June 7, 2022

Ep 9. Pushback, Part 1

Ep 9. Pushback, Part 1

Hear stories of a couple of doctors that are pushing back on a dysfunctional system by upending their practice model.


Date: 6/7/22
Name of podcast: Dr. Patient
Episode title and number: 9 Pushback Part 1
Episode summary:
Part 1 of stories about doctors and patients who are pushing back on a broken healthcare system. Learn about concierge care and direct primary care, from two doctors that left traditional fee for service practice models for these alternatives. 

Guest(s):
Dr. Charles Dillon, University Associates in Chicago
Dr. Cindy Rubin, In Touch Pediatrics & Lactation in Chicago 

Key Terms:
[11:42] - physical extender - someone certified in basic medical training - Physician Assistant, Nurse Practitioner, Nurse Midwife
[14:47] - Guillan-Barre Syndrome - immune disorder where your body's immune system attacks itself

References:

Dr. Dillon site:  https://www.doximity.com/pub/charles-dillon-md

Dr. Rubin site:  https://intouchpediatrics.com

Direct Primary Care Coalition:  https://www.dpcare.org

DCP Nation:  https://dpcnation.org

https://www.medicaleconomics.com/view/difference-between-concierge-and-direct-care

Transcript

Heather Johnston:

This is Dr. Patient, a podcast that examines all the aspects of the patient provider relationship. I'm your host, Heather Johnston, MD, a real life doctor and patient. This week I'm looking at ways that doctors are pushing back on the dysfunctional system that they've been enmeshed in. And this is a part 1, because lots of doctors and patients are starting to take matters into their own hands. So there are a lot of stories to be told on this topic. Today, I have two doctors as guests who will be talking about the different models of healthcare delivery that they've chosen for themselves and their patients. A traditional model is called fee-for-service, which means that doctors are literally paid for each service that they perform - see a patient, get paid, see another patient, get paid, order a test, get paid, and so forth. Okay, keep that in your mind as you hear about these other models. My first guest today is Dr. Charles Dillon from University Associates, affiliated with Northwestern Hospital in Chicago. He was in practice for many years before he left to launch what's called a concierge practice. Concierge medicine is where the patient pays an annual fee directly to the doctor, which includes all of the care and communication that happens within the office. And between the doctor and patient - visits, calls, minor tests, etc. The fee can range anywhere from about $1200 to $10,000 a year or more. So whether you're seeing one time in a year, or 25 times in a year, it's the same one lump cost. If you need to see a specialist or if you need care outside of the office walls, like an Xray, MRI, or other higher level of tests, you go over to a clinic or hospital and have those completed and build your insurance. On the doctor end, they stay in business through those annual fees and also by billing your insurance for the visits that you have. I asked Dr. Dillon to talk generally about how he came to the decision to practice in this way, and how concierge practices are set up.

Charles Dillon MD:

There's different types of concierge type practices, some that are so high end that actually a doctor will have very small number of patients and will actually fly around the country with them to to get opinions on their illnesses. The most common type of concierge practice is one where a doctor is just trying to limit the number of patients to a reasonable number so they can actually spend the time to listen to their patients and properly care for them. And that's the type of practice that I'm in.

Heather Johnston:

How exactly does concierge medicine work? I'm a patient. I go and what do I do?

Charles Dillon MD:

And so the patient decides when they need to come in. And they can they can schedule a visit and can usually get in to see me if it's an urgent problem, if they call in the morning, that same day, or the next day. For routine problems usually can get them in a week. For a complete physical, usually within a couple of weeks. So it gives the patient a lot of flexibility as to accessing their physician to help them maintain their good health

Heather Johnston:

as a patient to find concierge care. Basically, you're paying an annual fee. Correct which includes everything that's done inside your office walls, right?

Charles Dillon MD:

Yeah, yes, but it's not insurance. So we always tell patients no, you still have to have insurance. If I have to send you to the hospital for some specialized tests, that goes through your insurance. That's not through my practice.

