From Hospital Rounds to DPC: Dr. Kathryn Dreger’s Story of Empowerment

Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Maryal Concepcion (01:18):
Direct Primary care is an innovative
alternative path toinsurance-driven healthcare.
Typically, a patient pays theirdoctor a low monthly membership
and in return builds a lastingrelationship with their doctor
and has their doctor availableat their fingertips.
Welcome to the my DPC storypodcast, where each week.

(01:39):
You will hear the ever sorelatable stories shared by
physicians who have chosen topractice medicine in their
individual communities throughthe direct primary care model.
I'm your host, Marielleconception family physician,
DPC, owner, and former fee forService.
Doctor, I hope you enjoy today'sepisode and come away feeling
inspired about the future ofpatient care direct Primary

(02:02):
care.

Dr. Kate Dreger (02:06):
Direct Primary Care is making what we know has
worked for generations startworking again.
But this time, with thescientific advances of the 21st
century, we are harnessing andcelebrating the importance of
accessible, personal andpersonalized expert medical care
that lasts for years.
I'm Dr.
Catherine Dreger Prime, PLC, andthis is my DPC story.

Dr.
Kathryn Dreger is a boardcertified internal medicine
physician and the founder ofPrime, PLC, a Direct Primary
Care practice in Arlington,Virginia.
She completed her residency atGeorgetown University where she
now serves as an assistantprofessor of medicine.
Since 2014, she has beenrecognized as a Washingtonian
Top doc, five years in a row,and honored by Northern Virginia

(02:55):
Magazine and WashingtonConsumers checkbook as a top
rated primary care physician.
In 2016, Dr.
Dreger launched Prime PLC toreimagine how healthcare is
delivered, restoring time,trust, and personalized
relationships to primary care.
She continues to care forpatients in the hospital while
running her thriving DPCpractice, and she's the author
of an upcoming book on thefuture of patient-centered

(03:17):
medicine.
Today I am so excited to welcomeDr.
Kate Drager to the podcast.
It has been a wonderful, set ofyears that I've known you since
the very first summit I everwent to when I didn't even
really know what Direct PrimaryCare was back in 2019 in San
Francisco, to havingconversations with you as we've,

(03:40):
worked and advocated for policytogether on Capitol Hill.
And now we're able to sit downand have a longer conversation
about your history as to why youchose DPC.
So thank you so much for joiningus today.

Thank you so much for having me.
This is a real honor and I'mvery happy to be here.

Awesome.
So one of the things I wannapoint out from the get go is
Back in 2019 when I didn't evenreally know what direct primary
care was, you would ask theaudience what is primary care?
And so I think about when youand I were talking about a week
ago before this podcast, and youwere asking, like, what, what,
what about my story is helpfulto the audience?

(04:18):
I, I say to you and I say toeverybody, every one of us
brings a different perspectiveto the.
The definition of what Directprimary care is because we serve
our patients uniquely becauseour patients hire us to be their
doctor.
I am humbled that you andeverybody who has shared on this
podcast is showing that that isthe truth about primary care in

(04:41):
general, and especially directprimary care, when you can even
highlight more the relationshipthat you can have with your
patients.

Yeah.
I think it's very interestingwhen you think about direct
primary care as a uniqueoffering and how just messed up
that is because it should bethat everybody can have a doctor
like this.
Amen.
Right.
And if you have a healthcaresystem, if you think about it

(05:09):
from a societal perspective, youwant everybody to be able to
access care and you kind of wanteverybody to be able to have.
Their own physician.
And the fact that we're to thispoint where it's a unique
offering, I think really speaksto how much we have lost our
way.

Yeah, and I think it also goes back to why
you and I advocate for that.
This is just primary care at theend of the day, or at least what
primary care should be.
So, on that note, I will say ifyou would like to join us in
advocacy, please join us.
Join us at the DPC Coalition.
But when it comes to yourjourney into direct primary

(05:47):
care.
Yeah.
You've been doing this foralmost 10 years now, and so I
have Yeah.

Nine.
No, it's nine.
Nine in October.
Yeah.
I started in October, 2016.
So nine years.
Mm-hmm.
Yeah.

And that.
I'm sure it doesn't feel like itbased on, I'm sure it doesn't
feel like it, especiallycompared to the years prior to
DPC in your medical career.
Right, right.
So I would love if you couldbring us back to just the fact
that you're an internal medicinedoctor, because even though I
would say a majority of thephysicians who have shared their

(06:20):
stories on my DPC story arefamily physicians, we absolutely
have a growing number ofinternal medicine physicians,
pediatricians, as well asspecialists who are not focusing
on primary care, who are doingdirect primary care as a
business model, or they're aprimary care physician doing
direct primary care as abusiness model.

Yeah.
I mean, I think that thedifferences between, in primary
care, between pediatrics,internal medicine and family
medicine are probably smallerthan their commonalities.
I think if you look, certainlylistening to your podcast and
remembering back to my medicinetraining, the the breadth of

(06:58):
full scope.
Family medicine is, isremarkable.
And it involves hospital care,right?
And I, people often ask me,what's the difference between
internal medicine and familymedicine and peds?
And I think a lot of it is justage, right?
I small people scare me.

(07:19):
They get really sick reallyquickly and they're so precious,
right?
Like, I feel like you give me an85-year-old coming to the end of
life.
I'm your person.
I'm good with that.
And I think, so internalmedicine may be skews more,
those complicated end stagemulti-system organ failure

(07:40):
patients than family medicine.
And I certainly love thosepatients, but I don't think
there's very much differencebecause I think one of the
things that certainly policymakers don't think about is that
patients don't actually know howsick they are.
I mean, we saw that firsthand inthe COVID Pandemic, where you

(08:01):
would have a photograph ofsomebody who is morbidly obese
and the loved one would say he'stotally healthy.
And what they mean is fullyactive, fully independent, but
actually metabolically verysick.
So, so I always liked adults.
I've always liked the hospital.
When I started in 2002, we didour practice.

(08:23):
The, the practice that I joinedwas a attached to the hospital.
I joined somebody who'd been in,in practice for 15 years and we
admitted all our own, which waspretty convenient'cause you
could walk over this littleskyway and be in the hospital,
in the er, and if somethinghappened, you could run over to
the hospital and run back.
And then followed them up in thenursing home and saw them back

(08:46):
in the office.
And I found that to be hard.
But, but so rewarding and somuch easier, quite frankly, than
when somebody gets admitted andthen you get like typed computer
generated vomit and you'retrying to figure out what
happened and why they did thingsand, and what really went down.

