Replay with Dr. Amy Vertrees BOSS

 You are listening to the Boss Business of Surgery Series Podcast, episode 42. Today I talked to Dr. Tea Nguyen and we talk about dropping the safety nets. Have you thought about not being employed and not accepting insurance? Tune in to see how she's doing it. Welcome Surgeons Residency didn't teach us everything we needed to learn to be a successful surgeon.

While we spent our time caring for patients and learning how to operate, we didn't learn how to advocate for ourselves or navigate our career. I'm your host, Dr. Amy Ries. I'm a general surgeon, certified coach and founder of the Boss Businesses Surgery Series. This is where you'll learn those lessons not taught in residency.

All right, welcome back. I'm a very special guest. This is Dr. T . She is a podiatrist and she is maintaining a cash-based practice, and we are gonna talk about how to do that and the.  good things, the bad things, and, and also just talking about and, well, let's be honest, mostly complaining about insurance.

Yep. . So I think this is gonna be a really fun conversation and I think it's gonna uncover there's so much that we don't know, um, about insurance and billing and, you know, how, uh, we can overcome some of these challenges. And so I'm really looking forward to hearing all that you have to say. So Dr. Wen, welcome to the Boss Podcast.

I'm so excited to be here. Dr. , 

I love your podcast. I love that it's all surgical. I love it even more that it's female led because you know there's not a whole lot of female surgeons on this planet , so I'm glad to be here. 

I'm so glad it. Tell me a little bit about yourself. 

Yeah, so my name is Tea, like the Drink, and I'm a podiatrist here in Santa Cruz, California. I'm married to a general surgeon. Uh, we met right in college. I don't know if college sweethearts is a thing. We weren't high school sweethearts, but I married him. It's been 20 plus  years. We have a four year old. Daughter together, and actually Vylet is the reason I decided to go into private practice.

I had gone through my fellowship in Texas in wound care and thought I was going into academic medicine. So my mentality about practicing medicine was that I would just show up and be the doctor. Or, you know, run studies or do research and, you know, things that were fun for me at the time. But then I got an, an employment job out here in California and it just didn't turn out the way I had dreamt it would be, I thought being employed was going to be easy, that it was going to be relatively easy. You know, you'd show up, you have a schedule full of people, you get a check every two weeks. I thought that was the thing to do. And then I got there and I so disappointed. I was like, what's a modifier?

What's a 99 4 13 different? How is that different from a 99 2 12? Like why does that matter that I have to justify what I do to somebody who doesn't have a medical degree? They're in control of how dollars are. Being brought into the practice. And that was so frustrating, even more so as a surgeon, because now I have to decide which surgical code to use, and if I didn't bill it correctly, I would not get paid.

And that has happened before where we do a prior authorization for a code, but you open them up and it's not what you expect. So you had to do something different. And the dollars I got paid for that experience was zero. So it really invalidated. What it meant to be a doctor here. And so I had opened my practice in 2018 thinking it was the employment situation that bothered me.

But in reality now looking back, it was really the insurance-based practice that really had a vice grip on what doctors could do or not do, and really interfered in the patient interaction. So in 2018, I had my daughter, then I opened my private practice. So, And then not even a year in, I was thinking financially deeper than I could even comprehend.

I had to pay for a biller. I had to pay for a billing software. I had to understand what Availity was. Um, and all of the claim denials. I had to like follow up on claim denials. I had to understand prior authorizations, which required prior authorizations imaging.  and then I had to justify it by talking to somebody on the phone who's considered a peer, when really they're not even in my specialty.

It was really insulting. And so within the first year, I was drowning so quickly cuz I had to spend so much on my overhead that I started to look for a different way. And then that's how I learned about direct care. So in 2020 I started to ease out of the insurance heavy practice, get letting go of these contracts one at a time, and now it's 2022.

and I feel like this is the part of medicine that nobody really talks about openly because it's like it's against the grain, it's against what everybody does. It's the grant against tradition. But it really is, it's given me a lot of purpose in how I practice medicine in being a wife, a mother, and a business owner.

So that's what I really wanna share about is direct care. Specialist and podiatrist. 

You have so many different perspectives on there that I think they're really worth mentioning in the, with the push for employed models and things like that, so many people have no idea what's going on. And you're absolutely right.

I really loved your point about having this misplaced resentment toward our employers where really, um, they're just, they're trying to get paid too. Um, It can be very confusing to see where the actual issue is. And I've experienced so many of those parallel things that you're talking about is once you start really digging into what's going on behind the scenes, it can be incredibly frustrating to see that we have an army of people trying to fight this army of people who are all just trying to, how are they fighting to get us paid or not get us paid , you know, it's, it's a.

So unnecessary, the amount of time and effort on both sides and what is significant waste to the system. And maybe we should start just from the very beginning of the first concept you mentioned about this idea of, of coding and billing. A lot of people don't even necessarily understand what's going on behind this.

And what were some of the things that you learned about? Coding and billing that, that someone who's just finishing, um, any kind of training or going into a, um, a profession, what do they need to know? Do you think about the idea of coding? Coding and billing is the way we get paid. It's a way we justify what we do to get paid and it doesn't stop at the code.

So when we talk about coding, if you're new to coding, you wanna know what is the code to see a brand new patient? Is it a 9, 9 2? 9 9 2 0 4 9 9 2 0 5 and it doesn't stop there. You now have to justify in your soap note why it's a. Three, four, or five. And that in translation to the administrator is the length.

So you have to hit certain targets, like in your H B I section, you have to hit components that they define that you have to hit. Was there a history, was there conservative treatment? And then, and then you have to go into the review of systems. Did you hit five review reviewer systems or did you hit 10?

