June 28, 2024 • 48 mins
In this episode, we'll delve into the intersection of innovative healthcare models wit a special focus on Level Funding Health Plans and Direct Primary Care (DPC) with Dr. Justin Altschuler.
Learn all about the benefits of Level Funding Health plans compared to traditional health insurance, highlighting cost control and flexibly in structure. Hear firsthand accounts of employee experiences, including increased access to care, satisfaction with services, as well as gain insights into future trends, market growth, and potential challenges as these healthcare models become more prevalent and more.
Learn all about the benefits of Level Funding Health plans compared to traditional health insurance, highlighting cost control and flexibly in structure. Hear firsthand accounts of employee experiences, including increased access to care, satisfaction with services, as well as gain insights into future trends, market growth, and potential challenges as these healthcare models become more prevalent and more.
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Transcript
Episode Transcript
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(00:04):
Welcome to another podcast with Benefits inBrief. I am your host, Jeff
Turner, Managing partner for Northern California. Alyric Group a LIT group, is
a national insurance company. We arethe eleventh largest employee benefits firm in the
nation. We help employers in allareas of business needs is including insurance,
(00:31):
and our tagline is we provide nationalscope while providing local service. So if
you'd like to learn more about ElyricGroup and what we're doing for businesses in
our community, reach out to meor to Caitlin, who's on this call
right now. Nine to one sixsix' three one seven eight eight seven.
(00:52):
With that, I'm super excited todaythis this is a two part series.
We are going to be talking aboutsome of what I refer to as
next generation healthcare solutions, and thisparticular topic today is super excited about it.
We've we've got an expert that we'vebeen able to get some of his
(01:15):
time, doctor Justin Altshuler, andI give you a little background on him
in a minute. But we're gonnawe're going to talk about direct primary care
and that might be a new topicor new you know item that you never
heard of before and actually just givingyou a little background on a direct primary
(01:40):
care has been around since the beginningof the twenty first century, although lately
it's gaining a lot of traction.Small, but it's growing fast and it's
here to stay, and I reallyam excited about what it's doing and how
it is changing the lives of individuals, not just uh, you know,
(02:04):
employees, but individuals that maybe haveunderstood it and have been able to tap
into it. We're gonna talk moredetail and depth on that as we drive
into this. So with that,I'm going to introduce our guests. I
want to say welcome to doctor Altschuler. Call him doctor A a lot of
times, as I probably Butcher hislast name. So good morning, justin
(02:30):
now are you good morning? I'mI'm glad to be here, Thanks for
having me on. Yeah, yeah, So doctor doctor Altshuler, he's actually
the first Sacramento direct primary care practicecalled Sequoia MD. In fact, I'm
going to put in the chat areahis website, so those who are interested
(02:55):
in learning more about Sequoia MD andwhat what doctor A's doing there, you'll
be able to click on that link. So doctor Ah your board certified Family
Practice practitioner. It looks like youkind of specialize in in a couple of
areas, and I noticed on onyour website addiction seems to be a big
(03:19):
part of your practice, right,Yeah, I'm actually double boarded in family
practice and in addictions, and theaddictions is related to check primary care,
but a little bit separate at thesame time. Yeah. Yeah, I
noticed that you have served in thecommunity and most recently Cares Community Health,
(03:40):
serving as an associate medical director,providing primary care to patients who have complicated
medical, psychiatric and stuffs and abuseproblems. Is that is that? Is
that? So? Is that alocal entity here in the Greater Document Area.
Yeah, you know, before Ibefore I started this practice, I
(04:00):
was working at what's called the federallyQualified Health Center or an f q HC,
which is a clinic that has adesignation to to essentially serve underserved population.
So it's a it's a center thatis basically built, design and run.
(04:24):
The idea is for for people whowould either way struggle to access care
or who have you know, havedifficulties access and care or barriers or you
know, there's there's various sort offocuses. But that's the that's the jumps.
Yeah, and that's kind of beenkind of the impetus, right,
(04:45):
kind of through leading down the paththat you've taken to direct primary care,
which I want to talk a littlemore about here in a minute. But
I also understand I just well,I wanted to ask you when did you
When did you know that, Hey, this is the profession I wanted to
pursue. You wanted to be adoctor. I mean, was it like
when you're five years old, likemost of us want to be a fireman.
(05:09):
Yeah, I mean I think I'mstill figuring it out for sure.
I think, you know, forme, medicine was a way of combining
a lot of diverse interests and itwas a way fundamentally of helping people and
being of service. And so Ithink for me that what that means actually
(05:34):
continues to evolve, and I kindof hope that it always continues to evolve,
right because when we're when we're learningand we're growing and we're changing,
like that's to me a big partof the point of life. And so
you know, I think for me, like medicine is this evolving rather than
(05:55):
static. Yeah, to try andyou know, be helpful to people,
right, Yeah, yeah, Ilove that. I noticed that. You
know, there's some other areas thatyou focus on in your practice. Do
you want to talk to those.I know that diabetes is a big,
big part of your practice as well. Maybe you can talk to that a
(06:15):
little bit, but you know,I don't want to kind of pigeonhole you
in certain Yeah. Yeah, soappreciate I mean, I yes, I
you know, we we spend afair amount of time taking care of people
with type one diabetes. Specifically thatis generally not the type of diabetes that's
in the news. It's that typeone diabetes is an autoimmune disease, and
(06:38):
we take care of patients with typeone in a model very similar to direct
primary care, which I'm sure we'llget to in a minute. And then
we also do some transgender medicine.I think that one of the big themes
that runs through the work that wedo is that we try and take really
(06:58):
good care of people who needs arenot otherwise being met. And it turns
out that's a lot of people acrossa lot of diseases and disciplines and sort
of different formulations, And you know, that is very much true for for
people that suffer with a substance abusedisorder as well. And you know,
(07:18):
the the question for us is howdo we you know, how do we
how do we take care of peoplewho are not getting their needs met in
other ways? And that means differentthings in different populations. You know.
I take one, diabetes and addictionand transgender care sort of an addition to
primary care are things that we justhappen to be skilled in that I would
(07:41):
be the first to acknowledge that,you know, if I were trained and
felt comfortable taking care of other things, I'm sure that there would be in
need there as well. Yeah,yeah, I certainly kind of visualize what
you're talking about just in our communityand driving around and seeing the homeless population
and you know, being transparent.My mom was bipolar and we had some
(08:07):
issues and quite frankly would have beenhomeless and on the streets if you know,
family like myself hadn't intervened and gother the care that she needed.
So I certainly empathized with a lotof those folks out there that maybe don't
have support system and help right andguidance. New Yeah, absolutely, I
mean I think that the other youknow, I think one of the misnomers
(08:28):
honestly around substance abuse is that theyou know, people that have a substance
use disorder are on the streets.And that is certainly true that many people
who who are homeless have a substanceuse disorder and struggle with substance abuse.
But I also think that that canreally be a challenge because people will say,
(08:50):
well, we'll look at themselves orlook at their family members and say,
well, look, you know,they're still holding down a job,
or they still have a house overtheir head, or their their husband hasn't
left them yet, they must nothave that bad of a problem. And
it is true that whatever the problemis, it can always get worse.
(09:11):
But I think that part of youknow, part of what we you know,
part of a public service message todayis just to be really clear that
you know, it does not havingthe substance's disorder is not synonymous with being
unhoused. And and I think wehave to be really clear about that because
(09:33):
you take care of a lot ofpeople with substance use disorders, the vast
majority of them have jobs and havefamilies and are housed, and and you
wouldn't know from looking at them thatthey that they have this diagnosis that they
really struggle with. Yeah, Imean this could be a whole topic by
(09:54):
itself. Sure, I mean weneed to do another podcast right just on
this one topic. Now. Iappreciate perspective and yeah, I can see
that that's very helpful. So soI do want to kind of segue into
you know what the the main themewas of today and talk about direct primary
care. So i'd mentioned, youknow it although it's been around since the
(10:16):
twenty first century, it's it's changed, you know, like to your to
your point, you know, it'sevolving. It's it's a lot different than
when when I grew up, whenI was a little guy. I can
still remember my doctor coming to myhouse when I had a cold or something,
you know, with this tethoscope,and it's totally different than it was
back then. But we've kind ofgotten away from from I think, you
(10:39):
know, you're as a doctor,what your you know, your mission and
your vows and what you you knowyou you committed to in terms of serving
the community. And you know,we can get into a whole nother segment
in terms of the insurance industry.But I want to I'm gonna read one
of the quotes from your your websiteand then we can kind of dive into
(11:00):
this a little bit. But andI see this, and you know,
in the industry that I'm in,obviously, with being a health insurance consultant
broker, employees, you know,we hear stories all the time of employees
that are struggling or frustrated or angrywith the current system and how it's working
or not working. Here's a quotefrom your website. Doctor visits often feel
(11:24):
impersonal, expensive, overwhelming, AndI think that, in a nutshell,
pretty much describes our current healthcare system. Would you not agree? Yeah?
