Startup DPC Show Episode 8: DPC Doctors advocating for policy solutions

On this episode of the Startup DPC Show, I sit down with Dr. Chad Savage of YourChoice Direct Care in Brighton, Michigan. Dr. Savage and I practice about 45 minutes away from each other - he’s in Brighton, MI and I’m in Detroit, MI. We’ve gotten to know each other well because we attend the same conferences and sometimes end up on the same flights to and from these conferences!

We both spoke during the opening main-stage session at the DPC Nuts and Bolts Conference in November 2018, hosted by the Docs 4 Patient Care Foundation. Dr. Savage is a relentless advocate for his patients, for his profession, and for the broader DPC movement.

Paul Thomas MD, Lee S. Gross MD, Ellen McKnight MD, Chad Savage MD, and Josh Umbehr MD at the DPC Nuts and Bolts Conference in Orlando Florida. Drs. Gross, Savage, and Umbehr are also involved in the DPC Action organization.

Dr. Savage is also a Board Member of the new DPC Action organization. In this Startup DPC Episode 8, we talk about direct primary care, the legislation that's impeding the DPC model, and the opportunities for future legislative changes that could improve health care options for individuals, families, and businesses.

What is DPC ACtion?

DPC Action is a non-profit organization dedicated to promoting and advocating for improved access to affordable health care through independent Direct Primary Care practices.

There are several political advocacy groups for medicine, but none were focusing on the independent direct primary care doctor. DPC Action speaks for the independent DPC doctor. The organization is largely self-funded, but does take donations on their website, here.

Dr. Savage talks about adding value, both for his patients, and in changing the legislation. The current legislation isn’t designed perfectly for the practice of direct primary care medicine.

DPC Action and Dr. Savage are working with Congressional leaders, Senators, the White House, and representatives from the Treasury Department and the IRS. One of their first meetings was with the Secretary of the Treasury and Dr. Savage worked with some adversarial forces during this meeting.

This meeting bore fruit, however, and it affected future legal changes affecting HSA spending and direct primary care practices.

Current Legislation Affecting DIrect Primary Care practices

Currently, the use of HSA funds to pay for direct primary care practice is debatable and murky. There is not a clear answer on this issue. We discuss the IRS Code 213(d) and 223 and how these are a barrier for the direct primary care model at this time. Here are the basic definitions of these IRS Codes:

HSA-qualified medical expenses are defined by IRS Code, Section 213(d) and include amounts paid for the diagnosis, cure, mitigation, treatment or prevention of disease for the purpose of affecting any structure or function of the body.

Internal Revenue Code (IRC) Section 223 allows individuals who are covered by a compatible health plan, often referred to as a High Deductible Health Plan (HDHP), to set aside funds on a tax-free basis up to the contribution limit to pay for certain out-of-pocket medical expenses.

Legislative Solutions to our current challenges in direct primary care

As a solution to these barriers, Dr. Savage and I discuss S 3112. Dr. Savage is a prolific writer, and he penned this opinion in Real Clear Politics regarding S 3112:

S. 3112 — which has a companion bill in the House, Congressman Chip Roy’s HR 5596 — would lift unnecessary HSA restrictions, let Americans spend HSA dollars how they see fit, liberate employers, and unleash Direct Primary Care.

Furthermore, this legislation would help HSA owners take full advantage of an incredibly low-cost and high-service care model: Direct Primary Care (DPC). These clinics offer substantially reduced medications, imaging, labs and other services. Though President Trump’s June 2019 Executive Order partially addressed and expanded HSA use for DPC providers, S. 3112 would solidify these corrections in law. This step would make HSA dollars go farther and provide more quality services.

HOW CAN I LEARN MORE ABOUT STARTING A DIRECT PRIMARY CARE Practice?

If you want to learn more about starting and growing your direct primary care practice, look no further than our courses on how to start and grow your direct primary care practice. We at Startup DPC have begun compiling some of the best content available on this blog and in our courses.

The best place to start is to take our Direct Primary Care Business Plan course, available here. From there, you can learn how to attract new patients to your direct primary care practice and how to find the perfect location or build out the practice of your dreams.

Thanks for reading and watching, and best of luck in your direct primary care journey!

- Dr. Paul Thomas with Startup DPC

Which is the Best Direct Primary Care Conference?

Why should you attend a Direct Primary Care Conference?

If you are looking to start and grow a direct primary care practice, you should definitely attend one or all of the major direct primary care conferences held in various locations across the US. These will be especially important for in-person networking and meeting other courageous physicians who are starting and growing their direct primary care practices. It will also show you what’s possible for you, your practice, and your future.

All of these conferences are excellent, and they each have their strengths and weaknesses. In general, these conferences are great places to learn about the practice of direct primary care and to connect with thought leaders and colleagues. There’s a distinct ethos of the DPC movement, and you can immerse yourself in this environment and learn some of those intangibles that are hard to pick up through other mediums.

You can find doctors who are practicing in your community and start building some mentoring relationships that can be valuable over the long term. You can also find a cohort of DPC docs who are at a similar stage in their journey. Take the time to connect with these doctors as well, as you will likely face similar challenges in your individual practices.

What are the three major Direct Primary Care Conferences?

The three major direct primary care conferences are the AAFP DPC Summit, the Docs 4 Patient Care Foundation DPC Nuts and Bolts Conference, and the Hint Summit. In short, you can benefit from all three conferences. It might come down to cost and geography for you, but there’s value with each conference. 

Here’s what’s on tap for 2020:

The American Academy of Family Physicians (AAFP) DPC Summit

The AAFP DPC Summit in June or July of each year caters to independent direct primary care physicians, and DPC doctors set the agenda. There are typically three days of educational sessions with a broad range of topics. The location bounces around the country and has been in Chicago (2019), Indianapolis (2018), Washington D.C. (2017), and Kansas City (2016). The 2020 conference will return to Kansas City from July 17th to 19th.

The focus is on the independent Family Medicine DPC practice, but there’s also information for larger DPC practices as well as more corporate DPC structures. The content and speaker selection is driven by a group of ten or so practicing DPC doctors and a few medical students and residents. There are scholarships available for medical students and residents, and the application can be found on the AAFP website. Further, Internists, Pediatricians, and Medicine-Pediatric doctors have also been known to attend.

In 2017 I was a panelist at the AAFP DPC Summit on starting a direct primary care practice, in 2018 I was a main-stage speaker and delivered “DPC Hustles Harder”, and in 2019 I was a main-stage speaker discussing how to build your personal brand to grow your direct primary care practice.

Dr. Paul Thomas of Plum Health DPC delivering his “DPC Hustles Harder” Presentation at the AAFP DPC Summit on building a strong business brand and a strong personal brand to grow your Direct Primary Care practice.

The Docs 4 Patient Care DPC Nuts and Bolts Conference

The DPC Nuts and Bolts Conference presented by the Docs 4 Patient Care Foundation is in Orlando each November, usually during the first or second full weekend in November. Dr. Lee S Gross organizes the Nuts and Bolts Conference, and he is a relentless advocate for the DPC model and movement. After the 2018 Nuts and Bolts conference, he posted this on his Facebook page:

I spent this weekend with some of the most inspirational and brave physicians I have ever met. It is time for physician leaders to step up and take back control of health care on behalf of our profession, our patients, and our nation. It is time for us to call out those that put themselves in between the doctor and patient.

I’ve saved this specific quote from Dr. Gross because it’s so damn inspiring – I’ve read this aloud at the AAFP DPC Summit 2019 and got chills as I said it on stage in front of 300 or more doctors.

Within this quote is a great mission statement: I believe that it’s time to take back health care for our profession, our patients, and our nation. Inspiration from Dr. Gross and other attendees comes standard at the Nuts and Bolts Conference.

The DPC Nuts and Bolts Conference is valuable in that there’s excellent DPC content and a strong showing of practicing and prospective DPC docs. The only point of contention with this conference is that there are some political overtones and some speakers with a political agenda.

Dr. Paul Thomas of Plum Health DPC at the podium during the Docs 4 Patient Care Foundation Nuts and Bolts Conference, sharing about passion, purpose, authenticity and caring. — with Ellen McKnight, Chad Savage, Josh Umbehr, and Lee S. Gross at Rosen Hotels & Resorts Orlando.

The Hint Summit

The Hint Health Summit is usually held in San Francisco each year, but in 2020, it’s moving to Denver. Hint Health sponsors this conference, and they describe themselves as “the direct primary care solutions company that partners with visionary provider organizations to build successful DPC programs.”

