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Join Grace Torres-Hodges, a podiatrist with a passion for physician autonomy and patient-centered care. We’ll delve into the significance of clarity in purpose and how the direct care model empowers physicians to prioritize their patients’ well-being. Discover how this approach not only enhances the doctor-patient relationship but also addresses burnout and creates a meaningful impact in the health care landscape. Tune in for insights on aligning values, fostering autonomy, and delivering exceptional patient outcomes.

Grace Torres-Hodges is a podiatrist.

She discusses the KevinMD article, “Breaking free: the power of physician autonomy in patient 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 Grace Torres-Hodges. She’s a podiatrist. Her KevinMD article is titled “Breaking free: the power of physician autonomy in patient care.” Grace, welcome to the show. How are you doing?

Grace Torres-Hodges: Thanks for having me. Great.

Kevin Pho: So first, let’s briefly share your story and journey to where you are today.

Grace Torres-Hodges: I am a podiatrist and foot surgeon here in Pensacola, Florida. I’m the owner and founder of Torres-Hodges Podiatry, and we’ve been in business since 2001. I did my undergraduate schooling at Vanderbilt. I didn’t go directly into medicine; I actually worked in Washington, D.C., for a while before finding medicine again through a sports medicine mentor I had in grad school. I found podiatry and went to the New York College of Podiatric Medicine in Manhattan, and I did my residency training in podiatric medicine and surgery at St. Vincent’s in Jacksonville. I actually came home to practice in Pensacola because both my parents practiced here also. One of the reasons I didn’t go into medicine immediately is that I thought they were pushing me, so I had to find it myself. So, ironically, autonomy has to be felt within yourself first, before you really feel like you want to go into it.

I’ve been in practice, like I said, since 2001, and went through all the changes a new practitioner would normally go through, doing well practice-wise, clinically and financially, to stay afloat in a solo private practice. In 2013, Obamacare and the ACA came in, and things were changing, and things were already changing as practices switched over to e-prescribing and EMRs and everything like that. Long story short, and this is something many of your listeners probably have also felt, it’s the overwhelming strain of third-party, insurance-based medicine.

I went to a meeting in 2013 that opened my eyes to the free-market medicine movement, which was mainly direct care, and mostly direct primary care. As a specialist, because our care is so episodic, I thought, “How in the world do you do that?” I found a way, just by going through it, and I found others who had already done it. So one of the biggest things is always looking for a mentor, and I had some great mentors along the way. In 2017, I went 100 percent cash. It was a very strategic transition. I am very happy with the way I’m practicing now, and it’s much more stable. My patients benefit from it also, which is probably the biggest plus. It’s relationship medicine again, and I’m open to doing more of what I want to do, not only clinically but also in my private life. So that’s my thing. The article I submitted to KevinMD has to do with finding that. I use the term “compass”: finding your way back into it. For me, direct care ended up being a way to find physician autonomy again. So that’s basically where I am right now.

Kevin Pho: Sure. So your KevinMD article, in which you talked about your journey, is “Breaking free: the power of physician autonomy in patient care.” Talk about your practice today. What’s it like?

Grace Torres-Hodges: It’s an insurance-free practice, a direct-pay practice, and it’s a direct-pay practice because of the type of care I do. I do a full scope of podiatry, from conservative care all the way to surgical intervention, and I’m on staff at all my local hospitals, including the Andrews Institute in Gulf Breeze.

Probably the best way to explain this is that my aha moment came when I had to deal with the plumber at our house, and how easy it was for me to get what I needed, and for the plumber to be satisfied in his business. Long story short, what do you do? You call and ask around on your social media and among your friends and family: “Who do you use?” You call them up and make an appointment, and they evaluate and assess. They give you an actual price, an estimate; they give you a quote. You make the decision; it’s up to you. When you decide to go with that individual, you let them do their thing the way they want to get it done. You’ve already agreed on a payment, you pay them and everybody’s happy in the end, because you’ve got your thing fixed, and they got paid for doing their job at the value they priced it at. I couldn’t figure out why we couldn’t do that in medicine, and really, that’s basically what it comes down to.