Heather Johnston:

That fee is different for all concierge docs. You said that and it ranges from this or that. But it's obviously a very exclusive opportunity. What's the solution for everyone else?

Charles Dillon MD:

That's the problem. I can't say that this is a solution for all patients or all doctors. There aren't enough physicians in our entire country to be able to have small concierge type practices. So it's really for those patients who want that type of a relationship with a physician, who feel that because of their family history, their medical history that they need that closer, more frequent contact. But for the general public at this point in time, it's it's really not feasible. Medicine got to the point where either I was gonna go out of business going broke because you had to keep ramping up the number of patients that you would see, spending less and less time with each patient, or get out of traditional insurance practice.

Heather Johnston:

For people that don't understand the mechanics behind all this, why would you have gone broke and had to have spent less time with your patients.

Charles Dillon MD:

It's interesting when we had paper charts, also billing papers would be in the chart in a separate section as well. And it was fascinating when I was contemplating getting out of all insurance, looking through some of those charts. And, and for example, seeing how in 1992, the amount that Medicare would pay for a complete physical dropped in about two thirds of the payment less 20 years later. And that became untenable.

Heather Johnston:

From about what to about what, generalizing?

Charles Dillon MD:

So if if they were paying $500, for a complete one hour physical back then, it was dropping down to $100. And all of the expenses over that same timeframe skyrocketed. I mean, the rents, the overhead staff, all the equipment, it just became ridiculous. I have a friend who was a high level vice president of one of the biggest insurance companies. And she used to tell me that every time Medicare dropped their payments to doctors, which consistently was happening every few years, instead of keeping up with inflation, they kept cutting them. And she said that with their meetings of all the executives, they would kind of applaud every time Medicare lowered their payments to doctors, because they would follow suit and lower their payments to doctors. Interesting. It's kind of an unfair system, because hospitals have all the negotiating power. And individual practices have very little. So the pie used to be split reasonably fairly between what physicians would get paid and what doctors would get paid. And unfortunately, what happened is that hospitals got almost all of the pie and primary care physicians, were just getting the crumbs. And in order to make ends meet, my accountant said, either you're going to have very brief, more frequent meetings with your Medicare patients, or you're going to have to drop out of Medicare, because you can't pay all the bills on what they're paying. Very sad.

Heather Johnston:

It really is. So what percentage of your patients were Medicare?

Charles Dillon MD:

So about a third of my patients were Medicare, but they took up about two thirds of the time.

Heather Johnston:

About how much time did you use to spend with patients, before you changed to concierge, like at the end, when it was becoming a problem? And then how much time do you spend now?

Charles Dillon MD:

Well, that's why I got out, I did not want to change how much I spent with them. For a yearly complete physical Medicare, non Medicare, I typically allot a one hour timeframe. Now, in most internal medicine practices, that would have been 20 minutes. And that's how those practices were able to survive, though there are a lot of practices, they had to cut it down to 15 minutes. So I refused to change the quality of my care. And, for example, you know, just this week, I had a physician contact me that I know and wanted me to see his elderly mother with multiple medical problems to try to put the pieces together as the care was fairly disjointed. Well, I allotted two hours for this complicated case. And I spent an hour in advance collecting records that were available to me electronically. In my old practice, that would have been untenable, absolutely impossible to try and do.

Heather Johnston:

So before you changed and went into concierge, how were you feeling as a doctor in a traditional practice?

Charles Dillon MD:

Well, it was it was starting to get overwhelming. Primarily the burdens we were getting from insurance. You would get these denials and then you would have to do rebuttals, and then you would have to get on phone calls and try to fight for your payments. You're always fighting with the insurance companies over them suddenly changing a medication plan. And somebody had been well controlled whether it was their diabetic meds, their cardiac meds, hypertension meds, whatever. And suddenly they were non formulary. And at the last minute you are having to make major changes that that could adversely affect your patients. We were dealing with that every single day. It used to be if a doctor felt that a patient needed a CT scan, you could order it and get it done. All of a sudden, you had non physicians and insurance companies making a decision whether or not the physician could get a study done. And the amount of time that that took make it made the days very long and very painful. So the joy in medicine started to disappear.