And for a specialist like us, like podiatry, we are exclusively musculoskeletal. That is why people come to. But the level that we know, what we know is heavily dependent on our training. That's why we know it so well. And so, you know, you, I had to step back and look at why is my code a 99, 2 0 3 when it took somebody to refer the person onto me?

And in reality, what I know is actually expert level. It just happens to be easy for me because I've done it so much. It's routine for me. So now why can't I build that as a 9 9 2 0 5? Because it did require specialization to answer the, the question at hand or to solve the person's problem. So I was at a really, like a huge conflict at how somebody else can judge what I do and give me the value that they deemed was my.

Versus me saying My hourly rate is my hourly rate. And like a lawyer, you have to kind of think like a lawyer sometimes. Whatever time you spend, that should be how you pay. You shouldn't have to justify it with these bloated notes for somebody else to try to read and interpret and decide yes or no, you're gonna get paid.

So that's coding . Well, and it's actually changes. And here's the problem, is that we don't necessarily recognize it changes unless, you know, because the 2021 guidelines now actually eliminated the components for H P I and for review of systems and even exam components to it too. Before we, like you would say, well, we can't, uh, Count your abdominal exam because you didn't say any bowel sounds.

You know, the, that frustration is gone and they did simplify it in 2021, uh, where you can now, it's basically most on either time component, which changed from the time component from last time. So you better keep up. And, um, it changed into medical decision making. So you have to, again, justify just like you're saying, it's, it's justifying what you do and, and.

For me, the coding aspect is probably one of the most stressful parts of the note, because your choices are either under code and don't get paid or over code and be considered, you know, either have to pay back in the future or be accused of fraud. Those are your two choices. . That's my impression of coding

That's not fun. I, I've not learned about this in medical school. Yes, but you know, in podiatry it's even more, or even in orthopedics or anyone who does sided surgery, whether you're doing the right side or the left side. That adds another layer of complexity because now your codes, if you're talking about the ICD 10 codes, you have to be so specific as to which toe did you work on, which finger did you work on?

Was it the right, was it the left and in the foot? It's a TA code. It's not like you can say L one as in the left great toe. It's a TA or a T five. And so there is a whole new language to learn, and like you said, you have to keep up with it. And I'm so far removed from. I didn't even realize there was a change in how you code these things.

But then you see these notes that like get copy and pasted over and over again. And on the bottom you see very clearly I spent 45 hours, 45 minutes with a patient, uh, coordinating care. And so, and so you're, you're kind of like spreading white lies in these notes just to get, just, just to justify what you're doing.

And I find that to be so undermining to all of our educat. I, I completely agree. Um, and then I just heard today that the 2023 guidelines are gonna be different as well. So now, right. Fun times , I know. Just, it's, it's super fun. And the idea behind that is that they are going to be basing up more on time and everyone's like, oh, great, it's gonna be more simple.

And I was like, no. What does the time mean? Does that time hit the, the door is the amount of time beforehand. This current iteration of like the 2021 says that we can consider some of the time that we take before the note of reviewing, um, images and things like that too. But, you know, it doesn't include the students and it, and so there's so many exceptions.

Even the simplicity of time is not so simple. , it's awful. It really, it, so I'm, I'm a fast learner, but that was one thing I did not wanna learn, and that's what forced me to move out. You either play the game and if you play the game, who wins? It's always the. Once you pick it up, they're gonna be like, oh, let's change it again.

And what doctor has that time and mental capacity to keep catching up? And that's why we have such a high rate of burnout, especially in employed physicians. And I find that to be incredibly disturbing because this is a system that started off with good intentions. You know, doctors just wanted to do the doctor thing and has someone take care of the administrative level.

But now, 20 years later, look at what has happened. It's burning out doctors where we are most.  in the pandemic. Doctors are being let go because we were demanding too much. We were demanding our own value. And what institution is ever going to tell a doctor they are worth more than the what they're being paid for?

What institution will ever empower a doctor other than saying, nice job, here's a pizza party. . Yes. And you had two great points that I thought that were really helpful. Um, the very first, which I fully, completely agree with, which is of course I could do it, but I don't want to . Right, exactly. And that's where the, the problem is, is that I know I could do it, but I just don't want to And you shouldn't have to

Exactly. That's the. . The second one is like, how do we get here in the first place? And you hit the nail on the head on that one as well, which is a long time ago. We said, you know, why don't we just let the doctors do the doctor stuff? And the problem is that we've abdicated so much responsibility of all of this that we've completely lost control of, but we lost the reins of it.

We are now, you know, at the mercy of everyone else to. Get paid for what we're doing. And so rather than this administrative assistance of just saying, Hey, let the doctors do the doctor's stuff now, it's like now we control what the doctors do and we feel that, we feel the lack of control. We feel the, uh, the inability to manage our, uh, Our ability to get paid and and things like that.

And that for me is probably the most powerless and frustrating feeling is feeling that you're at the mercy of this and these nonsensical rules that change all the time. I like your idea. The house always wins. . . It's not an idea. It's a fact, right? That's the purpose. Whoever has the money controls the decision, and so when doctors don't have that exchange, we don't really have a whole lot of patient care involved and that hurts our.

Right. And I know, um, we were talking before we started recording that your husband, uh, being a bariatric surgeon went through this experience. And so take us through that experience, because I think that's also pretty revealing. I, I love my husband. He, he gives me insight to the general world cuz he's an associate at a really wonderful practice.

He loves his job and he loves being employed. Complete opposite of me. I am basically unemployable at this point, . So it's really great because now I'm on the other side of the insurance based practices. You know, we're biased to the situation that we have. So he always kind of gives me the insight of what it's like to be employed in the insurance based system.

