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We’re joined by Landen Green, a family physician with a passion for transforming health care. Discover the game-changing concept of direct primary care (DPC) as Landen sheds light on its benefits – from accessible same-day appointments to significant cost savings. Learn how DPC is reshaping the doctor-patient relationship, offering personalized care, and reducing administrative burdens.

Landen Green is a family physician.

He discusses the KevinMD article, “Direct primary care: more access, more savings, more care.”

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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 Landen Green. He’s a family physician, and today’s KevinMD article is titled “Direct primary care: more access, more savings, more care.” Landen, welcome to the show.

Landen Green: Thanks for having me, Dr. Pho. I really appreciate the opportunity to be on your show.

Kevin Pho: So let’s start by just briefly sharing your story and journey to where you are today.

Landen Green: Sure. I’m a board-certified family medicine doc. I did medical school at Campbell University in North Carolina, where I met my wife, who’s also a family medicine physician, and that’s where I started my own primary care practice using the direct primary care model of care. My clinic now is called Caravel Health DPC.

Kevin Pho: All right, so in your KevinMD article, where you talk about direct primary care, you also go more into your story. So give us a little bit of a before and after in terms of what your practice was like before your direct primary care practice, and some of the motivations that led you to start direct primary care.

Landen Green: Sure. I actually started the practice right out of residency. It doesn’t take very long in the system, even in residency, to realize that family medicine has changed from what it used to be. It doesn’t seem very authentic or genuine anymore, and maybe the motivations of corporations aren’t exactly aligned with the provider’s motivation to really take care of patients. So I felt that I wasn’t able to be the doctor that I wanted to be, and, probably more importantly, I wasn’t able to be the doctor that my patients needed me to be either.

Doctors are frustrated with seeing 40 patients a day and going home and doing a ton of notes and not spending time with their family. Patients, at the same time, are frustrated with having to wait three to six months to see a doctor and then waiting two hours in the waiting room just to see a different provider that they’ve never even seen before. So there’s frustration on both sides, and that is sort of what led me to say, “You know what? This isn’t working for anyone. Let me see if there’s something out there that may be better.” That led me down the path of direct primary care, which seems to be better for both parties. Patients are happy, and doctors are happy.

Kevin Pho: So before we go further, let’s discuss some definitions in terms of what direct primary care is. I’ve had several direct primary care physicians on, but for those listening who aren’t familiar, just give us a 30-second definition of what that is.

Landen Green: Sure. The 30-second definition is that it’s really authentic and genuine family medicine. Patients pay a low monthly fee, generally between $50 and $100, in exchange for health care, and the doctor doesn’t bill insurance. So patients can come into the office for unlimited office visits or video visits without any additional co-pays or visit fees. A lot of times they can text, call or email their doctor directly.

A lot of other things are included in that $100 or $50 a month. In-office testing, like strep tests, COVID tests, flu tests and urinalysis, is included. Procedures like joint injections, stitches, abscess drainages and toenail procedures are included. So there are no additional fees for all of these things.

Then we provide better access and better affordability for things like medications and labs. A lot of direct primary care clinics dispense medications right from their office for at-cost pricing, so they don’t profit off of it, and the same goes for labs. Most of the common blood tests, like a CBC or CMP to check blood counts or kidney, liver and electrolytes, those kinds of things, are between $5 and $10, and there’s no sort of barrier between patients and their doctor about ordering these tests.

Kevin Pho: And to be clear, this is in contrast to what’s known as concierge medicine, where you hear of fees like $2,000 to $3,000 per year.

Landen Green: Correct. That’s a very common question. Anytime you say there’s a monthly fee, that it’s a membership-based model, a lot of people sort of say, “Oh, well, I can’t afford that. That’s for the rich.” And direct primary care is really not like that.

Both concierge and direct primary care give excellent care, right? With both, you have better access to your doctor, and you get a doctor who knows you. But really, the difference is the money and the way that insurance is used. In concierge medicine, the fees are higher, generally double or triple the monthly fee, and patients still have a co-pay or a visit fee when they see the doctor, and they’ll still get a bill from their insurance for the visit. Whereas in direct primary care, there’s no co-pay, there’s no visit fee, and they’ll never receive a bill from their insurance.

But direct primary care clinics can still use insurance when it’s necessary. We can still send a medication to a pharmacy and have the pharmacy bill the insurance, or send a lab to the actual lab and have the lab bill the insurance, if that’s what’s advantageous for the patient. But a lot of the time, probably 80 or 90 percent of the time, this primary care stuff is cheaper and more easily accessible without bringing insurance into the picture.

Kevin Pho: Now, with most of the direct primary care physicians I talk to, it’s always a story of them practicing in a traditional system, and then they get burned out after 10 or 15 years of practice, and then they switch over to direct primary care. You’re a little bit different, in that you went straight out of residency into direct primary care. So tell us what kind of exposure you got to direct primary care during your residency training that made you want to really explore that path.

