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.
