On this episode of the show, I'm interviewing Dr. Andrea Otto-who is a Board Certified Family Medicine Physician.
Andrea attended the University of Missouri- Kansas City School of Medicine. After practicing medicine in the army, as well as for an outpatient family medicine clinic, Dr. Otto said goodbye to the dysfunction of modern Medicine to start her new sproutMD Direct Primary Care office. Dr. Otto is passionate about caring for individuals who have had bad experiences with medical care in the past, or who have been marginalized or are in underserved populations. She truly wants to ensure that everyone can access affordable and high-quality primary care without stigma, judgment, or bias.
Dr. Otto truly believes that living a healthy lifestyle including proper nutrition and exercise can significantly reduce the risk for disease, and can be used as a treatment option for many as well. She always prefers to try non-medication treatments such as nutrition and other lifestyle changes before starting medications as long as it is medically safe to do so.
Phone #: (314) 394-2973
This episode has been transcribed from Otter.ai
Hello, and welcome to STL Active St. Louis's premier health and wellness podcast. STL Active aims to give listeners in the St. Louis area the information they need to succeed and progress with their health and fitness. This podcast is brought to you by stlouispt.com. And hosted by Doctor of Physical Therapy, Greg, Judice.
Hey, everyone, it's Dr. Greg, owner, and physical therapist at Judice Sports & Rehab. On this episode of the show, I'm interviewing Dr. Andrea Otto from Sprout, MD, Dr. Otto opened her practice in 2018. As a Direct Primary Care practice. We discuss the current state of medicine, subscription-based medicine. And finally, answer the question, what is direct Primary Care Medicine? Without further ado, let's get into the interview with Dr. Otto. All right. Welcome to the show. I'm happy to have Dr. Andrea Otto here with me.
Thank you. I'm happy to be here.
Very good. I'm excited. This is a long time coming! We met quite a while ago, almost two years ago. So it's good to have you here. So why don't you introduce yourself, tell us a little bit about your background, so that my listeners know kind of who you are?
Excellent. So I'm a family medicine physician. I grew up in a tiny little town in Kansas. And so my idea of medicine was very, very pure, very Norman Rockwell ish. Going to medical school, I went to medical school in Kansas City and then joined the military, did my residency in the military practice for five years after residency in the military, kind of got a good taste of military medicine, and then was eager to try civilian medicine as I got out and realized how broken the system was, as soon as I was sort of jumped in, jumped in with both feet. So I really strive to provide well-rounded care, I love to get to know my patients. And those things really weren't that possible in the system. So that's where I am today.
Gotcha. So you own a business now? Correct. Tell us about that.
So I own sprout MD Direct Primary Care in Kirkwood, we are a small, essentially a micro practice very small practice. myself, my partner, Dr. Allen, and our office manager/medical assistant, Diane. Awesome.
So I think the biggest thing that we talked about before this recording was that we wanted to talk about what is direct primary care, but I think people need to understand why it has to exist. Why is this the normal system broken? So I know this is gonna be a long answer. So go into it. Got it, I want to get into the details.
So Direct Primary Care is essentially health care. True health care provided directly to the patient, without the interference of insurance companies, hospital administration, third parties intervening in that care. And the payment is provided directly back to the physician that eliminates any third parties, anyone else having an influence on the care that's provided to that patient. But it also takes out the huge financial burden that most practices face, allowing us to provide that care at a much more affordable rate. So that's kind of the idea. Direct Primary Care is a membership-based practice. So instead of, in contrast, a fee for service, which is you pay a fee for every service, you get every visit every procedure, every injection, direct primary care is more inclusive. It is a monthly membership, that covers almost everything that you can do in the practice. And, different direct primary care practices run a little bit differently in terms of what they include and what they don't. But ours, essentially, it's a monthly membership, that each patient pays based on their age, that allows them to have unlimited office visits each month, unlimited text, video chat, email, phone call interactions with their physician directly with their physician. And as well as most procedures that we do in the office are included, aside from any medications we may administer or dispense from the office.
And so they have access to you? Correct. So it's not just the office manager or the nurse or the MA, they actually get to talk to you.
Yes, all of my patients have my cell phone number. They can call me or text me anytime they need anything.
That's awesome. Very good. So we're gonna get more into what is direct primary care, but let's maybe get into why the normal system is broken. I think a lot of people know that something's wacky with health care these days, and why is everything so expensive? And why are hospitals getting bigger and bigger and there's a lot of questions but go into that if you would,
right. So, in traditional healthcare, you've got a person providing a service, a physician or you know, PA, Nurse Practitioner, or whoever that provides the service directly to the patient. But you also have a lot of layers, multiple layers of administration. On top of that, you think about having an IT department, a coding department, a collections department, you've got HR, you've got, you know, this huge, multi-level organization, that all add cost to that basic interaction between the physician and the patient or the provider of care and the patient. So, as health care costs have continued to rise, insurance premiums have continued to rise. healthcare organizations, hospitals, and such know that insurance companies are going to are not going to inverse reimburse everything, just as it's billed. So sometimes they end up billing more knowing they're only going to get reimbursed a certain percentage. So as those costs continue to go up, it makes more and more it creates more and more issues for patients fear in terms of what their medical bills may be, they put off health condition, medical conditions, they put off health care. And then when they finally get into the system to say, let me go ahead and bite the bullet and get this condition taken care of, they're left with a system that's focused on financial gain. So you've got to have short visits, a very limited amount of time with the person provided with your physician, the person providing your care, many times not enough time to get through your concerns and have to schedule another visit that might be you know, six or eight weeks out. So creates very disjointed care in terms of separated visits, or seeing different physicians, or medical providers each time you go back. So direct primary care kind of restores the continuity kind of eliminates all of the excess levels of hierarchy there, to bring it back to just the physician and the patient.
So awesome. And that's very similar to how we do things here as well. So I'm going to ask some questions. And I know the answers, these are to get a certain response.
So what was I guess? What was your experience as a provider in that, like, what would be the typical patient session length? If they came in for a visit? How long would you have to spend with them?
So on average, five to 15 minutes, the most visits that barely gives you enough time to take an inadequate history from the patient, let alone examine them, and teach them what they need to know about that condition or that diagnosis so that they can heal themselves or promote healing. Occasionally, we would be able to get extended visits, which were 30 minutes, but only for very complex patients or essentially anything that they knew in advance that we could bill a higher level of a visit to justify that time.
And so what's different about that now, now that you're on your own, what would a complex visit look like?
So I don't have any complex visits, I have all standard visits, and they're all an hour long. Every single patient when you book an appointment, it's an hour, whether the patient has a stubbed toe or a sprained ankle or a blood pressure follow up, we book it for a full hour. Often I use that time to address other concerns that I have about their health that they may not be thinking about. But the majority of the time I use it to get to know the patient better to ask them. You know, tell me about your kids. Where did you go on your last vacation? You know, when's the new grand-baby coming? To really get to know who they are, what their hobbies are, what drives them, so that I can help promote their health in a way that that really helps improve their life.
That's huge. And I'm thinking back to my wife's primary. I know he's not listening to this. So I can say this. But I know for a fact he knows nothing about her. Yeah, she's there for five to 10 minutes. And then she leaves and maybe her prescription got refilled. Or maybe she has something else to talk about, or some papers, some handouts, but knows nothing about what's on the papers, right? And then she's on her own. And the person knows the doctor knows nothing about her what her goals are, anything about her life, or what her aspirations or health history or anything is, right? And then she's on her own. So that's that is the system that is the norm, right? That was your experience as a physician, that's my and my wife's experiences, clients of a physician is no time no quality, no personalization, right? That's got to be frustrating as a provider.
Yes. And I think as a physician, you either are constantly, you know, feeling guilty for not doing what you know, is right, or fighting the system to be able to do what's right for your patient. Or you just give up and do whatever people tell you to do. You essentially become a slave to the system and do what you're told.
And you just kind of become complacent to an extent and just suck it up and deal with it. Right. And that's not a way to live.
Correct. I think I spent a lot of time just sleepless nights worried about a specific patient, Did I miss something? Was there something else I could tell there was something else they wanted to tell me, but I didn't have the time to be able to sit with them. Just my you know, my conscience just drove me crazy that I was that I wasn't providing the care that these patients needed.
You know, it's funny that you say the conscience thing, I joke with some of my other like, gym referral partners, and like, why are you doing this on your own? And I say, Well, I may not be making as much money. But let me tell you, I can sleep really well at night.
And so my experience was not short visits, it was as a provider. in corporate physical therapy. I was seeing three, four, or five people at once. Mm-hmm. So it was just bouncing back and forth between people. And nobody ever got the undivided attention. So that was so frustrating. And exactly like you said, if there's a complex client coming in, you do your best, but you might get 30 minutes one on one, right. But more than likely, you're just gonna have them piled up one with other folks. And it's so frustrating. Yeah, I can appreciate that. And that's why we're talking is because we have similar business models. So very quickly. So did your military experience that was your residency? Yes. Okay. Did your military experience cause you or give you kind of insight of what the opposite of corporate America could be? I think we go into the what your experience was with the military and how it differs from DPC and the norm.
Yes. So I think it gave me a completely different perspective from traditional mainstream medicine. I loved being in the military, I loved practicing military medicine, I loved taking care of soldiers, their families, their children, retirees, I, you know, as a family medicine resident, and as a physician practicing in the army for five years afterward, I, I did everything I delivered babies, I, you know, covered the ICU, I covered inpatient, I took care of, you know, did lots of procedures. And, you know, the things that frustrated me about military medicine, it was not the cost, there was no cost for patients, there was nothing holding them back from coming to their visits and getting their medications or, you know, going to urgent care, or, ER, if something bad happened, because all of that was covered, that was free for them. The things that held me back were are the things that bothered me, were more some of the overutilization, some of the patients that just didn't want to schedule their follow up, and then decided to go to the ER for their blood pressure medication refill, or, and the lack of continuity, you know, physicians would PCs are, you know, essentially moved to the next duty station about every three to four years, and all of those patients that live there, lose their physician or have to start with somebody fresh. And I really felt like that was a drawback from the system, you know, in that system, I was really looking forward to practicing medicine in the civilian world, thinking those things will be better, I'll be able to keep continuity with my patients, I will be able to keep them on board and make sure they schedule their follow up appointments and come back and check in on them. But of course, you know, the rosy outlook when you start quickly deteriorates as you figure out how the system really works.
So what you thought were the negatives that you could address with typical medicine. Just were more problems on the other side, correct. Those might have been addressed. But there were just numerous other issues. Right. So then, I guess what was kind of the final breaking point for you that said, I gotta do something different here.
So I was working for a small community hospital, here in St. Louis, not actually a small hospital, a community hospital here in St. Louis, which was being taken over by a larger Medical Group. And I was given, essentially an ultimatum to practice within their restrictions, or leave. And their restrictions were worse than what I was already experiencing. I already knew that there was no way I could change my practice to be worse than what it was and be able to live with that. So I knew I had to leave, I had to get out. Essentially, it was, you know, more patients per day, less time per patient, more, either, you know, having nurse practitioners and physician assistants that would see my patients for me, and, you know, minimal oversight over them. And really just not being able to connect with my patients anymore, not being able to have any direct communication. In the prior arrangement when I was working for the community hospital. If a patient called and left a message, I could call them back and I could just chat with them at the end of the day over lunch if I had time. But in the new system they actively worked against that prevented it so that you as a physician, you were only providing face to face care. Which is what you can bill for. So it came down to, I felt like the larger organization was much more focused on money on the business side, and focused even less on patient care and quality of care, and the relationship between the physician and the patient. So
why did doctors tolerate that?
Because they think they don't have another option.
Okay. So let's get into that. There obviously, is another option. And that's why you started your practice. So
Once you like, I guess, what we're kind of the biggest issues that you wanted to address, obviously, time was one of them. So the biggest issues were starting, or that that you had with medicine before starting your practice, where, what?
So it was essentially, time spent with patients. But also communication, I missed being able to actually communicate with my patients' in-between visits, to get feedback on, you know, whatever this new medication we started a week ago, I want to follow up in a week and say, Is it working? Are you having any side effects? How are you feeling? We gave you this home exercise program? Are you noticing any changes? Are you having any problems with it, and I wasn't able to do that until they came back for a follow-up visit, which really limited things. So really, it was time, it was communication, and it was the relationship that you know, sort of the feel of the practice that I was unhappy with and wanted to do better.
And medicine is just more fun when you actually know your people.
So I guess maybe tell us the client story. Because that's it's such it's so important, like the lady that just left here, before you came in, to get to know her and her goals. And her aspirations mean so much more than just her shoulder, her shoulder hurts, like that's such a crappy goal, shoulder pain. Like that's not a goal. that's a that's a word. So maybe tell us what the difference in a plan of care or a situation would be before till now?
Absolutely. So, I love providing care and developing relationships with individuals who are not able to get what they need from the traditional system, they either have health-related anxiety or have a more complex issue that's been undiagnosed or incorrectly diagnosed. And really, in general, people are fearful of doctors, because of how they've been treated in the past. And I feel like I'm able to connect with those people better. Now, I you know, for example, I've had multiple patients who were terrified of getting blood drawn. And really, as we sit down over sometimes multiple visits and or phone calls, or whatever, and get to the root of their issues. Sometimes it's a true fear of needles, which we can talk through, sometimes it's a fear of what the results are going to say. And sometimes it's something completely unrelated. But when you get down to the root of their, their fear, or whatever is holding them back, we can work through that and help them to get to the point where we can address health issues, whether it's continuing to proceed forward and get that blood work or help them get that blood drawn, versus saying, look, I understand you don't want to get blood drawn, but we can make your health better even without that. So we're not required to do all of those things, we can give the patient the choice. It's awesome.
And just being able to have that conversation rather than say, this is how it's going to be absolutely because when you have five minutes with someone, this is how it's going to be otherwise, it's not going to get done.
Correct. But also you'd have a checklist of things that you have to do that the insurance requires each visit. So I may say, your insurance needs me to tell you that you need pneumonia shot and you need a mammogram and you need a colonoscopy and you need you to know, whatever your preventive health measures are. And if that patient doesn't get those things, either the visit may not be paid for the physician may not be reimbursed, the patient could be dropped from their insurance. And now I have the luxury of being able to really educate patients on why certain things are indicated and what the risks and benefits are. And help reassure them about you know what the results could be.
And that's huge. Just being able to have that true connection.
I think they use the term motivational interviewing. Yes. Is that correct? Absolutely. Okay, so that's crucial and motivational interviewing takes time. Yep. Because to get down to the root of the problem, you actually have to figure out what the problem is. And then go on step deeper to the goal and then go a step deeper to the why of the goal. And so you can't just ask what's bothering you today? It goes way further than that. So, right, that's, that's huge.
And I also think kind of to turn that on its tail. I not only want to interview my patients using those specific methods, I want my patients to be interviewing me during the entire visit for those same reasons. I want them to know my motivation and my goal for them and why I think those things are important. I don't want to just glean all the information from them, or give all the information that I have for them, I want to tailor that towards what they need and what's going to benefit them the most.
So go into the, your motivations and goals, because a lot of times we are so patient-centered, I'm using quotations on that patient center that sometimes I'm only thinking about the client. So maybe go into that a little bit.
Right, I think, going back to the conversation we had about conscience, that's the biggest thing, by all means, I have to be practicing in a way that I can sleep with a clear conscience at night, knowing I'm doing the right thing for every patient that I had an interaction with that day, that is the number one thing. And when that transition happened that I had the choice of either, you know, moving on with the larger Medical Group versus leaving, it was a no brainer, I was ready to leave medicine altogether, I was going to quit, I was going to find something else to do as a profession. Because I felt like there were not any other options. I just felt like I was constantly going to be stuck in a system that was going down the same path. So I had to have, I had to look for other options. And initially, I didn't know about direct primary care. So I was going to quit. I actually heard about DPC at a conference. I was at an AFP, the American Academy of Family Physicians has an annual conference every year. And I was at a conference. I think by a pure stroke of luck, or fate or divine intervention, whatever you want to call it. I was in that phase of needing to make a decision whether to move on with the large group versus leave medicine happened to be at the conference when I was trying to kind of wrestle with that decision. And I happened to be in a lecture hall when the next lecture started talking as the last one was finishing, and I was kind of looking at my schedule to see what room I was supposed to go to next. And I just stopped to listen for a second to the person that was giving this lecture. And it was actually a DPC physician, it was Julie Gunther, she's in Idaho. She's amazing. And you're gonna know her name? Cuz Absolutely.
It's a life-changing moment. And I'll never forget when I heard Jared Carter, yeah. And you will never forget. Yeah, so that's amazing.
Yeah, so I kind of heard that talk. And my jaw dropped. And I was like, Wait a second, there is a way that I can practice real medicine in a way that's good for patients and for me. So yes, it's patient-centered, but it's also physician-centered. It's helping me to do what I do best, and to feel fulfilled and doing that. This is a model that I could practice until, you know, well into my 70s or 80s. I don't ever want to retire. I love it. So that when I found out about that option, that's when my whole world changed. And I was motivated to from that day on, this is what I'm gonna do, and started from there.
I mean, patients have got to love working with a doctor who's happy to be there and excited to be there and cares about them. I hope
I mean, that's, that's like you said, it's doctor centered as well because you get to treat the way that you love to treat. Absolutely. It's something you don't want to retire from. Right. I can imagine a lot of your colleagues at the other place are probably counting down the days. Right, right. Like, how many days till the debts paid off? How many days so the kids are out of college? And then how many days until you know, I'm done retirement.
Right. And you don't have to do that. Correct. You get to enjoy it. Absolutely. Okay, so I'm gonna go back just a hair here. As healthcare providers, our goal is to get to the root cause fix the root cause. The insurance model, the normal model these days, has a problem. Where do you think the root cause is? Is it hospitals? Is it insurance companies? Is it the doctors? Where is the problem? This is a big, big question. Yes. But I just want to get your perspective on this because this is not something that shows up on this podcast very often.
Right? I think I think the entire system is broken. You know, we think about health care in the United States. And it's not really health care, you know, and many people have said this before, the system is not focused on preserving and promoting the health of the individual or even the health of the population. The system is focused on diagnosing and treating and managing disease, illness, and injury. Health insurance is focused on the same thing. And so, therefore, the entire system has to shift to concentrate on those things that are valued by the system in. If a primary care physician does a well visit with a patient and educates them on, you know, health-related factors, you know, nutrition and exercise and stress management and prevention and screening, and, you know, here are the things that you can specifically do based on your family history or your medical history to improve your health, the reimbursement for that is very low, there's not really any significant incentive for systems, hospital systems or otherwise, to try to get patients in to do those things. Because they get reimbursed way more when the patient comes in for a sick visit, or they have a medical problem.
And it seems like the reimbursements are kind of arbitrary. It seems like they're just kind of made up, right. So like, what the visit you just described sounds like the best visit ever, where they talk about everything that you would need to know, to prevent a serious condition from happening in the near future. But the my back has hurt for the last two weeks. And I'm recommending an injection or surgery that reimburses way more. Right? Right, what I mean, who comes up with these numbers.
So I think it's just a system of a system issue where they were essentially, physicians get reimbursed more for procedures, anything that you can do that is a surgery and injection, you know, a biopsy because those take skill and time. But because it's something that is measurable it is you've done something measurable to the patient, having a patient come in and tell me about their stress levels. And we talk about stress management techniques, there's not something measurable that's done to the patient. On the insurance side, there's definitely something measurable that's done for the patient on the patient side, and on from my point of view, but it's hard to quantify how successful that visit was to be able to reimburse for it. Then also prevention. If I have 100 patients, and I'm treating them and preventing disease and keeping them healthy until whatever age, there's not a measurable way to say how much healthier those patients are then another group of 100 patients, according to the insurance company, they don't care about that. They just care about how well and how cheaply you can manage these patients medical conditions when they arise.
Okay. That makes sense. And I mean, it's it's frustrating that that's the way they do things. And I'm coming back to an example that I have when I was working in corporate treating Medicare folks, yes, very specific set of directions that you have to, you have to follow, you have to ask pain scale, every visit and document you have to ask this every every session and document. The evidence is showing that the less you bring up the question of pain, the better they're going to do the better outcomes. So why do we keep asking questions, doing stuff? That's not helpful, right? It's literally just to check a box. So that if you forget to check the box that they don't have to pay you, right. But the biopsychosocial model of pain right now, is that if you don't talk about pain, you talk about function and all the benefits that you're getting, you're more likely to get better. Right? And I can, I can feel myself getting frustrated with this conversation just because it's so so dumb, is the whole system is just is dumb, it doesn't make any sense.
And then you think about all the time that you've wasted, checking boxes and asking questions that you could have spent connecting with the patient and providing them with the treatment they needed and the education they needed. To get through whatever they're going through. Its it seemed very counterintuitive to me how much time I spent putting together a chart, checking boxes, doing all of this busy work filling out forms for insurance companies that didn't benefit the patient at all. And all those things were significantly taking away from my time being able to spend with my patients.
Without a goal. How much time do you spend documenting these days?
You know, I type some notes, just little notes as I'm in with patients. I spend, I probably spend more time entering orders, you know, ordering bloodwork for a patient or an X ray for a patient, reviewing records that I get from other specialists because I have time to review through every single one that comes back or ER or urgent care visits. But the actual time and documentation is very small. Now I probably spend, gosh, less than five minutes documenting for every one hour visit. Okay. So it's I'm able to focus, you know, 55 minutes with that patient directly.
That's huge. Yeah, that's a big difference compared to where you were, I'm sure. Absolutely. If you got a five to 10 minute visit. It's probably another five to 10 minutes of documentation. Yep. It's just frustrating. Yeah. Okay, so so let's hear more about Sprout and what what you guys do kind of what you're we're up to these days. What's New for you?
So we our, Gosh, my current partner, Dr. Clarissa Allen joined me last August, so about a year ago, a little over a year ago, we have kind of built this practice together and grown it together. And it's sort of our little, you know, shared venture. As soon as she joined in, she was in and she's, you know, full bore on which I love. We have recently taken over another area in our suite. So we now have kind of two exam rooms, and then an administration room or an administrative room, because we had outgrown our, you know, little supply closet that we had initially getting started. So we're kind of expanding, really getting things organized and refining our processes to make everything run efficiently to continue to keep the lines of communication open with patients. But also really analyzing where we want to go moving forward. As far as you know, our business model, Dr. Allen is almost full, she has very few spots left on her panel. So we will be closing to new patients and starting a waitlist, which we hate to do, because we want to continue to have more patients, but we don't want to compromise the care of the patients we already have. Absolutely. So we're setting that boundary, where we go from there is is up in the air at this point. So
okay, so you have a a list of patients, you have a maximum number of patients correct. And you won't take any more so that you can really focus on the people that you already have. Absolutely. And that's where this subscription-based model comes in. And that was one of the things you mentioned early on. Why subscription base? Why is that important?
Right. So I think the biggest thing that one of the big issues I had with traditional clinical medicine, once I was out of the military, was that a lot of my patients would avoid coming in or avoid contacting us when they had a medical condition until it was so far advanced that they couldn't function. And by then it made it much more difficult to evaluate and treat and potentially fully cure. And most of that was out of fear. They were fearful of the system, but also much more so fearful of the cost associated with the visit or the workup or the you know, imaging or labs or specialty referral that they may need. So subscription-based care takes that out of the picture. A patient pays a monthly subscription, and they can come in or contact us a text, email, whatever, for any concern they have no matter how small. So they're not putting things off until they're so bad. They You know, they're causing permanent damage. And that was my biggest motivation to do subscription-based care to not have a copay or anything that would hold people back from coming in whenever
they had a concern. Because you could have very well just been an out of network fee for service provider. Correct. Okay. And that's very close to how we work. We have a subscription base, but it's not many people take us up on that. Yeah, because in general, physical therapy is episodic. Right? Right. But we should be marketing more like a dentist would where you come in a couple of times a year to get your right wellness check, right? And then if you need something in particular, we can advise you on what else you need. So I love the subscription base. But I know you've touched on it. What was that what was like the final kicker there that forced you into subscription versus fee for service.
It was, like I said, Really the you know, being able to make pricing transparent and predictable for patients, they knew exactly how much they were going to owe every month. And it was very rarely going to be anything different than that. There was no there were no surprise fees, there were there was nothing that came through on a bill or that wasn't covered, or that was more expensive than they thought. But it also kept the door open for communication. So we don't have to if we don't build per encounter, patients can contact us as much as they want and keep those lines of communication open.
That's awesome. So typically, in my world, things usually follow the 80/20 rule, where 20% of people are going to use 80% of your time and then 80% of people are going to use 20% of your time. I would imagine when people have more access to you. Does that follow the same way? Do you have a few people that use a lot and come in several times a month? Or how do people kind of respect your time and still get the care that they want?
Right? So it's a very similar, similar way that things play out in my practice, there are certain patients at certain times that have a new medical condition or a new symptom, something, something urgent comes up and they're utilizing much more of our services over the course of a short period of time. But our goal is to always get people to where they they don't wait and that they you know, contact us for what Ever concerns they have literally emailed me, Hey, I read this article, I was wondering what you thought about this new vitamin or whatever. And they those lines of communication are always open. For the patients that don't contact us as much we reach out to them, I'll shoot them a quick text and say, Hey, it was just checking in making sure that you know, seeing how you're doing, checking in on your medications, or, you know, on this symptom that you had at our last visit to make sure it's doing better. And I love to get updates from my patients, even that are completely unrelated to medical issues, you know, pictures of their new grandbaby or from their most recent vacation, and I love that they share those things with me, so that I can really be a part of their lives.
So how did you? Is it just being yourself? Or was there something specific that you did to build those relationships where people want to reach out to you like, who wants to talk to their doctor? Right? But how did you get to that point? Because obviously, your people love you. And that's awesome. Right? Is there something? Was it something mindful? Or is that just you?
So I think, in my former practice, in the system, I regularly tried to educate patients on their insurance, the restrictions that their insurance had on the system, the restrictions of the system, what I felt needed to be done, and why that wasn't possible, or how we could get around it and do what I thought needed to be done, or get them the support that they needed. So the vast majority of my former patients knew how broken the system was, and why it wasn't working. So they all understood why I was doing what I was doing as soon as I switched over. Otherwise, you know, as far as you know, building new patients and maintaining patients over time, it really is communication. And I want, I want to get to know my patients, I invest a lot of time and energy in that. And I feel like they get it, they appreciate that. They know that I'm giving them medical advice that is very personalized, that is considering their specific health and lifestyle factors, their family history, their day-to-day life, their hobbies, and coming up with a plan that makes sense individually for them. But I think it's, you know, as a physician, it would be easy to be aloof. And you know, here's my diagnosis, here's what I think here's what you got to do. But I really feel a passion for educating patients to helping help them understand what's going on with their bodies. What things could we do to help, you know, naturally to help fix those things or help counteract that? And how we know when we're moving in the right direction, how we can keep tabs on things, let's do a phone call in two weeks, let's, let's track this specific symptom, I want you to put it on a calendar and then take a picture with your cell phone and send it to me in a week. So being able to keep tabs on those things, and encouraging patients to contact me back really opens those doors.
That's excellent. And I think the education to have them be mindful of their own health is the biggest thing there. Yes. Because a lot of people are just so passive about, oh, well, you know, I'm taking this medication and that's Yeah, that's what they gave me. Right, It is what it is, right? Why? Why are you taking it? This is why it's important. With his This is what how we can get off of it would be better for you long term. These are the things I need you to monitor. Right? You're having some sort of journal, I have people use a pain journal. Yeah, same kind of thing. That's huge. And having the time to do that. It's got to be really fulfilling because you didn't have that before. Yes. Awesome. Okay. We're gonna take a short break. I had a couple of thoughts. And I needed to just press pause for a second.
Collect them together. Yes.
Because they're kind of like four or five that just kind of jumbled up. So all right.
That's how the brain works. Yes.
So I wanted to get into this subscription base a little bit more. That is, this is more for me. The subscription base is is fascinating, because you're going to be able to build better relationships because your numbers limited, right? My number keeps growing because it's fee for service. Right? Okay. All right. That's where I want to go next because I had I needed to word this correctly. Right. So I'm going to touch again on the subscription base, something that has kind of occurred to me here. By having a subscription base, you have a set number of clients. So you're not going to have more than that unless you're just feeling super generous that day. But you're not going to have more than that. And so you have a maximum number of people that you have to keep in contact with and I would imagine there's got to be a benefit in terms of that communication and relationship built with the clients with the fact that you don't have 1000 Clients every year correct, you've got a much smaller number than that. Yes, we would like to go into detail, I guess a little bit on that because I'm interested to hear about that for my practice, too.
Yeah. So I think in a fee for service practice, you as a business, you have overhead, we all have costs that we have to meet, we have to pay our bills, we have to keep our doors open. In a fee for service practice model, you essentially have to fill each visit, you have to have income coming in each visit all day long, to be able to meet that overhead or a certain number of visits per day to make that amount work. And it has to be in a model that is able to be billed. So a 30-minute face to face visit with a patient, whether it's billed to insurance or the patient pays cash, you have to have an increment that you can bill in virtual visits, versus in person visits, but you still have to meet that overhead. So the motivation is to fill every spot every appointment spot, which then limits the amount of time that you can spend with each individual patient. But it also limits your availability for those patients that aren't face to face with you. Right, then, if someone has a question, they send me a picture of a rash or a cut or a, you know, has, you know, they have a symptom they're concerned about, I want to be able to get to those things periodically throughout the day, rather than being completely backed up with scheduled patients. And then not having any time until the end because I had to see those patients just to meet my overhead. But I also don't want my motivation to be, well, maybe we need to double booked a couple of appointments just in case somebody cancels, then you're further cutting down the appointment time, which is something that happens in the traditional system all the time. As opposed to you know, the subscription model, my goal at the end of every day is to finish the day with an appointment that did not get booked an open appointment that did not get booked, that would have been available, if someone needed it, if someone had something urgent that came up, we would have been able to see them. And that's the difference. It's more of a, I want to be available for my patients when they need me when they decide to reach out to me or as soon as a problem arises. And I want to be able to be responsive to that I want to be able to handle urgent issues because I know them better than an urgent care physician or an ER physician. And oftentimes, many of the things that I can do take much less time and you know, you know it much easier as far as getting in and out of the of the office in terms of you know, someone cuts themselves and I we need to get it stitched up. Or someone has an injury and they need an injection or a muscle relaxer or whatever. Those things are much easier for me to take care of them for them to wait two hours or more at the urgent care, see somebody for three minutes that don't know them, hands them a bunch of prescriptions and a referral to who knows who. And they don't really know what to do with that and why. So that's really the big difference. It's the open access, the open lines of communication, and the ability to keep the schedule flexible to adapt to what your patients need that day.
And that can be beneficial to you and your patients.
All right. I like that I'm going to have to think about seriously think about incorporating that. So I may have some questions afterward. we're done recording absolutely how we might make that happen. So subscription based medicine, we're gonna stay on that topic, but we're gonna change gears a little bit. What is the difference in direct primary care and concierge medicine? That's a I hear the word thrown around a lot. I but I'm not really sure if it has a specific definition or if it's a marketing term or what what is it?
Yes, so. So concierge medicine, a lot of people know about that they've heard about it, sort of VIP medicine. Essentially, you have to have good health insurance in order to see a concierge physician, because they still bill your insurance for everything they do just like a fee for service practice. But on top of your insurance premiums, you're also paying a fee, to that practice, to be able to have open access, open lines of communication. You know, same day and next day visits, email, text message, video chat, and essentially having your own personalized physician. Most concierge practices bill $100 to $250 to $300 a month. Some of them only accept patients on year long subscriptions. And clearly that can get really expensive. There are not a lot of patients that can afford that. But again, you were talking about why does this even need to exist. concierge medicine arose out of the need for that the patient's had to get more personalized care and better quality care and more time spent with them. But again, you're alienating anyone who doesn't have health insurance or has a high deductible plan or can't afford $250 a month. In contrast, direct primary care is the same access and availability But without the high price tag, it's much more affordable per month on average, you know, 50 to $100 a month maybe. And no insurance billing. So people that don't have health insurance can use direct primary care, people that do have health insurance can use direct primary care, they still, everyone's still pays the same low monthly membership, to get that same access and availability without having to do any insurance billing at all.
Okay, so I guess what would the difference be there? Would you have a larger list? Theoretically, because you're charging less per month, are you just gonna make less?
Correct? So we are, we have a much smaller list. So because we don't bill insurance, I don't need coders. I don't, I don't need a coding department. I don't need a billing department name your entire staff, I don't need a collections department. I don't need an IT department. So we can eliminate all of the overhead that those practices still have to pay. It brings our overhead down to astronomically low, which is how we can afford to set our membership rate so low and still make ends meet. And I think the overall motivation for me wasn't to, you know, make a large salary, the overall motivation for me was to provide great care for my patients, and to make it sustainable. So yes, I'm not making nearly as much as those consumers physicians are, but I guarantee that I'm probably happier than them. Okay, that's,
that's exactly what I wanted to get into there. Okay, perfect, because kind of my impression was direct primary care is gonna have a much higher longer list, shorter visits, because it so I was completely totally
backwards, backward, right?
longer list, shorter visits, because to make the same, they have to see more people and
just like the case, but it's, we're addressing the other side of the equation, which is the overhead.
Right. Okay. And I think it's, that's, that's huge, because a lot of the concierge there, they've got maybe a spa attached to them, or they've got some of the plastic surgery, right, not surgery aesthetic, the aesthetic work that they can do, and there's a laundry list of other services they offer. Right? That might be included might not might get billed insurance, correct. Okay. So just a different model. Right. But similar in terms of the goal initially, but right to the major overarching goal is the access, right? And so they both reach a similar goal, but with a different tactic.
Absolutely. And I think the one of the biggest differences in indirect primary care is that uninsured patients can still come to me, and patients with high deductible plans can still come to me. There's nothing that restricts us from, you know, providing discounts for patients that are, you know, getting discounts on labs for patients that don't have health insurance, or are our insured patients using those discounts. So it allows me to really take care of the full spectrum of patients, which I love, I love taking care of people who are, you know, afraid of the system or have not been able to get health care because they haven't had health insurance, or have gotten fragmented care, because they've don't have health insurance. And I love really putting the pieces together for them and helping them to, you know, address their health and learn about their bodies and what they need to do to become healthier overall.
That's awesome. All right. So shifting gears again, here, are there are there certain types of folks that just aren't a good fit for direct primary care? I'm thinking like the the 25 year old who's fairly healthy is never really had any issues. You know, they're making decent money, like, where do they fit into the equation?
Right? I think, you know, the, the, you know, the overall healthy person that comes once a year, it may not make sense for them to pay a monthly membership each month. Some people can still use a health savings account, or, or whatever to pay their membership. So maybe tax free money, maybe a little bit extra, you know, a little bit less overall. But, you know, the the only benefit for them would be if an urgent need came up, we may be able to save them an urgent care visit or an ER visit or answer questions that they might be anxious about and may have an effect on their health because they're delaying conditions and things like that. The in terms of patients that aren't a good fit. We have a lot of difficulty, if with patients that have multiple different specialists, especially if they're in multiple different networks, which I think is an overarching problem with medicine in general. It's very difficult to get records and to consolidate records from multiple different systems. There's one system in St. Louis in particular, that's very difficult to get records from unless you're in their system and can Login directly. And for patients that see multiple specialists in that system, I actively encourage them, gosh, you probably really just do need a primary care doctor in that system because I won't be able to get access to those notes for a week. They
make it hard on purpose. You know, I possibly,
I try not to think that I hope for the best.
It's been my experience. I'm not 100% sure who you're talking about. But if I had to guess you probably probably could. But my my opinion is that they make it hard on purpose. But I'm also a pessimist. So
we can balance each other out with that for sure.
why would someone not want to work with you? is there is there? I mean, it seems like such a logical decision. I mean, I saw your prices online, that seems like, duh, why wouldn't you do that if you saw your physician twice a year, you'd be paying more,
right? So I think, you know, some people don't want to, to understand what's going on with them, they just want to be told what to do. They want to say, okay, I've been told I have this problem, please give me a pill to fix it, I will, you know, take it every day, and I'll get out of your office, those patients are probably not a great fit, and they probably don't want to come see me, because I'm going to talk their ear off about what they should be doing about that medical condition. As well as all the other prevention and screening things and all of the other ways that they could be, you know, making changes to be healthier. People that don't have the time or energy to really make a lot of changes in their life, you know, we can experiment with different ways and you know, trial and error to find things that fit with their lifestyle. But sometimes they just don't have the extra bandwidth to put in the extra work. And I tell people, gosh, you know, we did a month membership, we did a full physical and a well woman exam, and we did all your bloodwork. And here's what's going on. But you don't have time to address all this stuff now. So let's just cancel your membership, you can go back to your regular doctor if you need stuff or go to urgent care. And when you're ready to take those steps come back. I can't guarantee that we'll have space open. But I don't want to keep taking someone's money if we're not giving them benefit. And I really actively tell people, there's no hard feelings if you get to the point where whatever difficult medical condition has been diagnosed and treated appropriately. And now it's sort of on autopilot, and you can go back to the traditional system, by all means do so. There's no hard feelings, I want to be useful for as many patients as possible. And I don't want to be sort of stuck on the backburner and not being able to help somebody. So
okay, I love that. So with you mentioned it a couple of times now, with your schedule being full, and your partner schedule being close to full. Okay, what happens if someone if one of my listeners wanted to contact you? And your full? What's next for you as a as a business? What's next for you know, you as a person? What is kind of your, your next thing? Yeah, so
it's, as a business, it's a difficult decision to make. And as a physician, it's a difficult decision to make. We talk about, you know, do we want to grow our practice, do we want to hire another physician, and that's, it's very difficult because I'm very picky about who practices under my business, and who takes care of potentially takes care of my patients if I happen to be out of town or whatever. So it would be extremely difficult for me to find someone that would be a good fit. But I'm open to the idea. Right now, as we fill, we'll be starting a waitlist. So if someone really wants to see us and they're motivated, they can put their name on the waitlist. And if we have a patient that happens to move or leave the practice and a spot opens up, then we can start pulling in new patients from that waitlist. We also share anyone that contacts us, we also share the information for other local direct primary care practices, so that they can find the place that fits them best. Whether it's finding a medical home in one of those practices and staying there long term, or going there temporarily and coming back or coming to us temporarily, and then moving to one of them. The options are there that that we can kind of coordinate coverage there too. So
that's cool. So you're promoting some other theoretically, competitors.
So that you're the people that contact you can receive excellent care somewhere else. Yes. If you're full, you're not willing, you're not you're not going to just hide them. Right. They still need care somewhere else. So that's very cool. Right. So are you. You mentioned earlier that you didn't feel like you had any other options. Do you encounter other physicians dealing with similar things?
Absolutely. Absolutely. And I wanted to go back for a second. We talked about competitors. I don't consider any of those offices or practices, my competitors. We're all colleagues. We are all working together toward a common goal to create more awareness and education on direct primary care and we're all growing together. Them existing has helped me grow my practice. They have helped give me advice and share supplies and support me in times that I needed it. And I return the favor to them. We all consider ourselves colleagues, we're in this game together, we're not competing against each other or, you know, trying to find what our niche is so that we can kind of cornered the market on that area. We're all sort of organically growing together. So
see, that is an awesome mentality to have and something I wish we had in the physical therapy world. Maybe I just need to go do that. Right. Easier said than done? I'm sure. Right. All right. All right. I like it. So changing the subject, because I just noticed your name tag, what's what's your name tag.
So I have a badge. We got probably about a year, year and a half into the practice. We decided we probably needed badges so that we could look official. And, you know, certain events that we would go to wouldn't let people in if they weren't physicians or medical professionals. And of course, if you didn't have a badge, they wouldn't let you in. Because of course, all medical professionals have a hospital ID badge. So we kind of toyed around with the idea of creating badges with our logo on it, and our name and and all that. But we, you know, we hated the idea of putting a photo on there, that was just a, you know, stiff, stuffy photo of a doctor in a white coat and right, stern look, right? So we decided to take our photos with Instagram filters, like little cheesy ears and glasses and bunny noses, and put those pictures on our ID badges. So that's what we're every day. Occasionally people notice them and recognize the filters and laugh about it. And we kind of have a chuckle about it. Because it's sort of in passing looks official. But when you look close to it, it's definitely a sense of humor.
Because I'm seeing whiskers and heart ears. Yes. Yes, that is.
That is good stuff. So I did have one other question on the on the name. Yeah, so why sprout MD why the leaves, what, what's what's with the name?
Right. So I guess the, the bare bones reasoning was, I needed a an office name, that I could have a simple domain name that wasn't already taken. I needed a practice name that wasn't already taken. And I needed to be able to design the logo and the tagline myself, because of course, on a limited budget, I didn't want to have to pay anyone to do those things, and then have to raise rates. Because of that, I wanted to build my website, myself, I wanted to build my business Facebook page, myself, I wanted to design my business cards myself, so that we can keep all of that overhead as low as possible. And just kind of brainstorming ideas. The idea of sprout came to me, and it sort of reflects back to growing up in Kansas and you know, working on the farm, my grandparents farm and in the garden, picking vegetables and weeding and just watching them grow. And I love that idea of of sort of new growth and turning over a new leaf starting something fresh and new and different. But it also kind of came to me as a as in the symbolism of a sprout a, you know, there's, it's this tiny little delicate thing that exists in a world of, of, you know, chaos, maybe it's a little sprout, like, you know, breaking through a crack in the concrete. And that little sprout could easily be run over or broken or you know, it's just very vulnerable. But if you nourish that sprout, if you if you continue to provide it with what it needs, it has the ability, the capacity to completely change the landscape, it can create a bigger crack, it can change the look of that concrete, it could grow into an oak tree, it could completely, you know, change everything in the environment. It's growing up in, regardless of how hostile it is. And I think it's kind of a metaphor to the medical system in general, sort of impersonal and dry and you know, concrete, and then this lush little sprout trying to grow against all odds. And that's kind of how I see our practice. So that is awesome. You've seen
my logo, so yeah, I can appreciate a sprout. Yes. For those of you who've only seen the podcast logo, I have two leaves and sprout MD has two leaves. Yep. So we are very similar with our logos here and we both created them ourselves. So that's awesome DIY friends here. So very cool. So before we before we hang up here, tell us something fun about you.
I man, I have four kids. And my husband is a surgeon so our lives are crazy and hectic. And we always strive to do something as a family or have something as comic relief. Do something silly and Goofy and unpredictable, just to kind of break the monotony and keep things interesting. So I'm the mom that goes skipping and dancing around the neighborhood on walks with my kids, that builds forts and tree houses in the backyard with the kids that, you know, build sled tracks in the winter, and we all go sledding together. Just you know, I'll wear goofy things in public just to embarrass my kids.
I as is tradition,
and you know, my mom did the same thing. And I loved it. And I knew I needed to bring that to life with my family. But I also kind of bring that to work sometimes, too, with the name tags, you know, with the, you know, just other little things around the office that are just completely different that are that are unexpected, and non traditional, in a good way.
Very cool. You sound like a fun mom. Hopefully, hopefully, they think so too. So anything else that you wanted to discuss? I think I think you've answered all my questions. If you wanted to get into another topic. We certainly can. It's up to you.
I can't think of anything else that I that we haven't touched on. All your questions are great. Well, thank
you. Yeah, it was great having you. I'm excited to continue to work with you and you know, get to know a bit more about you and the subscription based medicine. I think that's gonna be a big game changer for me. So perfect. Um, you know, one other thing I know, you had introduced me to another DPC physician. Yeah, I think the most admirable thing that I've heard about you, obviously, you are very passionate about helping people and is being as ethical as possible as a physician. Yes. But the fact that you were able to introduce me to another, theoretically, again, a competitor, not not to you, right. To help me out, that was very cool. So I just want to put that out there on the recording that I appreciate that. Absolutely. And, you know, that's that's kind of sounds like part of your mission is to expand DPC. The knowledge of it the mission of getting people the care they really deserve to rather than the typical model. So I certainly appreciate that. And that's, that's what just wanted to share that, while it was on the recording here. Absolutely.
And I think it's, it's important for all of the businesses that surround healthcare that are really focused on, on good quality, patient care and doing the right things for patients to really band together and support each other. We're all in network together, I can't provide a lot, I can't provide any of the services that you provide. And there are so many things that my patients can benefit outside of what I offer, and I love to share those things with them. But also to kind of create a big list of people that are a