How To Put The Care Back In Healthcare (w/Dr. Eric Crall)

– What? I’m live? How’s it going? Z-pack, we have a really special guest today. Yesterday we did a show about direct primary care, this new model of primary care where we take the insurance company out of primary care and go directly to the patient’s. Today, we have Dr. Eric Crall, who actually has built a very similar model and can get into the weeds about it. Because many people ask me, how do I build Health 3.0 ZDogg, as a patient how do I get the care that I used to get back in the 20th century where my doctor spent time with me? Doctors are saying, how do we stop having this moral injury of serving an insurance company and a computer instead of our patients and ourselves and the answer I think firmly is direct primary care, which we’re going to talk about today with our guest dr. Eric Crall, welcome Eric.

– Thank You.

– Eric, you’re a family doctor?

– I am a family physician.

– In Tampa.

– Yes.

– And you have a practice that uses this model.

– Correct.

– And we connected through Hint Health which was the tech and service company that helped me run Turntable Health. It helped me do a direct primary care practice in the form of managing the patients, making sure I kept track of everything, creating an ecosystem where I could learn from other doctors doing this. Because we need to change, its not just tweaking polishing the turd, ‘let’s fix primary care’, no, no, no, no. We need to absolutely blow it up and rebuild it the way it should be and I think you are one of the people on the front lines of doing that. And so a question for you, let’s start with this, how did you get in to changing a practice to a direct primary care model?

– Let me be clear, I’m an early adopter of the direct primary care model. There were many brave souls that went before me who are known to be the innovators.

– Garrison Bliss–

– Absolutely.

– Yeah.

– In fact his niece Erica is one of the ones who I credit with getting me into the direct primary care space.

– She got me into it too.

– How about that!

– So she’s a lovely human being and was so passionate about not letting anybody get in the way of her and her patients. So that was sort of your intro to it as well.

– It was 2009 before the Affordable Care Act where I first learned about it and I just filed it away. I was very happy in my employed practice.

– [Dr. Damania] Employed practice?

– Oh yeah. I was hired an employee of a hospital so.

– Oh!

– [Dr. Crall] 17 years as an employee just like most of the docs out there.

– Are you more machine than man now? Twisted and evil?

– Call me mister Arigato.

– That was Styx, right?

– Yes. ♪ I am the modern man, ♪ ♪ Secret secret, I’ve got a secret ♪ ♪ With parts made in Japan ♪ Okay back, focus, focus ZDogg. So, you were in the system for 17 years as an employed physician of a hospital. Tell me more about this.

– So I know the old way, now I’m doing it the new way. Fortunately I was exposed early enough as I said, 2009. I filed it away that if the status quo ever was bad enough, that’s something that I would love to do. But what the Affordable Care Act did was it got people used to paying their own, paying out of their pocket for services. Because all of a sudden everybody says, “Wow, we have these high deductibles, “my insurance isn’t paying for anything anyway.” So I saw that well the high deductibles going up every year there’s gonna be more and more people who are gonna find value in a membership-based practice. So 2013, we’ll get into it more I’m sure, but after a few years things did get bad enough and I just made the jump in 2014. And I just made the jump cleanly. I dropped all insurances, dropped Medicare and became a direct primary care physician, so that I could work only for my patients not for the insurance companies.

– So you effectively unplugged from the matrix, that’s how I like to consider it. Because I was the same boat,

– [Dr. Crall] Exactly, correct

– employed physician. And when you unplug, you go, okay everything is broken. And we talk about this on the show all the time. I don’t need to rehash why, you know with the Affordable Care Act yeah, you have to spend all this deductible until the insurance actually kicks in. And it’s dumb anyways, because insurance shouldn’t be for your oil change and your prevent of care, it should be for when stuff goes really wrong.

– [Dr. Crall] Correct. And so this idea that then you said, “Okay, I can’t do this anymore.” A lot of doctors, a lot of doctors, can’t do this anymore. But–

– They don’t know they have a better way.

– They don’t know they have a better way, self-deception is a huge thing! I did it for years in my practice where I told myself lies. If I can just work another 10 years and survive and outlast this, then maybe I can find another thing that I can do or go into administration or do something like that, but it’s a lie. Because every day you’re suffering this moral injury, having to work in a system that is the matrix and there’s agents running it, that have no interest for patients, they have interest for profit. So when you unplugged, what was it, how did you spin up what we call direct primary care? Which is flat membership fee, for and sort of all you can treat buffet of care.

– [Dr. Crall] Yeah.

– How did you do that?

– Well, all employed physicians have a non-compete typically where if they’re gonna leave their employer, they have to go 10 miles away.

– [Dr. Damania] So dumb by the way.

– [Dr. Crall] It is.

– Yeah.

– So all I had to do was pick a day, and say okay, I’m gonna go 10.2 miles away, which is what I did and I made sure since I knew a year or so ahead that I was gonna do it that basically all my patients prescription refills came due like in the same month. So that I wasn’t allowed to call them and tell them I was leaving, but all my patients knew the month after I left that I was gone because they had to call the office for their refills.

– And so literally I just went 10.2 miles away, opened the office, opted out a Medicare so that… and it’s funny you opt out a Medicare, because you love to take care of your Medicare patients. It’s not that you’re shunning Medicare. I wanted to be able to take care of my Medicare patients and so opting out, allowed me to have a monthly membership-based relationship with them.

– Let me unpack that because we talked a little bit about that yesterday with Dr. John Bender. Our staff at Turntable, didn’t opt out and the reason is they were young doctors. And the concern was, if for whatever reason our experiment failed, which ultimately it did after three years for reasons we’ll talk about, they couldn’t, if you opt out of Medicare, you can’t see Medicare patients for at least two years. Now, what we need to clarify for people especially doctors who are thinking of making this jump, Medicare will not allow you to stay on the Medicare, bill Medicare in any way for any patient, if you’re ever charging a Medicare patient a membership fee. Because they consider it some kind of double charge.