And so he has shared with me that of his frustrations as well as a bariatric surgeon in his bariatric surgeries. A lot of it has to be prior authorizations. We have to get a prior auth for that. His office does that. So once we get the prior authorization from the insurance, basically it's a permission slip that says, can we do the surgery and get paid?

So he gets back done, and then with that piece of paper that says the prior authorization, you can do the surgery, we will pay you. He does the surgery and then. Months, Y I think it was over a year after the surgery was done, it was successful. There was no major complications. You know, he does a great job at what he does, but suddenly he, he gets a notice saying that the insurance retracted and said, we changed our mind.

We're not paying for it. And now the ownership is on the patient, but then the patient wouldn't probably have undergone the surgery. Not realizing that the insurance wasn't going to cover it, and that puts a pa, puts the patient and the physician relationship at such a hinge. Now they're blaming the doctor that we didn't code right, or we didn't do it right or whatever it is for something that we really shouldn't have the responsibility in knowing about, which is insurance coverage.

We do it as a courtesy, but because we are full hearted, we wanna do the best with what we have. Just like you were saying, if we. We should, but oftentimes we should not , you know, that is our mentality. Like if we can help, we'll try, but then we get trampled on by the third party payer who says, tough luck.

We don't have a door to knock on. Let the patient deal with the doctor instead.  and you know, we talked a lot about, uh, the doctor insurance, you know, relationship, but a lot of times patients don't recognize the fact that they are the ones that have chosen the insurance. Like the problem that they have with the insurance is what they have chosen.

We are just, as you mentioned, uh, it's a courtesy for us to assist them. Getting paid from their insurance company, but it's not really looked that way. You know, we take ownership of that relationship Yeah. As well. Um, and everyone signs their own contract. You know, the, the patient signs the contract with their insurance company based on, and that's how they got the deal that they got.

And they come to us. With this relationship already in place, and now we have a relationship with the insurance company as well, which says that if I do this service that you have offered to your client, then you agree to pay us this certain amount. And so, you know. I think that, uh, we'll talk about this as well, of course, as the thing you mentioned before, it's that relationship we have to have that relationship with the insurance company to be able to build them.

So take us through that experience that you were just talking about, that when your husband, you know, wanted you to help out with the patient. , I feel so bad for him because surgery in itself is already costly and it's even more so when we're dealing.  third party peer because there's hyper-inflated costs associated with working with insurance companies because insurance have already said, we're only paying a percentage of whatever you decide to bill, period.

It's not a hundred percent. And so now we're over-inflating our prices. So what has happened in my husband's situation is that, you know, he, he doesn't really know the inner workings. The what we need to code for, how we get the authorization. And then, you know, letting patients know the consequences of this is only a courtesy, prior authorization, but in fine print, if you look at your prior authorization, it does say it does not guarantee payment.

So not only did we go through all of the work, it still says we're probably not gonna pay. Or, you know, if you get paid, we're still gonna take it back and there is no repercussion. Of course, we can argue and say, well, the patient can complain to the better bureaus and all of that thing, but who on earth has that time to sit on a phone to wait 40 minutes just to get through an insurance agent?

And if, if you multiply that by how many patients are typical in a day, 30 people. , depending on your practice, who has that time to sit there. But rather, instead, we sit back as surgeons and we're like, you know what? My hourly rate is worth more than that phone call, so we'll just eat the cost and find it somewhere else.

Mm-hmm. , because we are exhausted, we are energy depleted, and there's really no more fight in us. And I think that's another reason to burn out, is we truly feel there's nothing we can do to help the situation. So in his scenario, the patient got the. So how do we help the patient? We try to help 'em with payment plans.

We try not to send them to collections, understanding the circumstances, but we can't do that under an institution because we don't see that on an institution level. You know, you get you as doctors. Us as doctors get paid as a check. We just do the work, but we never really know what happens behind the scene unless you own the business.

So all of these patients that are being sent to collections, we don't see that patients that are, you know, going bankrupt because of the bills that they get from insurance is not paying. We don't know that. We don't ever see that. The fact that they maybe went homeless because they can't afford their medical bills, we don't see that.

And that's the veil that we are, we've put ourselves in when we just choose to say, I just wanna be the doctor. I just wanna show up and help people. That's. Let's 

take 

us to the scenario where you had, your husband was seeing somebody in that needed a foot surgery and he said, why don't you just go see him?

What was the problem with that? Oh, this. This is a fun one because it really reminded me of reality. So there was, I'm no longer contracted with insurance, right? Not even the state insurance. Definitely not the government insurance. So it's just all cash. And so the hospital consulted me and said, I can't get ahold of any other podiatrist.

Will you please evaluate this patient? So they know me so well as to call my cell phone. And I said I would be happy to, but here is the condition number one. Podiatry does not. Paid to do call number two. I'm not contracted with any of your insurances, so you would have to relay to the patient that whatever, I see them for you, that they're gonna get a bill and they have to pay for it.

And of course, everyone's flabbergasted like, oh, that's never happened before. And so who's on call? Who gets paid to do the call is general surgery. My husband's team. And so my husband had pulled me aside and said, Hey, if somehow you can get insurance to. For you to see this patient do the surgery and so on, would you do it?

I said, absolutely. If I get paid for my time, I'll do it. Doesn't matter. I just need to get paid by whoever hospital the patient, third party. And I explained to him, however, you need to understand that the insurance that he has, I'm not contracted with, which means I cannot legally bill that insurance and expect to get payment because no relationship exists.

There's no contract in. And then he continues to say, what if we can somehow get the insurance to pay you? And I was like, what world do we live in? Where that's a possibility. If you don't have a contract, you don't have a contract. And my husband's, he's a smart man, he is quick, he understands surgery very, very well.

But on the business side of insurance, what that contract even means, not a clue. So I asked him, who do you think is gonna pay for this? The government  like, well, they're not gonna pay me cuz I don't have a contract with him, so it doesn't matter what he has, no one is going to pay me. And even if they did, I probably will never see it.

