Great question! I'll share with you how I knew I was ready (hint: I wasn't), what mindset I needed to adopt to do it, and the steps you can take to prepare for the transition.
Whatever you decide, I am cheering you on. We all deserve the work life balance we were promised, and I’ll help you along the way.
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
How do you know if you're ready to opt out of insurance? What a tricky question. Let's dive right into it. This is easier if you hate insurance, and you have financial security from another source. If you're a student, or resident or fellow, you're going to have a much easier time adopting direct care. Because what's that phrase, they say you can't teach an old dog new trick, something like that. So the further along you are in your practice, the more tethered you are with insurance, the harder it's going to be. That's what I've observed. And if you're coming from an employed situation, but you've never run a business before, you've never looked at the p&l, you don't know what to order, it's not really that bad, it's actually relatively easy to have a direct care because then you just need a plug and play your phone line your computer and your marketing strategy.
Dr. T 1:44
And that's it, you're not having to buy all these extra newest software to accommodate those billing insurances. If you're coming from an insurance based practice, like me, where you owned it, or you were the CEO, making those decisions. And you saw the money coming in, this will be the most challenging part for you, because you already have your set beliefs about what it's like to practice medicine and what it's supposed to look like. And you're going to be really used to the grind of seeing a lot of patients having to spend a lot of after hours of doing unpaid work. And then you anticipate payment eventually, even if they're not always on schedule. So you have a rhythm that you're very useful, even if it puts you at a chronic stress state. Yeah, it's really weird. We get used to a chronic state of stress. And yeah, you put yourself in a situation where you're used to stress. So you are used to having all of this stuff around you not realizing that it's not normal. That's where it gets really challenging.
Dr. T 2:46
So let's talk a little bit I'll start with when I knew I had to take the leap. And when I was a year into my practice, which really wasn't that long ago, I opened in 2018. I found myself within the first year spending so much to support insurance. Here were the tangible things I spent on an EMR that required a billing software, there's a ton, so I just picked the one that other people had not realizing that that individual EMR required an add on billing software. So they weren't even a software at the same time, they had to like integrate. So it was not seamless as they portrayed it to be. But anyway, so there was an extra expense to that. Then I paid into a coding subscription, because I didn't know all of the codes and they kept changing. And in the modifiers. That stuff was just very confusing for me. It just I never learned it. And so I had to learn on the fly. So I bought the subscription for that I had to get a biller, I went from having somebody I outsourced it, and it didn't work out, because they weren't chasing the money that you know, for the claim denials. So I had to get somebody in house to keep a closer eye on the money coming in and in the stuff that needed to be followed up on. Then I also had to have a staff member make prior authorization calls just to just to see the patient. There were some HMO plans that required a prior authorization before they could even step foot in the office. And then there was insurance verifications to even see if those people's insurance I could see them if my services as a podiatrist was reimbursable.
Dr. T 4:21
So suddenly, that became our job to figure it out. Even though we weren't the ones choosing those insurances for people. Then I needed another staff member to handle the volume of patients to help with a turnover. So the more patients you see, the more rooms you have to clean, the more instruments you have to sterilize. And then they had to schedule follow ups. And then we had to remember to follow up on things like labs or specimens that were sent out. So there was a lot of needed staff support in this model, the volume based model, which is the insurance model, and of course with the volume based model, I need a bigger space. So I had, let's say 123 exam rooms that were running simultaneously. So imagine one person, three exam rooms and the staff to support the turnover and the bigger space, you know, every square footage, costed me money.
Dr. T 5:11
So bigger space meant bigger rent. And then along the line following other consultants that traditional consultants, they said the while they convinced me to get more machines that would help increase reimbursements like an ultrasound. And there's always talk around how do you maximize your revenue, you buy stuff to support it. So if you used ultrasound for injections, for example, you can build a different code and get paid more. And so I was convinced to do so bought these machines. So I had these leases to upkeep with and then certainly the upkeep of the billing seminars, because my billers didn't know podiatry. And, you know, if I didn't keep an eye on my money, nobody else is going to care as much as I did. So that's the tangible cost of an insurance based practice.
Dr. T 5:56
Now, let's talk about the intangible. So even after you get paid by the insurance company, you will always be at risk of an audit, which means they have the right to say we're going to review select charts. And if you have missing documentation that does not support the code that you build, they may request that money back. Now, whether you're right or you're wrong with your medical decision, it doesn't matter because they are wasting your time that you cannot debate. So that's time that you have to deal with or have a staff member understand to deal with submit all of those things in and if you are messing around with the government, they are going to demand that you pay it even if nothing has been proven right or wrong, because otherwise you get penalized for late payments. And then you have to go through the rigmarole to prove yourself and all those things. So that's the intangible time loss as it relates to insurance.
