Direct Primary Care has been criticized by some naysayers as a luxury only available to the wealthy, but for Dr Ryan Nuehofel, this has been anything but the case for his practice. Self-termed a ‘concierge safety-net clinic,’ NueCare has provided care to many underserved patients via Direct Primary Care arrangements. In this episode Dr Ryan Nuehofel, founder of NueCare discusses his motivation for starting a Direct Primary Care practice and how he has been able to serve a predominately underserved population by going direct. Contrary to popular belief, many of his patients, though considered underserved, get far more attention and service due to the fact that they pay for services outside of insurance or Medicaid.
[01:27] Could you tell us about your Direct Primary Care Practice?
[01:51] What kind of population does Dr Neuhofel’s clinic serve?
[05:21] What challenges has Dr Nuehofel dealt with when dealing with underserved patients.
[08:48] Has Dr Nuehofel ever had to resort to collections?
[09:55] Where Dr Nuehofel got the idea to start a Direct Primary Care practice?
[12:18] How did Dr Nuehofel go about finding a location, hiring staff and getting legal help?
[14:37] Administrative hassle of a fee-for-service practice versus a Direct Primary Care practice.
[15:25] Dr Nuehofel’s response to criticisms of Direct Primary Care being for the wealthy.
Dr Ryan Neuhofel is a Direct Primary Care doctor and the founder of NeuCare in Lawrence, KS. In addition to being a Direct Primary Care doctor, he is among the founding members of the Direct Primary Care Alliance, a grassroots organization devoted to supporting Direct Primary Care doctors through support, education and advocacy, and a a national advocate for the Direct Primary Care movement.
“What’s scarier to you: Being in a career that you spend time, money and energy to do and not be able to do it the way you want to for the next 20 years or taking a couple of years where it may be rough, you may have to take a loan out, you may have to moonlight, to end up coming out on the other side practicing medicine the way you always envisioned and that made you apply to med school in the first place?”
To embark on one’s own as a direct care doc can be daunting these days, especially when one considers the challenges that must be faced. This is the question Dr Jeff Gold posed to himself when thinking about leaving his nearly decade-old successful practice owned by a local hospital system and starting his own direct care practice. In some way or another, every direct care doctor faces the question when deciding on the model.
In addition to “just” caring for patients, there’s business planning, marketing, regulatory hurdles and, not-to-mention, financing. After four years of medical school and three years of residency, it would seem at first thought that such matters are best outsourced to administrators. After all, we trained to be doctors didn’t we? Not administrators.
Like most other young primary care doctors straight out of residency, Dr Gold took this path, starting a practice under the management of a major hospital system. But after traveling that path he came to realize that this was not what he went to medical school for. Having to see up to twenty patients per day, take time from patient care to fill in insurance codes, and see patients in office for reimbursement, he, like many other primary care doctors, felt like the system of insurance-based care got in the way of caring for his patients. So he made the jump to direct care .
While daunting at first, the decision has allowed him the opportunity to practice medicine with a freedom and joy that he’s never experienced. While at times the challenge of running a business and having to market oneself can be daunting, he notes, being able to help his patients when they need it and how they need it is priceless. This is why Dr Gold embarked on the “road less traveled,” and he has “not regretted it one iota.”
[1:21] Dr Gold talks about his direct care practice.
[02:17] Where Dr Gold’s practice is located.
[03:01] What kind of demographic population Gold Direct Care serves.
[06:42] How long did it take from Dr Gold’s decision to start a direct care practice to starting his practice.
[10:05] What hurdles Dr Gold faced transitioning to direct care .
[13:30] Particular moments during a day’s work that motivate Dr Gold.
[16:55] Many direct care doctors recount similar experiences of being inspired by the model.
[19:14] Dr Gold offers to host other medical students, residents and doctors.
The US healthcare system is failing us. Prices our increasing far beyond our ability to pay, yet health outcomes are far below those of other countries with developed healthcare systems. Many solutions have been posed, yet the one that is shown to be effective has yet to fully take hold: Direct Primary Care.
In this episode Dr Roussel discusses the current healthcare crisis, where we are and how we got there. Moreover, he explains why DPC is the answer to the crisis. Finally, he responds to certain criticisms of DPC that have been leveled by critics of the model, many of whom are financial stakeholders with a vested interest in maintaining the status quo.
[2:07] Purpose of the Direct Primary Care Podcast is to be a resource for those interested in Direct Primary Care—particularly those on the fringe, those who are interested in the model but don’t quite see how it would work in the mainstream.
[2:10] The podcast is not just for doctors but also those in the insurance industry, health administration, policy makers and economists.
[2:44] Our discussion will deal with Direct Primary Care only—not concierge, not other models for healthcare delivery
[3:00] What is Direct Primary Care?
