Episode Transcript
Ep.182-POD-Dr. Diana Girnita, Dr. Anastasia Boyer, Dr. Daniel Paull
Pablo Gonzalez (Producer): Hey doctor, welcome back to another one of these compilation episodes. This one is about the moment that couple of members of our community decided to transition into direct care. We are joined by Dr. Diana Gurnita, Dr. Anastasia Boyer and Dr. Daniel Paul. Dr. Diana Gurnita didn't feel like she was getting enough time with patients and that led her to looking elsewhere for a way to do that.
She talks about how she had to educate the market. And what she was starting and the transition over economically, right? , she had to do some side gigs and, get over the fear of not being able to pay bills. And finally she talks a little bit about the peer pressure in the community and the medical community when you're doing something different Dr.
Anastasia Boyer Her commute was killing her. It's not familiar. She also had a different idea of, what being a doctor and having quality care look like. So she talks a lot about the transition and considerations, in this like leaving quote unquote the family and weighing the financial risks and how she did it.
And then Dr. Daniel Paul, he's just kind of a different character. He just really had a vision straight out of medical school and started a completely different model because , his priorities were having leverage. And, , he talks about going from, you know, the beginning of doing this thing different to this moment now that he has this like incredible economics to, to work effort ratio that I think is really, really interesting.
So hope you enjoy this episode.
Enjoy.
Daniel Wrenne: Diana, welcome. Thank you so much for having
me. I'm excited. I think we have a lot to talk about because I'm very into this direct care model. And for those of you listening, you know, I'm very into it. I've, we've been covering it a lot and talked to a lot of different people in the model and have been exploring different ways of doing it.
But what's especially unique about you is you're actually not only working in direct care, but you're in direct specialty care. So you've kind of taken it to the next level, and I'm excited to hear about like how you got into it. And you've even created a network of direct specialty care physicians to help connect patients with providers.
They're up to some great work and I'm excited to kind of dig into your story and how you've gotten to this point. I imagine you didn't start out in direct specialty care because that's just a pretty new thing, right?
But how did you get into this world of direct care and where you are today?
Dr. Diana Girnita: So you are probably aware, like many of us, that we spend some time in the traditional, as I call it, traditional medical system that things started to deteriorate, both for us, but also for our patients. And at some point in my life, I had the feeling that I don't have enough time with the patients.
I don't have, you know, I have the skills, but I don't have the time. And I was struggling to keep up with my electronic medical records more than I was keeping up with my patients. And I thought that the avalanche of messages that I was getting from the patients were also coming because I didn't have enough time to spend with them and kind of educate them.
So, when I saw that patients were struggling to get to me, patients were struggling to come for appointments, and then they were struggling financially to be able to afford an appointment with me, despite the fact that they were carrying what is called great insurance. There were so many limitations. And at some point, I decided that maybe for me, it's time to step out from the traditional system and create my own private practice, like a micro practice where I can do my job.
And I would feel less, I would say, less stressed about what was going on. And You know, in the process of thinking, how can I help patients, I realized that my specialty is so badly represented. We are about 6, 000 specialists in the whole United States. And, at that time I was located in Cincinnati and I saw patients traveling for two hours to come to see me.
And there was no way for me to make their life easier. And even when I talked to my former employer about implementing telemedicine, no one was interested. That was before the pandemic. No one was interested because there was no way to bill for such a way. So. I really thought initially that telemedicine is a great opportunity, and then I started to form my own company.
And my dream at that point was to serve people in the nearby states, like Kentucky, Ohio and Indiana. But then I realized there are so many other states that they do not have enough specialists. So that's my story in the beginning to become an entrepreneur, but then, you know, building up my practice, I sat down and I thought about things and.
I realized that, you know, my specialty is so expensive, you know, the way that I knew that things could be done, the way that patients would have to come in, pay with insurances. And then I realized that, I don't know anything about the prices that, a price for my consultation, the price for my laboratory workup and prices for x rays.
And there were many patients that were asking me how much is this going to cost me? And I felt so embarrassed that I had no idea even how much it's going to be my consultation. So I was looking right and left, and then I have a friend that was very familiar with direct primary care. And he introduced me, I mean, kind of reintroduced me to this idea.
I knew someone that was doing primary care, a former colleague of mine that was in the residency. And I started to look into this model, and then I compared this model to what I knew from back home, from Romania. You know, in Romania, you have two systems, the private system, where you have absolutely all the information that you need.
You know exactly when you go to a private practice or a private clinic. At the door, you have all the prices for the consultations, for the laboratory workout. So patients will know exactly what to expect in terms of financial expectation. So and I thought, you know, why is this not possible here? And how is it possible for the primary care to do that and not the specialist?
So, that's how I started to explore the idea, and that was about four years ago. And then, little by little, as a very good friend of mine said, I started to realize that a specialist can do this, can be in direct care.
Daniel Wrenne: So rheumatology is your specialty and your practice is called Rheumatologist on Call. Is that when you started Rheumatologist on Call was four years ago?
Dr. Diana Girnita: Yes, correct. I started to build up the company almost four years ago. And then, you know, after. I started in 2020 was the first year where I was seeing patients in the middle of the pandemic.
Daniel Wrenne: Yeah, which in some ways probably I would imagine it helped if you were doing telemedicine, particularly with the whole adoption of that as a potential service.
Dr. Diana Girnita: Yes, but I was talking about telemedicine two years before the pandemic came and I was trying to, you know, open up the brain of people about using telemedicine for the use of the patients and for us as well. But it was a big, big struggle. Yeah,
Daniel Wrenne: and change is, it's hard sometimes to get things to change off.