Landen Green: When I was a second-year is actually when I first sort of heard about direct primary care, from a YouTube video by Dr. Farrago. That video just sort of opened my eyes a little bit and made me reach out to other direct primary care doctors who were close to my residency training site, to see if I could do an elective rotation with them. So I ended up doing an elective rotation in direct primary care and fell in love with it.

When you’re in residency, or when you’re in a health care facility, or when you’re doing anything in medicine, you come across people who are burned out. So every day you’re seeing what your future could look like, and to me, I knew that that was the path I was sort of heading down. So I’m very, very thankful to have stumbled across direct primary care.

Kevin Pho: And when you made the decision to open your direct primary care practice, what was the reaction from your colleagues and your program director? Did they have any doubts? Were they asking, “What are you doing?” What was their reaction?

Landen Green: I think everyone had doubts, including myself, but if you don’t have doubts, then I don’t think that you’re being realistic either. So that’s sort of expected, but there were definitely a lot of doubts. I think a lot of the doubt comes from not really understanding it. But once you understand it and realize how affordable primary care is, and the fact that I don’t need a patient panel of 3,000 or 4,000 to earn a living, it really just sort of brings everything into focus and makes it easier.

Kevin Pho: All right, so take us into that transition. You finish your family medicine residency, and you open a direct primary care practice. Tell us what happened next. How difficult or easy was it to build up that patient panel?

Landen Green: It was pretty difficult to start out with, but then it sort of snowballed into it being, knock on wood, fairly easy at this point. The reason that it may have been a little bit harder for me is that I moved. I’m from North Carolina, trained in Pennsylvania and moved to Southern California, so I wasn’t a known entity. I didn’t have a lot of family or friends, and so that was something that was sort of working against me. Over the first two months of opening, I had one patient sign up, and my goal for the first year was to have 100 patients. Now, six months in, I have about 140 patients.

So the snowball effect really, really happened. Sometime in January, I started to advertise a little bit more on social media and was starting to have 20 or 30 patients sign up per month. And now, basically almost a year, not even a year into it, word of mouth is really starting to pick up. Patients really, really love this service, and people just love talking about what they love, right? So I have a lot of my patients talking to their friends and family, and even if their friends and family don’t sign up, it’s interesting, and so they’ll talk to other people about it, and eventually, somewhere down the line, I’ll have a patient sign up. So the first two months were hard, just sort of getting my name out there, but since then, thankfully, it’s been a steady 20 to 30 new patients a month.

Kevin Pho: Your KevinMD article is titled “Direct primary care: more access, more savings, more care.” Take us into a typical day of a direct primary care physician. What’s your typical day like?

Landen Green: I usually get to the office around 8:30 and check emails, to make sure no one emailed me any questions overnight, because a big part of the model is that patients can directly contact their doctor. So I get text messages and emails and phone calls from patients fairly frequently, and that’s the first thing I do when I get in in the morning. Of course, I set barriers with patients too, so it’s not too much of a burden on me, but at the same time, I want them to know that if they feel like they need a doctor, they shouldn’t hesitate to reach out to me. So that’s the first thing I do.

Then maybe I’ll see a patient at 9, and that visit may go until 9:30 or 9:45. Then maybe I’ll have another patient come in for a blood draw, so I’ll draw their blood and then they’ll leave. Then maybe I’ll call some patients and talk about their lab results from last week. Then I’ll have a patient come in and pick up their medication, and then at maybe 11, I’ll have a new member patient. My new member visits are 90 minutes long, so we really get to set a great foundation for their health moving forward, and I’ll draw their labs too. So that takes us to about 12:30. Then maybe I’ll take 30 minutes for lunch and do the notes. So that’s pretty much how the day goes throughout the rest of the day. And then maybe I’ll get a phone call from a patient who’s having some burning when they urinate, or some urinary tract symptoms, and then they’ll come in and we’ll test their urine.

So it’s very similar to a typical flow of primary care, where you’re seeing a lot of different things. I would say it’s more personal, because I know pretty much everyone who comes in, and I get to spend more time with them. And I feel like I am actually doing more, versus what I was doing before, where it was, “Here’s your CBC and CMP. See you later.” Now it’s really talking about all those things and being able to offer them all in the same place too.

Kevin Pho: One of the features, of course, of direct primary care is that patients have increased access to you: phone calls, text messages. How obtrusive is that? Are you getting texts in the evening? Are you getting texts during the weekends, during family time? What’s that like when you’re not in the office?

Landen Green: So far it’s been OK, because I really try to set barriers with patients from the very beginning. So from the first new member visit, I go over when they should call me, when they should text me and when they should email me. The conversation sort of goes like this: If you’re having left-sided chest pain that’s radiating down your left arm into your left jaw and you can’t breathe, call 911. Don’t call me, because I’m just going to tell you to call 911. But after you call 911, then have a family member call me and let me know what’s going on, because if I have a patient who’s going to the emergency room, I do want to know about it. That way I can talk to the emergency room doctor if they’re having a hard time finding out about the patient’s health care, or I can even go to the emergency department with them if I’m not doing anything else. So that’s the first thing I tell them.