Heather Johnston:

Have you gotten it back?

Charles Dillon MD:

Absolutely. I love medicine, and it's rejuvenated me.

Heather Johnston:

So this is probably a very obvious question, but I'm going to ask it anyway, How has being in a concierge practice affected your relationships with your patients?

Charles Dillon MD:

I think in a very positive way, my patients are very thrilled to be able to actually call me and speak with me. It's. medicine has changed a lot in the last 15 to 20 years. There's a lot of physician extenders, and that can be extremely helpful. But a lot of my patients feel that when they see specialists, and they have follow up questions or issues. They all go through a physician extender, and they're not always sure that their question is being asked and answered in an appropriate way, and they can't get through to the specialists that they were they were seeing,

Heather Johnston:

Can you explain what a physician extender is?

Charles Dillon MD:

So there are there are nurse practitioners and physician's assistants, who, who help in many ways make practices run more efficiently. They shouldn't really replace the care of the specialist they should add to that care. But unfortunately, their role has grown tremendously. For example, with my heart failure patients, they used to go to a cardiology clinic for heart failure and see a heart failure physician, you know, two or three times a year. And then all of a sudden, it became once a year, they would get to see the cardiologist, and the other visits during the year would be to the nurse practitioner. Now, they are very helpful, but they are not a cardiologist. And and the patients are, are noting the change.

Heather Johnston:

I think that's true. A lot of people that I've talked to lately said that they can't imagine being able to get a hold of their doctor.

Charles Dillon MD:

Sad, but true

Heather Johnston:

They cannot do it because you send messages through an electronic medical record system most of the time now, but the reply that you get back is almost always from a nurse, or a nurse practitioner, or a physician's assistant, I'm not knocking any of them, I think they're incredibly essential to the system. But you know, if I'm sick and having a problem, personally, I really want to talk to my doctor. That's the person I've chosen to give me my health care so I have trust with them. I don't have trust with the people that I don't know, that's really an inherent problem now.

Charles Dillon MD:

it is a big problem. And I mean, I think it it, unfortunately can lead to catastrophic outcomes. I mean, just to give you an example, all of my patients also have my email. And so my patients can contact me from wherever they are in the world. I had a patient a few months ago, and he had gone to Hungary on a vacation. And all of a sudden I get this email, and it said, Doctor, you know, both of my legs, starting in my feet in the last day or so have started getting numb and it's starting to rise up into my calves. And he said, I think it's just the way I was on the plane for a long time or the way I slept last night. Now, if he had, you know, tried to in a traditional system email the doctor, that wouldn't have happened. If he would have called a physician, he wouldn't have gotten a call back. I immediately was able to email him. Tell him please stand up on your toes. Then stand up on your heels. And please tell me that you're able to do that. And he goes Doctor, I can't do that. I said, Okay. I think I know what your problem is. And you have to get to the closest emergency room immediately. And sure enough, he had Guillan-Barre Syndrome and ended up on a ventilator a few days later.

Heather Johnston:

Oh gosh, in Hungary

Charles Dillon MD:

In Hungary, and it was a tough situation. The family ended up spending the money and got a medical jet to fly him out of the country here to Northwestern, where he was off the ventilator after about three more weeks, but then had to go to rehab for a couple of months. And I saw him this week, and he actually walked in without his walker for the first time.

Heather Johnston:

Wow, wow. What would you say your job satisfaction was maybe on a scale of one to 10, before you switched, and after you switched?

Charles Dillon MD:

I would say it was probably down to a five. And I always loved medicine, and I loved caring for patients, or it was always up at that nine level. But because of the hassles with insurance companies, it just kept plummeting. So it there were days that you would just dread it because you know, you have all of these, these companies that you have to contact, different insurance companies, and fight to get the appropriate test done for your patient. And that's not why you go into medicine to fight with insurance companies.

