Lee 00:00:14 Today on physicians taking back Medicine Direct Primary Care, or DPC. Is it the answer for the rural health care shortage? Recently, the Trump administration passed a law allowing patients to use their health savings accounts, or HSAs, to fund direct primary care memberships. They also floated a pilot program involving DPC and Medicaid patients. Today, we're going to hear from DPC pioneer and advocate doctor Lee gross, as well as three other physicians who are providing direct care in rural areas.

Lee Gross 00:00:52 My name is doctor Lee gross. I'm a family physician. I'm originally from Cleveland, Ohio, attended the Ohio State University for my undergraduate case Western Reserve University in Cleveland for medical school, went on to do my residency at University Hospitals of Cleveland and realized that in Cleveland, if you weren't working for one of the two major hospital corporations, you simply didn't work in Cleveland. That was corporate environment that I really wasn't all that interested in. So we picked up and moved to Southwest Florida beginning in 2002 and set up a practice there and very quickly realized that everything that we went into medical school for, we wrote those essays as students to say why I want to go into medicine.

Lee Gross 00:01:34 All of that was crumbling under my feet. My career was essentially being stolen and taken away by third parties, insurance companies, and quickly found that we had to find a better way.

Lee 00:01:48 You tried to do everything within the quote system to the best of your ability.

Lee Gross 00:01:53 Yeah, I was a fairly early adopter of the electronic medical record in 2002 two because it was an incredible tool for work, practice and approval workflows and improved efficiencies. It did everything I wanted it to do. Where things went off the rails pretty quickly. The government came in and started regulating and certifying electronic medical records, and suddenly the system completely changed. And now essentially, it became a glorified cash register or government compliance tool that really no longer reflected the nuances of office visit. It did not work for any of my workflows anymore, and essentially because I stuck with that system that was no longer certified. I was getting penalized by Medicare for not upgrading to a certified system, while the certified systems were like $30,000. And so I had to run parallel systems, one that worked for my office, and the other one which kept me from getting Medicare penalties.

Lee Gross 00:02:47 Every time I tried to find a way to generate revenue to keep the lights on my practice and adjusted for inflation, they were lower payments. And so we were are finding alternate revenue streams. I used to do stress tests a imaging facility and Medicare banned that ability. So we changed it around. And so the stress tests came to our office and Medicare banned that and had a relationship where we would bring in ultrasound techs and red dot space Medicare band that it was like I was playing this game of whack a mole with Medicare, that every time we found a way to stabilize the finances of our practice, Medicare would take our knees out from under us and make it to them. Couldn't do it simultaneously, I would be getting 20% pay cuts from Florida and Cross, and it was an unsustainable model. I'd go with a group of doctors and halls of Congress and say, hey, don't cut our pay, don't cut our pay. We want a bigger piece of the pie. And I walked out and the anesthesiologist would be waiting in the lobby, and they'd come in next and they'd said, don't cut her.

Lee Gross 00:03:47 Hey, don't cut our pay. We need a bigger slice of the pie. And then they'd walk out and surgeons would be behind them. And so they would very quickly realized that we were all fighting for larger pieces of a very small pie. And, you know, there was always going to be somebody that loses in that battle. And we realized that we didn't need to just change the way you slice the pie. We needed to blow up the pie and think of a completely new way of doing things. And the epiphany came when a small business owner came up to us and said, my insurance premiums for my toys are skyrocketing. I can't afford to pay them anymore. I'm going to have to find another way. And all my employees are already seeing you as their doctor. I know what I pay the insurance companies and I see what they pay you. We're all getting ripped off. And I said, why don't I just hire you to take care of my employees? And that's that was our epiphany moment was, why are we insuring primary care? Why are we inserting so many obstacles and barriers between doctors and patients, filing an insurance claim for every single touch at a primary care level, and dealing with hundreds of thousands of complex cones, and then dealing with deductibles and co-payments.