Paul Thomas, MD of Plum Health DPC at the Hint Summit 2018 - the conference topic was Breaking the Status Quo in health care and ZDoggMD was the keynote speaker!

I attended the Hint Health Summit in 2018, and I enjoyed it immensely. I got to rub elbows with speakers like Zubin Damania aka ZDoggMD, Garrison Bliss, Clint Flanagan, and Zak Holdsworth. For the Hint Summit, Hint Health has a bigger budget and can afford big name speakers like ZDogg MD and Marty Makary et al. But, they are trying to sell you a product, the Hint billing platform.

The one criticism that I have is that the content is tailored for larger DPC groups and more corporate DPC structures. Because of this, the content was not as valuable for an independent DPC practice like mine relative to the content presented by the AAFP and the Docs 4 Patient Care Foundation. However, I have heard that there may be some changes to the 2020 Hint Health Summit content and format.

This is a good opportunity to introduce this concept: it matters who you spend time with, and by spending time with successful and inspiring people, you can raise your frequency and increase your chances for success. Motivational speaker Jim Rohn famously said that we are the average of the five people we spend the most time with.

By immersing yourself in these conferences with exceptional DPC docs, you will pick up on the pearls, the tips, and the idiosyncrasies that make these doctors successful. Your choice to attend these conferences will depend on costs, distance traveled, and proposed content.

All three conferences are great for networking. They will raise your frequency and show you what’s possible for you and your practice in DPC and beyond. 

HOW CAN I LEARN MORE ABOUT STARTING A DIRECT PRIMARY CARE PRACTICE Right Now?

If you want to learn more about starting and growing your direct primary care practice, look no further than our courses on how to start and grow your direct primary care practice. We at Startup DPC have begun compiling some of the best content available on this blog and in our courses.

The best place to start is to take our Direct Primary Care Business Plan course, available here. From there, you can learn how to attract new patients to your direct primary care practice and how to find the perfect location or build out the practice of your dreams.

Thanks for reading and watching, and best of luck in your direct primary care journey!

- Dr. Paul Thomas with Startup DPC

Startup DPC Mailbag: Questions about Starting a Direct Primary Care Practice right out of Residency

This is Dr. Paul Thomas with Startup DPC (https://www.startupdpc.com/) and I receive new questions each day about how to start and grow a Direct Primary Care practice. I believe in the power of the Direct Primary Care model to restore our broken healthcare system for both patients and doctors. That's why I'm really passionate about this topic and why I'm on a mission to educate my fellow physicians and the public about their options in the direct primary care model.

Our questions today come from a Resident Physician in Florida. Here's the questions:

If I have a big student loan debt, can I still start a direct primary care practice?

1. How did your decision to pursue DPC work affect your student loan repayment strategy?

I graduated from Residency with a student loan burden of $170,000. This was the average student loan burden for graduates in 2013. In 2019, the average student loan burden increased to $190,000. That being said, I went on a straight 10-year repayment plan, and I spent about $2,000 each month on my student loans.

In order to do this, I didn't splurge on unnecessary expenses and I focused on the practice I wanted to build. I also started moonlighting as soon as possible in residency to have enough money to pay down my student loans and have a comfortable lifestyle.

In short, my large student loan debt did not deter me from starting my direct primary care practice. My mission of serving others via this DPC model outweighed any misgivings I had about a large student loan balance. If you have a dream of starting a DPC practice, you can do it, even if you have a big loan balance.

How do you build a strong personal brand while a Resident Physician?

2. As residents, we’re mostly responsible for our patients. We connect with some of them but don’t know how to engage them while they wait for us to complete residency, what was your strategy?

This question is really about building a strong personal brand, and how do you build a strong personal brand in during your Residency training. It comes down to engaging with people in your community in a positive way.

Be a leader, a volunteer - work with different free clinics or hold a board position. Reach outside of your network and get to know professionals from other fields, like law, finance, philanthropy, the food and beverage industry, the hospitality industry, and others.

You can also take time to build your presence on one or all of the following social media channels: Facebook, Instagram, Twitter, LinkedIn, YouTube, TikTok, or SnapChat. If you build a strong personal brand on these channels, you'll be more easily able to invite your audience to become patients of your direct primary care practice.

I take a deep dive on these concepts in my course on Attracting Patients to your Direct Primary Care practice, here: https://www.startupdpc.com/take-action

Can you work a second job (moonlight) while starting your direct primary care practice?

3. Private practice finance is a big issue, didn’t working multiple jobs interfere with your time commitment to your private practice patients?

No, you can work 20 hours a week pretty easily while you start your direct primary care practice. For me, I was moonlighting for 12 hours on a week day and 8 hours on a week end day and earning enough to support myself and pay down my student loans.

I worked at an urgent care for $70 to $80 an hour, which allowed me to grow my direct primary care practice organically. I worked at my DPC practice 4 days each week and at the urgent care 2 days each week. I was able to care for and manage my DPC patients easily over that 4 day work week, as I had fewer patients at that time.

HOW CAN I LEARN MORE ABOUT STARTING A DIRECT PRIMARY CARE PRACTICE?

If you want to learn more about starting and growing your direct primary care practice, look no further than our courses on how to start and grow your direct primary care practice. We at Startup DPC have begun compiling some of the best content available on this blog and in our courses.

The best place to start is to take our Direct Primary Care Business Plan course, available here. From there, you can learn how to attract new patients to your direct primary care practice and how to find the perfect location or build out the practice of your dreams.

Thanks for reading and watching, and best of luck in your direct primary care journey!

- Dr. Paul Thomas with Startup DPC

Startup DPC Mailbag: How Much Money Do You Need To Start a Direct Primary Care Practice?

Just about everyday, I get some great questions about starting and growing a direct primary care practice. A colleague just read my book and asked the following questions:

How much money do you need to start a direct primary care practice?

This is a question I recently received from someone interested in the direct primary care movement. And, it's a good question. I'll start by saying that I've addressed this question in great detail in my course on Writing a Business Plan for your Direct Primary Care practice.

So, for a full answer to this question, please go to our Take Action page and check out the Business Plan course!

To answer the question more directly, a direct primary care practice can be started with $5,000 or with $50,000. It depends on how expensive your lease is, how many staff members you have, how much equipment you need to buy, and how resourceful you are.

For many doctors in the direct primary care movement, they know how important it is to keep their overhead low. A lower overhead leads to a lower price point for patients and therefore a more sustainable medical practice.

For me, I launched my practice with about $20,000 in the bank. I bought a $700 exam table, a $1,700 EKG machine, and a $700 pulmonary function test (PFT) machine. I spent about $600 each month on rent, $450 each month on my malpractice insurance, $300 monthly on the electronic medical record system, $500 monthly on medications, and $500 monthly on lab work. Those were the biggest expenses when I started, and my monthly expenses for the first few months of practice were in the $3,000 monthly range.

This low overhead made it easy to break even for operations, and I broke even for operations with around 85 patients or 85 members in my practice.

A quick breakdown of the Startup Costs for our Direct Primary Care Practice

How much money do you need to start a direct primary care practice? Here's some basic numbers during my first few months of operation with our direct primary care practice at Plum Health DPC:

• One-time purchases:

  • Exam table $700

  • EKG Machine $1,700

  • Legal services/patient contracts $2,500

  • PFT Machine $700

  • Bookcase $200

  • Comfy Chair $200

  • Basic supplies and equipment: $1,000

  • Small Business courses/educational resources on how to operate a business successfully: $1,000

• Monthly costs:

  • Lease on a space $600 monthly

  • Malpractice Insurance $450 monthly

  • Electronic medical record system $300 monthly

  • Cost to purchase medications $500 monthly

  • Cost of laboratory services $500 monthly

  • Cost of misc supplies and equipment $500 monthly

In my first 9 months of practice, my overhead costs averaged at $3,664 monthly.

By month 9, my revenue was at $7,679.10, aka profitable!

Conclusion: You could start a very simple DPC Practice for $5,000 to $10,000, because we started our direct primary care practice for a relatively small amount of money.

Again, I take a deeper dive into these startup costs for a direct primary care practice in our business plan course.

#Startup #DirectPrimaryCare #StartupCosts #Overhead #ProfitAndLoss

What is the typical startup cost for a direct primary care practice?