That doesn't happen in the real world. So having to explain to my husband that I'm opted out of insurances was a difficult concept. He's like, well then who's gonna pay you? I'm like, that's a really good question. Who is gonna pay me? Sometimes you just have to put that hat on him and say, my time is valuable.

I have the skills. Pay me and I'll do the service just like a plumber, just like a lawyer, just like anybody else except in medicine. I was reminded of this, this phrase that someone offered a while back, uh, cuz I was just on call and there was a lot of, of self-pay. Patients probably will never see a dime of any of that.

And, uh, it, it struck me.  in medicine, we're probably the only industry where it seems very reasonable to work for free. You know, that we're just somehow expected to work for free, and it's not just, you know, the, the patients that come in expect the, uh, what our services for free, but the, you know, the, the copay is a hassle and all these other things.

Mm-hmm.  and how could they be charging all this for. You and I both know, it's not just our time, like when I operate on someone and I don't get paid for that. I'm not doing it for free. I'm actually paying to do it. I have to pay my office and my overhead and my staff and all the things like that. And, um, it could be a real challenge to, to do that, uh, and to survive in, in a situation where no one really expects us to get paid.

It's very strange, and I don't think I realized this until I started to have to, until I started having money conversations with patients, and then I started getting judgements from other colleagues like, how dare you charge patients, whatever it is you're doing. I had this exact scenario where I was subleasing to another medical office, and their intention was just to have somebody to refer their patients to because their, their patient list was crowded, it was overloaded.

They couldn't see any more. And so they thought if I signed on as a sublease into their space, then they can just easily refer to me taking the burden off of them not realizing that I wasn't contracted with those insurances. So what did I do? I discharged 'em cash. I said, you don't meet criteria for Medicare to pay for this service, and this is the dollar amount.

and that person made me feel guilty for charging people for what I was doing, as if I was like, as if there was an underlying tone that I should have just billed the insurance for something that's not covered. When it's clear as day, it's not covered. It's not covered. You can't get any fans here in coding or billing.

That's fraudulent. I was not willing to take that risk for something that was so minute. . You know, just pay for the thing, for the thing that you want. I mean, it seems very straightforward.  just pay for the thing. . Yeah, just pay for it. Oh my God. , the first step is, you know, I'm not gonna be employed by somebody.

And then the second step is that I'm going to now remove this safety net of insurance and go out on my own. Um, how did you mentally get past those two Big safety. I think this is the biggest thing for, for me, was that I just, I honestly, I was naive enough to believe that I could do it. I think that's what happened.

I was like, well, this person runs their business quite poorly. I could probably do better. That was the realization I had. I was like, A lot of these doctors don't have medical backgrounds, or excuse me, business backgrounds, but they're running their business quite well. They're flourishing, so why not me?

Somebody who loves to learn and loves to be resourceful, why can't I figure it out? But that's where I started with why can't I? Second to that was I had a daughter. I said there was no, I knew that there was no employment situation that would give me flexibility that I wanted to be, to be a new mom.

Essentially like who was going to give me two weeks off if my daughter had covid or daycare closed, right. Without the risk of getting fired or replaced. So I just hated having that power hang over my shoulder and, and so the r the only solution I had at the time was really no other opportunities came up.

That's my reality is that there wasn't really a job opening that offered schedule flexibility to the point where I can just be with my daughter as needed. And so that's kind of, I think I didn't have a. That was the point where I was like, well, I guess I'm either unemployed or I try something, and so I just chose to try something.

And through those trial and errors, I did go through some professional consultants and they all kind of told me the same thing. They said, well, you gotta see more people to make more money.  and I said, I understand the math, but I don't understand how you're gonna expand 24 hours in a day, plus the energy that I need to sustain that  consistently.

So I had to look long term. I said, is this the model where I'm seeing 30 patients a day who pay, you know, in return? The revenue is so poor I could barely keep up with my staff. And cuz you know, staff requires wage increases. You gotta give them livable wages at this point and how can I compete with that in this model?

And I just saw that long. It wasn't going to work. So I think for me it was the active viewing of my future self saying, can I sustain this model, seeing 30 patients in a day for the next 15 to 20 years? Or am I just gonna burn out by year five and leave medicine entirely? We have everything that I've gained in the last 10 plus years.

And say, I'm just gonna work at Target for $18 an hour. I don't even care anymore at this point, because you don't have to chart at Target. You get really cool discounts at Target, like all of these other op, like you can walk away and it's not a big deal, you know? Whereas in medicine we are so invested, we put so much weight in all that we put into it.

It's really hard to step away from the norm and try something completely new and completely different. But I think I was kind of at a point of desperation. I said, I am committed to. Medical knowledge. I'm committed to helping people in this way, and if I fail, at least I tried and that's what I went with.

Amazing. Because it takes just such a amount of just courage to be able to do that. You were very clear on what you wanted. You know, I wanted the flexibility and, you know, I want to use my knowledge, although I could do it many different ways, I, I'm gonna make it work the way I want it to work. I think I was really lucky in the sense that I was resourceful in already knowing to look for the possibility of it existing.

And if we just kind of like open our eyes a little bit wider, you would see chiropractors, physical therapy, natural path, osteopath. They've already opted out because they already had the most stringent coverage already, so they already knew. They already set the pave way for the rest of us to do it. Now it was just a matter of me adopting it to my own in a way that works for.

And you mentioned that, you know, it's not like you could just say, I'm not taking insurance anymore. Um, what has been your process for, um, that you've learned for how to sort of offload. I hadn't, I've spoken to a lot of doctors who were already, either they went outta residency and straight into cash practice, or they were, you know, insurance based for a long time and they transitioned out themselves.

