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Join Paula Muto, a vascular surgeon, and Jeffrey Gold, a family physician, as they discuss the state of the health care system. Explore the evolution of primary care, the challenges of fragmented patient care, and the impact of administrative burdens on doctors and patients. They delve into the benefits of direct primary care, its potential to improve doctor-patient relationships, and how technology is transforming the health care landscape. Discover the role of transparency, competition, and accountability in a direct pay model, and explore the implications for health care costs, accessibility, and patient outcomes.

Paula Muto is a vascular surgeon. Jeffrey Gold is a family physician.

They discuss their KevinMD article, “The rise of direct pay: a solution to the fragmented, impersonal and costly medical system.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Paula Muto and Jeffrey Gold. Paula is a vascular surgeon. Jeffrey is a family physician, and together they wrote the KevinMD article “The rise of direct pay: a solution to the fragmented, impersonal and costly medical system.” Paula and Jeffrey, welcome to the show.

Paula Muto: Thanks, Kevin. Thanks for having us.

Kevin Pho: So I’m going to ask each of you to just briefly share your story and journey to where you are today, and then we’ll talk about the article. Paula, you’ve been on before, but for those who didn’t listen to our episode together, just briefly share your story and journey.

Paula Muto: Sure. So I’m a surgeon, as you say, from a family of surgeons in Massachusetts for a collective century. I’m also the head of UberDoc, which is a direct pay platform. We’re trying to kind of disrupt the system with a little price transparency and access. I’m a frontline doctor. I see patients every day, and the system doesn’t work, and we’re just trying to change it.

Kevin Pho: Fantastic. And Paula, how do you balance what you do as a vascular surgeon with your company?

Paula Muto: So, because our company has so many doctors around the country, and they’re practicing physicians, I feel like I need to be in front of my patients every day to understand exactly how the world is changing. And then, a lot of times, the afternoons become running a platform. It is a challenge, but I think there are a lot of physician entrepreneurs out there who are really desperately trying to change the system, and the only way we’re going to change it, especially for physicians to be empowered, is to remain close to our patients and our colleagues.

Kevin Pho: And we’re going to talk about that in your KevinMD article. But first, Jeffrey, briefly share your story and journey to where you are today.

Jeffrey Gold: Yeah, I grew up in Swampscott, Mass., on the North Shore of Boston, and now practice in Salem, Mass. I worked as an employed family physician in the system, for the big hospital system, for the first 10 or 12 years of my career, and for all the reasons I’m sure you are familiar with, I got to the point where I was either going to quit medicine completely, end up in an institution, or have a heart attack or stroke.

I was 38 at the time. I’m 47 now. And I said, “The system is not going to change by me just complaining about it. I actually have to do something.” I kind of got tired of listening to myself complain. I heard about concierge medicine in the Boston area, but I didn’t really feel that it got to the root of what the problems are with our current system, and I had never heard of direct primary care. And when I did hear about it, it was like the light bulb went off, and I said, “This really is what I’ve envisioned.” I’ve just never been able to kind of formulate the idea in my head, but people in other parts of the country were already doing it.

I sought them out, got great counsel and advice, and opened up the first independent DPC practice in Mass. back in January of ’15, and was told that it would fail, it would never work, and I’d be back begging for my salaried job. But here I am seven years later, and I have a family nurse practitioner working underneath me and supervised by me. I have an internal medicine colleague that we share office space with, with the same model. And since I’ve opened, there are, I think, somewhere between 15 and 20 DPC docs practicing in Mass. independently now. My hope is to continue to grow the model and support other physicians and residents and med students to revisit what real primary care can look like, and the power of what it can do when it’s allowed to practice medicine and not insurance.

Kevin Pho: So, Jeffrey, let me follow up, because I’m always interested in that transition, and a lot of employed primary care physicians were in a similar position to the one you were in back when you were in your late 30s. How was that transition itself? Because doctors I talk to, they like that financial security of that employed position despite all the difficulties. What made you actually take that leap and take action? And in general, just how was that for you?

Jeffrey Gold: Yeah, I think it’s a great question, and I think it’s the rate-limiting step in changing the system. We actually had, a couple weeks ago, you may have heard about it, a big medical system on the South Shore of Boston that just closed overnight and left 80,000 patients without a primary care doc and a bunch of staff without jobs. And the risk you take of being in a corporatized model is just that. But yet, the medical board in Massachusetts sends out an email to every licensed physician saying that you’re responsible for not abandoning these patients, and taking care of them, and making sure they get their meds. But yet, corporate just decided to close. So what do you do? Take care of them in your garage? Ultimately, the responsibility is with us. So why shouldn’t the control be with us?