(09:07):
So, so that's how, that's what Ilove and that's what I started
doing when I, when I got out oftraining in 2002.

That's amazing.
And, it's, it is.
It is so interesting.
I'm sure that the listeners outthere are picturing the patient
who you are describing somebodywho's metabolically not healthy,
but they are healthy accordingto their, their relatives.
And I think also it, especiallylooking back to the pandemic, I

(09:37):
think this is where a level offear came out about how COVID
was ending up killing, peoplewho were young people who go to
the gym and it, it really, wasa, whether you like to face it
or not, like metabolic healthmatters and Right.
It absolutely impacts yourability to have an immune system

(10:00):
that is robust and is able toadjust whether you're vaccinated
or not, so.
Right, right.
I, yeah.
And then there's just

random.
Randomness of illness, right?
Yeah, absolutely.
That we know well as physicians,that you don't have to have done
anything wrong to just havesomething horrible.

Right?
Totally, totally.
Yeah.
When you made the decision tobecome an internal medicine
physician and you joined thispractice, I'm wondering what
were the opportunities at thetime that you decided to join
this practice?
Because I think about hownowadays, the stats in
California that 80 to 90% offamily medicine residents choose
a role that is employed under acorporation.

(10:40):
And I'm wondering what theoptions were for you when you
were graduating residency.

Yeah.
So when I finished residency, wedidn't really have hospitalists.
And really there were hardly anyemployed physicians.
So everybody went into privatepractice.
I work at a community hospital.
We had 200 people on staff whowere family medicine and

(11:07):
internal medicine who were alladmitting their own patients.
So I sort of did what everybodyelse was doing.
And I liked it actually becausemy business partner had a
computerized record, which nowI'm really dating myself.
When you got to work past thepterodactyls and the dinosaurs.

(11:29):
Life was in black and white.
2002.
The your sound is off.

It's, it's so I don't cackle over
your, your amazing jokes.
It's great.
Okay,

that's fine.
I just nobody was using acomputer, right?
So everybody was using like thepaper charts, which has its own
level of pain that I reallythink we all need to remember
when we get com annoyed withcomputers that you are like,
where is their physical chart?
Like where is the piece of paperI need to write on?
And now you can do it kind ofremotely.

(12:03):
You can be downstairs, you canput the order in without having
to run up and put orders inmanually and then wait for the
secretary to take it off.
So, there are huge advantages tocomputers and he had a
computerized.
Healthcare record.
So, and he'd been using it fortwo or three years.
So I thought this was greatbecause I could, as a new

(12:23):
physician, enter all my data.
And he also did something thatwas very, very interesting is he
was involved in PPR net, whichis a research organization.
And they were using the data andactually studying how doctors
deliver better care.
Like how can you trainphysicians to kind of finagle

(12:45):
their office to get betterpopulation health, right?
And what are the barriers andthat kind of thing.
And they did some wonderfulresearch and from probably late
nineties to early 2010s and weparticipated with that.
And part of what we did was wewould actually get our patient
metrics and those would bepulled every quarter and we

(13:06):
learn how to read them and thenhow to use those lists and.
Call our patients up who weren'tdue.
And so I, I was actually reallyinto taking good care of not

(14:02):
only my individual patients,both in the hospital and in the
office and in the nursing home,and also just'cause they were
just ordinary functional peoplewho came in once or twice a
year.
And benign stuff and and severestuff.
But also learning how to use,it's gonna leverage the computer
to actually deliver better carefrom a population perspective.

(14:24):
Right.
So like I was super excitedabout that and the person I was
who hired me, who lately we, Ibecame a partner in the
practice.
It was super clever.
It was really nerdy.
It was a good time.
Yeah.
Initially.

Yeah.
I think it's awesome'cause itdefinitely sets the groundwork
for somebody who is passionateabout what primary care really
is and not what codes defineprimary, primary care.
'Cause even though you'retalking about research, you're
talking about.
Meaningful versus meaninglessdata.
Right.
So tell us a little bit aboutyour, when you think about

(14:58):
meaningless use versusmeaningful use, what are the
things that that you thinkabout, especially as the like?
Oh, absolutely.
Let me tell you my examples ofmeaningless use that I
experienced in fee for service.
So

there are so many, and I'm sure many people
have are listening to this andthinking, oh yeah, let me get
out my pen.
I, I think, I think my favoritestory it's called this person
Isabelle, which is not her name.
So Isabelle was lovely lady whohad absolutely terrible

(15:37):
diabetes.
Like, terrible, like hemoglobinA1C on a good day was 13.5 like.
So what she liked to do was shereally liked sodas, particularly
Cokes.
So she would drink six to 10cans of soda a day, right?

(15:59):
Her BMI was 45 and she justloved that fizz of the coke and
I tried everything.
She did not like the idea ofgiving herself injections.
She didn't wanna do this, that,or the other, right?
So eventually we worked on a lotof things.
We bought the mini cokes, welike finagled.
If she would do the shot after ashower, she would take like one

(16:20):
of those once daily long actinginsulins.
And I got her hemoglobin A1Croutinely down to nine.
Which like for me was like, Imean, yes, I am like, I am so
cool.
I am so proud of myself.
And then.
Then I did the meaninglessabuse.

(16:42):
Right.
And, and I had to put in thedata.
So you had to have enoughpatients to make the metric,
right?
Like you had to have somethinglike 30 people.
But there, there was some reasonwhy it worked in primary care
where you had to have a, a, acommon disease because you have
so many patients, we don'tactually have a lot of patients

(17:05):
with any one condition.
And then you had to whittle itdown so that 10 of those
patients were actually Medicarepatients who during the year
that was being studied, werebetween 65 and 74 years old.
Right?
So you had, so I had to findsomething that had 10 of those

(17:25):
people.
So it was diabetes.
And when I looked at my wholepopulation in the office, like
my average hemoglobin A1C, andall my diabetics was 6.4.
Which I was like, nerdy.
Yay.
Right?
Yay.
Okay.
As an internist, I'm feelingsuper nerdy, super successful.