Every direct primary care practice is different! When you’ve seen one DPC practice, you’ve seen one DPC practice, meaning that each clinic is going to be unique based on geography, demographics, state laws, and the doctor’s preferences. Therefore, there’s going to be a wide range in startup costs for a Direct Primary Care practice.

If you’re just buying supplies to furnish a small office, you should plan on spending $10,000. If you need legal help to set up contracts, you should add in $2,500. If you include things like your first month’s rent, malpractice insurance, the cost of your electronic medical record, internet, utilities, and phone lines, you should budget an additional $5,000. If you have a medical assistant on staff, you can plan on spending $3,500 each month for their salary. So, startup costs for a modest one or two room office might be $17,500 without a staff member or $21,000 with a staff member, which could include your first month of operation.

What is the average malpractice insurance cost for a family medicine doctor?

The next question is harder for me to answer. I only know what my experience has been like. For me, I purchased malpractice insurance for $450 each month. I was told that Wayne County’s malpractice insurance rate is the highest in the State of Michigan, so this cost is likely much lower in other areas of the state.

The price of the policy does decrease as we add more doctors in the practice.

Are you able to make a decent living as a direct primary care doctor?

Yes! Yes, you can make a good amount of money as a direct primary care doctor. It depends on how good you are at running a business, the cost of your overhead expenses, the prices you charge your patients, and the number of staff members that you have.

The person who asked this question went on to say: “ You have roughly 500 patients paying you about $69 each month, which comes out to only $34,000 each month! And then you have overhead costs like rent, utilities, taxes, staff payroll, etc… Additionally, you’re placing yourself on call for your patients around the clock. Is it worth it?”

For me, I didn’t start a direct primary care practice to make money. I started my direct primary care practice to take care of my patients on my own terms, to develop a fulfilling practice of medicine, and to treat my neighbors and patients with kindness and respect. I definitely want to make money and I need to make money to be successful, but it’s not the main motivation for my practice. In fact, nothing pays like autonomy - I can practice medicine how it’s supposed to be practice and I am not at the mercy of a giant hospital system telling me what to do or how many patients I must see in an hour or in a day.

How is direct primary care different than concierge medicine?

That’s another can of worms, and I’ll leave you this blog post that I wrote for Plum Health DPC, which is one of the most frequently visited pages on our blog and a top hit on Google when you search for DPC vs concierge medicine. Here’s that blog post!

How do you offer your direct primary care services to small businesses?

We offer the membership services to small businesses in our neighborhood. We have several small businesses enrolled in our services at Plum Health DPC. The employer usually pays for the monthly costs of the employees, and the employees pay for any additional services like labs, meds, or imaging services. Here’s our sales page for employer groups via Plum Health DPC.

How can I learn more about starting a direct primary care practice?

If you want to learn more about starting and growing your direct primary care practice, look no further than our courses on how to start and grow your direct primary care practice. We at Startup DPC have begun compiling some of the best content available on this blog and in our courses.

The best place to start is to take our Direct Primary Care Business Plan course, available here. From there, you can learn how to attract new patients to your direct primary care practice and how to find the perfect location or build out the practice of your dreams.

How can I find a Great Direct Primary Care doctor?

If you’re looking for a great direct primary care doctor and you’re in the Detroit area, we’re at Plum Health DPC. If you’re not in the Detroit area, there’s a great website called the DPC Mapper where you can find a DPC doctor near you!

Thanks for reading and watching, and best of luck in your direct primary care journey!

-Paul Thomas, MD

Startup DPC Show Episode 7: Conversation with a Doctor with 12,100 Instagram Followers

The Startup DPC Show aims to educate doctors who are starting and growing their direct primary care practices. If you want to take a deeper dive into starting and growing your direct primary care practice, check out our courses where we walk you through different skills that you need to be successful in your DPC practice.

Our guest today is a second year family medicine resident physician at UMass in Boston, Dr. Rami Wehbi. Dr. Rami is smart and savvy when it comes to many things, and it's remarkable that he has 12,100 followers on his Instagram channel, @DrRami.DO.

Direct primary care is different from fee-for-service medicine in several ways, and one of the big ways is that doctors have to reach out to their patients directly to get them to sign up for their services.

Family Medicine Resident disheartened by the current state of primary care

Dr. Rami has always been motivated to have a private primary care practice. He wants to take care of his patients on his own terms. He then searched for private practices that were successful. He first found concierge medicine, and then he found direct primary care. He reached out to me a few years ago and we hit it off. Together, we recorded an awesome episode for his Beyond Medicine Podcast, which can be found here. Dr. Wehbi is smart and kind, and he knows how to build a great following, either via podcasting or through his social media channels.

Paul Thomas MD of Plum Health DPC and Rami Wehbi DO a second year resident at UMass Family Medicine Residency Program, talk about challenges and opportunities in the Direct Primary Care space.

Educating Doctors about the Direct Primary Care model and movement

A big part about what drives me as a person is my mission to educate other doctors about the direct primary care model and movement. Further, I want to help doctors create the best direct primary care practices that they can, and that’s a big reason for this Startup DPC website, courses, and content.

Family Medicine Resident inspired by the potential of the direct primary care model

For Dr. Wehbi, it’s inspiring for him to see our successful direct primary care practice and other successful DPC practices across the country. Dr. Wehbi wants to be able to deliver a higher quality of primary care services. The average primary care doctor has 2,400 patients in their panel and they often see 25, 30, or even 35 patients each day. That means that these fee-for-service or insurance-based doctors have to see 3 or 4 patients each hour. These quotas are often written into the doctor’s contract.

For Dr. Wehbi, it’s mind-boggling that doctors would be expected to see 35 patients each day.

For me, it’s mind-boggling that you’d be expected to see 35 patients in a day and expect people to get quality care. It just doesn’t make any sense.

In our direct primary care practice practice, we have 640 patients total as of this blog post and my panel has 460 patients. I usually see 1% to 2% of my panel each day, so around 4 to 10 patients each day. This allows me to have 30 minutes to 1 hour with each patient and to really develop those strong, trusting relationships that can lead to better health.

What happens when patients need to see a specialist in the Direct Primary Care model?

Because we have fewer patients, we have more time to dedicate to our patients. We have more time to think and care and demonstrate compassion. We also have more time to look things up and to read up on a new diagnosis or the updated management of an old diagnosis. Further, we can work with our local specialist colleagues and develop cash-pricing for their specialty services. Finally, we leverage an e-consult platform called Rubicon MD to get specialty consults done in a matter of 4 to 12 hours.

Why would i pay for a membership-based service when I already have Insurance?

Well, you can restructure your insurance coverage to make it a more of a catastrophic coverage plan, meaning that you pay a lower premium and carry a higher deductible. Then, you can pair that low-premium, high-deductible health insurance plan with a direct primary care plan. This could end up saving you money as those insurance premiums can be quite expensive, and you can get better health care services as you have a trusted doctor at your fingertips.

Direct primary care for employer groups

For employer groups who buy insurance through the current fee-for-service insurance-based system, there is a ton of money lost on the middle men, plan benefit designers, and insurance brokers. Direct primary care clinics offer a way to lower the cost of health care for employees and employers by removing these middle men and offering excellent care and service to employees. And, having best-in-class service for employees will be another benefit for large employers looking to attract and retain top talent.

DOES DIRECT PRIMARY CARE MAKE SENSE FOR A PATIENT WITH MULTIPLE CHRONIC MEDICAL CONDITIONS?

Yes, direct primary care is a great system for patients with multiple chronic medical problems. The idea here is that the direct primary care doctor will have more time to fully address all of these multiple medical problems and how they interact with each other. By spending more time with our patients, we definitely prevent several costly and stressful visits to the emergency department or urgent care center each year.

“The urgent care system is a symptom of a failed primary care system. If your doctor had enough time to see you when you cut your finger or had bronchitis, you wouldn’t even have to go to an urgent care.” - Dr. Paul Thomas

For example, we recently had a patient who cut their finger at 5:30 pm on a Monday evening. They called me and I came in to sew up the laceration right away.

