The Direct Care Way

Saved by Grace...Dr. Grace Torres-Hodges

November 15, 2022 Tea Nguyen, DPM Season 1 Episode 40
The Direct Care Way
Saved by Grace...Dr. Grace Torres-Hodges
Show Notes Transcript

Dr. Torres-Hodges talks about the business aspects of running her private practice, the advantages she had with having physician parents. She discusses exploring membership-options but prefers fee-for-service. Direct Care offered her time to work at a free clinic one day a week as a way to give back and connecting with patients since she can spend more time with them free of insurance restrictions.

Listen as to why she's sees those coming out of training adapt easier than those of transition from an insurance-based practice.

Is there a formula that will determine the success of a direct care? Not yet but some market research will help. 

A common misconception about Direct Care is that is serves only the wealthy but that is the exact opposite of what it does.

"We did not go into medicine to do all the minutia."
"There is no magic formula...there is a lot of trial and error."
"We need to instill working smarter, not harder."

Follow Dr. Grace Torres-Hodges at

Dr. Tea:  I don't know if you noticed, but every 10th episode is a really, really special episode, and this one is no different. Welcome to episode 40. I am going to share with you a conversation I had with my own personal mentor, Dr. Grace Torres Hodges, who had recently earned her MBA degree, and she is a practicing podiatrist.

Doing direct care in Florida and was receptive enough to talk with me about direct care and all of the things. Really, I let her take on the conversation because she had just gotten back from speaking at the Nuts and Bolts 2.0 conference, which is. All DPC doctors. So DPC is direct primary care doctors and she spoke as a specialist and some of the challenges that specialists have that is different from primary care.

And so she was able to give us an inside look to that conversation. So I hope you enjoy this one. And oh yes, there was just so much to get into that. There will be a part two, so stay tuned for that one too. Alright, here you go. Enjoy. I'm so excited to have. Very own private mentor. I call her, although I've not paid her , but she should be charging me for all the questions I've ever asked her about transitioning from the insurance-based practice into direct care.

And I met Dr. Grace Torres, what, two years ago. And I feel like I've known you forever because I've constantly. , you know, at the start of something new, at the start of the transition, I was so afraid of what I didn't know, and Grace was really literally that saving grace for me, that anchor that said, look, it's fine.

I've been doing this a lot longer than you have, and look where I'm at. And so Grace is alive. She's well , so I invited her on here.

Dr. Grace: And I'm so excited every time I see you, uh, move further along on the direct care path and spread the, spread The good news, um, you know, I, I think yeah, two years is when two years ago we met, but actually you contacted me a little bit right before.

It's right at the beginning of Covid, right before Covid even, I think Yeah, to a certain extent. So, um, COVID seems to be the one that actually opened the eyes of direct care to everybody else. , you know, uh, those of us that were in it before, um, were just really more jaded by all the insurance things. I, I, I recall my, my, my transition all the time, whenever I have to speak in front of groups.

And, um, most recently I was going through that again because I just came back from, from Dallas, from the 2.0 D P c, uh, nuts and bolts conference and. It's full circle for me with that one because, uh, 2013 was when I first met that group. And, um, and also through the American Association of Physicians and Surgeons.

And I, you know, was the lone podiatrist at that, at that conference. Actually, I take that back. There was one other guy that was there that was interested, but, you know, we were at the beginning of Obamacare had just been, um, Regulated and approved, and the exchange was about to start. Um, and the, the website just crashed.

And, um, that's what we were, we were in the midst of all that because we like, I remember that. Yeah, we were. We were, we were about to get inundated by all these people. And my thing was, um, I have a very smart office manager, my husband, who actually has an insurance background. He was the one that actually got me out of, uh, got me on the straight and narrow to, to get away from insurance and saying, you know, these guys are just like taking advantage of y'all.

And you don't need to be your, your skillset, your knowledge, your, they can't function without you. So, You better start looking at maybe getting out of it. And I didn't believe him at first because I had all the fears like everybody else, like everybody that always comes and says, will it work? I mean, will it work even in my area?

