Dr. Tay Sha Howell is an Emergency Room physician and former Medical Director for the Oklahoma Wound Center and Diabetic Limb Salvage Program. She now has a Direct Wound Care practice and shares what that's been like.
Connect with her on LinkedIn
Dr. T 0:00
Owners of a direct care practice are more likely to experience higher job satisfaction than the insurance based practice. And it's no wonder why direct care is independent of insurance. Patients pay the doctor directly for their expertise, the doctor gets full autonomy in how they care for patients and how they get paid. They have chosen this path with a love of medicine. This is the direct care way.
Dr. T 0:24
By listening to this podcast, you may even start to believe that you too can have a successful direct care practice. Come listen with an open mind as I share my personal journey and how I pivoted from an insurance based practice to direct care right in the middle of the pandemic. And the valuable lessons along the way. This podcast may be the very thing you need to revitalize your medical practice. I'm your host, owner of a direct care podiatry practice, Dr. Tea Nguyen.
Dr. T 0:52
So today, I want to welcome Dr. Taysha Howell, she is the founder and CEO of Direct Wound Care and Consulting. She's been doing this for a little over three years. I'm just reading your LinkedIn at this point. So I actually found Dr. Howell, because I was really interested in direct specialty care, and your name had come up, I think in one of the Facebook groups, but you were also doing wound care. And that is my biggest passion in podiatry is helping people heal without any amputation, unnecessary amputation, I should say. And that's how I got connected. So I want to welcome you, Dr. Howell. And could you give us a little introduction about yourself?
Dr. Howell 1:35
Yeah, thank you for having me. So my journey has been I actually started in Emergency Medicine and did that for 10 years, then I needed to wear my mommy hat a little bit more, and transition to wound care. And that's actually what I was meant to do. Funny where life takes you, and you don't really know that's going to happen. But anyway. So I worked at a growing busy Wound Care Center in the metro area here in Oklahoma City, and started new programs, added more dogs, very busy, had a great team, and then just kind of hit a wall, thinking I cannot do this for the last 10 years, or what have you of my career, just more and more frustrated. And so I began to look around and actually had a conversation with Jake Hampton, who is one of the founders of the Free Market Medical Association. And he started talking to me about direct primary care and direct specialty care and introduced me to several other direct care physicians and multiple different aspects. ER, Internal Medicine, Family Practice, Surgery and so I started kind of exploring that. He recommended that I find somebody else doing direct model of wound care, wherever that was in the country and try to pick their brain and see, you know, how how to set up a practice like that, because I just could not envision, you know, how do you set your prices? How do you, you know, all of that. And there, so I looked and looked and looked, and there really wasn't anyone doing direct model wound care. So it's definitely been a work in progress, kind of making it up as I go. And, you know, never say never. It's been really, really wonderful. And just what I needed, I think I would have left medicine had I not switch to this model, simply because, you know, most of us go into medicine to help people but the time that you actually get to help them get to be, you know, smaller and smaller, and just more and more time, you know, on the phone or banging your head against the wall about, you know, peer to peer insurance denials and things like that. So I just felt like there were 15 people in the exam room with the patient and I dictating care that had nothing to do about what they actually needed for their wound, or what they wanted to do, or what I thought was medically necessary. So it's quite a leap of faith. And it's hard not to be able to be that wound care doc for every single patient. Because, you know, it's not for everybody, but for those that I am able to take care of It's so rewarding, both for them and for myself and I Now I've seen in some of your posts T, about how it's not our, it's not that big a deal to not be there for everybody, because that's just the way, you know, the way it is. I have lots of people say, Well, who would come to you and who can even afford to do that, but won't care, at least in my area is done in outpatient hospital clinics, centers, and they're very expensive. And there's usually two charges, one from the hospital and one from the physician. And so even if the patient has insurance, sometimes their contract to insurance price with their co pays, and their coinsurance and all that is some, you know, amount up here. And their percentage of it, you know, as 20% of something really high, which is still, you know, for a weekly visit really adds up. My model is transparent with pricing on my website. And so for the majority of folks, it's less expensive to come see me than to pay cash, or even sometimes use their insurance at a hospital center, patients that have Medicare and a secondary insurance can basically go to most any one Care Center and not pay anything, you know, have zero out of pocket. And I would say 40 to 50% of my patients are those double or triple insured, Medicare patients that are still choosing to come to me even though they could go elsewhere. So it's been, it's been really interesting, who, who decides to come, but again, I've just I've loved being able to have so much time with each patient, and I'm never behind, I was always behind before, you know, it was like you had to see, you know, 5 million people every day, you know, not had to say I'm so sorry for your way, you know, we're running behind, or have the staff say that, you know, to every single patient. So it's it's been really rewarding. And in so many ways.