So I looked to them for kind of comfort and what to expect and what they, what the, the ones who transitioned out of insurance had warned me is when you go from insurance based to direct care, you're actually marketing to a. Clientele. In a sense, you're marketing to people who expect to pay, who value to pay.

And so the language in how we offer our solution is completely different. Whereas when you're in the insurance model, people just choose you because you're in network. It's convenient for them, it's covered. And so maybe that leads to over-utilization, cuz you're like, well it's covered anyway. Let's just see the doctor.

Right. Versus when you're, uh, in a cash. You're really talking to people who are more prone to be proactive, preventive, and they wanna know what's the newest, the newest and latest technology in the problems that they have. And in my case, it's foot care problems. They want non-surgical options or minimally invasive options.

So seeing what I had on my plate, um, and understanding that there, there is going to be a. My demographics, I think, really gave the reality that I am really starting all over again, which meant I need to have a safety reserve, a cash reserve for me building up a new business model, even though it's under the same umbrella, it's still Pacific Podiatry is still my practice name, but transitioning from insurance based to direct care, the model, the financial model is completely.

So it's kind of like starting from the ground up again, which means you need a cash reserve, should this not work? And so that's kind of what I led with. Now did you have to loan for that or is this something that you, uh, saved from your, your prior business experience? , yeah, I was able to save a little bit and then my husband had the, gave me the support and he said, whatever it is that you need to do, let's just figure it out.

Cuz he saw how miserable I was and he's like, I don't wanna be married to that version of you . Well, he said it with his eyes. Of course he did not say it, say it , but he's like, it seems that you're very unhappy, so what you think is going to work for you, you know, he basically supported.  throughout the process, even though he was clearly confused.

He was like, why would anyone do this? ? Um, cuz he was fairly comfortable and happy with where he was at, but he saw that I, I just couldn't stand the structure that I was existing in and I couldn't be creative and I couldn't problem solve. You know, you can't problem solve when you're seeing 30 to 40 patients a day.

You're just doing the same. But when you see fewer patients and then you get paid more, you actually get to. Be more innovative. You get to create solutions that work individually for people. You're not, you're not working off a protocol. And I find that to be fascinating with Medi, Medi with medicine. I find that to be fascinating with medicine, which is why I went into medicine.

Yes. Oh gosh, what a great point. I can't problem solve when I'm seeing 30, 40 patients a day. And I completely agree on, on both of those things is that you can get so caught up in doing the work that you never have the ability to get out of it because you're so busy doing the work and. , there is something really inspiring about starting to create some of these processes for yourself.

You know, I know me personally with sort of like a little bit of a professional lag of like, is this all there is? And it kind of  opened up this idea of like, man, this is kind of fun and interesting and, and also heartbreaking and awful, but also fun and interesting. . Yeah. Yeah.  and, and really seeing how it's, it's kind of like taking open up the hood and looking at what's, what's working underneath there and tinkering with stuff and seeing how to make it better and optimizing it.

Um, and that's, that's a really fun thing to do. Yeah, I think it really, going into direct care meant I saw fewer patients, which freed up a lot of brain space and a lot of energy space for. Endeavors that is still within the realm of medicine. So now I can consult with other doctors who wanna have a direct care practice, for example, or you know, I started my own podcast, or I'm journaling more.

And it's just, I think these are the creative outlets that allow us to be better doctors.  because there isn't always a protocol for treating every single patient. Right. You have to pick and choose, you know, what's gonna work and what's not gonna work. And you have to be okay with exploring, which is medicine.

Medicine. That's how we call it a practice cuz we're still practicing. Yes. . And it's kinda the, the evolution too of the, this idea, like some of the business aspect of it too is like, well, I'm a doctor, I shouldn't have to do this, and then now I don't get to do this.  and then, well, maybe I can do this, and now I actually want to do this.

Mm-hmm. . And I think that's the evolution that, that some of us that are going to these, these private practice and different models are looking into is that, you know, we, we get to do this and this is actually a way for us to maintain control over our career. Um, now when you're looking at the, the cash pay aspect of it, how do you determine pricing?

Where does that come? Pricing was very challenging for me because I had no idea , what my hourly rate was even worth. And so I would look on indeed.com and I'm like, okay, well what are nurse practitioners getting paid? What are the salary offerings that there is, just so I can get a general idea of what's out there?

And then I looked back to what I wanted to get paid and the way I looked at what I wanted to get paid had a lot to do with starting with the end of mind. So what should my salary.  and then working backwards. So if my salary was, you know, whatever number that is, okay, let's break it down to how many days do I actually want to work?

And then in each of those days, how much revenue do I need to generate? And then I break it down even farther. How many patients can I actually see and give quality care?  and that gives me a general hourly rate. Of course, it fluctuates if I'm doing clinical work versus surgery, but that at least gave me a starting point where I don't want to see 30 people.

I don't have the energy or brain capacity to see 30 people, but I can see 10 people, maybe 12 at most. And so I broke down those numbers as a a general ballpark, and of course I consulted with other people within the community just to get a general idea of what were the lawyers' hourly rates, and those varied as well.

if you were more experienced, your rates would be higher. And then in my surgical services, I looked at who else was doing what I was doing, and if nobody else is doing it, then I can command a little bit more. So it was a accumulation of different things. And this day and age, this year at least, we're pushing more for price transparency.

So there's a website, I believe it's called savings md.com, where people, consumers can shop for. They can look at the prices that people are posting online and get a general idea of what the cost of things are. And so that's also a way that, that's also a reference that I have in how I price my surgeries, for example.

And of course, we always wanna be the better deal. You know, you give quality care in this cash-based model versus insurance. So by sharing with people that they're actually saving money by paying direct versus waiting for their deductible to be. That is a selling point and most people are more willing to pay for con.