I mean, I think that's what'sreally interesting to me when when we think
about the healthcare system sort of writtenlarge right now, is that it doesn't
(11:46):
work for pretty much anybody, right, It doesn't really work for you know,
most most doctors feel very frustrated withthe system they're working in. You
know, rates of physician burnout areare astronomical forty fifty sixty percent, and
you know, there's a lot ofreasons for that. And I don't mean
to overly simplify things, but abig part of that is I think doctors
(12:13):
are frequently very frustrated because they can'tgive the care that they want to be
delivering. Right, they like mostdoctors, most of my colleagues that I
know, they don't like keeping peoplewaiting. They don't like rushing through appointments.
They don't like, you know,lacking the time to explain to a
patient what's actually going on. Andthat's the position they find themselves in,
(12:35):
and patients don't like it. Right, Nobody likes waiting eight weeks to be
able to see somebody. Nobody likesgetting seven minutes in front of the person
that you've waited eight weeks to seeand not getting your questions answered. You
know, no one likes feeling rushed, and no one likes the cost and
the expense of it, to bequite honest, right, I mean,
(12:58):
I think it would be one thingif we were paying a lot and felt
like we were getting phenomenal service andgetting a phenomenal product for it. But
I think unfortunately, we feel like, very justly, we're paying a lot
and we are not getting much forthat, right we're getting we're getting something
that doesn't really need our needs,and that's you know, that's a really
(13:18):
lousy place to be. And thenI think if you sort of expand that
out, you know, employers aresuper frustrated because I think most employers they
want to take good care of theirpeople. I mean, perhaps I'm very
naive about human nature, but Ido think that people generally want to do
the right thing. And you know, they kind of look at and this
(13:39):
is you know, this is moreyour domain. You can talk about it,
but they look at the price ofthings and they say, look,
I can't. I can't run abusiness and sort of provide super top light
healthcare for people. And when Ido, you know, spend all this
money, what am I getting forit? Anyway? And so I I
do think it's this very very interestingsystem, that situation rather that we all
(14:03):
feel kind of trapped in. Right, We're like, look, I don't
like this. I want something different, And everybody, every sort of major
player in the system, is actuallysaying something very similar. And what's fascinating
to me, is also wanting somethingvery similar. Right. So I think
that most of the people, youknow, whether you're on the provider side,
(14:26):
you're on the patient side, oryou're on the buyer side, everybody
basically wants something very similar. Peoplewant lower costs, of course, but
people also want better service, theywant better care, they want connection,
they want their problems to actually getaddressed and answered, and so I think
that the question really becomes less aboutwhat is it that ideally we want and
(14:50):
much more about how do we dothat? And you know, I think
that's kind of what we're what we'regoing to get into and what we're going
to talk about. Yeah, soto and everything you're saying, I hear
regularly. In fact, I wasin a client's office yesterday and she was
venting the whole time. So Ijust just kind of listened to her and
(15:11):
just said, yeah, I hearyou, I understand, and you know,
I'm I'm glad that you feel comfortableenough to at least let me know
how you feel about what's going onand and I'll do my best to take
care of you and resolve that.But yeah, I hear. I hear
this on a regular basis from myside as well. So let's talk.
(15:31):
Let's let's talk about what actually isdirect primary care. And you know you
kind of alluded to a little bit, you know, you've gone down this
path, or let's let's let's let'stalk about that. What is what is
direct primary care and and maybe youcan help me too. And I don't
want to, you know, I'mnot trying to bad mouth anybody, but
(15:52):
every once in a while, youknow, I'll talk about direct primary care
with somebody and they say, oh, yeah, might heard about the concierge.
So can you get kind of explainwhat is there a difference between those
two? Yeah, I think Iwould. I think that the thing that
makes the most sense is really tosort of talk about what it is and
(16:12):
how and why it came to be. And I think fundamentally it is a
response to frustration, right. Itis a response on the part of doctors
to say, I just I wantedto deliver care better. And I think
that you know, you talked inearlier in the episode about how much it's
(16:33):
been growing, and I think thatthat's honestly really what it's about, Right,
It's about people saying, I wantI want to do this differently,
I want to do this better,and so where it's I want to start
a little bit with where it startedand that we can sort of evolve that
into you know, how employers canfit in. But at its core,
it is a direct relationship. That'sthe direct part of direct primary care.
(16:56):
It is a direct relationship between adoctor and a patient, and there are
actually a lot of different ways thatthis gets organized and structured, but usually
what this means is that there isa monthly fee that the patient pays to
the doctor, and in exchange forthat monthly fee, people get taken care
(17:18):
of. And it's honestly not morecomplicated than that. Like you can think
about a gym membership or a selfphone bill or whatever it really is.
You know, you pay a membershipfee and in exchange for that, the
doctor the clinic delivers care and whatyou know, it seems so simple,
(17:41):
but you have to understand, Ithink, what what that is in response
to, or what that's an alternativeto? Right, so when you know
when the alternative is probably that youremployer contracts with an insurance company and sends
the insurance company money every month asa premium, or if they're self insured,
(18:04):
you know, it's a little bitdifferent. The insurance company in turn
turns around and contracts with a medicalgroup, which is a collection of doctors
that had basically banded together. Themedical group is made up of physicians and
(18:26):
so the dollar goes from the employer, to the insurance company, to the
medical group, to the physician,and essentially each layer, so the employer
going to the insurance company, theinsurance company going to the medical group,
and the medical group into the physician. At each layer, someone has an
(18:48):
agenda and someone has an idea aboutwhat should be happening and what care should
look like and what's important and what'snot important, and those agendas filter into
the actual patient encounter. It isalso true that if you have that many
layers, there's a lot of costassociated with it. There's a lot of
(19:10):
cost associated with that, and thatcost is it comes from all different places,
right. Some of that is administrativecost that comes from it from just
having that many different layers in place. Some of that is profit at various
levels of the system, you know. Some of that is well meaning you
know, improvement initiatives and things likethat, and and even within the physician
(19:37):
office there's there's quite a lot ofcost that is dedicated to interfacing with whoever
is next up on that chain tomake sure that the money or the reinforcement
comes in. And so the conceitwith direct primary care in that context seems
(20:00):
like like, you know, kindof aggression, breath of fresh air.
It's very it's it's very simple,right, It's like, no, no,
no, no, I'm a doctor. You need my help for whatever
reason. You pay me, andI take care of you and and and
that's it, right, There's there'snone of this other stuff that's kind of
that's kind of there our practice.And I would say the majority of direct
(20:25):
primary practices operate pretty subscriptions, prettystrictly on a subscription model. So not
only are office visits bundled into thatmonthly cost, but so are you know,
phone conversations, text messages, emails. You know, most most offices
(20:45):
will do some sort of video visitsor phone visits. Because again, when
you have that direct relationship, theincentives really get reoriented. And it's no
longer from the physician's perspective, whatdo I need to do in order to
generate a bill to send to theinsurance company to get reimbursed. The question
(21:06):
instead is what do I need todo to take care of the person in
front of me? And it turnsout that that's actually a very different set
of things by and large than itis to get paid by an insurance company.
And so the incentives get changed.They're just very different than they are
(21:29):
when you need to figure out howto build the insurance company in order to
generate the revenue to keep the practicegoing. Yeah, you mentioned, you
know telephonic, you know same dayappointments. And there's a whole list of
different items that I saw on yourwebsite. I'll just name off a couple
(21:52):
of them here. On site advancedimaging, on site, comprehensive lab care
navigation, extra dieted appointment, housecalls. You know, that's that's a
biggie right there. I mean,how many physicians can do that? Yeah,
I think, and it's I mean, I think it's important to recognize
(22:15):
that, you know, what thismeans is different, right. It does
not mean that every It does notmean that every visit is a house call,
right right right right? That Likeyou know, when people are local
and they can't leave the house forsome reason, you know I can stop
by. It means, you know, like there's a there's a woman I
(22:36):
take care of who's a neighbor.It's basically on the route from from my
office to my house that I walk, and I had medications and so I
just stopped by her house and droppedthem off for her right, And so
I think that it really goes backto a very sort of what I was
saying before, where if the if, the practice and the orientation is really
(23:00):
what do I need to do totake care of people rather than what do
I need to do to get reimbursed? Things change, And I think one
of the big things that changes isthat there's just a lot less overhead,
which means prices can come down.And with a lot less overhead and lower
prices, you can then structure yourdating differently. And you know, at
(23:26):
the top, we sort of talkedabout how a big part of the current
system is positions feeling frustrated because theycan't do what they want to do.