Often doesn't happen as quickly as we, we would like, and going into the big venture, I mean, four years ago, were you nervous or scared or fearful, I think sometimes that's a pretty scary jump to go from this system that's like steady paychecks to this entrepreneur world of entrepreneurship of, you know, unknown, Did you have any fear around that?
And if so, like, how was that managed?
Dr. Diana Girnita: I have, I had a lot of fear. I have to admit that I had, I went into this, as you guys say, cold turkey. So I didn't transition through, because there are practices that will transition to cash pay. From the insurance work. So they still take some insurances, private insurances.
They still take Medicare, but they also accept cash. I did it the other way. I just straight, I went straight to cash and it was not easy. And it wasn't easy because you know, things were not set up. Everything was set up, but it was very hard to educate patients that what I do. It's extremely valuable. it's not in any way tricky, and it's the way that patients were educated to get services.
And to polish that kind of language to what you say to the patient, what you convey to the patient, it's very hard. Once the patients come to us, and I'm talking us about specialists that are doing direct care, they understand after, probably after the first visit, that the value that we provide, that we offer, And the care that we offer is excellent, and we really give everything that we are supposed to give, because we are not stressed by the environment.
We are not constantly looking at the computer, and we don't have 30 patients waiting at the door to be
Daniel Wrenne: seen. Yeah, you can spend the time with the patients that they deserve. And then also the transparency of what is being paid is right there. And then on top of that, like when you're paying for a service as a patient and as a provider, when it's transparent like that, forces, like the incentive is to make sure and add value to kind of like, you know, you want to be able to make it worth more than they're paying as a physician.
And also the patient is worried about that too. They're like, is this worth my money? And so that's healthy, I think, incentive that gets created in that sort of environment versus in the traditional healthcare system. Like nobody knows what anybody's paying. It's just like, kind of like monopoly money in some ways.
And that doesn't drive any of that incentive, but it is difficult. I imagine to kind of, cause you have to reshape people's belief system or like kind of, people are not used to that as the way things
Dr. Diana Girnita: work. That's very true. Patients are, and again, I don't want to use words that will be offensive to anyone, but I feel like in the current system that we live, we are brainwashed all together, patients and physicians.
To work a certain way and to reach out, to get care a certain way. And when you bring something different, like every product that is different from what you are used to use every day, it takes time. But the fact that you provide the highest quality of care that is turning back in, 10 times, I would say.
And the satisfaction that you have as a physician to really spend the time with the patients and see the outcome of these patients, you really have the time to see how patients. are improving and you have time to listen to them. And that's the other thing. I think that we are not only, with one hand we put orders and with the other hand we had a prescription.
We are healing patients. And it's extremely important for the patient to build up trust. Patients do feel like the system betrayed them. And by saying the system, they only see us, the system is us. We are the face of the system. Unfortunately, when they think about medical care, they think about their doctors.
They don't think about anybody else besides us because the main interaction that they have with the system is their physician. So how are they going to know who to blame? They're going to blame us. For things that they're not happy and rebuilding that kind of trust. It's extremely important for both
Daniel Wrenne: sides.
When you made the switch, was it, so you mentioned cold Turkey. I know you went all in on cash pay, like from the get go, which that's, I love that. that's my style. I mean, I would. I think if you're going to believe in something, you just got to go all in. Did you also go all in, like, did you just stop the system job?
Yes,
Dr. Diana Girnita: I stopped one. So I work in academia. I work in private practice. What I continue to do is I took some locums job to support my family, and that was extremely helpful for me. And while I were building up my practice. So while I was building up my practice, I took some locums job, which were helpful. And I kept my academic appointment.
So that was also helpful because it kind of. Kept me connected with the system, but I was not depending on the system. Now, for those physicians that are interested to jump into direct care, they also have to be prepared to find side gigs, I would say, to support their income, because that takes some time until you build up a practice that is viable and is able to provide you the paycheck that we are used to.
I can imagine, I don't know what your position situation was, but I can imagine someone that's like sole breadwinner for a family. And in that instance, it's like literally like you gotta have some level of income. And so that baseline income, that's very high priority important.
Daniel Wrenne: I remember when I started my business, like that was like number one priorities. Like I gotta, I always would say the first thing was breakeven. And when I described breakeven, I meant like paying the business's bills and not paying me. And then second phase was like, feed the family, you know, and that was like a pretty big accomplishment is like, we're feeding the family, we're doing good.
And then, beyond that, it's, all the other stuff, but. I think there's also financing. People can get financing to help with things like that and have mistakes.
Dr. Diana Girnita: But many things you can figure out by yourself. I'm sure we are very, very smart people. And there is also something about physicians.
I would sayonce we want something, we go for it. We work hard and we use all our resources to figure out things. It's not easy to figure out finances, but it's not something that you cannot do. And as you said, don't expect to pay yourself. Probably the first six months I didn't pay anything, any dollar to my pocket, but I pay everybody else.
And I was so, so happy that I was able to pay everybody else. I had my husband to support my family. But the fact that I didn't take any money from my pocket to put into the business, that is also, I think, an accomplishment.
Daniel Wrenne: it can be scary, but it's a, it's kind of like one of those good, scary things.
Like you get a little nervous about it on the front end, but you know, it's like a healthy fear and that's the kind of thing you lean into and it's typically. Good for you, but it is a little scary. Was it like something that was paralyzing at any point? Did you ever like struggle with the fear or did you have that same sort of description I described?
Like, was it, did you kind of lean into it and you're like, this is healthy.
Dr. Diana Girnita: I had moments when I said to myself, this is very hard. You know, I cannot handle all of this. But at the end of the day or the next day, I woke up and I said, no, I started on this road and I'm going to continue with this. It's not easy.
