Transcript
Speaker: Hey everybody, welcome to the exit podcast.
Speaker: This is Dr. Bennett.
Speaker: I'm joined here by Dr. Patrick Roll with Covenant MD, a direct primary care practice in Pennsylvania.
Speaker: I wanted to get him on the show to talk about their alternative system for delivering healthcare that's of particular interest to entrepreneurs and those who want to be independent of corporate health insurance.
Speaker: Welcome to the show, Dr. Roll.
Speaker: Thanks for having me.
Speaker: So you heard me say Dr. Bennett.
Speaker: I'm like a Dr. Pepper kind of a doctor.
Speaker: Oh yeah, I was wondering.
Speaker: So tell us a little bit about what direct primary care is.
Speaker: Well, the name direct care comes from direct primary care doctors making, so to speak, a direct contract with their patients.
Speaker: And what that means is by directing, by contracting directly with our patients, we're not contracting, we're third parties like insurance companies.
Speaker: So practically that means that our patients are paying us a low monthly fee
Speaker: Typically in DPC practices around the country, it might be anywhere from $20 to $100 to $150 a month.
Speaker: And we don't bill health insurance for any primary care services.
Speaker: So that removes the third party from the primary care equation, lets us really kind of streamline and innovate the primary care product, make it very patient-centric, give a much, much higher focus on the patient-doctor relationship, and makes the patient
Speaker: come out happier and the doctor come out happier as well.
Speaker: Yeah.
Speaker: So with a DPC practice, you can have all your checkups, your labs, your prescriptions, and even a lot of things that would normally be an urgent care or even an emergency room visit taken care of.
Speaker: So like setting a bone, stitching things, that kind of thing.
Speaker: Yeah, so the idea is that about 90% of healthcare needs would be covered under the direct primary care arrangement.
Speaker: So for that monthly fee, it typically covers all visits to the doctor without any co-pays.
Speaker: Typically, that's how we do it in our practice.
Speaker: We tell our patients really anything that urgent care can do, we can do.
Speaker: So we're on call for our patients 24-7, 365.
Speaker: We do go on vacation.
Speaker: We just hand that off to our partners as need be to cover our patient panel.
Speaker: But it means that we know our patients really well.
Speaker: We get to know them long term.
Speaker: So we know who it is that's calling.
Speaker: We usually know the context with which they're calling.
Speaker: We know their health care history and everything.
Speaker: So it makes it a lot easier to practice.
Speaker: I should add that it's possible to do that because in direct primary care,
Speaker: because our patients are paying us that monthly fee, we're able to limit our patient panel.
Speaker: So out in the insurance taking world, we family doctors might cover anywhere from two to 3000 patients on their panel.
Speaker: Whereas in direct primary care, we're able to limit it to probably 800 max.
Speaker: So what that equates to instead of 20 to 30 visits a day,
Speaker: It takes us down to about a very manageable six to eight visits a day.
Speaker: And even that's a very busy day.
Speaker: So I would say I see anywhere from maybe two to eight patients a day.
Speaker: It gives us a lot of time with them.
Speaker: It allows us to really focus on their needs.
Speaker: I don't have to dread anymore my patients coming in with that list of things they want to address in a visit that's maybe only budgeted for 20 minutes, including maybe seven minutes with the nurse.
Speaker: in 13 minutes with face-to-face time with a physician patient.
Speaker: Back in that environment, I always used to say, I can address maybe your chief complaint, maybe one other thing, but if anything else needs addressing, I'm going to make an appointment to come back and see me.
Speaker: And because typically space is very limited in busy practices, they'd have to come back in maybe one to two months at best.
Speaker: To address those other things.
Speaker: So in this environment and direct primary care, we're able to address all of those things in one visit.
Speaker: And because our schedule is usually open, it's usually relatively unbooked, even a couple of days ahead of time.
Speaker: We're able to really schedule those visits whenever we need them, whenever our patients need them.
Speaker: So, I mean, it sounds like it could potentially be a little bit like private school where it's great if you can get in, but it's tough to get in.
Speaker: Is it pretty hard to get on your list?
Speaker: Yeah, good question.
Speaker: My patient panel is closed.
Speaker: Part of the caveat of being a direct primary care doctor is that that panel eventually has to close in order to continue to deliver the services that
Speaker: that we need.
Speaker: So, uh, it's really limited by the providers I can hire, uh, to, to fill the demand for direct primary care services.
Speaker: Yeah.
Speaker: So, okay.
Speaker: So fair enough.
Speaker: It is, it is tough to get.
Speaker: So, uh, do, do people, um, do people wait in line?
Speaker: How does that work?
Speaker: So, uh, in my, I have two locations with COVIDMDA, I have, uh, one in Lancaster, Pennsylvania, one in York, Pennsylvania.
Speaker: I have a physician partner whose panel is still open to new patients.
Speaker: I have a physician's assistant partner here in Lancaster whose panel is open.
Speaker: Then I have a physician assistant partner in York, her panel is open.
Speaker: So I'm the only provider that's closed right now.
Speaker: In the history of my practice, when we've been completely booked up, we just put patients on a waiting list and then as space becomes available, we can take them off that waiting list.
Speaker: So ideally we hire, ideally we hire providers that, uh,
Speaker: we can keep up with the demand so that there's never a waiting list, but that's been hard to navigate sometimes.
Speaker: Got it.
Speaker: So if I'm local, I can, I can go to covenant.
Speaker: I just can't see Dr. Roll right now.
Speaker: That's correct.
Speaker: Okay.
Speaker: Got it.
Speaker: Okay, cool.
Speaker: So, uh, you've got, you've got your basic, uh,
Speaker: bumps and bruises and colds and daily primary care stuff taken care of.
