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EXIT Podcast Episode 30: Healthcare for Entrepreneurs (feat. Dr. Patrick Rohal)
378 Plays3 years ago
Most primary care doctors serve 2000-3000 patients per year, which means they basically get ten minutes with the patient, once or twice a year. Dr. Rohal's practice (covenantmd.net) serves 800 patients per provider on a direct subscription basis. With no insurance, and no elaborate coding or billing, he's able to keep overhead costs much lower and spend much more time understanding the needs of each patient.
We discuss the direct primary care model, as well as Christian health-sharing ministries, and other tools for entrepreneurs to meet their family's healthcare needs outside the corporate insurance system.
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Transcript
Introduction to Direct Primary Care (DPC)
00:00:17
Speaker
Hey everybody, welcome to the exit podcast.
00:00:19
Speaker
This is Dr. Bennett.
00:00:19
Speaker
I'm joined here by Dr. Patrick Roll with Covenant MD, a direct primary care practice in Pennsylvania.
00:00:25
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.
00:00:35
Speaker
Welcome to the show, Dr. Roll.
00:00:37
Speaker
Thanks for having me.
00:00:39
Speaker
So you heard me say Dr. Bennett.
00:00:41
Speaker
I'm like a Dr. Pepper kind of a doctor.
00:00:44
Speaker
Oh yeah, I was wondering.
What is Direct Primary Care?
00:00:48
Speaker
So tell us a little bit about what direct primary care is.
00:00:52
Speaker
Well, the name direct care comes from direct primary care doctors making, so to speak, a direct contract with their patients.
00:01:00
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.
00:01:09
Speaker
So practically that means that our patients are paying us a low monthly fee
00:01:15
Speaker
Typically in DPC practices around the country, it might be anywhere from $20 to $100 to $150 a month.
00:01:22
Speaker
And we don't bill health insurance for any primary care services.
Benefits of DPC: Patient-Centric Care
00:01:27
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
00:01:43
Speaker
come out happier and the doctor come out happier as well.
00:01:48
Speaker
Yeah.
00:01:48
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.
00:02:00
Speaker
So like setting a bone, stitching things, that kind of thing.
00:02:06
Speaker
Yeah, so the idea is that about 90% of healthcare needs would be covered under the direct primary care arrangement.
00:02:13
Speaker
So for that monthly fee, it typically covers all visits to the doctor without any co-pays.
00:02:19
Speaker
Typically, that's how we do it in our practice.
00:02:22
Speaker
We tell our patients really anything that urgent care can do, we can do.
00:02:26
Speaker
So we're on call for our patients 24-7, 365.
00:02:32
Speaker
We do go on vacation.
00:02:33
Speaker
We just hand that off to our partners as need be to cover our patient
Personalized Care in DPC Model
00:02:37
Speaker
panel.
00:02:37
Speaker
But it means that we know our patients really well.
00:02:41
Speaker
We get to know them long term.
00:02:44
Speaker
So we know who it is that's calling.
00:02:46
Speaker
We usually know the context with which they're calling.
00:02:48
Speaker
We know their health care history and everything.
00:02:51
Speaker
So it makes it a lot easier to practice.
00:02:55
Speaker
I should add that it's possible to do that because in direct primary care,
00:03:00
Speaker
because our patients are paying us that monthly fee, we're able to limit our patient panel.
00:03:04
Speaker
So out in the insurance taking world, we family doctors might cover anywhere from two to 3000 patients on their panel.
00:03:16
Speaker
Whereas in direct primary care, we're able to limit it to probably 800 max.
00:03:22
Speaker
So what that equates to instead of 20 to 30 visits a day,
00:03:26
Speaker
It takes us down to about a very manageable six to eight visits a day.
00:03:30
Speaker
And even that's a very busy day.
00:03:31
Speaker
So I would say I see anywhere from maybe two to eight patients a day.
00:03:36
Speaker
It gives us a lot of time with them.
00:03:37
Speaker
It allows us to really focus on their needs.
00:03:41
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.
00:03:54
Speaker
in 13 minutes with face-to-face time with a physician patient.
00:03:59
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.
00:04:13
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.
00:04:23
Speaker
To address those other
Flexible Scheduling and Timely Visits
00:04:24
Speaker
things.
00:04:24
Speaker
So in this environment and direct primary care, we're able to address all of those things in one visit.
00:04:29
Speaker
And because our schedule is usually open, it's usually relatively unbooked, even a couple of days ahead of time.
00:04:38
Speaker
We're able to really schedule those visits whenever we need them, whenever our patients need them.
00:04:44
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.
00:04:52
Speaker
Is it pretty hard to get on your list?
00:04:56
Speaker
Yeah, good question.
00:04:57
Speaker
My patient panel is closed.
00:05:00
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
00:05:11
Speaker
that we need.
00:05:12
Speaker
So, uh, it's really limited by the providers I can hire, uh, to, to fill the demand for direct primary care services.
00:05:21
Speaker
Yeah.
00:05:21
Speaker
So, okay.
00:05:22
Speaker
So fair enough.
