This week, I was interviewed for the DO (Doctor of Osteopathic Medicine) Magazine by one of our rotating students. Here’s what I had to say:
What would you like residents and attendings to know about opening and running a DPC?
At the core, practicing in a direct primary care (DPC) model allows physicians to engage in work that is satisfying. We can all agree that work is satisfying when we have autonomy, we can engage in complex decision making, and when there's a direct relationship between effort and reward. Unfortunately, these factors are slowly being eroded from employed practice in large health system groups or in insurance-based primary care.
As a direct primary care doctor, you have the ability to regain your autonomy, to be your own boss. You set your schedule, you determine the price points, you decide on which days you work, you decide when you go on vacation, you decide on which medications you will stock, and you determine which areas of medicine you will focus on. Interestingly, by doing this, by practicing on your terms, you will attract a certain patient or customer for whom this style of practice resonates. You will find patients who respect, appreciate, and seek out care from the authentic doctor who has established this DPC practice. It’s hard to put this concept into words, but you may find your patients have a lot in common with you in interests and in personality.
When I finished my first book on direct primary care, I sent a press release about its publication to Devin Scillian of WDIV and host of the Flashpoint program. He invited me to an interview on his program after he received the press release and asked some very insightful questions. He closed the interview with the topic of money – “I don’t know how to ask this delicately, but is this lucrative for you? Do you make a fair amount - enough money? Or are you just messing with the system?” Now this is something that we talk about at every national DPC conference. My answer was informed by a panel of physicians at the 2017 DPC Summit hosted by the AAFP. The moderator asked if the panelists – a smattering of doctors in vastly different DPC practices – were making more or less money. The consensus seemed to be that folks were making slightly less money but had much greater fulfillment because of the autonomy that they experienced while practicing in the DPC model.
Informed by that conversation, I followed with this answer, “As the membership grows, as the doctor gets to full capacity, you earn about what you would make as an employed physician, maybe a little bit less. But, we have a saying in the direct primary care movement that nothing pays like autonomy. I can be the physician I was meant to be. And, in this model, it’s really inspiring for other doctors who want to join this movement because you have the ability to practice medicine on your own terms, and not at the dictates of insurance companies or government health care systems.” You can see the full interview here: https://www. plumhealthdpc.com/blog/2018/12/23/family-doctor-on- flashpoint-with-devin-scillian .
And for me, five years into the practice, this feeling still holds true and still resonates with me. I’m making slightly less than I would have had I signed the contract with the large hospital system. But, that higher income would have come with seeing 25 to 35 patients each day. That higher income would have come with less time with my family and more time clicking check boxes. That higher income would have come with less time for self-care and a higher risk of burnout. That higher income would have come with a decline in my mental and physical health.
And you’ll find that I’m not alone in how I feel about this topic. You will find that DPC docs are a self-selecting group who take risks for the sake of their independence and the integrity of their practices. They continuously advocate for policies at the State and National level that protect their ability to practice with autonomy. DPC Docs aren’t likely to make or keep alliances with larger organizations at the expense of their autonomy. As long as we stay alert and proactive, DPC and independent practice will thrive.
How has Plum Health navigated the business challenges of a DPC practice?
Many doctors look at the direct primary care model and practice style wistfully. They see the benefits for both patients and doctors and they aspire to become a DPC doctor. However, they think that this is only achievable after becoming an MBA. But… You DO NOT need an MBA to be successful as a DPC doctor - if you’re smart enough to finish medical school, gritty enough to complete residency, and compassionate enough to choose primary care, then you have ALL of the ingredients of a successful DPC doctor and business owner. Direct primary care is all about removing the middle men and the barriers between doctors and patients. What makes this DPC practice model so unique and so powerful is the doctor’s ability to get rid of the unnecessary steps and intermediaries between doctor and patient, delivering a streamlined and intuitive primary care service to patients. So doctors, I know that it can be a scary leap to go from an employed physician with no training in branding, marketing, sales, web development, search engine optimization, and other essential skills for a successful DPC practice, but you don’t need to hire an MBA to do this. What you can do is read through the available resources in the DPC ecosystem, learn the new skills that you can, and hire individuals for the skills you don’t have, but you do not need to hire an MBA to manage the entire process. We need more doctors to stand up, start their own practices, and take back medicine for the betterment of the doctor-patient relationship and the health of our communities.