That's not in my mind at least, you know, the fact that I
spend an hour generally with a newpatient in the office and half an hour
(23:48):
with follow ups. I actually thinkmost of my primary care colleagues would like
to do that as well, butthey can't really do that and make the
numbers work when you have all thisother overhead. And so if you take
out all that of other overhead,you can actually drop prices and keep a
(24:12):
very reasonable practice revenue stream coming inand the difference between those, you know,
basically feats right back into taking bettercare of patients. Yeah, which,
actually I mean when you think aboutit that way, I mean the
end result is healthier people as awhole, which would help drive down healthcare
(24:34):
costs overall. Yeah, I meanI think that again, you know,
we could probably spend a whole episodetalking about this, but I think that
there are a lot of there's alot of really interesting knock on effects.
Right, So I'll give you afew examples that I think are illustrative of
(24:55):
how you can lower costs and atthe same time actually improve quality. Right.
So, you know a lot oftimes if I'm a primary care doctor
and I'm seeing someone in a standardmodel and I have, you know,
maybe ten minutes to see them,and they're coming to me with a problem
(25:18):
and I only have say seven minutesto have a conversation with them about what
the problem is before I have tomake a decision. I'm probably going to
order a lot more labs because Idon't have the time to figure out do
I actually need these labs. Ihave to make a decision get I have
to get them out so I canget the next person in, and so
(25:42):
the number of labs that I orderedto try and evaluate something is higher than
it might need to be had Ihad say, fifteen or twenty minutes to
talk to them. In a verysimilar way, I mean, you'd say
the same thing about imaging and thelikelihood that I need to necessarily get imaging
for someone versus being able to spendmore time getting a really good history from
(26:07):
them and doing a comprehensive exam.If you sort of continue following that down,
there are problems that I and mostprimary care doctors are fully trained to
handle, but maybe we don't doit every day, and so if we
have an extra ten minutes to refreshour memories about which labs to order for
(26:30):
something or what we need to doublecheck on, we can do that,
which means we can save referrals toa specialist at each of those steps.
Quite frankly, most patients, Imean sometimes people say, look, I
really want to see the specialist,and I say, great, that's fine,
let's send you there, right,But most times people are much more
(26:52):
interested in actually getting their problem addressedthan they are about how that gets done.
And most of the time people wouldactually that the person that they're seeing
is able to address their problem ratherthan going to talk to five different specialists.
So in this context, what happensis I can spend much more time
with people. I can make muchmore thoughtful decisions about when I need to
(27:15):
involve specialists, what labs I needto order, what imaging I need to
order, what additional testing I needto order? And you know, I
would say ninety something percent of thetime what I need to order is less
because I have a much better graspof what I'm actually trying to figure out.
This really continues, right, SoI might say to someone, look,
(27:38):
you know, if I don't havea good relationship with them and I
don't really know them, I mightsay, look, this is really serious.
I need to go to the emergencydepartment again, because I don't have
that time. But when I havea lot of confidence that not only have
I explained it to someone where theyreally need to be concerned and where they
don't need to be and what theyneed to be looking out for, and
(28:00):
I know that if they call theoffice tomorrow and things aren't going well,
I can see them back right andif things deteriorate tonight, they can get
a hold of me because they havemy cell phone. It really changes a
lot of times how much I needto send people to the hospital or to
the emergency department or whatever. Andyou know, I I say this not
(28:26):
to be sort of derogatory towards mycolleagues that are in a more traditional model,
but actually with a great deal ofsympathy, right, Like, they
all know how to do this.This is most of the time what they
would prefer to do. And they'restuck, right, and impatients are stuck.
And again this goes back to peoplejust feeling really stuck. Yeah,
(28:48):
I mean you brought up a goodexample and I've seen this over and over
and over again on my side wherewe have employees that are using the er
for doctor visits, yep, andit's just such an expensive way to do
it. And like to your point, you know, these these positions you
are, I have a brother that'san er doctor. How much time do
(29:08):
they really have to address that situation? Well? And what's the er built
to do? Right? I mean, the emergency department is built for emergencies,
right, and they very well withthat. And when they know when
they need ninety minutes to stabilize someonebecause they're truly having an emergency, they
take that time and they're great atit. I think that the challenge is
(29:30):
is when you have people showing upto the emergency department with problems that really
are not well suited to be handledin an emergency department, that's where that's
where things really become sticky, right. I mean it's like I don't do
certain you know, I wouldn't takeout someone's gall ladder or appendix in my
office because this is not an operatingroom, right, like, like that's
(29:51):
not what we do. We're notset for it, we're not built for
it, we're not trained for it. And and so I think it's really
about trying to match, you know, needs to appropriate venue. And it
turns out the appropriate venue for alot of problems is primary care. And
when you have a primary care systemthat is overstressed, overburdened and can't simply
(30:15):
can't deal with the volume of problemsthat are being thrown at it, those
problems don't go away. They gosomewhere else, and generally they go into
venues and settings that are a notas well equipped to take care of them
and be much more costly. Yeah, and then you get first and again
it comes back to it, youget frustration. Yeah, yeah, yeah,
(30:36):
you articulated it really well. Mytakeaway is, you know, a
couple of things. A personal relationshipyep, I know. You know.
Again just hearing it from my sideto employees complaining, Hey, I don't
feel like I have a personal relationshipwith my physician. I really didn't get
to choose them, right, Andif I did use them, most of
(30:59):
the time it's because a family memberor a friend said, hey, go
to this doctor. Yep. Yeah. Well, and I think, you
know, we really practice in amodel that the relationship itself is often healing,
like before we even get to medicationsor tests or anything. Simply having
a trusting relationship with someone that's lookingout for you, I think is actually
(31:22):
tremendously valuable. And you know,not everyone feels that way, and that's
okay, and it's good that peoplecan you know, the people that do
feel that way can pick us andfind us. And the people that want,
you know, that are much moreinterested in what I call a widget
model, can go to a widgetmodel and like that's okay, that's okay,
But we really view actually the relationshipis kind of the foundation for everything,
(31:48):
right, Like we we say,first we develop a relationship with people,
and then in the context of thatrelationship, we try and solve whatever
medical problems they have. And youknow, in a certain way that sounds
kind of fluffy and kind of aMorphOS right, but I can tell you
that in practicality, when when weyou know, when I know you and
(32:13):
when you know me, like,things really change, they really change.
And I think that they change ina pretty profoundly positive way. And I
do feel pretty strongly that that lackof relationship between doctor innovation is one of
(32:39):
sort of the core injuries of ourcurrent system and a core problem about what
is leave people feeling so frustrated.And so I think, rather than,
you know, rather than run fromthat, we really run towards it,
and we say, well, thenlet's let's actually prioritize the relationship, yeah,
(33:00):
and try and build on that.Yeah. I've stained some statistics.
I can't remember where, but Isee so much stuff come across my desk.
But they're saying the statistics say thatprimary care is the front line.
It's it's everything really quite frankly,Yeah, I mean I I think ideally
(33:20):
that's true, right, But II think it's you know, what's what
I think is sad is that forprimary care to effectively be the front line,
it's not. Again, I thinkit's it's not a widget, right,
It's not a primary cure widget anda person widget. It's it's a
(33:42):
relationship, right. And so tothe front line means that you're, you
know, as age from a patientperspective, you're calling someone that you know,
right, You're reaching out to someonethat you know. You are not
reaching out to a system, You'rereaching out to a person. And and
I do think that that that thatindividual, personalized aspect is a huge part
(34:10):
of what is really missing from thediscussion. And and so again that's I
mean, that's that's just a bigpart of kind of what we do and
why we do it. It's itis it is building that that relationship,
which again in our mind is justpretty foundational too to all the other stuff
(34:35):
that then comes. Yeah, yeah, so you know, to that to
that topic, you know, youyou know, you know, Jeff Turner,
you know, you know I'm uniqueand different from you know, my
given my own siblings, right,yeah, yeah, and you know,
and I and and part of thattoo is you know, I know,
(34:57):
the patients, because I know thefolks that I take care of, the
patients where when they call, reallywhat they're kind of saying is I'm just
feeling nervous. And I know thefolks where when they call, like they
never call, and so if they'resaying something's wrong, I just I interpret
that really quite differently, right,And because I know that the people,
(35:22):
I have a pretty good idea of, you know, what might be going
on with them, and I think, you know, I think, Jeff.
The other thing that I really wantto mention here is that this often
gets talked about as like, youknow, you know my medical history.