Especially cuz I live here, you know, I live on the Gulf Coast in Florida. Not only is it geriatric, uh, heavy, but I'm also in a military town, so we have a lot of federal Tricare and champs and all that too. So everything really is already, the, the mindset here among patients is that everything should be covered.

I've put my time in, it should be covered. But, um, you know,  even at the start of my practice. And a lot of what I learned was from my folks who were both physicians. Um, they are, were in general, uh, surgery. My dad and my mom was internal medicine. Um, I was free labor in their office, so I grew up in that office.

A lot of my business. Sense in running a practice. I learned from them. So I, that's my advantage. But, you know, the specialties are completely different. Um, and, but you know, with that in mind, I watch them. Practice medicine, the old-fashioned way. You, you know, my mom was the type that would take patients after she examined them in the exam room, take 'em to her room, and literally sit down with them one-on-one for a good 15, 20 minutes.

She was notoriously known for running behind the mall, was near her office. So patients would say, uh, how, how long is she? , the staff would say, she's about two hours. We'll, we'll call you when your time you go shopping. You know? So, um, she spent the time, it was, she was always worth the weight. My father was very good about explaining procedures and drawing everything out.

I picked up that skill from him. So I draw procedures out for patients and, um, I I, if you don't create that common bond with them and that relationship with them, why, you know, they're entrusting. They're, they're, that's a lot when they come to you. And that's the beauty of medicine is because, you know, you're, you're, someone's trusting you to do something for them.

And it's that giving back. Um, and I think that's what all of us went into medicine to do. We did not go into medicine to do all the minutia. And, um, so that's, that's what direct care has been a saving grace for me because I didn't realize that you could do it that way. So, um, whenever I have somebody like yourself reach out to me, I am more than happy to, like, I.

Help them through it and guide you through it. But there's no magic pill and there's no magic, um, formula. Everybody has to do it their way. But, um, there's a lot of tried and tri trial and error that we've gone through already that we try and share back.

Dr. Tea: Do you think that there is some kind of relative formula as for one doctor to decide if it's going to work in their community?

Because like, I'm, I was in the same situation and most of the people in my community were low income or on Medicare, and so that was 60% of my revenue. So having to opt out of the, you know, the, the financial aspect was a huge blow to me. Mm-hmm. , but I was prepared for. . Right. What do you think, how should somebody be prepared to start transitioning from insurance into direct care?

Uh, I, you know, one of the things that I think that I see very different is when you get a resident coming in and talking to me and asking about direct care, their mindset and their lifestyle.  is very different than a transitioning doctor who has already been used to receiving a X salary or from their practice and everything.

So your lifestyles are different. To a certain extent. It's easier when they're a resident and transitioning when they have that it's a lower, you know, they low ball, the, the numbers a little bit better, and that way it's easier to build. You have to, when you're starting out fresh, if you recall, even, even in your insurance based practice, When we started fresh, we still had to build rapport in the community.

And, you know, there were days early on that I, I didn't have full, full schedules. I mean, you were only seeing, you know, 10 to 12 and then you build up to 20. And for some reason we have this mindset that, um, the more, more is better. That means we're more successful. And that's not, that's not necessarily the case.

The idea of, um, working smarter not harder is, is something that we need to instill. Back to, yeah, to doctors. But there's, there's always that, uh, the numbers game of, of increasing, increasing. So with regards to your question, uh, is there a, a formula? It, it's really reading the demographics in your area. You have to do a good market research in there.

But I do see in, in, in mentoring others, I've noticed that the ones that go straight out have a little easier. Reaching, reaching their, their goal. Um, if you're transitioning, be realistic and you almost have to like, take away all the, the fancy and get back to really the nuts and bolts. Get very lean with, um, your expenditures.

you know? Um, and that's, that's it. It's, I wish there was a, a formula, but, uh, I'm, I'm working on something, so I'll, I'll just kind of leave that out there. I am working on that. , I knew you were regarding pricing and strategy, but, um, you know, I, I'm trying to explain it in a way that everybody can appreciate it, so,

Dr. Tea: because we know.

primary care doctors exist in rural places. Right. And it works for them because they're working off of a membership, so they can still offer a low monthly fee. Mm-hmm.  and see a certain number of people. But specialists have a different challenge. We, we pull from a smaller pool of people to serve in a way.

