Maryal Concepcion, MD, FAAFP 00:00:00 Direct primary care, and a typical day in my practice is literally what I envisioned primary care to be when I went to medical school.

Austin Littrell 00:00:16 Welcome to Off the Chart: A Business of Medicine podcast, featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. I'm your host, Austin Littrell. This episode features a conversation between Medical Economics editorial director Chris Mazzolini and Maryal Concepcion, the owner and CEO of Big Trees, MD. Dr. Concepcion joins the show to talk direct primary care, sharing the story of her own transition from traditional fee-for-service medicine to starting her own direct primary care practice.

Chris Mazzolini 00:00:55 Dr. Maryal Concepcion, thanks so much for joining me today.

Maryal Concepcion, MD, FAAFP 00:00:58 Thank you so much for having me, having me, Chris.

Chris Mazzolini 00:01:01 Let's start off by discussing what exactly direct primary care is and how it differs from traditional fee for service medicine.

Maryal Concepcion, MD, FAAFP 00:01:10 So I really appreciate this question because recently I gave a talk to a bunch of medical students and residents who were interested in DVC, and I definitely was, you know, it was called out appropriately that I was like, but what is DTC? And so I will absolutely start there and absolutely be happy to distinguish it from fee for service insurance based medicine, because that is it.

Maryal Concepcion, MD, FAAFP 00:01:34 Deep-Sea. At the heart of everything I do is what has saved my medical career. And so direct primary care is if you think about our grandparents generation medicine, how they access care is they called their local doctor who they knew and their doctor was able to help them. The doctor was usually of the town, of the community, lived with the, lived with the people themselves and was able to do lots of different things. Deliver babies, you know, take care of cuts, do sutures, take care of colds, take care of lots of things. Because. The doctor not only knew the people that they were taking care of lived with them. So. Felt their financial, you know, struggles, economic struggles, access to other services. in my case, target like. Targets an hour and a half away. So I mentioned that because the doctor understands being a local. Part of the community, what is going on in their community and how best to address it. So you take this idea of a local doctor who is able to take care of their community and the health of.

Maryal Concepcion, MD, FAAFP 00:02:42 Their community and generationally the health of the community. And fast forward that into 2024. Where you have the ability to talk to that doctor not only in person, just like old fashioned days. That doctor can go to your house, but also you have the ability to text that doctor or do a zoom call with that doctor or talk to that person. If you're overseas and your doctor is logging in with you on a connection where you're not even in the same country. So that is how I would describe DPC or direct primary care. and that's what I will always strive to, to include in my talks in the future, because it absolutely is important to clarify what it is. Now, the second portion of your question, in terms of how does it differ when you have this picture of what direct primary care is and you literally see that it is a it is a relationship between between the doctor and the patient. It's very easy to understand also from the olden days, like how was the financial relationship between those two managed? And that was in whatever chicken's money, whatever, you know, was accepted.

Maryal Concepcion, MD, FAAFP 00:03:53 And so in 2024 we have stripe, we have cash, we have checks. We have lots of ways. But patients directly pay their doctor. So some people say like a Netflix or gym membership subscription. And that is where the the distinction is very much made because in concierge medicine and in fee for service, typical traditional insurance based medicine, you have doctor wishes for something to happen to patient. But somebody comes in and says, we do not approve that. The eye of that company says, we do not approve that. And there is someone coming in between the doctor and the patients relationships that we get rid of.

Chris Mazzolini 00:04:41 So let's talk a little bit about, you know, the challenges in traditional medicine. We could probably do a podcast for, you know, for days on that topic. But I guess to hone it in, can you describe a bit what your experience was like in the traditional fee for surface medicine. And what what that was like for you?

Maryal Concepcion, MD, FAAFP 00:05:02 Absolutely. So I graduated Creighton Medical School in 2011, and I graduated residency.

Maryal Concepcion, MD, FAAFP 00:05:09 family medicine residency in Modesto, California in 2015. I had a little bit of a gap because my father had a stroke, and I took time off to take care of him. But when I look at my journey in from graduating medical school to graduating residency, and then the one month shy of six years that I spent in fee for service as an attending, I really look at it as here is a way of doing health care, where medical students who are very much bright eyed and bushy tailed, are going into I really want to do my best at urology, my best at family medicine, my best at whatever. And the first year of residency is very much okay. You're learning. We get it. We'll go slow. It's okay. And while you're at it, make sure that you learn these 99213992 and fours. Don't ask why we do the coding this way, but this is how we do it. And then you get so involved. And this is the way that you do health care in your usually corporate practice of medicine clinic setting that you don't necessarily think about what what am I doing? Like how come I can't control the number of minutes that I have per patient? Why am I getting triple booked? How come I'm not being asked if, you know, I would like to do the procedure rather than refer that person out to a specialist when I have the skills to do that.