Speaker: Plus, you know, if you, if you, you know, put a nail into your hand or something.
Speaker: But you do encourage patients to get insurance for catastrophic coverage, which, you know, as you mentioned, is supposed to be the point of insurance is to cover catastrophic outcomes.
Speaker: Right.
Speaker: So what are some elements of things that you don't cover that you would encourage someone to have some coverage for?
Speaker: So we certainly wouldn't cover specialty visits whenever that's needed.
Speaker: I tell them we cover almost all emergent care.
Speaker: If something requiring emergency care comes up, it's something that requires an emergency room.
Speaker: So certainly if they call us complaining of chest pain, we tell them to call 911, any stroke symptoms, certainly.
Speaker: Complex lacerations, injuries, maybe complex fractures, we would send them on to the emergency room.
Speaker: But there's a lot of even emergent things that we can handle here.
Speaker: So probably my most common reason to get called in
Speaker: in an evening, weekend, or holiday is to do stitches.
Speaker: So that's probably the most common thing that I'll do after hours.
Speaker: But so we do tell them that when it comes to specialty care, that they would have to either continue with specialists that they're currently seeing, or we just refer into any of the hospital networks in our local area.
Speaker: So there's really no barrier to doing that.
Speaker: We can easily do that.
Speaker: Um, we, we also emphasize that in direct primary care, we're really trying to, to limit the fragmentation in care, uh, that is so rampant in our healthcare system.
Speaker: So, uh, with direct, with, with primary care doctors being so, um, squeezed for time, uh, they can handle, you know, the, the very, the very basic things.
Speaker: Um, but when it comes to more complex care, maybe complex, high blood pressure, um,
Speaker: even some depression, anxiety, it's kind of incentivized in the healthcare system to refer to other providers that, that provide specialty care for those things.
Speaker: So a nephrologist for high blood pressure, for instance, or a kidney doctor for high blood pressure, an endocrinologist or hormone doctor for diabetes, perhaps a psychiatrist for anxiety and depression, but in direct primary care, we have the real, we really have the key ingredient, I think, and that is time.
Speaker: We have time with our patients.
Speaker: We have time even outside of the clinical visit to research things as we need to, to really make sure we're giving optimum care and that we're trying to bring as much as we can under that direct primary care envelope.
Speaker: So perhaps we can decrease a bit of that fragmentation of care that's occurring in our healthcare system.
Speaker: And so that we can really assist the patient by being a quarterback
Speaker: for their health care, being as engaged as we can with their specialty providers if they see them.
Speaker: Maybe trying to take as much of that specialty care under our umbrella as we can in the way of blood work.
Speaker: We do blood work at discounts in our office.
Speaker: We could dispense medications at cost in our office.
Speaker: So there's a lot that we can do maybe to
Speaker: decrease their exposure, so to speak, to specialty care, but certainly keeping it within what is prudent for the patient.
Speaker: Yeah, that's been such a frustration of mine is that virtually any time where I'm going to a primary care, their job feels like
Speaker: They're like a referral service or their job is to say, you're being paranoid, go home.
Speaker: Like a lot of actual care happening there.
Speaker: It's just like, does a specialist need to hear about this?
Speaker: Yes or no.
Speaker: And then I feel frustrated with the money I'm paying for that visit.
Speaker: Yeah.
Speaker: And I feel like this model really lets me, I went to medical school with a dream of being a family doctor.
Speaker: I kind of, I wanted to be a generalist.
Speaker: I wanted to know as much as I could and be all I could for my patients.
Speaker: You know, I kind of really had this Marcus Welby-ish vision for general practice, small town doc, home visits and everything.
Speaker: And
Speaker: So, yeah, that was kind of a vision that I'm trying to implement in DPC.
Speaker: It's a beautiful idea.
Speaker: And that leads to my next question, which, you know, it says here you offer home visits at no extra charge.
Speaker: And that's just such a wholesome image.
Speaker: I'm picturing the stethoscope and the leather bag and the whole.
Speaker: Do you request that?
Speaker: What are those visits like?
Speaker: Uh, the, the most common reason we would do home visits now is, is for, uh, when a new baby arrives, one of, one of our parents, uh, has, has a baby.
Speaker: Then when I bring them into the practice too, then, uh, you know, when they're, when mom and baby are discharged from the hospital, they kind of limit their, uh, exposure to, uh, germs in the office, particularly in the era of era of COVID.
Speaker: Uh, that's probably the most common reason to do home visits, but, um,
Speaker: I've just always enjoyed getting to know patients in the context of their home, really bringing them the convenience of being able to deliver primary care in the home.
Speaker: If mom is at home with the four kids and it's not easy for them to pack them in the van to come to our office for the one kid that has an ear infection, it sometimes is easy for us to just take a drive down the road and see them ourselves.
Speaker: So yeah, that's been, and you asked about the leather bag, you know, it was kind of a, I wanted to get that as right as I could when I was building the website and make that part of my brand.
Speaker: So I think if anyone goes to my website, covernd.net, I think that that picture is going to be front center of the leather bag.
Speaker: Excellent.
Speaker: I love toting that thing around.
Speaker: Yeah, I bet.
Speaker: I bet.
Speaker: That's just such a great image.
Speaker: So, yeah,
Speaker: That's something that's no extra charge subject to availability, obviously.
Speaker: What elements of the practice are included in the overall fee and what elements are kind of a la carte?
Speaker: So the a la carte items include after hours visits.
Speaker: So if there needs to be any sort of, so our business hours generally 8.30 a.m.
Speaker: to 5 p.m.
Speaker: Monday through Friday.
Speaker: Anything after hours, weekends or holidays will charge $50, whether we go to the patient's home or where do they come into the office.