View this post on Instagram

I was driving home from the office and I received a phone call from one of our #PlumHealth members - it was 5:23 pm. I quickly turned around and headed back to the office, meeting my patient at 5:30 pm. He was washing dishes when a glass 🥃 broke in his hands and created this V-shaped laceration. We ran it under some warm water 💧 to flush the wound, cleaned it with an antiseptic, and injected 💉 some lidocaine into the wound edges. We pulled back the flap to make sure there wasn’t any more glass sitting in the wound. Then, we used some 5-0 (very thin) suture material to close the wound, keep the skin flap vitalized, and minimize the appearance of the scar. We wrapped up just before 6 pm - that’s 27 minutes from making the phone call to being all sewn up. Best of all, because he’s a member of the #PlumPack, there’s no charge. This procedure would have cost at least $150 at the urgent care and perhaps $1,500 at the emergency 🚨 department. These are some of the many reasons that I love being a #directprimarycare doctor. This is why I do what I do - to deliver affordable, accessible healthcare.

A post shared by Paul Thomas MD (@plumhealthdpc) on Feb 3, 2020 at 4:50pm PST

This model of care allows you to take full ownership of your patients - you can take radical responsibility for your patients.

Where to Find an Excellent Direct Primary Care Doctor?

If you’re looking to find an excellent direct primary care doctor in your neighborhood, check out the Direct Primary Care Mapper, here. If you’re in Detroit or Southeast Michigan, don’t hesitate to reach out to our Plum Health DPC clinic here in Corktown.

How can you start your own direct primary care practice?

Many medical students, medical residents, and doctors are looking for the best way to start and grow their direct primary care practices. Fortunately, Startup DPC has begun compiling some of the best content available on this blog and in our courses.

The best place to start is to take our Direct Primary Care Business Plan course, available here. From there, you can learn how to attract new patients to your direct primary care practice and how to find the perfect location or build out the practice of your dreams.

Thanks for reading and watching, and best of luck in your direct primary care journey!

-Paul Thomas, MD

Startup DPC Show Episode 6: Interview with Harvard-Trained DPC Pediatrician

Harvard-Trained Pediatrician Starts Her Direct Primary Care Practice in Dallas Texas

Welcome to Episode 6 of the Startup DPC Show, and in this episode we have the pleasure of speaking with Tonya McDonald, MD. Dr. McDonald is a Pediatrician and the founder of Radiance Pediatrics in Dallas, Texas. Dr. McDonald trained at Harvard Medical School, graduating in 1998 and she completed her Pediatrics Residency at Baylor College of Medicine.

Dr. McDonald is a Pediatrician and the founder of Radiance Pediatrics in Dallas, Texas. Dr. McDonald trained at Harvard Medical School, graduating in 1998 and she completed her Pediatrics Residency at Baylor College of Medicine. She is the featured Direct Primary Care doctor for our Startup DPC Show, Episode 6.

Dr. McDonald was recently interviewed by Harvard Medical School’s Magazine in a section called The New Black Bag. Here’s a segment of the interview:

This past spring, she opened Radiance Pediatrics, a direct primary care practice that provides in-home and virtual pediatric care to families who pay a flat monthly fee. For this fee, families get extended visits, same- or next-day appointments, telemedicine visits, and direct access to McDonald through phone, text, and email.

“In some ways, this is a throwback, an old-school approach to medicine,” she admits. “But it gives me the opportunity to help rebuild the doctor-patient relationship. It’s a gift to be able to truly bond with families.”

Not long ago, McDonald was part of the 78 percent of U.S. physicians struggling to cope with burnout, a problem some have labeled a public health crisis.

“In the past five years, I was seeing up to thirty children a day, feeling sad that I couldn’t practice medicine the way I wanted,” McDonald says. “Insurance dictated what I could do.”

McDonald knew it was time for a change. And she’s far from alone.

As shown in the interview from HMS above, Dr. McDonald is a quintessential physician on the front lines of the healthcare system, dealing with a packed schedule and not having enough time to fully take care of patients. I also love that she says that she now has the opportunity to rebuild the doctor-patient relationship - I put that in bold for emphasis. Now that we have some context, let’s jump into the interview!

Dr. McDonald’s Startup DPC Story

Dr. McDonald had heard about direct primary care ten years ago, but put it in the back of her mind. Three years ago, while working for Children’s Hospital of Dallas, she got tired of seeing 24, 25, or 30 high-risk pediatric patients each day. This was especially difficult when she was taking care of high-risk, high-needs children with complicated medical problems and adverse social determinants of health. Having only 10 minutes for these patients didn’t work for Dr. McDonald.

The final straw was when her pediatric group was “restructured” to an even higher volume practice with multiple physician extenders in the group. She was laid off, took a severance package, and started planning her transition into direct primary care.

Caring for an underserved community with Direct primary care

Dr. Tonya McDonald is serving pediatric patients and families on the south side of Dallas. Dr. McDonald states that there’s a lot of money in Dallas, but most of that wealth is concentrated in Downtown or on the North Side of the city. She goes on to say that the south side of Dallas has a majority minority population - about 40% African American and 30% Hispanic. The median income in the community is roughly $55,000 each year. She alludes to the historical context of living in the south with restrictive housing covenants, which accounts for income inequality and segregation in this area. Dr. McDonald wants to serve in this type of community because she’s a black, female Pediatrician and she enjoys taking care of people in this population. She also alludes to making an impact by being a role model for kids who may not be able to see a black pediatrician, and she also discusses how it’s empowering to serve in a medically underserved community.

Photo of Dr. Tonya McDonald making a house call, courtesy of Harvard Medical School’s a New Black Bag series.

How Direct Primary Care can Address Health Disparities

Dr. Tonya McDonald discusses how some people hear about a “members only” clinic and think that it’s exclusively for the rich. On the contrary, she takes care of folks who are truly in the middle - these are the folks that make too much to qualify for Medicaid or Children’s Health Insurance Program (CHIP) but they don’t make enough to afford private insurance. These patients are willing to save up and cash pay for their healthcare services, but they didn’t have access to affordable options. Now that Dr. McDonald is in the market, these families now have that option to save up and cash pay for an affordable, accessible pediatrician. These families understand the value of direct primary care and the cost savings therein.

How much does a pediatrics direct primary care membership cost?

For Dr. Tonya McDonald and her Radiance Pediatrics practice in Dallas, she charges a monthly membership that costs $125 per month for children from birth to 2 years of age, $100 per month for children 2 years of age to 15 years of age, and $75 per month for adolescents and young adults from 16 to 26 years of age. She also has some discounts available.

Membership Fees:

One Time Enrollment Fee: $100 Per Child

Introductory Monthly Fee For First 25 Families:

0-2 Years - $125

2-15 Years - $100

16-26 Years - $75

Discounts Available: 3 Or More Enrolled Children; Foster Care Children; Full Annual Payment; In-State College Student

Knowing the market when setting your prices

Dr. Tonya McDonald took a look around at the different healthcare costs in the marketplace, namely the costs for home births, doulas, midwives, and similar services. She notes that families in her community were often paying $5,000 to $12,000 for 9 months of care from a midwife and $2,000 to $3,000 for perinatal care from a doula. In that context, paying $100 each month for high-quality, evidence-based pediatric care is not that much money.

“People who value you will pay you what you’re worth.” - Dr. Tonya McDonald

Dr. McDonald also talks about folks in her community who pay $125 for lash extensions plus $75 every 2 to 3 weeks for maintenance of her lashes. In that context, paying $100 each month for high-quality, evidence-based pediatric care is not that much money. She goes on to say that “People who value you will pay you what you’re worth. And those who don’t want to pay you what you’re worth probably wouldn’t pay you consistently for the long term, even if you were half the price because they just don’t value you.”

What are the monthly expenses like for a house call only Pediatric Practice?

Dr. Tonya McDonald works out of a co-working space and she’s surrounded by other entrepreneurs. These folks are smart risk-takers, they’re all about new ideas, and they help her to become a better business person. By renting space at a co-working space, she doesn’t have to use her home address as her business address. She also has storage space for her supplies as a part of her rent, which is $300 per month.

She bought a separate car via her business because it’s easier and cheaper to maintain with commercial insurance. Buying this relatively inexpensive car helps to build credit for her business as well. She buys a lot of her supplies via Henry Schein and Amazon, and she even splits supplies with other local pediatricians. This helps to keep her overhead low.

They are not able to dispense medications in Texas, because it’s not legal for physicians to dispense medications in Texas. This is one of the rare exceptions in the DPC landscape, as virtually every other state in the US allows for physicians to dispense medications from their offices, but not Texas.

Malpractice Insurance is $71 monthly for claims-made coverage. She shopped around and looked at 4 different carriers and also negotiated. She states that as a DPC practice, you have a lower volume, you don’t have 2,000 or more patients, so you should be paying a lower malpractice insurance rate. She expects her malpractice insurance to max out at $300 per month.