– [Dr. Crall] Correct.

– it’s incorrect, but it was a law designed to protect seniors. But now, it’s fallen behind the times. Because now in order to charge a membership fee you have to tell Medicare, I will not bill you for anything directly to Medicare for at least two years.

– And that’s okay if your goal is to be straight direct primary care and only work for your patients, you’re fine top down a Medicare.

– But weren’t you terrified doing that? Because what if it failed you have to go back to your employed physician and now you can’t bill Medicare patients.

– And therein lies the rub. See the reason that physicians are afraid and your example that Turntable, was they’re afraid that their practice may not remain financially viable. So they need to be able to moonlight in emergency rooms and do other things to get income, so they’re afraid to let Medicare go. The new model is gonna be based on networks forming around the country, bringing the direct primary care benefit to employers. And so all these employees are looking to have a direct primary care doctor, there’s gonna be this huge pool of patients for direct primary care doctors to now take on. So these networks are going to form, they already are by the way, to bring employers and doctors who are providing the direct primary care service together. So that a DPC doc can open up a practice and within a year, be 75% full, maybe completely full within a year. So there’s no need to be worried to going into it that it’s gonna be, it’s not gonna be viable financially and they can just let it go, make a clean break, have no third party payers whatsoever other than the employer in that relationship–

– Which is truly a first-party player.

– [Dr. Crall] Yes.

– Because the employer is paying the healthcare for their employees directly. We talked about this yesterday. And as such, their skin is in the game. They want their employees to be healthy at a good cost,

– [ Dr. Eric] Yes.

– And all the insurance company is, when it comes to primary care in that situation, is a parasite. All they’re doing is racking up administrative costs, refusing claims, and making us, here’s the worst part. Making us jump through hoops before we can actually get paid for our services. If you throw them out of primary care, which I said in my TED talk in 2013 and I got hate mail from insurance companies, like threats. I said, insurance has no place in primary care if it’s billing a fee for service. It has no place. And so you get them out, you directly contract through networks, with employers. Employers pay for your primary care services whether flat-fee or however it is, and then you keep their employees out of trouble and if you fail, then the employer provides the catastrophic coverage that covers hospitalization, etc, etc, etc. But what about like labs and imaging and those kinda things, how do you manage those?

– Well, as we talked about earlier the ecosystem that Hint is developing, the entire ecosystem around direct primary care is developed now. Where you can get labs done, for a cash price, for pennies on the dollar. You can get an x-ray for 30 bucks, you can get an MRI without contrast for 250 bucks. That is the, now that there’s a cash market, these services are readily available. This isn’t some special pricing for Dr. Crall. Anybody who knows about it, can go get an MRI for $250. And you know the medicines through GoodRx and these other platforms that are allowing people to get discounted medications, those are readily available. There’s no reason to pay.

– So, okay. First of all you guys should know Hint, we tagged this, Hint’s sponsoring the show. And the reason I agree to work with Hint, because I hate sponsors, you know that right? It makes me violent when I have to consider a sponsorship because if there’s any conflict, if it’s something I don’t like, I just can’t do it. But with Hint, they ran our practice, they helped us make these networks and that sort of thing and now they’ve learned so much and grown their network so big that I think the world needs to know, if you go to hint.com you can learn about direct primary care, you can connect with their experts, there’s a community there. What you said about paying for these tests, now, I will tell you there’ll be comments, I’m looking through the comments. There’ll be people who say, “Now, wait a minute. “So you’re telling me I have to pay for insurance “and this membership fee of,” how much is your membership fee?

– $60 a month for adults

– 60 bucks.

– 60 bucks a month, okay. So, for adults. Less for children?

– [Dr. Crall] 50.

– 50 for kids.

– [Dr. Crall] Family max of 150.

– Family max of 150.

– [ Dr. Crall] Very important.

– So if you have a thirty children and you’re Catholic or Mormon, you get a deal basically. So–

– Well I’m not here to talk about my practice, so that’s okay.

– Yeah, yeah, yeah. At that price, people say, “Well now, I have to pay extra “and then you’re telling me but the tests, “I could get cash tests, “but my insurance would cover that, right?” Wrong. Your deductible, if you’re a family, could be as high as $6,500.

– I’m busting at the sims to respond to that.

– [ Dr. Damania] Tell me, tell me.

– One of my favorite things in life to do is talk to a group of really smart people. Usually it’s, well it could be CFO’s, CEOs–

– [Dr. Damania] Could it been Tad?

– I haven’t met Tad, it could be though.

– He’s really smart. Anyway sorry, go on.

– And it’s to ask them the question, what do you think is the number one driver in rising health care costs today? And I love asking smart people that question because they always say the same things, oh well, it’s technology, it’s doctors are afraid of being sued, it’s you know, there’s a lot of reasons that they always give.

– [Dr. Damania] Pharma.