And so there you have it a very complicated way on pricing things. . Yes. No, I, but it's actually straightforward. . Yeah. The logic of it is fantastic. And, and I completely agree. I mean, the, these prices are all over the place, you know, for lawyers and, and also even for insurance companies too, you know, it, it doesn't make a lot of sense, but that's how that, that's how it is.

But we already know insurances only pay a percentage of your billing efforts. So you already know insurance, the bar that in the insurance. , it's not actually the bar, it's actually the lowest bar. So you know, you got nowhere else to go but up at this point. Exactly, and, and I think this is the whole reason that that direct primary care took off is the fact that, you know, we have this, this, we build the insurance company, this fee, you know, a large fee, and they give us a percentage of that fee and then we collect a minor percentage of that.

And to do so, we have to have a massive overhead just to get that lower fee. Mm-hmm. . And by dropping a lot of the, the middlemen aspect of it is that you can actually make more rather than less. So that safety net is not really a safety. It's an illusion. Safety net of insurance is an illusion. And it's an illusion because everybody else is doing it.

Mm-hmm. , but you know, that's what makes it really hard, is that when it's not mainstream, then we fill our minds with fear, with stories that aren't real. Until you reach out to somebody who's actually doing it and you're like, oh, they're doing it just fine. Just relax. . Just follow the protocol. . And, um, I thought you had a great point too, is that you're now marketing to a different group and you know, even doctors now, if you even mentioned marketing, oh, this feels, oh, this feels dirty, this marketing business.

Mm-hmm.  you're talking about, but , yeah. But take us through, you know how that is going for. Marketing. You know, I'm no marketing queen by any means. I have the same medical education as anyone else. We were taught how to solve a problem, right? But we were never taught how to make money by solving a problem.

And I feel like that is such a hindrance in the physician's empowerment in general because the system is really designed to disempower physicians. Because if we disempower, then it's easier to be reliant on the system.  what we have today. Mm-hmm. . So as far as marketing goes, it's really looking at different fields, not just medicine.

Cuz medicine is like the worst case scenarios in how to learn marketing . Cause that's really like fear mongering is what it comes down to. You know, like if you don't do this, you have, you'll have cancer and die. No. That's not what marketing is at all. Marketing in the simplest term. It's just telling people what you have to solve their problem.

But you do it in a way that they understand. We don't talk about. Like in surgery, we don't talk about the really cool stapler that we just got, right? We talk about respecting cancer. That's the solution we're trying to sell. And then we take 'em on a journey. You know, you wanna live a full life with your family, run on the beach and not be hindered by cancer.

We have a solution. So that is a whole language, whereas in. Medicine. We are taught to sell ourselves. We are taught to sell. We did a surgical residency, we did a fellowship. You know, this is why you need to pick me as your applicant. We talk a lot about our ego and ourself and even amongst colleagues when we're writing publications.

How many papers did you publish? How many of this did you do? It's always about ourselves and that's why we're so poor at talking about marketing cuz we never really tap into our ideal client's problem. We never tap into their pain points and. I had to learn it through different means. And I listened to a lot of podcasts outside of medicine just to understand what that even looks like.

And it's so practical. It's like, you know, you don't really have to market toilet paper cuz everybody needs it, right? But yet there are still commercials for toilet paper . So, you know, we just sell the need. Like you need nice cushy toilet paper and then how do you sell it? Right? And that's the same thing in medicine.

How do you sell your solution? Um, and the funny thing is, we do it every day. We just don't call it that. So for example, . If a patient comes in with cellulitis, what are you selling to them? You are selling them an antibiotic that is a self. You have to convince them that their problem is severe enough. If they were to ignore it, this is the consequence.

And what is the solution? The antibiotic. What if they chose an alternative, like a supplement, thinking that it's equivalent. It's our job to educate them the consequences of that as well. So it's a whole field. Education, but also speaking in their language so it doesn't sound like gibberish. I love this concept that, you know, I don't want anyone to miss is, you know, a lot of times we're so worried about our own qualifications, what people think of us, what we're doing is that we forget that what we're selling is the solution.

Just the solution to their problem. Mm-hmm. . Yeah. They don't care about your degree . They do not. They expect you to be the expert. That's the thing. They expect you to have higher education. You are the best in their. Exactly why are you still talking about yourself? Everybody expect that

I love that. It's absolutely true. Um, and you know, it's interesting too cause it leads me into a little bit of a different direction of this idea of the patient who comes in. When you mentioned the supplements, you know, we had the, the cancer patients who.  want something different. You know, we offer them the traditional medical treatment and they say, you know, I wanna do this supplement instead.

You know, how we take personal events to this. But at the same time, I mean, you know, they came to us to get a solution to their problem and we offer them the solution that we offer them, and they take it or leave it. Um mm-hmm. And it doesn't necessarily mean anything about us as well. Um, they, they can also choose to solve the problem in the way that they want to solve their problem, but in the end, It's, it's really the problem is that not anything about us or them.

You know, patients won't connect or take medical advice if they don't feel connected in what you're having to say. So for example, if you're just telling 'em, take this drug and that's it. , they're not really likely to engage in that process because they're just gonna see you as a pill pusher because you didn't take the time to listen to their struggles.

You didn't take the time to look at them like they're another human being who has a serious conflict between western medicine and maybe an alternative medicine. Mm-hmm. . So in direct care you have that extra time. I have like an hour cushion time to be with my patients and to listen to them, to understand that perhaps they will never bite on my Western medicine.

Recomme. , but perhaps if I can help walk them through the process, then they may be a little bit more, I guess the word compliant is not what we're using anymore, but they might be more willing  to hear what you have to say, but they have to know that you are first listening to them. Before they can hear what you're saying.