It's not supposed to be easy, and I kind of took that as learning. opportunities. And I really want people that are engaging into this to understand that, we in the medical world, we only see the medical world, but we should look outside of the medical world, talk to people from outside, learn from them and Understand that the challenges that you have, everybody has, probably in every business is not like we are unique.
We do face some unique challenges because of the, mentality that is training us and, is kind of shaping the mind of the patients that they can only get care with an insurance card. But in the current system, once the patients see that they do not have access to medical care when they need it, they will look for options.
What is happening in our days. Is patients are looking actively looking for options, options for finding a physician or finding cheaper medications, for example, or a way to pay for their procedures, they are actively looking and that's why you see all this huge companies like Amazon and, you know, the independent pharmacies like Mark Cuban pharmacy, they are actively Uh, showing up because they know there is a huge interest towards cash pay.
Daniel Wrenne: And when it, when everything gets all stirred up, like it is now, that's when all these opportunities come about. And that's where things like, I mean, direct care, I see, I see as big time expansion potential as all this stuff gets stirred up
Did you, I'm curious when you made the jump, did a lot of your colleagues or people around you, did they kind of give you the sideways stare and they're like, are you sure?
Like, what, explain that
Dr. Diana Girnita: again. A lot of them were confused about what I was doing and I believe that's absolutely normal. Yeah. And a lot of them today are calling me to ask me, how can I do this? Right. And you're like, I'm doing it. Yes. And, you know, there are still people. That are asking me, how is this possible?
I never thought this is possible. And you probably, they're probably right, you know, cause you don't think about. Options until you're really in that point, that breaking point, that you want to change something you, you understand that you either accepted or you should work to change things.
Daniel Wrenne: Welcome to the podcast. Thank you. I am excited.
If you could share maybe just a little bit about like your story, I'm curious, like, why did you go into medicine? What was your path to start? Maybe a little bit about training and then how you got to this point where you have
Dr. Anastasia Boyer: a practice.
I've always really just wanted to be a doctor. That's since I was three years old, that's what I was telling my parents I wanted to be. Wow. One time I like briefly entertained the idea of becoming an ice cream truck driver, because I thought that you could eat all the ice cream, but you shouldn't really eat all your profits.
So other than that. Doctor was the plan just from the beginning. It probably sounds like cliche, but I did genuinely want to be a doctor to help people and serve my community. So that's always been the plan all along. And I'm one of the boring traditional med students. I went college at IU Bloomington, studied chemistry and Spanish there.
And then I went to an osteopathic medical school. Well called the West Virginia School of Osteopathic Medicine in Lewisburg, West Virginia. So I spent a lot of time there just kind of walking around the grounds. It's very pretty volunteering, that kind of thing. So, and then after residency, I moved back home to Indiana where I grew up.
Crawfordsville, Indiana is a small town, kind of west central of Indianapolis. And I'm a national health service course scholar. So they like, thankfully, wonderfully paid for my med school. And in turn, I did four years of service and then underserved community. And I was like shocked to find out Crawford's though my hometown qualified.
So that was awesome. I got to practice for four years there. And then I got married and we bought a house and we have a big blended family with six kids and we ended up finding her. what we hope is our forever home out in the east side of Indianapolis. So I never really had intentions of leaving my old clinic because it's where I grew up.
I love my patients. It was a hard choice, but the commute was really kind of the deciding factor. It. Sometimes would be as much as an hour and a half or two hours each way. And so I'm spending my whole day driving and four of my kids are younger. They're two, four, six and eight. And so I wouldn't get home till bedtime and I felt like I was missing out.
So. I'd always been interested in kind of the direct primary care concierge model because you get so much time with your patients. And I got an email from Freedom Health Works and Freedom Doc that said they were opening a clinic in Zionsville and Zionsville is only about 30 minutes from where I live now.
And it's very close. to where I lived when I was working in Crawfordsville, so it just seemed like the perfect match and everything just felt into place.
Daniel Wrenne: So you were working in a clinic and it was a commute, long commute and Pretty long hours, and you have kiddos, and I know how I have three, I don't have six, but I have three, and I know how bedtime is chaotic, but also important to be around, and ideally even more than that, and so what other Pressures were you dealing with like around, I'm thinking back to like, you're in that practice.
Was there other things that were causing you concern about the way that things were going at work or at home or the balance or what kind of led you up to this point of like, even considering an email from someone about an opportunity?
Dr. Anastasia Boyer: Well, I, like I said, I loved the clinic I was at. It was great. It was a lot busier than direct primary care is because in the typical insurance model, you really have to see a certain number of patients per day to break even and to meet your metrics so that the clinic makes a profit.
And it was just very busy. Typically doctors see anywhere from maybe like 16 to. Almost 30 patients in an eight hour day. And that usually ends up being maybe like 15 minute appointments, 30 minutes, if you're lucky, a lot of times you'll end up double booking, trying to squeeze patients in, you know, we're sick, but you can't come in in the morning.
We want to make it work for patients the best we can. But if you're already in a 15 minute slot and you double book it, you end up running really behind, it's just frustrating for patients that they have to wait on you and really like. I do genuinely love to get to know my patients like on a much deeper level than just what are your medical problems, what are your medicines you take, your surgery, your family history.
I want to know like, what is home like for you? Where did you grow up? What do you like to do for fun? Because all of those things have an important impact in our health and our wellness and our healthcare plans together. And really, in the 15 minute visits, especially in the traditional model, it's really hard to get enough accomplished to build that rapport with the patient where they trust you enough to kind of open up and tell their full story.