Speaker: So that's an extra fee there.
Speaker: I mentioned the most common reason for me to come into the office after hours would be for stitches.
Speaker: So they're paying the monthly fee.
Speaker: even though they may come in and pay that $50 fee for stitches, they're me to the doctor they know in the office without a weight in the office that they know.
Speaker: The doctor does the stitches.
Speaker: I often know the kiddos pretty well if it's a kiddo that I'm stitching up.
Speaker: And $50 out the door, of course, in addition to their monthly payment.
Speaker: But if you take that $50 plus the monthly fee,
Speaker: compared to what they would have paid at urgent care or even the ER, depending on what part of the body the cut is on.
Speaker: And usually just one visit for stitches like that pays for a year's membership in our practice.
Speaker: So that's one a la carte charge is that after hours fee.
Speaker: Our patients also will pay for any lab tests that they need.
Speaker: And because we don't carry insurance contracts, we are able to negotiate the best cash pay price that both local labs and the big national labs can offer us.
Speaker: So what that means is for a battery of annual fasting blood work, if you will.
Speaker: So we'll say that's a standard kidney and liver function, that that might be a cholesterol panel.
Speaker: It might be a screening test for blood sugar.
Speaker: It might be thyroid function.
Speaker: If they pay insurance negotiated prices in the normal market, and if those labs aren't covered before the deductible, they might expect to pay anywhere from $300 to $400 for those tests.
Speaker: In our office, it comes to $17.
Speaker: So while they do pay for labs, we're able to tell them
Speaker: exactly what the cost of each test is, and they can make the decision based on our advice to go forward with that.
Speaker: So labs is the second thing.
Speaker: Another thing is medication.
Speaker: So we do keep a pharmacy in our office and we carry all the common antibiotics, all the common primary care meds.
Speaker: Again, it's pennies on the dollar and we're able to quote them prices for that.
Speaker: We don't, we don't upcharge for any of our
Speaker: meds, we just charge them costs.
Speaker: So there's really no incentive to us if they can find a better deal at the pharmacy down the street.
Speaker: So we make a lot of use in our exam rooms of GoodRx.
Speaker: GoodRx.com is a website that compares cash pay prices at most local pharmacies.
Speaker: So it's easy for us to pull that up and just compare that to our costs.
Speaker: Usually we're beating GoodRx, but if they can get it better at Wegmans, for instance,
Speaker: Then we'll let them know that we can just easily send the prescription to Wegmans.
Speaker: It's up to them.
Speaker: We're also contracted with a mail order pharmacy and that pharmacy can mail their, their medication, particularly chronic medications to them directly to their home at, at very similar prices that they could get through our pharmacy in the office.
Speaker: So just an added convenience there.
Speaker: So the a la carte charges, after hours, fees, medications, labs, and then,
Speaker: Sometimes there might be procedure fees, but usually those come in.
Speaker: And so for instance, our local pathologists here, if we do skin biopsies, they'll just client bill us for the pathology fee.
Speaker: So we just tell a patient while there's no charge for any primary care procedures we do, there may be an additional charge that will be charged by our pathologist partner.
Speaker: usually $7 to look at the pathology specimen from a skin biopsy.
Speaker: But otherwise, all primary care procedures are covered.
Speaker: That would include EKGs, stitches, skin biopsies, pap smears, and things like that.
Speaker: What about maybe slightly bigger things like an endoscopy or colonoscopy?
Speaker: So that's something we wouldn't do in our office.
Speaker: We're not credentialed to do those tests.
Speaker: So we would send them for endoscopies and colonoscopies to our local gastroenterology or general surgery practices.
Speaker: Got it.
Speaker: So if I'm trying to sign up for this,
Speaker: I need to expect to pay the fee.
Speaker: I need to expect to pay for after hours, labs, medicines, things like that.
Speaker: And then I probably need to have some kind of high deductible plan that covers me in the event of... And so like the...
Speaker: The worst case, if I'm trying to, I'm trying to like define the boundaries of like, what's, what are you going to run into if you do this?
Speaker: So the worst case is probably like, I need a lot of expensive specialists, but it's not enough to hit my deductible.
Speaker: Like that's going to be a really expensive year if I'm on this.
Speaker: Sure.
Speaker: Okay.
Speaker: So, um, I wanted to ask you also, um,
Speaker: If I'm at the all-you-can-eat buffet, I'm maybe getting people who are trying to get their money's worth out of the all-you-can-eat buffet.
Speaker: And so if you are offering sort of this unbounded access to you for a monthly fee, do you get a lot of kind of hypochondria and people who want to be seen a lot?
Speaker: Yeah, great question.
Speaker: In trying to sell this business model to my wife, because she was the first one I really had to sell it to in order to open my own business and go into debt to do this and everything, she had a very similar question.
Speaker: Won't you attract all the hypochondriacs?
Speaker: And I think
Speaker: The answer is no.
Speaker: I think every doctor's patient panel is going to be balanced by those that are, I would call them higher utilizers of primary care services and those that just, it's even hard to get them to come in for their annual physical.
Speaker: And I would say our breakdown of those patients aren't really any different from the years when I did work in an insurance taking practice.
Speaker: So
Speaker: For our higher utilizers, again, I think we have the privilege of time with them.
Speaker: We get to know them really well.
Speaker: We make maximum use of telemedicine.
Speaker: Certainly, if the patient prefers to have a face-to-face visit in the office, that we can do that.
Speaker: Otherwise, we can use secure email, secure text messaging.
Speaker: We can use video visits as well to support
Speaker: sort of streamline our time and the patient's time.
Speaker: Um, and even, even make our communication asynchronous, asynchronous, if you will, in the form of email, if that's appropriate and if that's fine with the patient.