– Pharma, you know. And all the answers they give are correct. But there’s a gentleman by the name of David Goldhill who made an inspiring talk at one of the direct primary care conferences a few years ago and gave an elegant description over an hour about why, the number one driver of health care cost in this country, is simply the fact that we use insurance in ways it was never intended to be used. So it’s abuse of insurance that has led to the cost. So that all these claims that are being generated for predictable, everyday expenses that people could just be paying out of their pocket for, it’s all that administrative cost of all those claims, that is responsible for cost. So, as I said the Affordable Care Act, it got us used to the idea that we’re paying out of our pocket for health care services. So the lightning bulb goes off, what is the health care system look like in the future? It’s getting back to using health insurance the way it was intended to be used, which is only for unpredictable, high-ticket items that would that would break you financially if they occurred and then paying for all of your predictable expenses, out of your pocket. And that’s where direct primary care comes in, ’cause it’s just a low-fixed monthly cost, like a gym membership and then hopefully you’ll have, tax deferred money and HSA accounts or whatever where you can go buy your labs, your x-rays, but you’re just paying for all that out of your pocket. You wouldn’t want that to go through an insurance company because the the insurance costs skyrocket because of all those claims. So we want to be paying for our health care services by ourselves, that’s what keeps the cost down. ‘Cause now x-ray facilities, labs they all have to compete with each other for your healthcare dollar.

– Okay, you and I agree 100%. Here’s what the contrary opinion will be and this is what people will say, “But, but, but, but, but, but “as it is I can’t afford health care, “you’re asking me to take this into my own hands. “But as it is, wait, but it’s insurance should cover that “and the government should pay for insurance for everyone “in terms of Medicare for all “and then we all be covered and we control costs “’cause the government won’t let you do certain procedures.” What do you say to that? Well hopefully, all of the lobbyists for the insurance industry will, you know will be handled in such a way that the government can change the IRS laws, that they can change the way HSA accounts are done. ‘Cause if everybody could have an HSA that has 5000 bucks in it, and family members could share their HSA accounts,

– [Dr. Damania] Yeah, yeah.

– So that each family could be like its own insurance company where you’re helping each other pay for expenses through your HSA accounts. I mean, if the government took everybody who’s on Medicare and Medicaid and gave them all five grand in an HSA, from what I understand, they would save money than rather having to pay all those claims that come through.

– But heaven forbid we have people manage their own care and money. But so okay, okay, okay. This is important.

– [Dr. Crall] Yeah.

– This is not a conservative thing, it’s liberal thing, it’s not a libertarian thing. This is just, plain common sense.

– [ Dr. Crall] It is.

– Right now, alright? There’s a $6000 deductible. Now, what if you could instead, put that $6000 in a health savings account or at some kind, I don’t like health savings account ’cause it has a political tinge to it. I like something like just a savings account. That then grows tax-free and you should be able to use that money to spend on primary care as a membership. So now you have unlimited, all-you-can- treat access to amazing, reconnected, relationship-driven, team-based, technology-enabled care,

– [Dr. Crall] Yes.

– Where the doctor spends time with you, where we reconnect to our love of why we went in this in the first place,

– [Dr. Crall] Correct.

– You love your patients, your patients love you, we can fight like family members and punch each other and yell and scream, but we deeply love each other because we live in the same neighborhood and we care. And no insurance person shows up to say, “These are the boxes you click, “so we can be the middleman.” The patient isn’t your customer, we’re your customer, the insurance company. So here’s how I see it and then you tell me where I’m wrong. Let the government fund those savings accounts for people who are on Medicaid and Medicare. Let them then provide either, let insurance companies that currently exist provide the catastrophic wraparound coverage,

– [Dr. Crall] Their due place.

– Their due place.

– [Dr. Crall] We need them for that.

– Why wouldn’t insurance companies wanna be insurance companies? I don’t think they wanna be in primary care, they just don’t… you know again it’s complicated, because I’ve talked to these companies. And I’ve spoken internally for these companies, where I’ve told them here’s what we did it Turntable Health, we took y’all out of the equation. So how about this, how about you guys actually pay the membership fees, for some of your high-risk patients and watch what happens? Because you’re gonna, all the rest of those downstream costs are gonna drop. Because where does the healing and prevention happen? It’s here.

– [Dr. Crall] Right.

– So now what you’re doing is, you’re actually working with Hint and others to build networks that then directly negotiate with employers to push out all the crap and how’s that been working?

– Ironically just yesterday, I met with a company with 350 employees. And so they are self-funded, you kind of went into that yesterday and explained it a little bit. So that company is paying all their own claims, but they have a major third-party payer that makes it so complex that they’re not allowed to shop for that $250 MRI, they have to pay a, it’s a fifteen hundred dollar MRI that’s discounted to a thousand. But if only they could shop it on their own, they could pay 250. So anyway, this self-funded employer says, “We love the direct primary care model, “we want our employees to be able to select “a direct primary care physician,” and then they switch the type of insurance they have, it’s self-funded but they go to a different payer that unbundles it all. So that they no longer have to follow a specific network, with specific pricing and they can get the best price for meds, they can get the best price for consultants, they can shop everything. So they are in control of all their supply chain costs and all their employees get a personal relationship with a physician that they can see whenever they want as often as they want to, by video, by text, that is Health 3.0 that you’ve been talking about and like you said yesterday, it is happening. This is not some dream that we know we can get to, it’s happening.

– Man I’m gonna weep hearing this because this is what we’ve been trying to work for for all these days and years, right? And the thing is when you say that we’re at a tipping point when this is happening, I can tell you I have never seen it so close. I’m supposed to speak for the Healthcare Administrators Association, HCAA, in like January, February, March something in Vegas. And I saw this and I’m like wait, who are these guys? I got on a phone call with them. They represent the third-party administrators that you talked about, that are creating these plans for self-funded employers. And they told me they wanted me to speak because they believe that the future is this sort of unique, unbundled plans with DPC Direct Primary Care, at the core. This is the organization that represents these payers, these third-party payers. Like if that doesn’t get you excited, the stodgiest people, with the most–

– Yet the future is right around the corner, that’s how close we are.

