Speaker 1 0:00
Concierge, you're still in the same system, but now you have to pay extra money to be in it, right? They're doing insurance, and then they charge you money on top of the insurance. I just call it fee for service with a gold necklace. And so when people talk about like, oh, you're limiting access, or you're only helping the rich, or you're cherry picking, they're talking about concierge. As direct primary care is increasing, and they're going towards employers. More individuals are experiencing it. People understand. Oh, this is not concierge. This is actually probably better.

Austin Littrell 0:32
Welcome to Off the Chart, a visit to medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Alzin Latrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics senior editor Richard Payerton sat down with Dr. Kenneth Q, a family physician, founder of the direct primary care practice UDOC in the Richmond, Virginia area, and lead author of the Direct Primary Care Alliance's State of Direct Primary Care report. Today, they're talking about how many patients actually follow a physician who leaves fee for service, the Medicare billing rule that slows down new direct primary care practices, why the model keeps getting confused with concierge medicine, and what changes once the practice grows past a handful of doctors. With that said, Dr. Q, thank you for joining us. Let's get into the episode.

Richard Payerchin 1:23
Dr. Q, thank you for joining us today.

Speaker 1 1:26
Hey, Richard, good to be with you today.

Richard Payerchin 1:28
And we're going to dive into some details from the report. Just a quick note on terminology. A moment ago, we had talked a little bit about some of the alphabet soup of healthcare, and a lot of times people talk about direct primary care with the abbreviation DPC. We'll use both terms in our discussion today. And before we dive into the report, can you introduce yourself and talk about your medical practice?

Speaker 1 1:52
Sure. I'm Dr. Kenneth Q. Family Medicine. I started my direct primary care practice straight out of residency, and this weekend will be five years for us. I'm in the Richmond area. There's four doctors now, all friends of mine. The other three are all friends of mine, and we're spread out across two of the neighborhoods in Richmond. So two offices. My journey in direct primary care started actually when I was a fourth year med student. I've always been interested in the health system, and somebody told me about DPC in my fourth year, and it was just a breath of fresh air when I went to summit. Yeah, everywhere else, everyone's like, "Oh, this is broken. That's broken. Everything's helpless. But the DPC community was where it seemed like there was a fix and something big was happening. And so, all throughout residency, interviewed a lot of people, visited dozens across the country, and so really just hit the ground running when I graduated residency, and have been very grateful to have started my career in the direct primary care model.

Richard Payerchin 2:50
One thing that certainly caught my ear: congratulations on the anniversary. That's fantastic.

Speaker 1 2:54
Yeah, thank you.

Richard Payerchin 2:55
Yeah, I'll tell you what. Regarding the direct primary care alliance and the committee, just to by way of introduction, can you explain how did the report come about?

Speaker 1 3:05
Sure. So I was actually vice president of the alliance at the time, and you know, in the DPC community, there's a lot of chatter and a lot of numbers that get passed around. You know, word of mouth, and I realized people just kept saying things like, "Oh, what's average panel? It's this. What is the average price? It's this. How should I price this? Well, this is generally what people do, and yet when I was starting to engage with some people in academia, I realized we don't actually have reports. There, there is no objective fact anywhere. It's just hearsay, and of course the community is small, and so I feel like the the conversations are close to truth. But I was like, hey, what if we engaged in a large survey? We are the DPC Alliance, which is supposed to represent all DPCs. I think it would be a good idea if we put together a committee that ran this big report and had everybody contribute so that we can actually get some hard numbers on paper, and so that was kind of the driving thought behind it. Now there are other surveys, like the AFP does a biannual survey on the DPC community, but a large percentage of DPC doctors have left the AAFP, and also their survey is very long, and so we, with that in mind, we wanted to say like, hey, let's try capture all the people that aren't really engaged in any sort of organized medicine anymore. Plus, let's make a survey that people will actually respond to at a higher number, and so that is the kind of initial thinking that that started the project.

Richard Payerchin 4:48
One of the things I find fascinating in, like I said before, I joined medical economics as a community journalist, I wasn't aware of the level of just medical and scientific studies that are taking place at any. Time once you start start to get into that world, it's frankly kind of amazing to think of how many different topics and issues and ideas are studied and quantified. And I noticed that in the report about that research gap, I thought that was very interesting to note. Maybe just to not to belabor the point, but regarding the survey respondents, it looked like you had number one both pretty good turnout, as well as a significant number of respondents who were not immediately members of DPC Alliance. Can you talk about that?