Lee Gross 00:04:50 Why are we doing something so complex or something that's so simple. So what we did is we sat down. We came up with a business plan, what we were going to do, a subscription based primary care, where we would charge a flat fee for unlimited services that we did in our office. So why fees right now are $89 a month for adults, $30 for one child, and $15 for each additional child, and having charged nothing for our services in the office, no co-pays, no deductibles. And we do not bill anything to any third party for a fee for service visit.

Lee 00:05:22 Doctor Leigh Gross has two office locations. One of them is in a rural part of Florida.

Lee Gross 00:05:28 It's a very underserved community, one of the lowest income populations in the state of Florida for family, household. That's a location we've been at now for probably almost six years. You know, if you wanted to set up a private fee for service practice in a rural setting, you're going to need two 3000 patients and a very full schedule in order to keep your practice afloat.

Lee Gross 00:05:49 And you're not going to do that, or certainly not at the start. Your patience may be scattered over 100mi². I mean, it could be 30, 40 miles away from the nearest doctor. Nearest hospital. And so, with a drift forever trip. Marvin, you can't have a successful practice that's profitable with 300 patients. With 400 patients, if you keep your overhead low enough, which is an effective and viable practice model in a rural setting, which if you tried to do that without doing a drug timer curse, it just fits the model. You would need massive state and federal subsidies to keep that practice of what you don't need to do that on a direct primary care side of things.

Lee 00:06:28 Lee, this is why I wanted to interview you, because you just gave me an epiphany. Like, why aren't we talking about DPC in rural areas for the exact reason that you just elucidated, which actually never even crossed my mind. You're 100% right. A rural area, by definition, is an area of sparser population.

Lee 00:06:48 You want to bring doctors into that area. There's no way they're going to be able to open a big clinic with all the infrastructure, but they absolutely could open a DPC with 3 to 600 patients if they charge a reasonable amount. I haven't heard that floated as one of the solutions to the rural health care crisis. And I think it's brilliant.

Lee Gross 00:07:09 It's something that we definitely talked about in trying to pass legislation in Alaska, which is a state that probably would benefit the most from something like this. You know, it seems like the big push nowadays is for telemedicine, for rural. And telemedicine is okay. I mean, I think it's one important piece, but it's not telemedicine with your doctor, somebody that knows your history and has access to your raccoon. And I think the primary care component in rural health care is it's unlimited technology, but it's unlimited telemedicine visits with your doctor that has access to your record. And plus, in person, it's nice to have the option to be able to make assessments over the phone.

Lee Gross 00:07:47 And that's what their are premature. Piece of this does. And can really be flexible about it. Which you need in the cross world Utah and cross Wyoming to a lot of the central part of America. It's really critical that access.

Lee 00:08:01 Well, when you're thinking about fiscal responsibility and the massive amount of money that we spend on health care, and you're thinking about, okay, we're going to expand access to telehealth. Of course, if you are a primary care doctor or in some setting like this where you're able to take care of your own patient, that makes all the sense in the world. But instead, I think what we've seen are these pop up telehealth type of phone call clinics that are really very limited in what they actually can do. It ends up being a lot of like when people walk into these minute clinics for self-limited problems, and it actually ends up costing the system a lot of money for problems that maybe are going to get better on their own, or problems that ultimately are going to require a visit to the primary care doctor.

Lee 00:08:44 So I think you're right. It's one of those slippery slopes where we say, yes, we want to expand telehealth, but when we just expand it without putting any sort of parameters around it and may actually end up costing more money and not improving health outcomes.

Lee Gross 00:08:57 I agree with you 100%. The other thing with the rural health care clinics is because most of them are set up on a fee for service basis. You do need to have subsidies. You need to have tax subsidies, federal local state subsidies. And that was kind of one of the issues that came up during my testimony before the United States Senate is that they they kind of did the back of the napkin map and said, can you tell me why it is that that we pay $5,000 per year for every person enrolled in a federally qualified health center, yet you're charging $1,000 a year for unlimited fine or a chairperson. Why is it five times more expensive for the HHS? Granted, it's complicated, but you know, the short answer is you're not paying for primary care, but you're paying for a federal bureaucracy to implement the primary care.