I had lots of conversations with patients I got frustrated for, because everything was so delayed for them, and we’d find other ways out. The medicine gods basically helped me, because so many of the promising and innovative treatments are typically never covered by insurance to begin with. I do laser. I do a lot of aesthetic medicine here, and a lot of preventive care, which third-party payers, I think, assume should just be included. You still have to use your head. There’s that phrase: “Don’t pay me for the time I spend; pay me for the years it took for me to get like that.” That’s where there’s a disconnect with the third-party insurance folks.

As a result, all my prices are now listed online. Because podiatry is episodic, it’s hard to do a membership base, which is what the DPC, or direct primary care, models were always based on. So you treat it almost like a mechanic or a plumber would, just when patients need it. The nice thing is that you can bundle; you’re not restricted by any kind of protocol. It’s your protocol. For instance, in my case, I offer bundled services for things like a series of treatments, like lasers for musculoskeletal problems or for nails, or surgeries. If I’m doing more than one procedure on a foot, we can bundle it. Why do I have to charge for each one individually? I also have a relationship with the facilities I work with. The biggest thing I tell patients all the time is to ask for cash prices, because people don’t see the price when they’re not the one paying.

And because there’s an onus on the part of the patient, my patient base right now is so much healthier. There’s a lot more preventive, proactive care, because they have a stake in it themselves. On the contrast, everybody always asks, “Well, then you must not care about poor people.” And actually, because my time in the office is more intentional, I can volunteer my services outside. Before, when I was in an insurance-based practice, I didn’t have any volunteer time to dedicate. Every community has an indigent clinic, and I have time for that now. Because my time in the office is intentional, I can spend time elsewhere and offer services there. So it works out. It’s a plus-plus, a win-win, all the way across.

Kevin Pho: How difficult was it to build up your patient panel? Because as a primary care physician, if I referred a patient to a podiatrist, of course they would have the option of going to the in-house podiatrist affiliated with a certain medical center, versus someone who is direct pay. So from a patient standpoint, talk about the choice they’re facing. Was it difficult to build up a patient panel, given that patients were confronted with that choice?

Grace Torres-Hodges: I was coming from an established practice. I was 15 years into practice already, with a name and a reputation, coming into it. The hardest thing was seeing many of my patients leave originally, because when you tell them, “I’m no longer taking insurance, and you’ll have to pay out of pocket,” the idea is still foreign to them. Now it’s changed tremendously, just within the last three years, probably. But that’s one of those things: You never want to feel rejected by people you’ve been taking care of for a long time.

With regard to your question, I hate to say it like this, but just as when you’re buying a TV or any kind of service, you look at the outcomes, you look at the patient satisfaction, you look at the reviews and everything like that. Let your work speak for itself. The plus of going with any specialist or physician outside of a system is that there are no protocols, and the delay it takes to get in to someone who’s in network, versus sometimes same-day visits with me, is night and day.

Case in point, I’ll use the example of a fractured foot. Eighty percent of my patient base still has insurance, yet they choose to come and see me. Why? Because they believe the care I’m giving them is in line with what they want out of their foot care. I had a patient who dropped meat from her freezer onto her foot. She could have gone to the emergency room and had it covered by her insurance, but she called me, actually texted me, and I can do it all within a 30-minute visit. I’ve got the X-rays here; I can take care of it. The cost is not just financial; it’s their time also. There’s a lot of value people have to understand when it comes to the care they’re given that’s not just money-driven. It’s also how they feel: the satisfaction they feel and the trust they feel. And I really love that direct care is getting back to relationship, and to the essence of what we do and why we do it.

Kevin Pho: Sure. So you’ve worked, of course, within the insurance system and then in a system without insurance. Contrast your days under those two systems.