Speaker: Yeah.
Speaker: I wonder if getting away from the scarcity mindset almost helps to put that anxiety to bed a little bit.
Speaker: Yeah.
Speaker: I think that's exactly right.
Speaker: So I, I think in my, my, my wife's big reservation was, um, yeah, I, I,
Speaker: When I was working in the insurance-based practice, she saw how stressed out I was, the hours that I put in and just kind of keeping up with my notes and everything.
Speaker: And she was just worried that with being, taking 365 24-7 call, what kind of quality of life would that be?
Speaker: Would that be even worse?
Speaker: And I'm six years into it now.
Speaker: And I think, my wife is actually the administrator for our practice and talks to a lot of prospective patients and everything.
Speaker: So I was really able to offer them
Speaker: or even potential provider physician employees, what exactly life in our practice is like.
Speaker: So I would say I can count on probably both my hands, how many times I need to come into the office in the calendar year.
Speaker: So it's not too burdensome.
Speaker: I might handle one or two text messages an evening, maybe a few over a weekend.
Speaker: Um, usually it's very brief exchanges, uh, uh, pretty simple.
Speaker: So, uh, the quality of life is, is certainly much better than, than what I had in the, in the situations I was in previously.
Speaker: Cool.
Speaker: Yeah.
Speaker: And I wouldn't make fun of those people because, uh, there's, there's a, there's a lower functioning version of me who's very much, uh, a high utilizer.
Speaker: I tend to freak out, uh, all the time.
Speaker: And, um,
Speaker: And, uh, my dad, my dad used to, he, he would calm me down by being like, let me tell you about the time I beat prostate cancer and pancreatic cancer and testicular cancer.
Speaker: He just tells me about all the times he thought.
Speaker: Yeah.
Speaker: Right.
Speaker: So, uh, so you're, you're really selling me.
Speaker: Cause I really feel like if I, if I had a doc that I, that I knew I could get, you know, on a moment's notice to just have the conversation, it would be, uh, it would be really reassuring.
Speaker: So that's, that's, that's awesome.
Speaker: That's really, really cool.
Speaker: Um, okay.
Speaker: So, uh, you wrote this fantastic blog post titled how the Amish made me a better doctor.
Speaker: Uh, did you actually, it sounds like you spent some time in a conventional like corporate healthcare environment, but then you spent some time at this Amish Mennonite clinic.
Speaker: Can you, can you tell us a bit about your experience at that clinic and how it led you down this road?
Speaker: Yeah.
Speaker: So, uh,
Speaker: Not from Lancaster County PA, my wife is.
Speaker: So we moved here several years ago and was working in a big sort of standard health care system here in the Lancaster area.
Speaker: And this opportunity came up to to work for this independent clinic in a small town here in Lancaster County that that catered specifically to the to the Amish and Mennonite.
Speaker: and I, it seemed like frontier medicine to me.
Speaker: It seemed like, uh, that was the very dream, uh, that Marcus Welby is a dream that I had when I, when I started medical school.
Speaker: So I couldn't resist, um, was, was a bit tough at first on a couple of fronts.
Speaker: One, there was just a lot of OGT on the job training, refreshing and, uh, getting used to casting and splinting.
Speaker: We had our own x-ray machine.
Speaker: the Amish really expected the primary care doctor to do as much as he or she could and avoid the emergency room.
Speaker: So saw a lot of incredible soft tissue trauma, a lot of bone trauma, just did a lot of things that I just never envisioned myself doing as a primary care doctor.
Speaker: It was a real adventure.
Speaker: But,
Speaker: So I think it made me a better doctor in a sense that it gave me much more a taste of the breadth of general primary medical care and family medicine from babies all the way up to the elderly.
Speaker: The other way it made me a better doctor is it brought home the true cost of care.
Speaker: So I'll never forget my first couple of weeks there.
Speaker: I had an Amish gentleman come in suffering from migraine headaches and I prescribed for him, you know, what I was used to prescribing a medicine called Imatrex, generic name is sumatriptan, medicine that a migraine sufferer can take that would, that would help to abort the headache or, or, or help it to go away.
Speaker: And so I thought that I would try this medicine for this, for this gentleman.
Speaker: And when insurance is the third party payer,
Speaker: we're often insulated from that cost of care.
Speaker: That's putting it mildly.
Speaker: We really have no idea what the cost of what we're prescribing is to either the third party insurer or to the patient.
Speaker: And that fact is a lot more dire in this day and age when deductibles are so high.
Speaker: But in any case, I prescribed Imitrex for an Amish patient.
Speaker: They went to the pharmacy down the road and lo and behold, it was...
Speaker: 250, about $250 for nine tablets.
Speaker: Typically comes in nine tablet packets and quickly called me back that, that day and said, he just couldn't do that.
Speaker: So there's just an example of how my eyes were opened to the cost of care.
Speaker: That clinic was already pretty well adept at connecting their providers with, with self-pay resources in the community.
Speaker: Of course, the Amish don't carry typical health insurance.
Speaker: For many, many years, they've been doing what sharing plans, modern sharing plans are doing now.
Speaker: So church members pay into one pot, so to speak, and that money is used to fund members' health insurance costs.
Speaker: So that's how the Amish have been doing it for many years.
Speaker: So they're looking for the best care at the best prices.
Speaker: So we knew where to go to get an MRI for $450, for instance, to get a CAT scan for $250.
Speaker: We had cash pay prices for labs and things like that.
Speaker: We knew what the specialists were in our community that would deliver good cash pay prices for our Amish clients.
Speaker: So yeah, those, those are a few ways where I, I think working in that practice really, really made me a better doctor.