Lee Gross 00:09:40 And so many layers of administration and oversight and systems and reporting. And you don't have all those labors. Some would say, well, then you don't have proper oversight. And how do you know the provided quality care? Which was a fair argument that I would certainly say that primary care is not the cost driver in the system, it's the downstream utilization of a poor primary care that is the cost driver in health care in the United States. And it's easy to track downstream utilization outside of a practice where that's information is already being collected by Medicare and easy access to that information. You can tell which practices are being efficient and how they're utilizing downstream services, which are the true cost drivers.

Lee 00:10:18 Now let's meet three physicians who are providing direct care in rural areas.

Multiple Speakers 00:10:24 I'm Lee Gillum. We moved to Lexington, Tennessee when I was four years old. County population is about 26,000. I went to college at UT Knoxville, med school UT Memphis, married my high school sweetheart. He's a big cattle farmer, and so it just made sense that we would come back, live on the family farm.

Multiple Speakers 00:10:43 And then I would practice here. I started out of residency at a brand new practice that's a hospital in the next town. Over was opening up here. I worked for them for two years and I hated it. I was not cut out to see 2530 patients a day and try to manage multiple chronic health conditions in a 15 minute appointment slot that was overbooked. I was not someone who was happy with sending my primary care patients with the long list comorbidities to the local urgent care when they were sick and needed the most. And so I after two years as an employee physician, I broke my contract and opened up my DPC. So we are at about six and a half years now. It'll be seven years in November and I couldn't be happier with that decision.

Lee 00:11:38 Talk about what it's like to have a direct care practice in a rural area.

Multiple Speakers 00:11:45 It's done wonders for my community. In this role, I'm taking care of people who need me more. People who don't have other options. You know, in larger cities, there are charity clinics.

Multiple Speakers 00:11:55 There are organizations that will see uninsured patients on a sliding scale. There's not a whole lot like that here. So for a community like ours that has a large percentage of working uninsured individuals with high rates of chronic disease, it's been a game changer for a lot of my patients. Of course, we still see our insured patients and we love them and we want to help them too. But there's more reward involved when you're seeing people who just don't have access otherwise. And so it's been it's been a great experience for me to be able to step in and provide.

Lee 00:12:33 What are your thoughts on how DPC can affect the rural shortage?

Multiple Speakers 00:12:37 What I am saying is that we have a lot of clinics in the area that are independent, small, nurse practitioner owned and run traditional model practices, and we've seen several of those go out of business for financial reasons. It just doesn't seem like the solo independent model is feasible. We have a lot of uninsured patients, but we also in Tennessee, have have a significant portion of our patients who are on Medicaid and Medicare.

Multiple Speakers 00:13:06 And the reimbursement there is not always fantastic. So the smaller practices are having a tough time surviving here. And if they're not surviving, they can't stay. And so for me to find a way to simplify and limit that overhead so that I can maintain a sustainable primary care practice in this community has meant a lot. And BPC is what's allowed me to do that.

Multiple Speakers 00:13:35 My name is Doctor Nehemiah Weimar. I'm a board certified pediatrician. I own and founded Culver Pediatric Center, which is a direct primary care clinic within Culver, population 1500 focused on educating and empowering families, and our community in rural Indiana can save rural health care access. Absolutely. We are a healthcare desert here in Marshall County. We have one local hospital oligarch and they're closing down service lines. At first they closed down pediatric rehab. They closed down the infusion center. You can say, okay, those are not mission critical. Then they closed down OB. They closed down the ICU. So as these service lines are getting closed down and patients have to travel further and wait longer for these type of specialty type services, then it's up to us, the primary care local doctors, to be able to manage a lot of the things that it used to be referred out.