00:05:23
Speaker
It is, it is tough to get.
00:05:27
Speaker
So, uh, do, do people, um, do people wait in line?
00:05:30
Speaker
How does that work?
00:05:32
Speaker
So, uh, in my, I have two locations with COVIDMDA, I have, uh, one in Lancaster, Pennsylvania, one in York, Pennsylvania.
00:05:40
Speaker
I have a physician partner whose panel is still open to new patients.
00:05:44
Speaker
I have a physician's assistant partner here in Lancaster whose panel is open.
00:05:48
Speaker
Then I have a physician assistant partner in York, her panel is open.
00:05:51
Speaker
So I'm the only provider that's closed right now.
00:05:55
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.
00:06:05
Speaker
So ideally we hire, ideally we hire providers that, uh,
00:06:10
Speaker
we can keep up with the demand so that there's never a waiting list, but that's been hard to navigate sometimes.
00:06:16
Speaker
Got it.
00:06:17
Speaker
So if I'm local, I can, I can go to covenant.
00:06:20
Speaker
I just can't see Dr. Roll right now.
00:06:23
Speaker
That's correct.
00:06:24
Speaker
Okay.
00:06:24
Speaker
Got it.
00:06:24
Speaker
Okay, cool.
Insurance and DPC Coverage
00:06:26
Speaker
So, uh, you've got, you've got your basic, uh,
00:06:32
Speaker
bumps and bruises and colds and daily primary care stuff taken care of.
00:06:36
Speaker
Plus, you know, if you, if you, you know, put a nail into your hand or something.
00:06:44
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.
00:06:57
Speaker
Right.
00:06:57
Speaker
So what are some elements of things that you don't cover that you would encourage someone to have some coverage for?
00:07:06
Speaker
So we certainly wouldn't cover specialty visits whenever that's needed.
00:07:12
Speaker
I tell them we cover almost all emergent care.
00:07:14
Speaker
If something requiring emergency care comes up, it's something that requires an emergency room.
00:07:20
Speaker
So certainly if they call us complaining of chest pain, we tell them to call 911, any stroke symptoms, certainly.
00:07:27
Speaker
Complex lacerations, injuries, maybe complex fractures, we would send them on to the emergency room.
00:07:34
Speaker
But there's a lot of even emergent things that we can handle here.
00:07:36
Speaker
So probably my most common reason to get called in
00:07:42
Speaker
in an evening, weekend, or holiday is to do stitches.
00:07:44
Speaker
So that's probably the most common thing that I'll do after hours.
00:07:49
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.
00:08:04
Speaker
So there's really no barrier to doing that.
00:08:07
Speaker
We can easily do that.
00:08:08
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.
00:08:19
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.
00:08:31
Speaker
Um, but when it comes to more complex care, maybe complex, high blood pressure, um,
00:08:36
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.
00:08:46
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.
00:09:02
Speaker
We have time with our patients.
00:09:05
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.
00:09:17
Speaker
So perhaps we can decrease a bit of that fragmentation of care that's occurring in our healthcare system.
Role of DPC Doctors as Coordinators
00:09:25
Speaker
And so that we can really assist the patient by being a quarterback
00:09:30
Speaker
for their health care, being as engaged as we can with their specialty providers if they see them.
00:09:38
Speaker
Maybe trying to take as much of that specialty care under our umbrella as we can in the way of blood work.
00:09:45
Speaker
We do blood work at discounts in our office.
00:09:51
Speaker
We could dispense medications at cost in our office.
00:09:54
Speaker
So there's a lot that we can do maybe to
00:09:58
Speaker
decrease their exposure, so to speak, to specialty care, but certainly keeping it within what is prudent for the patient.
00:10:07
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
00:10:19
Speaker
They're like a referral service or their job is to say, you're being paranoid, go home.
00:10:26
Speaker
Like a lot of actual care happening there.
00:10:29
Speaker
It's just like, does a specialist need to hear about this?
00:10:32
Speaker
Yes or no.
00:10:33
Speaker
And then I feel frustrated with the money I'm paying for that visit.
00:10:38
Speaker
Yeah.
00:10:39
Speaker
And I feel like this model really lets me, I went to medical school with a dream of being a family doctor.
00:10:45
Speaker
I kind of, I wanted to be a generalist.
00:10:47
Speaker
I wanted to know as much as I could and be all I could for my patients.
00:10:53
Speaker
You know, I kind of really had this Marcus Welby-ish vision for general practice, small town doc, home visits and everything.
00:11:03
Speaker
And
00:11:04
Speaker
So, yeah, that was kind of a vision that I'm trying to implement in DPC.
00:11:10
Speaker
It's a beautiful idea.
00:11:11
Speaker
And that leads to my next question, which, you know, it says here you offer home visits at no extra charge.
Additional Services and Costs in DPC
00:11:18
Speaker
And that's just such a wholesome image.
00:11:21
Speaker
I'm picturing the stethoscope and the leather bag and the whole.
00:11:26
Speaker
Do you request that?
00:11:28
Speaker
What are those visits like?