And doctors? We’re partly to blame for this. You get treated how you allow yourself to be treated. And for me, I just got to the point where I couldn’t. I love medicine. I love patient care. I love using my brain and learning stuff every day. I come from a family that ran a small business in retail, and I never thought that that would be something that I would even consider doing. But the reality is we have to take control back, and the only way to do that is to control how you practice and control the dollar and who you’re taking the dollar from. I’m a firm believer in that. I think the use of insurance as a payment model is ridiculous. It’s absurd. We don’t do it in any other economic model.

But what’s happened is people have come to believe that everything in health care is so expensive that if you don’t use insurance, you’ll go broke. Well, the irony is the insurance is making people go broke, and the lack of transparency is what’s making people go broke. Primary care, if it’s allowed to function, 80 percent of your care can be handled in the primary care setting, and we’re not expensive. We’re not doing brain surgery. We’re not doing joint replacements. It’s cognitive, it’s relationship-based, and that’s what it should be. And when you actually lift that sheet up, lab work and medicines are all really affordable in most of the cases if you get insurance out of the way and just see what it costs.

So for me, I just didn’t know what else I was going to do. Was I going to just leave medicine? I mean, what do you do as a doctor who spent your 20s training, and then you just say, “Am I going to go teach, or what?” I mean, I’m sure I would have found something, but I think my calling has always been this, and I don’t think it’s a job. I think it’s a calling. Everybody’s always investing in the new tech platform or data or whatever, but the one thing we’re not investing in is the human relationship, and that’s what makes health care function, especially downstream. If I have to send a patient to a surgeon like Paula, there should be communication between her and me: “This is what we’ve done, this is what my questions are, this is what I can’t fix, and I need your help.”

The fragmentation is what is making the system just unattainable for patients and doctors. And look, if a doctor is satisfied with their guaranteed salary and benefits, as you suggested, and they want to hit the easy button, that’s OK. Look, I’m a free-market guy. Make your choice, and do what you think is best for your family and you, but please don’t complain about how you’re being treated, because you’re making a conscious choice.

Twenty years ago, it was either going to concierge medicine and charging high prices and whatever, but now there are options out there. I mean, in the New York Times yesterday, there was a big article published on what’s going on for all doctors, from primary care to specialties, and the reality is this is here. There are specialists doing this. There are different ways to do this, but it’s going to be up to us to fix it.

Paula Muto: I think it’s interesting just to comment on the evolution. Primary care is in the office, and specialty care is in the office, too, where our technology has moved us into different sites of service, and with that shift of site of service, things are better, faster, cheaper. So it makes plenty of sense in 2023 to sort of return back to that relationship, because ultimately, it is a relationship between a patient and a doctor, and there doesn’t need to be all this nonsense in between. That was built in the old days, when we all rounded at these big hospitals and all of our patients stayed in the hospital for 7 to 10 days after surgery. I mean, it just doesn’t happen like that anymore.

Kevin Pho: And both of you talk more about that in your KevinMD article, “The rise of direct pay: a solution to the fragmented, impersonal and costly medical system.” Now, Paula, how did this article come together?

Paula Muto: So I like to say that it’s like a rumble of a specialist and primary care, right? A family practitioner and a surgeon. I mean, Jeff and I are natural colleagues because we’re both passionate about health care, and also about our patients, and we see the solution. We both lived in this world and see that it works, and we want other people to know about that.

So our article is really about, and I like to use Jeff’s analogy, the concept of primary care as the quarterback, not the gatekeeper. You’re not taking the tickets at Fenway Park. You’re Tom Brady. You’re the one who’s passing the ball. And so we’ve kind of devolved into this, because of insurance, not for any medical reason, to follow these paths. And so I think that, wanting to return back to that really high quality, and Jeff is understating it, DPC doctors have the best outcomes in the country right now. Employer-based plans are running to DPC, that model, because it’s better, faster, cheaper. So if you want to find a great doctor, you want them to be DPC, because they work for you. It’s as simple as that. They don’t work for anyone else but you. And so those statistics are hard to beat in the world of value-based care and everything else.

So our article has really talked about how it’s really very simple to return to that. And how do you do it? You take the car, and you don’t use your car insurance for the oil change. You use insurance for those big events in life that you need insurance for, and you try to restructure your doctor-patient relationship with a transparent direct pay model. The patients have to meet you halfway, and the doctor has to meet you there. And that’s part of my mission, to give doctors an easy tool to start that journey. Whether you’re a specialist in internal medicine, primary care, or neurosurgery, we just want you to start that journey.