(17:47):
And then I put the data in andthe only data that counted were
the 10 between 65, age 65 and74.
And I remember putting it in,and I, I knew, I knew the six
people of the 32 who were justlike Isabelle, like, ah God, I
tried, right?
I tried, can you do one donut,not two donuts, that kind of

(18:11):
stuff.
All six of them were in that 10.
And so from CMS and Medicare'sperspective, I was a terrible
doctor and I should be punishedfor my lack of medical care by
reducing my fee schedule bywhatever percentage and.

(18:34):
Even thinking about it now, Iget kind of furious.
It just the way we were doingperformance metrics was thinking
about them critically.
Did you make a difference inthis person's life?
Did you help them?
Can you help them?
I always joke that sometimespatient care is, you know, you

(18:57):
lead the horse to water.
You ha hang onto the bridle, youput the horse underneath the
water and still they will notdrink.
And eventually you're like,dude, if you're thirsty, there's
like a great big pond overthere.
Help yourself have some water,right?
And so when we were reading ourmetrics, we could divide those

(19:21):
patients into the people.
We were like, okay, we're doingthe best.
Can you see them?
Can you get anywhere?
And the people where you wouldbe like, why did they not?
Why did they not come back?
That's not like them.
And it turns out like, the dogdied or something happened or
they switched jobs and they'dcome back in, but you didn't
know to call them.
And these lists can help you dosort of things that are u

(19:44):
useful.
Right.
But being punished when I'dactually made a big difference
was really maddening there.
That's polite.

I, I would agree.
That's polite.
But yes, it's maddening is alsopolite to, to to describe the
ridiculousness of, the, thecurrent fee for service system
and the insurance driven way oflife.
And it is, it has led to datadenying people care without even
having the physician's opinionincluded in that decision

(20:16):
making.
Right.
So, so from here, you werestill.
Doing hospital medicine, you'restill doing outpatient medicine.
You're still, you're still doingyour thing and then you weren't,
you decided to open Prime PLC.
And I'm wondering, because backin 2016 there were not as many
DPCs as there are now.

(20:37):
Mm-hmm.
Definitely not as many DPCs inyour area as there are now.
And I'm just wondering, what wasit that inspired you to change?
Because you had been in practicefor a good number of years, you
had an established practice.
Yeah.
And you had you had, a panel whowas, was equaling, whether it's

(20:58):
fair or not, some kind of incomethat you became used to before
changing over.
So I think I, I

think it's a little bit like a death of a
thousand cuts, right.
I think that I'm a very nerdyperson.
So when, pay for performancecame out, I was like, I don't
understand.
Like I must be missingsomething.
I'm always the person who'slike, what am I missing?

(21:29):
Like, did I, did I not get thememo that this works?
Like, so I started reading itand I live basically inside the
beltway.
I want you to know there arenice people inside the beltway
for people who hate peopleinside the Beltway.
We actually have a functionalsociety.
We're all very nice and verynormal, okay?
And it's not a swamp.
It's got roads and everything.

(21:51):
Anyway, so I happened to, Ihappened to know people who
worked on the pay forperformance stuff, and I got to
talk to'em.
I went out and had a beer.
I was like, this is like notworking.
And I remember talking to onepolicymaker.

(22:13):
One of the things he said thathe's like, listen, I, I know all
about healthcare reform.
I live it every day.
I am completely in tune.
I mean, in terms of theday-to-day running of a medical
practice.
I don't really know anythingabout that.
But, but that's not important towhat I do.

(22:34):
And, and it was comments likethat.
You're like, well, how can youreform a healthcare system when
you don't understand what, howthe bricks work, right?
Like, if you don't understandhow the little pieces work, the
little pieces, like how can youpossibly fix it, right?
So that I could see happening,so I could hear it kind of going

(22:58):
through.
And I read a lot about.
Our poor healthcare outcomes asa nation.
And I don't know if you've everread this, if anybody's really
in the mood to really something.
Yeah.
There is a report from theNational AC Academy of Sciences,
which was the Institute ofMedicine, which I think is
called now the NationalAcademies of Medicine.

(23:19):
But the Institute of Medicine,as it was called at the time,
issued a report on shorterlives, poorer health, and why do
we have poor health outcomes?
And one of the biggest reasonsis we don't have primary care
physicians.
So I'm watching my practice getlike hammered and I'm hearing
people making decisions likeactually speaking to them and
they don't understand how thesystem works.

(23:41):
And I'm reading the science thatsays what they're doing is wrong
and.
I'm trying to make it work andwe are trying to use the
computer and bill for the thingswe need to bill.
And because I was also workingin the hospital, I'm having to
do all the things in thehospital to make the billing and
coding work in the hospital.
I'm learning all of that and allof that bureaucracy and all of

(24:03):
those things that aren'tactually patient care, but like
the patient has to stay in anextra night, otherwise they
don't qualify for this and, andif you don't add this IV in the
right time, then they can't getrehab and all of those
bureaucratic, silly, ridiculousthings that actually impact
care.
And that was hard.

(24:24):
But then I started realizingthat I was working so quickly,
like we, I think we added.
We basically went from seeing 15people a day to seeing 22 to 24
internal medicine patients aday.
And I will say, I don't know howfamily medicine people do it in
internal medicine, we have allthese like long nerdy list and

(24:45):
people have like 10 medicalproblems and you're going
through all of them and it'shard to do that in 15 minutes.
It really, really is.
And so, I had a lady come in whowas like, I said, how are you
doing?
She's like, well, the move wentokay.
And I was like, what move?
She's like, well, I movedapartments.
I'm like, I don't remember youtelling me you moved apartments.

(25:06):
Like I would've remembered that.
She's like, no, I told you.
I said, well, why did you move?
She's like, well,'cause my backwas so painful I couldn't live
there anymore.
And I was, I was like, what?
What?
Back pain?
I went back to my note, therewas nothing in there about back
pain, and she just put her handon my, on my hand and was like,
Dr.
Drager, it's okay.

(25:27):
You looked really, really busyand you were typing a lot that
day.
And I thought, oh my God.
Like I can, I, I know how totreat back pain for God's sakes.
Like I am now treating thecomputer and I'm not treating
the patient.
And, and you can probably hearin my voice like these things,
like on all fields, you look atit and you're like, this is

(25:48):
actually not, there's no senseto this.
And I sort of wanna state forthe record, it's not'cause I'm a
wuss, right?
It's not'cause any of us arewusses, right?
We all were, we're all the kindof weirdly wired people who,
when you said you're told like,I would like you to stay up and
work continuously for 30 hours.
We're like, great.
And can you please give me agood grade?