You do not need an MBA to be a successful DPC doctor.
What is your story? What attracted you and how did you get involved with a DPC practice?
I initially discovered direct primary care while on a road trip – I was driving back to Detroit from a residency position interview at the University of Minnesota. I heard a podcast interview with none other than Dr. Josh Umbehr discussing his startup in Wichita, Kansas. It was refreshing to hear a Family Medicine doctor speaking so passionately about saving people money, delivering better care, and practicing in a unique way. The message resonated with me, but at that time I was pursuing a faculty position at a residency program because I enjoyed teaching so much. Suffice it to say that I filed this “direct primary care” concept in the back of my mind.
Between my second and third years of residency, I went to the Michigan Academy of Family Physicians (MAFP) annual meeting in Traverse City. It was July 2015 and a full year before I graduated from Residency. This was a critical moment because I had to decide in which direction I would take my career. There I met Dr. Clint Flanagan of Nextera Healthcare in Boulder, Colorado. He spoke unequivocally about the value of being a primary care doctor and the tremendous value that we provide for our patients. His passion for the profession came through in a way that I hadn’t experienced before.
These two leaders in the field served as a contrast to the typically burnt out and grumbling physician that I had met thus far in training. Even the best doctors grumbled about paperwork, prior authorizations, late patients, packed schedules, and all of the other difficult parts of being a primary care doctor. At that point, I knew that I would pursue an alternative practice model. It only made sense – less-than-fulfilled physicians practicing in a less-than-ideal system surrounded me and I knew that life could be better on the other side.
Additionally, I always had this inner drive to deliver medicine in a more equitable and just system. Direct primary care seemed to align with my values as an individual and as a doctor, but I needed to dive deeper. As an elective rotation, I drove out to Wichita, Kansas and Boulder, Colorado and spent a week learning from both Drs. Umbehr and Flanagan. I kicked the tires, took copious notes, and tried to bring the best of their practices to my community in Detroit, Wayne County, and Southeast Michigan. How did I accomplish this feat in the middle of residency? I wrote an elective rotation curriculum for myself and I presented it to my Program Director. I was the Chief Resident during my third year, and she accepted the curriculum that I gave her. It allowed me two weeks of travel and immersion time in these practices and I had to meet the criteria that I set forth in my curriculum. If you’d like to download that elective rotation curriculum, you can find it on our website: www.StartupDPC. com.
At this point, I had already written my business plan. You see, a few months prior to the elective rotation, I had taken a mandatory rotation called Practice Management. During that rotation we had to write a business plan for a potential clinic. They had intended the assignment to be an exercise in futility wherein you became overwhelmed by the complexities of running a practice in the fee-for-service system. Instead, I wrote a relatively simple eight-page document demonstrating how I would run my direct primary care practice. With my business plan in hand, I spent time with Drs. Flanagan and Umbehr and learned a great deal about their practices. They also read over my business plan and gave me their advice and critiques.
How has Plum Health fostered a better doctor-patient relationship?
We value the doctor-patient relationship. We intentionally set up one-hour initial appointments and thirty-minute follow- up appointments so that we can have enough time to really get to know our patients. We also have enough time to engage in shared doctor-patient decision-making, and thereby empower our patients to make the choices that are best for their health, wellness, families, and budgets.
We value autonomy, the ability to choose what is best for our patients apart from the insurance company mandates and algorithms.
We also value price transparency for our healthcare services, so our patients can make the best decisions possible for their personal and financial wellness.
How has Plum Health achieved the quadruple aim of medicine-- improving the work-life balance of physicians to make the triple aim of medicine happen?