Dr. T 6:49
Don't forget about the time that you spend stressing over when you were going to get paid, because oftentimes, the payments were not always predictable. It wasn't always 30 days, sometimes it was nine months, I had a payment a year and a half later for a surgery that I performed. And so we're constantly monitoring the accounts receivable, the AR in the 30 day pocket, the 90 day pocket, the six plus month pocket, and we're just chronically looking at this and just wondering if it'll ever get paid. And then of course, the time that you have to justify your medical recommendations, your physician, you and I were physicians, we made the recommendations. Why do we even have to read justify it regurgitate what's in our SOAP Notes take on these peer to peer calls that isn't even our peer of our specialty, then you have to explain to patients what their deductible meant and why they owe us the difference if they didn't mean it. What does that mean? If they met it? All of the things? What about the coinsurance? What about the copay? These are terminologies related to insurance, it's confusing to them, it's confusing to us. Sometimes they bring in the EOB, the explanation of benefits as just more time for you to spend on the patient's insurance stuff. And then of course, the claim denials, those are frustrating. And then you have to think about do you need to send the patient to collections? Like do you want to send patients to collections? Was it really ethical to do so right? Like, how do we tease out what was ethical and what wasn't?
Dr. T 8:13
How can you send a patient to collections if nobody knew the price of anything, and there was no room to negotiate for pricing, because the insurance rate is just what it is ultimately being a doormat for when patients find out that they're very good insurance wasn't very good. after all. That's how I knew I was really over it. So I was already losing a lot of money. And I realized that I needed to change the trajectory of my current way of doing my current way of thinking the way my practice was running. Because I was at the point of how bad can it be if I were to opt out, like what worse could possibly happen than what I'm experiencing now. So here were the things that I did to level up. I first number one, learn from others, I observed other cash practices and try to understand what it was that they were doing that worked for them. I wanted to learn as much as I could. And thank God for social media, I was able to easily connect with other direct care doctors. So I did that. And then I number two, I defined my life goals.
Dr. T 9:16
My goal was never to get sucked into my clinical practice. For the rest of my life. I wanted to live outside of clinic I didn't want to think about my business 24/7 in this way. So I made sure that I define what my life goal was, which was ultimately financial freedom and freedom in my time. That was important to me. I had a kid and I wanted to be sure I was there for everything every day. Number three I then define my niche because I needed to stand out from the insurance options. Being a cash practice simply wasn't enough. being accessible is part of the equation but I really needed to find a niche that people understood, desired and needed. So I had to work on my business skills to get Get to that. Then number four, I got really clear on who I served and finally accepted that I wasn't for everybody. And I wasn't the emergency room department. I am a specialist with a practice that has set hours. And I got really clear on who it was I wanted to serve in order to support my lifestyle that I desired. And then number where I lost count number five, I finally learned to value myself, despite the gaslighting that's been happening in the culture of medicine. As of today, yeah, we have been gaslit.
Dr. T 10:34
To believe to bend over backwards to get paid nearly nothing to work hard hours, to wear our exhaustion as a badge of honor on our sleeve. As a physician, this day and age, that way of life is gone. Once you're in direct care, and you see how easy it is to run your medical practice how easy it is to help people where they're happily paying you. You won't even think about those 80 hour work weeks anymore, you won't even question if seeing 40 patients a day is a good thing for you. For me, it wasn't. So I learned to value myself. And I make sure that my mind is set straight. Every single day, I go into my office, that I am there for a specific reason. I'm there to help people. and to stay open, I would not be able to help people if I was not profitable. So that was it for me.
Dr. T 11:27
So what was the strategy, the strategy next for me was to figure out what it was that people would pay cash for. Yes, having Quick Access is really great. But the niche part, being known for your specialty is equally important so that when people speak of your name, what you do is synonymous with that, and then learn a couple of more skills for things that people are paying for that's within your scope of practice that you want to do is really going to help you increase your cash flow. So offering non covered services, for example. And then I added those services. And then I focused on those services, I wasn't trying to do everything, I focus on the select few, then I got more organic Google reviews. What I mean by organic reviews is people I actually saw and helped rather than there are services where you can buy testimonials, which is really weird. But you know, big corporations, they've got big pockets, they can spend money on this type of technology. But I spent a lot of time just texting my patients, even my friends that I've treated for free to get a testimonial to get me active on Google, which helps my ranking a lot. When I got overwhelmed. I took it as a blessing to step away from my business. It's really hard as a business owner to step away, I get that because you feel like if you step away, you're not being productive, you're being lazy, whatever it is, whatever beliefs you have around that, but it's necessary to give yourself space, I gave an analogy of stepping back as a way to propel forward kind of like a bow and arrow, you need to pause and pull back before you can build that momentum to shoot forward.