What do you do for Pediatric Vaccines in your direct primary care practice?

Dr. McDonald has partnered with some pediatricians in town to purchase single vaccines from their bulk stock. She has a PedsPal account, so she knows how many vaccines she’ll need for the year, and she keeps a log of what she uses and pays the pediatrician for these vaccines. She then bills her patients directly for the vaccine cost, at cost. If her patients are uninsured, she directs them to the county health department for their pediatric vaccines, which are $5 per shot. Finally, children over 7 can get their shots directly from the pharmacy, covered by the insurance with no copays, so she directs families to this option as well. For a few of her patients, she can give the vaccine and bill through VaxCare, which bills the patient’s insurance for the vaccine.

Thank you for reading! To watch the full conversation, see our YouTube video below.

Resources for starting and growing a direct primary care practice

If you’re interested in learning more about starting and growing your direct primary care practice, head over to our courses where you can learn how to attract more patients to your practice, write the perfect business plan, or find the perfect space for your growing DPC practice.

Sincerely, Dr. Paul Thomas

How to Get More Referrals For Your Direct Primary Care Practice

How to Get More Referrals for your Direct Primary Care Practice

Direct primary care doctors often want to know how to get more referrals to their direct primary care offices from the local healthcare ecosystem. How do you get the nursing staff and discharge coordinators to send patients from the hospital, emergency department, specialist clinics, or urgent care clinics to your direct primary care practice?

One good way is to go to those places and meet with the nursing staff, front desk staff, and physicians. Our practice in Detroit is called Plum Health DPC, and we've gone to all of the local urgent care clinics and emergency departments to make sure that our practice is listed as a Primary Care office accepting new patients. We’ve also visited the handful of specialist offices in the Detroit community to make them aware of our services.

What you should bring with you:

1. A flyer describing your services, usually an 8.5 x 11 inch page with information on the front and back. Bonus points if it’s in full color.

2. A stack of business cards with your name, title, email address, street address, and phone number.

3. Your smiling, positive, outgoing self. Use positive body language to communicate that the patients being referred to your office will be in good hands.

To go above and beyond, maybe you could act like a drug rep and bring lunch - a box of Jimmy Johns or something similar - to the emergency department break room and introduce yourself to all of the ED workers. You can bring lunch to the specialists’ offices and urgent care clinics in your community as well.

Good luck with your journey! - Dr. Paul Thomas

Here’s a portion of our promotional flyer that we hand out to our local businesses and local healthcare ecosystem, like the emergency departments, specialist offices, and urgent care clinics.

Direct Primary Care Book Nearing the Finish Line

I’m really excited because my second book on Direct Primary Care is nearing the finish line! I’ve written 20 chapters and 120,000 words about the process of starting and growing a direct primary care practice. Many of the lessons in the book have been learned the hard way - through my own experiences and my own failures in starting a practice. I also share about my victories and successes, as well as the lessons learned from conferences and speaking to other Direct Primary Care doctors, like the lessons learned through the conversations on this website. If you’d like to sign up to receive an email notification about the progress of the book, just drop me a line at Paul@StartupDPC.com or leave your email in the “Subscribe” box at the bottom of the page. Thanks for reading! - Dr. Paul Thomas

Wow! that word count tho - getting up there with 120,643 words in my next book on how to start and grow a direct primary care practice.

Startup DPC Show Episode 5: is Direct Primary Care feasible for Pediatricians?

is a direct primary care practice feasible for a pediatric doctor?

There are so compassionate doctors out there who want to take better care of their patients, and they see the direct primary care (DPC) model as a way to accomplish this honorable goal. During our Startup DPC Show Episode 5, we talk with Dr. Ashley Walker, MD of Hurley Medical Center about what it takes to start a Pediatric-focused direct primary care practice. For some context, this interview was recorded in mid-October 2019.

Ashley Walker, MD is a second-year pediatric resident at Hurley Medical Center. She has worked in the military as a general practitioner and is now completing her Pediatric Residency. Therefore, Dr. Walker has a unique perspective and should she start a DPC practice, she will bring her own unique strengths and insights to that practice.

Why do you want to go into the Direct Primary Care Model?

Dr. Walker discusses why she wants to start a DPC practice, and she talks about having more autonomy to do what’s right for her patients.

How much should pediatricians charge for direct primary care services?

Most Family Medicine direct primary care practices charge a price that’s based on age, and it increases as a patient ages. Our price point for kids is $10 per month for kids, which would not be sustainable for a pediatric practice. Other price points in the marketplace include places like Nova Direct Primary Care, and they charge $29 per month for pediatric patients.

During our conversation, I thought of a physician I met at the 2018 AAFP DPC Summit, Dr. J. Bryan Hill at Gold Standard Pediatrics. His prices are as follows:

·      ​Birth to 2 Years: $70 per month

·      2 Years to 12 Years: $45 per month

·      12 Years to 18 Years: $35 per month

There are definitely fewer pediatricians operating DPC practices, so I was unable to find an average cost at this time, but the above is a reasonable place to start. The idea is that younger children will need more frequent visits, and thus will pay more for the service informs Dr. Hill’s price points.

This pediatric pricing is in contrast to how adult medicine pricing works for the typical DPC practice. The adult pricing usually increases as patients increase in age, with geriatric patients paying the most. In pediatric pricing, the youngest children will pay the most because they require more care and attention and more frequent visits.

Are There Conferences Where You Can Learn More About Direct Primary Care?

There are three major conferences where you can learn more about Direct Primary Care:

Paul Thomas, MD of Plum Health DPC and Ashley Walker, MD of Hurley Medical Center talk about what it takes to start a Pediatric-focused Direct Primary Care practice. We had fun with this one!

• Docs 4 Patient Care Foundation DPC Nuts and Bolts Conference

• American Academy of Family Physicians (AAFP) DPC Summit

• Hint Summit 2020 — Take Direct Primary Care to New Heights

Is Direct Primary Care a more equitable way to practice Medicine?

I believe that direct primary care is a more equitable way of delivering primary care medicine. First, there are so many people who fall through the cracks of our current health insurance based system for delivering care. If you earn too much so that you’re disqualified from Medicaid and if you don’t earn enough to comfortably afford private insurance, the current fee-for-service can be harmful. DPC gives folks another option for receiving high-quality, compassionate primary care medical services.

Specifically for Dr. Walker in Flint, Michigan, anytime you work in an urban, underserved community, you have a great opportunity to give back to your community.

Are patients allowed to pay for Direct Primary Care services with HSA Funds?

As written, the current tax code precludes folks from using their HSA funds to pay for direct primary care services. Pragmatically, people are using their HSA funds to pay for direct primary care services. It’s up to you, with input from your trusted lawyer and trusted accountant regarding whether or not you want to take the additional risk of accepting payments via your patients’ HSA accounts.

How can you balance home and work life when you are a Direct Primary Care doctor?

You start by setting clear expectations for your patients about how you want them to treat you. You can teach people how to treat you by the way you respond to their requests. For example, it’s really good to be responsive to your patients’ phone calls, text messages, and emails. However, sometimes it’s better to be more responsive during the week days and normal business hours and less responsive during the weekends and after hours for non-urgent concerns. Of course if there’s an urgent or emergent concern, you should respond immediately and give proper guidance.

For me, I really protect my Saturdays and Sundays as dedicated time with my family. I make sure that all of my patients are aware of this. I also take enough vacation time to stay fresh and focused when I’m at the office and to create great memories with my family. This is a balancing act, and over time you can figure this out.

For patients who work long hours and can’t come in during normal business hours of 9 am to 5 pm, I can come in to the office early and see them at 8 am or stay late until 6 pm. I do this on mornings or evenings when my spouse is working so that I can maximize the time that I have with my family.

Do Direct Primary Care doctors typically use an answering service?

For me, all of my patients have my cell phone number so they can easily text or email me with their concerns. With their concerns clearly communicated, I can easily triage their text messages and concerns. I haven’t used an answering service for this reason. I think the majority of DPC doctors operate like this.

How do you negotiate prices for meds, labs, and imaging services?

There are typically flat prices from Medication Wholesalers like ANDA Meds out of Florida or Bonita Pharmaceuticals here in Michigan. We use Regional Medical Imaging in Flint, Michigan, and they have flat cash prices for their imaging services. We have a list of our prices and when we order an imaging study for one of our patients, we simply show them the price points and ask if they’d like to pay cash for the imaging study or use their insurance plans. For Lab services, this is a bit of a game and it takes grit and determination to get the lowest prices, especially when you’re working with LabCorp or Quest Diagnostics. My best advice is to ask around for other DPC practices’ price points on laboratory services and see if one of these lab companies will match those prices. Keep calling and asking until you get what you want.