Right. In reality, that's that'sa part of it. It's not I
(35:45):
don't even know if it's half ofit, right, because it's pretty easy,
honestly for me to communicate to anotherdoctor someone's diagnoses, right. Computers
can do that, right, Yeah. But you know, I tend to
know the name of my patient's wivesand the names of their husbands, and
the names of their kids, evenif they're not my patients, and how
(36:06):
their relationships are going. And youknow, you know, Jeck loves his
job and is really excited about whathe's doing. But Mike Kates's job and
he's been getting headaches ever since he'sbeen working at this place, right,
And then the conversation becomes much moreabout, you know, to Michael and
his headaches. It's like, look, Mike, I've recognized that, you
(36:28):
know, since you started at thisjob, you have been having all these
sort of health conditions that you've beencoming to me with, Like how do
we actually talk about making your jobwork better for you? Right? And
I think that that But that's whatI mean about a relationship, right,
(36:49):
It's it's like an actual relationship.It's not It's not like, oh,
you you are a person that Ionly know in the context of your six
medical diagnoses in which medication you're on. Like that that again, to me,
it misses the point, right.And I think you know when people
when you sort of started the episode, you talked about like I remember as
a kid, and you know,the doctor would come to our house and
(37:13):
and those kinds of things, andwhat is that? I mean? What
is that really? I mean?Is or what makes that special? Is
it is it special because someone's comingor is it special because it's a person
that you know that cares enough aboutyou to show up for you when you're
not doing well, right, Andand I think again, we we think
(37:36):
much more sort of like behaviorally orperformatively of like oh well, the waight
time is X or the wait timeis why, as opposed to relationally right,
and like, yeah, yeah,if someone's waiting for us for like
seven minutes, I'm pissed like thatthat it's very rare that that people wait,
right, Like when people call,my expectation that they're going to be
(37:57):
seen today or they're going to beseen tomorrow, right, and if I
can't even one of my colleagues,Well, so it's it is that stuff
as well. Right. I don'tmean to say that that stuff doesn't matter,
because it does, sure, butthat's it's sort of part and parcel
this larger this larger thing. Yeahyeah, and you talk about the widgets.
(38:19):
I'm just visualizing it right now,like you know, you go in,
okay, you know, there's getweighed, You go in, you
wait, and then they come inand then okay, all right, we're
going to prescribe this medication. That'skind of kind of the experience that I've
had personally, right, Like yeah, and I'm like, okay, well,
I get I mean it's it's just, yeah, very frustrating. I
(38:44):
love what you're saying. Definitely resonateswith me. That's why we got you
on and you and I you know, been talking now for a good year.
We're trying to make inroads here quitefrankly in the Sacramento area, which
is predominantly HMO the widget system.You know, we know, we realize
(39:07):
what we're up against, but weboth wholeheartedly believe this is a better way
to do it. So that's whatI wanted to get you on here,
and I really appreciate it. Ido want to mention there's a couple of
other thing you guys saw. Itlooks like in terms of prescriptions. Yeah,
you have a little bit of cloudthere as well. Can you talk
(39:30):
to that? Yeah, I meanso, yeah. So we we stock
a fair number of prescriptions in theoffice that we can then dispense to people
for a pretty nominal cost. Youknow, I'll be totally transparent. We
we take margin on them, butusually the cost of patients, I mean
(39:53):
very frequently, the cost of patientsis literally less than their insurance copey and
it's certainly, you know, lessthan generally what they would pay if they
did not have insurance or they havevery high deductible or whatever. It is
again almost always cheaper than what theyou know, people will use coupons a
(40:15):
lot, like, it's generally cheaperthan that as well. Again to be
totally transparent, like it doesn't workfor everything. There are times where the
our cost is higher, in whichcase I encourage people to go to the
pharmacy to get things filled. Becauseagain, part of part of having a
relationship with someone who wanted them todo well, and part of them wanting
(40:37):
to do someone do well is isbeing a good you know, trying to
be a good steward of their resourcesas well, and and so but it's
pretty nice, right So if weyou know, we see if we see
someone in the office and they haven'tbeen feeling well, and we you know,
we diagnose pneumonia and they're here,you know, we can hand them
(40:58):
probably not one hundred percent, butusually their antibiotic prescription for you know,
three or four bucks, and thenthey can go straight home and they don't
have to deal with going to apharmacy and waiting in line and doing all
that stuff. Yeah, and andthat you know, that's that's similar.
Someone comes in for a urinary tractconfection. Someone comes in and they have
high blood pressure. You know,we can probably get there. You know,
(41:21):
their their first three months of bloodpressure medications for I don't know,
three or four bucks, maybe less. And then we see them back and
we check in on how they're goingand we can adjust. And again,
you know, some people prefer togo to the pharmacy, and that's fine.
There's a there's a you know,there's a large number of medications that
we can't or don't stop for variousreasons, and those people, you know,
(41:44):
those we send to the pharmacy.So it's it's not a panacea,
and I don't want to pretend likeit is, but for a lot of
people, for a lot of fora lot of people, and a lot
of what people need, it's ait's a big it's a big convenience.
It's a value add right, Itjust me and you know, wouldn't it
(42:05):
be nice if it helped her orientedaround trying to make your life easier as
opposed to what is the maximumly difficultway we could we can make something happen.
Yeah, yeah, you mentioned thatin order to engage with you.
It's a membership. Yeah, orMatt, can you speak to that a
little bit and talk about that whatthat looks like. Yeah, so it
(42:28):
depends, you know, for primarycare, it depends a bit on how
old you are, but and youknow, different primary care practices are different,
but you know, usually it's youknow, probably somewhere between. Well,
kids for us, I think areabout forty bucks a month. Older
folks are one twenty five if Iremember, our pricing great and our standard
(42:51):
monthly is is one hundred dollars amonth. And I think it's actually worth
sort of talking about, just exceptuallyfor a couple of minutes, about why
we only see people in the contextof a membership. And again, it
really goes back to this idea ofa building relationships with people, right,
(43:15):
And so fundamentally we are interested inhaving a practice filled with people that we
want to have a relationship and thatwant to have a relationship with us,
right, And our belief is thatover the long haul things will sort of
sort themselves out, right, Andso you know, there are for any
(43:37):
individual person, guaranteed they're going tothere's going to be months where they receive
much more in dollars than they pay, and there are going to be months
hopefully when people don't need us atall, like you don't need your doctor
every month, right, And again, our sort of focus is if what
(43:59):
we think about is that we're buildinga relationship, then the question is basically,
how do we just build a businessmodel that supports a relationship over time?
And this is how we've come todo that, right, Is it
the best way? I don't.I don't even know that it's the best
way, honestly, but it's away that seems to work, and that
(44:21):
for the folks that see us,they tend to be very happy, and
it allows us to practice in away that keeps us generally pretty happy and
wanting to continue to practice. Andyou know that that doesn't seem half bad.
And so I think, you know, I think like part of the
reason we're having this discussion is ishow you know, is trying to bring
(44:45):
employers into that, right and tryingto to craft solutions that allow that allow
employers to both marry, you know, a comprehensive health plan with these types
of services. And you know,it turns out that's complicated, right,
(45:06):
and that's that's your job, Like, thank goodness, because I can't do
it. But that's something where therethere are options available when you know when
we want to try and when wewant to try and bring that Yeah,
and you and I have been havingthat discussion now for a good year and
we're we're still working through that,trying to figure it out. And in
fact, uh, part two ofthis will be a particular vendor that you
(45:32):
introduced me to that I feel hasa like mind and and I think that
I feel pretty good about where thiswhat they're bringing to the table, and
in this regard around direct primary care, which is pretty exciting. Actually,
California is it is the difficult market. I will say this that I know
(45:53):
several of my peers that are outsideof California they've had more traction in this
area. But you know, Ithink, you know, persistence in something
you believe in eventually, you know, good things will start to happen.
So, doctor Altuler, the bestway to get a hold of you,
(46:14):
it depends who you are a littlebit, right, but I think probably
the best way is to just callthe office, right and I can tell
you that ninety nine percent of thetime that will get you in touch with
a live human within that twenty seconds. I can't. You know, there
are times when we are super busy, but again, our standard is that
(46:36):
you know there will actually be ahuman that answers the phone. I can't
promise that that human is going toknow exactly how to address what you need,
but you know, we we liketalking to people. So you can
certainly call and the phone numbers onthe website and maybe just share what that
phone number is. Yeah, it'sa nine one six six six eight seven
(46:59):
ones explore. So I think thatthat's that's probably the easiest way. There's
a ton of information on the websiteabout kind of what we do and how
we do it and all of that. There's a contact form for us on
the website, so that will generatean email to us and we'll we can
get back to people pretty quickly,you know, and if someone if someone
(47:20):
out there is like, Okay,this sounds great, I'm sold, I
want to sign up. You canactually sign up work here on the website,
and we say that, yeah,we get back to probably within a
couple hours about trying to schedule youthat first appointment, and you know,
it's again it honestly it is.We try to try and make things easy,
(47:45):
like to try and not make thingscomplicated, right right, Yeah,
keep it simple. Yeah, Iappreciate that. So again, the number
is nine one six six six eightseven one sixty four. And I will
say this that you can also reachout to me Psyche. You and I
can you know, communicate regularly,and I can connect you with with doctor
(48:05):
A as well. So yeah,him, I communicate regularly. So well.