Speaker: They gave me more breadth of, of care and more experience with a, with a broader breadth of care and really helped me zero in on that, that true cost of medical care that needs to be part of, and it continues to be part of our conversation in the exam room.
Speaker: You know, what is the cost of care?
Speaker: instead of that just being handled outside by a third-party payer.
Speaker: Yeah, and did you, so in the case of the patient that needed Imitrex, how does seeing the sticker price for the procedures affect the way people get care or the way that you offer care?
Speaker: Like, are you more likely to offer holistic interventions like diet and exercise?
Speaker: Like, do you have more of those conversations because...
Speaker: of the sticker price?
Speaker: Yeah, I absolutely do.
Speaker: And it's not because of the sticker price.
Speaker: You know, I have no, you know, I'll use diabetes as an example, type two diabetes.
Speaker: That's it.
Speaker: It's interesting times with, with type two is I really think that the best medications for the treatment of type two diabetes are actually the newer medications that are very expensive.
Speaker: and may really need the assistance of a health insurance product to assist our patients to afford them.
Speaker: And I would have no hesitation in prescribing them.
Speaker: They're great medications.
Speaker: They really help to address what is the problem in type 2 diabetes, which is insulin resistance.
Speaker: But yes, I do.
Speaker: Because I have time to spend with my patients, I'm really trying to harp on lifestyle.
Speaker: Um, so I would talk to my diabetics, uh, about a low carb or the ketogenic diet, uh, something that might help to control their blood sugar far better than any medication that I can prescribe in many cases.
Speaker: So if you take time to coach them through a low carb diet, um, they may even be able to greatly decrease their insulin dose or even come off of their insulin altogether.
Speaker: And they, they may not require as many medications as they've been on.
Speaker: If that leads to some weight loss, it may improve their blood pressure.
Speaker: They may be able to come off of their blood pressure medicines.
Speaker: So we talk to them, talk to our patients a lot about lifestyle, diet, exercise.
Speaker: I talk to my patients a lot about sleep.
Speaker: So if you can zero in on some of those lifestyle things, then some of these chronic diseases do very much improve.
Speaker: Diabetes with diet, anxiety, depression with better sleep and exercise.
Speaker: So yes, those are low cost interventions, saving our patients a lot of money.
Speaker: But in the case of diabetes, if it requires the assistance of some of these other medications to help control blood pressure and even assist them in losing weight, then we do everything we can to get them on those medications.
Speaker: Yeah, in the case of the Amish, if they're not taking your advice to get catastrophic coverage on top of their direct primary care, I know you mentioned that they have essentially a health-sharing arrangement.
Speaker: Yeah.
Speaker: Do they have a different approach to things like cancer, things like car accidents, or is it just that they handle it with this health-sharing thing instead of conventional insurance?
Speaker: Yeah, they would still handle it within that health-sharing approach.
Speaker: environment and not use traditional insurance even to pay for the very expensive things.
Speaker: So even those really higher cost things like cancer surgeries are handled within the sharing plan.
Speaker: Okay.
Speaker: But they still do get that type of care.
Speaker: They just, they still absolutely get that type of care.
Speaker: Yes.
Speaker: So yeah, they, they, they don't, they typically don't avoid even the higher cost care when it's medically indicated.
Speaker: It isn't always the case.
Speaker: Sometimes cost can be quite a barrier with them and they might be more prone to do other alternative things by other alternative providers in the community.
Speaker: So we do our best to try to navigate that system too.
Speaker: Yeah, that was going to be another question is I'm sure that in that environment you...
Speaker: you surely dealt with cultural differences, especially as regards technology and Western medicine.
Speaker: And how did, how did you navigate that?
Speaker: Yeah, that was, that, that was a challenge.
Speaker: You know, one big change in coming into being a doctor for the Amish and Mennonite is
Speaker: Whereas in the typical practice, doctors still enjoy or providers still enjoy some prestige.
Speaker: In the practice with the Mennonite and the Amish, I think medical doctors were on par with sometimes the uncle down the road that doled out medical advice and had some herbs to offer.
Speaker: You're just one other guy they can talk to.
Speaker: Just one other guy they can talk to, exactly.
Speaker: So they're a whole stream of other holistic providers, some of them very good, chiropractors, some of them very good.
Speaker: But sometimes we really had to battle against advice that we felt was just very detrimental to their health.
Speaker: Can you give me an example of things that you had to fight them with?
Speaker: One big example that I recall was Lyme disease.
Speaker: So that's been a controversy for some time.
Speaker: But in different tests for Lyme, there were providers in the area that would put electrodes on their fingers and would use electrical current to diagnose the chronic and acute Lyme.
Speaker: And we would use that information to then treat Lyme with a pretty complex and usually pretty expensive cocktail of herbal remedies for what may or may not have been Lyme.
Speaker: So in just talking about with my patients about how we would test Lyme, what some of the limitations of our testing would be.
Speaker: What tests are validated for diagnosing Lyme?
Speaker: What tests are not validated for diagnosing Lyme?
Speaker: What is validated as a treatment for Lyme and what are not?
Speaker: I think that was one big challenge that comes to mind.
Speaker: But you're not just having a single...
Speaker: not particularly patient 12 minute conversation, you know, once a year with like, you've got time to kind of massage and acquire some personal credentials, even if they don't care about your degree.
Speaker: Correct.
Speaker: So yeah, we do, we, we do want to treat the patient certainly in, with respect to their values and what they, what they think, and in terms of their finances, what they feel that they can do.
Speaker: Yeah.
Speaker: Another, another comment.
Speaker: Go ahead.
Speaker: Well, I was just going to say, so I have, I have a doctor buddy who, um,
Speaker: Basically, so my, my, uh, I don't know what your take is on the whole COVID situation.