Dr. T 7:15
I remember being in the Wound Care Center, and there was a gentleman, he would be sitting there with his arms crossed, looking at me upset. And I had just arrived to his room and I said, what's going on. He's like, I've been waiting here for two hours. And it made me think about how much I didn't know what was happening behind the scene, how little control I had in that. And then all of the weight gets shifted on me that I made him wait two hours, but really, I had no idea when they even checked in. Right, my job was just to show up, provide the diagnosis and treatment and then move on to the next room. So it was literally five minutes interactions. I thought it was doing a great job because I was like, oh, it's it's volume, I can see one patient after another and they're healing fast and all the things. But I think we forget when we're in that system, we forget that these are human beings who have no idea, they don't have a medical background of what we're even doing for them. Because they've never had the chance to understand it. And by spending five minutes or less with them, they don't even know they don't even get the buy in of what you're doing. You know, why are you scraping them making a hole bigger? Why did you take up a callus and created a hole now, that kind of stuff? And a lot of these patients, I think they I do think they get kind of lost in the cracks. And it makes them feel powerless in the sense that the doctor was too busy to even answer my question. I don't know why they're prescribing this drink. For me the supplement for me, I don't know what they're doing for me. But this wound isn't healing. And so it's the doctors fault, right? We don't have that relationship in that model as deep as when I want to, which is why I opted out as well. And you're right. There's no other direct care wound doctor that I've spoken to that has made it work. So I want to know, was this something that you what made it work for you? Or what was your angle in attracting those types of people who were going to spend money out of pocket instead of their insurance?
Dr. Howell 9:13
Well, I actually started or plan to start, like in February or March 2000. And so the world shut down really when I was, you know, really planning to bite the bullet and hang my shingle. So I had a nine month sabbatical, which was just what I needed at that time and then started at the very end of 2000s. So it hasn't quite been three years but and my my practice is intentionally part time because I do some speaking and consulting some other non clinical things by design, but I just start Did I mean when I first started I honestly because there was nothing to model and I couldn't really I had talked to other direct model physicians but not the specific field. So I didn't really know what to expect or where my patients would come from, the longer I've been doing this, and the more reviews that I've gotten on Google, I have more and more patients, you know, find me just by searching for wound care. And so I have to be upfront with them. In the very even though my website talks about that it's, you know, direct pay, no insurance, transparent pricing, that has to be one of the first things that I talk about when the patient calls because they may or may not realize that I have that I don't take insurance that I started just, you know, introducing myself to several of the Direct primary care physicians, and the there's Oklahoma ER is a facility in this area that affiliated with the with the free market community and surgery center of Oklahoma. And so I just sort of trying to get my name out there for that, I had a few patients from my previous community kind of on opposite ends of Oklahoma City. So really, hardly had any of my old patients come, but some have found me, you know, over the months and years when they needed me. So most of my patients have come from word of mouth or their physician said, You need to see Dr. Howell even though she doesn't take insurance, or they have a good percentage of them have gone from one care center to One Care Center seeing different provider, and they aren't making the progress that they you know, are looking for. And so they've come for a second or a third opinion. And, you know, I tweaked my prices, a little bit went up, you know, just a bit. So I think I did a pretty good job and trying to figure that out, I wanted it to be pretty simple. So mostly based on online time spent with the patient and a little bit to do with acuity of procedure, you know, more liability, I guess, with more complicated procedures, but mostly, it's about time, and patients seem to kind of understand that, that the longer visits take more time, or if they have a whole bunch of loans and need a whole bunch of different products, then that warrants a little higher charge. So I've tried to kind of break that down and make that as clear as it can be ahead of time with the patients. So I had a an excellent billing company when I did take insurance. And I consulted with her because she also did some billing for other doctors that didn't take insurance any longer. And so she she recommended that I charge less for my new patient visits than I would normally play into especially based on time because this versus it's takes such a long time and then try to make it up on the backend. Because she was like, you know, hardly any patient that's going to come to you the first time is not going to keep coming back. I mean, they like that, that attention and the time I take and the detail. I mean, even in the insurance world where it was, you know, quick, quick, quick. So and I think that's worked pretty well for me, because that that new patient is it's kind of a shocking amount sometimes to people when they're like, where am I going to get that? You know, and at the same time, I think we'll, they'll pay it for a chiropractor, or they'll pay it for a massage or they'll, you know, they're they're paying it for other things. So one of my friends said, don't try to anticipate what other people are going to spend their money on. So when you're in this model, and you only have so many hours a day, but you're having so much time with the patient, and you you know, you charge a little more, it just works out, so..