Dr. Grace: Right. We're not the primary per person that people seek medical care from, although we do a lot of primary care and podiatry, and so that is, , you know, part of our practice. And so have you ever considered a membership type of pricing for your, uh, practice?

I actually, I actually did. Um, you know, because especially look, look at our seniors and then our diabetic care and everything like that personally, it, the, the issue that I had with it was, um, because the care tends to be episodic and because the relationship developed even before I left insurance based. I was very preventative care. And so I had them on regular schedules. They weren't coming in as often as like a monthly, a monthly, monthly thing. Um, the, the other thing was more importantly, they were willing to pay a visit rather than a membership. And having talked to some of the, Like the M D V I P doctors, one of the issues that they had was they felt like they were tethered to their patient the entire time when they were member membership.

Um, I, I don't wanna be tethered, that's my personal thing with it. Um, . If there was a way, I think I would do it. And I think that for some specialists, I mean, I, I, I, I know you've, you've ventured into membership and if it works for you, it really depends upon the demographic. I have a, I have a lot of diabetics, I have a lot of seniors, but healthy seniors, I have a lot of kids and parents pay for children.

Uh, Episodically, it's not going to be a chronic, chronic thing. So I really, I tried, but it didn't work in my, in my, in my realm. Um, I wish we, you know, you're always looking for that revenue stream, though. Um, the beauty of, at least in podiatry, we have so many other revenue streams, not just our visits, because we have procedures, we have surgeries, we have orthotics, we have, um, in-office dispensing you know, that that offers lasers, that offers a lot of other, um, um, venues for us to work with. So, yeah, I wish there was, I wish there was a way, but I think like certain ones like rheumatology, I think, um, endocrinology because there's that chronicity, um, with their, with their care.

Dr. Tea: So yeah, I. . I like having both, but I can see where it can be confusing. Cause the reason why I implemented a membership was to serve the lower income people. Mm-hmm.  so that it's just an act because I had so many already in mm-hmm.  in my panel before. I was like, well, how can I give back without, like going, without bankrupting my practice? And so this was the only way that I saw was it's not working on a. uh, numbers, it's actually a way for me to give back. So if they are buying into my membership for palliative foot care, they can also get x-rays, you know, covered. Right? Because it's like they sprained something, they stepped on some, like I don't make a big deal about it, right? Because I know they're gonna tell their friends and their family members and it, it kind of works out.

It's not working out in a profitable way as a fee for service, I don't think, or not yet. There is a tipping point. So I'm, I'm free to explore and that's kind of why I like direct care, cuz I get.

Exactly. Exactly. You know, and one of the things that you may wanna consider also is the fact. , you know, I'm, I'm all about giving back as much as possible, but when we have our practices set up the way that they are now as direct care patients that are coming here value the fact that we're, we're actually taking that time.

And so our time here is much more intentional. It's also better managed too, to the point where, you know, I cut the number of days a week that I, that I work as a result of it so I can spend a full day doing.  in a, in a, um, in a free clinic. You know, so, you know, your patients that are seeing you, um, as, as in the direct care of practice, they're, they're the ones subsidizing your ability to go in and go elsewhere.

Um, you know, my thing with charity was always that when, when someone's on insurance still, and if you're still taking third parties, every write-off that you do is a charity. You know, when you think.  and, but I'd rather give the charity to the ones that I want to give rather than being told how much to, to take  a paycheck.

Um, you know, but as far as, and what's interesting is that there's this misconception with, um, direct care that we only take care of. Rich folks, and it's not, it's, that's probably the furthest from the truth because, you know, when we do go and if I have a patient, even if they're doing surgery, you know, one of the things for me is that we can make payment plans with the patient.

We can set up bundled services. There is not a rule set that it's, um, that it has to. Done or paid this day or anything like that, you can make a payment plan cuz you have that relationship with them. I barter, I had my logo for our, for um, my, my consulting was a barter, um, for a nail kit for nail surgery.