Speaker: I, I have definitely, um, heard every voice I think on, on that situation.
Speaker: And I'm not, uh, I, I don't, I wouldn't pretend to be an expert on anything.
Speaker: Um, but I am, I am skeptical enough that I, I, I don't just sort of buy, uh,
Speaker: you know, what, what is being popularly propagated about it.
Speaker: But I did have a doctor friend who was like, Hey man, I'm in the hospital every day.
Speaker: I'm seeing this happen.
Speaker: It's really serious.
Speaker: You should take it seriously.
Speaker: It's a problem.
Speaker: And, and just, and it wasn't because like, Oh, he's a doctor.
Speaker: It's because he was my friend.
Speaker: And I knew he was smart.
Speaker: I knew he wasn't full of crap.
Speaker: And so I think having the, having the personal proximity to your patients and being able to develop that relationship is huge.
Speaker: Yeah, exactly.
Speaker: Especially when it comes to conversations about COVID and you know, like you have, my patients are just all over the map about what they believe about COVID, what they want to do, vaccines, treatment, the whole nine yards.
Speaker: So,
Speaker: Yeah, this requires.
Speaker: Yeah, that's where I really enjoy knowing my patients well, though my views may differ from my patients view sometimes in the context of that that relationship I've established with them now over many years.
Speaker: It's really helped streamline the pandemic for us.
Speaker: Yeah, I wanted to ask you about have you had to deal with more distrust or pushback from patients in the last few years, or does the nature of your practice kind of insulate you from that?
Speaker: Yeah, I think it did insulate us somewhat.
Speaker: When the pandemic occurred or began and the lockdowns occurred, we sort of hit the ground running.
Speaker: We were already utilizing telemedicine.
Speaker: So we just pivoted into a much higher emphasis on telemedicine at that time.
Speaker: So our patients were used to interacting with us in that way.
Speaker: So that was pretty streamlined when we made that transition.
Speaker: And then, yeah, as I said, as things developed and people got settled into their respective camps, if you will,
Speaker: regarding all the facets of COVID.
Speaker: Yeah, because we knew them and we had that relationship established with them.
Speaker: I think still those conversations went pretty well for the most part.
Speaker: Awesome.
Speaker: So you are a provider in the direct primary care space, but you're also a patient yourself in a health sharing ministry.
Speaker: Can you tell us how that's been for you?
Speaker: Well, unfortunately I can't tell you too much because either I'm very healthy or I'm just really stubborn like most middle-aged male guys and just never go to the doctor.
Speaker: And I think being a male physician, it ratchets that up even higher.
Speaker: But my family are higher utilizers of a sharing plan.
Speaker: So I think it's been a great experience really since I opened my practice.
Speaker: Really the attraction of health sharing plans is that it is good comprehensive care for a much lower price than what we would pay for premiums to a standard insurance product.
Speaker: So we were members of Samaritan Ministries for a few years.
Speaker: We used Sedera for a couple of years and now we've transitioned to Zion Health.
Speaker: And we've made those transitions just generally based on the sharing plans that we could utilize as a small employer here in Lancaster.
Speaker: I think we were really happy with all three of those products in our market.
Speaker: They're really quite common.
Speaker: these sharing plans.
Speaker: But I think it's been great for my family.
Speaker: The reimbursement has gone very well.
Speaker: We certainly enjoy the lower premium prices, if you will.
Speaker: Yeah.
Speaker: So I did a little bit of reading between our last conversation, and it looks like the biggest difference between insurance and a health share is that a health share is not technically legally obligated to cover your costs in the same way that an insurance company is.
Speaker: That's correct.
Speaker: Now, everybody that I know who participates in one of these sharing organizations has been pretty happy with the help that they've gotten.
Speaker: But have you ever seen that difference cause a problem for someone?
Speaker: No, I've never seen it.
Speaker: The ones that have the biggest market share, probably in our area, Samaritan Ministries, Christian Healthcare Ministries, and Zion Health is starting to come around too.
Speaker: They've all, right,
Speaker: they've all been very happy with them in the six years that I've been treating patients with them.
Speaker: So that while they're not legally obligated to cover costs, they're not gonna be subject to rules and regulations.
Speaker: This differs per state that would usually govern health insurance companies.
Speaker: They usually deliver very well on their intent to cover what they purport to cover.
Speaker: Yeah, I mean, I imagine as a sort of upstart product, the need to be reputable for covering things has got to be really high for them.
Speaker: So they probably would need to err on the side of...
Speaker: of saying yes, especially if it's like, you know, somebody has cancer.
Speaker: So, so it's really tragic.
Speaker: The kind of thing that you buy insurance for, you know, just one or two of those stories could be, uh, an enormous problem for them.
Speaker: Right.
Speaker: Right.
Speaker: So yeah.
Speaker: How, how do they make that viable?
Speaker: Um, any one reason,
Speaker: I'll take Zion health for instance, if you're, if you're a smoker, then they would charge your family an extra $50 a month to be a member of the, of the plan.
Speaker: If you have a preexisting condition and all the sharing plans do preexisting conditions differently, some will not cover for the first year.
Speaker: And then they kind of, over the course of maybe three to five years, we'll sort of ramp up coverage until it's considered a preexisting condition.
Speaker: So,
Speaker: I think that's how they guard their costs a little bit and are able to offer such good prices for premiums.
Speaker: So if you are in an uninterrupted coverage situation, like I have corporate insurance right now and I switched to a health share plan, this may be deeper than you want to go, but do the pre-existing conditions still count as pre-existing conditions or is it like the continuum kind of?
Speaker: They all have their definitions as to what constitutes a preexisting condition.