Kevin Pho: So Paula, from the patient perspective, run me through a typical case study or story. If a patient went to your clinic, you’re a vascular surgeon, run me through a typical scenario of how that would work.

Paula Muto: You mean UberDoc, or just my office? Just in general?

Kevin Pho: Just, I would say, in general.

Paula Muto: In general. So typically, I’m a modern doctor. I get referrals from primary care physicians whom I do not know anymore. I work in a community with two rival hospitals. So sometimes they’re Red Sox fans, sometimes they’re Yankee fans, and the patients end up at the wrong stadium. As a specialist, you kind of straddle these areas.

So I’ve always been direct-to-consumer online. Patients find me online. They Google their symptoms, like restless leg, and they find me, and so they can come in that way. I see them in person. I even see them sometimes by telemedicine. And then I get a lot of referrals. I work really closely with a federally funded health center. I train family practice residents, so they come in and they see my work. I do a lot of work with venous disease and with the wound center. My husband and I do all the wounds in the Merrimack Valley. And so, understanding how you intervene on these patients.

So typically, when a patient enters my office, they’ve either picked up the phone and made the call, they’ve gone online to try to book, or they get referred by their primary care or the health center. Those are the kind of three avenues patients can access. Now, if I don’t have anyone answering phones, they don’t get an appointment. If they need a referral authorization, they come in, I might see them, and then, oops, I don’t get paid. And then we try to do some procedure on them, and you don’t get paid because you didn’t have that first referral. So you need to have that front end to be able to be on top of that. And many times you have those nasty notes in your glass: “If you do not have your referral, go home.” And so, not a great way to survive, but I live in the system that way.

Kevin Pho: So, Jeffrey, contrast that as a direct primary care physician. Talk to me about the patient experiences for patients who come to you.

Jeffrey Gold: Yeah, I think the key is I don’t even have one foot in that system anymore. And I always say I’d rather be a janitor at a Taco Bell than go back to what I was doing and have any toe in that system. I don’t think it’s broken. I think it’s built exactly the way it’s wanted to be built by the people who built it. But the patients and the doctors, and I include nurses, therapists, the caregivers, are the ones.

And for me, for my patients, the hope is that it’s direct. I have one office staff, one medical assistant, and one NP, but they can email me directly. They have my cell phone for nights and weekends if urgent issues come up. And I will tell you, everybody says one of their biggest fears about leaving the system to do DPC is they’re going to be bombarded at night or on the weekends. And the reality is that may have happened when I first opened. I think people were subconsciously like, “Ooh, I’ve got to test this out and see if the money that I’m paying him directly is good value.” But when you respond and they know you’re there for them, I can honestly say that in the seven years I’ve been doing this, there have probably been 15 to 20 times I’ve had to go in on a night or weekend to stitch somebody or really do something that required me coming in. Most of the time, when you know each other, it can be a text message, it can be an email, and that’s where I think the power of the relationship, rather than a series of transactions, comes in.

And I’m going to say, if I go back to your last question to me, this was not easy. I’m not going to sit here and say this transition was easy. I wrote an article about five years ago that you accepted onto the blog. I really think we’re addicted to health insurance, and I think it’s the worst addiction this country has, because it’s literally bankrupting people. And trying to break people and get them through that withdrawal period was not easy. Everyone knows the system sucks. They know it’s working against them, but then you sit there and you say, “Well, why do they not leave?” It’s like the Stockholm syndrome, that they feel they’re captive and identify with their captor. Some patients actually have asked me, is it illegal to pay me money? I mean, just to get service from me. It’s insanity.

But I think for the patient, the hope is that they, and I think Paula used a great word, a quarterback, they have somebody. Even if it is something that’s out of the scope of my ability or my training or my knowledge base, I have the resources available to look things up. I look things up with my patients in medical resources all the time, and they appreciate that. I mean, as a generalist, they know that I’m not going to be able to keep up with every possible study or new guideline that comes out. So I look things up with them all the time, and I think it’s just being their advocate. I mean, this isn’t a hard job for certain reasons, but when you have that relationship and a patient has an advocate, the whole game changes.

So for them, I really hope it’s the things that I can do here. They feel I’m accessible. I mean, we guarantee we’re going to see somebody no later than the next day, depending on the urgency. Ninety-eight percent of the time they’re seen the same day, because I don’t have to see 20 to 25 people a day anymore in eight-minute increments to justify my value to a third party.

Kevin Pho: So, Jeffrey, how many patients typically would you see daily, and how long would you spend with them?