– But it takes people like you, who are up on the front in 2013, who are running out there taking arrows in their back as pioneers, right? Who are having the sleepless nights and setting it up, so we deeply appreciate that. I know because I went through it. I went from complaining about administrators, to becoming an administrator, in my own clinic. And now I just feel sorry, I feel bad for administrators because their job, it’s a kind of a moral injury itself, you have to serve multiple masters. You wanna serve the patient, you wanna serve your doctors and your staff and then you have to serve the organization and the finances. And in a system where doing good for your patient, means doing poorly financially, that’s a disaster!

– [Dr. Crall] It is.

– But what you’re setting up, and what direct primary care is doing, and again, I’m gonna pitch our sponsor. Companies like Hint, they’re enabling doctors who aren’t necessarily innate entrepreneurs, they’re not accountants, they’re not people who are like really good at like acquiring patients and being salesmen an this kinda thing, they will manage that on the backend with software that will help free you to then do this.

– Exactly.

– You’ve worked with them for a while, has it been good?

– I couldn’t imagine doing direct primary care without Hint. Especially getting into the direct to employer space because it’s the ecosystem that matters. It’s the fact that I have a platform that allows me to communicate with my patients very elegantly and securely and it integrates with Hint. The electronic records that direct primary care docs use are very low-cost. It’s a very low overhead to go into a direct primary care practice. It’s all integrated through Hint.

– Isn’t it low-cost, it’s low-cost ’cause you’re not doing billing.

– [Dr. Crall] Correct.

– You’re not going, “Well, did I document “the level five visit with a 12-point “of systems that I didn’t do? “But I’ve clicked the box that says it’s negative,” right? The current system forces us to become liars, just to get through our day. We click boxes, we ask questions of pregnant women like how’s your prostate, and it’s just dumb. Here’s a great comment Elisa Leilani makes. If you put every car claim through insurance, your premium would skyrocket. Paying for health care makes sense. It’s exactly that. What if McDonald’s was covered by insurance? First of all you go into line and you’d have to eat only be able to get those items that are covered and if it was done the way we do medicine now, it would be some person like a doctor telling you what item you’re gonna have and then running it through the process. The line would be out the door, cost would skyrocket because there’s a space between you and the real cost, that would be shunted to employers, and then to the government and ultimately to who? To the patient. Because the patient is paying higher premiums and all of that. By doing this we can drop costs and actually improve outcomes but more importantly for me in my mind, save our professions.

– Exactly. Yeah, that’s the third piece. It’s like everybody wins when this happens; individuals, families, employers, physicians. For actually getting back to what they went to med school to do, take care of the patient. I mean nothing will save a physician from burnout or opening up a bait-and-tackle shop down in the keys instead of practicing medicine, than transitioning their practice to a direct primary car model. I mean that’s where you rediscover the joy in practicing medicine.

– I’ve almost never heard a doctor who switched to DPC who’s come back and gone, “I really regret that.” They all say I was awakened, I unplugged from the matrix, I rediscovered joy, it’s hard and I think the hardest thing is getting patients into the practice.

– Correct.

– Because the perception is I’m paying extra for this? No, no, no, no, no, no, no. You’re actually gonna save money but the problem is and this was the problem with Turntable, we didn’t have the surrounding infrastructure and ecosystem.

– [Dr. Crall] Yes, exactly.

– Right? So okay, here’s the thing. Turntable, pay us 80 bucks a month. Because we had a big team and we specialized in chronic disease etc, so that was our price point. I think even that might have been a little low for what we did, because our overhead was too high. Come past this but you’re gonna need wraparound insurance because you know, and that insurance ain’t cheap because they don’t carve out primary care.

– [Dr. Crall] Yes, you’re double-paying that.

– You’re double-paying! You’re paying the insurance company to cover you with shh! I almost said the S-word but this is a sponsored show, I’m gonna say shardy. Really shardy primary care. And that you have to click boxes, you see the guy for five minutes that you’re paying for that in your premium.

– [D. Crall] Yes. But the you’re extra paying us. Now what if this, what if you unbundle that, that’s what you said, unbundle the primary care and you now get to choose who your primary care doc is.

– Because there’s no network, you work for whoever you want.

– What does that mean? It means that if you suck, Dr. Crall, that patient’s gonna walk.

– Yeah the people who are critical about DPC, they say, “Well, we like primary care in the 2.0 space, “where we can regulate it and control it. “We don’t want primary care to go back to 1.0.” You don’t have to regulate it because it’s free space, if you don’t do a good job of providing service, your patients will go somewhere else. So yeah.

– Bingo, that’s it.

– Our patients were, you know I’ll tell you so, our biggest source of patients ultimately, because we solved this problem, was Nevada Health Co-op, which was a not-for-profit co-op. They said, we’re a new company, funded with OMA Obamacare loans, we’re gonna experiment. We’re gonna pay you guys, 75 or whatever the per patient per month was and you’re gonna do our primary care Turntable and we’re gonna call it the Turntable plan, And we’re gonna put it on the exchange, and we’re going to provide the wraparound insurance and it’s gonna be a cheaper plan because they are, the patients to pick that plan know that they can only use you as their primary care. So this was a kinda coercive model. But the patient’s knew going in, okay this is what I want. And we saved money for them, we reduced claims, they had great, seamless coverage and they went out of business for reasons unrelated to us. A at that point, these 3,000 patients that were relying on us, we had to find them, doctors in this 1.0, 2.0 mess that is Las Vegas and that was heartbreaking for us. Because we’re like, they were getting this amazing care with government subsidies to help them pay for the insurance and this is the model we were too early. And so what I see, what you guys are doing with Hint, with Hint you can disintermediate insurance entirely!

– [Dr. Crall] Completely like a gym membership.

– Like a gym membership.

– [ Dr. Crall] That’s it.