(26:10):
Please click.
Who does that?
Nobody does that.
Okay.
So then my business partner.
Decided to retire.
And he retired way earlier thanI ever thought he would.
And that was in like right atNew Years of 2015.
And then I actually had adecision to make, right?

(26:35):
Like this is like, you, you getpushed into a decision, you're
unhappy, but, but now you haveto choose.
And so that's when I startedlooking at my options and, and
do I become a hospitalist?
Do I join a bigger practice?
Do I try and go solo, maybe gointo academics?
But for a long time I had beenlooking at direct primary care

(27:00):
and kind of thinking about itand comparing this model of care
to the reform that people weredoing and thinking, no, no, no,
this is actually.
This is actually way moreelegant because what Direct
Primary Care does is it, itempowers critical thinking and

(27:24):
it empowers expertise at thelevel of patient care.
And it is a free marketsolution, which Americans love
free market, right?
So if your patient doesn't likeyou and you don't do a good job,
they can fire you and gosomewhere else.

(27:44):
So then you are now working foryour patient, right?
And then a colleague died and myfavorite aunt died just like two
months after that and threemonths after that.
And then I decided.

(28:43):
Life is short.
And if I, if I don't do, ifthis, if I do this and it
doesn't work then I'll just dosomething else with my life.
'cause I can't work like thisanymore.
I can't worry that I'm gonnahurt somebody because I couldn't
hear them'cause I was doing somany other things at the same
time.

it's so relatable that it's so
heartbreaking because I, Itotally, I can picture you at
the computer.
I can picture your patientholding your hand and saying,
it, it's okay.
And and the, the passivity aswell as the entitlement that we
get from our patients becausethey don't necessarily have a

(29:23):
relationship with us in fee forservice and as much as they do
in DPC.
And they you can see like theJekyll and Hyde in our patients
because it's like they'rereally, really.
Desperate for help.
And then some of them are sojust like resigned to, I know
I'm not gonna get help here.
It reminds me of a time to killwhen Matthew McConaughey, sorry

(29:46):
for being a spoiler is talkingabout a very, terrible case that
was involving a black child andsaid to the all white jury, now
imagine if that child was white.
And it makes me think about whenwe put ourselves in our
patient's shoes and when wethink about would we like to be
on the receiving end of thattype of care?
It it is it, it makes me atleast stop and think about the

(30:10):
shame I have for some visitsthat were just like that for
myself in clinic.
And I'm sure the listeners outthere can think about times when
they were going too fast or,wanting to walk out of the room
because they were behind andthey didn't wanna miss their
kids' soccer game or whatever.
These are things that that makeit so frustrating to be in a fee

(30:31):
for service, corporate driven,insurance driven.
Somebody who's not the doctor isdetermining how you deliver care
model.

Yeah, and I think, listening to what you're
saying, I mean, that is actuallythe heartbreaking thing.
Like I went into medicinebecause I think this is such an
honor and such a privilege totry and help people.
And I would never, ever, everintentionally not listen.

(31:01):
Right.
It was just, it's just you see,12 people by noon, right?
And then you're running out thephone's, ringing somebody in the
hospital needs fluids likeyou're running over back and
forth and it's, it's just verydifficult to do all of that
work.
Yeah.
And I think that's, that shameis part of that moral injury

(31:27):
where the only way the game isplayed is fee for service and
you're supposed to just get onwith it and you're supposed to
do it perfectly.
But when I look at.
Kind of the way we've createdthe current fee for service.
It's not by design.
There's a joke from a lot ofpolicy makers here that actually

(31:49):
is very common that nobody talksabout, which is reforming
healthcare is like putting,laying down track in front of a
moving train.
That's not actually reform,that's just panic.
There's no, there's no, that'snot how you sail a ship.
You don't just go like, oh,let's go this way.
Oh, look, oh look, there's anisland.
Ha ha.

(32:09):
No, you have a plan.
Like what do you want this tolook like?
You don't have a reactionarysystem, but we have a very
reactionary system.
And so, yeah, so I decided,forget it.
I'm gonna do somethingdifferent.

And I also just wanna call out that
it's wonderful that, you evenhad the discussion of, if it
doesn't work out, like I'm stillme, I can do other things.
I think that that's veryimportant to remember because it
is not everybody, everybody whocan go to medical school and
become a physician in the firstplace.
And so, if you're having theonly thoughts of like, I can't

(32:43):
do it'cause what if it fails andyou're not thinking the, I'm so
valuable that there's otherthings that I could achieve in
life and do in life.
That, that's a challenge there.
Right, right.
I also have a funny story about

this.
So, when I started the DPCpractice, you, you do the, the
math, how much money do you needto bring in, how many patients
to get to that money?
What's your overhead?
Blah, blah, blah.
And I figured like I, we couldmake, we could swing it for 18
months.
And so I had to opt out ofMedicare from the get go.

(33:15):
'cause most of my patients areMedicare patients which was
terrifying.
And you can't opt back in fortwo years at the time.
Right.
So I knew that if it was a bustand like nobody signed up and it
was no good, there would be atleast a six month window where I
had no income.
Right.
It turns out just for anybodyout there, you can actually work

(33:36):
in a prison without Medicarenumbers.
So there you are, it's anoption.
You get paid, it will beexcellent medicine.
People need you.
So that was my, that was my failsafe.
Yeah.
I had many fail safes.

Amen.
So timely that you mention,funding going into your DPC
because coming up in the comingup in the third week of October,
completely virtual is a summitthat I am collaborating on with
two, two physicians ob gyn andan orthopod.
And the conference is calledRise Up, but we're going to do

(34:14):
empowerment through teachingphysicians, including DPC
physicians, about side gigs,about locums and direct
contracting and how to do thingswhen you're opted out of
Medicare.
So I think this is soappropriate that you mentioned
that, right?
Because there's lots of, lots ofoptions.
Lots of options.
Yeah.
I,

I didn't know about that at the time, so I was
like.
Looking how far away the prisonswere from my house and how the
commute would work.

Oh my goodness.
But I'm, I'm, I, I think it, it,even like, I, I just think about
the, the time in which youopened in 2016 to opt out of
Medicare was very different thanlike when I opted out of
Medicare.
And it was during the pandemicwhen they're like, oh, you can
change back tomorrow if youwant.
Right.
Like two years of a commitmentis very, it, it's significant.