Heather Johnston:

Did you have to make those phone calls or someone in your office?

Charles Dillon MD:

Oh, typically it would start with someone in the office providing more records to the insurance company. But invariably, they would keep denying, and then it would have to go physician to physician. And and there are there are doctors who work for these insurance companies. And their their goal is to cut as many of these tests as possible to save the insurance company money, and in my view to increase their profits.

Heather Johnston:

Yes. And how did you fit those phone calls into your day, because that's not something that anybody schedules into their day of a full day of seeing patients?

Charles Dillon MD:

it was difficult, because early on, you could do those near the end of the day, and then just extend your day, much, much longer. But just before I finally gave up on insurance companies, it got to the point where you would try to schedule a time with one of these physician reviewers to discuss your patient's health care and the reason for the specific test. And they would no longer give you a specific time. And they would give you a time frame and say okay, we will be calling you between eight and 12. And in the middle of patient care, you're supposed to stop examining the patient to accept their phone call? It it was, it was a really nasty game that they set up because they knew that most physicians couldn't do that. And eventually, a lot of physicians just stopped doing it. And they wouldn't go to the bat for their patients because the hassle and the interruptions in their patient care was too great.

Heather Johnston:

That's crazy. That just happened to me with my physical therapist last year. I needed physical therapy on my arm after the breast cancer surgery. And my insurance company only gave me a few visits, which just wasn't sufficient. And the same thing happened. She, my physical therapist said she'd appeal it. But every time that happened, they would give her like an eight hour window. And she was with patients all day long, so she missed the call every time and then they just denied the claim.

Charles Dillon MD:

Yes.

Heather Johnston:

Man. I mean, there's so many hoops and barriers and challenges as a physician to just deliver quality health care to your patient. So I really understand why you made the move. Do you remember how many patients you had before in your traditional practice and how many you have now?

Charles Dillon MD:

It was about 2000 and now down to 500.

Heather Johnston:

Wow. And how many patients do you see per day?

Charles Dillon MD:

It varies. There are some days when it's quiet day and you may see three and a busy day today would be six or seven.

Heather Johnston:

What was a busy day before?

Charles Dillon MD:

Well, you might be seeing 16.

Heather Johnston:

In peds, 30.

Charles Dillon MD:

Yeah. Oh, I'm sure. It's funny because administrators, they make more than doctors. And and I my wife and I were downtown and out to dinner. We had reservations but the place was busy, it was like going to be another 20 minute wait, so walk over to the bar to get a glass of wine. There was a game on at the bar and so I the guy next to me just made a comment about wow did you see him score that and we got chatting a little bit. And he starts talking about how he's the hospital administrator. And I, I pretend I'm not a doctor or anything, I go, well, that was a really tough job. And it goes it really is. I said, so I bet, you know, getting doctors together on anything is like herding cats. He goes, yes. And they all think we love them. But we can't stand doctors. He was one of our hospital administrators. I knew him he didn't know me.

Heather Johnston:

That's great. That's great. I'm sure that doctors are very annoying for the administrative side. My second guest is Dr. Cindy Rubin. Dr. Rubin has worked at several big academic medical centers in Chicago, and recently left all that behind to start her own practice called In Touch Pediatrics and Lactation. And she's practicing under the Direct Primary Care model, referred to sometimes as DCPs. The D for direct refers to the fact that the patient pays the doctor directly, similarly to a concierge set up, but there are a few differences. DCPs are a bit more affordable, usually running anywhere from $30 to $100 a month. And these doctors do not bill insurance for their visits and tests with you. They exist off of the monthly membership fees. Yes. Let's run through a concrete model. So let's say a

Dr. Cindy Rubin:

The thing about Direct Primary Care is that it is totally outside of the system. So you're not billing insurance. And honestly, I think what I realized was that that's the only way to not see 30 patients a day and make any money. Not that I'm trying to be rich, but I do have to support my family. And I realized that if I just opened my own practice, but I was billing insurance, because of the small amount that I would actually be reimbursed for each of those patients, I would have to see 30 a day. That's the problem now. 10 year old has a sore throat and a fever. What would happen in a traditional fee for service model and what would happen in a direct primary care model? So in a fee for service, they would call and possibly have to wait hours to get a call back. Probably would be leaving a message on a nurse triage service or something, and eventually would get a call back. They would triage the situation, the nurse would triage you wouldn't reach a doctor. And they'd figure out whether or not it really needed to be seen that same day or if it could, they could just get some general information about taking care of viruses or colds. And if it needed to be the same day, then they would look for a place on the doctor's schedule for an appointment. If you're lucky, you would get an appointment with your own doctor. Next best would be at least an appointment in the practice, but with a different physician who you may or may not know. And it the next option would have been sending a patient to urgent care if they really needed to be seen, and we didn't have any appointments. Now, some places have different setups. And I've seen offices that have like an hour of walk-ins in the morning. And we actually tried that for a while. And there are definitely advantages to that, though, if you get 40 patients walking in then you have to see those in an hour and then go into your regular schedule. And that's what we were always worried about.

Heather Johnston:

Yeah. And then how would that look in a direct primary care model?

Dr. Cindy Rubin:

So direct primary care, my patient would call the patient line or text me saying what's going on, depending on what I'm doing that day and when they happen to contact me. I would get back to them within some period of time, directly, but it would be me. And find out more information, see how the kids doing. Same thing, not every patient needs to be seen physically. So I might be able to just give them some reassurance and instructions and then we'll touch base later and see how things are going. Or I would make an appointment.

Heather Johnston:

And they'd see you.

Dr. Cindy Rubin:

And they see me, only me.

Heather Johnston:

In a pretty timely way. I bet.

Dr. Cindy Rubin:

Yes.

Heather Johnston:

So your patients have your cell phone,

Dr. Cindy Rubin:

Essentially yes.

Heather Johnston:

And your email also?

Dr. Cindy Rubin:

Yeah.

Heather Johnston:

And does anybody abuse it?

Dr. Cindy Rubin:

No. That's a big question. You know how often I feel like I'd be woken up every single night with questions. But you're not. Just the patient knowing that I will be reachable in the morning makes people more comfortable, not necessarily calling in the middle of the night if they don't need to. But I impress upon patients or parents that if they're trying to decide whether or not to go to the emergency room, they need to call me. I mean, if they know they need to go to the emergency room, or call 911, call 911. But, you know, if they're not sure their kid wakes up with a fever and a sore throat, you know, they can probably wait until morning to be seen. And I can at least get them through that. And that's my job. I want to keep people out of urgent care and emergency rooms. And I'm happy to be woken up in the middle of the night to do that.

Heather Johnston:

I think though, you made an excellent point, which I want to reiterate, and just go a little deeper into, which is that they may or may not call you in the night, but knowing that they can reach you is huge. I think that's huge. Because I've heard friends with children say they sometimes call the practice in the middle of the night, because they know in the daytime they won't get through to anybody. Like either the phone is barely answered, or they leave message after message and no one's calling back. Or if they do call back they'll talk to a nurse and they really want to talk to the doctor, who is the person that has spent years building a relationship with them. And they know that doctor and the doctor knows them and their family. And that's who you want to talk to. This whole idea of physician helpers, while I value them personally, and I see that there's roles for them in certain ways. I on the patient side of my brain, you know, I don't want to talk to anybody but my doctor, and they don't know me. I guess maybe I have a particular way of communicating I don't know. But my doctor knows me and I want to talk to that person. Yeah, that's a real comfort to patients to know that you can reach the doctor that you've chosen for your kid or for yourself,

Dr. Cindy Rubin:

right. And if a patient calls me and their child does have underlying medical problems, I know. They don't have to sit there and list everything. I know who which parent is a worrier and which isn't. I mean, that makes a difference in how you're going to address the problem, potentially. Obviously, you're gonna give the same care to everyone. But you might spend a little bit more on the time on the phone with somebody who you know, is going to worry a little bit more.