Speaker 1 5:33
That's right. So I mentioned that this was fully truly a community community experience, right? A community effort. It wasn't just the alliance. I think I pretty much used every network that I had in the DPC world. I mentioned during residency, I had spoken to probably over 100 and visited dozens across the country, and then we encouraged everybody to reach out to their friends, and so we basically went to all the DPC watering holes, distribution channels, everything, everybody we knew, and said, "Hey, can you push the survey out? And understandably, again, with all these docs not generally always being fans of organized medicine, they're not all going to be in the alliance even. And so we wanted to reach everybody. So thanks to the help of the committee members, the alliance board, and even just everybody in the community sharing it, we were able to get pretty good penetration across all the practices, even ones that generally are a little more quiet, don't engage in social. Because you know, I really emphasize, like, hey, get just if you have a neighbor DPC down the street or across town, shoot them a text, send them an email, send it, send it, send it. And so I think just creating that that network was really helpful in getting as many people as we could and as we did.

Richard Payerchin 6:57
I'll tell you what, it's a great time to jump into some of the findings. Maybe kind of big picture. What would you like to highlight first about the report, and maybe what was most surprising to you?

Speaker 1 7:08
Yeah, I think some highlights would be the geography. That that was actually one of the more interesting things. So, as you saw in the report, 49 states, except for Alaska, Alaska, for whatever reason, their government has always been very anti-DPC. I think there was one at one point, but it's no longer there. And otherwise, you know, it's all over. Tends to match general population, like population DPCs matches population, with the exceptions of some of the big city states, New York, California, they tend to have fewer, and then you see a higher percentage in some of the middle of the country states, Kansas, Missouri, and then the other interesting thing was the high number was generally. I think it's like four of the top six states were where Medicaid didn't expand, so they're clearly meeting a need in those places. The demographics I think were pretty interesting as well. It was I believe like three fourths MD, about 70% women, and also roughly 70 75% family medicine. So odds are, if you are in a DPC, you have a female MD family physician. And then, yeah, the pricing, the pricing and the panel sizes were not necessarily. They they actually, I guess that's one surprising thing is they actually matched the chatter. Right, our word of mouth conversations that we've had at conferences and in forums and everything, it seems to match. So the panel sizes varied a lot, anywhere from like under 50 to over 1000. But when you isolated the people who said they were full, and we didn't define what full was. Full is just whatever you feel like. Essentially, that it could mean like you know I can't possibly see any more patients or uncomfortable where I'm at. But when you isolate just the people who said they were full, you hit the 400 to 700, roughly 600 mean that everybody talks about, and so that was pretty cool. And then pricing national average came out across everything at roughly $98, a little almost 99, and that seems to be it was higher than what people were saying on the ground. People were saying like 80 to 90, but it's actually higher, and a lot of that is because of the Northeast and the West and city practices. But we it got pretty close, and then the most surprising thing I would say is how small so many practices were. I think it was like 80, almost 90% of practices had one doc, and out of those 90% a third of them had no staff and no anybody else. Literally, it's just like. A one man or one woman shop. I I knew there were a lot of them. I didn't realize it was that many, so that was pretty surprising.

Richard Payerchin 10:07
You know, doctor, and that's been one thing that learning about the healthcare system in recent years. The notion of again just small. I guess the a one person shop is about as small as you can have to have a medical practice, like I had mentioned about those smaller and medium-sized independent practices and their decline, it's good to know that there are still some out there. I'll tell you what. One thing I want to make sure we get in there as well, because the report did actually kind of quantify an estimated number of DPC practices nationally. Can you talk about that figure?

Speaker 1 10:45
So that was done by Hint Health. Their their estimation. So Hint Health is a platform that does membership management. They also have electronic medical record and do some employer things. But I think they use their data, their platform data to estimate. Actually, I don't know what their methodology it was, but essentially they did a study. I think earlier in the year of 2024, where they reported roughly 3,600 logos. And what I mean by logos is practices. They didn't count number of clinicians within, and so that's the that's the number that we reported was the three 600, and they so our survey we decided to do physician only practices, whereas theirs was all commerce. And so you know when you look at the I think 450 460 people or respondents we got out of 3600 it's like 13% But when you think about like oh those also include a decent number of NP and PA practices, our percentage is probably higher. I would guess probably closer to 20% of penetration in terms of physician practices. So that that's where that number comes from. There wasn't, I don't think, any better guesstimate of how many DPC practices there are nationally.