Maryal Concepcion, MD, FAAFP 00:06:39 And then as you keep going on in residency, you're just pummeled with you have to see this many patients now because you're a second year, this many patients because you're a third year. You have to do it this way because you're told to do it this way. And then when you become an attending one, we call it the golden handcuffs. The idea of here you go, here's a sign on bonus. Here's the ability to just get paid a salary. We'll pay you that for three years, and then we'll start negotiating. But you don't have to think about what comes after negotiation. You just need to focus on you get to do what you want to do here. And then it's you know, overall it's like the lobster being put into cold water and the pot slowly boils. So my journey as an attending in fee for service when I started was was very much what I wanted. Just like the, you know, generic journey that I'm explaining in residency. I was very, very, I was very lucky to be part of a program that taught me how to do family medicine.

Maryal Concepcion, MD, FAAFP 00:07:44 Well, how to be a good doctor in terms of, you know, if a person has had a miscarriage on labor and delivery, when everything is going crazy to stop and say, hey, how are you doing? I had that modeled, and so it was very perfect for me to be able to go into a rural community where I could do those same things. When I continued in fee for service, I was with a $30,000 sign on bonus. I was, you know, we don't need to worry about how many patients you see a day. You'll just get a salary. here's a 401 k, here's a, in health insurance. And then what happened to myself during those months shy of six years that I was in fee for service, was I was noticing that I was not being able to do the things I wanted to do because I had more patients scheduled. I couldn't do the laceration repair. I'm sorry I can't get you in because I'm already booked or double booked or triple booked. You'll have to go to the urgent care.

Maryal Concepcion, MD, FAAFP 00:08:47 You'll have to go to the E.R.. Oh, doc, I haven't seen you in six months. So much has happened in six months. But I couldn't get in to see you, was what I heard too frequently. We reached hours. And when I say we, I need to clarify. My husband is also a family medicine physician trained in rural Nebraska, just like myself. Went to the same residency as myself. He and I did a job share so that we only worked half time because we wanted to plan to have children. So we were perfectly positioned for the pandemic to hit when one of us needed to be at home with our kids when we had them. but going into the three year mark of being employed, that was when for us, we experienced the you're no longer going to be on salary, we're going to be on our Vas going forward. We tried to negotiate our rates, but after that it was a very abrupt. Now we're done negotiating. We're not going to negotiate anymore.

Maryal Concepcion, MD, FAAFP 00:09:46 The contract that you will sign is that if you work for another company like Teladoc or Zoc doc. And you make money. We're going to own that exclusivity, the contract said. If you wish to practice an Arnold. Fantastic. Arnold, California is where I am now. But if we need you in LA, because there's a something pandemic that happens and we need you to practice there to see patients of ours there, we have the ability to move you. The non-compete clause, that is, unless you're with Kaiser, not enforceable in California, thank goodness. And the evergreen clause. Your rates will never be renegotiated. Just insult after insult. And it was. If you do not sign this by October 31st, you will be let go. And layering on top of that picture. A female doctor reading that at 28 weeks pregnant, worried about I'm going to lose my ability to access. My doctor and I live an hour and a half from the nearest NICU. I was terrified. I was absolutely terrified.

Maryal Concepcion, MD, FAAFP 00:10:47 And I said, I don't even know what to do with these feelings. It's. It's righteous rage with panic and anxiety and complete desperation as to like, this is not right. How do I make this? How do I fix this problem? Nobody ever told me in medical school that this would be an option, that of like experiencing. This is an option you choose when going into fee for service employed by a corporation or private equity. And I felt so many feelings stressing myself and my baby out. And that's when the podcast that is, you know, ranking in the top 60 on the US medicine podcast chart was created on the bathroom floor at 245 in the morning. I created a podcast, a domain. Have I ever podcast before? No, not before this date, but I the the sharing of stories continues to be a way for me to heal, but also for me to put stuff out there that helps other people's other, other doctors heal. and it all of that is rooted in because I had this experience in fee for service, because I had no autonomy in fee for service to be able to say, like, I'd love to learn.