You know, you can do things like that. So, old school medicine definitely do, you know, and so it, it's. , there's, there are a lot of options there. And I think, I think as more, more people find out about direct care, I think they'll be, they'll be happy to see it. Um, the thing about primary care, which you brought up was interesting because like I said, I just came back from this, this, um, Conference and the topic I was given was redefining, uh, direct primary care for the specialist.

And I know you and I have been also on, um, my D P C story, and one of the things that they mentioned at the end of that is like, and this is my D p C story, and you're supposed to say, um, yeah, my direct pri uh, primary care practice. The funny thing was that as I was researching for that and preparing that, um, lecture, every doctor does primary.

If we're really practicing medicine, every doctor does primary care. Primary care is not a specialty. Primary care is a designation, ironically, started by insurance companies. And the weird thing about it is, and it it, it was always all these things that were started by insurance companies were weren't bad to begin with.

They were, they were initially set up so that it could push patients to go and get regular checkups, and as a result of that, they had to, in their contracts designate. Specifically primary care and they designated specific specialists in family practice, internal medicine, and um, uh, and in OB G Y N to be that.

And then as time went on, they changed the reimbursement rates, the RVU's and everything like that. But you know, it. For every doctor takes care of patients that have chronic illnesses, takes care of patients in a preventative way. If we're doing our job right, we should be doing all those things also. So, uh, when specialists come to me and ask about can DPC work, I think one of the first thing that turns them off is that they're thinking it's just for primary care.

It's not, it's for everyone. If we are practicing medicine the way it should be, it just happens to. That name came up. The D P C is the, the main one because they were the first ones to really get this going, but that was just kind of a new, I know that's a little bit sidetracked, but I found that interesting over the weekend when I was going and I, I had the realization while I was giving the presentation.

Actually, that's a really good point, because now that I can spend more time with patients, I have to look at them as a whole person. So I Exactly. I call, I call it holistic care, but that's kind of what you should be doing anyway. . It's not a toe that's broken. It's actually who is it connected to and what are their obligations outside of the office?

Like can we actually take them to surgery? Right. Are they in their right mind to even have the surgery? Absolutely. Do they have enough support at home or even how is their home set up? You don't get a chance to ask. I know, you know, when we were in residency, how many times do you ask to have stairs at your house?

How many, how many stairs do you have to go up to your bedroom? How many times do you get up in the middle of the night? You know, those things count for.  because we don't want them to step on our surgery site, you know? Yeah. . But yeah. So, but that was kind of a, that was kind of a realization that I came up with when I was, when I was talking, it was like, ah, that makes sense now.

And so I think it all, like I said, it came all full circle for me when I was, when I was speaking there, but, you know, but I, I, whatever we need to do to really push this, it's it the way that. Insurance based practices are going, it's dying and it's going to kill off doctors also. And I hate to be that dramatic, but it's doing that already.

We're losing so many good doctors, um, out there in all specialties, you know, and the thing is, is that doctors are innately resilient and we're very proactive. We know that the, if we get to the root cause of things,  and the root cause is, is the interference. And I'm not an anti insurance person as far as, um, people sh need to have insurance.

Insurance is a risk management tool to protect you from, um, uh, financial disarray, from healthcare expenses. The problem is it there are not good stewards of money. There are other. Uh, insurance, uh, insurance type of plans that are out there other than the typical, what we call the boogas, which is Blue Cross United, Cigna Health, uh, Humana and Aetna.

Um, you know, just, but people need to be aware of it. There are a lot of health sharing ministries out there, but, you know, we were talking about the, uh, lower income patients. I, I don't know, even when I'm at the. . Every single one of my patients has a cell phone. Mm-hmm.  how they have a cell phone or they're smoking, um, they've gotta pay for that someplace.

Right. You know? Yeah. It's where you put your money. And one of the things with my, my patients I, is the fact that, um, you know, they will save up. You can budget properly. And if they take, if they take, uh, if they really consider their health to be something that they want to invest in, they need to. And you know, and we make it.

We make it easy.

Dr. Tea: If you would like to learn more about Dr. Grace, I will be putting her social media handle down in the show notes. Please be sure to subscribe and share this episode with anybody you think who would benefit from a direct care practice. I'll see you next time.