Right.
Right,

right,

right.

So when we talk about, what, what you
were noticing the, all of thesedifferent paper cuts and then
you decided to open up your ownpractice because you truly saw
it as a way to actively build apractice.
That was the type of practicethat you wanted to be a part of.
Mm-hmm.
You opened Prime PLC and you hadquite a bit of patients who were

(35:26):
with you when you opened, so youdidn't Yeah.
You didn't have, thankfully thatnobody's going to join me in two
years.
What else will I do?
Situation.
when we, and when we look at thenumber of practices who've been
on the podcast who havetransitioned their private
practices fee for service overto DPC, we see a five to 10%
buy-in from patients.

(35:46):
And so I'm wondering if youcould tell us about the fact
that your partner was retiring,you had this practice, people
have known you for over adecade, and they mm-hmm.
Were forced with the decision ofyou can be with Dr.
Dragger or you can be with theinsurance group.
How did, how did your patientsreact when you transition to
DPC?
So,

we had a 15%.
I had 15%.

That's amazing.

So, so, okay.
So I decided to do DPC aroundabout February, March.
Think it was March.
And between March and MemorialDay, I got a new logo, created a
website created a pamphlet and amailer.

(36:34):
Created new patient contractsand Signed up with an automated
billing service and, and thenbetween kind of Memorial Day
that year and then we opened onOctober 1st, really spent a lot
of time talking to the patientsand responding to phone calls
and trying to get people to comeover.

(36:57):
And I think the biggest thing,certainly for listeners who are
considering this, it is, it is avery important thing to keep in
mind when you're doing this andthat is that nobody cares about
us.
It is nothing to do with them.

(37:17):
And if you just save your breathfor how much you need it and how
much you're suffering, and howmuch happier you think you're
gonna be, that is not the salespitch.
Nobody wants to give you amonthly membership so that you
can go get your nails done.
Like no, no, no, no.
So I think that a lot of whatwe, what I did was just talk to

(37:40):
them about how much more timewe'd have together.
I could see them on the sameday.
I really wanted to have moretime to focus on them and listen
to them properly.
And I was frustrated that Icouldn't listen to my patients.
And I, I think patients deservebetter.
Right?
And then the other thing I didwas I said to people like, if

(38:01):
you can't afford it, let me knowand I will cut the rate.
'cause I was not doing this forthe money, I was just doing
this, so I didn't quit medicinecompletely.
So, that actually allowed us toopen the doors on October 1st
with 450 people.
Which I didn't know until yearslater was actually pretty good.

(38:23):
And it was a conversion rate, Ithink, and I just did the math.
I think it was like a 15%conversion rate.
I think it was about 20% from mypractice and 10% from,'cause of
the average.
And and it's been pretty steadysince actually I got to a max of
610.
620.

(38:44):
And then it, it was too much.
Mm-hmm.
It was too much to go over andsee the hospital patients and do
610.
'cause the thing I, I havenoticed is that the people who
sign up for my practice tend tobe much, much sicker.
So they tend to want to pay forit because they know, they have

(39:06):
so many specialists and so muchgoing on that they need somebody
to really sit with them and gothrough it.
So they're pretty intensivecare.
Not ICU Care, but I'm caringintensively.
And and so I, I closed thepractice off and then just
slowly drifted down.
And now and now I'm about 5 20,5 15, 5 20.

That was really hard for me to like, not.
Vocally expressed by MaryCatherine Gallagher.
Level of excitement that youjust said what you did, because
so many people think that DPC isa way to cherry pick the well
patients so we don't have totake care of the sick patients.
Oh, no, no.
And the fact that you said,yeah, the fact that you said
that the people who are sick arevalue healthcare access even

(39:49):
more, it is fricking true.
And also, just like if you can'tsee that, I don't know if you're
also doing healthcare reform bylaying those tracks down while
the train is, is chugging along.
Because you see, especially ouradult patients or the kids who
are with chronic illnesses, it'slike those are the people who

(40:10):
are so grateful.
When you just call to check onthem, like, I have two I have
two adults who one's older than90.
One's older than 80.
And we had a fire, recently andit was in their neighborhood and
I didn't know if they had,because they don't use cell
phones like I do.
And so I called them to makesure they knew that like they

(40:31):
needed to be aware of evacuationorders.
And they were like, oh my God,you're, oh, you're calling me.
Oh, this isn't about anappointment.
You're just checking on me.
And I'm like, yeah, yeah,because that's what we get to
do.
We just get to take care of youguys.

Yeah.
And I think those phone callswhere you called to check on
someone, like you're justthinking about them and and we
were doing it before in fee forservice.
You just couldn't get there.
You just couldn't get toactually make that phone call.
And I think.
I think that kind of care makesa huge difference.

(41:06):
I also think the concept thatdirect primary care doctors
cherry pick their patients isactually very harmful to the
movement.
I don't think it's true.
I think that for many people whoare struggling to build their
practice, any patient is apatient.
Right?
And, and I mean, that's why wewent into medicine, right?

(41:27):
If you wanted to have an easyjob, you, you went to the wrong
school, right?
'cause it's long, long, longroad to get an easy job.
You get an easy job some in aneasier way.
Right?
And I think that's somethingelse that I, I, I, I did wanna
mention think one of the thingsthat has been very harmful to
the healthcare system.
Has been a sort of dumbing downof primary care that primary

(41:50):
care is so easy that all we dois cold and we titrate high
blood pressure meds.
And then we like, occasionally,occasionally give you a diuretic
for your swollen ankles.
And that's about it.
Right.
And I think if we were to say tothe average person, like family
medicine, do you think it wouldbe useful to have one person who

(42:11):
could see you when you'repregnant, deliver you and take
care of your infant and yourchildren and your mom as she's
dying of cancer?
And have one person have allthat knowledge, would that be
useful?
I think everybody would say, ohmy God, that's amazing.
And in fact, I think manyAmericans would say That's not

(42:33):
possible.
Right?
And yet that's what familymedicine does.
And if you had like somebodysay, okay, could you take care
of somebody in the office andthen somebody in the intensive
care unit and somebody at the rehas enough knowledge to do all
of those things, I feel muchLaMer right now than a family
medicine doc.
Just wanna say, if you were justtaking care of really old,

(42:55):
decrepit people with lots ofmedical problems all the time,
would that be useful?
Yes.
Yes, it would be useful.
And we don't pay for that,right?
We don't actually value that.
We've actually said like, yeah,that's so easy.
You don't need a medical degree.
And I think that that reallyundermines the power of what.
Medical care is and, and what aphysician degree is.