Their, you know, open up more about mental health or about how things are at home. Are they safe at home? In 15 minutes, you don't usually have time to address much of that, but in direct primary care, because we limit the patient panel to much, much smaller, my average appointments are an hour. New patients.
I booked 90 minutes. I want to make sure that I don't leave any stone unturned to say I am evaluating your medical problems from all aspects. What are like the social factors, environmental factors, spiritual factors that impact your health? Like, why aren't you at Where you want to be wellness wise, is it stress?
Is it your schedule? And those are things that I now have time to work on with patients. So it really was multifactorial decision to change from the traditional insurance model in a federally qualified health center to direct primary care. A lot of it was home life balance spending. a lot of time commuting a lot of time at home charting on weekends and evenings and also wanting that quality time with the patients being able to have the time to investigate alternative treatment options for them make sure they're getting the very best care I can
Daniel Wrenne: provide not the 15 minute rushed somebody's waiting outside and And then if they need, I'm sure every once in a while you would have people that were like, pretty, there's a problem that came out, and usually it's like that very last minute of the 15 minute visit, they're like, oh, by the way, and then, and then all of a sudden you're like, oh, no, I need to talk to you, continue talking to you about this, but then I have like, six people in the waiting room, and, and then things compound, and
Dr. Anastasia Boyer: Yeah, and then it stresses the patient because they can tell you're rushed.
It stresses the nursing staff and then everyone waiting in the waiting room. It's just kind of a snowball effect.
Daniel Wrenne: Did you feel like it was not how you'd envisioned practicing medicine in any way in that setting at times or?
Dr. Anastasia Boyer: Well, I guess when I dreamed of being a doctor back in the day, you know, you get the vision from scrubs or Grey's Anatomy or whatever.
Like I didn't know all of the minutiae that goes into it with the charting and the insurance quality metrics and checking the boxes just right and writing your notes a certain way so insurance will approve that ct scan that medicine that physical therapy order things like that it's sad but we spend at least half our time charting really, I would say as, as much or more time than we spend with the patient, we probably spend charting on them.
And then also answering like other telephone notes and things like that, where we have to just, you're on your computer a lot more than I thought. And I always kind of envisioned being a doctor as like. The old style kind of your, you took care of everything. The family doctor, you know, delivered the babies and did the surgeries and knew the patients and visited them in the hospital
Daniel Wrenne: and knew their first names and like said hi to them at the grocery
Dr. Anastasia Boyer: store.
Yeah. And then home, like home visits and just really knowing the whole family and having that. Close personal relationship, individualized care that you really can't get anywhere else besides the direct primary care
Daniel Wrenne: world.
Yeah, that's what I think of as like the practice of the old days, like small town doctor has a few hundred patients and they know them all by first name and they have the relationship and I've heard people say different numbers, but like, say you have to have 2000 patients or more. In that setting, and I don't think it's possible to have a relationship that's close with that many people.
I've seen some studies on it. Actually, I think there's been some studies that say like 150 to 300 is like max capacity of number of relationships, like not just like names on a sheet of paper, but like you actually know the people relationships for any one person to have. And in that traditional model, it seems like that's just impossible.
And even just the time component, like you have to You have to give yourself the time to build up the relationship too. And then the relationship too is trust will breed trust. And then the trust allows you to deliver better care. People have to trust you. They hold everything back when they don't trust you.
I mean, people hold stuff back anyway. They just don't feel comfortable until they. Trust you and that's important in health care. I would imagine. I mean, you need to know these things and they yeah, but people are uncomfortable It's kind of like money. We talk about money people are uncomfortable talking about money Oftentimes same sort of thing with health care, but that's why trust is so important Was that something that basically making it difficult to provide the best patient care possible in that model?
Was it getting in the way of like I imagine it was Based on our conversation so far, but I just kind of, you know, make sure that's what I'm hearing is like, was it getting in the way of providing care?
Dr. Anastasia Boyer: I would say that in the traditional model, it's really more of a superficial level. So you're still addressing all of their medical problems, their medicines, their labs.
It's more so treating like the physical body, but as an osteopath. We believe that wellness is in mind, body and spirit, and a lot of times you don't really get to that mind spirit part when you are only with someone for 15 minutes because you haven't built that trust. And I mean, that's fundamental for them to be able to open up to you.
So I think that there are amazing doctors in both models for sure that provide excellent care. It's just really time. And trust and rapport is that's why people trusted their doctors that, you know, did home visits and knew their dog's name and had been taking care of them for 20 years because they knew them completely, almost like a friend.
And that's really how I want my patients. to feel with me that it's not some scary, sterile exam room that we are kind of like friends sitting down, having a cup of coffee together. We have an hour to chat. Tell me what's going on in your life. What are your goals? Where can we go from here so that you feel you're well, you're at your vision of healthiest.
Daniel Wrenne: Yeah, I think people have different definitions of quality health care or quality experience or whatever. So, everybody is welcome to their own view on that too. I mean, there's the minimum level standard and then there's, some people have like, maybe expect even more attention than, and time and relationship than even just hour long visits.
But, Everybody is going to have their different flavor of that. So you were, had the, a little bit of frustration in your view of healthcare. You kind of saw it a little bit differently and you decided to make the shift. Was it like, boom, I'm making a shift. Was it like, I'm frustrated, I'm out. I'm going to consider opportunities.
I'm in boom, easy peasy. Or was it, I imagine it was probably not so simple. It
Dr. Anastasia Boyer: wasn't very simple. I felt the strong emotional connection to my last clinic. It's where I grew up. I knew my patients personally as friends growing up. I didn't want them to feel like I was abandoning them for a different place.