And I guess the, going back to the idea of a problem is that their problem is, is that they don't necessarily understand what we're trying to sell them. You know, our, our western based solution of it too. Yeah. So not addressing the problem, problem is not them accepting it or not the, the medicine itself.

It's then the problem is they're understanding that that's what is helpful for them versus something. Well, if you're only given three to seven minutes of an appointment in the insurance based model, like how can you expect someone with no medical background to really understand what your solution is if you don't give them the time?

Um, because not everybody understands what medicine does. Now, what is the other difference that you've noticed? So you know, clearly like the, the person that you're choosing, that they may come to you as different, and now the marketing is a little bit different. What else have you found is d. I think that is a huge part of the practice because the common concern people have when they're in the insurance based model is, my patients won't even pay their copay.

I said, isn't it obvious they picked you because you were in network? Therefore, they were not really looking to pay more than they had to. So are they gonna complain about the copay? Yeah, because they picked you as the in network provider. Like why would they have to pay more if they're already paying into their premium or they got their insurance from the government or whatever.

It's, so that is a self-selecting process that I don't think we really understood until, you know, it's brought up to us. So now looking more in the direct care, uh, model, who do I market to? It's the same type of person. It's the person.  needs medical help, right? The caveat is it's the person who knows they have to pay out of pocket for excellent care.

So I'm not just giving average care because you can get average care. That's what health insurance is, right? You just do what you need to do, and that's kind of it. Whereas in direct care, you do have to sell a little bit more because you're selling a higher quality experience. So people pay for convenience.

They're paying for innovative solutions. They're, they're paying for things that make them feel good, where what other industry does. Medical spa, they will pay hundreds of dollars just to feel good. I paid $300 for a massage that is not therapeutic. It just felt good. , you know, so it's a, you know, people like prioritize how they spend differently, and so I had to really understand that my price is my price.

It's independent of who I am as a person, and the person who wants my time will pay.  and I had to sit with that, which meant I had to sit with a lot of rejections in the beginning because I thought I was selling to the same person. I thought the person who paid me through their insurance was gonna pay me cash, when in reality it's not the case.

Maybe a small percentage will understand. But it's never going to be the majority. It's so true. Um, because I, I do this, you know, I have my coaching business in mind too because I think if you do try to give your services to the wrong person, you will face a lot of rejection and you know, nothing has gone wrong there too, but you'll tell yourself it is.

And what you're finding is that, you know, , I can solve someone else's problem, and this is not the person who wants the solution that I have to their problem or their problem is not the one that I'm trying to solve. I think the biggest mindset is really to understand that you can't solve everyone's problem despite society, saying doctors have to help everybody.

We know that's not true. That's why there are specialists. Mm-hmm. . Mm-hmm. . So, you know, we already know we can't treat everybody and I know I can't treat everybody with foot problems like I have my. Scope of expertise. And so we, you know, we just have to really accept that not everybody that walks in our door is going to have a hundred percent, uh, solution.

There's just some things we're not good at and some things we're really good at. And that's the same as when you're choosing direct care, is that even though you have people who have a problem, that doesn't mean you have to solve them, and it doesn't mean that when you saw them, they will be happy. You do have to be selective and who you let.

you're home. I call my business my home because really it's a long-term relationship. Why would I want to pick somebody who is going to give me a hard time with every recommendation that I give versus somebody who is more than willing to pay double that and respect me for my expertise? So you also have to be selective to who you let in.

I know from personal experience is that these things that you say so effortlessly are really hard. Like facing rejections in practice. Yeah, exactly. Yeah. Facing rejection and facing people's disappointments and trying to lead with, you know, expectations that, that, you know, you'd never set. Um, how do you manage the mind drama that comes up?

I have, I have to be my own best customer, and I think this is going to be a, a hard thing for a lot of doctors because, you know, I've spoken to doctors who they're not their best ideal. Maybe they're cheap. Maybe they always wanna bargain. I don't know. And I had to really walk the shoes of my ideal client.

What does that mean? That means that I have to be, I had to be the one that is willing to invest in myself, which meant that I had to know what that feels like. And that comes in the form of me investing in myself. When I get a coach, for example, you know, if I'm putting down thousands of dollars for a self-development coach, that means I know the value of those thousands of.

versus if I pay $20 for a course online, how much more invested am I going to be to see that return with a course, that's $20. So there is meaning to what people pay, and the more skin you have in the game, the more invested you are in the outcome. And that's the same in patient practice. Patients who pay you that dollar amount is going to ensure their dollar goes very far, which means they're gonna be a lot more adherent to what you have to.

And so I think just having to be the ideal client for myself gave me a better, it just aligned with the values better. Like I understand what I put in, therefore my patients who pay me understand what they're putting in and that they're also still responsible at the end of the day for the outcome. Yes.

And I think that's so fascinating, the fact that, you know, when someone is willing to pay for something, they're actually more willing to get it. And because they're invested too, unlike the person that comes to us, and, and I always joke about this, the patient that comes in and says like, what are you gonna do for me so I don't have to do for me,  isn't that painful?

We, as doctors are so altruistic, we want to help people. It's like, , it's uncomfortable if you don't help people. Right? And then there's people who take advantage of that. They don't pay a single dime, but they give you the biggest headache and they expect you to give it all still. Like how do you, how is that sustainable?

It's not, Yes. I actually had a patient say those exact things to me. He's like, I, we talked about quitting smoking, and I was like, you really need to quit smoking so things would be better. I was like, I, he, his exact words was like, stop telling me what I need to do. I wanna know what you're gonna do.

Yeah, that's, that's, uh, very American . I, that's too bad. Um, but, you know, and I completely agree, you would think that the person who's paying more is expecting more of you. And really the person who's paying more is actually recognizing the value of what you have to offer and is probably more willing, um, to embrace that.