Multiple Speakers 00:14:32 So absolutely, I do believe that if doctors are able to keep a small panel size, we're able to take care of these things that typically you would have said, okay, I'm going to send this to the specialty center. I'm gonna refer this out. The magical solution that doctors need to take care of patients is time. And I tell that to families. I don't have access to secret medicine or magic treatments that nobody else has access to. What I have is time, and the reason I can do that is because my panel size is small. There is no way having the same brain, the same training. When I was in corporate medicine that I could do what I do now with my complex patients, and that is essential in a rural setting where going to a specialist might be one, two, three hour drive.

Multiple Speakers 00:15:19 I'm doctor Katie Worden Greer. I graduated from OU Medical School in 2011. I went to Mayo Clinic Jacksonville campus in Florida for my family medicine residency training. And then I came back and I worked for my native tribe.

Multiple Speakers 00:15:35 I'm Muskogee Creek in a rural setting in Oklahoma. Just 20 minutes from my hometown, across the road from where my family's allotment was after the Trail of Tears. So very rooted in this community. After about three years there, they started making me see patients and five minute appointment slots. And that was just obviously unsustainable. So I took the 2.5 hour round trip every day to drive to a different tribe. Chickasaw Nation and I worked there as a hospitalist for about eight years. And then I've started my own DPC clinic here about a year and a half ago in my hometown, a mile and a half from where I live. But then my clinic, I have 140 patients, which is nowhere near what I was making before out in the private world. But it's enough that I have autonomy. I can pay my bills. I still work one day a week at the Wewoka IHS clinic, the Indian Health Service clinic, until I shore my numbers up a little bit more, but that's coming from a town of 800 people.

Multiple Speakers 00:16:37 I have 800 people in my town, so I draw a lot from surrounding towns to the next biggest city. I'm an hour and a half from Tulsa. I'm an hour and a half from Oklahoma City. So there are people here that don't want to drive far and they still want to see a doctor.

Lee 00:16:51 One of the big questions that direct primary care doctors must ask themselves is whether or not to opt out of Medicare in order to charge patients who are Medicare eligible cash prices, doctors must be completely opted out of the program. That means that they can't build Medicare in any other setting, even if they're working in a different practice, like a hospital and urgent care or hospice. Because direct primary care practices, especially in rural areas, may take some time to grow to financial viability, these doctors are now restricted from access to moonlighting jobs because they can't bill Medicare. That puts them in a catch 22. Do they completely opt out of Medicare so that they can see Medicare patients in their DPC practice, or do they exclude Medicare patients from their outpatient practice because they need the income from billing Medicare, moonlighting to sustain themselves? Doctor Leigh Gross has been working in advocacy for direct care for many years.

Lee 00:17:56 I asked him about the status of Medicare opt out for direct primary care. What are your thoughts when it comes to the implications of more physicians taking the step of opting out and doing direct care?

Lee Gross 00:18:10 So that is a fair and valid concern because Medicare rules are very strict. And if you are taking cash for a patient, for a service that Medicare covers, that you must opt out of the Medicare system. And it's an across the board opt out, and you can't opt in in one location and one corporation in opt outs in another. You can't have a private cash practice that takes care of Medicare patients for cash, and then moonlight on a hospital, or an urgent care setting or social shifts in the E.R.. So you must have crossed the border, though it's a two year commitment to opt out. That's a big deal for people. So if your practice is not going fast, you're really making it difficult to find alternative ways of generating income. So it's a very high risk proposition. One of the areas that we're currently working in advocacy now with Medicare, but we've been working with the policy director of CMS specifically on trying to eliminate the need for opting out.

Lee Gross 00:19:10 I can tell you that it's something that they're receptive to. There are definitely some traps that we have to kind of explore and see how we deal with those.

Lee 00:19:17 I asked the doctors who are working in rural areas how it would have changed their practice if they had been allowed to opt out of Medicare.

Multiple Speakers 00:19:25 Here's Doctor Leah Gillam.

Multiple Speakers 00:19:27 I have not opted out. I'm in a hybrid practice right now. I only build traditional Medicare. I don't do advantage plans. The burden of prior authorizations there is just too great for me to have time to do. And it's an reimbursed labor. It's been a tough situation. It's a tough call for me to make patients that I cared for years that I love. And yeah, dealing with Medicare is a challenge. I wish it's something that I didn't feel compelled to do, but I I'm just not in a position right now where I'm willing to give up to patients that it would cost me to do it. But realistically, yeah, I'm taking that pay cut because I'm not attesting to meaningful use and things like that.

Multiple Speakers 00:20:09 I've got patients who have Medicaid secondaries to their Medicare, and I lose out about 20% of those visits because I'm not in network with Medicaid at this point. I just do it because in my heart, it feels like the right thing for me in this moment. I don't know that that's what I want to do forever, but for right now, it's where I am. I'm not taking new Medicare patients, and I haven't for most of the last year. But yeah, it would be fantastic if we could uncouple that requirement in different practice settings because it would have made it easier on me. Very much so starting out, if I hadn't been required to miss out on me learning opportunities because I needed those, I still need those.

Lee 00:20:55 Talk a little bit about why doctors are struggling with Medicare.

Multiple Speakers 00:21:00 Yeah, so it's not just caring for your patients. And that's what we're here for. At the end of the day, we're here to make sure everybody that walks in our exam room gets the best care that we can give them.

Multiple Speakers 00:21:08 And so to take the extra time to put together the data that it requires means that I'm taking time away from caring for patients, gathering that data and submitting it to Medicare doesn't improve their care. At any rate, I don't know if there's any data that exists that these requirements have significantly improved anyone's health. And so to ask me to gather and submit that data just to get paid for the work I'm already doing. It's incredibly frustrating, especially when realistically, a lot of the measures that we're asked to make aren't the things that our patients are not willing to do. You know, I've got a lot of patients that are Medicare agents that should be getting mammograms, colonoscopies, but for one reason or another, they're not going to do it either. They just don't believe in that, which is a curious belief. But people have it, and everyone's entitled to their own belief system, or they've got patients that haven't had colonoscopies because they're a solo caregiver for an elderly spouse, and they cannot leave the house long enough to do that.

Multiple Speakers 00:22:14 And so the idea that physicians are penalized for that is insane.

Lee 00:22:18 So you said, because you're not participating in submitting those data measures, you get paid less money than someone who is participating in that process.

Multiple Speakers 00:22:29 Correct.

Lee 00:22:29 Yeah. If you were to participate in those things, I'm guessing you would probably have to hire a staff member just to help you collect that data and submit it.

Multiple Speakers 00:22:38 It probably wouldn't require a full time staff member, but I would wind up paying a staff member. I already have significant over time to help me compile all that and get it submitted. And it's just not it's not been worth the undertaking at this point.

Lee 00:22:55 So basically you're getting paid less money to provide the same or better quality care and just doing it, taking those patients because you care about them, and then trying to offset the financial losses by maintaining your your traditional DVC practice.

Multiple Speakers 00:23:14 Yeah. The traditional practice and that they work two other jobs. I'm a hospice medical director and our county's medical examiner, so that does help to offset that sound.

Lee 00:23:26 Which you would have to take Medicare in order to.

Multiple Speakers 00:23:29 Yes. To work in this we do. Wow.

Lee 00:23:31 So that would be another advantage if you were able to opt out in one setting, but not in another. You're doing so many things for your community.

Multiple Speakers 00:23:39 Do you ever feel like you're doing enough? But yeah, we do what we can. And there's just, you know, in a community like this, it's maybe and three other physicians and some nurse practitioners and physician assistants, there's not enough people to fill all those roles. When I started the county medical examiner position, my mayor came to me and he's like, basically, you're the only person who's qualified. Will you do it? And so, so you do. But I wouldn't be able to balance those other needs and serving those roles in a traditional model. I just wouldn't have the flexibility to to set my schedule in a way that I could get all that done.