Jeffrey Gold: In the seven years I’ve been open, I’ve probably had four days total where I’ve had 12 patients that I’ve seen in the office, and that was a busy day. The typical day for me is usually in office, maybe three to six people. If it’s an acute issue, they’re getting a minimum half hour of my time. Sometimes it’s less, sometimes it’s more. Our annual checkups, to go over preventative stuff and go over their chronic conditions, are a minimum of an hour, but I can make my schedule. If I know somebody has a lot of social needs or whatever, I can schedule extra time if I need to.

But a lot we do through email and telehealth. If I’m depressed and anxious, the last thing I want to do is go sit in an office for 45 minutes when I can be at home and talk to my doctor, just like we’re doing now. The saying that I always put on social media when people talk about technology is, “Technology should enhance the relationship; it shouldn’t replace it.” There’s a difference between a patient having me on the other end of the call and a random physician or mid-level who knows nothing about them, and vice versa. The technology, our delivery models, are so archaic. It’s just insanity.

Kevin Pho: So, Paula, one of the criticisms I sometimes hear about direct primary care, or direct care in general, is that by definition, these physicians or these clinicians see fewer patients. We already have a primary care shortage, so if more and more physicians choose direct primary care, who’s going to see all these patients if these clinicians are seeing fewer?

Paula Muto: So I think that it’s not quantity, because you think about it, a lot of times the people waiting in those waiting rooms are just waiting for a bus ticket to come to see me, right? A lot of volume is artificial because of the gatekeeper concept, right? Out of those six patients that need to see Jeff, there could be another 12 that are just waiting to get a referral for their eye doctor. So I think that there is a shortage of specialists, but Jeff is a specialist, and so am I. Remember, every physician is actually a specialist.

I think we aren’t necessarily short on primary care providers, in the sense that we are turning out a lot of mid-levels that sit in walk-ins and CVS clinics, and Walmart is expanding, but those have limited scope. It might be good for a UTI prescription, but once you have that kidney stone, or something more complex, or renal insufficiency or something else, it triggers another layer, and the access to those layers is what’s obstructed.

I should say, just in terms of specialists, surgeons especially, like my colleagues in general surgery, you’re attached to a hospital, right? Because you’ve got to operate somewhere, right? And it makes it really challenging for them to be, quote, independent and work for the patient and so forth. However, doctors need to be better at that, too, because we tend to then be blinded to the cost for our patients. “Oh, I’m going to just do this in the hospital. I’m just going to order this test, or I’m going to do this.” And you forget that, wait, time out, you can’t do all this, because the patient may not be able to afford that. They’re not going to show up for that breast ultrasound. They’re not going to show up for these things because they can’t afford them.

So I do think that from a specialty standpoint, there are challenges, and we shouldn’t really move away from specialty without talking about consolidation, too, because the consolidation that happened at the primary care level is now happening also at the specialty level, which brings in a whole other realm of corporate kind of medicine. But I think that there’s availability out there. We just don’t resource it properly, and one of the things we’re trying to do is just take existing inventory and match it to patients in need. And I think we’re good for that.

Kevin Pho: We’re talking to Paula Muto and Jeffrey Gold. Paula is a vascular surgeon, and Jeffrey’s a family physician. Together they wrote the KevinMD article “The rise of direct pay: a solution to the fragmented, impersonal and costly medical system.” Now I’m going to ask each of you for your take-home messages to the KevinMD audience. Jeffrey, why don’t we start with you?

Jeffrey Gold: Ooh, take-home. I would say, and I’m going to steal Apple’s slogan here, “Think different.” Just because we’ve been doing this model for decades and decades doesn’t mean it’s right, and it doesn’t mean it’s effective. And just to touch on what you just said, I don’t know if there really is a shortage of physicians. I think there’s a shortage of a system that works for patients and doctors. I think they’re very different things.

So I would just say, think outside the box and really think about it: We’re all patients at some point. And just think and ask yourself, what type of care do you want for you and your family? And if you’re OK with what you have, that’s a choice. That’s fine. But I think if you really want to fix this system, it’s got to be a bottom-up fix, and it’s got to be doctors working together to demand different.

Kevin Pho: And Paula, we’ll end with you. Tell us some of your take-home messages to the KevinMD audience.

Paula Muto: So the Harris Poll just came out saying over 80, 85 percent of patients, people, adults, trust their doctors. And over 70 percent of people don’t like the health care system. I think that’s all physicians need to hear, right? To give them the confidence that what they feel is the right thing is in fact the right thing, and to take that first step and to step outside the system, because it’s not working anymore. And Jeff is right. The change has to start with us. But that first step is easier than you think.

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

Paula Muto: Thanks for having us, Kevin.

Jeffrey Gold: Thank you.