Speaker: So, you know, when it was diagnosed, are you stable on medications?
Speaker: Has there been any need for you to adjust your medications in the, in the last several months or so?
Speaker: But generally, if you make the change over from a standard insurance product to a sharing plan, then there, there may be just limited coverage for a preexisting condition.
Speaker: Now for Sedara,
Speaker: not Sedera, but for Zion health, that, that limitation in coverage might constitute, and I can't quote exact numbers, but maybe $50,000 for the first year, maybe 75 for the second year, maybe 125,000 for the third year.
Speaker: So while there's a limitation in coverage, when it comes to a preexisting condition that may be chronic, perhaps well controlled, it's still probably what they will cover is usually well within the bounds.
Speaker: Um,
Speaker: of what they will typically cost someone in a year.
Speaker: If it's uncontrolled diabetes and they may need to be admitted to a hospital because of complications of diabetes, that that's where, you know, potentially can get just a little bit dicey in terms of cost.
Speaker: If that condition was preexisting.
Speaker: Right.
Speaker: And you're, you're so covenant MD, how roughly how big is your team right now?
Speaker: There's let me see.
Speaker: There's eight of us.
Speaker: Okay.
Speaker: Between two locations.
Speaker: No, there's four providers and each of us has one nurse.
Speaker: Roger.
Speaker: And then office staff, that kind of thing.
Speaker: We don't have office staff.
Speaker: So my wife works part-time on administration.
Speaker: But usually the direct primary care model will work with one provider working with one nurse.
Speaker: So I've seen graphics that the typical FTEs or full-time equivalent employees that a provider needs is about 4.5, I believe.
Speaker: So when we don't need to hire a coder, we don't need to hire a biller.
Speaker: We keep our patient panels at much lower numbers.
Speaker: So each patient panel is like a solo practice within a larger practice.
Speaker: So my patients get to know my nurse really well.
Speaker: They get to know me really well.
Speaker: Our billing system is very streamlined and automatic.
Speaker: So there's a lot less of the attention we need to give to the administrative stuff.
Speaker: And we're able to give a lot more attention to the clinical stuff as we ideally should be.
Speaker: Okay.
Speaker: So in terms of how you provide benefits as an employer, do you do this model for your employees?
Speaker: How does that work?
Speaker: So yeah, we would offer them a free membership and covenant MD for their, for their, for their family member for themselves and their immediate family members.
Speaker: We, we do offer a sharing plan is it's just easy for us to cover that as a smaller employer.
Speaker: So we, we offer our, our patients Zion health.
Speaker: And so they make use of that.
Speaker: And then other standard insurance or standard benefit things like a 401k and things.
Speaker: Yeah, yeah.
Speaker: Well, I just got to think that's... Okay, so you have... We have a few doctors and medical students in the group.
Speaker: And from what I can tell, you've got more time with your patients, less brawling with insurance companies, lower overheads, more free time.
Speaker: Why didn't everybody do it this way?
Speaker: What are the trade-offs?
Speaker: What did you have to pay to get this gig?
Speaker: Yeah, so I think easier for me in a way to do it relatively early on in my career is I didn't come out with any debt.
Speaker: So I worked for four years between undergrad and medical school, paying down my undergraduate debt.
Speaker: And medical school was free for me because I did a scholarship through the U.S. Air Force, the Health Profession Scholarship Program.
Speaker: So medical school is paid for.
Speaker: I did seven years active duty for anyone considering
Speaker: career in medicine or law, I would just highly recommend looking into the armed forces, it's a great way to go.
Speaker: So one big barrier to someone maybe coming into direct primary care, even starting a direct primary care practice is being sidled with all that debt that doctors typically come out of medical school with and having to be under the thumb of that for many, many years.
Speaker: That's a big barrier.
Speaker: Another one may be a perceived risk
Speaker: lower security and not being under the auspices of a bigger healthcare system.
Speaker: The independent primary care practice is becoming a dinosaur in this day and age.
Speaker: They're usually now being bought up by bigger medical systems and they're usually a part of a bigger medical system that can offer things like loan forgiveness, that can offer pretty flashy benefits packages that a smaller practice just wouldn't be able to
Speaker: to, uh, to afford, um, that that's a barrier.
Speaker: Um, and to think of, of, so I think those are the bigger ones.
Speaker: The reason that, that being kind of a involved in a corporate health system would be a benefit to someone who has a lot of debt is just cause they pay more.
Speaker: Is that.
Speaker: Yeah.
Speaker: So yeah, where that would be a barrier is, uh,
Speaker: if they what's really attractive in a, in a more corporate environment, if they offer to pay down that debt and if they, if they spend, if they have maybe have an agreement where they spend such and such time within that system and that would, that would be a barrier to not have a program by which we pay off that debt.
Speaker: Another, another big barrier I would mention, you know, any, any,
Speaker: local doctors that worked for a local health system that might be interested in joining a smaller independent practice.
Speaker: Usually there will be non-compete clauses in a physician or provider contract that would say that after leaving our organization, you cannot work within, let's say 20 miles of where you were working before for a period of two years.
Speaker: So
Speaker: where we would be making a reputation in a local area and where we might be attractive to other providers maybe coming over for any number of reasons from a big corporate environment.
Speaker: It might be hard to lure them because they're sidled with that.
Speaker: There's those non-compete clauses that will interfere with them working at any other office in the local area.
Speaker: Yeah.
Speaker: So you've got, you've got eight,
Speaker: people on the rolls right now.
Speaker: And what's the, does this, do you want this to scale beyond what it is?
Speaker: What's the dream, the vision for the big picture?
Speaker: Yes, so it certainly is scalable.
Speaker: I think what's really on the rise is the use of direct primary care services by employers.
Speaker: So that's something that I really benefited from having partnerships with local employers from very early on in the life of my practice.
Speaker: So we currently contract with about 15 employers in our area, and they vary in size from employees of five all the way up to about 500.
Speaker: So for some of our employers, we're the only health care offering that we offer their employees.
Speaker: So usually the business will pay our monthly fee on behalf of the employee.
Speaker: They may also pay our monthly fee on behalf of any family members that choose to sign up with us.
Speaker: Some employers, if employees incur any costs in the way of medications or procedure costs or
Speaker: um, I mean, I would need pathology costs or, or lab costs.
Speaker: And sometimes the employers will even pay for those.
Speaker: So they get an entirely free primary care package.
Speaker: So I think, um, we don't do a lot of advertising in our local area.
Speaker: So we always get a sort of a steady influx of people just looking for an out of the box solution for, uh, uh, low cost, high quality primary care.
Speaker: But what also makes this scalable is what's catching on with employers as this being an option to control costs for primary care services.
Speaker: So currently you're getting onesie twosies, but you might at some point start getting kind of whales where it's all- Yeah, yeah.
Speaker: Right, and sometimes we do.
Speaker: So our York clinic, I opened that after probably
Speaker: just past our third year.
Speaker: So hard to open a separate clinic in a town that's about a half an hour for me.
Speaker: But what really made that work was a larger employer approaching us and saying, hey, would you consider advising us on building an onsite or near site clinic, direct primary care clinic?
Speaker: And that's how our York clinic started.
Speaker: So we are sort of a near site provider for a large employer there.
Speaker: And in addition to employees and family members from that large employer, we also serve the general population in the York area as well.
Speaker: So what's the vision for the future?
Speaker: Just this week, we're beginning talks with a large well-known employer in a local area.
Speaker: that is considering using us to deliver primary care to their employees.
Speaker: So we're kind of working out whether that's going to be, will employees come to one of our locations in York or Lancaster, or would it be more attractive to them for them to have maybe a smaller clinic that's on-site or near-site?
Speaker: And what would it look like for us to build that out and hire a provider to staff it, a nurse to staff it?
Speaker: So there's a sort of conversations I think we'll begin to have a lot more of in the coming years, hopefully.
Speaker: Yeah.
Speaker: Me and the, me and the guys occasionally will talk about the pirate ship and you, it, it feels really good to be the captain of a pirate ship.
Speaker: Right.
Speaker: A certain number of people that that makes sense for.
Speaker: And then eventually you kind of have to be the pirate admiral and there's a couple pirate ships.
Speaker: Right.
Speaker: And I, I, the,
Speaker: The interesting question to me about people who are in your position where they've got their ship is like, do you foresee a time where this becomes a business that you are involved in administrating or do you really want to stay the guy with the stethoscope and the leather bag?
Speaker: How does that feel to you?
Speaker: Yeah.
Speaker: And maybe that's a key question for entrepreneurs, right?
Speaker: Yeah.
Speaker: how long are they going to remain the technician, so to speak.
Speaker: And, uh, so for me personally, there, there's always that, uh, there's always that pull.
Speaker: So I think we'll always be a doctor.
Speaker: Uh, I, I love, I love being a primary care doctor.
Speaker: Um, I certainly put a lot of blood, sweat and tears into the training.
Speaker: Um, and, and right now I'm trying to find a balance.
Speaker: Um, you know, how, how can the business, uh,
Speaker: pay me to do more of the administrative business owner stuff and less of the technician stuff.
Speaker: Because I think as things scale and get a little bigger and we get more employees that there's the demands on the business side are, are, are harder.
Speaker: They take, they take more time.
Speaker: And so there's, there's just going to be this this this pull both ways.
Speaker: But I think, yeah, I don't want to be, I don't ever not want to be, be a physician in some respect.
Speaker: Yeah.
Speaker: I mean, you mentioned the pain that you went through to get this credential.
Speaker: That's a lot more pain than getting an MBA.
Speaker: So it might make sense to have an MBA do the MBA stuff and have you stick to doctoring.
Speaker: That's, but you know, good, good problems to have.
Speaker: So that's, that's exciting.
Speaker: Well, this has been just an awesome conversation.
Speaker: I feel like the guys are really going to enjoy this discussion, particularly from the perspective of, you know, both,
Speaker: Both from the side of, you know, I'm a patient and I want to get away from the corporate health system.
Speaker: Like, there's that appeal to it.
Speaker: But also, I love stories of people who say... So we have so many guys who are like, I feel trapped.
Speaker: I feel like I have to do this one thing.
Speaker: Yeah.
Speaker: I've definitely talked to doctors for whom medicine is really dehumanizing.
Speaker: And, uh, and like there's lots of depression, there's lots of like psychological problems in the field.
Speaker: And I think a lot of it is because of this lack of human scale and this, this, uh, you know, they're, they're sort of, um, driven by debt and by, you know, sort of running around like a, like a chicken with their head cut off.
Speaker: And you have found this niche that,
Speaker: And, you know, admittedly, you know, there were circumstances that made that easier for you to do, but you found a human way to do this.
Speaker: And so that is...
Speaker: So cool to me.
Speaker: And I'm really excited to show the guys.
Speaker: Thank you so much for taking the time.
Speaker: And for those of you that want to check out, if you're in the Pennsylvania area, we have a couple of Pennsylvania guys.
Speaker: You want to check out his practice.
Speaker: It's covenantmd.net.
Speaker: Otherwise, if you're interested to learn more about exit group, you can check us out at exitgroup.us or follow us on Twitter at exit underscore org.
Speaker: Thanks a lot, Dr. Rol.
Speaker: Great.
Speaker: Thanks for having me.