How often do you do point-of-care testing?

We do point-of-care testing frequently. Just about every week, we’ll run an EKG, typically for folks with anxiety-related or musculoskeletal-related chest pain. An EKG machine costs about $1,700, so it’s an investment but ultimately worth the cost for the value it provides to our practice.

We also have a PFT machine that cost us about $700. This is another useful tool in our office. We do point of care glucose testing, fecal occult blood testing, rapid flu, and rapid strep testing. We also have a microscope in the office and we use this just about every other week or every month to help in diagnosing a case of vaginitis.

We don’t offer point-of-care testing for lipid panels or A1c testing because we get the results next day through our laboratory vendor.

Is Malpractice Insurance Affordable for Direct Primary Care Practices?

The biggest line items in your budget are square footage and staffing. If you hire a medical assistant and pay them $17.50 per hour, this will come out to $3,400 each month including salary and payroll taxes. When we were renting a small space, it was $600 each month. Now, we’re renting a larger space and it’s $2,800 each month. Each month, we buy roughly $1,500 to $2,000 in medications. Each month, we spend $1,500 to $2,000 on labs. These are the bigger line items in our budget.

As for malpractice insurance, it comes out to roughly $450 monthly or $6,000 for the year at our practice. Also, our practice in Detroit has some of the highest malpractice rates in the State of Michigan because I was told by my insurance broker that Wayne County is a highly litigious county.

How do you or how should you staff your clinic?

As a solo doctor, you can handle many of the daily tasks in your DPC practice and you don’t necessarily need to hire a Medical Assistant or Nurse. However, hiring a Medical Assistant to help you draw blood, fill out forms, return faxes, call the lab company, take incoming phone calls, and go through the contract with prospective patients can be tremendously helpful. This can free up your time to spend more of your time and energy to focus on patient care and grow your business by reaching out to new patients and small businesses with employees who may want to sign up for your service.

Thanks for reading and thanks for watching - sincerely thank you to Dr. Ashley Walker for the excellent questions about direct primary care - I wish you the best of luck in your journey!

If you’re looking for more excellent content like this that can help you start and grow your direct primary care practice, check out our courses on Writing a Business Plan, Attracting More Patients to your DPC practice, and How to Find the Perfect Space for your DPC practice.

- Dr. Paul Thomas, MD

The Startup DPC Show Episode 4: What's It Like to be a Direct Primary Care Doctor?

What’s it Like to be a Direct Primary Care Doctor?

Just about every week, a new medical professional visits our Plum Health DPC clinic in Detroit, Michigan. Earlier this month, we had a great visit from John Zakhary, a medical student from upstate New York. John is studying at Touro College of Osteopathic Medicine and he wanted to know more about our Direct Primary Care (DPC) model of healthcare delivery. John spent the day at our practice, observing how we take care of our patients at Plum Health and getting to understand the flow of our practice.

Before he came through, John read our book, Direct Primary Care: The Cure for Our Broken Healthcare System. Beyond the content of the book, and beyond the day of learning in the clinic, John had the following questions. He wanted to know more about how DPC addresses the problems of the current fee-for-service system, how we’re able to spend more time with patients, and resources that make DPC effective.

Here’s the full interview on YouTube, and below is the transcription of the conversation - enjoy!

Written by Paul Thomas MD and John Zakhary, DO Candidate, Class of 2023, Touro College of Osteopathic Medicine - Middletown, NY 

How Does Direct Primary Care Address Problems in the Current Fee-for-Service System?

[John] I think one of the big issues with primary care is that it's not incentivized enough for providers and it's not that accessible for patients. My first question is, how does Direct Primary Care make healthcare more accessible for patients and what problems in American healthcare do you think this delivery model is addressing?

[Dr. Paul] There are a lot of people who fall into the gaps of coverage. For our practice in Detroit specifically, there are a lot of people in Michigan who earn out of Medicaid coverage, so if you make $17,000 or more, you disqualify yourself from Medicaid in Michigan. That's a lot of people who are in the service industry like hairdressers, truck drivers, bartenders, restaurant workers, et cetera. That’s  a huge portion of our population! There are actually twenty-eight million Americans who are uninsured currently. Everywhere in the United States, you're gonna find folks who are uninsured. There are also folks who are underinsured. Perhaps if you're making $50,000 per year you might purchase a low premium, high deductible health insurance plan or catastrophic coverage plan that doesn't really afford you great primary care access. That's where direct primary care can come and be very impactful. We can start providing that basic bread and butter primary care access and really give people great health care experience while we're at it.

What is the Value of Direct Primary Care for Patients?

[John] It seems like there's a financial incentive for patients. How would you describe the value that your office offers to patients that they really couldn't get elsewhere?

[Dr. Paul] Let’s say you're uninsured, underinsured or on Medicaid, a lot of times you go to the emergency department because it's “free” or an urgent care because it's low cost. But you really don't get that consistency of having a solid primary care physician who can be your advocate and can guide you through difficult problems that you might be facing, like a chronic condition such as high blood pressure, diabetes, chronic back pain or some of the most common concerns that we have, a physician who can guide you through managing that without opiates, whereas like you might see somebody in the emergency department. Just to get you out of there, they might give you five or ten Norco.

It's like that continuity piece and having somebody who actually cares for you and wants to help you with your concerns. In other environments, like an emergency department, really high volume primary care office or really high volume urgent care, the incentives aren't there to build relationships. It's more about getting the work done for the patient in the immediate term and then getting out the door quickly. On to the next person.

Does the Direct Primary Care Model Allow You to Spend More Time with Your Patients?

[John] How much time do you spend with patients and what can you do with your patients with that time that other providers aren't able to do?

[Dr. Paul] A typical family physician is going to have about 2,400 patients; that’s the average that's across the board for any family physician, internist, or pediatrician. You just have to see about 24 patients a day or one-percent of your panel each day to make enough money to keep the lights on, pay your staff, pay for your overhead, your rent, your lease, et cetera. In our model, we can keep the panel to about 500 patients so we’re seeing one-percent of our panel, or about five patients a day. That means we can spend 30 minutes to one hour with each patient rather than 15 minutes or 20 minutes in the fee-for-service system. Plus, our charting system, or electronic medical records system is pretty streamlined; It takes us five minutes to write a comprehensive note. When using an electronic medical record such as Epic, or other popular EMR’s that are used in hospitals, there's a lot of box checking, it's pretty clunky and it takes a long time just to write basic primary care notes. And then to bill that out, it takes longer than that; it has to go to a biller and a coder just to ensure reimbursement and you get paid 90 days later. All of these problems are baked into our current system for primary care, and direct primary care resolves a lot of those challenges.

What are Some of the Resources that Make your Direct Primary Care Practice More Efficient and Effective?

[John] One of the things that disincentivizes medical students from going into family medicine or any primary care field is that they don’t think they can accomplish much with their career or with their patients, or perhaps. When I shadowed you however, I was  fascinated by all of the resources that you had that made your job easier and enabled you to handle more involved cases that providers might normally refer for. Could you speak to some of the resources you use that make your job easier?

[Dr. Paul] When you were here, we had a patient with depression and I just pulled up a Beck’s Depression Inventory that I have in a Google form. They put in their unique medical record number, ‘150’ for example, and then they answer that questionnaire digitally while in the office. I review it, we compare it to the last visit, and we refill their prescription in the office. For example, Sertraline 50 milligrams is two-and-a-half to three cents a pill, so they have their 60 or 90 day supply of Sertraline for three to nine dollars, and they have my cell phone number in case they have a breakdown or something concerning happening in regards to their depression. 

We also have more complicated patients with multiple chronic conditions, and we have enough time to set aside an hour to really dive into their conditions. What’s your hemoglobin A1C? How has your blood pressure been? How's your back pain? 

And we really look at all the medications they are taking to make sure that they're on an even keel, taking their meds, not having any side effects or contraindications; things like that to make sure people are healthy and then taking it one step further. For example, “I would like to bring your A1C down further; let's talk about exercise.” We can spend 20 minutes just talking about diet. Those are the tools that I have, but it’s mostly time based. I just have more time to dive into these conversations with people.

How Do You Mange Referrals for Your Patients?