Dr. T 13:56
I wanted to ask you about when you had your model set up with your pricing and things like that, and you were trying to market yourself to get patients did you get pushback from other doctors or patients when you say you don't take insurance? And then how did you respond to those push back?
Dr. Howell 14:13
I don't know about pushback from other physicians. I think they were surprised or curious, I guess. I mean, I had one vascular surgeon say, you know, I love this idea. And we're very supportive of other physician entrepreneurial, you know, endeavors but because I'll be really curious to see if you make it like
Dr. T 14:39
I'm looking at your prices and they're really reasonable. So I just it's cheaper than a lot of like you said the other alternative services definitely.
Dr. Howell 14:49
Dr. T 14:49
But you're on but you're seeing them frequently. So it makes sense to break it down because the accumulation of what they will spend you ultimately to get healed. Right makes sense. worth it, Yeah
Dr. Howell 15:00
And I mean, we did this even in the insurance world where if patients lived far away, or their copay, or whatever, I mean, if we can figure it out, like I'll have some of my earliest patients were just strictly Medicare and with a secondary, and you know, fixed income, and but they, they ended up, they had home health, and I was like, you know, I can see you every two weeks or every three weeks. And that's not ideal, you know, if you're having a problem, I might ask you to come back in a week. So we make sure we're on the right path. So each patient, we just try to, you know, figure that out, some of them feel so much more comfortable having me take a look at it, and then guide their health nurses that there no, I want to come every time or I really, you know, I live two hours away. And so, you know, can we stretch this out. So and same with trying to figure out a dressing, if they're truly paying out of pocket, I mean, sometimes if they have insurance, you know, Medicare or commercial, I, we can get their supplies, you know, covered depending on the documentation and all that crap that I thought was going to get away from that.
Dr. T 16:07
That's gonna say,
Dr. Howell 16:09
That's still out there.
Dr. T 16:10
But it's good to know that as a cash practice, you can still offer that as an insurance, but you still have to document as if you were with the insurance. Okay.
Dr. Howell 16:19
I have a, I have a very simple EMR, but it still puts in the codes. And I mean, I did the insurance, you know, won't care for 14 years. So I'm not going to forget those codes, either. Right? So
Dr. T 16:33
Dr. Howell 16:36
You know, as long as I can generate the codes, and you know, that kind of thing. So, yes, as much as possible, you know, home health lab imaging supplies, we can try to work out with their insurance, and so that, that makes it a little more approachable, um, it's truly just the doctor visit that they're paying out of pocket, but some folks that don't have insurance at all, or their insurance isn't covering their supplies, then I, I still kind of have that same, you know, compromise approach, what I think is going to help you best is this. And if that's not, you know, affordable or agreeable to you, then we can try Plan B or C or D, you know, I mean, like, whatever is going to work for them. So, I mean, I, I use the analogy, often when I talk about what I do, it's like when you're trying to buy a new air conditioner, when you got you have your answer, you have your service call, and then you they give you the options, you know, you want this model, this model or this model needs, it's really about the communication with the patient. And I, I love that I love I have what is called a micro practice, so I don't have a staff. And so I know exactly what's being told to the patient, all steps of the way, I know exactly what's happened with their documentation, and who got the notes. And if we sent it to the supplier, and you know, the DME company, or all of that I know exactly, you know, there's only myself and the patient or their providers, other providers. So that was always something that was kind of a control freak. And so I had a great team, but sometimes things would not get communicated in the chart, and then you never knew what was happening, or would it home health really say or anyway, so I think patients like that too.
Dr. T 18:25
What wouldyou say is your best return on investment in terms of marketing? Like if I had a budget, what would be your one marketing advice for this type of practice.