I appreciate your time. I knowyou probably have a busy day,
and you know, this has beena great conversation. I'd love to continue
this. Maybe we'll do another one, dive a little deeper into some other
topics. But yeah, it's beengreat having you on, Jeff, thanks
for thanks for having me on.This is fun and I'm I'm always I'm
(48:27):
always happy to talk about this stuff, so I really appreciate it. Yeah,
all right, good scene. Youtake care, I have a good
day. You two touch it.M
Welcome to another podcast with Benefits inBrief. I am your host, Jeff
Turner, Managing partner for Northern California. Alyric Group a LIT group, is
a national insurance company. We arethe eleventh largest employee benefits firm in the
nation. We help employers in allareas of business needs is including insurance,
(00:31):
and our tagline is we provide nationalscope while providing local service. So if
you'd like to learn more about ElyricGroup and what we're doing for businesses in
our community, reach out to meor to Caitlin, who's on this call
right now. Nine to one sixsix' three one seven eight eight seven.
(00:52):
With that, I'm super excited todaythis this is a two part series.
We are going to be talking aboutsome of what I refer to as
next generation healthcare solutions, and thisparticular topic today is super excited about it.
We've we've got an expert that we'vebeen able to get some of his
(01:15):
time, doctor Justin Altshuler, andI give you a little background on him
in a minute. But we're gonnawe're going to talk about direct primary care
and that might be a new topicor new you know item that you never
heard of before and actually just givingyou a little background on a direct primary
(01:40):
care has been around since the beginningof the twenty first century, although lately
it's gaining a lot of traction.Small, but it's growing fast and it's
here to stay, and I reallyam excited about what it's doing and how
it is changing the lives of individuals, not just uh, you know,
(02:04):
employees, but individuals that maybe haveunderstood it and have been able to tap
into it. We're gonna talk moredetail and depth on that as we drive
into this. So with that,I'm going to introduce our guests. I
want to say welcome to doctor Altschuler. Call him doctor A a lot of
times, as I probably Butcher hislast name. So good morning, justin
(02:30):
now are you good morning? I'mI'm glad to be here, Thanks for
having me on. Yeah, yeah, So doctor doctor Altshuler, he's actually
the first Sacramento direct primary care practicecalled Sequoia MD. In fact, I'm
going to put in the chat areahis website, so those who are interested
(02:55):
in learning more about Sequoia MD andwhat what doctor A's doing there, you'll
be able to click on that link. So doctor Ah your board certified Family
Practice practitioner. It looks like youkind of specialize in in a couple of
areas, and I noticed on onyour website addiction seems to be a big
(03:19):
part of your practice, right,Yeah, I'm actually double boarded in family
practice and in addictions, and theaddictions is related to check primary care,
but a little bit separate at thesame time. Yeah. Yeah, I
noticed that you have served in thecommunity and most recently Cares Community Health,
(03:40):
serving as an associate medical director,providing primary care to patients who have complicated
medical, psychiatric and stuffs and abuseproblems. Is that is that? Is
that? So? Is that alocal entity here in the Greater Document Area.
Yeah, you know, before Ibefore I started this practice, I
(04:00):
was working at what's called the federallyQualified Health Center or an f q HC,
which is a clinic that has adesignation to to essentially serve underserved population.
So it's a it's a center thatis basically built, design and run.
(04:24):
The idea is for for people whowould either way struggle to access care
or who have you know, havedifficulties access and care or barriers or you
know, there's there's various sort offocuses. But that's the that's the jumps.
Yeah, and that's kind of beenkind of the impetus, right,
(04:45):
kind of through leading down the paththat you've taken to direct primary care,
which I want to talk a littlemore about here in a minute. But
I also understand I just well,I wanted to ask you when did you
When did you know that, Hey, this is the profession I wanted to
pursue. You wanted to be adoctor. I mean, was it like
when you're five years old, likemost of us want to be a fireman.
(05:09):
Yeah, I mean I think I'mstill figuring it out for sure.
I think, you know, forme, medicine was a way of combining
a lot of diverse interests and itwas a way fundamentally of helping people and
being of service. And so Ithink for me that what that means actually
(05:34):
continues to evolve, and I kindof hope that it always continues to evolve,
right because when we're when we're learningand we're growing and we're changing,
like that's to me a big partof the point of life. And so
you know, I think for me, like medicine is this evolving rather than
(05:55):
static. Yeah, to try andyou know, be helpful to people,
right, Yeah, yeah, Ilove that. I noticed that. You
know, there's some other areas thatyou focus on in your practice. Do
you want to talk to those.I know that diabetes is a big,
big part of your practice as well. Maybe you can talk to that a
(06:15):
little bit, but you know,I don't want to kind of pigeonhole you
in certain Yeah. Yeah, soappreciate I mean, I yes, I
you know, we we spend afair amount of time taking care of people
with type one diabetes. Specifically thatis generally not the type of diabetes that's
in the news. It's that typeone diabetes is an autoimmune disease, and
(06:38):
we take care of patients with typeone in a model very similar to direct
primary care, which I'm sure we'llget to in a minute. And then
we also do some transgender medicine.I think that one of the big themes
that runs through the work that wedo is that we try and take really
(06:58):
good care of people who needs arenot otherwise being met. And it turns
out that's a lot of people acrossa lot of diseases and disciplines and sort
of different formulations, And you know, that is very much true for for
people that suffer with a substance abusedisorder as well. And you know,
(07:18):
the the question for us is howdo we you know, how do we
how do we take care of peoplewho are not getting their needs met in
other ways? And that means differentthings in different populations. You know.
I take one, diabetes and addictionand transgender care sort of an addition to
primary care are things that we justhappen to be skilled in that I would
(07:41):
be the first to acknowledge that,you know, if I were trained and
felt comfortable taking care of other things, I'm sure that there would be in
need there as well. Yeah,yeah, I certainly kind of visualize what
you're talking about just in our communityand driving around and seeing the homeless population
and you know, being transparent.My mom was bipolar and we had some
(08:07):
issues and quite frankly would have beenhomeless and on the streets if you know,
family like myself hadn't intervened and gother the care that she needed.
So I certainly empathized with a lotof those folks out there that maybe don't
have support system and help right andguidance. New Yeah, absolutely, I
mean I think that the other youknow, I think one of the misnomers
(08:28):
honestly around substance abuse is that theyou know, people that have a substance
use disorder are on the streets.And that is certainly true that many people
who who are homeless have a substanceuse disorder and struggle with substance abuse.
But I also think that that canreally be a challenge because people will say,
(08:50):
well, we'll look at themselves orlook at their family members and say,
well, look, you know,they're still holding down a job,
or they still have a house overtheir head, or their their husband hasn't
left them yet, they must nothave that bad of a problem. And
it is true that whatever the problemis, it can always get worse.
(09:11):
But I think that part of youknow, part of what we you know,
part of a public service message todayis just to be really clear that
you know, it does not havingthe substance's disorder is not synonymous with being
unhoused. And and I think wehave to be really clear about that because
(09:33):
you take care of a lot ofpeople with substance use disorders, the vast
majority of them have jobs and havefamilies and are housed, and and you
wouldn't know from looking at them thatthey that they have this diagnosis that they
really struggle with. Yeah, Imean this could be a whole topic by
(09:54):
itself. Sure, I mean weneed to do another podcast right just on
this one topic. Now. Iappreciate perspective and yeah, I can see
that that's very helpful. So soI do want to kind of segue into
you know what the the main themewas of today and talk about direct primary
care. So i'd mentioned, youknow it although it's been around since the
(10:16):
twenty first century, it's it's changed, you know, like to your to
your point, you know, it'sevolving. It's it's a lot different than
when when I grew up, whenI was a little guy. I can
still remember my doctor coming to myhouse when I had a cold or something,
you know, with this tethoscope,and it's totally different than it was
back then. But we've kind ofgotten away from from I think, you
(10:39):
know, you're as a doctor,what your you know, your mission and
your vows and what you you knowyou you committed to in terms of serving
the community. And you know,we can get into a whole nother segment
in terms of the insurance industry.But I want to I'm gonna read one
of the quotes from your your websiteand then we can kind of dive into
(11:00):
this a little bit. But andI see this, and you know,
in the industry that I'm in,obviously, with being a health insurance consultant
broker, employees, you know,we hear stories all the time of employees
that are struggling or frustrated or angrywith the current system and how it's working
or not working. Here's a quotefrom your website. Doctor visits often feel
(11:24):
impersonal, expensive, overwhelming, AndI think that, in a nutshell,
pretty much describes our current healthcare system. Would you not agree? Yeah?