[John] I remember when I was shadowing you that there was a patient who presented with a fractured distal phalanx of the thumb, and he was really concerned due to a basketball tournament he had coming up. What you did was you you wrote a report to an orthopedic surgeon on this website who was on call, he gave you his input, and I think you had the whole thing resolved in just a couple of hours. I thought that was amazing. Could you speak to how that process works and what that resource is?

[Dr. Paul] I actually saw that guy earlier that week and he’s a really busy restaurant owner who jammed his thumb playing basketball and he thought it was a bad jam; I thought it might have been fractured, so I ordered the x-ray. He ended up getting it done that Friday at two o'clock and I had checked ‘stat’ on it. They read it right away, they read it as a fracture, and I called to confirm with the radiologist. We quickly took those images from the digital record of that x-ray and put it into what's called Rubicon, the Econsult platform that you mentioned. We sent that to an orthopedist who gave a recommendation, and they actually recommended that he require a pinning surgery. But then we sent a text message to a local hand surgeon specialist that I worked with previously, and he recommended splinting and following up with him in the next week. We made that appointment for the week after, and made a point to consult with another doctor who encouraged continuing with the splint and then after healing for four to six weeks, engaging in some higher intensity physical therapy. As a physician, I regularly utilize text messages, email, Econsult platforms and phone calls with the radiologist, and we were able to give a comprehensive care plan to this guy. 

Let's say you got the x-ray done at 2 o'clock on a Friday. Good luck getting in to your PCP in the fee-for-service system. And then, good luck getting a specialist consult that same day or two specialist consults for that matter. That doesn't happen every day, but it happens at least once a month where we’re diving into situations with differing opinions on what to do with patients and trying to help patients navigate those difficult decisions. 

How are Direct Primary Care Doctors Able to Provide At-Cost Labs, Meds, and Imaging Services?

[John] One of the other things I thought was fascinating about your office is how accessible imaging, labs and medications are for patients and the agreements that you set up with different imaging centers and labs in the area. Could you talk a little bit about how that works and what that is?

[Dr. Paul] For the patient who got the hand x-ray, the cost was $45 at Regional Medical Imaging which is just down the street from us, and that x-ray would have been $150 to $200 at the hospital. We have the benefit of having an online portal, seeing the digital recording online, and having the radiologists cell phone number so that we can call and discuss it.

We also draw blood in our office and run a comprehensive metabolic panel for six dollars, whereas a patient, if they went to the hospital, might pay $150. We have all those prices on our website, plumhealthdpc.com if you want to check it out; we're saving patients 50 to 90 percent on those labs. It’s the same for medications which we purchase at wholesale prices and give to our patients for at-cost prices. As I mentioned earlier, Sertraline 50mg, I believe, is two-and-a half or three cents a pill. These patients are paying about 90-cents a month, or a couple of dollars for a three month supply.

How Are Direct Primary Care Doctors able to Provide Same-Day and Next-Day Appointments?

[John] One of the other things that I loved about your office was the ease in scheduling a same or next day appointment, even by call or text. I’m wondering if you reserve time slots each day for last minute, same day appointments and how quickly a patient could get in if they needed to see you?

[Dr. Paul] That happens every day. I typically have about three or four scheduled patients each day, and I usually fill in with two to five same day appointments depending on the day and time of the year. You came in early January, so you saw a lot of people just walking in, just like the patient with the fractured thumb. He got that x-ray at two o'clock, texted me to share the results of his x-ray, and asked when he could see me, so I told him to “come right now!”. A lot of folks are texting me each day and getting an appointment. Yesterday, for example, a little three year old girl came in with her father because he had noticed her eyes had some purulent discharge. Her eyes were erythematous, there was some puss, and her eyes were red. He sent me a text at one-thirty and I saw her at three o'clock. That's typical, that’s standard, that’s every day. We're really happy and proud to do that because that's what differentiates us from any other doctor. Our patients will text me anytime and I guarantee a same day or next day appointment appointment. Let's say you text me at 4 o'clock. Perhaps I could offer a four-thirty or five if you're lucky, but definitely eight-thirty or nine the next morning, I can see you. 

Business Management

In Order to Start Your Direct Primary Care Practice, Did You Take A Leap of Faith?

[John] Can you speak to the leap of faith that you took starting PlumHealth fresh out of residency and any challenges or setbacks that you might have faced in the process.

Dr. Paul: [00:14:53] Yeah, I think it is more of like a leap of determination.

Dr. Paul: [00:14:55] I think, you know, as a physician, when you graduate from residency, you're always going to have an opportunity to moonlight on the side. And, you know, so for me, I worked in urgent care for 20 hours a week on the side and that allowed me to have a reasonable income and then four days a week where I could devote to building up plump health. So, you know, if you're willing to sacrifice it for me, I don't have like a country club membership. I live in a reasonable house. I drive like a Ford Fusion. Know, I'm not living large here, but I am investing into my business. You know, that's really important to me that I'm investing in club health so that I can have like a really sustainable practice that I enjoy working at each day. And that makes a happy when I come to work each day. So like. Part of my ethos is investing in my business. And building a practice that aligns with my personal values of back and serving people in the community. So I knew that I could be successful in this model as long as I had some kind of side income for a year. And so I did that. I worked in urgent care for a year during my first year of starting my direct care practice. And then when I built up to, let's say, 150 members of my T.P.S. practice, I could walk away from urgent care work and focus full time.

Dr. Paul: [00:16:16] And by my Direct Primary Care practice. Sure. So, you know, part of that process was I took some small business courses. I wrote a business plan in my residency. If you if you're watching this, you want to learn how to write a business plan. If you want a copy of our original business plan and our current business plan, it's on one of our courses on this website, startup T.P.S. Slash Take Action. There's like a business plan. Course you can take it takes about an hour to go through that course, show you everything you need to have your business plan. That's like mandatory. You have to write a business plan. That's a skill I didn't know how to do. There weren't a ton of great resources, so I wanted to put together a course to help the next doctors want to do this. The next thing I did is I took some small business courses that taught me about branding, marketing, how to build out an office, etc.. Again, I've tried to put some of those resources on my Web site, like how to office, how to brand yourself, how to market yourself. All those things to help the doctor, the next doctor. Well, let's assume through T.P.S. practice.

[00:17:16] So in my for me, when I graduate residency, I took two small business classes. Each were about eight weeks and they covered a whole bunch of different small business topics. And then on top of that, I read about 50 business books in the first year after residency. I read authors like Gary Vaynerchuk and his classic CRUSH IT!, Grant Cardone and The 10 X Rule as well as If You're Not First, You're Last, Tony Robbins, Seth Godin and others. Just like a lot different, you know, virtual mentors. In a way, you can kind of get a flavor for how they operate their business through their books.

What is the typical panel like for a Direct primary care doctor?

[00:17:57] John: Sure. Yeah. And so something you mentioned, you mentioned that for a Direct Primary Care doctor, it's typical to have a patient panel of about 500. How is the process of building a patient panel and how many patients did you need to break even?

[00:18:14] Dr. Paul: You could say sure, yeah. There's two different things there. And I talked about this in the business planning course, but there's like a break even on your operational expenses. And for me, when I first started, my overhead was about five thousand dollars a month. That was the rent lease EMR malpractice insurance. The amount that I spent on meds and labs each month was about $5000 on average in my first one year. So if you think about the number of patients, that's five. That's one hundred patients. If you're making 50 dollars per member per month, that's about $5000 you break even operationally. Then, you know, when you want to start paying yourself, you're looking at getting to like two hundred patients because then you're making $5000 for your overhead five thousand dollars to pay yourself and then incremental your overheads going to increase with more and more patients could give five more minutes, more supplies, maybe hire somebody, use additional services to make your business run smoothly and then your your overhead is going to gradually increase over time. Yes, so a break even point, depending on your price point, depends a lot on your lease. The price of your lease and the customers that conservatively might be a hundred around one hundred patients.

How do you balance being a physician and a small business owner?

[00:19:33] And then when you can start paying yourself probably around 200 patients right now, something that I foresee as a potential challenges. You are a doctor. You're a compassionate family doctor. At the same time, you're a business owner. Sure. How do you balance your time between the two and how do they how do those two aspects of your life kind of interact with each other?

