How this physician built a direct specialty care practice [PODCAST]

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“I am here to testify that it is possible, and I am not alone in this specialist direct care market. There are other specialists’ practices like mine, hidden gems for patient care. During my journey, I learned specialists are thriving to remove the “middlemen” and reconnect with patients. Patients are eager to shop for their health, discover transparent pricing and excellent quality. Patients and physicians desire mutual accountability. Since the direct primary care movement started approximately ten years ago, many patients that signed up to this model quickly realized the benefit of having access, affordability, and price transparency.

Specialists in direct care now exist across the country. In the last two years, I have been in contact with many thriving physicians providing a direct care model. However, it was so hard to find and connect. Our hope – and our patients’ need – is that connecting patients with direct care specialists gets easier. We are working on that now – we are working to change the system because our patients need it – and practicing good health care depends on it.

This is just the beginning of a new era in medicine, where patients and physicians reunite.”

Diana M. Girnita is a rheumatologist and founder and CEO, Rheumatologist OnCall. She can also be reached on Facebook, Instagram, and YouTube.

She shares her story and discusses her KevinMD article, “The emergence of direct specialty care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Diana Girnita. She is a rheumatologist, and she wrote the KevinMD article “The emergence of direct specialty care.” Diana, welcome to the show.

Diana M. Girnita: Thank you, Kevin. It’s such a pleasure to be here. I’m very honored and delighted to be on this show.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Diana M. Girnita: Sure. I am a rheumatologist. I was born and raised in Romania. I completed my medical school in Romania, and I came here in 2005 with a postdoctoral fellowship at Harvard University. I completed that, I followed with another fellowship in transplant immunology at the University of Pittsburgh, and then I finally decided to go back to the clinical world, and I completed the internal medicine residency, followed by a rheumatology fellowship at the University of Cincinnati.

In 2019, I decided to step ahead and take one of my ideas live. I was really passionate about broadening the access to rheumatology, and I was also passionate about telemedicine, when many people did not want to embrace that, before the pandemic. And I started a company called the Rheumatologist On Call. But on top of offering rheumatology services, I wanted to change a little bit the way that care is delivered here. So this practice is a direct specialty care practice, which is actively seeing patients in nine U.S. states.

Kevin Pho: Tell me a little bit about your practice, the types of patients that you see, and a typical workday.

Diana M. Girnita: Sure. So my practice is a little bit unique, because it combines evidence-based medicine with integrative medicine. I felt for a while that we are missing the point. We are trying so hard to target certain molecules in patients’ bodies, but we forget about what is important for their lifestyle. So, as you know, probably very little time is spent in our training to understand the value of nutrition, stress management, sleep, and exercise. So I took the time to educate myself in all these aspects, and I try to incorporate that into the patient’s plan, and that works great. Patients are very appreciative that a physician is taking the time to talk to them about all of these aspects.

And in terms of the flow in my practice, as I was telling you, I am able to see patients in multiple states. Many specialties, including mine, rheumatology, are in high demand in the United States, but also worldwide, because all the diseases are very complex and they can involve multiple organs. These patients need a very wide approach, and that’s why you have to have time with the patient. You have to understand where they come from and bring them to a better spot. So, as you know, these days the time with the patients is very limited. It’s between seven minutes, usually, in the traditional practice, to 15 minutes. So I started there. I wanted to dedicate more time to the patients, and I start with 60 minutes. So all my appointments will start with 60 minutes, and then we will cut down to about 30 minutes for follow-ups, which gives time, and there is no pressure on the patient to tell you what’s going on quickly, and I have the time to do a lot of education for these patients.

So that’s something that I do. And because those patients, they have to travel for a long time, you know, most of these patients are in areas where there are not many specialists around. They can access me from everywhere. They can access me from their house or their car, not ideal, but it happens, and they can have access to care without spending the time or money to travel somewhere else.

Kevin Pho: Talk more about your journey into direct specialty care, in your KevinMD article titled “The emergence of direct specialty care.” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Diana M. Girnita: Sure. I think the story that I share in this article is very, very common these days. This is a story of a 64-year-old patient that was otherwise healthy. Unfortunately, in a matter of a few weeks, she developed a very severe and disabling inflammatory arthritis. She went through a very stressful situation in her life, and after that she developed this inflammatory arthritis. This is not uncommon. Now, her primary care physician tried to help her, and he did everything that he could, but at some point he needed a specialist. So he gave this referral to the patient, and the patient, although she’s living here in the north side of California, where we have many big health care systems, was unable to find an appointment sooner than six months. And this is common, again. This is something that happens all the time.

But her primary care physician took the time to research her options, and he knew about me, so he referred the patient to me. I was able to talk to the primary care physician, kind of sort out the situation on the phone, and then I immediately called this patient and scheduled her the next day.

The other thing that was a little bit intriguing for the patient was the way that she interacted with our office. Nobody asked her for her insurance, and when she had the appointment, she was able to be involved in her plan. So we decided together what she needs in terms of consultations, in terms of laboratory services, imaging services, and I was able to give her a plan that contained all the costs that would be involved in all her medical care. And that was important for this patient, because she had a very high deductible, and she was researching by herself how much she was supposed to pay with her deductible, and that came out to thousands of dollars, and my plan was discounted to a few hundred dollars. She was surprised by the fact that I was able to, you know, provide her the cost of everything, and I was very transparent about that. And on top of that, she had the time and attention when she needed a physician. So that’s the story behind the direct specialty care practice that I have.

