I wanted to care for people, so I became a direct primary care doctor [PODCAST]

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“I’ve started to understand many aspects of business, and although we’ve done some pretty amazing things in the past two years, we’ve also made people frustrated and mad while trying to care for them. And so, I still reflect on these basic questions frequently, like checking the vitals of one of my patients. Are we still meeting that goal? Are we still steadfastly patient-focused? Do we still show patients that we care in all our actions?”

Allison Edwards is a family physician and founder, Kansas City Direct Primary Care. She can be reached on Twitter @KansasCityDPC.

She shares her story and discusses her KevinMD article, “I wanted to care for people, so I became a direct primary care doctor.”

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Transcript

Kevin Pho: 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. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. On today’s show we have Allison Edwards. She’s a family physician, and we’re going to talk about her KevinMD article, “I wanted to care for people, so I became a direct primary care doctor.” Allison, welcome to the show.

Allison Edwards: Hi, thanks for having me.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Allison Edwards: So I attended Kansas for my medical training and then the University of Colorado for residency, where I was chief. What’s interesting is that the article itself talks about that transition from what I thought my career was maybe going to be in residency and, as residency progressed, to where it took me.

Kevin Pho: All right. Since the article is such a big part of the story, let’s jump right into that. Talk about that article and that transition point in your life.

Allison Edwards: Absolutely. I hope that a lot of physicians go into medicine with the ambition to give, to care for people, to be caretakers, and I’m no different. That was why I went into it. That’s why I went into primary care. It’s not necessarily the quote-unquote rational choice in medicine, because we all know primary care is not as well compensated as all the specialties. But for me, it was more than the monetary motivation. It was the intrinsic motivation to help people.

So I followed that track. I matched into a residency program through Denver Health with their FQHC location. We took care of all of the refugees coming in through the state of Colorado, and so you would see so many different cultures and so many different languages, and it was incredible to give to this population. But the more I moved through my training and my practice and took on more and more patients, as we all do from intern to second to third year, I realized that the way the system was set up to try and help these people wasn’t actually accomplishing that goal in a meaningful way.

This is my opinion, obviously. I think a lot of people quibble with me on the way the FQHC system is set up. But what I realized was that with those 15-minute visits, on that treadmill over and over all day, I was not able to address the needs of my patients, who had suffered severe trauma, who were in a different culture, some of whom didn’t even know what a prescription was. I remember one time talking to somebody about ChapStick, and another time about sunglasses, right? The level of care that I needed to provide was more than just slapping a prescription at somebody and moving on. These people needed high touch.

That was where my dissatisfaction with the FQHC system, and frankly with the fee-for-service, insurance-based system, really started to set in, and where I started to think more and more about direct primary care: getting the insurers out of the room and thinking about how we holistically serve the patients sitting right in front of us.

Kevin Pho: Yeah, I think certainly what you describe, I’m a primary care physician myself. Every 15 to 20 minutes, and there are some doctors who see between 30 and 40 patients per day. I’m certainly fortunate to see only between 18 and 20 a day. But “high touch,” I think, is a great way to put it, because it’s very difficult for us in primary care to do that now. Before we get into talking more about direct primary care, for those who aren’t familiar with that model, just give a brief direct primary care 101 to get everyone on the same page.

Allison Edwards: Absolutely, and thank you for letting me explain, because some people are like, “Oh yeah, I know about that. Concierge.” Not quite. The concierge model is one that I think is heard about more, and how we in the direct primary care world define it is that in concierge, you’re still billing insurance, and then on top of that you’re doing some sort of a retainer or an access fee, so you’re getting paid twice. In the direct primary care model, we provide unlimited primary care for a flat monthly fee, and we don’t use third-party payers for that.

Phil Eskew came up with a really good definition in 2015 that was published, and that’s the one that we’ve stuck with: just the unlimited primary care. If there is a copay of some sort, and some DPC clinics do charge a copay, that copay is significantly less than the monthly fee. And then, of course, there’s the no third-party payments. So that is the crux of DPC.

Kevin Pho: All right, so now that we’ve defined it, tell us about that journey into the direct primary care world.

Allison Edwards: Absolutely. So like I was saying, I was in residency. Please read my article, because I think it makes this a lot more emotional and is a lot more nuanced than what I’m describing right now. But at the end, I was like, “I’m done. I can’t do this.” And I was like, “I am going to start my own direct primary care practice.” So I packed up, we left Denver, and I went back to Kansas City, where I’m from. I hung my shingle, bootstrapped, took some locum shifts, financed it myself, and opened the doors on January 2nd of 2017.

Which, hilariously, this is how bad of a business person I was, was the federal holiday. Nobody was working, and nobody expected doctors’ offices to be open. I flipped my open sign, I stood there proudly, and I had zero patients, because it’s not an appropriate day to be open as a clinic.

