Own Your Own DPC practice in Tampa Bay, FL

Beginning in July 2016 PGY3 family medicine residents will have the opportunity to come to the Tampa Bay area and have their own direct patient care (DPC) practice.  There is no need to start with a hybrid model; there is no need to be on any insurance plans or be a Medicare provider.  Spend your career working only for your patients, not insurance companies.  In Tampa Bay you will have the unique opportunity to participate in a network of DPC docs in order to grow your membership quickly enough that enrolling in insurance plans or Medicare will not be needed.  

My DPC practice has grown to 350 members after 16 months. Concurrently, small business owners (<50 employees) in Tampa Bay are realizing they have the ability to provide their employees access to their own personal physician with no out of pocket cost no matter how often they seek care, keeping them healthier and more productive.  Be a “preferred physician” in MyDPCnetwork and grow your DPC practice in Tampa Bay quickly.  Contact me at drcrall@mydpcnetwork.com if you are interested in being your own boss as a family physician and never file a claim to a health insurance company or Medicare from the first day you start in your practice.  

The 21st Century Employee Retention Tool -- Direct Primary Care

It has taken 60+ years to finally undo the employee retention strategy that has largely contributed to the spiraling cost of health insurance.  Since the IRS allowed companies to deduct expenses on health insurance for their employees back in the 1950s, that became a dominant employee retention tool; and the more comprehensive the insurance, the greater the "benefit".  It became so common to get full health insurance through our employers that we really didn't even stop to question how little sense that made.  It wasn't until the cost of offering that coverage became prohibitive that we have stopped to contemplate what we have been doing all these years.

The purpose of insurance is to insure against high cost, low probability events.  If you know you are going to have certain expenses over the course of the year related to everyday health needs -- acute illnesses as well as the care of any chronic illnesses you already have -- why would you use insurance to pay for that care?  If we used our car insurance to pay for oil changes, tire care and car maintenance, the extra cost of submitting all those claims to the car insurance companies would drive up the cost of auto insurance to unaffordable levels.  Sound familiar?  Look at the irony of our situation.  This employee retention strategy has become so expensive that companies near the 50-employee level are actually laying off employees to avoid tax penalties for no longer offering the expensive employee-retention strategy of the last century.  And offering a group health insurance plan that carries a high deductible (the only way that group plan is affordable) is no longer really a benefit to the employee because their out-of-pocket cost for receiving care is so high that they often delay seeking care or avoid it entirely.

The new employee retention strategy is to offer "access to care".  Direct Primary Care (DPC) is lost cost, high access care.  A small business owner can purchase, for $40-$50 per employee per month, the ability for his employees to see their own personal primary physician as often as they like, at no cost to them.  There are no co-pays for office visits and all the tests and procedures that are performed in the primary care physician's office are included in the monthly membership.  The employee has access to care 24/7 so he can stay healthy, recover from illnesses more quickly, and miss work less often.  In addition, in a DPC practice, there are many opportunities to receive care without even going to the doctor's office (UTI, rashes, skin infections, stress-related problems) by doing a "virtual visit" over the phone, face-time, Skype, etc.  Again, less time away from work.  This is a true benefit for employee as well as the business owner.  There are many different ways for the employee to get coverage for catastrophic illness at reduced cost to themselves and the employer -- individually or through a less expensive small group plan.  I would be happy to discuss this is greater detail with any interested business owners.  #group-to-individual strategy

River Jordan Direct Family Medicine has rebranded itself to more effectively do B2C and B2B marketing, and to emphasive the fact that you are getting your own personal physician.  We are now myDPCdoc Family Medicine!  For individuals and families who have questions on how having a DPC physician can benefit them, you can email me at drcrall@myDPCdoc.com.  Business owners can reach me at drcrall@myDPCnetwork.com.
You can also follow me on twitter for regular updates on info related to health care and health benefits.  #myDPCdoc   #myDPCnetwork

The Cost of Not Having a DPC Physician

The most common question I hear from prospective new patients who already have insurance, and don't yet understand the DPC model, is "Why would I pay you $40 a month when I already have insurance?"  In many cases, a DPC practice saves more than the amount of the membership fee.  The following is a sampling of the many opportunities DPC affords for savings:

-- there are no costs, such as co-pays, when you see the doctor

-- there is a lower likelihood of expensive urgent care services due to the accessibility to the doctor

-- there is a lower likelihood of expensive imaging tests being ordered due to the extra time that the physician has to determine the cause of symptoms, using less expensive and less invasive diagnostic tests

-- The physician will proactively look for the least expensive medications, when medications are needed.

-- you are less likely to be referred out for expensive specialist evaluation due to the extra time the physician can spend looking for the root cause of your problems

-- when testing is needed outside of the office, the physician proactively looks for the least expensive way to get testing done using very economical cash pricing options when possible

-- you are less likely to miss time away from work due to same-day accessibility and the opportunity to get well quicker.