(43:19):
So I think that direct primarycare allows you to use that
knowledge properly.
Right.
To say to your patient, I don'tknow, let me go home and like
read the latest study on that.
Like even while you're changing,I'm gonna go, there was an
article that came out.
I, hold on, hold on.

(43:40):
Come back.

Amen.
And, especially for newlisteners out there and for
listeners who have beenlistening for a while, I will
proudly remind people that myhusband was let go relieved of
his position as a fullscopefamily medicine doctor.
The last insurance acceptingdoctor who you could see if you
were pregnant, needed aprocedure, et cetera, in our
entire county because thecompany that we worked for went

(44:02):
to a non-physician model.
So I absolutely, this is not tosay about nurse practitioners or
non-physician providers, but tosay that the medical degree does
matter, that knowing, thousandsof hours, I think when, when
before, when, before we jumpedon this call, we were looking
up, 12 to 16,000 hours oftraining is what we go through

(44:23):
minimally in primary care toknow what's normal and to know,
like what you can handle and to

know when, when to move, right.
When to move quickly and, andwhat to do about that.
And I think that.
A lot of the cost savings we seein Direct Primary Care come
about because we know what thehospital would do and how long
it will take.
So, you could do something inthe office.
Like my favorite story, if And apatient come in on Monday

(44:52):
afternoon and she said, I'vebeen having like, I think I had
Melan this weekend.
I'm like, sorry, what?
And so she very clearlydescribes the GI Bleed over the
weekend, right?
Started on Saturday afternoonand last bowel movement was

(45:14):
Sunday evening, right?
So now it's 24 hours later.
Well, if you haven't beenbleeding for 24 hours later in
the hospital, you get sent home.
That's just how that goes,right?
So I know that she would be senthome, she's hemodynamically
stable.
She looks good, but she needs ascope, right?
So I leave the room, I call mycolleague the

(45:35):
gastroenterologist.
I'm like, oh my God.
Like she's, I do stat labs,right?
Her labs are fine, her bloodcounts are fine.
She's, she's, she's dropped alittle, but not a lot.
So she's medically safe, right?
He's like, I can scope hertomorrow at seven 15.
And there's no way in the feefor service model that that

(45:58):
works, right?
It just doesn't work.
But that saved her an entirehospitalization.
She had a non bleeding ulcer.
He like checked it, we put heron meds, she didn't bleed again.
And, and like I said to her, Iwas like, listen, if it happens
again, go to the er.
'cause you know what, it'salways open.
And that's what it's there for.
It's for actual emergencies,right?
So.

(46:18):
I think we've lost sight of thefact that direct primary care
and old primary care saves moneybecause we are able to do very
clever things.
Right.
And I think that's valuable.

Totally.
And layer on top of thattransparent access to, what does
A CBC actually cost, under$6?
Oh my God.
Like what does a, what does amammogram cost?
I will say my story here mostrecently I had a recall for my
mammo, and that's not covered.
So the, when the lady was likethat'll be$330 copay.

(46:51):
And I'm like, Hmm, thank you.
I would actually like to switchto the cash price because I send
my patients to this imagingcenter and I'm like, I know that
what I will spend in cash isless than what my insurance is
charging with the copay.
So I saved money because I wasadvocating for myself knowing
the prices, like a restaurantcharges.
So, oh my God.
Yeah, it was amazing.
And they, and they let you doit?

(47:12):
Oh, absolutely.
Yeah.
And it's not common that they,how, how much was it?
How much this, so I paid, Ithink I paid maybe 290 and it
was gonna be 330.
So it wasn't a huge, hugedifference.
Right.
But at the same time, like Iknew the math, like I, I could
actually calculate it as she wastelling me like, that's more

(47:33):
than I am gonna pay if I just goto the cash price.

That's ridiculous.
Yeah.
How did we get here?
Yeah,

it's

nuts.
Yeah.
Yeah.

So I wanna ask about the idea that
you went above 600 patients,610, 620, and then you went back
down into the five hundreds.
Because I think that's somethingthat more people are facing
right now.
Like, how big is too big?
When am I comfortable with mysize, with my panel size?
Mm-hmm.
And because you still dohospital care, you still look

(48:06):
after your patients in thehospital as well as your
outpatient practice.
I, I'd love if you could talk tous about your thoughts when it
comes to, how do you, how do younavigate what is a full patient
panel quote unquote, foryourself?
Yeah.
Especially if you want to do,different levels of care like
hospital medicine.

Right.
So I should make clear that I, Ido.
Have hospitalists taking care ofmy patients.
I go and see them and I writenotes and I talk to the
hospitalists, but I'm not doingthe admissions largely because
I'm solo low.
And I think that I would not seemy family and that would just be

(48:46):
bad.
So I'm, I'm very fortunate.
I mean, all the internists arelovely, they're very patient
with me, but it's just comingalong and saying, okay, we did
this last month.
This is actually what happened.
Okay, I'll see them on Tuesday.
Do you want me to do this part?
And, and I think I, I thinkit's, they tell me it's helpful
to them and, and it's certainlyincredibly helpful to me and

(49:08):
very rewarding to me.
So, so that's how I work in thehospital medicine.
I, I think, for me, when I goabove like 55, 60 hours a week.
That's when I start saying like,okay, this is too much.
The staff were like, you need tostop accepting new patients.

(49:28):
Like you need to just stop.
'cause of course, when youaccept a new patient, it's about
four hours of work.
Just to get their chartorganized and all of their echos
and scans and cts andconsultations and get all of
that done.
And then you've got the firstvisit, right?
So, so every time you're seeingnew patients, every time they
sign up, it's like an extra fivehours of work each time.