But really my family is the most important thing to me and they always will come first. And so I wanted an opportunity where I could have that home life balance. And really with direct primary care, I, I tell my patients, I want to take care of you like you're my own family. And I didn't feel like that was possible in the traditional model, but now I have time to really get to know my patients.
And I do, I think of them, okay, if you were my sister, What kind of care would I want you to get? And that's what I try to offer them. It wasn't a quick decision necessarily. It's been something that I wanted to do for a long time. And ever since residency in Lewisburg, they have the Greenbrier Resort there.
They have the concierge medicine style. I just never knew how I could. Start up my own practice because they don't teach you any business at all in med school, nothing. They don't even teach you how to bill. So it's like, I would have no clue where to start to order medical supplies or how do you determine what EHR you want to use the electronic health record or how do you find lab core quest to do your blood work?
I would have no idea. So. I just was blessed with the opportunity with Freedom Healthworks and Freedom Doc, where they can manage the entire business side. And I just get to practice medicine how I love to practice.
Daniel Wrenne: So you were a little intimidated with the learning all the financial business stuff. And what about the risk part?
Was it scary? The idea of Starting a business yourself. 100 percent on your
Dr. Anastasia Boyer: own. Yeah, absolutely. I even told our CEO in my interview for this like job. Technically, I'm a small business because it's an LLC, but yeah, manage the financial part of it. I told him I was like, this is my livelihood. This is how I feed my kids and put a roof over their heads.
Like, I'm afraid he'd. What happens is this going to work? And he said, same thing. This is my livelihood too. This is how I take care of my family. I'm not here to take advantage of you. We want doctors to be happy, patients to be happy, and it's just a good balance for everyone. And really coming out of med school, most doctors have a significant amount of debt.
It can range from. Like I was super blessed to get the scholarship through the National Health Service Corps to the West Virginia School of Osteopathic Medicine is one of the most expensive schools in the country. Out of state tuition is 49, 000 a year. I mean, a lot of people come out with half a million dollars and just student loans, not counting their college loans.
So with that. Like insurmountable debt, plus a mortgage and car and all those things, really, you have no savings to typically fall back on to live off of while you start your own practice. So it is super intimidating. And I think it's the number one challenge why people are afraid to jump from the traditional model and start their own practice and just kind of not look back.
Daniel Wrenne: The financial part is the most intimidating part you think for most people. Absolutely. Yeah. I can see that and it makes a lot of sense. And I think I hear that a lot from people. It's like, you know, whatever business risk, not even business, I mean any risk, people are intimidated by taking big risks. But I think we're seeing a lot within healthcare, a lot of physicians are so frustrated with it that it's like that in itself is a risk, like continuing to work in a environment that's in conflict with your values.
That in itself is a huge risk and you kind of have to weigh all those things. You were able to find kind of a setup that is a little bit of a hybrid. Maybe we'll talk about that a little bit more as well. But like, so making the jump completely on your own was felt very intimidating to the point where you're like, I don't think I want to.
Dr. Anastasia Boyer: I never would have done it on my own completely without someone that has business background, legal background because there's just so many things that you can miss without someone helping you that has that financial business background.
Daniel Wrenne: Daniel. What's up, man. I'm excited to have you, man. and I love what you're doing first of all I absolutely love innovators and people that are doing things a little bit differently and I think Your practice is fantastic.
It's very innovative. What's interesting though about saying it's innovative is actually in some ways like, kind of like the way I think it maybe used to be done back in the day. Like it's really simple. As well, and it's not what I think people would think of is innovative, but it's definitely a different way of doing things.
And I think it's fantastic. So thanks for coming on, man. Yeah. Thanks
Dr. Daniel Paull: for having me. I appreciate your kind words there. So yeah, it is kind of a throwback the model to maybe what things were like before. There was health insurance was really so, so involved. So used to be your doc, you'd have your doc, they would do house calls.
I mean, to find someone who remembers house calls, they have to be probably into their eighties by now. And when they were a kid, they remember the doctor coming to their house. You know, the doc would have been office with maybe his wife was the receptionist. And like, that was pretty much it. His notes were just notes for himself, or maybe he would.
Occasionally send them out, but they were really notes. So he knew, or he or she knew what they were doing last time. So they were literally notes and. You know, I'm not like a reactionary type person. I just think that with healthcare, I mean, what I've done and I, well, really what I've done is I've removed all of the parasites, I got rid of all the parasites.
And when I boiled it all down, it's kind of looks similar to what it used to look like just with a modern twist with technology, of course, you know, I'm not writing paper charts, everything's electronic, I carry an ultrasound around with me. So, you know, I don't really use paper a whole lot. So, but the core of it's the same, which is basically.
with the patient. I think when you do that, you can have a much better outcome, you know, cause right now the system is built. There's all these high volume practices. It's built for one problem. One patient, you know, five said maybe seven minutes of face time. So God forbid the patient has multiple problems at once.
Like they're going to get terrible care. And if they're a bad historian, like There's no help. I mean, God help them. I mean, if they can't, you know, if they're forestoring and the multiple problems, those are the people that get the worst care in our current system.
Daniel Wrenne: Yeah. And so if you look at, do you guys listen and check out his website?
It's it's, it kind of gives you a glimpse of what we're talking about. It's easy orthopedics. And so your website, like your front page, transparent pricing. That's a big deal. I mean, I, I don't know that I've ever seen that on a physician's website. Most of the time, nobody knows what's going on there. House calls.
You already mentioned that delivering relationship based care. You've kind of hit on that already. Those are like, those are not happening at all. Those are big time differentiators and I guess you can infer this from the website, but in orthopedics, and I think a lot of people are like, what is that possible?