– And this is the thing like and so, people who can’t afford it will say, “Well, I can’t afford it.” Well that’s great. When you get it right, the government can subsidize your fees. They can fill up your personal savings account and you can then choose your doctor who you’re gonna give that money to, right?

– Right.

– You can even make the choice, I don’t want a doctor and I don’t wanna take care of myself, that’s your choice but you’ll pay the consequences, in terms of your health outcomes.

– And it’s ironic that the actual cost is so low, that we use the monthly gym membership as an analogy but the cost of having your own personal physician is the same roughly on the order of a gym membership, of a grooming fee monthly to have your dog groomed, this average cellphone bill, I mean these are things that people prioritize and now, because the cost of direct primary care is so low they can have their own personal accessible physician for the same cost as all these other things that they currently budget into their monthly expenses. So Kristy Sites asked a question, that I think there’s a lot of confusion, right? Because it’s hard to communicate this easily. Well, how would this work if you get sick on vacation and you had to go to the hospital? So what happens to your patients they go on vacation?

– I formed a network, this is in Tampa Bay, but I formed a network with other physicians so we cover for each other. Today I’m here seeing you, if any of my patients needs to be seen there are two doctors within five miles of my practice that will see them and you don’t have to pay, it’s all agreed, it’s a contractual agreement.

– What if Kristy goes to California, gets an appendicitis. How is that paid for?

– Well, hopefully she has a truly catastrophic insurance plan or a cost-sharing plan, something similar–

– Liberty, one of these, yeah.

– Right exactly, Medi-Share. But we encourage all of our patients to have that for a catastrophic. We just want them to only have insurance that covers catastrophes and do everything else directly.

– So you crash your car into a wall, that’s car insurance.

– [Dr. Crall] Oh, yes.

– You need to prevent the car from leaking oil, that’s what you guys do.

– It’s out of your budget. You plan ahead for it, you know it’s gonna be there, every three months you’re gonna have to do it, you plan it

– Kristy’s confusion was common in our patients at Turntable but what happens if I get really sick? That’s what your insurance is for. What happens if I’m somewhere else and I get sick? Well, we’re gonna call that hospital, you’re gonna call us because we have a relationship, you have my cell phone number.

– [Dr. Crall] Yes, of course.

– You’re gonna call me and go, “I’m in the ER in California “with right lower quadrant pain.” They’re not gonna say, they’re gonna say, “It hurts! My Tumtum.” And you’re gonna say, “Okay, let me talk to your hospitalist. “Hi, I’m her doctor, these are the things “you need to know about her, “she gets very anxious if you put her in confined spaces, ” make sure to pre-medicate her, “also I want you to call me and fax me “that discharge summary the minute you know what’s going on “and she and I are gonna be in cahoots, “so you better communicate with me.” That’s freaking care.

– We are our patients’ advocates, getting through the maze of the healthcare system. So when our patients need services elsewhere, we are their advocates, so we stay involved in the process.

– How’s that different than concierge medicine? People will be like, this is for rich people.

– Thank you for asking. That’s one of my favorite questions. The biggest difference between DPC and concierge is that we all are looking for a way to free ourselves from the administrative burden of insurance, concierge physician, continue to bill insurance.

– [Dr Damania] Yes they do.

– They narrow their panel to two or three hundred and charge an access fee so they can keep the doors open but they still deal with all the burdens of billing insurance. Direct primary care doctors, just get rid of insurance completely and so we can offer fees on the order of $60 a month rather than 1,500 to $2,500 a year. It’s the same personalized service, just a lower cost because we eliminated the cost of billing insurance.

– Concierge for the masses is what I like to consider DPC, it’s like you get this amazing, you get your own doctor who knows you, you get all the time you need with that doctor, and, new ways of communicating. Actually before I ask you about that I wanna read Debbie Danish’s comment because she’s a supporter of the show and a subscriber and also, she has the name Debbie Danish, which is the dopest alliterative name I’ve ever heard in my life She says I’m here and I’m a 3.0 supporter. My guidance practice is sending out letters this month, letting everyone know that they are gonna start practicing the way they want to. Unplug from the matrix, right? Take care of patients. Now, unique ways to communicate with our patients, they’re not paid for by insurance, but in indirect primary care…

– Your patients are paying you to manage their care and everything’s included. So you don’t worry about whether you’re gonna get paid to do this video visit. They’re just paying you to manage their care and that encompasses everything.

– So yesterday John Bender showed up and we didn’t get to show this on the show. He had an app he has a robot, a beam robot in his clinic and he can drive the damn robot from his app and talk to patients when he’s here. So he was there walking through his clinic and his staff was like, ” Hey Zdogg!” And I could see them. That is unique innovative technology, that allows you to have a face-to-face with your patient. Insurance ain’t gonna pay for that. But you don’t even have to think about it because your goal is take care of the dang patient in a way that helps them.

– That’s what I love. I never think about cost, whatsoever. Never enters the equation. If I have a patient comes in and I’m removing a mole, I’m not thinking, gosh, I wish they was back in the day where I could get 300 bucks for removing this mole. I don’t worry about cost, I never think of it and that’s the beauty of DPC. everybody pays every month, whether they come in or not and so that allows the cost to be low per person.

– Yeah, because your sub-setting is a big pool of risk and so that means you could spend more time with your chronic disease patient. you can spend more time, Bender does some suboxone and treats opioid addiction. You can do that if you choose to do that, if that’s an interest of yours.

– And you’re diabetic, they can come in every week and go over their sugars. They can come in every month and go over what they’re doing to lose weight. They’re not paying anything no matter how often they come in so you can manage them.

– Can they just text you and

– of course.

– be like here’s my sugars?

– Oh yes.

– Can they share their Apple watch data with you?

– Absolutely. So when they go into AFib and they get all scared I saw that episode, yeah.