I share that because what I learned quickly was that I was a doctor, but I was also starting on this journey of becoming a business person and an entrepreneur and a small-business owner, and that was one that I hadn’t really. I wanted to care for people first and foremost, and the whole business of medicine came as a sidecar attached to my journey to provide the best patient care possible.

Kevin Pho: It’s really interesting. So tell me about how that start was. Did you have any mentors? Did someone teach you how to do this? How did you go about starting something like this?

Allison Edwards: Yeah. The direct primary care community is an amazing network of people who are very supportive of one another. If you have the ambition to open a direct primary care practice, there are, even in your neighborhood, mentors available. Connect with them. Google “direct primary care near me” and see who’s there. If you are obviously kind and not abusive of somebody’s time and bandwidth, you will get a lot of really great support and networking out of that.

So that’s what I did. There were some amazing trailblazers that I was lucky enough to have near me, who provided a lot of incredible insight. And then I also like to tell residents and students who are interested in direct primary care: You’re a physician. You have been taught how to learn, or I should hope you’ve been taught how to learn, because you can’t possibly learn everything in med school and residency. So you have this skill set of teaching yourself, and business is no different than any other subject. You can teach yourself quite a bit through reading, trial and error, and hiring good professionals to be around you.

Kevin Pho: So we’ve been talking about direct primary care for, I would say, about 10 to 15 years now. What’s the status of direct primary care in 2022? If a primary care physician is eager to transition into a direct primary care model, how difficult is it for that person?

Allison Edwards: That is the question with direct primary care, right? There are a lot of options. For those who are risk-averse, maybe, who want to make sure that they can continue to have that set, expected salary, there are some sort of DPC-like entities out there. They tend to be serving employers, or on-site clinics, or things like that, and I’m happy to talk offline with anybody who wants to about the brands associated with that. So there are those options, and those are pretty cool, because they operate on a capitated payment model.

Taking a step down, if you’re like, “I don’t really want to work for somebody, and I’m OK with bearing a little bit of risk,” with regard to starting with a smaller company or a mom-and-pop shop, the DPCs that started, as you said, 10 to 15 years ago are growing. They’re looking for partners. They’re looking for people to join. That gives you a level of autonomy that you may be looking for, and it allows you to be in a direct primary care practice without starting one. But those smaller mom-and-pop operations, like my clinic, don’t have the same bandwidth that a corporate model does, right? You have to bear a little bit more risk when you work with a smaller entity.

And then, of course, you can jump in and start your own direct primary care practice, and there are a lot of people out there who are still like, “That’s it. I want to own my own. I want to be the entrepreneur. I want to be my own business owner.” It’s always a welcome addition to any community, because a rising tide raises all ships. We are not competitors. There are enough people around to get everybody in.

Kevin Pho: We always hear about some of the great pros of direct primary care: more time with patients, a smaller patient panel, better work-life balance, things like that. But in general, how successful are direct primary care practices? I actually don’t often hear about direct primary care practices that go out of business and things like that. In general, how successful are they?

Allison Edwards: So there’s no official market data, right? There’s nobody out there with a pencil and a clipboard taking stock of everybody. So all I can offer is anecdotes, and the best way to answer that question is to say that a direct primary care practice started by a physician from the ground up, similar to what I did, is a small business, and not every small business succeeds. It does take a certain amount of grit, of tenacity, of willingness to learn some new things like website design and SEO marketing and, frankly, OSHA rules and payroll if you’re going to hire people and bring them on. There are people who are drawn to it because they’re like, “Yes, I want to be my own boss, and I want to do all this.” And then once they start to get into the nitty-gritty and the weeds, it’s like, “Actually, this is not my thing. It’s not what I want.”

So going back to your previous question, if you’re interested in direct primary care, and the idea of running a small business or managing people or learning all of those CLIA waivers and things like that, like for you, find a direct primary care practice out there that’s hiring, because you would be a welcome addition. If you, as they say, drink the Kool-Aid of direct primary care, there are places out there for you.

I don’t have a good specific answer as to how many succeed and how many fail, other than that if you look at some of the aggregators, the maps out there, the number of clinics is just growing year after year. The conferences are well attended. The number of people who are entering into this is growing year after year, and so there’s certainly momentum behind the movement.

Kevin Pho: So let’s take a step back and ask a more macro question. What do you see as direct primary care’s role going forward? Do you still see it as a growing niche? Do you see it as a model that can take over general primary care? What do you see as direct primary care’s role in the next few years?

Allison Edwards: Well, you’re looking at the biggest cheerleader for direct primary care, so my answer is maybe going to be different than somebody else’s. But I think that direct primary care is the only way to practice primary care that makes sense. So to answer, I think it should take over. I think it should be the way that we default to. And there’s a lot more behind that answer, because I think implementing a practice model, quote-unquote, at scale involves a lot of things that need to be thought about in a really pointed manner.