Or, you know, and I would love to take a step back first. it'd be really helpful to talk about kind of like how you got here in the first place and how you kind of got to this point of starting this.
New innovative practice.
Dr. Daniel Paull: Gotcha. A short story with me is I come from a family of engineers, like everybody, like both sides of the family, engineers, everyone.
So that's probably what I would have done. And I not had a bad skiing accident where I broke my right arm and both of my legs when I was 14. And so obviously I was pretty messed up from that. And I had all this orthopedic surgery, and it kind of got me all again. And I was like, this is pretty cool. I think this is what I want to do.
So, 14 years old, I made the decision, which isn't uncommon in the world of physicians, and sometimes that 14 year old mentality will come back to bite you decades later when you get to the reality of the decision that you made when you were so little. But anyways, so I do that, go to college, go to med school in Miami.
University of Miami. And then I do residency, five year, uh, fortunate enough to get into orthopedic surgery residency, which is pretty hard to do. I was out in Toledo, Ohio. So I spent five years there. And then I started a fellowship in hand surgery. So I was just going to do hand surgery. And this is where things kind of went off the rails.
So a couple of things went on. So I'm in the middle of this hand surgery fellowship, which is an optional year that I've decided to do. I don't need to do, I've decided to do it. And it's a year long. And I'm like halfway through and I'm looking for a job. And I'm looking for a job in Colorado or in Connecticut, which is where my wife's from and where I'm from.
And we're in Colorado now. And it's like, man, I just can't find one, you know, or if I find one, the best word for it is abusive, where like, you know, they want you taking all their call all the time. They're giving you the short end of the stick just continuously. And it kind of created this existential crisis where I was basically like, what am I doing?
Like, what am I doing? I mean, I've, I, you know, college medical school residency, you're just grinding, grinding, grinding, grinding your heads down. And then when I finally had a second to look up and I'm like, wow, these jobs are pretty terrible. You know, like their bet, you know, all I was doing was talking to, I remember interviewing for one of this old senior partner, which is telling me bitterly how much money he made in the nineties, you know, and then how much money he's offering now is like, you know, whereas it's a big disconnect there and you know, the chops out in Colorado, or like I said, abusive at best.
And so that was going on. So it's existential crisis of like, you know, what am I doing? I'm at this point, I've dragged my wife over the country, you know, for my training. And we wanted to go back to Colorado. And it's like, well, I don't know if I'm going to be able to do that with my job. So that's going on.
And then at the same time, the fellowship to put it lightly or bluntly was not a positive educational experience. So it kind of created this huge negative ball of like motivational, unhappy energy. And like, I had to do something with it. So I quit my fellowship, like I broke my lease and we just moved out to Colorado.
And I had the idea for the practice from a friend who started something similar in Miami, but with internal medicine. And I said, you know, he's the happiest guy I know, from my medical swim class. And he's doing really well financially. I'm like, there's something here. There's something here. I don't know what it is, no one's done it for orthopedics, but I was at a point where, you know, I'm living in my in laws basement.
And is that I'm just going to go for it. So, I mean, a lot of people say like, oh, that's really brave, but it wasn't some sort of calculated. Let me sit down and do it. It was a desperate desperation where maybe you don't have the time to really think these things through. You just kind of go for him. And that was about four years ago.
So it's done pretty nicely over the past four years. You know, the key, their keys, there's key components to it. One is I don't take any insurances. I don't take private insurance, Medicare, Medicaid, TRICARE, nothing. I treat them all the same. I don't take any of them. And because if I do take insurances, it will run me into the same problem that every other practice is having, where you don't control your overhead and you need a staff of ratio for approximately 5 to 1, and your reimbursements go down after a year, and it becomes this high volume.
Crazy practice that's not even profitable and turns into insolvency that gets bought up by private equity or a hospital. So, I knew I didn't want to do that, and then what I realized is, oh, I get to spend a lot more time with patients. And then I said, I'm actually, I think, delivering better care, because if they've got five or six problems, I can go through all of them.
And my overhead is, I decided to be mobile, which keeps the overhead down. So I see patients in their homes or at various offices, I don't pay for any of this, I'm value added when I'm there, right? Like if a certain provider's like, hey, this guy's got shoulder pain, can you come see him in my office? Sure, you know?
If they said, but I'm gonna charge you, I'd say, well, I'll see him at their house, you know, I always have that default option. And so I keep my overhead low, so I don't need to really turn the treadmill up high to really, you know, do well. So that's kind of the journey in a nutshell.
Daniel Wrenne: Everybody's always like, man, it sounds scary and courage, like you were saying.
But when you're, you point out a few things I think are super important. You were living in your, did you say your in laws basement? Yeah. We moved into the in laws basement, in laws basement. I could, I would guesstimate that means you had a very modest lifestyle.
Dr. Daniel Paull: Oh yeah. I mean, I mean, they were, we weren't paying the rent.
They were just nice enough to give us like housing and food. I mean, so we would pay our own personal expenses, but. They were minimal.
Daniel Wrenne: Yeah. When your lifestyle is very modest, it's way less intense to go because that's the biggest startup cost. When you're starting a business, the biggest cost is like yourself most of the time.
And so when you have a modest lifestyle, that's huge. And so that reduces a lot of this. Anxiety people have on the front end you could you don't know you don't you can also reduce your lifestyle before you do it Some people do that as as well, but I think that I would suspect that that helped you Not feel so intimidated going into it because then you didn't have as big of a nut to crack Early on and you could focus in on because that's the other thing I suspect too in the early days It was it was slim pickings.
Oh, yeah at the very beginning, right? You weren't just rolling the money right away.