I believe that the direct primary care model empowers patients with a transformative opportunity to take more personal responsibility for their health. By practicing in a DPC model, you will empower your patients to take better care of themselves. For example, I met a man named Frank last year who enrolled in our practice at Plum Health DPC. Frank works as a truck driver and delivers medications and supplies for a local pharmacy company. His employer does not provide health insurance and he earns too much to be enrolled in Michigan’s Medicaid program. But, his salary isn’t high enough for him to comfortably afford health insurance. Frank knows that he has high blood pressure and diabetes, but it was too expensive for him to access the fee-for-service system. When he tried to use the fee-for-service system, he spent about $100 monthly for medications and around $500 for a visit with lab work to check his kidney function, electrolytes, and long-term blood sugar values (hemoglobin a1c level). Because of this high cost of care, Frank neglected his personal health. Unfortunately, due to his uncontrolled diabetes, Frank went to the hospital for a large abscess in his right hand. Frank required a long hospital stay with intravenous antibiotics and a complex incision and drainage procedure, followed by further debridement of the wound. At the time of discharge, the discharge nurse informed Frank of our Plum Health DPC practice. Frank signed up that day, and followed up with us the day after discharge. We reviewed all of the medications he was taking – a statin for high cholesterol, two blood pressure medications, and two insulin products. These medications might have cost $100 to $200 monthly at the pharmacy, which would have been cost- prohibitive for Frank. Frank started with our practice, got his comprehensive metabolic panel for $6, his Hemoglobin a1c for $6, and a 90-day supply of his medications for $11.52. We gave him 90 tablets of the lisinopril, 180 tablets of the metoprolol, and 90 tablets of the statin for that $11.52. We were able to get Frank’s Tresiba and Novolog for free from NovoMedLink, a special program from Novo Nordisk. What happened after was tremendous – Frank started to actively manage his medical conditions. He took an active log of his blood sugar levels, and had fasting glucose levels of 139 mg/ dL, 121 mg/dL, and 111 mg/dL during his first week of taking the new regimen. We talked and he told me that this was the first time that his medical problems felt manageable. There are so many people who have given up on taking care of themselves because health care has become too complicated and expensive. As DPC doctors, we have a unique opportunity to empower our patients to live their best lives. For me, helping people like Frank is the reason why I started my direct primary care practice and why I continue to work diligently in my DPC practice. I believe that health care should be affordable and accessible, and the opportunity to serve people like Frank makes that personal and professional mission come full circle. Caring for Frank and patients like Frank allows me to achieve my Ikigai, my reason for being. When I am able to solve complex challenges for patients and empower patients to take care of themselves, I am fulfilling my purpose and working in my true vocation. I am good at this job, I’m delivering a service that the world needs, I’m being paid for this work, and I’m doing what I love. These are the elements of the Ikigai framework, and they are fulfilled in caring for folks like Frank. I’m proud of the work that I do and I am grateful to have the opportunity to serve people and the greater community in this way, and I’m very excited for you to have this same opportunity.
How has the COVID-19 pandemic affected Plum Health?
We have had to become more flexible in our health care delivery.
We have shifted to more curbside testing and virtual care to ensure the safety of those that visit us in the clinic.
Direct primary care and the continuous revenue stream from monthly billing, has allowed us to have a stable income during this time
We weren't fired or furloughed by a larger health system, or replaced by mid-level providers during this time
In fact, our care has become more needed by our patients as they've been grappling with their typical health care concerns and all of the issues surrounding covid - vaccinations, infections, exposure, testing, etc...
Where do you see DPC practices going in the future?
There is likely an 80/20 rule at play
80% of patients and physicians are fine with the current system
20% of doctors and patients are looking for something like DPC, even if they don't know what to call it
Currently, only 1.5% of the primary care workforce practices in the DPC model
So, there is a huge growth potential for direct primary care
As more and more entrepreneurial and tech savvy doctors graduate from residency, we'll see more and more physicians adopt the DPC model
Further, doctors do not want to feel like cogs in the health insurance industrial complex, they want to have time to care for their patients face to face, time to understand them and time to make complex decisions, and the DPC model offers doctors that ability.
I'm excited to see more and more physicians offer this model and help their patients in this way.
HOW CAN I LEARN MORE ABOUT STARTING AN DIRECT PRIMARY CARE PRACTICE?
If you enjoyed reading this blog post and if you want to learn more about starting and growing your direct primary care practice, look no further than our book and 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, in our book, 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