that goes to show you how they think. Because they don't appreciate your skillset, your knowledge, your worth, they don't put a value to that.

Understand that that's your asset and that's what you're offering to them. And if they don't want it, that's fine. That's their choice. You know? And with regards to that, one of the things that I was able to do once I started managing a group of panel that actually. Wanted to see me and would reimburse me at the rate that we could run the practice.

Also it freed up my schedule so that I could actually volunteer at our local community clinic. I'm wonderful. One, I think I'm the only one at our clinic. That's actually a practicing physician. The others are all retired. But we have a beautiful clinic that serves the needy and the uninsured downtown um, able to spend time there to give back because

it's being subsidized by my patients that are actually coming in to see me so I can actually help more people as a result of it. So don't get discouraged by the naysayers. They'd never were going to follow you anyway.

And There's so many pluses to being in direct because of autonomy. You're getting full amount for what you're worth for your visit. Um, And The time that you get to spend with the patient, you actually get to, to do your work properly. I don't understand how you can do an exam in seven minutes.

I just don't, you know, there's no way you're going to get to know the patient, you know, I recall watching my mom, she's the internist, and she would bring the patient after the examination in the exam room. She bring them to her office and they'd say my mom, taught me a little trick all the time in, in the chart and I still do it now always write one special story about the patient in their chart.

So you'll always be able to remember it and always write down their kids' names in the chart too, so that you can remember something personable about them, because that will help you also remember that patient. So little tricks like that. I remember her showing me that my dad is a surgeon. He spends a lot of time with them you know, doing the, during the exam, but, and then afterwards uh, he loved to really make sure that he put things in, in people language rather than doctor language.

And he would draw everything out. You don't have that time. If you're going to be doing a 10 minute pre-op consult. So, you know, You know, there's again, a lot of pluses that the autonomy, the, the, the time with the patient, your time afterward also, you know, we have a life outside of, of, of medicine. I have children, I was able to go to my children's activities because I didn't have the weird schedule, you know, I had T because I could control my schedule.

That's what it was, but I wanted to take a break and patients understand it. That's, what's neat about it because patients, when you make a relationship with the patient, they get it, you know, even, even phone calls, you know, a lot of people always say, I can't believe you give your cell phone to patients.

I've been giving my cell phone to my surgery. Post-ops all these years. That's, you know, 20, 21 years now. Have I had it abused a couple of times, but. Really the majority of them, they are so apologetic. I'm so sorry to bother you, but you know, that's usually the case. And now with the fact that we have email that's accessible on the phones, you know, that's, that's an easier way to even get ahold because it's not it, they understand that it's on our time, but Yeah, I, if you respect the patient's time, they respect your time also.

So I don't run behind my staff, loves it. There's not a lot of extra paperwork, a lot, not a lot of waiting on the phone, you know, for, for authorizations and other things. The coding you know, the fact that you can't uh, 9, 9 2 1 4, 4 primary care and a 9 9 2 1 4, 4, a specialist should be the same reimbursement, but in some insurance companies, that's not the case, you know, that doesn't make sense.

So there was a lot of nonsense with it. So I'm happy with what I'm doing and I'm, I'm trying to convince more people to do it. That's awesome.

So what is the best way for others to reach out to you after this podcast?

So I am on social media.

You can find me at Torres Hodges podiatry or at Dr. Grace DPM. I am on Facebook, Instagram, Twitter, and LinkedIn.

thank you so much for joining

us today. Oh, it was a blast. I hope someone gets even, you know, what you always want is that you want one Pearl to come out of this and if somebody learns something from that, I am so grateful. And so thank you for inviting me.

*Transcript generated by AI so please forgive errors..

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