I mean, I think that's what'sreally interesting to me when when we think
about the healthcare system sort of writtenlarge right now, is that it doesn't
(11:46):
work for pretty much anybody, right, It doesn't really work for you know,
most most doctors feel very frustrated withthe system they're working in. You
know, rates of physician burnout areare astronomical forty fifty sixty percent, and
you know, there's a lot ofreasons for that. And I don't mean
to overly simplify things, but abig part of that is I think doctors
(12:13):
are frequently very frustrated because they can'tgive the care that they want to be
delivering. Right, they like mostdoctors, most of my colleagues that I
know, they don't like keeping peoplewaiting. They don't like rushing through appointments.
They don't like, you know,lacking the time to explain to a
patient what's actually going on. Andthat's the position they find themselves in,
(12:35):
and patients don't like it. Right, Nobody likes waiting eight weeks to be
able to see somebody. Nobody likesgetting seven minutes in front of the person
that you've waited eight weeks to seeand not getting your questions answered. You
know, no one likes feeling rushed, and no one likes the cost and
the expense of it, to bequite honest, right, I mean,
(12:58):
I think it would be one thingif we were paying a lot and felt
like we were getting phenomenal service andgetting a phenomenal product for it. But
I think unfortunately, we feel like, very justly, we're paying a lot
and we are not getting much forthat, right we're getting we're getting something
that doesn't really need our needs,and that's you know, that's a really
(13:18):
lousy place to be. And thenI think if you sort of expand that
out, you know, employers aresuper frustrated because I think most employers they
want to take good care of theirpeople. I mean, perhaps I'm very
naive about human nature, but Ido think that people generally want to do
the right thing. And you know, they kind of look at and this
(13:39):
is you know, this is moreyour domain. You can talk about it,
but they look at the price ofthings and they say, look,
I can't. I can't run abusiness and sort of provide super top light
healthcare for people. And when Ido, you know, spend all this
money, what am I getting forit? Anyway? And so I I
do think it's this very very interestingsystem, that situation rather that we all
(14:03):
feel kind of trapped in. Right, We're like, look, I don't
like this. I want something different, And everybody, every sort of major
player in the system, is actuallysaying something very similar. And what's fascinating
to me, is also wanting somethingvery similar. Right. So I think
that most of the people, youknow, whether you're on the provider side,
(14:26):
you're on the patient side, oryou're on the buyer side, everybody
basically wants something very similar. Peoplewant lower costs, of course, but
people also want better service, theywant better care, they want connection,
they want their problems to actually getaddressed and answered, and so I think
that the question really becomes less aboutwhat is it that ideally we want and
(14:50):
much more about how do we dothat? And you know, I think
that's kind of what we're what we'regoing to get into and what we're going
to talk about. Yeah, soto and everything you're saying, I hear
regularly. In fact, I wasin a client's office yesterday and she was
venting the whole time. So Ijust just kind of listened to her and
(15:11):
just said, yeah, I hearyou, I understand, and you know,
I'm I'm glad that you feel comfortableenough to at least let me know
how you feel about what's going onand and I'll do my best to take
care of you and resolve that.But yeah, I hear. I hear
this on a regular basis from myside as well. So let's talk.
(15:31):
Let's let's talk about what actually isdirect primary care. And you know you
kind of alluded to a little bit, you know, you've gone down this
path, or let's let's let's let'stalk about that. What is what is
direct primary care and and maybe youcan help me too. And I don't
want to, you know, I'mnot trying to bad mouth anybody, but
(15:52):
every once in a while, youknow, I'll talk about direct primary care
with somebody and they say, oh, yeah, might heard about the concierge.
So can you get kind of explainwhat is there a difference between those
two? Yeah, I think Iwould. I think that the thing that
makes the most sense is really tosort of talk about what it is and
(16:12):
how and why it came to be. And I think fundamentally it is a
response to frustration, right. Itis a response on the part of doctors
to say, I just I wantedto deliver care better. And I think
that you know, you talked inearlier in the episode about how much it's
(16:33):
been growing, and I think thatthat's honestly really what it's about, Right,
It's about people saying, I wantI want to do this differently,
I want to do this better,and so where it's I want to start
a little bit with where it startedand that we can sort of evolve that
into you know, how employers canfit in. But at its core,
it is a direct relationship. That'sthe direct part of direct primary care.
(16:56):
It is a direct relationship between adoctor and a patient, and there are
actually a lot of different ways thatthis gets organized and structured, but usually
what this means is that there isa monthly fee that the patient pays to
the doctor, and in exchange forthat monthly fee, people get taken care
(17:18):
of. And it's honestly not morecomplicated than that. Like you can think
about a gym membership or a selfphone bill or whatever it really is.
You know, you pay a membershipfee and in exchange for that, the
doctor the clinic delivers care and whatyou know, it seems so simple,
(17:41):
but you have to understand, Ithink, what what that is in response
to, or what that's an alternativeto? Right, so when you know
when the alternative is probably that youremployer contracts with an insurance company and sends
the insurance company money every month asa premium, or if they're self insured,
(18:04):
you know, it's a little bitdifferent. The insurance company in turn
turns around and contracts with a medicalgroup, which is a collection of doctors
that had basically banded together. Themedical group is made up of physicians and
(18:26):
so the dollar goes from the employer, to the insurance company, to the
medical group, to the physician,and essentially each layer, so the employer
going to the insurance company, theinsurance company going to the medical group,
and the medical group into the physician. At each layer, someone has an
(18:48):
agenda and someone has an idea aboutwhat should be happening and what care should
look like and what's important and what'snot important, and those agendas filter into
the actual patient encounter. It isalso true that if you have that many
layers, there's a lot of costassociated with it. There's a lot of
(19:10):
cost associated with that, and thatcost is it comes from all different places,
right. Some of that is administrativecost that comes from it from just
having that many different layers in place. Some of that is profit at various
levels of the system, you know. Some of that is well meaning you
know, improvement initiatives and things likethat, and and even within the physician
(19:37):
office there's there's quite a lot ofcost that is dedicated to interfacing with whoever
is next up on that chain tomake sure that the money or the reinforcement
comes in. And so the conceitwith direct primary care in that context seems
(20:00):
like like, you know, kindof aggression, breath of fresh air.
It's very it's it's very simple,right, It's like, no, no,
no, no, I'm a doctor. You need my help for whatever
reason. You pay me, andI take care of you and and and
that's it, right, There's there'snone of this other stuff that's kind of
that's kind of there our practice.And I would say the majority of direct
(20:25):
primary practices operate pretty subscriptions, prettystrictly on a subscription model. So not
only are office visits bundled into thatmonthly cost, but so are you know,
phone conversations, text messages, emails. You know, most most offices
(20:45):
will do some sort of video visitsor phone visits. Because again, when
you have that direct relationship, theincentives really get reoriented. And it's no
longer from the physician's perspective, whatdo I need to do in order to
generate a bill to send to theinsurance company to get reimbursed. The question
(21:06):
instead is what do I need todo to take care of the person in
front of me? And it turnsout that that's actually a very different set
of things by and large than itis to get paid by an insurance company.
And so the incentives get changed.They're just very different than they are
(21:29):
when you need to figure out howto build the insurance company in order to
generate the revenue to keep the practicegoing. Yeah, you mentioned, you
know telephonic, you know same dayappointments. And there's a whole list of
different items that I saw on yourwebsite. I'll just name off a couple
(21:52):
of them here. On site advancedimaging, on site, comprehensive lab care
navigation, extra dieted appointment, housecalls. You know, that's that's a
biggie right there. I mean,how many physicians can do that? Yeah,
I think, and it's I mean, I think it's important to recognize
(22:15):
that, you know, what thismeans is different, right. It does
not mean that every It does notmean that every visit is a house call,
right right right right? That Likeyou know, when people are local
and they can't leave the house forsome reason, you know I can stop
by. It means, you know, like there's a there's a woman I
(22:36):
take care of who's a neighbor.It's basically on the route from from my
office to my house that I walk, and I had medications and so I
just stopped by her house and droppedthem off for her right, And so
I think that it really goes backto a very sort of what I was
saying before, where if the if, the practice and the orientation is really
(23:00):
what do I need to do totake care of people rather than what do
I need to do to get reimbursed? Things change, And I think one
of the big things that changes isthat there's just a lot less overhead,
which means prices can come down.And with a lot less overhead and lower
prices, you can then structure yourdating differently. And you know, at
(23:26):
the top, we sort of talkedabout how a big part of the current
system is positions feeling frustrated because theycan't do what they want to do.
That's not in my mind at least, you know, the fact that I
spend an hour generally with a newpatient in the office and half an hour
(23:48):
with follow ups. I actually thinkmost of my primary care colleagues would like
to do that as well, butthey can't really do that and make the
numbers work when you have all thisother overhead. And so if you take
out all that of other overhead,you can actually drop prices and keep a
(24:12):
very reasonable practice revenue stream coming inand the difference between those, you know,
basically feats right back into taking bettercare of patients. Yeah, which,
actually I mean when you think aboutit that way, I mean the
end result is healthier people as awhole, which would help drive down healthcare
(24:34):
costs overall. Yeah, I meanI think that again, you know,
we could probably spend a whole episodetalking about this, but I think that
there are a lot of there's alot of really interesting knock on effects.