Maryal Concepcion, MD, FAAFP 00:12:01 Point of care ultrasound. You have $5,000 earmarked for this clinic to do you know, things for like doctors to learn other skills, tools to be brought into the clinic to serve the community better. And we're a rural community where I live. My husband and I continue to be the only full scope family physicians in the entire community. So if you're pregnant, you can see us, or you can go to the next county over if they accept your Medi-Cal. And it's just devastating that in a typical world of fee for service medicine, if we had only had the option of you sign our contract or you will be fired and we had left, this community would no longer have any access to a full scope family medicine physician. And because of direct primary care, we were able to stay in our community, and our patients who knew us absolutely were invested in the idea of, I can't lose my doctor and not I can't lose what my insurance covers.

Chris Mazzolini 00:13:00 Can you tell me a bit about your practice? So like just describe for the listener how your practice works.

Chris Mazzolini 00:13:07 we I feel like, you know, most of our listeners probably are trapped in the fee for service medicine. So, like, what is this other way? How what is it? What does a day look like for you in a direct primary care practice?

Maryal Concepcion, MD, FAAFP 00:13:18 Yeah, absolutely. So a direct primary care practice, given that, you know, when I say that it is truly primary care, that's that's literally what it is. It's it's also taking a step back to say, I need this time for this patient, for this problem that they're experiencing right now. So if that is we're here to talk about, you know, the the cholesterol labs that came back. But I also know that your 64 year old son just died. So I'm gonna create a two hour appointment apartment block and whatever time we need in that two hours, we're going to talk about that. So direct primary care is literally the relationship based medicine. And that's what drives even our scheduling. So in a typical day, I will do a majority of my care virtually because I don't need to generate visits that are nonsensical visits for people to come in because I need their codes.

Maryal Concepcion, MD, FAAFP 00:14:08 I joke that, you know, and I, in the medical economics publication that you guys had published, I said, it's like it's not the game of how many tickets a chuck-e-cheese can I get in a day any longer? It is about what does my patient need at the time that I'm in front of them. And that can be in front of them. Be a portal message via zoom. Visit via whatever we need to get them care. But we do not have to justify what we're doing by codes. And so it's very easy to go back to the like. I don't know what the code for whatever diagnosis is anymore. I have to google that because I'm just taking care of you and okay, you have hypertension, I get that. I don't know what the code is, but I know how to treat hypertension and I'm free to treat hypertension not only in a way that allows me to spend time with the patient, but I'm also able to say like, you know what? That's very frustrating that cholesterol medicine wise, you have to pay $30 a month with your insurance plan out of your pocket for that medicine.

Maryal Concepcion, MD, FAAFP 00:15:04 Or what if we did $27 and you can get 2.75 years of that same medicine? Which one would you choose? And, you know, it's you could get that mammogram, but they won't approve a 3D mammogram. They'll only approve a 2D. And I'm sorry to say, if you're if your family has breast cancer, the insurance company doesn't care. But we can for $200, order you the exact mammogram that you want. And if there is need for a breast surgeon, you know we can. I have the time to call that breast surgeon's office up to go there. Like I went to a post-acute rehab facility and they were like, you're you're a doctor or a doctor. You're what, like you, doctors don't come and visit their patients. But. But we can because we get just paid to be. Doctors and doctors do a lot of things. My father was a social worker. Most of what we do is social work. Most of what we do encompasses mental health. You cannot do that in an eight minute visit when you have four people in the waiting room who have been waiting an hour and a half and are very upset when they see you, it's very uncomfortable.

Maryal Concepcion, MD, FAAFP 00:16:08 Direct primary care and a typical day in my practice is literally what I envisioned primary care to be when I went to medical school.

Keith Reynolds 00:16:17 Oh, you say you're a practice leader or administrator? We've got just the thing. Our sister site, Physicians practice your one stop shop for all the expert tips and tricks that will get your practice really humming again. That's physicians practice.

Chris Mazzolini 00:16:34 But when you were setting up your practice, what are some of the things that you had to do? You know, a lot like you said, you know, doctors go from residency and into their careers and they sort of, you know, just kind of. End up whether it's a group practice or, or a private practice or a hospital, whatever it is. And they sort of just kind of get on this track, but like to, to go into a to create a DPT practice, you actually have to sort of like start it, you know, from scratch in a way. So, you know, I'm thinking about things like marketing, you know, communicating with your patients about how you're different from traditional.