[00:19:59] Yeah, that's a great question. I think on one side of your brain, you're the doctor where, like, you leave no stone unturned. Mistakes are frowned upon at best and punished at worst. Right. If you make a mistake, you're going to hear about it from your attending, going to get chewed out or whatever in the business side of things like mistakes are valued because of the learning experience. You made a mistake. That's also you're never going to make that mistake again. Are you going to do things differently in the future? It's indirect. As for learning, and the more mistakes you can in quick succession, you can be more successful. You can become so like when I take care of my patients. I definitely have my doctor and where I'm focus on the details and making sure that I hear everything, the history and come up with a comprehensive care plan. But when I'm working on my business, I'm turning on my business brain where I'm making really quick decisions and trying to do things relatively quickly and not over think things are hammer on things for too long. Because when you wait too long, you're going to miss opportunities. So that's not something you're taught in medical school. You're just not. And that's something you kind of have to learn through experience.

[00:21:16] Right. The other challenges, like, you know, being the doctor and seeing patients and then being a business person, collecting revenue, collecting money from your patients. And that was my next question then. Me super uncomfortable. Listen, I know I was just treating you for diabetic foot infection, but you also have an outstanding balance of two hundred dollars because this has, you know, this hospitalization set you back. And if you're honest with people, you just level with them like, listen, I'm I'm your doctor might also make money, too. Usually it works out fine as long as you communicate with people about what you need to do. And then as you grow, perhaps you delegate more of those tasks to your medical system or you hire a billing company. So that if it really makes you uncomfortable for me, I'm able to navigate that pretty easily. It's just. Yeah, I'm delivering you a valuable service. And you've been out selling, sending balance 50 bucks or 100 bucks. Can we sell your balance or do you need to close out your account? Do I need to write it off? I'm good with you that just let me know. Right. And a lot of ways to respect that approach.

[00:22:24] Right. And I would say everybody has different circumstances. At the same time, however, you know, obviously you're you're offering an extremely valuable service asset, an extremely affordable price. And, you know, I think that just those circumstances allow for more honest conversations between people. And you also have more time to you know, maybe this is just something back to some of the questions I had earlier. But the amount of time that you have with your patients also enables you to have those types of conversations about their personal life, about maybe stress, financial issues, other things that are going on. I noticed that when I was there. You do a lot of listening. You do a lot of listening and they do a lot of talking. And not to say that you're not doing your job, but it's I you could say it's therapeutic for them in a way, and it helps you to understand what they need and to help them more, you know? Yeah, totally.

[00:23:18] I mean, I think the majority my job is just listening to people.

[00:23:22] I'm carrying out their concerns fully and then coming up with a plan to address those concerns. And a lot of time with therapy is just then having somebody that they can trust to tell them his concerns about. Now, I haven't told anybody about this, but I'm struggling with this and just being listening here, not judging and just, you know, sometimes not saying anything and just listening. Tell me more about that or I'm sorry to hear that. What can I do to help? And sometimes it's like I don't know if he can. I just wanted to tell you that. Or it might be. They really open up about a concern. And that's like it sounds like you're depressed. Let's do a depression screening. And you. Yeah, there's there's a lot that goes into these appointments. And as a family doc, I'm grateful for this practice model because actually the more time just to listen.

[00:24:09] Right. How are we doing on time? I still got a few more questions for if that's a good idea.

[00:24:13] Let's let's do it then. Definitely fewer minutes.

How Do You Purchase Malpractice Insurance for your Direct Primary Care Practice?

[00:24:17] All right. I did have one more business question, and that was. Sure. How malpractice works, is it the same for you as it would be for another family doctor?

[00:24:26] Yeah, I think it's essentially the same. You know, I called up a few different malpractice carriers and I asked them for good prices. One of the pieces of advice I give to doctors starting their GP practices is get three quotes. Call. Don't be lazy. Don't take the first quote. You know, if you're building out a new office or if you're getting a malpractice insurance or if you're getting a website designer or if you're hiring a photography to provide for. Look at three different quotes. Compare and contrast. Gather the information. Then quickly make a decision or move on. For me, I got three quotes on malpractice insurance. One. You know, sometimes a little bit lower because I'm seeing one fifth of the patients of a typical family doctor. I'm spending five times as much time with those patients. So my malpractice insurance should be a little bit lower just in full transparency. I pay about 450 a month. It's like fourteen fifty a quarter for that malpractice insurance. It's pretty standard about six thousand a year. So it's it's not that different. The only difference is if you've always been employed by a hospital system, you've probably never made that phone call. There's some terms you need to understand, like tail coverage and maximums and all this kind of stuff. But if you have a good agent, you can ask them to describe it to you and then you call the next agency and you ask them to describe their coverage for you. And then you reach out to a mentor of yours. Look at your older family, doc who's bought a few different insurance coverage is and say, what do I need to look out to for where can I get burned in this?

Personal Questions

How Much Money Do You Make in Direct Primary Care?

[00:26:07] John: Right. OK. I have a few questions that are potentially sensitive, more personal about you and kind of, you know, the personal side of what you do, if that's all right.

Dr. Paul: Yeah, sure, man.

John: I think one of something else that disincentivizes people from going into primary care, especially family medicine, is compensation for the work that they're doing. And what I'd really like to understand is. And especially as a business owner, how would you say our income compares to that of a different family doctor? And more of a traditional office setting?

[00:26:49] Dr. Paul: I think that's a great question.

[00:26:50] I think every medical student would want to know that before choosing a Direct Primary Care path. So, you know, when I graduated, I was offered $165,000 each year plus a $10,000 signing bonus by the institution that I trained with pretty standard. When I was moonlighting in urgent care, I was making $70 an hour. We're seeing about four patients an hour or three to four patients an hour. So that that was like, you know, for reference, that's that's the kind of money I was offered or what I was making moonlighting. You can get higher if you're in a rural or. It depends where you are. All these are regionally dependent.

But metro Detroit, it's pretty saturated with physicians. So you're not going you're not going to get like a huge salary unless you're doing a huge volume. Like if you're seeing 40 patients a day, perhaps you could earn up to $400,000. That's like exactly the opposite of what I want to be, too. You know, I want to be spending more time with my patients. So in the first year of my practice, I pay myself what a resident might make, you know, six, seven thousand dollars a month. I've paid myself progressively more and more. Last calendar year, the year 2019, I paid myself about $110,000 over the course of the year. Now, I could have paid myself much more. But this last year, I also spent two hundred thousand dollars building out this beautiful office that I occupy now.

[00:28:23] John: It's beautiful. Yeah.

Dr. Paul: Yeah. Thank you. Awesome. Yeah. And and, you know, so part of this is as a business owner, I think differently about money than an employee might think about money. So for the doctor that I hired, she has the opportunity to make $200,000 to $240,000 a year, whereas perhaps I would want to make less than that. So I can keep reinvesting money into the business to grow a more sustainable practice for the future and for future growth.

So like right now, I'm sacrificing my personal income for a long term income potential in my business. And I think that's not the way doctors typically think about income. Many Doctors say to themselves, “Did I just sacrifice eleven years of undergrad and med school residency? And now I just want to get paid, you know?”

But as a business owner, you're thinking differently. You're you're investing for the long term. And that's a I'm I'm kind of playing the long game. I could pay myself more, but I would come at the expense of like I grow more slowly in terms of my business because I wouldn't have enough money to invest in marketing or invest in hiring another doctor or hiring another medical assistant or building up an office which helps us be sustainable long term.

What is the Income potential for a Direct Primary Care Doctor?

[00:29:39] John: Exactly. As a lot of people know, you're doing something else.

[00:29:43] Dr. Paul: The other thing is like I'm intentionally working a lower income community.

[00:29:47] And in terms of the spectrum of charging people money for DPC, I'm on the lower end, charging $10 a month for kids and $49 a month for adults as their starting rate. Whereas other doctors in the movement are charging on average, let's say, $70 or $80 a month or $90 a month. So, you know, it the cool thing about this is don't let my salary dictate what you can earn. If you want to go out and make half a million dollars a year in a DPC practice, you could probably do it. You probably bordering on a Concierge Medicine service. You know, you'd probably charging like $120 a month or something like that. But if you want to do that, it's your right. You have the autonomy. And so that's like the second part of the answer is, like a lot of DPC doctors are making a little bit less than what they would have in the fee for service system, but they're more fulfilled. And then they might say nothing pays like autonomy because you get to decide what to charge your patients, what you want to do for your patients, what kind of service you want to offer, the hours that you want to work. Yeah. If I worked 8am to 6 pm every day, I might be making more money, but I'm working 9 am to 5 pm and I have a really good work life balance.