Heather Johnston:

That's a great example of just knowing somebody, it's a relationship. Right?

Dr. Cindy Rubin:

Right. And we're totally losing that. Because I have to say in the fee for service model, more times than not people were going to the urgent care. And they were bypassing the nurse triage because they knew that they were gonna have to wait forever, and probably wouldn't get in anyway. And so they would go straight to the urgent care and they'd see a different person every time. And half the time they wouldn't even trust what happened there and then they'd call us and it's. It serves a purpose, but it is not it should be used for urgent care. And primary care, which includes sore throats and fevers during regular working hours, should be taken care of by the primary care doctor.

Heather Johnston:

So you mentioned that in your job at the big medical center, you were seeing 30 patients a day. How many do you see now?

Dr. Cindy Rubin:

So anywhere from one to three. Now my practice is also home visits, it's all home visits. So that does decrease the number of patients I can see even more than a typical direct primary care.

Heather Johnston:

Wait, we got to get into this. We gotta get into this because I went on house calls with my dad as a kid and I loved it. So I want to hear more about that. So do you only do home visits?

Dr. Cindy Rubin:

I only do home visits right now.

Heather Johnston:

So you you don't have an office where they come to?

Dr. Cindy Rubin:

No.

Heather Johnston:

Let's hear about that.

Dr. Cindy Rubin:

Yeah, so I decided to do that. because it just is keeping my overhead low in the beginning. It's such a nice thing for parents to not have to pack up and get to the doctor's office.

Heather Johnston:

It sounds like a total luxury.

Dr. Cindy Rubin:

Yeah, and I like being able, yeah, yeah. And I like being able to provide that service. And it also opens a window into that person's world and their resources and their limitations. And, you know, with babies, you can see where they're sleeping and make sure that everything's safe. And, you know, just it makes a big difference. And kids are more comfortable. Parents are more comfortable. You're at home.

Heather Johnston:

I don't know if I could think of a mom that wouldn't like to have a pediatrician walk through their house when they have a baby. That's

Dr. Cindy Rubin:

exactly.

Heather Johnston:

So even for teenagers, do you go to the new for everybody? So for teenagers to see their room? Do you see their room?

Dr. Cindy Rubin:

Yeah. Yeah, if they want me to.

Heather Johnston:

That's cool. So how long do you spend on those visits?

Dr. Cindy Rubin:

So, again, it kind of depends on what's going on. But I'd say on average, one and a half to two hours.

Heather Johnston:

Wow, that is so awesome.

Dr. Cindy Rubin:

Not necessarily for a sick visit. That is a sore throat and fever. That may be quicker. But for well checks.

Heather Johnston:

Yeah. That's incredible. That, what a gift to have that much time with somebody. Really, I mean, you can just have so much more impact on their health and their life positively when you have that kind of time.

Dr. Cindy Rubin:

Yeah.

Heather Johnston:

So are you doing stuff like drawing blood or swabbing for strep? And like, how high how high and level of care do you go in someone's house?

Dr. Cindy Rubin:

Yeah, for me personally, because I'm a still new and can't afford necessarily all the equipment and everything yet. I am, I am doing swabbing for COVID and strep. And I can do like a urine dip test. But I'm not doing actual lab draws. So if anybody needs a lab draw, or more

Heather Johnston:

vaccines?

Dr. Cindy Rubin:

So vaccines, I'm doing

Heather Johnston:

good.

Dr. Cindy Rubin:

So vaccines I'm doing unfortunately, it is very difficult for small practices to obtain vaccines, because they are very expensive. And they're sold in bulk. And they expire eventually. And so if you have to buy a $100 vaccine, and you have to buy 10 of those, and you only have five patients right now who maybe need that particular vaccine than you, you're, I mean, you're putting out a lot of money up front. And we are not contracted with insurance companies. So if we do buy vaccines up front, we have to figure out a way to either bill insurance for those vaccines, or the patient has to pay out of pocket. And those are expensive.

Heather Johnston:

Which one are you doing?