– Man I’m terrified of that. It’s great, it’s great that we’re democratizing health information, it’s bad that we don’t know what to do with it yet. And that gets me to a thing, actually I wanna ask you this, it’s important. What’s to stop you from over ordering tests that you’re not paying for and what’s to stop you from over treating and driving up systems costs?

– Well first of all, we have personal relationships with our patients, we’re not afraid of being sued by our patients, they’re not going to sue us, they know that we are concerned about them. So you’re no longer ordering tests just because you feel like you need to cover yourself, so that’s one thing. Number two, all we care about is what the patient needs. We’re not serving a third-party payer so if they need a test we order it but we’re not gonna order something just because it has to be done. But the the most important answer to that question is, we have the time to figure things out and get to the root causes of problems, without having to just ship them off. So if you come in you you have a headache, I mean I can spend an hour with you and talk about stress, talk about your diet, all the things that are going on. I can formulate a likely diagnosis, prescribe a treatment plan and see you back. Call you the next day, call you next week and lo and behold your headache gets better. MRI saved, you don’t need that MRI. And I don’t need to send you to a specialist if you have heartburn, as long as you get your root cause, you talk about diet, you spend time with the patient and talk to them, you don’t need to send them for specialty visits and tests.

– I’m guessing you also wouldn’t just start people on narcotics to get them out of your office.

– Well no. They might have some depression, which is exaggerating their response to their pain and maybe we need to talk about that–

– Oh heaven forbid! What? No. This is the root of so much of our opioid epidemic, is we’re treating psychic pain. We’re treating trauma, childhood adverse experiences. And we’re not stepping up as doctors because we can’t and you don’t think that causes moral injury? Where you go oh, this guy’s now addicted to the Percocet that I started for the headache that was caused by the fact that this person had been abused all their childhood and now is getting a trigger and it’s causing this real symptom of real pain, and then they’re going to the ER and treated like a criminal when they’re addicted or dependent on the Percocet. And I guess that’s Jason Robert Beck’s question, he’s a supporter as well the show. Speaking of cost, the DPC model allows for excellent primary care. Any thoughts on making the model work to include preventive services like nutrition, movement, social determinants?

– Well it automatically includes that. When we have a new patient come in we’re asking about all those health-related factors, the social determinants, that’s part of getting to know the patient. It automatically includes that but I think what you’re getting at is like with Dr. Bender’s case I think he mentioned, they had a whole team where they had a dietitian. Most direct primary care practices don’t include that entire team because the direct primary care doc is just doing that. I mean if you have an hour visit, I mean what are you gonna talk about for an hour? You’re getting into all those social aspects.

– That spot-on. You know our service, our health coaches were really big on the social determinants. here would go to people’s houses, they’d go running with them, they would look through their shopping lists to see what they’re buying and go, “You know what? “You cannot eat Campbell Soup “if you have congestive heart failure. “It has a butt ton of sodium.” But patients don’t know this. They’re thinking of salt? But I’m not adding salt to my stuff. Mike Lubin from Hint Health said, “Hey everyone, exciting news, “Hint Health is launching a low-cost, high-value, “wraparound insurance plans that our DPC doctors can offer “in combination with their DPC memberships, “that patients can buy directly from their DPC doctors. “No more need for expensive insurance “that conflicts with direct primary care, stay tuned.” That’s exciting.

– Yeah, that’s coming right off of the cost-sharing model. There’s these four cost-sharing plans out there but there’s the again, new technology, new companies emerging to cater to this model where, okay, now you can have a true wraparound insurance product.

– [Dr. Damania] Amazing!

– It’s low-cost because it only covers catastrophe. Supporter Susan Grant says, “Do you treat families and children?” We talked about that.

– Absolutely, birth to death.

– [Dr. Damania] Birth to death.

– Right.

– So cradle to grave.

– And the vaccines are the only challenge there because in a direct primary care practice, I can’t really order both vaccines and administer them and include them in the monthly membership. So, I do encourage my patients to go to the health department for their vaccines and they’re the health department is a great place to get vaccines.

– I’m so glad you brought that up because when we were running Turntable, here I am advocating vaccines everywhere I go, we can’t bill for vaccines, which means we don’t get reimbursed for them. So like you said, if you order a but ton of them and they go bad, you’re kinda outta luck. So we would send people to the health department but then for flu shots you know what we did? We just bought a but ton of flu shots and we gave them out at a loss to us because we believed in that. And if there was a kid who needed a particular vaccine, we were like, you know what? Let’s just order it and suck it up because we care about our damn patients. Now, we shouldn’t have to do that.

– The local pharmacies have pretty much taken that over anyway,

– [Dr. Damania] Yeah, it’s true.

– Most of my patients can get a flu shot at a local pharmacy so that’s not a problem–

– Problem was the kids. So the local pharmacies weren’t doing kids and so we ended up doing that for them. And again, because we’re passionate about vaccines, we know what works in medicine.

– [Dr. Crall] Correct.

– There’s a lot that doesn’t work.

– And I digress but the birth to death thing, I do take care of kids from birth to death but it seems that many parents will have their child see a pediatrician until they’re two, so they can get the bulk of the vaccines kind of covered that way and so I do tend to see more children after age two.

– We did that as well. Because the infants, because there’s so many vaccinations, it’s just easier to have the pediatrician in there. That’s fee for service standard features, now here’s the thing. What if that pediatrician were DPC?

– [Dr. Crall] It would work perfectly.

– It would work perfectly.

– Then we would all sorta bulk purchase the vaccines–

– [Dr. Damania] Bulk purchase the vaccines.

– So we could all offer them, imagine.

– But then Eric, how will the anti-vacciners accuses of shilling vaccines for money? If we make no money on the vaccines? What will happen to them Eric? Will they cry themselves to sleep because they can attack us anymore?