Dr. Daniel Paull: No, no way I mean for all intents and purposes you're poor. I think that first year I got like the child tax credit or something You know like cuz I wasn't making any money. I mean I think, Oh my gosh, I mean, times have certainly changed.
I think I maybe made 500 my first quarter, which, you know, my friends are coming out of fellowship, getting starting salary, 500, 000, 400, 000. I'm living in a basement. I made 500 my first quarter, but I was really lucky to get that. And it snowballed from there. You know, it was just figuring things out, but no, the modest lifestyle is huge.
It's like a trade off between autonomy and not having and stuff. So if you can free yourself from the mindset of, I need a lot of stuff, you can have a lot of autonomy and I do consulting now for other docs who are looking to do something similar. And you know, one complaint that I get, not from the people who actually.
Pay me to consult from the people that don't want to pay me to consult is that, uh, well, what am I supposed to do? I've got this house and all these payments and all these, my kids are in private school and have all these cars. And it's like, well, you golden handcuffed yourself. You took the golden handcuffs and you cinched them around your wrist and cinched them in together.
Now you have no ability to move because your payments are so stupidly high. And it's like, why did you do that to yourself? You know, it doesn't, I mean, you can still have a very nice existence without decadent and needing the nicest of every single thing. I mean, you can buy your luxuries later when you have more wealth.
I mean. But they don't. They buy them immediately. And I think that creates a big problem. Because to go back from that is hard. Maybe it's not just them, but it's also their family and their kids are now used to that lifestyle. Yeah, it's
Daniel Wrenne: like It's the opposite direction. It's difficult. If you sign a big monster contract, you know, even if it's paying a bajillion dollars and then you've got a five year lock in and then you're, you know, you buy the really nice house and you're doing it for your family It would good intentions and then the private school, like you're saying, and then all the other stuff comes with it.
And then the productivity stuff starts to kick in after a year. And then you realize, man, you got to work long hours. You're not even seeing your family. And then they start to, and then you realize you don't have any control. And then you start to feel like burnout, you know, frustration, like this place sucks, but at that point you got no options.
I mean, that's a scary place to be. And unfortunately I see a ton of people that are in that exact spot.
Dr. Daniel Paull: Oh, I believe it. I mean, they've dug, they've dug them. They've been digging their own grave, one shovel full at a time. And the irony is, is you may be working so hard that your relationships with your spouse deteriorate.
Yeah. And you end up getting divorced and you don't see your family, which is the whole reason they may have done that stuff. So, I mean, they really trap you, the hospital systems and these large employers, they know they, they want you to buy a large house. They want you to buy the nice cars. They want you to be stuck and they give you a non compete too.
So. I know they can give you a decent contract the first two years. And then when it comes up for renewal, if they want to, they want to, and they can really hammer you. And you essentially have very
Daniel Wrenne: little recourse. I didn't even mention non compete. That's even worse. And then what happens to it? Yeah, I've a lot of times they have the realtor like waiting for you when you go visit and they're like, Oh, let's go to the million dollar house neighborhood.
And the hospital has the realtor that they kind of like introduce. I mean, it's I have suspicion that it is an intentionality. Aspect to that which is pretty sad, but it does benefit the hospital has incentives to kind of lock people down Oh, yeah, and the best way to lock somebody down is to get them to buy a big old fancy house Yeah, they
Dr. Daniel Paull: want leverage right?
You got a non compete and you need that salary. You are salary addicted They've got all the leverage in the world. They say hey, you need to travel out an hour to go see patients at this Faraway clinic we just bought. I don't want it. Well You have to. Okay. I mean, I don't, it doesn't jive well with me. I mean, for me living in the basement, like what are you going to do to me?
Right. Yeah. I'm already in my in laws basement. I'm comfortable there. Not that I want to stay there forever. You know, like I don't need any money. I mean, I don't need a ton of money at that time. And then as we got more money, I mean, right now I'm in my own basement. Boarding this. So in the world, but you know, we did that one suite.
The business was stable and we had wealth and we could sort of buy things. And even as, even as the wealth increases, I, we still try, I mean, we still buy quality things, but I try to remain frugal. I think frugality is super important. Yeah. Um, you know, some people, I would say the difference between that and being cheap is someone who's frugal will still spend for quality and buy nice things and do things they want to do, while someone who's cheap just will try to not spend any money if at all possible.
I think frugality would be a good trade among a lot of physicians if they could harness that. But like a lot of them don't because of all this like, you know, they've been waiting, waiting, waiting, waiting. They finally gather like, I deserve all this really nice stuff. And I guess they do, but you know, they're setting a trap
Daniel Wrenne: for themselves.
Yeah, and that's a bad spot to be in. It can come and bite you and at that point you don't even want to admit that you're having trouble with work because you're realizing you don't have any options. You have to kind of like put on your smile and like, which I think would even compound that further because you're like cognitive dissonance.
It's like, you know, you're doing one thing and in reality, it's completely a different thing. You're like, who am I? You know, I mean, that's, That kind of stuff really weighs on people and it's a tough spot to be in. The good news about, I mean, if you're listening and you're in like that sort of spot, like you don't have to like continue.
The best thing to do is to kind of cut the lifestyle to free up the control to make choices. You're not gonna be able to quit the job until you free up the lifestyle in that sort of situation. You have to do the lifestyle thing first. And then you'll start to feel those options. I've worked with some people that have like sold a big fancy house, moved in with their parents in the basement and kind of went back the other direction.
It's totally possible and you can get the control back. It's just, it just takes some hard decisions. Yeah.
Dr. Daniel Paull: It's all about leverage. So you've built yourself. If you buy all that stuff. Right. And like, I totally get the reason why someone buys it, you know. It's not a morally corrupt decision. It's just causes you long term pain.