Full access primary care
Generally monthly or annual fee
Low cost (<$100/month)
[3:49]Direct Primary Care doesn’t cover insurance, not labs, meds, imaging or specialist visits.
[4:00] My interest in Direct Primary Care
I learned aboutDirect Primary Care as a medical student.
My motivation going into medical school was to practice straight up general medicine, making use of my training to help every day folks with every day problems.
[4:30] On the hospital wards and in clinic, I would witness residents and attendings having to see 15-20 or even 30 patients per day, many of them coming in with limited primary care access.
I did not think that I could practice primary care without burning out.
[4:45] Initially, thought of becoming a specialist, as 99% of my class does, or just staying out of clinical medicine, perhaps going into academia or industry.
[4:55] Towards the end of my third year of medical school, I learned about a new model being pioneered in Seattle by Dr Garrison Bliss.
It involved a low cost monthly fee in exchange for all-access primary care.
[5:02] Just being able to see a few patients per day—maybe up to five or six—while having the flexibility to help many more over the phone and email would allow me to be the doctor I went to medical school to be.
[05:22] So I decided to go into primary care, choosing to go into internal medicine residency with primary care track at a a Harvard Medical School affiliated program.
[05:30] There I had the opportunity along the way to spend time in Direct Primary Care clinics and be mentored by Dr Garrison Bliss, Dr Josh Umbehr, and Dr Jeff Gold. I also had the opportunity to meet many more Direct Primary Care doctors atDirect Primary Care Summits.
[06:10] My current Direct Primary Care practice is in Louisiana.
[06:34] Healthcare is now in a state of crisis.
[06:44] It’s riddled in debt.
[07:02] There is a huge shortage of primary care doctors.
[07:12] Physician burnout/satisfaction is rampant.
[07;22] The insurance model in healthcare is outdated.
[07:30] Healthcare services have expanded virtually exponentially in the past fifty years since health insurance was rolled out in the 1950’s and 1960’s.
[08:20] Health insurance has continued to cover virtually all of healthcare needs, even as healthcare services have come to include not only catastrophic events but also every day services—eg preventative care, regular management of chronic diseases.
[08:40] Rates have consequently increased dramatically to the point that premiums are on average not affordable, and the cost is only increasing.
[08:55] It’s as if car insurance expanded to cover all car repairs—oil change, tire change, battery replacement, etc—or homeowners insurance covered replacing a heater or an AC or a new paint job. Of course the cost of the premium would go up.
[09:19] For insurance to be affordable it needs to cover rare events, not common ones. Otherwise it’s not pooling risk, it’s just pooling money.
[09:22] Then insurance becomes not insurance but an financier, like one would pay a car dealership for unlimited repairs or apple for AppleCarePlan.
[09:33] And if we want to talk about financing models for healthcare, that’s well and good.
[09:43] But if we are going to talk about subscription type plans for healthcare, which I think is the way to go, then who better to provide the subscription service then the doctor. Why outsource financing when it’s not necessary?
[10:01] Direct Primary Care as the answer
[10:12] Direct Primary Care lowers overall cost of care by 30-40%.
No third parties for most services
Doctors available any time
Continuity of care
Less need for duplication
Less legal risk because of patient rapport. Not just overall cost for the system less but also for the individual
[11:07] Direct Primary Care fee can be paired with HD health plan, which is much cheaper.
[12:04] Doctor patient relationship has been nearly third party free for 2,000 years. Only in the age of managed care has insurance come to be the responsible party for paying for medical expenses.
[12:27] Hospital growth is a modern trend due to third party payment
[12:40] Unfounded criticisms against Direct Primary Care
[12:53] 1. Unfounded Criticism #1.It will reduce the number of primary care doctors
Actually, the reason so few enter the field is because of the stress of burnout, low pay, etc
Can encourage new med students, residents to enter the field, and can keep other doctors from retiring
[13:33] We have the physician staffing right now to provide Direct Primary Care to everyone.
[14:30] 2. Unfounded Criticism #2. It’s going to harm patient care because doctor’s aren’t regulated/connected/integrated, etc.
Data doesn’t support this and it’s empirically untrue.
[15:19] 3. Unfounded Criticism #3. It’s financially unfeasible for the underserved.
This happens to be empirically untrue: Ryan Neuhofel, Josh Umbehr, many others
There’s nothing against helping people pay their fee.
[16:00] Direct Primary Care doesn’t solve the need for insurance, but it reduces the cost of it and what the plan needd to cover.
Dr Landon Roussel is a Direct Primary Care doctor who lives in Baton Rouge, Louisiana. He founded the Direct Primary Care podcast in 2016 as a way to support the Direct Primary Care movement as it continues to resolve the healthcare crisis from a grassroots level, one doctor-patient relationship at a time.
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