– I prefer not to think about that.

– you really are burnout immune. If you think about that for a minute you’ll burn.

– Speaking of burnout I did wanna come back to the physician burnout piece because I don’t know that’s the fourth aim or I think we might even be up to the fifth aim but it doesn’t matter, direct primary care takes care of them all. It’s like that physician burnout piece is critical and I find that even among the docs who were doing direct primary care, if you ask them they’ll tell you, oh yeah, it’s great, I love it. But deep down, they’re just as stressed about how they’re gonna stay open and is this gonna work.

– [Dr. Damania] Yeah, yeah, we were, yeah.

– And a lot of them feel just as stressed as they did when they were fee-for-service docs but in a different way. Again, that’s where the whole network piece comes together. Because as these networks form, doctors are gonna be able to confidently go into direct primary care at a low overhead and not be afraid of having to stay on Medicare so they can work in ERs to pay the bills.

– [Dr. Damania] Dude.

– So everybody wins with this, everybody.

– here’s the thing, this is why I agreed again, I don’t take sponsorships lightly anymore and I start hurling feces at sponsors I don’t like. I almost did it recently. Um, Hint and others like yourself, are trying to make it easier, safer, more comfortable and more stress-free for people to spin up a DPC practice. I wish, now Hint was there when we did our thing, we would not have lasted a year without Hint. We went three when our insurance company went out of business but even the insurance company, we were using Hint to do the membership model billing for them. Having those pieces takes that stuff off our plate because doctors are risk-averse, they like to stress about their patients, they don’t like to stress about everything else. So that’s what I think I’m so glad you mentioned this because for me that’s what was transformative about what people like Hint are doing and others in the DPC space that are building these networks and are trying to do that, Dave Chase at Rosetta and others.

– [Dr. Crall] Right.

– We’re all together in this ship. We believe in it profoundly, it’s almost like a religious cause for us because we know it can save medicine.

– [Dr. Crall] We know, I know.

– Can save it.

– And as I listened to Dr. Bender yesterday, I was struck too by the 3% of docs in the country doing direct primary care, that shocked to me. I guess because I’m in this space, I feel like it’s actually on the steep part of the growth curve like you know.

– [Dr. Damania] I think you’re right.

– So, I lost my train of thought there.

– We were talking about kind of taking the pain and the stress off and I’m having to be an exponential growth. The comments here are interesting, they really, people are really feeling this idea that we could save medicine but here’s a question for you. How about our specialists, our surgeons, our you know dermatologists, people who are also struggling. It’s not like just this hurt is a primary care thing, it’s across the board.

– [Dr. Crall] Yeah.

– What do you think about this?

– They are not able to do a direct approach because they have higher cost services they’re providing but they are happy to provide cash pricing at a rate that they consider fair and reasonable for their service, not to have to send that claim to the insurance company. In a community where direct primary care doctors practice, we reach out to a specialists, you let them know what we’re doing, we want to build a network of specialists for our cash pay patients. What is the lowest amount that you consider fair and reasonable that you will accept from our patients? And they go and they either use their insurance or if they do have only truly catastrophic, they just pay cash fees. The specialists are very happy to take cash fees for the same reason we’re happy to not bill insurance.

– Right, it’s less administrative overhead, they know they’re gonna get paid on time, XY and Z.

– And in the model where this all comes direct to employer, the employers are gonna be paying the specialist directly.

– To me, employer mediated health care like this is the is the answer in the DPC space because you know, you know, the employer is gonna to love the fact that you’re taking care of their patients, their patients feel they’re patients. Their employees, their teammates, get amazing care, and then if they have to go to a specialist the employer pays for it without question, because they trust you to be the shepherd of that care. You’re gonna pick, we used to have something we called our Good Guys Network. It was a specialist that didn’t suck. And in a town like Las Vegas, that’s a struggle because–

– It’s a list I wanna be on.

– Right? I would like, as a hospitalist I’d like to be on the list that other DPC docs choose to take care of their patients in the hospital. Do you round in the hospital at all or do you hand it off?

– I don’t, I stopped doing that years ago, even before I went into direct primary care because of the hospitalist movement. I mean back in 03, 04 it got to the point where our value was recognized as being mostly in the office seeing our patients, and the hospital’s really wanted the hospitalists that are there 24/7 taking care, so you know.

– Now the downside of that, as a hospitalist I’ll say this, the reason we were great hospitalists and Imma toot my own horn and my organization, Palo Alto Medical Foundation, is we were all on the same team with the primary care docs. So you’re a PCP I’m a hospitalist, I would go spend a half day in clinic hanging out with you, they made us do that. Just so we knew each other.

– [Dr. Crall] Wow.

– And we hated it as hospitals because we’re like, I don’t wanna do clinic. But we would go, we knew everybody. So when J. Schlumberger admits a patient, calls me, I’m like, I’m gonna take real good care of him J. ’cause I know what you like and I know you care about your patients. And that relationship transcended the fact that now there’s a different doctor in the hospital. So when that patient came to the ER and I was coming down to admit, I’d say hey I’m dr. Damania, I work with J. Schlumberger, he and I are buddies, were in the same organization, I represent him. My job is to keep you safe and sound through your hospitalization, take good care of you and to communicate with him. Hope that’s okay. Hand them the card that has the same name of the organization. Imagine you’re in a DPC network and you have hospitalists in that network.

– [Dr. Crall] I know.

– Transform medicine.