(49:51):
So I, I think that's a personaljudgment.
My sense is if I had apopulation that maybe wasn't as
sick, I could probably see morepeople.
But you know, you get to like400 Medicare, over 65 patients

(50:45):
with 15 medical problems apiece, and it starts getting a
little tricky.
I mean, I think everybody makestheir own decision, I guess is
what I would say.
Yep,

yep, yep.
It's good.
And so here I'd like to askabout pricing because just going
back to again, the, the DPCecosystem was much smaller in
2016.
Yeah.
And you had pricing, that isstill very reasonable.
I mean, your website also says,we're not accepting patients at
this time.
But in general, how did youthink about your pricing knowing

(51:16):
that, you've mentioned, I needthis amount of money to like
you, you mentioned overhead, youmentioned the, the, the math of
DPC, but how did you calculateyour pricing when you opened and
has it changed over the years?
So I.
I

sort of did a tiered pricing.
I feel like somebody who's 2018to 29 is generally not that
complicated to take care of, andsomebody who is 95 is right.
And so I just have an age-basedpricing.
Kind of goes up a little bit as,as you get older.

(51:53):
And it's once you get to 60,it's flat, so I don't go up past
60.

Has

it

changed over time?

Oh, no.
And I probably should'cause it'snine years and I haven't
increased my rates.
And my, my brother actually hasan MBA and he's just like
despairs of me.
It's like, what are you doing?
I'm like, yeah, it's, it's likethe, the money isn't quite the
same as it was.
He's like, you're such an idiot.
So I do, I do probably need toincrease it, but I always feel

(52:23):
bad.
But I probably should increaseit.
It's been nine years.

It's

bad when your patients come in.
They're like, Dr.
Drag.

Oh my goodness.
I, I have, I have a, I have a,I, I think I mentioned this on
the podcast before, but I have aperson who's a 94 and she said
to me, Dr.
C, I'm gonna live to a hundredbecause then my care will be a
dollar a month, which is like 67cents after stripe fees.
And I was like, amen.

(52:53):
Let's do it.
Let's, let's do it.
So I, I our, our care pricinggoes down after 99 and 364 days,
but yeah, it's it's, oh, that'sdelightful.
I love it.
I love that.
I love it.
And I'm like, dude, if that getsyou motivated to like, still
like live a quality life, amen.
Like that the, that you canclaim that your healthcare is a

(53:15):
dollar a month.
I'm like, let's do it.
I may have to do that.
That's so great.
Yeah.
Okay.
Well, I wonder what your brotherwill say about that, though.
I know he's a super guy.
He'll be fine, but he's just,yeah.
Oh my gosh.
So one thing I wanna ask aboutalso is that you have a signup

(53:36):
fee.
And I do think that, you, youcalled out very, very relevantly
that when you onboard a newpatient, it can take multiple
hours to onboard that patientbecause the conversation is part
of the, the, the welcome to thepractice.
But it's also, making sure thatinsurance cards are there.
And even though we don't billinsurance, we still need the
insurance card information ifwe're gonna, use their insurance

(53:59):
for ordering labs or mammogramsor sending referrals, et cetera.
And so, just the, the nuancesof, or the details of getting a
person onboarded, gettingrecords, there's definitely
tools that are out there to helpus go faster when it comes to
getting records.
But going through those records,putting a story together, it's a
little bit different for youbecause you had.
You knew your patients, at leastmost of them before you opened.

(54:21):
Yeah.
But I'm wondering if you couldtell us about how you use the$75
signup fee as part of the theway that members signed up at
your practice.

I mean, I think part of it was, was also meant,
it's meant to cover that initialsignup cost and moving,
requisite over and doing all ofthat.
And then also when we firststarted, you could only bill at
the end of the month.
And so, you, you ended up withsort of no money until the end

(54:52):
of the month.
Even though you were gonna bedoing a whole lot of work to get
everything sorted out and getpeople plugged in.
And and so it was a way to sortof offset that upfront cost at,
at, not in exorbitant levels, soit's, it's, it's the same fee
for everybody, but my olderpatients, it's 1 25 a month, so

(55:12):
it's not even a month's fee.
So that's kind of how, that'swhy I did it.
And I've kept it that waybecause, like, I just had a lady
join at her first visit was twodays ago.
And I, I did actually spendabout four or five hours going
through all her records, right.
And her allergies that were infact, really severely persistent

(55:35):
asthma.
And she'd been.
So many places with her, quote,allergies that were well
controlled, but this weird coughand, and you're like, wait.
And so you go back and back andback and there was a
pulmonologist way back who'ddone PFT and diagnosed asthma,
but it had just gotten lost.
It, it had just gotten lost.

Yeah.
And I, I will say that it'ssomething to think about.
On the Facebook groups you maysee people poo-pooing a signup
fee.
But I do think that it, it is away to help cover your fees of
your practice, especially if youare newer and your opening and
you have membership fees, butyou also have an onboarding fee
or a signup fee.

(56:17):
It does help with the, the costof having a practice.
And so, I, I think it's, it isdefinitely something to think
about and not just poo poobecause somebody says it's not a
cool thing to do.

I think the other thing it does actually is
separates whether or not peopleare kind of interested.
I mean, that's not a perfectexample because if you don't
have the money, you don't havethe money and it can be
prohibitive.
So I, I think that's adouble-edged sword, but I do
think it's very easy to sign upfor something if you don't

(56:50):
actually have to pay anythingfor, a month or two.
Right.
So it kind of, this is a, thisis a contract, right?
This is a, do you want me totake care of you?
Yes, I do.
It's a, it's a commitment onboth sides.
So.
I mean, and I think that's whyit's a, it's, it's a free
country.
You can charge a fee or notcharge a fee, whatever works for
you.
Right.

Yeah.
And I will say, like you saidearlier, when you asked your
patients, if you can't pay, letme know.
It's your business.
You get to decide like if youneed to waive a fee or if you
need to do whatever you have to,but it's your business.
And so, but I, I do like that interms of you're putting skin in
the game.
So when it comes to and, andalso I just wanna mention here,

(57:30):
thank you for clarifying interms of that you do work with
hospitalists, but like, I thinkabout just with that, the
hospital visits that you do, do,I, I just think about how even
as a resident there would be, myco-residents taking care of my
patients in the hospital, butwhen I would talk with them
about, Hey, this person livesalone at home, like, discharge

(57:51):
is da, da, da, it's gonna bedifficult to da da, or like, I
know the, the sun, the son tocontact or whatever.
I think that the primary careinvolvement at any level even if
you're not the primary admitterand taking care of person in the
hospital, it still makes a hugedifference to paint that person
as a person and not just anumber.