00:11:30
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.
00:11:40
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.
00:11:53
Speaker
Uh, that's probably the most common reason to do home visits, but, um,
00:11:58
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.
00:12:10
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.
00:12:25
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.
00:12:37
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.
00:12:44
Speaker
Excellent.
00:12:45
Speaker
I love toting that thing around.
00:12:46
Speaker
Yeah, I bet.
00:12:48
Speaker
I bet.
00:12:48
Speaker
That's just such a great image.
00:12:50
Speaker
So, yeah,
00:12:54
Speaker
That's something that's no extra charge subject to availability, obviously.
00:12:58
Speaker
What elements of the practice are included in the overall fee and what elements are kind of a la carte?
00:13:09
Speaker
So the a la carte items include after hours visits.
00:13:12
Speaker
So if there needs to be any sort of, so our business hours generally 8.30 a.m.
00:13:19
Speaker
to 5 p.m.
00:13:20
Speaker
Monday through Friday.
00:13:22
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.
00:13:30
Speaker
So that's an extra fee there.
00:13:32
Speaker
I mentioned the most common reason for me to come into the office after hours would be for stitches.
00:13:39
Speaker
So they're paying the monthly fee.
00:13:42
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.
00:13:54
Speaker
The doctor does the stitches.
00:13:55
Speaker
I often know the kiddos pretty well if it's a kiddo that I'm stitching up.
00:14:00
Speaker
And $50 out the door, of course, in addition to their monthly payment.
00:14:04
Speaker
But if you take that $50 plus the monthly fee,
00:14:07
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.
00:14:14
Speaker
And usually just one visit for stitches like that pays for a year's membership in our practice.
00:14:25
Speaker
So that's one a la carte charge is that after hours fee.
00:14:31
Speaker
Our patients also will pay for any lab tests that they need.
00:14:36
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.
00:14:51
Speaker
So what that means is for a battery of annual fasting blood work, if you will.
00:14:57
Speaker
So we'll say that's a standard kidney and liver function, that that might be a cholesterol panel.
00:15:04
Speaker
It might be a screening test for blood sugar.
00:15:07
Speaker
It might be thyroid function.
00:15:10
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.
00:15:24
Speaker
In our office, it comes to $17.
00:15:25
Speaker
So while they do pay for labs, we're able to tell them
00:15:31
Speaker
exactly what the cost of each test is, and they can make the decision based on our advice to go forward with that.
00:15:39
Speaker
So labs is the second thing.
00:15:41
Speaker
Another thing is medication.
00:15:43
Speaker
So we do keep a pharmacy in our office and we carry all the common antibiotics, all the common primary care meds.
00:15:52
Speaker
Again, it's pennies on the dollar and we're able to quote them prices for that.
00:15:57
Speaker
We don't, we don't upcharge for any of our
00:16:01
Speaker
meds, we just charge them costs.
00:16:03
Speaker
So there's really no incentive to us if they can find a better deal at the pharmacy down the street.
00:16:09
Speaker
So we make a lot of use in our exam rooms of GoodRx.
00:16:13
Speaker
GoodRx.com is a website that compares cash pay prices at most local pharmacies.
00:16:21
Speaker
So it's easy for us to pull that up and just compare that to our costs.
00:16:25
Speaker
Usually we're beating GoodRx, but if they can get it better at Wegmans, for instance,
00:16:30
Speaker
Then we'll let them know that we can just easily send the prescription to Wegmans.
00:16:33
Speaker
It's up to them.
00:16:35
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.
00:16:52
Speaker
So just an added convenience
Concerns and Considerations in DPC
00:16:53
Speaker
there.
00:16:53
Speaker
So the a la carte charges, after hours, fees, medications, labs, and then,
00:17:00
Speaker
Sometimes there might be procedure fees, but usually those come in.
00:17:08
Speaker
And so for instance, our local pathologists here, if we do skin biopsies, they'll just client bill us for the pathology fee.
00:17:16
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.
00:17:27
Speaker
usually $7 to look at the pathology specimen from a skin biopsy.
00:17:32
Speaker
But otherwise, all primary care procedures are covered.
00:17:36
Speaker
That would include EKGs, stitches, skin biopsies, pap smears, and things like that.
00:17:43
Speaker
What about maybe slightly bigger things like an endoscopy or colonoscopy?
00:17:49
Speaker
So that's something we wouldn't do in our office.
00:17:52
Speaker
We're not credentialed to do those tests.
00:17:55
Speaker
So we would send them for endoscopies and colonoscopies to our local gastroenterology or general surgery practices.
00:18:02
Speaker
Got it.
00:18:03
Speaker
So if I'm trying to sign up for this,
00:18:07
Speaker
I need to expect to pay the fee.
00:18:10
Speaker
I need to expect to pay for after hours, labs, medicines, things like that.
00:18:16
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...
00:18:29
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?
00:18:36
Speaker
So the worst case is probably like, I need a lot of expensive specialists, but it's not enough to hit my deductible.
00:18:45
Speaker
Like that's going to be a really expensive year if I'm on this.