Lee 00:24:20 Once again, DPC saves the day.

Multiple Speakers 00:24:22 It does, you know.

Multiple Speakers 00:24:24 I think a lot of people are really reluctant to do this in a rural area, just because of the idea that there isn't the same, you know, pool of potential patients to pull from. But I think it's important for people who might consider this to keep in mind that people aren't satisfied with what they're getting, that'll trust the system. And if we're ever to regain the trust, especially of rural people who they don't tend to trust outsiders all that readily. And if we're to try to convince them that those of us in health care really do have their best interests at heart, we've got to have a model that allows us to have time for them, time to have the difficult conversation, time to answer the question, and time to work through some of the skepticism that so many people have. And that's not happening in a ten minute visit and a traditional model of care. You just can't answer all the questions and address those emotional needs without being allowed the time to do that. And DPC is the only way I've found that I've been able to make that difference.

Lee 00:25:25 For those who are questioning whether DPC is viable in a rural area, Doctor Katie Burton Greer has advice.

Multiple Speakers 00:25:32 I just want to encourage anyone that's interested in going into direct primary care that it actually can be done in the middle of nowhere. I was very, very scared about that. I kind of took a big leap of faith, and I thought, worst case scenario, I'll go back to the grind. I took the leap of faith and here I am. My goal was to get to 100 patients at a year and I hit that goal. I'm hoping to get another 100 by next year and it can be done. People want the choice. People want to be able to see a doctor. People want access to their doctor. People want to save money. People understand memberships now. I mean, explaining the difference between insurance and membership based office visits. You know, a little bit of a learning curve, but people get it. They're used to paying for Netflix or gym memberships. And the old analogy of why does primary care have to be expensive? You don't go to your car insurance every time you need new wiper blades or tires.

Multiple Speakers 00:26:24 It just when you explain it that way, it makes a lot of sense and people get it. And my patients love it, I love it.

Lee 00:26:31 Here's doctor Lee gross again, sharing his thoughts on the future of the direct care model.

Lee Gross 00:26:37 What started off as maybe a dozen of us 15 years ago is now thousands in all 50 states. As we see this growing, it's not just primary care, it's specialty care. It's endocrinologists, it's rheumatologists. So people that are doing a lot of chronic disease management are contemplating shifting to a subscription model that just makes more sense for predictable finances for the practice. This better for patients as well. And I would say we're extending careers. People that would have liked to be that we kept, including people that are going into pharmacare, that would have not gone to find that care because we make any viable specialty and we make it financially viable when they can emotionally viable Level and fix alarm blocking system. We should fix everything. Absolutely not. Is it a panacea? Absolutely not.

Lee Gross 00:27:25 Is a country club medicine? Not a chance? It is hard work, and it takes a lot of effort to grow the practice, and sometimes a great financial hardship to the practice. As you're growing. So this is not a ticket to wealth. But I'm encouraging to see younger people go into this and go, well, we set up kind of educational conferences. The first time we did is I expected a bunch of gray haired people like me showing up that are just mad, you know, that they're not making as much money and they're working longer hours, and the insurance companies are telling them what to do. And I thought I'd have a room full of gray hairs, but what I got was a room full of very young people just out of trading that already are discouraged by the system. And that blew me away, that we are burning out our doctors in trading for burning on the first two years of their career, and then blaming the particular doctor for a physician shortage, that that's far from the truth.

Lee Gross 00:28:22 And so it's nice to finally see some of those young faces coming true by seeing, wow, there really is a path forward in climate care that I can have it all happen to health and career, and they could do some respecting with their hand practice the kind of medicine that I wanted to be.

Lee 00:28:40 Thanks so much for listening to this episode of Physicians Taking Back Medicine, a new podcast sponsored by Medical Economics. I'm your host, Doctor Rebecca Bernard, bringing you true stories from day to day physicians just like you, who are working to improve the health care system.