Richard Payerchin 12:02
You touched on two points that I want to get into maybe a little bit more because both panel size and cost for a physician moving into or considering moving into a direct primary care practice. Again, not being a physician or a business owner myself, but I have heard from them some of the one of the main cause one of the main concerns is how do how do I begin to establish a panel if I am in an existing practice will patients follow me and what is going to be the optimal size for a patient panel to sustain you know my practice as a business can you share some thoughts on that maybe we can start with for a physician who is in an established practice. Have you talked to any doctors who've had experience with that, say, and how patients may follow them?

Speaker 1 12:52
Yeah. So this actually gets talked about at our conference pretty regularly. The and there's no study on this. This is another one of those like community chatter factoids, but the the number that's thrown out is roughly one to 5% of your fee for service panel will follow you. I've seen pretty mixed things, and I think it's it's about right. So, for example, my third doc that joined us, he came from an existing fee-for-service practice, and he did really, really well. Filled up super fast, and we actually had a doc who came briefly, but had to move for family reasons. Who wasn't even from the area, and some people followed him, like drove an hour to see him, and so the growth of a panel. There, there are a lot of different factors for how fast your panel grows, and one of them is whether you practice nearby for how long and how good you are, how much your people like you. But for the most part, those people who go into DPC who have practiced nearby and have a reputation in the community usually fill up really fast and do really well, and I'm talking about like they could be full within a year or less. So that that is probably the most consistent factor to filling a panel. You also asked starting from new. That's something that I did in in an area that I was new to, and so I had to moonlight for a good while at an urgent care. And my DPC was like a hobby for a couple of years before it really started picking up. And so, with the number of people who start straight out of residency increasing, I think that's a well-known playbook. Everybody moonlights. And one more thing to just throw in here: I know I'm kind of gone long, but the Medicare fact. One of the things we ask is, are you opted on Medicare? And I think roughly 10% or less weren't. And why that's important is because when you start out and you don't have a panel that follows you, you generally moonlight. Moonlight generally requires you to be opted into Medicare, and so what that means in federal law says that if you see a Medicare patient, you have. Bill Medicare. So what that means for those of us who have who had to start moonlighting or have to still moonlight, it means that you either don't see Medicare slowing the rate of growth of your practice, or you learn how to bill, which is just another headache. And so most people choose to just not see Medicare. So I think that reduces access for Medicare beneficiaries. It slows the growth of a DPC practice, and so one of the big things from a policy side is we're hoping that there's somebody can look into. I think it's got to be at the CMS level, getting rid of that kind of if you see Medicare, you have to bill Medicare rule that that would help. I think both the beneficiaries and the DPC practices.

Richard Payerchin 15:46
You know, Doctor, you mentioned a policy solution there. And before I forget, because one thing that you in our earlier conversation that had caught my ear, for example, you had mentioned about Alaska as not necessarily being legally friendly, say, or business friendly for DPC. Frankly, was just curious about your thoughts about either at the federal level and also at the state level, because there's plenty of state regulation over medicine as well. What are some additional policy solutions that would help direct primary care?

Speaker 1 16:15
I think our our model and our movement is very much based on one where we kind of are going resetting, right? The system's too complex, too broken, and so a lot of times when that question is asked, it's like, what else can we legislate into existence? But I think from our standpoint, it's just what are the barriers that currently exist for no reason, and how do we kind of reduce those? One thing that we're very passionate about, I think, every most doctors, not even just direct primary care, is certificate of public need, either reform or most likely repeal, right? Because when we're trying to find cash prices for patients who don't have insurance or are high deductible, and you have like two hospitals to pick from, and they're both like super inflated compared to the next state over that has a bunch of options and is you know a third of the cost. It's it's frustrating to you, and there are other I think cash pay adjacent like one bill that I've been trying to talk about a lot on the conference circuit and even trying to work into Virginia law is something called the well the initiative is called Patients' Right to Save, but the one that's the first section that's worked out really well is called the deductible credit. Basically, if you find a cash price that's cheaper than your in-network insurance rate, you can apply it to your deductible. So, clear example: X-ray through insurance is like $200, but cash pay is say 80. You then get to apply that $80 to your deductible. Now that's a small number, but you know it can matter, right? An MRI could be 5000 insurance and 1000 cash pay, and that's a meaningful dent. And some people actually do if if you don't have any incentives to shop, people will choose the $5,000 over the $1,000 if they can't apply that 1000 to their deductible, so this bill will allow patients have an incentive to shop, actually reward them for doing it, and actually even decrease the costs of the insurance companies, right? Because if they can't negotiate good price, well, the patients found one. Let's just do that. Less chance they they meet their out of pocket max or both through their deductible. So, so I think specifically for DPC, we're good where we are. The Medicare thing is is important to us right now, but a lot of the cash pay, transparency, adjacent, all those things are are helpful to what we do as we help patients navigate.