Kevin Pho: Whenever I hear about direct care, it’s primarily limited to primary care, so this is one of the few where it’s direct specialty care. Talk about some of the challenges that you had in terms of building up a direct specialty care practice, especially when there are so few of those around here in the United States.

Diana M. Girnita: I have to tell you that it was challenging. I looked at the direct primary care movement for a while, and I knew about them, but I thought, as a specialist, you need a referral system to back you up. The difficulty was to find out how to build up a practice without this referral system, or how to build connections to other primary care physicians to be able to refer patients to you. So that was a challenge.

And the other challenge is how to structure the care for a specialist and how to set up a price for your services. You all know, I think, we as physicians, we are not aware, when we practice in the traditional system, of the cost of our consultation, how much labs and imaging are going to cost. And that was another challenge. I did not know in the beginning how to reach out to have direct contracting with labs, with imaging centers. I had to knock on many, many doors multiple times to be able to get that. But when I was there, I realized that being able to contract directly gives you the power to negotiate on those prices. And instead of, for the same laboratory cost, you know, that a patient will go and ask and will pay, I would say, hundreds of dollars, you can discount it to tens of dollars. So that’s the power of direct contracting.

Kevin Pho: And how did you overcome that first obstacle of building a referral base and letting other primary care doctors even know about you? How did you overcome that obstacle?

Diana M. Girnita: I started with giving free lectures to a lot of the direct primary care physicians. I kind of built up a network of physicians, where I showed them that I’m there to offer them services. And for about a year, I was giving lectures every single month about topics that they were interested to hear, and then they started to call us with questions, and they realized that I’m there for them, to help them. That was the initial step. The second step was to, you know, reach out directly to people in my area, like primary care in my area, and offer them the services.

And then patients are eager to find a specialist. So many times, when they get a referral, they try to schedule through the panel of physicians from their insurance company, but when they hear that they cannot be seen for four to six months, they start to research, and that’s how many patients will find me. And then the word of mouth, I think that’s the most important thing. A lot of patients that interacted with me, and my former patients, that was the other thing, my former patients, a lot of them followed me. But the word of mouth of providing the care that the patient needs is the strongest asset that you can have for an independent practice like mine.

Kevin Pho: Now, do you have a subscription pricing model, similar to direct primary care practices?

Diana M. Girnita: I have that too, yes. It took me a while to develop the subscription model. The initial consultation is still fee-for-service, to see if you qualify for this kind of service. There is no point for patients that need one or two or three visits to pay a membership model. But let’s say you have a disease like rheumatoid arthritis or psoriatic arthritis or lupus that needs constant evaluation and monitoring of the labs, of the disease activity. For those patients, I do offer the membership model.

Kevin Pho: And what kind of training did you have on the business side of medicine to help set up contracting and negotiation? Did you have a background in this, or is this something that you’ve learned on the fly?

Diana M. Girnita: I learned on the fly. So I consulted with many lawyers. In the beginning, it was very hard to find a lawyer that would be able to provide me with the knowledge of this kind of direct contracting. It was quite challenging to find one. I have to be sincere that I had to go through four lawyers that were, you know, saying that they can do things, and then later on they would say, “I’m not qualified to do those things.” So finally I found one that was working with other direct primary care physicians, so she was able to understand better, from my perspective, what I was trying to do. And eventually I developed the contracts based on, you know, the research that I’ve done and the knowledge that she had.

Kevin Pho: We’re talking with Diana Girnita. She’s a rheumatologist, and she wrote the KevinMD article “The emergence of direct specialty care.” Now, for those other specialist physicians who may want to try a model similar to yours, direct specialty care, what kind of advice do you have to give to them, and what kind of red flags should they look out for?

Diana M. Girnita: So in the last two years, I was able to connect with other specialists that are doing direct specialty care, or some sort of direct care, or a hybrid model. So very soon after, I realized that there is huge interest in this kind of movement and rebuilding that relationship with the patient. Together with another physician, Dr. Kenny, we started the Direct Specialty Care Alliance, which is an organization that has the purpose to help other physicians kind of find their ways: first, educate them that they can do those things; second, give them the initial steps to start; and then later on, they will be able to develop their practices. And the other purpose of this organization will be to have this kind of network of physicians that will be able to help each other, will be able to refer patients to each other, if that’s the case.

And the movement is starting to grow, because there are many, many specialists that just want to practice medicine. They don’t want to be in productivity models. They don’t want to become burned out by a huge number of patients. And they just want to recreate, or, you know, come back to the purpose of their profession, actually.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Diana M. Girnita: I think that, you know, I remember what Steve Jobs said once, that those of us that are crazy enough to think that we can change the system, we might change it. And although this seems a very small scale at this point, it is a huge step for the patients, and it is also a huge step for physicians that want to practice good, excellent-quality care medicine. They can reach me. They can look up my website. It’s called rheumatologistoncall.com. Or they can look up the Direct Specialty Care Alliance website. It’s dscalliance.org. And they can also, we have a private group on Facebook where we share our journey and we try to help each other. It’s called Specialists for Direct Care.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Diana M. Girnita: And thank you so much for having me, Kevin.

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