00:18:47
Speaker
Sure.
00:18:50
Speaker
Okay.
00:18:52
Speaker
So, um, I wanted to ask you also, um,
00:18:58
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.
00:19:09
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?
00:19:24
Speaker
Yeah, great question.
00:19:25
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.
00:19:38
Speaker
Won't you attract all the hypochondriacs?
00:19:41
Speaker
And I think
00:19:45
Speaker
The answer is no.
00:19:46
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.
00:20:00
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.
00:20:09
Speaker
So
00:20:11
Speaker
For our higher utilizers, again, I think we have the privilege of time with them.
00:20:16
Speaker
We get to know them really well.
00:20:18
Speaker
We make maximum use of telemedicine.
00:20:22
Speaker
Certainly, if the patient prefers to have a face-to-face visit in the office, that we can do that.
00:20:27
Speaker
Otherwise, we can use secure email, secure text messaging.
00:20:31
Speaker
We can use video visits as well to support
00:20:37
Speaker
sort of streamline our time and the patient's time.
00:20:40
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.
00:20:49
Speaker
Yeah.
00:20:49
Speaker
I wonder if getting away from the scarcity mindset almost helps to put that anxiety to bed a little bit.
00:20:56
Speaker
Yeah.
00:20:57
Speaker
I think that's exactly right.
00:20:58
Speaker
So I, I think in my, my, my wife's big reservation was, um, yeah, I, I,
00:21:06
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.
00:21:13
Speaker
And she was just worried that with being, taking 365 24-7 call, what kind of quality of life would that be?
00:21:21
Speaker
Would that be even worse?
00:21:23
Speaker
And I'm six years into it now.
Personal Experiences and Benefits of DPC
00:21:25
Speaker
And I think, my wife is actually the administrator for our practice and talks to a lot of prospective patients and everything.
00:21:33
Speaker
So I was really able to offer them
00:21:37
Speaker
or even potential provider physician employees, what exactly life in our practice is like.
00:21:47
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.
00:21:55
Speaker
So it's not too burdensome.
00:22:00
Speaker
I might handle one or two text messages an evening, maybe a few over a weekend.
00:22:06
Speaker
Um, usually it's very brief exchanges, uh, uh, pretty simple.
00:22:10
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.
00:22:18
Speaker
Cool.
00:22:19
Speaker
Yeah.
00:22:19
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.
00:22:28
Speaker
I tend to freak out, uh, all the time.
00:22:32
Speaker
And, um,
00:22:34
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.
00:22:43
Speaker
He just tells me about all the times he thought.
00:22:44
Speaker
Yeah.
00:22:45
Speaker
Right.
00:22:48
Speaker
So, uh, so you're, you're really selling me.
00:22:51
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.
00:23:00
Speaker
So that's, that's, that's awesome.
00:23:02
Speaker
That's really, really cool.
00:23:04
Speaker
Um, okay.
00:23:05
Speaker
So, uh, you wrote this fantastic blog post titled how the Amish made me a better doctor.
00:23:14
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.
00:23:25
Speaker
Can you, can you tell us a bit about your experience at that clinic and how it led you down this road?
00:23:30
Speaker
Yeah.
00:23:31
Speaker
So, uh,
00:23:32
Speaker
Not from Lancaster County PA, my wife is.
00:23:35
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.
00:23:45
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.
00:23:59
Speaker
and I, it seemed like frontier medicine to me.
00:24:01
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.
00:24:09
Speaker
So I couldn't resist, um, was, was a bit tough at first on a couple of fronts.
00:24:14
Speaker
One, there was just a lot of OGT on the job training, refreshing and, uh, getting used to casting and splinting.
00:24:21
Speaker
We had our own x-ray machine.
00:24:24
Speaker
the Amish really expected the primary care doctor to do as much as he or she could and avoid the emergency room.
00:24:34
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.
00:24:48
Speaker
It was a real adventure.
00:24:51
Speaker
But,
00:24:53
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.
00:25:09
Speaker
The other way it made me a better doctor is it brought home the true cost of care.
00:25:15
Speaker
So I'll never forget my first couple of weeks there.
00:25:19
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.
00:25:39
Speaker
And so I thought that I would try this medicine for this, for this gentleman.
00:25:44
Speaker
And when insurance is the third party payer,
00:25:48
Speaker
we're often insulated from that cost of care.
00:25:52
Speaker
That's putting it mildly.
00:25:53
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.
00:26:04
Speaker
And that fact is a lot more dire in this day and age when deductibles are so high.
00:26:10
Speaker
But in any case, I prescribed Imitrex for an Amish patient.
00:26:13
Speaker
They went to the pharmacy down the road and lo and behold, it was...
00:26:17
Speaker
250, about $250 for nine tablets.
00:26:21
Speaker
Typically comes in nine tablet packets and quickly called me back that, that day and said, he just couldn't do that.
00:26:29
Speaker
So there's just an example of how my eyes were opened to the cost of care.
Lessons from the Amish Community on Healthcare
00:26:35
Speaker
That clinic was already pretty well adept at connecting their providers with, with self-pay resources in the community.