-- you are less likely to miss time away from work due to the possibility of alternative visit models such as phone visits or virtual visits when possible

-- some visits can be avoided by the opportunity to ask the doctor questions by text message or email

And finally, the insurance can be changed to a higher deductible, catastrophic plan that carries a lower premium that saves more than the membership fee.  Or changing 1 or 2 costly prescriptions to a cheaper equivalent can save more than the membership fee. So all these benefits essentially cost nothing if the net health cost goes down each month. 

Ultimately it's not just about cost but, rather, the opportunity to have a partner in helping you enjoy better health.  When your physician has the time to explain the pros and cons of diagnostic testing rather than just giving you an order to have it done, you may be spared the harmful effects (of radiation, for example).  When you understand the benefits and risks of prescription drugs, as well as the alternatives such as "therapeutic lifestyle change," you are less likely to experience the toxic effects of medication.  

In the end, it is generally I who asks, "How can you afford not having a DPC physician?"

The group-to-individual strategy

In the interim since my last post, my practice has made leaps and bounds towards the realization of its goals.  The time spent working on the practice, as well as in the practice, has led to increasing attention by local media, business owners and individuals/families for whom the DPC model is an ideal complement to their high deductible plan, cost-sharing plan or no plan.  My enrollment had risen to 280 patients by the end of the eighth month; there has been no single month with fewer than 30 new patients.  I have hired a nurse to complement my receptionist who works primarily as a care manager.  I have begun to enroll groups of patients whose monthly fee is paid by their employer.  

The most important development in my DPC transformation has been the recognition of an ideal strategy for employer engagement in the DPC model: the group-to-individual strategy.  An employer (with fewer than 50 employees) who wishes to provide coverage as a health benefit for his employees has several good options when combined with a DPC physician/group of physicians.  The expensive group insurance coverage can be discontinued, allowing the employees to purchase individual coverage with subsidies if they qualify, since their employer no longer offers them coverage.  The employer can, if he chooses, increase the employees pay by an amount that allows them to purchase their coverage, with or without also paying for their direct primary care.  The end result, even if the employer provides both benefits, is greater than 50% reduction in the cost per employee (more if the employees qualify for subsidized coverage) and unlimited access by their employees to a physician, keeping them healthier and happier with less missed work due to illness.  Everyone wins!  Even lobbyists for the insurance industry should be happy because insurance still needs to be purchased.  

As I engage more employers, I will be able to hire a small network of physicians, at guaranteed salaries, who will start with a panel of patients.  The network will then be able to engage larger employers, allowing a larger network, etc. etc. This will be the model that delivers on the promise of a reformed healthcare system.

So family medicine residents who are in their second or third year, who would like to practice DPC in Tampa/St. Petersburg/Clearwater FL at a guaranteed minimum pay, with a path towards "franchise ownership" of their own practice, should contact me to begin early discussions about the opportunity.

Four Months as a DPC Doc

At the end of my fourth month as a DPC doc, my total patient enrollment is 145, still exceeding my expected pace of enrollment.  My Medicare opt-out was approved effective October 1, and I enrolled 40 prior Medicare patients of mine in the first month as an opted-out doc.  For those considering DPC, the opt-out is essential and can only be done on the first day of each quarter; it also must be repeated every 2 years. You also need to plan ahead and have all necessary paperwork submitted at least 30 days prior to your opt-out date. Finally, and this is very important, you need to ensure that you are still registered under PECOS to be able to refer medicare beneficiaries for labs, X-rays, therapy services and DME. I am happy to assist anyone with the opt-out process.

So, after just four months, my monthly cash flow is enough to cover all my expenses and pay myself a small monthly salary.  Within the year I will no longer need my business line of credit for capital contributions. For those seriously considering DPC I'd be happy to share the numbers to show where the expenses go and how my monthly fees break down. 

I am ready to launch a full-scale marketing effort, rolled out throughout 2015, to target small business owners and small companies in order to provide direct primary care to their employees. I am on track with my plan to be able to offer employment to fellow family docs who would like to practice DPC in the Tampa Bay Area starting in the Fall 2015. I would like to know of any interested third-year residents or practicing physicians so I can stay in touch with you directly throughout 2015. 

On Jan 1, the CMS carrot turns into a stick for those tracking PQRS data, or those enrolled in Medicare shared savings ACOs. I'm sure physicians will be dissatisfied in unparalleled numbers beginning this year. Also, record numbers of patients will be sporting high deductible plans this year, increasing the strain on fee-for-service primary care physicians. The time has never been better to join the DPC movement. My early experience suggests anyone can do it. You don't need the backing of any company -- just a mentor and a small business loan. Or let's talk about coming to Tampa Bay with a guarantee until you reach profitability. 