Grace Torres-Hodges: With the insurance-based system, when we first got into it, especially when you’re a new practitioner coming straight out of residency, you think, “Oh my gosh, I’m getting on all these plans. That’s how I can get my patient base.” Yes, the network is there, and you have a steady stream of patients, but the price of your services is dictated by the fee schedule. Unfortunately, as the years went on, the fee schedule got less and less and less, and the cost of running a practice kept going up and up and up. There’s a disconnect there that you’re unable to manage. So where you could see 20 patients in the morning, now you have to see 30 patients just to make up the difference of the lower reimbursement and cover your expenses.

In a direct care practice, all my pricing is based on what it costs me to run this practice, just as a mom-and-pop store would figure it out, or a restaurant, or a storefront, or, again, a mechanic or a plumber. We do that in business everywhere else except in health care. So with my time, patients many times get same-day visits, or within a day, and they have access to me 24/7, because they can email or text me directly, particularly those who are already established. There’s no constraint of staying in the office; many times, for my established patients, I can do home visits. I don’t have to see as many patients. My average day is 10 to 12 patients. It is much more manageable. I don’t have all the extraneous paperwork and protocols: “Did I note this in my note?” The beautiful SOAP note that we all learned to do in medical school was really intended for yourself. It’s for the doctor; it was like your own notes. But because it became part of the third-party payer system, now you have to put in things that have nothing to do with your specialty, many times, and that just takes up time. I get to go home at night. I finish my notes during the day, and that alone saves you, in your whole life and everything. It’s just a cleaner, more streamlined, efficient way of doing things. Your staff loves it also, because they are not on the phone half the day with a carrier. So again, I’m a big, big advocate for direct care.

Kevin Pho: How big is your office staff?

Grace Torres-Hodges: I have two staff members. You don’t have to have extra people. We actually did downsize as a result of getting out of insurance, because I didn’t have to have someone doing all the referrals or all the follow-up, because, again, they were spending most of their time on the phone.

Kevin Pho: Do you find that your relationships with your physician colleagues have changed since you left the insurance-based model? You’re not affiliated with a specific medical institution. Did you have any changes in referral patterns? Did your colleagues ask you, “Why are you doing this?” Describe the relationship you have with your physician colleagues in the community.

Grace Torres-Hodges: I’m very blessed. I have a good relationship with my referral base here in Pensacola. The first time I mentioned it, because I’m one of the early adopters of direct care, particularly as a specialist, they all thought I was crazy. I think deep down they were wishing I’d succeed, but they were saying, “Oh my gosh, she’s going to go out of business. Poor Grace. She won’t be able to do it.” They’re not envious, but they’re happy now that I’ve done this, because there’s a path to follow.

As for the referral patterns, they really didn’t change. I was very attuned to educating both my patients and my referring physicians. It’s important that the physician understands that it’s not them; it’s the patient’s choice. I said, “You know what? Let the patient decide. I know it’s not you. If you feel like I’m the one who can take care of them,” because we have so many other great podiatrists in town, “let the patients decide if they want to come to me. This is the way it is. If they want to stay with someone in the network, that’s fine also.” There’s nothing different about the training, and nothing different about the medicine we’re going to offer. It’s the method, and the payment is secondary. There are barriers when it comes to the networks, and there are fewer barriers without them. So I think anyone who goes into a direct care practice, especially coming from an established practice, should maintain those communications with their physician colleagues. They know. They understand. They can feel it also, and maybe you might be able to inspire them to escape too.

Kevin Pho: Have any other physicians or specialists followed in your footsteps and gone to a direct care model?

Grace Torres-Hodges: As a matter of fact, there have been. When I first started this transition, back in 2013 and 2014, after that meeting, I got on social media and started getting involved in a lot of the Facebook groups, LinkedIn groups and other things. Through that network, so many people reached out to me, so much so that I actually formed a corporation to help other doctors, to mentor them through it. There’s a huge mindset change you have to go through with this. The training we got in medicine is top-notch; you can’t contest that. The problem is that it was so regimented that we didn’t know how to escape it. Dr. Arlen Meyers is known to have said that we’re conditioned to conform, and that speaks to the importance of maintaining independence. You didn’t want to stand out in med school, because you were afraid it might affect how you got into residency. Then, when you were in residency, you wanted to stand out, but you didn’t want to do it in a way that looked like too much, because then you might not get to go on that case. There was all that back and forth. But when you get out in the real world, you really have to stand out in order to do your thing, and we forgot how to do that, because for many of us, between undergrad, med school and residency, it’s at least seven years, and then some go into fellowship. That’s indoctrinated in you. So we need to find it again, and a lot of what I do is work with other physicians to help mentor them back through that process, to find that independence and that autonomy.