00:26:43
Speaker
Of course, the Amish don't carry typical health insurance.
00:26:48
Speaker
For many, many years, they've been doing what sharing plans, modern sharing plans are doing now.
00:26:54
Speaker
So church members pay into one pot, so to speak, and that money is used to fund members' health insurance costs.
00:27:03
Speaker
So that's how the Amish have been doing it for many years.
00:27:08
Speaker
So they're looking for the best care at the best prices.
00:27:12
Speaker
So we knew where to go to get an MRI for $450, for instance, to get a CAT scan for $250.
00:27:21
Speaker
We had cash pay prices for labs and things like that.
00:27:24
Speaker
We knew what the specialists were in our community that would deliver good cash pay prices for our Amish clients.
00:27:33
Speaker
So yeah, those, those are a few ways where I, I think working in that practice really, really made me a better doctor.
00:27:39
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.
00:27:57
Speaker
You know, what is the cost of care?
00:27:59
Speaker
instead of that just being handled outside by a third-party payer.
00:28:05
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?
00:28:22
Speaker
Like, are you more likely to offer holistic interventions like diet and exercise?
00:28:26
Speaker
Like, do you have more of those conversations because...
00:28:30
Speaker
of the sticker price?
00:28:31
Speaker
Yeah, I absolutely do.
00:28:33
Speaker
And it's not because of the sticker price.
00:28:35
Speaker
You know, I have no, you know, I'll use diabetes as an example, type two diabetes.
00:28:42
Speaker
That's it.
00:28:43
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.
00:28:55
Speaker
and may really need the assistance of a health insurance product to assist our patients to afford them.
00:29:03
Speaker
And I would have no hesitation in prescribing them.
00:29:06
Speaker
They're great medications.
00:29:07
Speaker
They really help to address what is the problem in type 2 diabetes, which is insulin resistance.
00:29:17
Speaker
But yes, I do.
00:29:19
Speaker
Because I have time to spend with my patients, I'm really trying to harp on lifestyle.
00:29:25
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.
00:29:39
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.
00:29:49
Speaker
And they, they may not require as many medications as they've been on.
00:29:54
Speaker
If that leads to some weight loss, it may improve their blood pressure.
00:29:57
Speaker
They may be able to come off of their blood pressure medicines.
00:30:00
Speaker
So we talk to them, talk to our patients a lot about lifestyle, diet, exercise.
00:30:06
Speaker
I talk to my patients a lot about sleep.
00:30:09
Speaker
So if you can zero in on some of those lifestyle things, then some of these chronic diseases do very much improve.
00:30:17
Speaker
Diabetes with diet, anxiety, depression with better sleep and exercise.
00:30:23
Speaker
So yes, those are low cost interventions, saving our patients a lot of money.
00:30:27
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.
00:30:43
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.
00:30:56
Speaker
Yeah.
00:30:58
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?
00:31:09
Speaker
Yeah, they would still handle it within that health-sharing approach.
00:31:13
Speaker
environment and not use traditional insurance even to pay for the very expensive things.
00:31:20
Speaker
So even those really higher cost things like cancer surgeries are handled within the sharing plan.
00:31:27
Speaker
Okay.
00:31:27
Speaker
But they still do get that type of care.
00:31:29
Speaker
They just, they still absolutely get that type of care.
00:31:31
Speaker
Yes.
00:31:32
Speaker
So yeah, they, they, they don't, they typically don't avoid even the higher cost care when it's medically indicated.
00:31:41
Speaker
It isn't always the case.
00:31:43
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.
00:31:58
Speaker
So we do our best to try to navigate that system too.
00:32:03
Speaker
Yeah, that was going to be another question is I'm sure that in that environment you...
00:32:08
Speaker
you surely dealt with cultural differences, especially as regards technology and Western medicine.
00:32:18
Speaker
And how did, how did you navigate that?
00:32:22
Speaker
Yeah, that was, that, that was a challenge.
00:32:24
Speaker
You know, one big change in coming into being a doctor for the Amish and Mennonite is
00:32:32
Speaker
Whereas in the typical practice, doctors still enjoy or providers still enjoy some prestige.
00:32:40
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.
00:32:57
Speaker
You're just one other guy they can talk to.
00:32:58
Speaker
Just one other guy they can talk to, exactly.
00:33:02
Speaker
So they're a whole stream of other holistic providers, some of them very good, chiropractors, some of them very good.
00:33:11
Speaker
But sometimes we really had to battle against advice that we felt was just very detrimental to their health.
00:33:22
Speaker
Can you give me an example of things that you had to fight them with?
00:33:29
Speaker
One big example that I recall was Lyme disease.
00:33:31
Speaker
So that's been a controversy for some time.
00:33:36
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.
00:33:50
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.
00:34:05
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.
00:34:17
Speaker
What tests are validated for diagnosing Lyme?
00:34:21
Speaker
What tests are not validated for diagnosing Lyme?
00:34:25
Speaker
What is validated as a treatment for Lyme and what are not?
00:34:29
Speaker
I think that was one big challenge that comes to mind.
00:34:35
Speaker
But you're not just having a single...
00:34:40
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.
00:34:56
Speaker
Correct.
00:34:56
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.
00:35:10
Speaker
Yeah.
00:35:14
Speaker
Another, another comment.
00:35:15
Speaker
Go ahead.
00:35:17
Speaker
Well, I was just going to say, so I have, I have a doctor buddy who, um,
00:35:22
Speaker
Basically, so my, my, uh, I don't know what your take is on the whole COVID situation.
00:35:28
Speaker
I, I have definitely, um, heard every voice I think on, on that situation.
00:35:37
Speaker
And I'm not, uh, I, I don't, I wouldn't pretend to be an expert on anything.
00:35:42
Speaker
Um, but I am, I am skeptical enough that I, I, I don't just sort of buy, uh,
00:35:49
Speaker
you know, what, what is being popularly propagated about it.
00:35:53
Speaker
But I did have a doctor friend who was like, Hey man, I'm in the hospital every day.
00:36:00
Speaker
I'm seeing this happen.
00:36:01
Speaker
It's really serious.
00:36:03
Speaker
You should take it seriously.
00:36:04
Speaker
It's a problem.
00:36:05
Speaker
And, and just, and it wasn't because like, Oh, he's a doctor.
00:36:08
Speaker
It's because he was my friend.
00:36:10
Speaker
And I knew he was smart.
00:36:12
Speaker
I knew he wasn't full of crap.
00:36:14
Speaker
And so I think having the, having the personal proximity to your patients and being able to develop that relationship is huge.
00:36:24
Speaker
Yeah, exactly.
00:36:26
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.
00:36:39
Speaker
So,
00:36:40
Speaker
Yeah, this requires.
00:36:42
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.
00:36:57
Speaker
It's really helped streamline the pandemic for us.
00:37:01
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?
00:37:13
Speaker
Yeah, I think it did insulate us somewhat.
00:37:16
Speaker
When the pandemic occurred or began and the lockdowns occurred, we sort of hit the ground running.
00:37:23
Speaker
We were already utilizing telemedicine.
00:37:26
Speaker
So we just pivoted into a much higher emphasis on telemedicine at that time.
00:37:32
Speaker
So our patients were used to interacting with us in that way.
00:37:36
Speaker
So that was pretty streamlined when we made that transition.
00:37:42
Speaker
And then, yeah, as I said, as things developed and people got settled into their respective camps, if you will,
00:37:54
Speaker
regarding all the facets of COVID.
00:37:56
Speaker
Yeah, because we knew them and we had that relationship established with them.
00:38:02
Speaker
I think still those conversations went pretty well for the most part.
00:38:07
Speaker
Awesome.
00:38:09
Speaker
So you are a provider in the direct primary care space, but you're also a patient yourself in a health sharing ministry.
Health-Sharing Plans vs. Traditional Insurance
00:38:19
Speaker
Can you tell us how that's been for you?
00:38:26
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.
00:38:35
Speaker
And I think being a male physician, it ratchets that up even higher.
00:38:42
Speaker
But my family are higher utilizers of a sharing plan.
00:38:47
Speaker
So I think it's been a great experience really since I opened my practice.
00:38:54
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.
00:39:08
Speaker
So we were members of Samaritan Ministries for a few years.
00:39:12
Speaker
We used Sedera for a couple of years and now we've transitioned to Zion Health.
00:39:18
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.
00:39:30
Speaker
I think we were really happy with all three of those products in our market.
00:39:36
Speaker
They're really quite common.
00:39:38
Speaker
these sharing plans.
00:39:39
Speaker
But I think it's been great for my family.
00:39:42
Speaker
The reimbursement has gone very well.
00:39:44
Speaker
We certainly enjoy the lower premium prices, if you will.
00:39:51
Speaker
Yeah.
00:39:51
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.
00:40:08
Speaker
That's correct.
00:40:09
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.
00:40:18
Speaker
But have you ever seen that difference cause a problem for someone?
00:40:22
Speaker
No, I've never seen it.
00:40:26
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.
00:40:36
Speaker
They've all, right,
00:40:37
Speaker
they've all been very happy with them in the six years that I've been treating patients with them.
00:40:42
Speaker
So that while they're not legally obligated to cover costs, they're not gonna be subject to rules and regulations.
00:40:53
Speaker
This differs per state that would usually govern health insurance companies.
00:40:59
Speaker
They usually deliver very well on their intent to cover what they purport to cover.
00:41:07
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.
00:41:23
Speaker
So they probably would need to err on the side of...
00:41:27
Speaker
of saying yes, especially if it's like, you know, somebody has cancer.
00:41:32
Speaker
So, so it's really tragic.
00:41:33
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.
00:41:42
Speaker
Right.
00:41:42
Speaker
Right.
00:41:43
Speaker
So yeah.
00:41:44
Speaker
How, how do they make that viable?
00:41:46
Speaker
Um, any one reason,
00:41:49
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.