Chris Mazzolini 00:17:09 So, you know, staffing, you know, what can you talk a little bit about, like what you had to do to sort of set it up?

Maryal Concepcion, MD, FAAFP 00:17:16 Absolutely. And I will say there's enough people in the direct primary care ecosystem, physicians. Absolutely. But also SaaS partners and health brokers that are so upset with the system because at the end of the day, we are all patients. And these people together have come over time to say, let's fix healthcare. We're not going to wait around for anyone else to do it. We literally have the the desire to be part of this change to health care, where everyday Americans can get concierge level care for an affordable rate, and something that may or may not be covered by employers to the table. And so when you have so many people working together, yes, you can create a VPC like I did from the ground up. I love like if I, you know, if when one day when I grow up and if medicine doesn't work out, I will go into marketing.

Maryal Concepcion, MD, FAAFP 00:18:07 That's what I joke about because I love graphic design. I love, you know, communication with people, I love connecting. Everyone's not like that, I get it. But we are at a time in the direct primary care movement that people can join on to DCS people can do a virtual option extension of a DP from where they are in residency. you know, there's so many ways to dice and slice the way you do DP that we have this saying, if you've seen one TPC, you've seen one TPC and we're all, you know, board certified regulated doctors. So we're not practicing like far out there medicine. This is like literally primary care Hair without somebody butting in and saying, we don't approve. You know, the. Whatever it is to get your patient access to simple care. when I talk about the other people in the ecosystem, there are people who are, talking with employers who might have multinational, multi-state, employee presence, and they can work with local direct primary care doctors to say, hey, I have five people in Oklahoma, or I have two people in Florida.

Maryal Concepcion, MD, FAAFP 00:19:10 Deep-Sea doctor, could you take care of these people? as a as a part of our health care plan for our company. And when you're delivering affordable access to your employees. Clearly. I mean, it's not it's not a, you know, pulling straws when we're saying that you have healthier employees, you have more, you have better productivity. You have a belief that the company is also caring or not a belief. You, you, the company is able to show rather that they care about their They're their employees, that they want their employees to be healthy because everyone makes a healthy company. there are people who are working on just doing the insurance parts to that to make sure that this is acceptable in different states and whatnot. But direct primary care is not any longer a thing where if you want to do DPC, you have to start it from the ground up. Most people do these days because I think most people are so traumatized by the experience and fee for service that they are. So there's so much fire and so much passion to do better.

Maryal Concepcion, MD, FAAFP 00:20:12 And they're like, don't have an MBA. Don't care.

Chris Mazzolini 00:20:15 So how do you talk to your patients about this? Because obviously, like, you know, it's a strong sales pitch, but you have to sort of like most patients are so used to, you know, your insurance and like, well, patients don't know about the coding aspect of it for the most part. You know, they know like that there's these sort of middlemen that are always involved with health care with, you know, whether it's, oh, they need to get approval for before my MRI, you know, and got to show you my insurance card and all that stuff. So how do you sort of like, what's your what's your pitch? You're like elevator pitch. How do you how do you describe it to a patient about the benefits and, the difference between what you do and, you know, sort of the traditional US healthcare way of doing it.

Maryal Concepcion, MD, FAAFP 00:20:59 Sadly, our patients are more and more, especially in our community, very familiar with the the codes that did not cover their services or, you know, the there is something that is turned into the insurance company that says we don't cover this.

Maryal Concepcion, MD, FAAFP 00:21:15 And, when we think about patients coming to our practice as people who have seen us before and are ready to see us again under our new model or patients who have never seen us. One of the biggest things that we have learned to start with as our elevator pitch is, how can I help you today? Like what brings you here? Because everyone's experience of the of the healthcare system is different, and that's what we are. Able to point out from the very first words out of our mouth. This is a relationship based practice. This isn't what insurance do you have? That is the number one question that you are asked if you show up in the air. What's the face sheet? What insurance does that have? That patient cannot be seen here transferred to another hospital. What patient? What insurance does that have? Does that patient have. Sorry you have. Kaiser can't be seen here. You have an HMO? United? Nope. We don't take it for us. It's what brings you here.