DPC/HDHP Combo Attracts Attention of Small Business Owners

I am celebrating my first month as a DPC doc.  I am celebrating the fact that I enrolled 50 patients, doubling my expectations for the first month.  All but four are former patients of mine, but this is still cause for celebration.  I am truly celebrating the fact that I have filed my affidavit to opt-out of Medicare and will begin enrolling Medicare beneficiaries under a private contract on October 1, so I expect a second influx of former patients at that time.  And I am celebrating the fact that my practice has garnered the interest of local small business owners sooner than I expected; this gives me the potential for growth at a much faster rate than expected.  For example, this week I am making a presentation to a local title company with 23 employees who begin open enrollment for 2015 this month.  Their family premium has risen to $1600 per  month.  I explained to the owner that my maximum monthly fee for a family is $150 per month, and this can complement the high deductible plan that carries a premium that costs $7000 a year less.  After the $1800 annual premium for my direct primary care, they save more than $5000 per year in premium.  The bottom line is that, due to the accessibility to care that they will get from me at no added cost, they are likely to save thousands; but even if someone in the family has a catastrophic event, and they reach the $6350 individual out of pocket max, the family will still spend $900 less than if they pay the higher premium for the comprehensive plan all year, with its $2000 individual out-of-pocket max.  In the absence of the DPC option, many of these employees will be forced to choose the HD option anyway, just to save on premium; but they will not have access to affordable care, so they will defer care, making it more likely that they will reach their out-of-pocket max anyway.  This is the scenario that leads to "coverage without care," a harsh reality of the present system.

I would like to invite 3rd year family medicine residents who might be interested in having a DPC practice in the Tampa/St. Petersburg/Clearwater area, and never have to file a claim to a third party ever, and have a great quality of life with a salary equal to that which would be offered to join a busy fee-for service practice -- follow this blog throughout your third year.  I will hire a physician for every 400-600 employees for whom I can contract to deliver care.  My goal is to be able to do this by Fall 2015.  I welcome your inquiries throughout the year.  I also welcome the inquiries of established physicians who have had enough of fee-for-service medicine.  Lets build a DPC network in the Tampa area that saves businesses millions while providing great, accessible care to their employees.  We can disrupt the prevailing business model of our healthcare system one region at a time.  

Doing More With Less

When I tell people that I am leaving a group practice to start a fixed monthly cost membership practice that will only cost them $50 per month, and they will never have any other costs for my services no matter how often I see them, their brow invariably tightens.  "How can you afford to do that?" they always ask, either genuinely concerned for my well-being or worried about my sanity.   "How can I afford not to?" I always reply. And after I explain it, they are usually left concluding the same.

Direct patient care practices come in various shapes and sizes, but they do lend themselves nicely to the micro practice model.  The overhead expenses in a DPC practice are inherently so low that the provider can run the practice with few staff and in small spaces.  In the fee-for-service model the provider collects about 70 cents on the dollar after contractual adjustments, then after overhead expenses of 50-60%  (often 70% with increasing requirements for extra staff and care coordinators), the net reimbursement can be as low as 25-30 cents on the dollar.  Contrast that with a DPC practice where 97 cents on the dollar can be collected, and with overhead of  20-25%, the net collection is in the range of 75 cents on the dollar.  So yes, I can afford to have a DPC micro practice, with 1/4 to 1/3 of the patient panel that I have currently.  What really matters, however, is the quality, access and affordability to which my patients will have access.  I will be able to do much more for my patients with much less. 

My direct patient care practice, River Jordan Direct Family Medicine (rjdirectfammed.md), will open its doors on July 28, 2014.  I am subleasing space from a specialist in an agreement that allows for low rent initially, and it will increase as my practice grows.  I will have just one staff member until I enroll my first 100 or 200 patients; only then will I need a full time medical assistant. My electronic medical record is free. I am not paying anyone else to "manage" the monthly payments, although there are several companies who cater to DPC docs by offering low cost solutions using gym membership software that has been modified for medical practices. I am going to use Quickbooks for this initially. I am using a medical supply company that caters to DPC docs by giving group purchasing power among all docs around the country who are in the micro practice model. So you can see that an entire industry is developing to support physicians who are going into business by themselves in a micro practice model.  For my part, I am catering to patients who have high deductible plans by compiling a list of low cost options for labs and radiology services, as well as cash pricing from specialists. "Consumer-driven" healthcare is a great idea, but unless patients have the ability to know what they are getting with their healthcare dollar, savings will not occur. We can't wait for the system to cater to cash pricing options; it is going to ride the fee-for-service wave as long as it can with little motivation to change quickly. So DPC docs offering low cost primary care, and helping patients find lower cost options for their additional care, will disrupt the system from the bottom up. The evolving support for the micro practice model allows physicians to do just that, and pass the saving to our patients. Once we bring employers into the model in larger proportions, we will be successful in disrupting the system.

I start July 28 with a member count of zero. Please check back regularly for a status update!