Dr. Howell 18:34
I would say introducing myself to the other mile to the direct primary care other direct specialty care providers in the area, that's probably where my you know, so it's just me literally introducing myself but you know, it's been kind of a, I did a lot of marketing with my previous hospital based clinic and it's kind of weird when you go to doctors offices to promote your center because you're not a drug rep. You know, but the front office staff is sort of walling you off or treating you like you're a drug rep. or product rep. And so I I worked hard to you know, do my research ahead and then be more of like, I want to introduce myself you know, because I have lots of patients that want to switch primary care doctors or need a primary care doctor so it's a you know, it's a two way street, I'm being a mutual productive Well, you know, relationships so and I'd say second is just having presence on like my Google Business asking for reviews from patients when they're dismissed or even family members because sometimes the patients are elderly and they're not super comfortable with you know, the doing the, you know, computer stuff or what have you. So the more I have had of that, the more just random phone calls I'm getting where patients are finding me on their own. So I haven't done a lot of like paid social media stuff I don't I mean, given how kind of very narrow or specific My area is, even though it's head to toe, I don't know if that's really gonna pay off that low. So I'm still trying to kind of figure that out doing some trying to find some networking groups in the area. So I'm still open to suggestions.
Dr. T 20:29
Well, I think marketing is there's no one way because what is the data, people need to have seven to eight different touch points to even make a choice. So you just have to show up practically everywhere in order for it to be effective. So it was kind of a trick question. I don't think that is one way. Yeah. It's an accumulation, and then suddenly, they find it to be the authority. And one day, it will just no more like you're just the go to person. But I do think it takes time for direct care to mature. So what I'm really cautious with the people who are interested in direct care is that this is not a get rich type of scheme. So just because we are charging more than what the insurance rates are, it doesn't mean that that we're going to suddenly be rich overnight. This takes a lot of maturity, we're having to change the way people think about their medical decisions and their doctors how they can choose. I think we're all kind of in the matrix and believing like, insurance was the only way until it wasn't until it wasn't working.
Dr. Howell 21:30
Dr. T 21:31
So I love the I actually really love the mindset behind a direct care practice, because we are actively doing it, we know what is working and what isn't. And it's really convincing the other 99% of doctors and patients that this is another viable way to get your medical care and to practice medicine. So did you have a mentor or business coach to help you along? Or, this is just also an accumulation of resources
Dr. Howell 21:58
Accumulation of you know, as I mentioned, the the introduction into the free market community, just the whole concept and just spent some time talking with, again, none of them were wound care providers, but just sort of learning more about the community and models and different things like that. And then my billing consultant who just helped me kind of think through, okay, if I want to make this much money, and I have this many people a day, you know, like how much to charge, you know, just that that kind of like true business model kind of stuff. And some suggestions on pricing, especially based on like, okay, Medicare pays for the because see, I was used to the outpatient hospital places service. So Medicare pays for the private office this much for this code, you know, just so I wouldn't be so terribly far off. But it's been definitely just sort of a leap. And I wish I'd had I wish I had found someone whether it was in town or across the country to at least have a little more idea of what I was getting into or how to set it up. But I think it's worked out. Okay, it's been a little slower than I expected, which I think is just part of the pandemic. And because I'm part time, and because I was really burnt out before and not so eager to be just, you know, go go, go go. So I mean, it's, I think there's more resources out there with some of the online groups that have been helpful some stuff on LinkedIn, and Facebook groups with direct specialty care, and even the direct primary care. And that's not all relevant to my practice, but a lot of it is helpful. So I think there's a lot more resources now than three or four years ago.
Dr. T 23:45
You're, you're the pioneer of wound care. I don't know if you know this. You are the one you are setting the way unfortunately surprised.
Dr. Howell 23:55
I mean, that's, that's okay. I mean,
Dr. T 23:58
I love that you mentioned it being a micro practice where you're part time and you're consulting because I think the reality is the landscape of medicine is really unpredictable. Whether your insurance or not, we for sure know that the reimbursement rates will go down. But we don't know what we don't know, either. So if we never tried to have a direct care practice, then we would never know if it would work or not. So I wanted to know, what is your demographics like how do we know that direct care could work or does work? Did you have a framework to go from like number of population of people? You said, You were already in a wound care center, there was multiple direct care doctors, like I didn't have any of that in my town. And I'm figuring out how it can work for different population. What do you think worked in yours?