Keith A. Reynolds 18:46
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute.

Richard Payerchin 19:39
You know, Doctor, a moment ago I asked about some of the different policy options, and and I don't mean to put the cart before the horse, and by that I mean to meaningfully change in effect different policies around direct primary care. People have to know what it is, and I'm curious about because I had seen even on your website there is like a frequently asked question. Section that asks or explains, asks and explains what is direct primary care. Can you talk about with the growth of primary direct primary care DPC? How are perceptions changing among doctors, patients, and policymakers?

Speaker 1 20:17
Yeah, I think the the big important one that I still have to beat the drum on this pretty loudly, and I think this is both a problem externally and internally in our community. Is the difference between us and concierge? All the criticisms towards concierge get lobbied against us as well, and whenever you explain what you do, patients initially go, "Oh, concierge, and why that's problematic is because the model is so different, but the culture is even more different, right? Because what we what we're doing is we're building a completely new system, new culture that's asking different questions. The questions: How do we do patient navigation better? How do we understand the costs better? And how do we bring that to as many people as we can? Concierge, you're still in the same system, but now you have to pay extra money to be in it, right? They're doing insurance, and then they charge you money on top of the insurance. I just call it fee for service with a gold necklace. And so when people talk about like, oh, you're limiting access, or you're only helping the rich, or you're cherry picking, they're talking about concierge, and I think they don't really understand what we're doing. But as direct primary care is increasing and they're going towards employers, more individuals are experiencing it. People understand, oh, this is not concierge. This is actually probably better. We're getting like the same level of service without all the trappings and without having to have insurance. And so it's it's slow. Our community is still fairly small, even though it's had pretty explosive growth in the last several years. I'm hoping that growth continues to go, and and each doctor is a megaphone to their community, just letting them know what this is, what we're about, and really explaining, you know, how we're how we're different. So yeah, you see, if you go back and read articles from like 2015, 2016 versus now, you'll see the tune change a little bit. There, there's a lot more conflation back then. There still is currently, but it's less than October.

Richard Payerchin 22:10
You know what? I'm curious about the business management side of direct primary care because a lot of physicians like to go. They want to go into medicine because they like medicine. They like helping patients, and running a business because you do have to have some business concerns on that. Can you talk a little bit about, I guess, what has been the biggest challenge in opening a practice and being an entrepreneur?

Speaker 1 22:35
I think when you're a solo doc, which I kind of was at the beginning, yeah, I'm saying like no staff or or anything like that. Is that like you are everything? You wear all the hats, right? You kind of you do the numbers, you do the advertising, you do the patient care, you figure out the tech problems. Like nothing happens without you, but also nothing happens because of you, and so you really got to be very dynamic and just be able to figure things out. Have some risk tolerance, like learn how to prioritize which virus to put out when. And doctors are generally selected to be people who are generally not risk tolerant and very good at following rules, and so I think the DPC docs that exist now are are certain variety of doctor that don't that have kind of like that live outside that that normal distribution, and and really have some sort of risk tolerance and have a lot of mental flexibility to figure stuff out, kind of the you know maverick archetype, and then as you get bigger, it gets more complex because now you're dealing with people who have their own issues, and then you have to be a lot more on top of all the compliance and paperwork, and certain things kick in at certain employee numbers. And I'm going through that growth phase right now as we have to start writing more things down, have to track more things, do a lot more cybersecurity, and I think that's part of the reason why in the DPC community you see a lot of you know one to two doc practices, and they just kind of stay there their entire the the lifespan of the practice. Five doctors seems to be the wall where people tend to stop, and I don't have a good answer for that. But my personal guess is that it just gets overly complex at that point. There's too many people to take care of, too many things you don't know and can't figure out unless you hire, you know, legal compliance, accounting, bookkeeping, and all all a team that people don't want to deal with, and they're just like, all right, this is good. And after five, it kind of explodes, right? You see these practices that are multi-state, you know, 1112, locations. They have some sort of funding, and it gets a lot more sophisticated after that. But yeah, so long tangent. But the business side, I think, when you start, it's just there's so much to do, so much to learn, and then if you do end up in a growth space, it's just like round two of so much to do and so much to learn. But now it's different.

Richard Payerchin 25:12
You know what, doctor? I'm curious about. You had mentioned, for example, starting working with direct primary care and learning about it. Did you say you were in your fourth year of medical school?

Speaker 1 25:22
Fourth year of med school, and I had my first exposure. Yep.