Yeah, and I think also the science is
helpful because sometimes peopleare like, oh, I don't know why
they're on that.
And you're like, oh, well thishappened and that happened, the
other happened and this is howwe ended up here.
Oh, I didn't know that.
Or you come in and, and somebodydidn't actually realize that
they had had cancer the yearbefore.
'cause it wasn't, they were in adifferent computer system so it

(58:33):
doesn't port over.
And the whole, different majorcorporate medical systems with
their own electronic medicalsystems can make it very, very
hard to get that data.
So I think some of it is socialand some of it is science as
well.
I mean in the science and art ofmedicine right there all the
time.

Dr. Maryal Concepci (58:53):
Absolutely.
So.
In closing for our maininterview, I wanna ask about
the, the idea that you mentionedyou can lead a horse to water,
but you cannot make them drink.
And you were, presented with thewater that is the DPC Kool-Aid
and you decided to jump in.
And so I'm wondering if youcould tell us what you would say

(59:15):
to those physicians who areaware that there is a pool of
water and that they can drink,but they're on the fence about
it.

I'm gonna answer this question by going
just slightly sideways.
Part of our job.
Is to take care of people at theend of their days.
Right?
And we see people of all agescome to their end and sometimes
it's sad and sometimes it'scruel and sometimes it's a
relief, right?

(59:44):
But we know we're mortal and yetsometimes I think we forget
we're mortal.
Like we're so busy taking careof the people that we forget
that we just have one life andwe can do with it whatever we
want.
I think imagining what it is youreally want out of life is, is

(01:00:10):
not easy to do because youactually have to be honest with
who you are and what you'rereally up for, right?
I teach medical students stilltoo.
And.
One of the things I say to themis, the problem with picking
your specialty is you actuallyhave to know who you are.
Not who you think you'd like tobe, not who you like, envision

(01:00:31):
yourself being, but actually whoyou are and what you actually
like.
So if you're on the fence ofdeciding to do direct primary
care, I think it's reallyimportant to think about what
the costs are to you, like thereal costs, what failure will
look like, and what it will looklike after you fail.

(01:00:52):
So if you fall on your face,scrape your nose up, blood all
over your jeans, you've tornthem, they were your favorite
pair, then what?
Like then, then what will youdo?
And if you can envision whatwill happen after you've, if you
fail, like, okay, I'm gonna workin a prison.
I was like, all right.

(01:01:12):
Okay.
Okay, I have a solution.
That is what, and I picked outwhere the prisons are and how
long the drive is.
There are like four of them.
I was like, okay, I think I canget a job there.
Okay.
I have a plan just envisioningwhat happens.
And on, on a personal note, Iwould say I immigrated here when

(01:01:35):
I was a teen and so I left mywhole country and came to a
different country.
And it's okay, right?
I've made a different life.
I love it here.
I love this country.
And I think knowing that you cando that, it just makes you feel
like, okay, it will be okay.

(01:01:55):
Right?
Even if you, even if you go andyou fail and it didn't work and
you have to go back, you're, no,you're actually not worse off
for trying.
And the joy.
I have now in medicine just tobe able to really listen to
people and really think aboutwhat they're saying and what
they're not saying and what theymeant.
And is that really how thathappened?

(01:02:17):
Because actually you just saidtwo completely different things.
Can you say that again?
Like really going through theirhistory so you can figure out
what the problem really is.
Then treating them becomes muchmore straightforward and you
have a higher success rate.
And, and that's, that's what we,that's what we did this for, is
to help people.
And so think about why you wentinto medicine, what you wanted

(01:02:40):
to do, whether or not this helpsyou get there.
And if you do it and fail,what's the worst thing that can
happen?
And I think going through thatin your own life and talking to
the people that love you andare, and will call you out on
stuff and support you.
I think that's what I wouldsuggest.

Dr. Maryal Concepcion (01:03:01):
I love it.
And with your wicked sense ofhumor, I also want to mention
that you are coming out withyour own book and I think about
when you told me that you weregoing to write your book, I just
think that it's so importantespecially as we see media being
so quickly used and, anddiscarded.
I, I do see the value in writingdown one story.

(01:03:24):
I mean, we celebrate stories allthe time on this podcast, but
I'm wondering if you could tellus about your book and where can
people find it?

Dr. Kate Dreger (01:03:31):
I have been writing this book for a long
time.
Very, very, very slowly.
I'm nearly done.
Full disclosure, I don't have apublisher yet.
I I need to get one.
But my goal with the book is toactually, in many, in many ways
tell the story of how I got todirect primary care, but use

(01:03:51):
that as a platform to explain tothe average person who isn't in
medicine, how the healthcaresystem works.
I think in this country we havea huge majority of people who
are unhappy with the carethey're receiving, and I think
very few of them understand howunhappy the doctors are.
I think explaining that how wegot here, what's happening, why

(01:04:15):
it's happening, and what we canpossibly do to fix it.
I'm hopeful that would behelpful.
It's not a book.
I mean certainly physicians canread it but it's really supposed
to be for people who aren't inmedicine but want better care.
And I think if we all actuallyunderstand how the system works,
we're much more likely to designsomething that will fix it

(01:04:39):
moving forward.
I mean, if the bureaucrat or thepolicymaker actually understands
how the doctors visit doctorspractice works, then maybe their
solution will actually help thedoctor's practice.
Thrive.
Right.
So, and if you're interested,you can go to my website, which
is prime plc.com and there's alittle button and you can put in

(01:05:02):
your email address and let me, Iwill let you know when the book
comes out.

Amazing.
And I do encourage people to goto Dr.
D Drer's website especiallybecause just hearing her speak,
during this interview, it'slike, can you imagine the impact
her words have on people who areour patients or future patients,
or who are another DPC doctor's,future patients?
And it's something that patientscan share amongst themselves to

(01:05:29):
help themselves feel moreempowered when they look for a
DPC doctor like you.

Dr. Kate Dreger (01:05:34):
Thank you.
Thank you.

Thank you for listening to another episode
of my DBC story.
If you enjoyed it, please leavea five star review on your
favorite podcast platform.
It helps others find the show,have a question about direct
primary care.
Leave me a voicemail.
You might hear it answered in afuture episode.
Follow us on socials at thehandle at my D DPC story and
join DPC didactics our monthlydeep dive into your questions

(01:06:00):
and challenges.
Links are@mydpcstory.com forexclusive content you won't hear
anywhere else.
Join our Patreon.
Find the link in the show notesor search for my DPC story on
patreon.com for DPC news on thedaily.
Check out DPC news.com.
Until next week, this isMarielle conception.

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