Dr. Howell 24:42
Well, I think there's a decent base of is not a huge percentage of the providers, but there is a decent and growing base of direct primary care providers here in my metropolitan area. And so they at least Get it in you now are funneling patients to me. So I think that's been helpful. I think honestly, because I've practice whether in the emergency department or in my old role as medical director for Wound Care Center have just been around a long time. And I know a lot of physicians and so when somebody says, you know, sometimes it's they've, they've heard of me, but don't really know, I'm not still in my old clinic and Southern, it's, you know, trying to introduce them to the whole concept and stuff like that. So I think they're still there. It sounds like maybe there's a little bit more of that direct model here. Although I really wouldn't say we're all that progressive here. But maybe in this realm,
Dr. T 25:50
I think you guys are because he had the surgery center of Oklahoma to set the way for transparent pricing for surgeries in a surgery center. Right, right, which I want in my community, I don't know if it can happen. But I've had conversations with some of the doc's who kind of set the framework on how it could work based on the demographics, the payers, and just the willingness of physicians to think outside the box. And I think you and I are certainly doing that. So thank you so much for sharing with us your journey and what that looks like, what's next for you? Do you think this is something that will be full time? Or do you like, your consulting side, too,
Dr. Howell 26:27
I think it'll stay part time. I mean, I've got a little wiggle room to ramp up on either end. But I think because of how rewarding I'm finding living my life outside of medicine, I have a much healthier balance. So I don't see me getting into the Dr. workweeks again, ever. And that's okay. So I'm hopeful that it'll continue to grow a bit more, I'll go to networking, things are all go to direct care things or marketing events. And there's always something else out there. I mean, I mentioned Never say never, you know, things will come up and be like, you know, would you consider being a supervisor for this? Or have you thought about that? Or so? I'm not sure what's next.
Dr. T 27:17
That's fair, that's fair. What one skill Do you think a physician needs to have in order to make that transition from the insurance based model into direct care? Do we have to wait till the burnout? Is the real question right?
Dr. Howell 27:31
You know, I, I want to say it's just courage to go for it, or confidence that you can do it. I mean, it is a bit of a leap of faith, I don't know, I didn't realize how burnt out I was until I was gone. From that. I mean, I just felt at the time, I felt kind of bored. I mean, I, I loved my team, I loved our mission, I loved, you know, helping my individual patients, but as a whole, I just could the whole, you know, horizon in the next 10 years are gonna be the exact same. Whereas before we would, we started, we grew up the clinic and added more docs and more hyperbaric chambers or more inpatient programs growing, growing, growing, but I was at a community hospital and it sort of just hit a plateau. And I thought, I'm, like, you know, when there was nothing else to focus on, then it was just that banging your head against the wall with the so I just thought that that's the part I at the time, I just felt like I'm bored. And I can't see this being very rewarding for me, once I left, I realized how much more that was really a symptom of burnout and kind of read more about it and and that kind of thing. So I would hope no, that I would hope people would, if they're interested, they would do it and not wait till they were burned out. Because that's such a demoralizing state to be in. Because again, I almost love medicine completely and just every day something new horrific, my all the changes gets worse and worse from my fellow colleagues that are still in that in that world. And it's a wonder any of us are practicing, you know, so definitely the direct model is keeping me where I'm, I feel passionate still about helping the patients and showing up and being involved.
Dr. T 29:28
What's your favorite part about direct care? What keeps you going?
Dr. Howell 29:32
Well, what's always kept me going is feeling like you make a difference with each patient or I love being able to have the time with the patient without that pressure of running behind or feeling the time crunch and that they're they're getting everything that they need from that visit and plenty of time to answer questions are plenty of time for me to explain what we're doing. I mean, even when I was in the ER that was really I really didn't want the nurse to be telling the patient what I thought was wrong with them, or what we were gonna do about it. They want to hear it from the doctor. And so I just like all that time with the patient.
Dr. T 30:08
What a great conversation. Thank you so much for sharing your journey and really being the pioneer in the direct care space for wound care. I certainly want to be able to build that for myself. I'm having some challenges seeing that possibility just in my community because I think community based, you know I think this is where there are existing direct care doctors already, primary or specialist. You just help accelerate the way for the rest of us, I think it's so new here with where am at. That I am really hopeful, that I can start pushing some of pathways for others. If they want to connect with you, or find you, how can they find you?
Dr. Howell 30:45
My website is directwoundcare.net LinkedIn (linkedin.com/in/tay-sha-howell-md-b95583a5)
Dr. T 30:51
If you like to stop, please give her a follow and send her a message. Let her know that we appreciate her. Because I appreciate you, so much. Thank you.
Dr. Howell 30:58
Thank you so much. It's nice to get to meet you.
Dr. T 31:01
Thank you so much for being here with me. If you enjoyed this episode and want to hear more, please like, share and subscribe so more people like you can have access to another way of practicing medicine, that direct care way. Let's connect find my info in the show notes and send me your questions. That might be the topic for future episodes.
Dr. T 31:22
And lastly, if you remember nothing else, remember this be the energy you want to attract. See you next time.