Richard Payerchin 25:26
In in, admittedly, this may have changed slightly in the last few years, especially because of the pandemic. But frankly, I'm just kind of curious about exposure in medical school to direct primary care. How much is there exposure? Is there do residents students and residents learn a lot about it? Is it kept hush hush, and what can improve?

Speaker 1 25:49
I think in med school you're free to learn whatever you want, and everybody has different interests. Organizations like the Alliance, actually, back when I was a resident. One of my main focuses was reaching out to med schools and trying to get people to talk about DPC and connect with their local DPCs as much as possible. I also started under our previous president Vance the resident and medical student section of the DPC Alliance, and really pushed for having a medical student and resident board position, so that there can be more representation, more awareness, at least of those groups. I think the bigger challenge, even more so than having people learn what DPC is, and of course we have our like conferences where there are scholarships and all that for students to come. But the bigger issue is most academic centers actually look down on primary care. When I, because originally I thought about doing emergency medicine, and when I was telling people in the ER that I was switching to family, they're like, "Are you kidding? That's for that's for nurse practitioners and PAs. Like, what are you doing? You're not going to have a job in 10 years. Yeah, and that's a prevailing talking point. And my school, I went to VCU in Richmond is actually one of the stronger family medicine ones. Actually, my class, I think we graduated the highest number of family docs since like 1997 and second highest in the history of the school. But yeah, even in such a family friend, family medicine friendly, primary care friendly institution, there was still this like prevailing. Oh, you're doing family med, like okay, and that's all across the country. And so part of what we try to do when we talk about DPC is to say, hey, primary care is actually really important, and there's a good way you can do it, and it's a viable option. And so we're kind of almost bearing the load of just telling people they can still do primary care, which is a pretty big weight, and you really have to you know go against a lot of prevailing thought in medical school in order to to preach that message.

Richard Payerchin 27:57
Either from the four corners of the report or just generally, what did I not ask about that you would like our audience to know?

Speaker 1 28:04
I guess I acknowledge them in a lot of places, but I think it's important to also acknowledge the help that we got. So Dr. Rebecca Bernard, Dr. Emily O'Rourke were on my committee, really helped me get this through, especially internally as far as like board dynamics go. And then Dr. Allison Hufstetler with the Robert Graham Foundation. She was the lead in terms of just leading the statistical analysis and all the the research side. I'm not a big research guy, and so she helped that. And then Shika was her postdoc that did a lot of the the footwork, and then Dr. Rebecca Etz, Larry Green Center, she helped review our questions, validate them, make sure we were asking them in the right way. So, really appreciate all those people helping to push this through and put it all together. And then DPC in general, I think DPC has a lot of potential. This is one thing that. So I I mentioned the different generations. I'd written about this several years ago. Just like everything else that evolves, this movement is evolving, and there's just so much potential for it to kind of fully transform how primary care is done and how we access healthcare in this country, and this next iteration, this next generation, will figure out new things. I'm excited about the people who are starting straight out of residency, because what I've seen with a lot of the current DPC practices is a lot of mid-career physicians who are used to doing things in a certain way, under a certain system, and they bring a lot of those habits into DPC, and they don't realize that they can actually do a lot more outside of it. And so, people like me who experienced a little bit of residency, but now have this like open field to play in and don't really know what the restraints of the fee for service system are, we're trying to figure out new ways. Do things better, faster, more efficiently. Take care of more patients, and it's all about asking the right questions. And I think this model that is fully unencumbered-I sometimes call it primary care unleashed, right? Unencumbered, unleashed from the the bureaucracy, from insurance payments and requirements-it allows us to distill what primary care really is, what the tasks to be done are, and then lets us focus all our time on thinking how to do it better. And so that's just the final thought I think about the future of DPC as this movement continues to grow and expand, and more people participate in the model.

Richard Payerchin 30:42
I'm Richard Payerchin, reporting for Medical Economics. My guest today has been Dr. Kenneth Q, lead author of the report "State of Direct Primary Care" and a direct primary care physician. Dr. It's been a great conversation about direct primary care. Thank you for taking the time.

Speaker 1 31:00
Yeah, thanks for having me.

Austin Littrell 31:20
Once again, that was a conversation between Medical Economics senior editor Richard Payerchin and Dr. Kenneth Q, family physician, founder of UDOC, and lead author of the Direct Primary Care Alliance's State of Direct Primary Care Report. My name is Austin Latrell, 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 subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching "Off the Chart" wherever you get your podcasts. 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, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business of medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical economics and physicians practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai