June 6, 2022 • 39 mins
Date: 6/7/22
Name of podcast: Dr. Patient
Episode title and number: 9 Pushback Part 1
Episode summary:
Part 1 of stories about doctors and patients who are pushing back on a broken healthcare system. Learn about concierge care and direct primary care, from two doctors that left traditional fee for service practice models for these alternatives.
Guest(s):
Dr. Charles Dillon, University Associates in Chicago
Dr. Cindy Rubin, In Touch Pediatrics & Lactation in Chicago
Key Terms:
[11:42] - physical extender - someone certified in basic medical training - Physician Assistant, Nurse Practitioner, Nurse Midwife
[14:47] - Guillan-Barre Syndrome - immune disorder where your body's immune system attacks itself
References:
Dr. Dillon site: https://www.doximity.com/pub/charles-dillon-md
Dr. Rubin site: https://intouchpediatrics.com
Direct Primary Care Coalition: https://www.dpcare.orgDCP Nation: https://dpcnation.org
https://www.medicaleconomics.com/view/difference-between-concierge-and-direct-care
Podcast website: www.drpatientpodcast.com
Podcast email, become a guest: drpatientpodcast@gmail.com
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Heather Johnston (00:04):
This is Dr.
Patient, a podcast that examinesall the aspects of the patient
provider relationship. I'm yourhost, Heather Johnston, MD, a
real life doctor and patient.
This week I'm looking at waysthat doctors are pushing back on
the dysfunctional system thatthey've been enmeshed in. And
this is a part 1, because lotsof doctors and patients are
(00:26):
starting to take matters intotheir own hands. So there are a
lot of stories to be told onthis topic. Today, I have two
doctors as guests who will betalking about the different
models of healthcare deliverythat they've chosen for
themselves and their patients. Atraditional model is called
fee-for-service, which meansthat doctors are literally paid
for each service that theyperform - see a patient, get
(00:48):
paid, see another patient, getpaid, order a test, get paid,
and so forth. Okay, keep that inyour mind as you hear about
these other models. My firstguest today is Dr. Charles
Dillon from UniversityAssociates, affiliated with
Northwestern Hospital inChicago. He was in practice for
many years before he left tolaunch what's called a concierge
(01:10):
practice. Concierge medicine iswhere the patient pays an annual
fee directly to the doctor,which includes all of the care
and communication that happenswithin the office. And between
the doctor and patient - visits,calls, minor tests, etc. The fee
can range anywhere from about$1200 to $10,000 a year or more.
(01:30):
So whether you're seeing onetime in a year, or 25 times in a
year, it's the same one lumpcost. If you need to see a
specialist or if you need careoutside of the office walls,
like an Xray, MRI, or otherhigher level of tests, you go
over to a clinic or hospital andhave those completed and build
your insurance. On the doctorend, they stay in business
(01:52):
through those annual fees andalso by billing your insurance
for the visits that you have. Iasked Dr. Dillon to talk
generally about how he came tothe decision to practice in this
way, and how concierge practicesare set up.
Charles Dillon MD (02:05):
There's different types of concierge
type practices, some that are sohigh end that actually a doctor
will have very small number ofpatients and will actually fly
around the country with them toto get opinions on their
illnesses. The most common typeof concierge practice is one
(02:30):
where a doctor is just trying tolimit the number of patients to
a reasonable number so they canactually spend the time to
listen to their patients andproperly care for them. And
that's the type of practice thatI'm in.
Heather Johnston (02:44):
How exactly does concierge medicine work?
I'm a patient. I go and what doI do?
Charles Dillon MD (02:50):
And so the patient decides when they need
to come in. And they can theycan schedule a visit and can
usually get in to see me if it'san urgent problem, if they call
in the morning, that same day,or the next day. For routine
problems usually can get them ina week. For a complete physical,
(03:12):
usually within a couple ofweeks. So it gives the patient a
lot of flexibility as toaccessing their physician to
help them maintain their goodhealth
Heather Johnston (03:23):
as a patient to find concierge care.
Basically, you're paying anannual fee.
Correctwhich includes everything that's
done inside your office walls,right?
Charles Dillon MD (03:36):
Yeah, yes, but it's not insurance. So we
always tell patients no, youstill have to have insurance. If
I have to send you to thehospital for some specialized
tests, that goes through yourinsurance. That's not through my
practice.
Heather Johnston (03:51):
That fee is different for all concierge
docs. You said that and itranges from this or that. But
it's obviously a very exclusiveopportunity. What's the solution
for everyone else?
Charles Dillon MD (04:06):
That's the problem. I can't say that this
is a solution for all patientsor all doctors. There aren't
enough physicians in our entirecountry to be able to have small
concierge type practices. Soit's really for those patients
(04:27):
who want that type of arelationship with a physician,
who feel that because of theirfamily history, their medical
history that they need thatcloser, more frequent contact.
But for the general public atthis point in time, it's it's
really not feasible. Medicinegot to the point where either I
(04:47):
was gonna go out of businessgoing broke because you had to
keep ramping up the number ofpatients that you would see,
spending less and less time witheach patient, or get out of
traditional insurance practice.
Heather Johnston (05:03):
For people that don't understand the
mechanics behind all this, whywould you have gone broke and
had to have spent less time withyour patients.
Charles Dillon MD (05:14):
It's interesting when we had paper
charts, also billing paperswould be in the chart in a
separate section as well. And itwas fascinating when I was
contemplating getting out of allinsurance, looking through some
of those charts. And, and forexample, seeing how in 1992, the
(05:36):
amount that Medicare would payfor a complete physical dropped
in about two thirds of thepayment less 20 years later. And
that became untenable.
Heather Johnston (05:51):
From about what to about what,
generalizing?
Charles Dillon MD (05:55):
So if if they were paying $500, for a complete
one hour physical back then, itwas dropping down to $100. And
all of the expenses over thatsame timeframe skyrocketed. I
mean, the rents, the overheadstaff, all the equipment, it
(06:18):
just became ridiculous. I have afriend who was a high level vice
president of one of the biggestinsurance companies. And she
used to tell me that every timeMedicare dropped their payments
to doctors, which consistentlywas happening every few years,
(06:40):
instead of keeping up withinflation, they kept cutting
them. And she said that withtheir meetings of all the
executives, they would kind ofapplaud every time Medicare
lowered their payments todoctors, because they would
follow suit and lower theirpayments to doctors.
Interesting.
It's kind of an unfair system,because hospitals have all the
(07:02):
negotiating power. Andindividual practices have very
little. So the pie used to besplit reasonably fairly between
what physicians would get paidand what doctors would get paid.
And unfortunately, what happenedis that hospitals got almost all
of the pie and primary carephysicians, were just getting
(07:23):
the crumbs. And in order to makeends meet, my accountant said,
either you're going to have verybrief, more frequent meetings
with your Medicare patients, oryou're going to have to drop out
of Medicare, because you can'tpay all the bills on what
they're paying. Very sad.
Heather Johnston (07:41):
It really is.
So what percentage of yourpatients were Medicare?
Charles Dillon MD (07:47):
So about a third of my patients were
Medicare, but they took up abouttwo thirds of the time.
Heather Johnston (07:54):
About how much time did you use to spend with
patients, before you changed toconcierge, like at the end, when
it was becoming a problem? Andthen how much time do you spend
now?
Charles Dillon MD (08:08):
Well, that's why I got out, I did not want to
change how much I spent withthem. For a yearly complete
physical Medicare, non Medicare,I typically allot a one hour
timeframe. Now, in most internalmedicine practices, that would
have been 20 minutes. And that'show those practices were able to
(08:29):
survive, though there are a lotof practices, they had to cut it
down to 15 minutes. So I refusedto change the quality of my
care. And, for example, youknow, just this week, I had a
physician contact me that I knowand wanted me to see his elderly
mother with multiple medicalproblems to try to put the
(08:50):
pieces together as the care wasfairly disjointed. Well, I
allotted two hours for thiscomplicated case. And I spent an
hour in advance collectingrecords that were available to
me electronically. In my oldpractice, that would have been
untenable, absolutely impossibleto try and do.
Heather Johnston (09:12):
So before you changed and went into concierge,
how were you feeling as a doctorin a traditional practice?
Charles Dillon MD (09:23):
Well, it was it was starting to get
overwhelming. Primarily theburdens we were getting from
insurance. You would get thesedenials and then you would have
to do rebuttals, and then youwould have to get on phone calls
and try to fight for yourpayments. You're always fighting
with the insurance companiesover them suddenly changing a
(09:46):
medication plan. And somebodyhad been well controlled whether
it was their diabetic meds,their cardiac meds, hypertension
meds, whatever. And suddenlythey were non formulary. And at
the last minute you are havingto make major changes that that
could adversely affect yourpatients. We were dealing with
(10:07):
that every single day. It usedto be if a doctor felt that a
patient needed a CT scan, youcould order it and get it done.
All of a sudden, you had nonphysicians and insurance
companies making a decisionwhether or not the physician
could get a study done. And theamount of time that that took
(10:28):
make it made the days very longand very painful. So the joy in
medicine started to disappear.
Heather Johnston (10:34):
Have you gotten it back?
Charles Dillon MD (10:36):
Absolutely. I love medicine, and it's
rejuvenated me.
Heather Johnston (10:43):
So this is probably a very obvious
question, but I'm going to askit anyway, How has being in a
concierge practice affected yourrelationships with your
patients?
Charles Dillon MD (10:54):
I think in a very positive way, my patients
are very thrilled to be able toactually call me and speak with
me. It's. medicine has changed alot in the last 15 to 20 years.
There's a lot of physicianextenders, and that can be
extremely helpful. But a lot ofmy patients feel that when they
(11:18):
see specialists, and they havefollow up questions or issues.
They all go through a physicianextender, and they're not always
sure that their question isbeing asked and answered in an
appropriate way, and they can'tget through to the specialists
that they were they were seeing,
Heather Johnston (11:39):
Can you explain what a physician
extender is?
Charles Dillon MD (11:42):
So there are there are nurse practitioners
and physician's assistants, who,who help in many ways make
practices run more efficiently.
They shouldn't really replacethe care of the specialist they
should add to that care. Butunfortunately, their role has
grown tremendously. For example,with my heart failure patients,
(12:08):
they used to go to a cardiologyclinic for heart failure and see
a heart failure physician, youknow, two or three times a year.
And then all of a sudden, itbecame once a year, they would
get to see the cardiologist, andthe other visits during the year
would be to the nursepractitioner. Now, they are very
(12:30):
helpful, but they are not acardiologist. And and the
patients are, are noting thechange.
Heather Johnston (12:42):
I think that's true. A lot of people that I've
talked to lately said that theycan't imagine being able to get
a hold of their doctor.
Charles Dillon MD (12:48):
Sad, but true
Heather Johnston (12:49):
They cannot do it because you send messages
through an electronic medicalrecord system most of the time
now, but the reply that you getback is almost always from a
nurse, or a nurse practitioner,or a physician's assistant, I'm
not knocking any of them, Ithink they're incredibly
essential to the system. But youknow, if I'm sick and having a
(13:12):
problem, personally, I reallywant to talk to my doctor.
That's the person I've chosen togive me my health care so I have
trust with them. I don't havetrust with the people that I
don't know, that's really aninherent problem now.
Charles Dillon MD (13:25):
it is a big problem. And I mean, I think it
it, unfortunately can lead tocatastrophic outcomes. I mean,
just to give you an example, allof my patients also have my
email. And so my patients cancontact me from wherever they
are in the world. I had apatient a few months ago, and he
(13:46):
had gone to Hungary on avacation. And all of a sudden I
get this email, and it said,Doctor, you know, both of my
legs, starting in my feet in thelast day or so have started
getting numb and it's startingto rise up into my calves. And
he said, I think it's just theway I was on the plane for a
(14:10):
long time or the way I sleptlast night. Now, if he had, you
know, tried to in a traditionalsystem email the doctor, that
wouldn't have happened. If hewould have called a physician,
he wouldn't have gotten a callback. I immediately was able to
email him. Tell him please standup on your toes. Then stand up
(14:30):
on your heels. And please tellme that you're able to do that.
And he goes Doctor, I can't dothat. I said, Okay. I think I
know what your problem is. Andyou have to get to the closest
emergency room immediately. Andsure enough, he had
Guillan-Barre Syndrome and endedup on a ventilator a few days
later.
Heather Johnston (14:51):
Oh gosh, in Hungary
Charles Dillon MD (14:55):
In Hungary, and it was a tough situation.
The family ended up spending themoney and got a medical jet to
fly him out of the country hereto Northwestern, where he was
off the ventilator after aboutthree more weeks, but then had
to go to rehab for a couple ofmonths. And I saw him this week,
(15:16):
and he actually walked inwithout his walker for the first
time.
Heather Johnston (15:20):
Wow, wow. What would you say your job
satisfaction was maybe on ascale of one to 10, before you
switched, and after youswitched?
Charles Dillon MD (15:30):
I would say it was probably down to a five.
And I always loved medicine, andI loved caring for patients, or
it was always up at that ninelevel. But because of the
hassles with insurancecompanies, it just kept
plummeting. So it there weredays that you would just dread
it because you know, you haveall of these, these companies
(15:53):
that you have to contact,different insurance companies,
and fight to get the appropriatetest done for your patient. And
that's not why you go intomedicine to fight with insurance
companies.
Heather Johnston (16:06):
Did you have to make those phone calls or
someone in your office?
Charles Dillon MD (16:09):
Oh, typically it would start with someone in
the office providing morerecords to the insurance
company. But invariably, theywould keep denying, and then it
would have to go physician tophysician. And and there are
there are doctors who work forthese insurance companies. And
(16:30):
their their goal is to cut asmany of these tests as possible
to save the insurance companymoney, and in my view to
increase their profits.
Heather Johnston (16:41):
Yes. And how did you fit those phone calls
into your day, because that'snot something that anybody
schedules into their day of afull day of seeing patients?
Charles Dillon MD (16:51):
it was difficult, because early on, you
could do those near the end ofthe day, and then just extend
your day, much, much longer. Butjust before I finally gave up on
insurance companies, it got tothe point where you would try to
(17:14):
schedule a time with one ofthese physician reviewers to
discuss your patient's healthcare and the reason for the
specific test. And they would nolonger give you a specific time.
And they would give you a timeframe and say okay, we will be
calling you between eight and12. And in the middle of patient
(17:36):
care, you're supposed to stopexamining the patient to accept
their phone call? It it was, itwas a really nasty game that
they set up because they knewthat most physicians couldn't do
that. And eventually, a lot ofphysicians just stopped doing
it. And they wouldn't go to thebat for their patients because
(17:58):
the hassle and the interruptionsin their patient care was too
great.
Heather Johnston (18:03):
That's crazy.
That just happened to me with myphysical therapist last year. I
needed physical therapy on myarm after the breast cancer
surgery. And my insurancecompany only gave me a few
visits, which just wasn'tsufficient. And the same thing
happened. She, my physicaltherapist said she'd appeal it.
But every time that happened,they would give her like an
(18:26):
eight hour window. And she waswith patients all day long, so
she missed the call every timeand then they just denied the
claim.
Charles Dillon MD (18:35):
Yes.
Heather Johnston (18:36):
Man. I mean, there's so many hoops and
barriers and challenges as aphysician to just deliver
quality health care to yourpatient. So I really understand
why you made the move. Do youremember how many patients you
had before in your traditionalpractice and how many you have
now?
Charles Dillon MD (18:56):
It was about 2000 and now down to 500.
Heather Johnston (19:02):
Wow. And how many patients do you see per
day?
Charles Dillon MD (19:06):
It varies.
There are some days when it'squiet day and you may see three
and a busy day today would besix or seven.
Heather Johnston (19:16):
What was a busy day before?
Charles Dillon MD (19:21):
Well, you might be seeing 16.
Heather Johnston (19:26):
In peds, 30.
Charles Dillon MD (19:28):
Yeah. Oh, I'm sure. It's funny because
administrators, they make morethan doctors. And and I my wife
and I were downtown and out todinner. We had reservations but
the place was busy, it was likegoing to be another 20 minute
wait, so walk over to the bar toget a glass of wine. There was a
(19:52):
game on at the bar and so I theguy next to me just made a
comment about wow did you seehim score that and we got
chatting a little bit. And hestarts talking about how he's
the hospital administrator. AndI, I pretend I'm not a doctor or
anything, I go, well, that was areally tough job. And it goes it
(20:13):
really is. I said, so I bet, youknow, getting doctors together
on anything is like herdingcats. He goes, yes. And they all
think we love them. But we can'tstand doctors. He was one of our
hospital administrators. I knewhim he didn't know me.
Heather Johnston (20:34):
That's great.
That's great. I'm sure thatdoctors are very annoying for
the administrative side.
My second guest is Dr. CindyRubin. Dr. Rubin has worked at
several big academic medicalcenters in Chicago, and recently
(20:56):
left all that behind to starther own practice called In Touch
Pediatrics and Lactation. Andshe's practicing under the
Direct Primary Care model,referred to sometimes as DCPs.
The D for direct refers to thefact that the patient pays the
doctor directly, similarly to aconcierge set up, but there are
a few differences. DCPs are abit more affordable, usually
(21:19):
running anywhere from $30 to$100 a month. And these doctors
do not bill insurance for theirvisits and tests with you. They
exist off of the monthlymembership fees.
Yes. Let's run through aconcrete model. So let's say a
Dr. Cindy Rubin (21:29):
The thing about Direct Primary Care is that it
is totally outside of thesystem. So you're not billing
insurance. And honestly, I thinkwhat I realized was that that's
the only way to not see 30patients a day and make any
money. Not that I'm trying to berich, but I do have to support
(21:53):
my family. And I realized thatif I just opened my own
practice, but I was billinginsurance, because of the small
amount that I would actually bereimbursed for each of those
patients, I would have to see 30a day. That's the problem now.
10 year old has a sore throatand a fever. What would happen
(22:22):
in a traditional fee for servicemodel and what would happen in a
direct primary care model?
So in a fee for service, theywould call and possibly have to
wait hours to get a call back.
Probably would be leaving amessage on a nurse triage
service or something, andeventually would get a call
(22:49):
back. They would triage thesituation, the nurse would
triage you wouldn't reach adoctor. And they'd figure out
whether or not it really neededto be seen that same day or if
it could, they could just getsome general information about
taking care of viruses or colds.
(23:12):
And if it needed to be the sameday, then they would look for a
place on the doctor's schedulefor an appointment. If you're
lucky, you would get anappointment with your own
doctor. Next best would be atleast an appointment in the
practice, but with a differentphysician who you may or may not
know. And it the next optionwould have been sending a
(23:39):
patient to urgent care if theyreally needed to be seen, and we
didn't have any appointments.
Now, some places have differentsetups. And I've seen offices
that have like an hour ofwalk-ins in the morning. And we
actually tried that for a while.
And there are definitelyadvantages to that, though, if
(24:03):
you get 40 patients walking inthen you have to see those in an
hour and then go into yourregular schedule. And that's
what we were always worriedabout.
Heather Johnston (24:12):
Yeah. And then how would that look in a direct
primary care model?
Dr. Cindy Rubin (24:17):
So direct primary care, my patient would
call the patient line or text mesaying what's going on,
depending on what I'm doing thatday and when they happen to
contact me. I would get back tothem within some period of time,
(24:39):
directly, but it would be me.
And find out more information,see how the kids doing. Same
thing, not every patient needsto be seen physically. So I
might be able to just give themsome reassurance and
instructions and then we'lltouch base later and see how
things are going. Or I wouldmake an appointment.
Heather Johnston (25:03):
And they'd see you.
Dr. Cindy Rubin (25:04):
And they see me, only me.
Heather Johnston (25:06):
In a pretty timely way. I bet.
Dr. Cindy Rubin (25:07):
Yes.
Heather Johnston (25:08):
So your patients have your cell phone,
Dr. Cindy Rubin (25:11):
Essentially yes.
Heather Johnston (25:12):
And your email also?
Dr. Cindy Rubin (25:13):
Yeah.
Heather Johnston (25:15):
And does anybody abuse it?
Dr. Cindy Rubin (25:17):
No. That's a big question. You know how often
I feel like I'd be woken upevery single night with
questions. But you're not. Justthe patient knowing that I will
be reachable in the morningmakes people more comfortable,
not necessarily calling in themiddle of the night if they
don't need to. But I impressupon patients or parents that if
(25:42):
they're trying to decide whetheror not to go to the emergency
room, they need to call me. Imean, if they know they need to
go to the emergency room, orcall 911, call 911. But, you
know, if they're not sure theirkid wakes up with a fever and a
sore throat, you know, they canprobably wait until morning to
(26:02):
be seen. And I can at least getthem through that. And that's my
job. I want to keep people outof urgent care and emergency
rooms. And I'm happy to be wokenup in the middle of the night to
do that.
Heather Johnston (26:17):
I think though, you made an excellent
point, which I want toreiterate, and just go a little
deeper into, which is that theymay or may not call you in the
night, but knowing that they canreach you is huge. I think
that's huge. Because I've heardfriends with children say they
(26:40):
sometimes call the practice inthe middle of the night, because
they know in the daytime theywon't get through to anybody.
Like either the phone is barelyanswered, or they leave message
after message and no one'scalling back. Or if they do call
back they'll talk to a nurse andthey really want to talk to the
doctor, who is the person thathas spent years building a
relationship with them. And theyknow that doctor and the doctor
(27:02):
knows them and their family. Andthat's who you want to talk to.
This whole idea of physicianhelpers, while I value them
personally, and I see thatthere's roles for them in
certain ways. I on the patientside of my brain, you know, I
don't want to talk to anybodybut my doctor, and they don't
(27:23):
know me. I guess maybe I have aparticular way of communicating
I don't know. But my doctorknows me and I want to talk to
that person. Yeah, that's a realcomfort to patients to know that
you can reach the doctor thatyou've chosen for your kid or
for yourself,
Dr. Cindy Rubin (27:39):
right. And if a patient calls me and their child
does have underlying medicalproblems, I know. They don't
have to sit there and listeverything. I know who which
parent is a worrier and whichisn't. I mean, that makes a
difference in how you're goingto address the problem,
(28:02):
potentially. Obviously, you'regonna give the same care to
everyone. But you might spend alittle bit more on the time on
the phone with somebody who youknow, is going to worry a little
bit more.
Heather Johnston (28:13):
That's a great example of just knowing
somebody, it's a relationship.
Right?
Dr. Cindy Rubin (28:19):
Right. And we're totally losing that.
Because I have to say in the feefor service model, more times
than not people were going tothe urgent care. And they were
bypassing the nurse triagebecause they knew that they were
gonna have to wait forever, andprobably wouldn't get in anyway.
And so they would go straight tothe urgent care and they'd see a
(28:40):
different person every time. Andhalf the time they wouldn't even
trust what happened there andthen they'd call us and it's. It
serves a purpose, but it is notit should be used for urgent
care. And primary care, whichincludes sore throats and fevers
(29:04):
during regular working hours,should be taken care of by the
primary care doctor.
Heather Johnston (29:10):
So you mentioned that in your job at
the big medical center, you wereseeing 30 patients a day. How
many do you see now?
Dr. Cindy Rubin (29:19):
So anywhere from one to three. Now my
practice is also home visits,it's all home visits. So that
does decrease the number ofpatients I can see even more
than a typical direct primarycare.
Heather Johnston (29:37):
Wait, we got to get into this. We gotta get
into this because I went onhouse calls with my dad as a kid
and I loved it. So I want tohear more about that. So do you
only do home visits?
Dr. Cindy Rubin (29:50):
I only do home visits right now.
Heather Johnston (29:52):
So you you don't have an office where they
come to?
Dr. Cindy Rubin (29:54):
No.
Heather Johnston (29:55):
Let's hear about that.
Dr. Cindy Rubin (29:57):
Yeah, so I decided to do that. because it
just is keeping my overhead lowin the beginning. It's such a
nice thing for parents to nothave to pack up and get to the
doctor's office.
Heather Johnston (30:12):
It sounds like a total luxury.
Dr. Cindy Rubin (30:12):
Yeah, and I like being able, yeah, yeah. And
I like being able to providethat service. And it also opens
a window into that person'sworld and their resources and
their limitations. And, youknow, with babies, you can see
(30:36):
where they're sleeping and makesure that everything's safe.
And, you know, just it makes abig difference. And kids are
more comfortable. Parents aremore comfortable. You're at
home.
Heather Johnston (30:50):
I don't know if I could think of a mom that
wouldn't like to have apediatrician walk through their
house when they have a baby.
That's
Dr. Cindy Rubin (30:55):
exactly.
Heather Johnston (30:58):
So even for teenagers, do you go to the new
for everybody? So for teenagersto see their room? Do you see
their room?
Dr. Cindy Rubin (31:06):
Yeah. Yeah, if they want me to.
Heather Johnston (31:09):
That's cool.
So how long do you spend onthose visits?
Dr. Cindy Rubin (31:14):
So, again, it kind of depends on what's going
on. But I'd say on average, oneand a half to two hours.
Heather Johnston (31:22):
Wow, that is so awesome.
Dr. Cindy Rubin (31:24):
Not necessarily for a sick visit. That is a sore
throat and fever. That may bequicker. But for well checks.
Heather Johnston (31:34):
Yeah. That's incredible. That, what a gift to
have that much time withsomebody. Really, I mean, you
can just have so much moreimpact on their health and their
life positively when you havethat kind of time.
Dr. Cindy Rubin (31:46):
Yeah.
Heather Johnston (31:47):
So are you doing stuff like drawing blood
or swabbing for strep? And like,how high how high and level of
care do you go in someone'shouse?
Dr. Cindy Rubin (31:56):
Yeah, for me personally, because I'm a still
new and can't afford necessarilyall the equipment and everything
yet. I am, I am doing swabbingfor COVID and strep. And I can
(32:16):
do like a urine dip test. ButI'm not doing actual lab draws.
So if anybody needs a lab draw,or more
Heather Johnston (32:28):
vaccines?
Dr. Cindy Rubin (32:30):
So vaccines, I'm doing
Heather Johnston (32:33):
good.
Dr. Cindy Rubin (32:33):
So vaccines I'm doing unfortunately, it is very
difficult for small practices toobtain vaccines, because they
are very expensive. And they'resold in bulk. And they expire
eventually. And so if you haveto buy a $100 vaccine, and you
(32:58):
have to buy 10 of those, and youonly have five patients right
now who maybe need thatparticular vaccine than you,
you're, I mean, you're puttingout a lot of money up front. And
we are not contracted withinsurance companies. So if we do
(33:19):
buy vaccines up front, we haveto figure out a way to either
bill insurance for thosevaccines, or the patient has to
pay out of pocket. And those areexpensive.
Heather Johnston (33:34):
Which one are you doing?
Dr. Cindy Rubin (33:36):
So I have been after searching high and low, I
have found a way to have thirdparties do the billing and
provide me with the vaccine togive in the home.
Heather Johnston (33:51):
It seems like local DCPs should band together
to buy in bulk. Does thathappen?
Dr. Cindy Rubin (33:57):
It does in some places, and in some ways, but
it's easier said than done.
Yeah, yeah. But I have had thehelp of other small practices to
provide me with the vaccineswhile they do the billing. And
I've also found a pharmacy.
Pharmacies don't have all of thekid vaccines anymore. So it was
(34:22):
really difficult for me to findone but I did find one who will
put through the billing, and Ican go pick up the vaccine and
then take it to the house togive the vaccine.
Heather Johnston (34:35):
Wow, that's great. Yeah. What happens if
you're one of your patients hasto be admitted to the hospital?
Dr. Cindy Rubin (34:43):
So I'm not, I don't have privileges at any
hospitals. So depending, youknow, again, I may be able to
keep a child out of the hospitalwhen otherwise they would have
been admitted because I can do acertain amount of observation
(35:04):
and treatment myself. But if ifthey have to be admitted, I
would have to send them throughthe emergency room probably. And
I haven't had to admit Anyway,that's all I'm saying. We've
been lucky enough to keep mypatients healthy so far
Heather Johnston (35:25):
You could still visit them every day,
right?
Dr. Cindy Rubin (35:27):
I can still visit them. So I can see them
socially. And I have the time toactually communicate with the
doctors who are taking care ofthat patient if the patient
wants me to. So I can give themthe patient's background, and I
can find out what's going on andhelp to interpret that and get a
(35:47):
better feeling for the follow upplan.
Heather Johnston (35:49):
I'm glad you're saying that part of it.
Because usually, when you're inpractice, you don't have time
during your day, like when wewere talking about what your day
was like earlier, there is notime in the day to have multiple
phone calls with a resident oran attending physician at a
hospital about your patient.
There is not time for that. Butgosh, think of the value for the
(36:10):
doctor taking care of yourpatient in the hospital to hear
from you, who knows the patientand the family so well. You can
give invaluable insight. [Yeah,]that's how it should be. [Yeah].
For people listening who mightwant to think about this for
themselves, if they don't havechildren? Where can somebody
(36:32):
find someone who practices withthis model that's near them?
Dr. Cindy Rubin (36:38):
So there is a couple of places, there's a DPC
mapper, that is I think at DPCNation if you go if you Google
that, and you will find most ofthe direct primary care
practices in the country andfind out what they specialize
(37:02):
because a lot of people have alittle niches as well, I
wouldn't immediately think oh mygosh, that I just can't do that.
That's extra. It is extra, forsure. But it's it's kind of like
the cost of your cable bill or agym membership. It's not crazy,
exorbitantly expensive. Andthere is a lot of value. My
(37:27):
practice is In Touch Pediatricsand Lactation. And they can
reach me by going to thewebsite, it's easiest place. And
there's a number of places whereyou can just contact me and that
will go directly to me. But mywebsite is www.intouchpeds.com.
(37:49):
And I provide I do the generalpediatrics, but I also do a la
carte breastfeeding medicine.
And I also have some extra kindof some,more comprehensive mom
baby packages for postpartum aswell. And those can be often
billed to insurance.
Heather Johnston (38:11):
Thank you so much for talking about all this
today. This has been sofascinating. And I hope that it
helps a couple of people who arelistening who are looking for a
different model. And maybe a fewdoctors listening will think,
you know, there's hope for meout there to do things
differently.
Dr. Cindy Rubin (38:26):
Absolutely.
We're very supportive community.
Like if you're considering thisat all. Try to find, you know,
contact me I can get you intothe Facebook groups and as we're
all just trying to helpeverybody figure it out and
survive. In this model.
Heather Johnston (38:45):
You can learn more about each of these doctors
and their practices in theshownotes. I've also thrown in
some other references there foranyone who wants to learn more
about these practice types.
Thanks for listening today. Tocatch up on more episodes and
get new ones delivered directlyto you, subscribe wherever you
find your podcasts - Apple,Google, Spotify, iHeartRadio and
(39:06):
more. If you'd like to be aguest or have an idea for an
episode, let me know atwww.drpatientpodcast.com That's
doctorpatientpodcast.com.
(39:28):
Here's the disclaimer. Eventhough I am a doctor, I'm not
your doctor. These stories, mycomments and all discussion is
purely reflection about what'sworking in the health care
system and what isn't. Don't useany medical information that you
hear in these episodes todiagnose or treat yourself. If
you have a question about yourhealth, get in touch with your
doctor or local health clinic
This is Dr.
Patient, a podcast that examinesall the aspects of the patient
provider relationship. I'm yourhost, Heather Johnston, MD, a
real life doctor and patient.
This week I'm looking at waysthat doctors are pushing back on
the dysfunctional system thatthey've been enmeshed in. And
this is a part 1, because lotsof doctors and patients are
(00:26):
starting to take matters intotheir own hands. So there are a
lot of stories to be told onthis topic. Today, I have two
doctors as guests who will betalking about the different
models of healthcare deliverythat they've chosen for
themselves and their patients. Atraditional model is called
fee-for-service, which meansthat doctors are literally paid
for each service that theyperform - see a patient, get
(00:48):
paid, see another patient, getpaid, order a test, get paid,
and so forth. Okay, keep that inyour mind as you hear about
these other models. My firstguest today is Dr. Charles
Dillon from UniversityAssociates, affiliated with
Northwestern Hospital inChicago. He was in practice for
many years before he left tolaunch what's called a concierge
(01:10):
practice. Concierge medicine iswhere the patient pays an annual
fee directly to the doctor,which includes all of the care
and communication that happenswithin the office. And between
the doctor and patient - visits,calls, minor tests, etc. The fee
can range anywhere from about$1200 to $10,000 a year or more.
(01:30):
So whether you're seeing onetime in a year, or 25 times in a
year, it's the same one lumpcost. If you need to see a
specialist or if you need careoutside of the office walls,
like an Xray, MRI, or otherhigher level of tests, you go
over to a clinic or hospital andhave those completed and build
your insurance. On the doctorend, they stay in business
(01:52):
through those annual fees andalso by billing your insurance
for the visits that you have. Iasked Dr. Dillon to talk
generally about how he came tothe decision to practice in this
way, and how concierge practicesare set up.
Charles Dillon MD (02:05):
There's different types of concierge
type practices, some that are sohigh end that actually a doctor
will have very small number ofpatients and will actually fly
around the country with them toto get opinions on their
illnesses. The most common typeof concierge practice is one
(02:30):
where a doctor is just trying tolimit the number of patients to
a reasonable number so they canactually spend the time to
listen to their patients andproperly care for them. And
that's the type of practice thatI'm in.
Heather Johnston (02:44):
How exactly does concierge medicine work?
I'm a patient. I go and what doI do?
Charles Dillon MD (02:50):
And so the patient decides when they need
to come in. And they can theycan schedule a visit and can
usually get in to see me if it'san urgent problem, if they call
in the morning, that same day,or the next day. For routine
problems usually can get them ina week. For a complete physical,
(03:12):
usually within a couple ofweeks. So it gives the patient a
lot of flexibility as toaccessing their physician to
help them maintain their goodhealth
Heather Johnston (03:23):
as a patient to find concierge care.
Basically, you're paying anannual fee.
Correctwhich includes everything that's
done inside your office walls,right?
Charles Dillon MD (03:36):
Yeah, yes, but it's not insurance. So we
always tell patients no, youstill have to have insurance. If
I have to send you to thehospital for some specialized
tests, that goes through yourinsurance. That's not through my
practice.
Heather Johnston (03:51):
That fee is different for all concierge
docs. You said that and itranges from this or that. But
it's obviously a very exclusiveopportunity. What's the solution
for everyone else?
Charles Dillon MD (04:06):
That's the problem. I can't say that this
is a solution for all patientsor all doctors. There aren't
enough physicians in our entirecountry to be able to have small
concierge type practices. Soit's really for those patients
(04:27):
who want that type of arelationship with a physician,
who feel that because of theirfamily history, their medical
history that they need thatcloser, more frequent contact.
But for the general public atthis point in time, it's it's
really not feasible. Medicinegot to the point where either I
(04:47):
was gonna go out of businessgoing broke because you had to
keep ramping up the number ofpatients that you would see,
spending less and less time witheach patient, or get out of
traditional insurance practice.
Heather Johnston (05:03):
For people that don't understand the
mechanics behind all this, whywould you have gone broke and
had to have spent less time withyour patients.
Charles Dillon MD (05:14):
It's interesting when we had paper
charts, also billing paperswould be in the chart in a
separate section as well. And itwas fascinating when I was
contemplating getting out of allinsurance, looking through some
of those charts. And, and forexample, seeing how in 1992, the
(05:36):
amount that Medicare would payfor a complete physical dropped
in about two thirds of thepayment less 20 years later. And
that became untenable.
Heather Johnston (05:51):
From about what to about what,
generalizing?
Charles Dillon MD (05:55):
So if if they were paying $500, for a complete
one hour physical back then, itwas dropping down to $100. And
all of the expenses over thatsame timeframe skyrocketed. I
mean, the rents, the overheadstaff, all the equipment, it
(06:18):
just became ridiculous. I have afriend who was a high level vice
president of one of the biggestinsurance companies. And she
used to tell me that every timeMedicare dropped their payments
to doctors, which consistentlywas happening every few years,
(06:40):
instead of keeping up withinflation, they kept cutting
them. And she said that withtheir meetings of all the
executives, they would kind ofapplaud every time Medicare
lowered their payments todoctors, because they would
follow suit and lower theirpayments to doctors.
Interesting.
It's kind of an unfair system,because hospitals have all the
(07:02):
negotiating power. Andindividual practices have very
little. So the pie used to besplit reasonably fairly between
what physicians would get paidand what doctors would get paid.
And unfortunately, what happenedis that hospitals got almost all
of the pie and primary carephysicians, were just getting
(07:23):
the crumbs. And in order to makeends meet, my accountant said,
either you're going to have verybrief, more frequent meetings
with your Medicare patients, oryou're going to have to drop out
of Medicare, because you can'tpay all the bills on what
they're paying. Very sad.
Heather Johnston (07:41):
It really is.
So what percentage of yourpatients were Medicare?
Charles Dillon MD (07:47):
So about a third of my patients were
Medicare, but they took up abouttwo thirds of the time.
Heather Johnston (07:54):
About how much time did you use to spend with
patients, before you changed toconcierge, like at the end, when
it was becoming a problem? Andthen how much time do you spend
now?
Charles Dillon MD (08:08):
Well, that's why I got out, I did not want to
change how much I spent withthem. For a yearly complete
physical Medicare, non Medicare,I typically allot a one hour
timeframe. Now, in most internalmedicine practices, that would
have been 20 minutes. And that'show those practices were able to
(08:29):
survive, though there are a lotof practices, they had to cut it
down to 15 minutes. So I refusedto change the quality of my
care. And, for example, youknow, just this week, I had a
physician contact me that I knowand wanted me to see his elderly
mother with multiple medicalproblems to try to put the
(08:50):
pieces together as the care wasfairly disjointed. Well, I
allotted two hours for thiscomplicated case. And I spent an
hour in advance collectingrecords that were available to
me electronically. In my oldpractice, that would have been
untenable, absolutely impossibleto try and do.
Heather Johnston (09:12):
So before you changed and went into concierge,
how were you feeling as a doctorin a traditional practice?
Charles Dillon MD (09:23):
Well, it was it was starting to get
overwhelming. Primarily theburdens we were getting from
insurance. You would get thesedenials and then you would have
to do rebuttals, and then youwould have to get on phone calls
and try to fight for yourpayments. You're always fighting
with the insurance companiesover them suddenly changing a
(09:46):
medication plan. And somebodyhad been well controlled whether
it was their diabetic meds,their cardiac meds, hypertension
meds, whatever. And suddenlythey were non formulary. And at
the last minute you are havingto make major changes that that
could adversely affect yourpatients. We were dealing with
(10:07):
that every single day. It usedto be if a doctor felt that a
patient needed a CT scan, youcould order it and get it done.
All of a sudden, you had nonphysicians and insurance
companies making a decisionwhether or not the physician
could get a study done. And theamount of time that that took
(10:28):
make it made the days very longand very painful. So the joy in
medicine started to disappear.
Heather Johnston (10:34):
Have you gotten it back?
Charles Dillon MD (10:36):
Absolutely. I love medicine, and it's
rejuvenated me.
Heather Johnston (10:43):
So this is probably a very obvious
question, but I'm going to askit anyway, How has being in a
concierge practice affected yourrelationships with your
patients?
Charles Dillon MD (10:54):
I think in a very positive way, my patients
are very thrilled to be able toactually call me and speak with
me. It's. medicine has changed alot in the last 15 to 20 years.
There's a lot of physicianextenders, and that can be
extremely helpful. But a lot ofmy patients feel that when they
(11:18):
see specialists, and they havefollow up questions or issues.
They all go through a physicianextender, and they're not always
sure that their question isbeing asked and answered in an
appropriate way, and they can'tget through to the specialists
that they were they were seeing,
Heather Johnston (11:39):
Can you explain what a physician
extender is?
Charles Dillon MD (11:42):
So there are there are nurse practitioners
and physician's assistants, who,who help in many ways make
practices run more efficiently.
They shouldn't really replacethe care of the specialist they
should add to that care. Butunfortunately, their role has
grown tremendously. For example,with my heart failure patients,
(12:08):
they used to go to a cardiologyclinic for heart failure and see
a heart failure physician, youknow, two or three times a year.
And then all of a sudden, itbecame once a year, they would
get to see the cardiologist, andthe other visits during the year
would be to the nursepractitioner. Now, they are very
(12:30):
helpful, but they are not acardiologist. And and the
patients are, are noting thechange.
Heather Johnston (12:42):
I think that's true. A lot of people that I've
talked to lately said that theycan't imagine being able to get
a hold of their doctor.
Charles Dillon MD (12:48):
Sad, but true
Heather Johnston (12:49):
They cannot do it because you send messages
through an electronic medicalrecord system most of the time
now, but the reply that you getback is almost always from a
nurse, or a nurse practitioner,or a physician's assistant, I'm
not knocking any of them, Ithink they're incredibly
essential to the system. But youknow, if I'm sick and having a
(13:12):
problem, personally, I reallywant to talk to my doctor.
That's the person I've chosen togive me my health care so I have
trust with them. I don't havetrust with the people that I
don't know, that's really aninherent problem now.
Charles Dillon MD (13:25):
it is a big problem. And I mean, I think it
it, unfortunately can lead tocatastrophic outcomes. I mean,
just to give you an example, allof my patients also have my
email. And so my patients cancontact me from wherever they
are in the world. I had apatient a few months ago, and he
(13:46):
had gone to Hungary on avacation. And all of a sudden I
get this email, and it said,Doctor, you know, both of my
legs, starting in my feet in thelast day or so have started
getting numb and it's startingto rise up into my calves. And
he said, I think it's just theway I was on the plane for a
(14:10):
long time or the way I sleptlast night. Now, if he had, you
know, tried to in a traditionalsystem email the doctor, that
wouldn't have happened. If hewould have called a physician,
he wouldn't have gotten a callback. I immediately was able to
email him. Tell him please standup on your toes. Then stand up
(14:30):
on your heels. And please tellme that you're able to do that.
And he goes Doctor, I can't dothat. I said, Okay. I think I
know what your problem is. Andyou have to get to the closest
emergency room immediately. Andsure enough, he had
Guillan-Barre Syndrome and endedup on a ventilator a few days
later.
Heather Johnston (14:51):
Oh gosh, in Hungary
Charles Dillon MD (14:55):
In Hungary, and it was a tough situation.
The family ended up spending themoney and got a medical jet to
fly him out of the country hereto Northwestern, where he was
off the ventilator after aboutthree more weeks, but then had
to go to rehab for a couple ofmonths. And I saw him this week,
(15:16):
and he actually walked inwithout his walker for the first
time.
Heather Johnston (15:20):
Wow, wow. What would you say your job
satisfaction was maybe on ascale of one to 10, before you
switched, and after youswitched?
Charles Dillon MD (15:30):
I would say it was probably down to a five.
And I always loved medicine, andI loved caring for patients, or
it was always up at that ninelevel. But because of the
hassles with insurancecompanies, it just kept
plummeting. So it there weredays that you would just dread
it because you know, you haveall of these, these companies
(15:53):
that you have to contact,different insurance companies,
and fight to get the appropriatetest done for your patient. And
that's not why you go intomedicine to fight with insurance
companies.
Heather Johnston (16:06):
Did you have to make those phone calls or
someone in your office?
Charles Dillon MD (16:09):
Oh, typically it would start with someone in
the office providing morerecords to the insurance
company. But invariably, theywould keep denying, and then it
would have to go physician tophysician. And and there are
there are doctors who work forthese insurance companies. And
(16:30):
their their goal is to cut asmany of these tests as possible
to save the insurance companymoney, and in my view to
increase their profits.
Heather Johnston (16:41):
Yes. And how did you fit those phone calls
into your day, because that'snot something that anybody
schedules into their day of afull day of seeing patients?
Charles Dillon MD (16:51):
it was difficult, because early on, you
could do those near the end ofthe day, and then just extend
your day, much, much longer. Butjust before I finally gave up on
insurance companies, it got tothe point where you would try to
(17:14):
schedule a time with one ofthese physician reviewers to
discuss your patient's healthcare and the reason for the
specific test. And they would nolonger give you a specific time.
And they would give you a timeframe and say okay, we will be
calling you between eight and12. And in the middle of patient
(17:36):
care, you're supposed to stopexamining the patient to accept
their phone call? It it was, itwas a really nasty game that
they set up because they knewthat most physicians couldn't do
that. And eventually, a lot ofphysicians just stopped doing
it. And they wouldn't go to thebat for their patients because
(17:58):
the hassle and the interruptionsin their patient care was too
great.
Heather Johnston (18:03):
That's crazy.
That just happened to me with myphysical therapist last year. I
needed physical therapy on myarm after the breast cancer
surgery. And my insurancecompany only gave me a few
visits, which just wasn'tsufficient. And the same thing
happened. She, my physicaltherapist said she'd appeal it.
But every time that happened,they would give her like an
(18:26):
eight hour window. And she waswith patients all day long, so
she missed the call every timeand then they just denied the
claim.
Charles Dillon MD (18:35):
Yes.
Heather Johnston (18:36):
Man. I mean, there's so many hoops and
barriers and challenges as aphysician to just deliver
quality health care to yourpatient. So I really understand
why you made the move. Do youremember how many patients you
had before in your traditionalpractice and how many you have
now?
Charles Dillon MD (18:56):
It was about 2000 and now down to 500.
Heather Johnston (19:02):
Wow. And how many patients do you see per
day?
Charles Dillon MD (19:06):
It varies.
There are some days when it'squiet day and you may see three
and a busy day today would besix or seven.
Heather Johnston (19:16):
What was a busy day before?
Charles Dillon MD (19:21):
Well, you might be seeing 16.
Heather Johnston (19:26):
In peds, 30.
Charles Dillon MD (19:28):
Yeah. Oh, I'm sure. It's funny because
administrators, they make morethan doctors. And and I my wife
and I were downtown and out todinner. We had reservations but
the place was busy, it was likegoing to be another 20 minute
wait, so walk over to the bar toget a glass of wine. There was a
(19:52):
game on at the bar and so I theguy next to me just made a
comment about wow did you seehim score that and we got
chatting a little bit. And hestarts talking about how he's
the hospital administrator. AndI, I pretend I'm not a doctor or
anything, I go, well, that was areally tough job. And it goes it
(20:13):
really is. I said, so I bet, youknow, getting doctors together
on anything is like herdingcats. He goes, yes. And they all
think we love them. But we can'tstand doctors. He was one of our
hospital administrators. I knewhim he didn't know me.
Heather Johnston (20:34):
That's great.
That's great. I'm sure thatdoctors are very annoying for
the administrative side.
My second guest is Dr. CindyRubin. Dr. Rubin has worked at
several big academic medicalcenters in Chicago, and recently
(20:56):
left all that behind to starther own practice called In Touch
Pediatrics and Lactation. Andshe's practicing under the
Direct Primary Care model,referred to sometimes as DCPs.
The D for direct refers to thefact that the patient pays the
doctor directly, similarly to aconcierge set up, but there are
a few differences. DCPs are abit more affordable, usually
(21:19):
running anywhere from $30 to$100 a month. And these doctors
do not bill insurance for theirvisits and tests with you. They
exist off of the monthlymembership fees.
Yes. Let's run through aconcrete model. So let's say a
Dr. Cindy Rubin (21:29):
The thing about Direct Primary Care is that it
is totally outside of thesystem. So you're not billing
insurance. And honestly, I thinkwhat I realized was that that's
the only way to not see 30patients a day and make any
money. Not that I'm trying to berich, but I do have to support
(21:53):
my family. And I realized thatif I just opened my own
practice, but I was billinginsurance, because of the small
amount that I would actually bereimbursed for each of those
patients, I would have to see 30a day. That's the problem now.
10 year old has a sore throatand a fever. What would happen
(22:22):
in a traditional fee for servicemodel and what would happen in a
direct primary care model?
So in a fee for service, theywould call and possibly have to
wait hours to get a call back.
Probably would be leaving amessage on a nurse triage
service or something, andeventually would get a call
(22:49):
back. They would triage thesituation, the nurse would
triage you wouldn't reach adoctor. And they'd figure out
whether or not it really neededto be seen that same day or if
it could, they could just getsome general information about
taking care of viruses or colds.
(23:12):
And if it needed to be the sameday, then they would look for a
place on the doctor's schedulefor an appointment. If you're
lucky, you would get anappointment with your own
doctor. Next best would be atleast an appointment in the
practice, but with a differentphysician who you may or may not
know. And it the next optionwould have been sending a
(23:39):
patient to urgent care if theyreally needed to be seen, and we
didn't have any appointments.
Now, some places have differentsetups. And I've seen offices
that have like an hour ofwalk-ins in the morning. And we
actually tried that for a while.
And there are definitelyadvantages to that, though, if
(24:03):
you get 40 patients walking inthen you have to see those in an
hour and then go into yourregular schedule. And that's
what we were always worriedabout.
Heather Johnston (24:12):
Yeah. And then how would that look in a direct
primary care model?
Dr. Cindy Rubin (24:17):
So direct primary care, my patient would
call the patient line or text mesaying what's going on,
depending on what I'm doing thatday and when they happen to
contact me. I would get back tothem within some period of time,
(24:39):
directly, but it would be me.
And find out more information,see how the kids doing. Same
thing, not every patient needsto be seen physically. So I
might be able to just give themsome reassurance and
instructions and then we'lltouch base later and see how
things are going. Or I wouldmake an appointment.
Heather Johnston (25:03):
And they'd see you.
Dr. Cindy Rubin (25:04):
And they see me, only me.
Heather Johnston (25:06):
In a pretty timely way. I bet.
Dr. Cindy Rubin (25:07):
Yes.
Heather Johnston (25:08):
So your patients have your cell phone,
Dr. Cindy Rubin (25:11):
Essentially yes.
Heather Johnston (25:12):
And your email also?
Dr. Cindy Rubin (25:13):
Yeah.
Heather Johnston (25:15):
And does anybody abuse it?
Dr. Cindy Rubin (25:17):
No. That's a big question. You know how often
I feel like I'd be woken upevery single night with
questions. But you're not. Justthe patient knowing that I will
be reachable in the morningmakes people more comfortable,
not necessarily calling in themiddle of the night if they
don't need to. But I impressupon patients or parents that if
(25:42):
they're trying to decide whetheror not to go to the emergency
room, they need to call me. Imean, if they know they need to
go to the emergency room, orcall 911, call 911. But, you
know, if they're not sure theirkid wakes up with a fever and a
sore throat, you know, they canprobably wait until morning to
(26:02):
be seen. And I can at least getthem through that. And that's my
job. I want to keep people outof urgent care and emergency
rooms. And I'm happy to be wokenup in the middle of the night to
do that.
Heather Johnston (26:17):
I think though, you made an excellent
point, which I want toreiterate, and just go a little
deeper into, which is that theymay or may not call you in the
night, but knowing that they canreach you is huge. I think
that's huge. Because I've heardfriends with children say they
(26:40):
sometimes call the practice inthe middle of the night, because
they know in the daytime theywon't get through to anybody.
Like either the phone is barelyanswered, or they leave message
after message and no one'scalling back. Or if they do call
back they'll talk to a nurse andthey really want to talk to the
doctor, who is the person thathas spent years building a
relationship with them. And theyknow that doctor and the doctor
(27:02):
knows them and their family. Andthat's who you want to talk to.
This whole idea of physicianhelpers, while I value them
personally, and I see thatthere's roles for them in
certain ways. I on the patientside of my brain, you know, I
don't want to talk to anybodybut my doctor, and they don't
(27:23):
know me. I guess maybe I have aparticular way of communicating
I don't know. But my doctorknows me and I want to talk to
that person. Yeah, that's a realcomfort to patients to know that
you can reach the doctor thatyou've chosen for your kid or
for yourself,
Dr. Cindy Rubin (27:39):
right. And if a patient calls me and their child
does have underlying medicalproblems, I know. They don't
have to sit there and listeverything. I know who which
parent is a worrier and whichisn't. I mean, that makes a
difference in how you're goingto address the problem,
(28:02):
potentially. Obviously, you'regonna give the same care to
everyone. But you might spend alittle bit more on the time on
the phone with somebody who youknow, is going to worry a little
bit more.
Heather Johnston (28:13):
That's a great example of just knowing
somebody, it's a relationship.
Right?
Dr. Cindy Rubin (28:19):
Right. And we're totally losing that.
Because I have to say in the feefor service model, more times
than not people were going tothe urgent care. And they were
bypassing the nurse triagebecause they knew that they were
gonna have to wait forever, andprobably wouldn't get in anyway.
And so they would go straight tothe urgent care and they'd see a
(28:40):
different person every time. Andhalf the time they wouldn't even
trust what happened there andthen they'd call us and it's. It
serves a purpose, but it is notit should be used for urgent
care. And primary care, whichincludes sore throats and fevers
(29:04):
during regular working hours,should be taken care of by the
primary care doctor.
Heather Johnston (29:10):
So you mentioned that in your job at
the big medical center, you wereseeing 30 patients a day. How
many do you see now?
Dr. Cindy Rubin (29:19):
So anywhere from one to three. Now my
practice is also home visits,it's all home visits. So that
does decrease the number ofpatients I can see even more
than a typical direct primarycare.
Heather Johnston (29:37):
Wait, we got to get into this. We gotta get
into this because I went onhouse calls with my dad as a kid
and I loved it. So I want tohear more about that. So do you
only do home visits?
Dr. Cindy Rubin (29:50):
I only do home visits right now.
Heather Johnston (29:52):
So you you don't have an office where they
come to?
Dr. Cindy Rubin (29:54):
No.
Heather Johnston (29:55):
Let's hear about that.
Dr. Cindy Rubin (29:57):
Yeah, so I decided to do that. because it
just is keeping my overhead lowin the beginning. It's such a
nice thing for parents to nothave to pack up and get to the
doctor's office.
Heather Johnston (30:12):
It sounds like a total luxury.
Dr. Cindy Rubin (30:12):
Yeah, and I like being able, yeah, yeah. And
I like being able to providethat service. And it also opens
a window into that person'sworld and their resources and
their limitations. And, youknow, with babies, you can see
(30:36):
where they're sleeping and makesure that everything's safe.
And, you know, just it makes abig difference. And kids are
more comfortable. Parents aremore comfortable. You're at
home.
Heather Johnston (30:50):
I don't know if I could think of a mom that
wouldn't like to have apediatrician walk through their
house when they have a baby.
That's
Dr. Cindy Rubin (30:55):
exactly.
Heather Johnston (30:58):
So even for teenagers, do you go to the new
for everybody? So for teenagersto see their room? Do you see
their room?
Dr. Cindy Rubin (31:06):
Yeah. Yeah, if they want me to.
Heather Johnston (31:09):
That's cool.
So how long do you spend onthose visits?
Dr. Cindy Rubin (31:14):
So, again, it kind of depends on what's going
on. But I'd say on average, oneand a half to two hours.
Heather Johnston (31:22):
Wow, that is so awesome.
Dr. Cindy Rubin (31:24):
Not necessarily for a sick visit. That is a sore
throat and fever. That may bequicker. But for well checks.
Heather Johnston (31:34):
Yeah. That's incredible. That, what a gift to
have that much time withsomebody. Really, I mean, you
can just have so much moreimpact on their health and their
life positively when you havethat kind of time.
Dr. Cindy Rubin (31:46):
Yeah.
Heather Johnston (31:47):
So are you doing stuff like drawing blood
or swabbing for strep? And like,how high how high and level of
care do you go in someone'shouse?
Dr. Cindy Rubin (31:56):
Yeah, for me personally, because I'm a still
new and can't afford necessarilyall the equipment and everything
yet. I am, I am doing swabbingfor COVID and strep. And I can
(32:16):
do like a urine dip test. ButI'm not doing actual lab draws.
So if anybody needs a lab draw,or more
Heather Johnston (32:28):
vaccines?
Dr. Cindy Rubin (32:30):
So vaccines, I'm doing
Heather Johnston (32:33):
good.
Dr. Cindy Rubin (32:33):
So vaccines I'm doing unfortunately, it is very
difficult for small practices toobtain vaccines, because they
are very expensive. And they'resold in bulk. And they expire
eventually. And so if you haveto buy a $100 vaccine, and you
(32:58):
have to buy 10 of those, and youonly have five patients right
now who maybe need thatparticular vaccine than you,
you're, I mean, you're puttingout a lot of money up front. And
we are not contracted withinsurance companies. So if we do
(33:19):
buy vaccines up front, we haveto figure out a way to either
bill insurance for thosevaccines, or the patient has to
pay out of pocket. And those areexpensive.
Heather Johnston (33:34):
Which one are you doing?
Dr. Cindy Rubin (33:36):
So I have been after searching high and low, I
have found a way to have thirdparties do the billing and
provide me with the vaccine togive in the home.
Heather Johnston (33:51):
It seems like local DCPs should band together
to buy in bulk. Does thathappen?
Dr. Cindy Rubin (33:57):
It does in some places, and in some ways, but
it's easier said than done.
Yeah, yeah. But I have had thehelp of other small practices to
provide me with the vaccineswhile they do the billing. And
I've also found a pharmacy.
Pharmacies don't have all of thekid vaccines anymore. So it was
(34:22):
really difficult for me to findone but I did find one who will
put through the billing, and Ican go pick up the vaccine and
then take it to the house togive the vaccine.
Heather Johnston (34:35):
Wow, that's great. Yeah. What happens if
you're one of your patients hasto be admitted to the hospital?
Dr. Cindy Rubin (34:43):
So I'm not, I don't have privileges at any
hospitals. So depending, youknow, again, I may be able to
keep a child out of the hospitalwhen otherwise they would have
been admitted because I can do acertain amount of observation
(35:04):
and treatment myself. But if ifthey have to be admitted, I
would have to send them throughthe emergency room probably. And
I haven't had to admit Anyway,that's all I'm saying. We've
been lucky enough to keep mypatients healthy so far
Heather Johnston (35:25):
You could still visit them every day,
right?
Dr. Cindy Rubin (35:27):
I can still visit them. So I can see them
socially. And I have the time toactually communicate with the
doctors who are taking care ofthat patient if the patient
wants me to. So I can give themthe patient's background, and I
can find out what's going on andhelp to interpret that and get a
(35:47):
better feeling for the follow upplan.
Heather Johnston (35:49):
I'm glad you're saying that part of it.
Because usually, when you're inpractice, you don't have time
during your day, like when wewere talking about what your day
was like earlier, there is notime in the day to have multiple
phone calls with a resident oran attending physician at a
hospital about your patient.
There is not time for that. Butgosh, think of the value for the
(36:10):
doctor taking care of yourpatient in the hospital to hear
from you, who knows the patientand the family so well. You can
give invaluable insight. [Yeah,]that's how it should be. [Yeah].
For people listening who mightwant to think about this for
themselves, if they don't havechildren? Where can somebody
(36:32):
find someone who practices withthis model that's near them?
Dr. Cindy Rubin (36:38):
So there is a couple of places, there's a DPC
mapper, that is I think at DPCNation if you go if you Google
that, and you will find most ofthe direct primary care
practices in the country andfind out what they specialize
(37:02):
because a lot of people have alittle niches as well, I
wouldn't immediately think oh mygosh, that I just can't do that.
That's extra. It is extra, forsure. But it's it's kind of like
the cost of your cable bill or agym membership. It's not crazy,
exorbitantly expensive. Andthere is a lot of value. My
(37:27):
practice is In Touch Pediatricsand Lactation. And they can
reach me by going to thewebsite, it's easiest place. And
there's a number of places whereyou can just contact me and that
will go directly to me. But mywebsite is www.intouchpeds.com.
(37:49):
And I provide I do the generalpediatrics, but I also do a la
carte breastfeeding medicine.
And I also have some extra kindof some,more comprehensive mom
baby packages for postpartum aswell. And those can be often
billed to insurance.
Heather Johnston (38:11):
Thank you so much for talking about all this
today. This has been sofascinating. And I hope that it
helps a couple of people who arelistening who are looking for a
different model. And maybe a fewdoctors listening will think,
you know, there's hope for meout there to do things
differently.
Dr. Cindy Rubin (38:26):
Absolutely.
We're very supportive community.
Like if you're considering thisat all. Try to find, you know,
contact me I can get you intothe Facebook groups and as we're
all just trying to helpeverybody figure it out and
survive. In this model.
Heather Johnston (38:45):
You can learn more about each of these doctors
and their practices in theshownotes. I've also thrown in
some other references there foranyone who wants to learn more
about these practice types.
Thanks for listening today. Tocatch up on more episodes and
get new ones delivered directlyto you, subscribe wherever you
find your podcasts - Apple,Google, Spotify, iHeartRadio and
(39:06):
more. If you'd like to be aguest or have an idea for an
episode, let me know atwww.drpatientpodcast.com That's
doctorpatientpodcast.com.
(39:28):
Here's the disclaimer. Eventhough I am a doctor, I'm not
your doctor. These stories, mycomments and all discussion is
purely reflection about what'sworking in the health care
system and what isn't. Don't useany medical information that you
hear in these episodes todiagnose or treat yourself. If
you have a question about yourhealth, get in touch with your
doctor or local health clinic
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