Maryal Concepcion, MD, FAAFP 00:22:06 How can we help you? And so the the conversation isn't even, like templated in terms of. Yes. You know, we say like we are we don't accept insurance for our primary care services. We say those types of templated things. But in terms of the main meat of our conversation, even in meet and greets, it's very focused on hearing the patient and what they're looking for to say. This is a great match for that. This is what we can do for you as a patient at our practice as a member of Big Trees. MD. If you are hearing a patient say, you know, lots of I will only see insurance. I will only see insurance. We we talk about. Tell me more like you. I hear you saying you you need to have insurance. Where is that? Where is that statement coming from? You know, the the open ended questions to figure out what is a person really wanting in the healthcare system, but also what they're not getting from the health care system.

Chris Mazzolini 00:23:03 So the last question I wanted to ask you is, you know, for all the listeners and our readers at Medical Economics who are, you know, still in the maze of fee for service medicine. And they, you know, they're listening to this or they're reading about DC and they want to know, okay, what can I do to take that first step towards, you know, transitioning my, my career into this model? where where should they go? Where can they get more information? You know, what what advice do you have for them to kind of take that first step?

Maryal Concepcion, MD, FAAFP 00:23:33 That's a great question and a question that so many more people are asking every single day. I would definitely say my DPC story is a fantastic resource because. And yes, I'm definitely biased in that. But what I've done is created a resource where you get a resource page where you can do things like there's a free checklist that says, exactly like, these are the things you just check off, just like any grocery list to do about DPC.

Maryal Concepcion, MD, FAAFP 00:23:59 there is the VPC directory, the VPC directory where people it's like an Angie's List. So if you're getting off the ground and you're like, I need somebody to build my website. Spend your money wisely and find someone who has worked with DPC doctors in particular, so that your money goes towards someone who understands DPC. From day one, we have the DPC frontier. That is an excellent website, especially for people to resource to excuse me, to reference if they're looking for what are the legal updates on my state in particular. And then you have the DPC Alliance. That's an organisation Organization for people to join in for, you know, support. When it comes to every part of their Deep-Sea journey. And you have the Deep-Sea coalition DP care that is the PAC to support the the, the political work on Capitol Hill to help get bills passed. right now, the HSA bill, the Primary Care Improvement Act is another, bill on Capitol Hill that is going to fix the tax code such that an employer can use their they can fund an employee's HSA, and those HSA dollars can be used to pay their Deep-Sea doctor.

Maryal Concepcion, MD, FAAFP 00:25:13 so there's many ways that people can get involved. But I think that zooming out, the most important thing is look for a Deep-Sea doctor near you and say, hey, I'm done. I can't do this anymore for whatever reason. Like, I just had a baby. I need to spend time with them. I can't do it anymore because I'm exhausted. I'm worried about doing bad medicine because I have too many people to take care of. I literally have no time for myself and I just got diagnosed with. You know, I just had an MRI happen and I can't do that anymore for my own health, whatever it is. Talk to the Deep-Sea doctor near you because Deep-Sea is in all 50 states. It is. There's Deep-Sea law in 34 states. It is incredible the support that one gets from this community because they're able to say, hey, I need help. I need to do something else. And there's lots of people out there. It's like a trust fall. It's like, we'll get you.

Maryal Concepcion, MD, FAAFP 00:26:07 No worries. Like we got you. Most of us don't have an MBA, and most of us are also killing it. So it's a great community to just start by asking for help in a mom group on Facebook. Call your local doctor, whatever it is. But literally it is a local model of care and the help can start locally and then go out from there.

Chris Mazzolini 00:26:27 Dr. Maryal Concepcion, thanks so much for joining me today on the show and sharing your story. I really appreciate it.

Maryal Concepcion, MD, FAAFP 00:26:33 It was an honor. Thank you so much for having me.

Austin Littrell 00:26:40 Again, that was Medical Economics editorial director Chris Mazzolini and Maryal Concepcion, the owner and CEO of Big Trees, M.D. My name is Austin Littrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you please subscribe on Apple Podcasts or Spotify so you don't miss the next episode. Also, if you'd like the best stories that Medical Economics and Physicians Practice publish delivered straight to your email, six days of the week,

Austin Littrell 00:27:06 Subscribe to our newsletter at medicaleconomics.com and physicianspractice.com. Off the Chart: A Business of Medicine Podcast is executive produced by Chris Mazzolini and produced by Keith Reynolds and Austin Littrell. Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family.

Speaker 5 00:27:25 Thank you.