Right, So I'll give you afew examples that I think are illustrative of
(24:55):
how you can lower costs and atthe same time actually improve quality. Right.
So, you know a lot oftimes if I'm a primary care doctor
and I'm seeing someone in a standardmodel and I have, you know,
maybe ten minutes to see them,and they're coming to me with a problem
(25:18):
and I only have say seven minutesto have a conversation with them about what
the problem is before I have tomake a decision. I'm probably going to
order a lot more labs because Idon't have the time to figure out do
I actually need these labs. Ihave to make a decision get I have
to get them out so I canget the next person in, and so
(25:42):
the number of labs that I orderedto try and evaluate something is higher than
it might need to be had Ihad say, fifteen or twenty minutes to
talk to them. In a verysimilar way, I mean, you'd say
the same thing about imaging and thelikelihood that I need to necessarily get imaging
for someone versus being able to spendmore time getting a really good history from
(26:07):
them and doing a comprehensive exam.If you sort of continue following that down,
there are problems that I and mostprimary care doctors are fully trained to
handle, but maybe we don't doit every day, and so if we
have an extra ten minutes to refreshour memories about which labs to order for
(26:30):
something or what we need to doublecheck on, we can do that,
which means we can save referrals toa specialist at each of those steps.
Quite frankly, most patients, Imean sometimes people say, look, I
really want to see the specialist,and I say, great, that's fine,
let's send you there, right,But most times people are much more
(26:52):
interested in actually getting their problem addressedthan they are about how that gets done.
And most of the time people wouldactually that the person that they're seeing
is able to address their problem ratherthan going to talk to five different specialists.
So in this context, what happensis I can spend much more time
with people. I can make muchmore thoughtful decisions about when I need to
(27:15):
involve specialists, what labs I needto order, what imaging I need to
order, what additional testing I needto order? And you know, I
would say ninety something percent of thetime what I need to order is less
because I have a much better graspof what I'm actually trying to figure out.
This really continues, right, SoI might say to someone, look,
(27:38):
you know, if I don't havea good relationship with them and I
don't really know them, I mightsay, look, this is really serious.
I need to go to the emergencydepartment again, because I don't have
that time. But when I havea lot of confidence that not only have
I explained it to someone where theyreally need to be concerned and where they
don't need to be and what theyneed to be looking out for, and
(28:00):
I know that if they call theoffice tomorrow and things aren't going well,
I can see them back right andif things deteriorate tonight, they can get
a hold of me because they havemy cell phone. It really changes a
lot of times how much I needto send people to the hospital or to
the emergency department or whatever. Andyou know, I I say this not
(28:26):
to be sort of derogatory towards mycolleagues that are in a more traditional model,
but actually with a great deal ofsympathy, right, Like, they
all know how to do this.This is most of the time what they
would prefer to do. And they'restuck, right, and impatients are stuck.
And again this goes back to peoplejust feeling really stuck. Yeah,
(28:48):
I mean you brought up a goodexample and I've seen this over and over
and over again on my side wherewe have employees that are using the er
for doctor visits, yep, andit's just such an expensive way to do
it. And like to your point, you know, these these positions you
are, I have a brother that'san er doctor. How much time do
(29:08):
they really have to address that situation? Well? And what's the er built
to do? Right? I mean, the emergency department is built for emergencies,
right, and they very well withthat. And when they know when
they need ninety minutes to stabilize someonebecause they're truly having an emergency, they
take that time and they're great atit. I think that the challenge is
(29:30):
is when you have people showing upto the emergency department with problems that really
are not well suited to be handledin an emergency department, that's where that's
where things really become sticky, right. I mean it's like I don't do
certain you know, I wouldn't takeout someone's gall ladder or appendix in my
office because this is not an operatingroom, right, like, like that's
(29:51):
not what we do. We're notset for it, we're not built for
it, we're not trained for it. And and so I think it's really
about trying to match, you know, needs to appropriate venue. And it
turns out the appropriate venue for alot of problems is primary care. And
when you have a primary care systemthat is overstressed, overburdened and can't simply
(30:15):
can't deal with the volume of problemsthat are being thrown at it, those
problems don't go away. They gosomewhere else, and generally they go into
venues and settings that are a notas well equipped to take care of them
and be much more costly. Yeah, and then you get first and again
it comes back to it, youget frustration. Yeah, yeah, yeah,
(30:36):
you articulated it really well. Mytakeaway is, you know, a
couple of things. A personal relationshipyep, I know. You know.
Again just hearing it from my sideto employees complaining, Hey, I don't
feel like I have a personal relationshipwith my physician. I really didn't get
to choose them, right, Andif I did use them, most of
(30:59):
the time it's because a family memberor a friend said, hey, go
to this doctor. Yep. Yeah. Well, and I think, you
know, we really practice in amodel that the relationship itself is often healing,
like before we even get to medicationsor tests or anything. Simply having
a trusting relationship with someone that's lookingout for you, I think is actually
(31:22):
tremendously valuable. And you know,not everyone feels that way, and that's
okay, and it's good that peoplecan you know, the people that do
feel that way can pick us andfind us. And the people that want,
you know, that are much moreinterested in what I call a widget
model, can go to a widgetmodel and like that's okay, that's okay,
But we really view actually the relationshipis kind of the foundation for everything,
(31:48):
right, Like we we say,first we develop a relationship with people,
and then in the context of thatrelationship, we try and solve whatever
medical problems they have. And youknow, in a certain way that sounds
kind of fluffy and kind of aMorphOS right, but I can tell you
that in practicality, when when weyou know, when I know you and
(32:13):
when you know me, like,things really change, they really change.
And I think that they change ina pretty profoundly positive way. And I
do feel pretty strongly that that lackof relationship between doctor innovation is one of
(32:39):
sort of the core injuries of ourcurrent system and a core problem about what
is leave people feeling so frustrated.And so I think, rather than,
you know, rather than run fromthat, we really run towards it,
and we say, well, thenlet's let's actually prioritize the relationship, yeah,
(33:00):
and try and build on that.Yeah. I've stained some statistics.
I can't remember where, but Isee so much stuff come across my desk.
But they're saying the statistics say thatprimary care is the front line.
It's it's everything really quite frankly,Yeah, I mean I I think ideally
(33:20):
that's true, right, But II think it's you know, what's what
I think is sad is that forprimary care to effectively be the front line,
it's not. Again, I thinkit's it's not a widget, right,
It's not a primary cure widget anda person widget. It's it's a
(33:42):
relationship, right. And so tothe front line means that you're, you
know, as age from a patientperspective, you're calling someone that you know,
right, You're reaching out to someonethat you know. You are not
reaching out to a system, You'rereaching out to a person. And and
I do think that that that thatindividual, personalized aspect is a huge part
(34:10):
of what is really missing from thediscussion. And and so again that's I
mean, that's that's just a bigpart of kind of what we do and
why we do it. It's itis it is building that that relationship,
which again in our mind is justpretty foundational too to all the other stuff
(34:35):
that then comes. Yeah, yeah, so you know, to that to
that topic, you know, youyou know, you know, Jeff Turner,
you know, you know I'm uniqueand different from you know, my
given my own siblings, right,yeah, yeah, and you know,
and I and and part of thattoo is you know, I know,
(34:57):
the patients, because I know thefolks that I take care of, the
patients where when they call, reallywhat they're kind of saying is I'm just
feeling nervous. And I know thefolks where when they call, like they
never call, and so if they'resaying something's wrong, I just I interpret
that really quite differently, right,And because I know that the people,
(35:22):
I have a pretty good idea of, you know, what might be going
on with them, and I think, you know, I think, Jeff.
The other thing that I really wantto mention here is that this often
gets talked about as like, youknow, you know my medical history.