The second thing I tell them is that if they twist their ankle really badly, or if they’re cleaning and they get some Clorox in their eye, and they’re not sure if those things are something they should go to the emergency department for, then they can call me first and we’ll talk about it. Maybe it is something you need to go to the emergency department for. Maybe it is something where, OK, it’s 10 p.m., but this is important, and I need to meet you in the office right now to save a trip to the emergency room. Or maybe it’s something where you can do this and this and this at home, and I can see you the next day.

Then the third scenario I tell them about is if it’s 2 a.m. and you just can’t sleep at night. Well, then don’t call me, because then I won’t be able to sleep, and it won’t be good for anyone. Instead, write me a really long email about why you can’t sleep, what things you’ve tried in the past, what hasn’t worked for you, what’s worked for you, what you’re thinking about and what you think might be helpful. That way we can schedule an appointment and go over that long email.

At the same time, I let them know that things like scheduling appointments or medication refills are best done in an email instead of a phone call or a text message, because I know I won’t miss their email, but if they text or call me, it might slip through, and that may happen. That also sort of pushes the patients into using my preferred method of communication, which is email.

Kevin Pho: Now, for those residents who are in primary care specialties, family medicine and internal medicine, who are listening to you and maybe considering a direct primary care practice straight out of residency, just like you did, what kind of questions should they ask themselves to see if they’re really the right fit for that path?

Landen Green: That’s such a hard question. I would say: Would you rather try something and have it fail, or not try it and always wonder what would have happened if you had tried it? Because that’s sort of what I asked myself. I said, “OK, I want to try this direct primary care thing, and if it fails and I lose some money, then that’s OK. At least I can live with myself, saying that I tried to do something different.” Versus if I had just stayed down the path that everyone else chooses, every day I would have gone to work wondering, “What if? What if?” So that’s what ultimately made the decision for me.

And ultimately, in residency, reach out to direct primary care doctors. We’re such a small, well, we’re not really small, but we’re such a close community, and we’re so ready and available and willing and wanting to help residents learn about direct primary care. Just reach out to someone in your area to see if you can shadow for a day, if that’s all you have, or do an elective rotation, and I guarantee you’ll find someone.

Kevin Pho: What about the burden of student loans, right? A lot of medical students graduate and finish residency with hundreds of thousands of dollars of student loans. Does that play a factor in the decision of whether to go into direct primary care, where it may be a little bit more financially unstable than going the traditional route?

Landen Green: That’s where I’ve gotten really lucky. For one, I bought and sold a home in residency at the perfect time, so I ended up getting a lot of capital from that. The second thing that I’m lucky with is that my wife is also a physician, and so we still have a stable income. As far as student loans, I’ll be on an income-based repayment plan, and so far that hasn’t even started yet, right? So that is something that I’m somewhat worried about, but it’s going to be income-based, and so I’m not overly worried about it.

But I would say that the number one thing that has been the toughest about being a direct primary care provider and starting out right out of residency is that you go through residency and you’re ready for your attending salary. For me, I’m over a year out of residency, and I still haven’t paid myself yet. The practice is doing really well on meeting overhead, but everything I make is going back into the company. Next year I’ll probably make maybe $100,000 to $120,000, and the year after that maybe $200,000 to $250,000. So it’s going to take three to four years before I start paying myself a physician salary, and that’s tough, because all through residency you’re struggling, and you want the new house, you want the new car, you want all these things. So that’s been the toughest struggle for me, even with having a spouse who’s a physician, and in California, I guess that doesn’t really mean much.

Kevin Pho: So as you reflect, and you’re still at the beginning of your journey, as you reflect on training and on when you made the decision to go into direct primary care, is there anything that you would have done differently? Is there anything that surprised you? Just reflect on that.

Landen Green: There’s not much that I would have done differently. Probably the most surprising thing is just how appreciative patients are for the service that I provide. When I text a patient just to check on them the next day, they are elated, and they’re just like, “Oh, it’s so cool that my doctor texted me.” They love it. The other thing that surprised me is, honestly, how fast the direct primary care practice has grown. A hundred forty patients in about eight months is outdoing my expected pace, and it’s all because of how much patients are loving the concept and the care. So that’s been the most surprising thing to me.

Kevin Pho: We’re talking to Landen Green. He’s a family physician, and today’s KevinMD article is titled “Direct primary care: more access, more savings, more care.” Landen, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Landen Green: For the fellow clinicians out there, if you’re struggling and you’re on the brink of burnout, just Google it and look into direct primary care. Talk to direct primary care providers in your area and see if it could potentially be a pathway for you. No, it’s not for everyone, and there are a lot of reasons why it may not be a pathway that you can decide to go down, but I would at least encourage you to check it out.

For the patient audience, same thing: Just check it out. There’s no harm in going to a meet and greet with a local direct primary care doctor near you, or just Google searching “direct primary care near me.” There’s no harm in doing those things and checking it out. With most direct primary care memberships, there’s no long-term contract, so you can try it for a couple of months, and if it’s not working for you, then there are no hard feelings. But if I had to bet, I would say that you would love it just as much as everyone else.

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

Landen Green: Thanks for having me, Dr. Pho.