Dr. T 13:07
That's how I view rest. It's necessary and you have to build it in your schedule. And it's not something that we really were taught, right, we were taught to burn around the clock, but we realize that's not working anymore. So rest is important. And when I got overwhelmed, I made sure to appreciate everything that I did get. Practice mind gratitude, I journaled exercise, I started planting stuff, I just did stuff to get my mind at a place of rest. And then I kept experimenting. When I was ready to go back to work well rested, I explored I experimented, I continued to stay in touch with the people who have direct care practices. I read a lot. I read business books, I listened to podcasts every day, I just surrounded myself in a way that would help me move forward. Rather than pulling me back things that would have pulled me back is hanging around people who would say that direct care doesn't work. I don't advise you to hang around people who keeps pulling you back, even if those people who are pulling you back are your friends and family. So keep that in mind. Make sure your environment is healthy to foster this new version of you. So even though I didn't feel ready, ready like to take the plunge. What I ended up doing was getting rid of the worst payer first, the one that gave me the most headache, the one that required a prior authorization for everything which ended up being Medicaid in my community. And I opted out of that one because I was like there's just no way I can keep getting paid $18 A patient it doesn't make any sense. I took the leap. I was terrified. But then I watched I watched what happened and this is what happened.
Dr. T 14:45
As soon as I stopped taking that insurance, more money came in. Why? Because I made more room for more money to come in. I wasn't trying to hang on to the pennies. I was allowing other people to come in who were willing to spend on their health care. I also had to have a lot of difficult conversations, I got skilled over time with making these difficult conversations less difficult, but it was necessary. It's just part of being a CEO of the business. And I did initially mail out notices to these patients who had these insurance. And of course, many of them were upset, they accused me of being greedy. They wrote nasty things about me, whatever. But again, when you're the CEO of your practice, you have to make these very difficult decisions for the long run for the future. And that's what happened. And then I started to opt out of the other ones that didn't affect me all that much, because I did the big one, the one that created most of the revenue. And I was like, if I survive through that, let's keep going. So I kept with the momentum, took a little break. And then finally I said, Medicare, I've had enough, Medicare was 50 to 60% of my revenue. And I was like, I don't love the idea that they can just take the money right back, even though they paid it out, even though the service was provided, they can just come back, take it back or give you hell about it. Right. And I just wanted a better, easier life. So I said, This is it. I sent my Medicare letter in and I said, I'm opting out on this date, and then I just cut the cord.
Dr. T 16:20
So since then, this has been two years now, I've had some really hard days, and I've had some great days. But ultimately, I accepted what business ownership is, is hard, but it's rewarding. It has its peaks. And it has its valleys. But Never did I regret opting out. Never. The people around me doubted me. And I almost absorbed their doubts, you know, when you're around that conversation all the time. Like, are you sure you wanted to do this? Why don't you just get back in? Why don't you just blah, blah, blah, right? You? It's it's easy to get absorbed by their doubts, but I didn't. Sometimes I did. At my weakest moment. When I had my rough days. I did almost think like, did I make the right decision? But Never did I try to sign back up to these insurances again, because that was a whole nightmare on its own just trying to get credentialed again. So no, no means no. It's because I had a point to prove. I wanted to prove that I could do it. And I wanted to show up for others, to show them that it's possible, which meant I really just had to prove it to myself to my own ego, that I could do hard things, and that it would be worth it. So how would you know when you're ready? Okay, so three things.
Dr. T 17:30
Number one, set yourself up financially, make sure you have some financial cushion, make sure you have another source of income or support before you take the dive. Number two, do it in a stepwise approach, while you simultaneously increase your cash flow, your cash flow might be selling more products, it might be offering non covered services, things like that. So you have to think creatively on how you can increase your cash flow. It might also mean to have the people who you've already served, refer to you and you have to ask them directly. Sometimes we think that they'll think of us, but when you do, ask them directly that can accelerate your referral and increase those types of patients into your practice. So make sure that you ask for what you want. And then number three, believe in yourself. Always, direct care is really delaying instant gratification for the long haul. But you do get some instant gratification in the way that when they show up, they pay you automatically you're not waiting nine months. So once you're set up, you will be solid in this way of practice for the rest of your career. And this is at least what I observed from other direct care practices that were successful. And I disbelieve that I could do too. So if you need more support, you want the roadmap. That's why I have this podcast. That's why I created the launcher direct care practice and 12 week course it's in the show notes. Click on the link, check it out before the prices go up. And if you are still suspicious, or you're like I'm not sure I even need the course. You can schedule a call with me or talk to the people who took the course and see what they had to say about that investment, and then decide your next move. But whatever it is that you decide, I'm cheering you on.
Dr. T 19:14
We all deserve the work life balance that we were promised and I will be here to help you along the way. That's all I've got for today. I will catch you next week. Take care.
Dr. T 19:25
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 19:45
And lastly, if you remember nothing else, remember this be the energy you want to attract. See you next time.