Right. In reality, that's that'sa part of it. It's not I
(35:45):
don't even know if it's half ofit, right, because it's pretty easy,
honestly for me to communicate to anotherdoctor someone's diagnoses, right. Computers
can do that, right, Yeah. But you know, I tend to
know the name of my patient's wivesand the names of their husbands, and
the names of their kids, evenif they're not my patients, and how
(36:06):
their relationships are going. And youknow, you know, Jeck loves his
job and is really excited about whathe's doing. But Mike Kates's job and
he's been getting headaches ever since he'sbeen working at this place, right,
And then the conversation becomes much moreabout, you know, to Michael and
his headaches. It's like, look, Mike, I've recognized that, you
(36:28):
know, since you started at thisjob, you have been having all these
sort of health conditions that you've beencoming to me with, Like how do
we actually talk about making your jobwork better for you? Right? And
I think that that But that's whatI mean about a relationship, right,
(36:49):
It's it's like an actual relationship.It's not It's not like, oh,
you you are a person that Ionly know in the context of your six
medical diagnoses in which medication you're on. Like that that again, to me,
it misses the point, right.And I think you know when people
when you sort of started the episode, you talked about like I remember as
a kid, and you know,the doctor would come to our house and
(37:13):
and those kinds of things, andwhat is that? I mean? What
is that really? I mean?Is or what makes that special? Is
it is it special because someone's comingor is it special because it's a person
that you know that cares enough aboutyou to show up for you when you're
not doing well, right, Andand I think again, we we think
(37:36):
much more sort of like behaviorally orperformatively of like oh well, the waight
time is X or the wait timeis why, as opposed to relationally right,
and like, yeah, yeah,if someone's waiting for us for like
seven minutes, I'm pissed like thatthat it's very rare that that people wait,
right, Like when people call,my expectation that they're going to be
(37:57):
seen today or they're going to beseen tomorrow, right, and if I
can't even one of my colleagues,Well, so it's it is that stuff
as well. Right. I don'tmean to say that that stuff doesn't matter,
because it does, sure, butthat's it's sort of part and parcel
this larger this larger thing. Yeahyeah, and you talk about the widgets.
(38:19):
I'm just visualizing it right now,like you know, you go in,
okay, you know, there's getweighed, You go in, you
wait, and then they come inand then okay, all right, we're
going to prescribe this medication. That'skind of kind of the experience that I've
had personally, right, Like yeah, and I'm like, okay, well,
I get I mean it's it's just, yeah, very frustrating. I
(38:44):
love what you're saying. Definitely resonateswith me. That's why we got you
on and you and I you know, been talking now for a good year.
We're trying to make inroads here quitefrankly in the Sacramento area, which
is predominantly HMO the widget system.You know, we know, we realize
(39:07):
what we're up against, but weboth wholeheartedly believe this is a better way
to do it. So that's whatI wanted to get you on here,
and I really appreciate it. Ido want to mention there's a couple of
other thing you guys saw. Itlooks like in terms of prescriptions. Yeah,
you have a little bit of cloudthere as well. Can you talk
(39:30):
to that? Yeah, I meanso, yeah. So we we stock
a fair number of prescriptions in theoffice that we can then dispense to people
for a pretty nominal cost. Youknow, I'll be totally transparent. We
we take margin on them, butusually the cost of patients, I mean
(39:53):
very frequently, the cost of patientsis literally less than their insurance copey and
it's certainly, you know, lessthan generally what they would pay if they
did not have insurance or they havevery high deductible or whatever. It is
again almost always cheaper than what theyou know, people will use coupons a
(40:15):
lot, like, it's generally cheaperthan that as well. Again to be
totally transparent, like it doesn't workfor everything. There are times where the
our cost is higher, in whichcase I encourage people to go to the
pharmacy to get things filled. Becauseagain, part of part of having a
relationship with someone who wanted them todo well, and part of them wanting
(40:37):
to do someone do well is isbeing a good you know, trying to
be a good steward of their resourcesas well, and and so but it's
pretty nice, right So if weyou know, we see if we see
someone in the office and they haven'tbeen feeling well, and we you know,
we diagnose pneumonia and they're here,you know, we can hand them
(40:58):
probably not one hundred percent, butusually their antibiotic prescription for you know,
three or four bucks, and thenthey can go straight home and they don't
have to deal with going to apharmacy and waiting in line and doing all
that stuff. Yeah, and andthat you know, that's that's similar.
Someone comes in for a urinary tractconfection. Someone comes in and they have
high blood pressure. You know,we can probably get there. You know,
(41:21):
their their first three months of bloodpressure medications for I don't know,
three or four bucks, maybe less. And then we see them back and
we check in on how they're goingand we can adjust. And again,
you know, some people prefer togo to the pharmacy, and that's fine.
There's a there's a you know,there's a large number of medications that
we can't or don't stop for variousreasons, and those people, you know,
(41:44):
those we send to the pharmacy.So it's it's not a panacea,
and I don't want to pretend likeit is, but for a lot of
people, for a lot of fora lot of people, and a lot
of what people need, it's ait's a big it's a big convenience.
It's a value add right, Itjust me and you know, wouldn't it
(42:05):
be nice if it helped her orientedaround trying to make your life easier as
opposed to what is the maximumly difficultway we could we can make something happen.
Yeah, yeah, you mentioned thatin order to engage with you.
It's a membership. Yeah, orMatt, can you speak to that a
little bit and talk about that whatthat looks like. Yeah, so it
(42:28):
depends, you know, for primarycare, it depends a bit on how
old you are, but and youknow, different primary care practices are different,
but you know, usually it's youknow, probably somewhere between. Well,
kids for us, I think areabout forty bucks a month. Older
folks are one twenty five if Iremember, our pricing great and our standard
(42:51):
monthly is is one hundred dollars amonth. And I think it's actually worth
sort of talking about, just exceptuallyfor a couple of minutes, about why
we only see people in the contextof a membership. And again, it
really goes back to this idea ofa building relationships with people, right,
(43:15):
And so fundamentally we are interested inhaving a practice filled with people that we
want to have a relationship and thatwant to have a relationship with us,
right, And our belief is thatover the long haul things will sort of
sort themselves out, right, Andso you know, there are for any
(43:37):
individual person, guaranteed they're going tothere's going to be months where they receive
much more in dollars than they pay, and there are going to be months
hopefully when people don't need us atall, like you don't need your doctor
every month, right, And again, our sort of focus is if what
(43:59):
we think about is that we're buildinga relationship, then the question is basically,
how do we just build a businessmodel that supports a relationship over time?
And this is how we've come todo that, right, Is it
the best way? I don't.I don't even know that it's the best
way, honestly, but it's away that seems to work, and that
(44:21):
for the folks that see us,they tend to be very happy, and
it allows us to practice in away that keeps us generally pretty happy and
wanting to continue to practice. Andyou know that that doesn't seem half bad.
And so I think, you know, I think like part of the
reason we're having this discussion is ishow you know, is trying to bring
(44:45):
employers into that, right and tryingto to craft solutions that allow that allow
employers to both marry, you know, a comprehensive health plan with these types
of services. And you know,it turns out that's complicated, right,
(45:06):
and that's that's your job, Like, thank goodness, because I can't do
it. But that's something where therethere are options available when you know when
we want to try and when wewant to try and bring that Yeah,
and you and I have been havingthat discussion now for a good year and
we're we're still working through that,trying to figure it out. And in
fact, uh, part two ofthis will be a particular vendor that you
(45:32):
introduced me to that I feel hasa like mind and and I think that
I feel pretty good about where thiswhat they're bringing to the table, and
in this regard around direct primary care, which is pretty exciting. Actually,
California is it is the difficult market. I will say this that I know
(45:53):
several of my peers that are outsideof California they've had more traction in this
area. But you know, Ithink, you know, persistence in something
you believe in eventually, you know, good things will start to happen.
So, doctor Altuler, the bestway to get a hold of you,
(46:14):
it depends who you are a littlebit, right, but I think probably
the best way is to just callthe office, right and I can tell
you that ninety nine percent of thetime that will get you in touch with
a live human within that twenty seconds. I can't. You know, there
are times when we are super busy, but again, our standard is that
(46:36):
you know there will actually be ahuman that answers the phone. I can't
promise that that human is going toknow exactly how to address what you need,
but you know, we we liketalking to people. So you can
certainly call and the phone numbers onthe website and maybe just share what that
phone number is. Yeah, it'sa nine one six six six eight seven
(46:59):
ones explore. So I think thatthat's that's probably the easiest way. There's
a ton of information on the websiteabout kind of what we do and how
we do it and all of that. There's a contact form for us on
the website, so that will generatean email to us and we'll we can
get back to people pretty quickly,you know, and if someone if someone
(47:20):
out there is like, Okay,this sounds great, I'm sold, I
want to sign up. You canactually sign up work here on the website,
and we say that, yeah,we get back to probably within a
couple hours about trying to schedule youthat first appointment, and you know,
it's again it honestly it is.We try to try and make things easy,
(47:45):
like to try and not make thingscomplicated, right right, Yeah,
keep it simple. Yeah, Iappreciate that. So again, the number
is nine one six six six eightseven one sixty four. And I will
say this that you can also reachout to me Psyche. You and I
can you know, communicate regularly,and I can connect you with with doctor
(48:05):
A as well. So yeah,him, I communicate regularly. So well.
I appreciate your time. I knowyou probably have a busy day,
and you know, this has beena great conversation. I'd love to continue
this. Maybe we'll do another one, dive a little deeper into some other
topics. But yeah, it's beengreat having you on, Jeff, thanks
for thanks for having me on.This is fun and I'm I'm always I'm
(48:27):
always happy to talk about this stuff, so I really appreciate it. Yeah,
all right, good scene. Youtake care, I have a good
day. You two touch it.M
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