There was an excellent quote that I heard from an economist out of the University of Michigan, whose name I cannot remember off the top of my head, but he basically said that scale in today’s modern society is when we stop thinking about humans as humans. We stop thinking about our customers and our employees as humans, and we start thinking about them as values on a spreadsheet. That’s what everybody is annoyed with, and that’s what everybody hates about modern society’s scaled business: All of a sudden, you lose the human touch.

What makes direct primary care wonderful is that we have stripped everything away and have gotten back to the physician and the patient, and that is what it is. We have put that human relationship at the center of the business enterprise. Every primary care relationship should be like that. I’m serious. I think every person should have a primary care physician that they have a direct relationship with, that nobody gets in the way of, where no insurer meddles. I just think that if a corporation is like, “Yeah, let’s do that at scale,” they are perhaps not going to be the best ones to implement it. It needs to be done. I believe strongly that it’s the way to care for people.

Kevin Pho: How do you answer one of the biggest criticisms of direct primary care? If direct primary care were to be the default model, we already have a clinician shortage, and direct primary care clinicians, by definition, have smaller panels, and that’s going to mean less access. So how do you answer that?

Allison Edwards: My answer to that is a little bit more macro. We do have a clinician shortage, and I said this in my intro: Primary care is not the most well-paid physician specialty. We don’t really attract people because of the compensation. And not only that, but primary care is a tough job. We talked about this, right? The physicians who rotate through 30 to 40 people over and over. And then on top of that, there are some good time studies that show that for every hour of clinical care, you’re probably doing about two hours of paperwork. So if you’re working a 40-hour clinical work week, you’re being asked to do 120 hours of work in a week, right? That doesn’t make any sense. It’s a really tough position to attract people to. We just don’t have a ton of people matching into it.

So the answer to that is that direct primary care may tighten up the availability of clinicians if we were all to switch to it overnight, but in the long run, it would become a more desirable profession, because you would have autonomy. You would have the time with the patients. You’d be able to manage them without the insurance companies getting in the way. And not only that, but you can design a direct primary care clinic to the compensation level that you want, right? You can take on more people. There’s no rule that says if you’ve got 600 patients, you need to stop. So I think the answer is that direct primary care creates a better career, and that’s how we actually change the dialogue on primary care and the primary care physician shortage.

Kevin Pho: We’re talking to Allison Edwards. She’s a family physician, and we’re talking about her KevinMD article, “I wanted to care for people, so I became a direct primary care doctor.” So Allison, for those primary care physicians who are interested in transitioning, who are tired of hospital-based practices and the fee-for-service system, what’s the immediate next step they should take if they want to consider transitioning to direct primary care?

Allison Edwards: “Direct primary care doctor near me.” Get in touch with the person closest to you who is already doing this. That is the first step. Be respectful, please. They’re busy. Don’t just show up in their office and demand an audience. But do some good online stalking; that’s always a good first start.

The next is that there are some trade organizations out there that can be really helpful. They can give you not the personal, on-the-ground story of how my DPC works, but rather the nuts and bolts. There’s the Docs 4 Patient Care Foundation, the Direct Primary Care Alliance, DPC Frontier, the Direct Primary Care Coalition, and then, of course, the AAFP has a really good online resource for direct primary care. So there are some really good larger trade associations out there that can give you more guidance as well.

And it’s possible. I think the big thing to reiterate, and what I say to so many people, is that if it is meaningful to you and it is something that you want to do, talk with your significant other, your family, or whatever, because financially, especially if you jump off and you’re like, “I’m going to start a new,” it’s tough. But it is the most rewarding thing. It is absolutely worth it, and you will figure out how to make it work.

Kevin Pho: My final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Allison Edwards: Absolutely. Number one is that direct primary care is absolutely worth looking into. If you’re a specialist listening, and you’re seeing patients where you’re like, “Man, they need a good primary care home,” please know, same thing: “direct primary care doctor near me.” Google it. It does require some discretionary income, right? That is also the elephant in the room. If your patient fits that category, direct primary care doctors are going to be great to be the quarterback of that person’s health care journey, so send them there.

The other take-home point, which I think we’ve discussed ad nauseam, is just that it’s possible. You can do it. I really want to empower primary care doctors out there to explore that entrepreneurial journey and become independent. We don’t need to be beholden to hospital systems. There’s a whole world out there, patients who need our services.

And then the last one is that I think we can overly complicate medicine, and it’s not that hard to see that the benefit from primary care comes from that relationship, the doctor with the patient over time: continuity, learning what makes them tick, and seeing them over a lifetime. I think you’ve probably seen the studies on quality of care, and the whole beast of trying to measure quality in primary care is an impossible task. But we do know that having comprehensive, longitudinal primary care over a lifetime is associated with better outcomes. For better or worse, it’s an important thing to just strip it all away and say, “You know, this is what’s important.”

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

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