I think the biggest misconception about direct care is that I, I only serve bougie people. I mean, I am bougie myself. Let's not lie here, . But that is not always the case. It's people who just wanna pay and get quick access or quality care or a long-term relationship. There are different parts. I have the entire spectrum of income levels of people who see me and it's, you know, you'd be surprised how the richest people, how stingy they can be like that.

Like you cannot overgeneralize, right? But you'd be surprised that people who actually have money and are very unwilling to. Outta pocket versus somebody who doesn't have a lot of money but are willing to pay. Cause you know, their health is their livelihood, so you can't judge a person on their ability to pay in any scenario.

And so I, I don't try to adjust my prices cuz I truly don't know what people's income levels are. I don't know what their priorities are. And oftentimes I've seen people who rely on state funding. Insurance and they drive way better cars than I do. They have nicer purses than I do, and it's just really a matter of prioritizing, like where you wanna spend your.

I completely agree. I think that we really deemphasize the relationship that we have with, with money. And there, there is a relationship that we have with money. And I could tell you when I'm on the boss Facebook group, when I have any post that talks about money, it's like crickets. You know? It's like I don't, we're embarrassed.

We're scared. Yeah. And I don't know what to say and I'm not sure I should be talking about this and I don't even understand what you're talking about. You know, it's, it's, uh, it's fascinating how taboo that. , it really should not be because how else are you going to get paid? I feel like the more we rely on employment, the the more disengaged and disempowered we are as physicians to knowing our self-worth.

And that's really harming to the public because if we don't have enough doctors, then we're all screwed. So , it's to your benefit to understand a little bit about the value of money in understanding the profits of a. I mean, you don't have to make like Mega millions the way the insurance CEOs are. That is unethical, but you know, whatever to his, their own.

But as a business owner, you need to make profit to sustain your business's doors to stay open and to employ your staff and to give them a good income. I completely low all your concepts and you know, taking them out again is just deciding what you want to make in a year. Deciding you know, what your hourly amount is going to be.

Deciding that this is the worth that you have and what you're going to offer, and then sticking to it. I think it's an amazing, simplistic lesson that we are completely missing by being disengaged for the process. It's really math, and I don't think this is emphasized. It's just a math problem. If you wanna, like, if you wanna make more, you see more, right?

We talked about that. Um, but you can also do math in a different way. You can rearrange it where you see less and charge more  and you have less overhead. Like there's a whole uh, you know, algorithm that we can process through. So it's a math game. So disa associate from the dollar amount from what you think your own value is, I think is really important because when someone, when a doctor says, well, the patients pay me this dollar amount because I'm worth it, what you're really saying is it's worth it to that individual to pay.

You don't attach your self worth to the dollar amount. That is what, that can be very harmful actually, because what if they don't pay you that dollar a amount? Then all of a sudden you feel like you're unworthy. And that's not the case at all. It's a matter of how they are prioritizing their. , and I think that's really important conversation to have.

Who determines the value of a service? It is not us providing the service. The value of the service is dependent on who's going to pay for it. Yeah. . Exactly. . Well, this has been really, um, en enlightening. I mean, I think that you've talked about a lot of concepts that I've now become familiar with in the on the Entrepreneur journey, but I.

In medicine. This is not something that we're taught, we're not taught to think in these, these simplistic ways that are really freeing in that aspect. And, you know, demystifying the idea that employment and insurance is a safety net. And in lifting off the, the veil of that and saying this is actually not the case.

Uh, I think it's gonna open up a lot of people's eyes. I think this is a really, really important concepts. I think what really pushed me is because I'm always pushing against the. And back in training, everyone said private practice is dead. And then I, now I reflect back on who was actually saying that it was people who were not in private practice.

So they didn't even have the experience to speak on it, but they were so adamant that private practice was dead because they were in the employment situation. So I think, I think taking advice from people who are actually doing the thing that you want to do. Serves you much better than li than listening to the naysayers who aren't doing what you wanna do.

Mm-hmm. . And I wish I knew that when I first heard about it, cuz that's, I didn't come into medicine thinking I own a practice. It was kind of like pushed against the wall for me, . But now that I see the joy that I have in my business and the freedom that I get to do whatever I want with my time to be with my family, I don't think you can put a price on that.

So private practice is not dead. It's well and alive. , it's, it's thriving. I completely agree. And I think the more of us that, uh, that speak up about the misconceptions that we have and how we've kind of been had in some ways, uh, and really understanding that we have a lot more control than we think we do.

Um, I think that's the service that we offer. Now you mentioned that you have a podcast, you, where could people find you with all these, you know, excellent messages that you're sharing with us? You can find me on Instagram at tdp. That is the business side of the. Um, where I talk about direct care exclusively and just being a business owner, I also have a podcast called The Direct Care Way.

You can find out on Apple or Spotify and you can find me hovering somewhere in Facebook, although the a the algorithm has changed the point where I don't even understand how it works anymore, . But let's just start at Instagram and I would love to connect with anybody interested in this. Absolutely, and I will make sure to put these on the show notes, um, as well as, you know, when this goes live, sharing it with all the folks that, that interacted with the boss thing, because I think this messages are so important and, you know, leaders create more leaders and so you and I, both being leaders here spreading the word, are gonna create more leaders.

And I really do think this is how we change medicine. You're totally right. You made me think about like, how is this institution, the current state of medicine going to. And it's not going to be another entity. It has to be from doctors working with patients directly. So I completely agree and I appreciate what your podcast is doing.

Likewise, and I appreciate you as well, and thank you so much for coming on. This was really fantastic. Thank you so much. For more information about the Boss Businesses Surgery Series, go to boss surgery.com.