So there have been so, so many. There’s a movement now. For the longest time, there was only direct primary care, but now we have direct specialty care. There’s actually an alliance; two of my friends, Dr. Granita and Dr. Kenny, started it. So I think you’re seeing that really expand. And after the pandemic, when there was such a stark awakening to the dysfunction in practice, particularly in the private practice sector, I think you’re seeing that movement change.

Kevin Pho: We’re talking to Grace Torres-Hodges. She’s a podiatrist, and her KevinMD article is “Breaking free: the power of physician autonomy in patient care.” Grace, for specialists who may be listening to you now and thinking of perhaps transitioning, like you, to some type of direct care practice, tell me what kinds of questions they should ask themselves to make sure this is the right path for them.

Grace Torres-Hodges: First, look at your books. You have to be financially sound, especially in private practice, and I’m going to address this as a private practitioner. If you’re transitioning from an employed position to private practice, there’s a whole slew of things we would help you get through, because that’s a major change, going from being dependent to completely independent. But for those who are currently in an independent private practice, look at your numbers. You are a small business; don’t forget that. You have to make sure your ins and outs, just like when we’re balancing them in a patient, are matching and staying where they should be. Talk to your patients, and see if there are things causing your patients to leave you. That’s one of the things. Ask yourself: What do you want out of your practice? What do you like to do? What do you feel you’re the best at? Start with those questions, your finances, your patients’ needs and what you want to do, and that’s always a good starting point.

Now, it’s not easy. There’s work with this. It is not a switch that turns on at night; it’s definitely a transition. It took me almost 14 months to get back to the same financial level I was at before dropping everything. More recently, I have a friend in Texas who was able to do it in four months; he was smart. There are so many tools available now to do that. But I think you have to find it within yourself: Look internally, and analyze your own practice first. That’s the key thing. And know your patient base. Work with the ones who are already with you. They entrust you with their care, you want to help them and you already have that relationship, so take advantage of that.

Kevin Pho: And my final question, Grace: Tell us some of the take-home messages that you want to leave with the KevinMD audience.

Grace Torres-Hodges: Probably I’ve got two. The first one would be that health care doesn’t equal health insurance. That’s something I think both physicians and patients have to understand. Health care is what we render to individuals to improve their well-being. Health insurance is a risk management tool and a means to pay for it, but not the only way to pay for it. That seems to get mixed up all the time.

And the last thing, and the most important for me, is to know your worth as a physician. You’ve gone through so much training. Your skills and your knowledge are what your patients are seeking, and that’s what you’re offering them. There’s that phrase from Hippocrates, from his book Epidemics: “First, do no harm.” How good can you be at doing no harm to someone if the system is harming you? You don’t have to change how you practice medicine; you just have to change how you interact with the system, because the current system is so dysfunctional. So I hope your listeners can find something that makes them happy, and find their autonomy again, because it’s all in us. Those would probably be the two I want to mention.

Kevin Pho: I understand you have a book coming out. Tell us a little about that.

Grace Torres-Hodges: Yes, thanks. I do have a book coming out. It’s called The Private Practice Solution, and it’s a guide for doctors to reclaim physician autonomy and restore the doctor-patient relationship. We’re in the formatting and layout stages right now. If you go to my website, drgraceddpm.com, and I will share it with you also, Dr. Pho, you can stay up to date on when it will be released. And I’d always welcome having an excerpt on KevinMD, and coming back on the podcast to talk about it.

Kevin Pho: Well, great. Thank you so much for sharing your perspective, time, and insight, and thanks again for coming on the show.

Grace Torres-Hodges: Thank you.