I mean, you've essentially created a zero leverage position for yourself. So you want to get leverage back to the point where, you know, the hospital says, we want you to do this. And you can say, I don't want to. And then you say, well, we're going to let you go. And you say, fine. Yeah. And they realize, oh, wait a second.
We need you. And then you have, you can, you can bargain or you can do leverage. You just, you know, and I think a lot of that comes from being in training as a resident where you have a zero leverage position. Pretty much the entire time. Maybe even negative leverage. I mean, it's really bad. I had only one single time in residency that I ever had any leverage.
Which was when I was supposed to sign these documents on time, you know, and I did, but their system went down. So I got them all late. It would have created some sort of warning in the system. I said, look, I'm happy to sign them. I realize your system went down. I just want something in writing saying that It's not my fault and they're like, Oh, we spoke to our supervisor and we don't do that.
And I'm like, well, then I'm on site and they went all the way to my chairman. Right. And he's like, Oh, he's very smart. He supported me. And then they did give it to me. And that is the only time I ever had any leverage in residence. Cause right. You make, you know, cause then something later happens and they're like, well, this is a history for you.
And you're like, no, that first time wasn't my fault. And they just do not care. So that way you have it in writing. You can throw it.
Daniel Wrenne: I mean, leverage is important and. Having the freedom. And so your model, no insurance, all cash, are people paying for services? Yeah, I think I know they are, but I mean, I think that's a question.
Dr. Daniel Paull: So by cash, how I define it is not interfacing with an insurance company. So for me, I can do whatever I want, as long as I don't have to interface with an insurance company, meaning I don't have to submit notes to an insurance company. I don't have that whole revenue cycle management, as long as I can stay out of that, then it works well for me.
So like I've paired that with like medical legal work. I also do personal injury work, which means I might not get paid for a year or two, or at all. But for me, interfacing with a lawyer is a minimal overhead requirement. Generates medical legal work, so that's fine. But going back though, do people pay for it?
Yeah, they do. Because, you know, there's a lot of people out there who don't have insurance, or their deductible is very high, and I am actually the most economical option for them. As compared to going in a system where they don't know what they're going to pay and they're going to, you know, they're scared of that.
So, I think people wrongly assume that a direct care model is like, oh, you're just seeing really rich people all the time. And that's really not what it is. They don't, I don't think they understand, they have a good understanding of the percentage of population with no insurance or bad insurance, who are looking for health care.
And you really serve that population much better than, You know, the in system stuff. So there's, they're out there.
Daniel Wrenne: Yeah. Most of the people I get to look at everybody's financial stuff in my day job. So I get to see all their insurance numbers. And I would say the majority of people have pretty stinking high deductibles on their health insurance.
That's more common than not having insurance, but there's also a pretty large, there's people that don't have insurance at all. There's people that have like health sharing, which is not technically insurance. So there's, there's all kinds of people that are doing that kind of deal, but maybe you could talk through the economics a little bit.
I'd love it if we could kind of just talk like high level, not like details, but like high level, like how is it, how are you able to make it work from a financial standpoint? I know your expenses are pretty low. That's a big deal.
Dr. Daniel Paull: Yeah. So my overhead, I haven't calculated in a while. When I sat at its lowest, it was like 800 a month, including malpractice.
And then my wife works with me now. So it's probably more like 2, 500 a month. So, I think you're looking at 60, 70 bucks a day, the cost of running the business. That includes malpractice, equipment, everything, right? You know, the staff is just me and my wife, so I've cut down an office, I've cut out staff. So, I mean, that slashes all your costs, essentially, to as low as you can get them, in my opinion.
But then, you know, if I see one patient, you know, and it's like, you know, I travel to them, I give them a steroid injection or something, that's like 400. So, you know, you can do the math there if you had a few of them together. So, if you had a few of them together, I mean, you're really not working a lot, you're really not working a lot, and you're doing quite well.
Is four a day reasonable? Yeah, four a day is reasonable. And I'm not always hitting four a day, sometimes more, sometimes less, right? And then I paired it with medical, legal work, or I'll do personal injury. And that's,
Daniel Wrenne: so, four a day is like 300 a year, minimum. And you're not And that's
Dr. Daniel Paull: net. Right, and you have to, and you also have the tax advantages of your whole business, so you're not getting destroyed on a W2.
So if the, mine's an S corp, so. I pay payroll taxes on my small salary, and then I take a monthly distribution, which doesn't go through payroll taxes. So, we actually come out a lot more ahead than someone who would get the equivalent amount. In salary, you know, you also write offs that you use for business.
Like my personal computer, my wife uses as a phone that we use to answer calls on. So, you know, there's, there's those, those intangible or, or I guess tangible benefits that you get, but the other question, which I think is important is that how many hours are you working also? So with the numbers we just ran, you're probably working three to four hours a day.
Okay, that's huge. Or four hours a day, let's say five hours a day. To be safe, yeah. You're talking, and we're overestimating here, you work five days a week, 25 hours, so which, and a lot of docs probably work triple that, or plus minus. So I mean, I think the other side of the coin what a lot of docs don't consider is how many hours are you working for this money?
Like, to me, it's like, well how much are you making? And then the follow up question is How much are you working? And they don't really seem to ask that secondary question because they all assume we're all busy as all get up, which isn't always the case.
Daniel Wrenne: Right now, at least for my specialty of orthopedics, they still do pretty well financially. I think that'll change as time goes on, as their reimbursements get slashed down 5 percent every year. Yeah. So they haven't quite hit that pain point, but I'm hoping more people start. The goal is to build the ecosystem of this kind of alternative model, which in my opinion is better.