– It is transformative. And I did complete my earlier thought ’cause when you mentioned Dave Chase and the Health Rosetta, the development of this employer space is so critical ’cause without engaging employers you’re gonna have a lot of individual direct primary care docs around the country opening up and trying to be viable. And it won’t really become an expansive movement, it’ll be kind of an undercurrent and it’ll take off but the way that it becomes the way of giving healthcare to the country is through the engagement of employers. And what Dave Chase has done at Health Rosetta, a critical piece of this. Because it’s the insurance brokers, and I recently understand that term as derogatory, the health benefits advisors, that put these plans together for companies. They are heavily incentivized to keep as many employers as possible under the old system ’cause it’s so complex and the costs are fixed and all their profits are built in to the old system. So these brokers don’t want to help us–

– [Dr. Damania] I’ve noticed that.

– Identify employers to convert them to the new strategy. So Dave Chase in the Health Rosetta, they’re actually training brokers, to be certified, to put together benefits packages like this, where you have direct primary care at the base and then you have a TPA or the stop-loss over over top of it like you mentioned earlier to pair it all together so every company can control their costs and they can give a benefit to their employees. And that’s how this becomes health 3.0.

– [Dr. Damania] Health 3.0.

– Through the employers.

– Alright, I think this, oh, go ahead, go ahead.

– but it is happening, that’s my point. It’s like that’s how it’s gonna really take off but it’s already happening.

– Every single hater on this show, okay? I don’t see it in the comments but I’ve heard it before, you talk, and talk, and talk about Health 3.0. It’s never gonna happen, your deluded. My wife asked me if I was deluded early on in this. Do you think you could be delusional? Because this thing sounds like it’s never gonna happen and it’s happening. It’s not just happening, it’s snowballing.

– ‘Cause from the ground up. We’re not waiting for them to figure it out at the top

– [Dr. Damania] No, no, no, no

– We’re fixing it at the bottom. You wait for them we’re done. We’re gonna have a single-payer plan that’s gonna pay for everything that’s broken, it’s gonna bankrupt the country and it’s gonna destroy medicine.

– Well you know the desktop computer, that was never gonna work, that was never gonna take off. It’s like oh, you can’t have desktop computers–

– People said the iPhone was gonna fail, that was total garbage. Too expensive, too whatever. Dude, this is the future of Medicine —

– It’s disruptive innovation and it’s finest–

– End, stop, disruptive innovation, fight the freaking power. It takes us, us meaning everyone in health care on the front lines to lead, working with our leadership administrators. You gotta incorporate them, gotta subvert the legacy players. Otherwise you’re just gonna go down but we’re gonna win and we’re gonna win big and it’s gonna transform care not just for us but for our kids, for our colleagues, for future kids who are like should I go to med school? I tell them hell yeah! Cause when you finish, you’re gonna be working in a system that is so true to the reasons you went in that you won’t even believe it. And don’t listen to anybody who says don’t go into medicine because we know, on the front edge of this change, that it’s going to happen.

– It is happening, it is gonna happen and there’s gonna be a graveyard of benefits advisors who they stayed true to the old system too long and then it was too late. I mean we have status quo benefits and we have next-generation benefits. And this next generation way of doing all this, it is 3.0. And I feel like I need to say, I’m late in the game to this, I’m just a guy down in Tampa who’s doing this in Tampa Bay. I gotta give credit, I don’t wanna stand here like I’m some innovator myself. I’ve gotta give credit to the guys like Clint Flanagan out at Nextera.

– Clint’s an awesome guy, yeah.

– At AORA Health and now Joel Bessemer at Strata. I mean these are guys that have been doing it. They are the true innovators. I’m thankful to be in a position where I can take this and with it in my small community but that’s what we need. We need groups of doctors in every major metropolitan area in the country, just setting up a little local network and then we all become affiliates of each other. So if you have a company with employees in Tampa and Boulder no problem, there’s already a network in Boulder. Dr. Flanagan and his team will take care of your employees in Boulder. And so that’s where–

– And then when everything, when all the costs come under control, then we can have true catastrophic Medicare for all. Catastrophic Medicare for all and we’re done. We’re not just Europe, we’re freaking better than Europe by an order of magnitude because American innovation, capitalism, entrepreneurship and freedom, combined with the Galitarian vision of everybody gets care, we don’t leave anyone behind, and we can afford it.

– That will be healthcare the way it used to be.

– But better.

– But better. With all the 2.0 components, yeah.

– Exactly. It’s the merging, it’s the transcendent. Take best of one, best of two, transcend it you get three and I think that’s a great way to end this show. Man, Eric Crall, what a freaking pleasure. You got me all fired.

– [Dr. Crall] So much fun, I got goose bumps.

– Um, me too. And that only happens when I’m about to have diarrhea. So that means that if I had a direct primary care doc, I would get that LOMOTIL right now, which I would grind up and snort, because it is a partial opioid agonist. On that note, I wanna thank our

– [Dr. Crall] Can’t top that. I wanna thank our Hint, seriously. They and–

– [Dr .Crall] Me too.

– Aren’t they tremendous?

– [[Dr. Crall] Yes. And I don’t say this because I’m shilling for them, because it wasn’t in any contract that I had to say anything about them in this episode. I am saying it because I believe it. That I think companies like that that are willing to take a risk, how risky is it to bet your entire company, on a movement that is only starting? That is the riskiest thing you can do and yet not only have they done it, they outlasted us as Turntable, we started at the same time. They are crushing it and they’re gonna catalyze this movement so I wanna thank them. Go to hint.com if you wanna learn about DPC, learn from their specialist, it’s a great consortium of thought leadership, actual tools and you don’t have to pay anything to do it. So on that note I wanna thank the Z pack. Please hit like, hit share because we gotta get Dr. Crall’s vision out there. And subscribe if you love the work we do because that will keep us sponsor free, except for sponsors we like and we out. Thank you Dr. Crall.

– Thank you.