00:41:57
Speaker
If you have a preexisting condition and all the sharing plans do preexisting conditions differently, some will not cover for the first year.
00:42:05
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.
00:42:14
Speaker
So,
00:42:15
Speaker
I think that's how they guard their costs a little bit and are able to offer such good prices for premiums.
00:42:24
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?
00:42:45
Speaker
They all have their definitions as to what constitutes a preexisting condition.
00:42:49
Speaker
So, you know, when it was diagnosed, are you stable on medications?
00:42:53
Speaker
Has there been any need for you to adjust your medications in the, in the last several months or so?
00:43:01
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.
00:43:11
Speaker
Now for Sedara,
00:43:13
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.
00:43:27
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.
00:43:40
Speaker
Um,
00:43:41
Speaker
of what they will typically cost someone in a year.
00:43:45
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.
00:43:56
Speaker
If that condition was preexisting.
00:43:59
Speaker
Right.
00:44:00
Speaker
And you're, you're so covenant MD, how roughly how big is your team right now?
00:44:07
Speaker
There's let me see.
00:44:09
Speaker
There's eight of us.
00:44:11
Speaker
Okay.
00:44:11
Speaker
Between two locations.
00:44:13
Speaker
No, there's four providers and each of us has one nurse.
00:44:17
Speaker
Roger.
00:44:18
Speaker
And then office staff, that kind of thing.
00:44:21
Speaker
We don't have office staff.
00:44:22
Speaker
So my wife works part-time on administration.
00:44:28
Speaker
But usually the direct primary care model will work with one provider working with one nurse.
00:44:34
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.
00:44:43
Speaker
So when we don't need to hire a coder, we don't need to hire a biller.
00:44:49
Speaker
We keep our patient panels at much lower numbers.
00:44:51
Speaker
So each patient panel is like a solo practice within a larger practice.
00:45:00
Speaker
So my patients get to know my nurse really well.
00:45:03
Speaker
They get to know me really well.
00:45:06
Speaker
Our billing system is very streamlined and automatic.
00:45:10
Speaker
So there's a lot less of the attention we need to give to the administrative stuff.
00:45:15
Speaker
And we're able to give a lot more attention to the clinical stuff as we ideally should be.
00:45:21
Speaker
Okay.
00:45:22
Speaker
So in terms of how you provide benefits as an employer, do you do this model for
Challenges and Opportunities in Starting a DPC Practice
00:45:32
Speaker
your employees?
00:45:32
Speaker
How does that work?
00:45:34
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.
00:45:45
Speaker
We, we do offer a sharing plan is it's just easy for us to cover that as a smaller employer.
00:45:52
Speaker
So we, we offer our, our patients Zion health.
00:45:55
Speaker
And so they make use of that.
00:45:58
Speaker
And then other standard insurance or standard benefit things like a 401k and things.
00:46:03
Speaker
Yeah, yeah.
00:46:05
Speaker
Well, I just got to think that's... Okay, so you have... We have a few doctors and medical students in the group.
00:46:15
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.
00:46:26
Speaker
Why didn't everybody do it this way?
00:46:27
Speaker
What are the trade-offs?
00:46:28
Speaker
What did you have to pay to get this gig?
00:46:33
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.
00:46:41
Speaker
So I worked for four years between undergrad and medical school, paying down my undergraduate debt.
00:46:49
Speaker
And medical school was free for me because I did a scholarship through the U.S. Air Force, the Health Profession Scholarship Program.
00:46:55
Speaker
So medical school is paid for.
00:46:58
Speaker
I did seven years active duty for anyone considering
00:47:03
Speaker
career in medicine or law, I would just highly recommend looking into the armed forces, it's a great way to go.
00:47:09
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.
00:47:23
Speaker
That's a big barrier.
00:47:25
Speaker
Another one may be a perceived risk
00:47:30
Speaker
lower security and not being under the auspices of a bigger healthcare system.
00:47:40
Speaker
The independent primary care practice is becoming a dinosaur in this day and age.
00:47:44
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
00:48:00
Speaker
to, uh, to afford, um, that that's a barrier.
00:48:04
Speaker
Um, and to think of, of, so I think those are the bigger ones.
00:48:13
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.
00:48:20
Speaker
Is that.
00:48:21
Speaker
Yeah.
00:48:22
Speaker
So yeah, where that would be a barrier is, uh,
00:48:27
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.
00:48:49
Speaker
Another, another big barrier I would mention, you know, any, any,
00:48:53
Speaker
local doctors that worked for a local health system that might be interested in joining a smaller independent practice.
00:49:02
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.
00:49:18
Speaker
So
00:49:19
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.
00:49:32
Speaker
It might be hard to lure them because they're sidled with that.
00:49:36
Speaker
There's those non-compete clauses that will interfere with them working at any other office in the local area.
00:49:44
Speaker
Yeah.
00:49:45
Speaker
So you've got, you've got eight,
00:49:47
Speaker
people on the rolls right now.
00:49:50
Speaker
And what's the, does this, do you want this to scale beyond what it is?
00:49:57
Speaker
What's the dream, the vision for the big picture?
00:50:02
Speaker
Yes, so it certainly is scalable.
00:50:05
Speaker
I think what's really on the rise is the use of direct primary care services by employers.
00:50:15
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.
00:50:25
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.
00:50:38
Speaker
So for some of our employers, we're the only health care offering that we offer their employees.
00:50:45
Speaker
So usually the business will pay our monthly fee on behalf of the employee.
00:50:51
Speaker
They may also pay our monthly fee on behalf of any family members that choose to sign up with us.
00:50:58
Speaker
Some employers, if employees incur any costs in the way of medications or procedure costs or
00:51:07
Speaker
um, I mean, I would need pathology costs or, or lab costs.
00:51:12
Speaker
And sometimes the employers will even pay for those.
00:51:15
Speaker
So they get an entirely free primary care package.
00:51:18
Speaker
So I think, um, we don't do a lot of advertising in our local area.
00:51:24
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.
00:51:37
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.
00:51:51
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.
00:51:58
Speaker
Right, and sometimes we do.
00:51:59
Speaker
So our York clinic, I opened that after probably
00:52:06
Speaker
just past our third year.
00:52:09
Speaker
So hard to open a separate clinic in a town that's about a half an hour for me.
00:52:15
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?
00:52:29
Speaker
And that's how our York clinic started.
00:52:32
Speaker
So we are sort of a near site provider for a large employer there.
00:52:36
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.
00:52:47
Speaker
So what's the vision for the future?
00:52:51
Speaker
Just this week, we're beginning talks with a large well-known employer in a local area.
00:52:57
Speaker
that is considering using us to deliver primary care to their employees.
00:53:03
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?
00:53:16
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?
00:53:23
Speaker
So there's a sort of conversations I think we'll begin to have a lot more of in the coming years, hopefully.
00:53:29
Speaker
Yeah.
00:53:30
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.
00:53:41
Speaker
Right.
00:53:42
Speaker
A certain number of people that that makes sense for.
00:53:46
Speaker
And then eventually you kind of have to be the pirate admiral and there's a couple pirate ships.
00:53:51
Speaker
Right.
00:53:51
Speaker
And I, I, the,
00:53:53
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?
00:54:15
Speaker
How does that feel to you?
00:54:16
Speaker
Yeah.
00:54:17
Speaker
And maybe that's a key question for entrepreneurs, right?
00:54:21
Speaker
Yeah.
00:54:21
Speaker
how long are they going to remain the technician, so to speak.
00:54:25
Speaker
And, uh, so for me personally, there, there's always that, uh, there's always that pull.
00:54:31
Speaker
So I think we'll always be a doctor.
00:54:33
Speaker
Uh, I, I love, I love being a primary care doctor.
00:54:37
Speaker
Um, I certainly put a lot of blood, sweat and tears into the training.
00:54:41
Speaker
Um, and, and right now I'm trying to find a balance.
00:54:45
Speaker
Um, you know, how, how can the business, uh,
00:54:50
Speaker
pay me to do more of the administrative business owner stuff and less of the technician stuff.
00:54:57
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.
00:55:07
Speaker
They take, they take more time.
00:55:08
Speaker
And so there's, there's just going to be this this this pull both ways.
00:55:14
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.
00:55:20
Speaker
Yeah.
00:55:21
Speaker
I mean, you mentioned the pain that you went through to get this credential.
00:55:24
Speaker
That's a lot more pain than getting an MBA.
00:55:26
Speaker
So it might make sense to have an MBA do the MBA stuff and have you stick to doctoring.
00:55:33
Speaker
That's, but you know, good, good problems to have.
00:55:36
Speaker
So that's, that's exciting.
00:55:39
Speaker
Well, this has been just an awesome conversation.
00:55:43
Speaker
I feel like the guys are really going to enjoy this discussion, particularly from the perspective of, you know, both,
00:55:50
Speaker
Both from the side of, you know, I'm a patient and I want to get away from the corporate health system.
00:55:55
Speaker
Like, there's that appeal to it.
00:55:57
Speaker
But also, I love stories of people who say... So we have so many guys who are like, I feel trapped.
00:56:08
Speaker
I feel like I have to do this one thing.
00:56:11
Speaker
Yeah.
00:56:13
Speaker
I've definitely talked to doctors for whom medicine is really dehumanizing.
00:56:17
Speaker
And, uh, and like there's lots of depression, there's lots of like psychological problems in the field.
00:56:23
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.
00:56:39
Speaker
And you have found this niche that,
00:56:41
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.
00:56:51
Speaker
And so that is...
00:56:52
Speaker
So cool to me.
00:56:53
Speaker
And I'm really excited to show the guys.
00:56:55
Speaker
Thank you so much for taking the time.
00:56:58
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.
00:57:03
Speaker
You want to check out his practice.
00:57:05
Speaker
It's covenantmd.net.
00:57:08
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.
00:57:15
Speaker
Thanks a lot, Dr. Rol.
00:57:17
Speaker
Great.
00:57:17
Speaker
Thanks for having me.