Dr. Cindy Rubin:

So I have been after searching high and low, I have found a way to have third parties do the billing and provide me with the vaccine to give in the home.

Heather Johnston:

It seems like local DCPs should band together to buy in bulk. Does that happen?

Dr. Cindy Rubin:

It does in some places, and in some ways, but it's easier said than done. Yeah, yeah. But I have had the help of other small practices to provide me with the vaccines while they do the billing. And I've also found a pharmacy. Pharmacies don't have all of the kid vaccines anymore. So it was really difficult for me to find one but I did find one who will put through the billing, and I can go pick up the vaccine and then take it to the house to give the vaccine.

Heather Johnston:

Wow, that's great. Yeah. What happens if you're one of your patients has to be admitted to the hospital?

Dr. Cindy Rubin:

So I'm not, I don't have privileges at any hospitals. So depending, you know, again, I may be able to keep a child out of the hospital when otherwise they would have been admitted because I can do a certain amount of observation and treatment myself. But if if they have to be admitted, I would have to send them through the emergency room probably. And I haven't had to admit Anyway, that's all I'm saying. We've been lucky enough to keep my patients healthy so far

Heather Johnston:

You could still visit them every day, right?

Dr. Cindy Rubin:

I can still visit them. So I can see them socially. And I have the time to actually communicate with the doctors who are taking care of that patient if the patient wants me to. So I can give them the patient's background, and I can find out what's going on and help to interpret that and get a better feeling for the follow up plan.

Heather Johnston:

I'm glad you're saying that part of it. Because usually, when you're in practice, you don't have time during your day, like when we were talking about what your day was like earlier, there is no time in the day to have multiple phone calls with a resident or an attending physician at a hospital about your patient. There is not time for that. But gosh, think of the value for the doctor taking care of your patient in the hospital to hear from you, who knows the patient and the family so well. You can give invaluable insight. [Yeah,] that's how it should be. [Yeah]. For people listening who might want to think about this for themselves, if they don't have children? Where can somebody find someone who practices with this model that's near them?

Dr. Cindy Rubin:

So there is a couple of places, there's a DPC mapper, that is I think at DPC Nation if you go if you Google that, and you will find most of the direct primary care practices in the country and find out what they specialize because a lot of people have a little niches as well, I wouldn't immediately think oh my gosh, that I just can't do that. That's extra. It is extra, for sure. But it's it's kind of like the cost of your cable bill or a gym membership. It's not crazy, exorbitantly expensive. And there is a lot of value. My practice is In Touch Pediatrics and Lactation. And they can reach me by going to the website, it's easiest place. And there's a number of places where you can just contact me and that will go directly to me. But my website is www.intouchpeds.com. And I provide I do the general pediatrics, but I also do a la carte breastfeeding medicine. And I also have some extra kind of some,more comprehensive mom baby packages for postpartum as well. And those can be often billed to insurance.

Heather Johnston:

Thank you so much for talking about all this today. This has been so fascinating. And I hope that it helps a couple of people who are listening who are looking for a different model. And maybe a few doctors listening will think, you know, there's hope for me out there to do things differently.

Dr. Cindy Rubin:

Absolutely. We're very supportive community. Like if you're considering this at all. Try to find, you know, contact me I can get you into the Facebook groups and as we're all just trying to help everybody figure it out and survive. In this model.

Heather Johnston:

You can learn more about each of these doctors and their practices in the shownotes. I've also thrown in some other references there for anyone who wants to learn more about these practice types. Thanks for listening today. To catch up on more episodes and get new ones delivered directly to you, subscribe wherever you find your podcasts - Apple, Google, Spotify, iHeartRadio and more. If you'd like to be a guest or have an idea for an episode, let me know at www.drpatientpodcast.com That's doctorpatientpodcast.com. Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments and all discussion is purely reflection about what's working in the health care system and what isn't. Don't use any medical information that you hear in these episodes to diagnose or treat yourself. If you have a question about your health, get in touch with your doctor or local health clinic