Dr. Tea  0:01  

Practicing medicine without insurance is possible. Imagine a private practice where you get to see your best patients every day, providing medical services you truly enjoy, all without the hassle of insurance. My name is Dr. Tea Nguyen, and I'm a recovering specialist who was completely burned out from insurance based medicine. I pivoted into direct care, where patients pay me directly for my medical services, and have never looked back. If you're a private practice owner or planning to become one who's looking to be free of the grind of insurance and you're craving it, simplicity, efficiency and connection with patients, you are in the right place. This podcast will help you map out your exit plan and uncover the mindset needed to thrive in today's economy. Welcome to the Direct Care Podcast For Specialists.

Dr. Tea  0:49  

I want to welcome Dr. Ashley Agan, who is an ENT doctor, because I can't say the alternative word, and I'm going to have you introduce yourself to everybody who's here.

Dr. Ashley Agan  1:05  

Hi. Thank you so much for having me. My name is Ashley Agan. I am a general ENT or otolaryngologist for, for, you know, for those wanting to, to make it complicated, I I practice in Dallas, Texas, and I see kind of like the full gamut of bread and butter ENT so everything from pediatric patients with recurrent ear infections to adults who have, you know, allergies and recurrent sinusitis to older adults who are having issues with hearing loss and kind of everything in between.

Dr. Tea  1:48  

These are the two disciplines that rarely cross paths. We don't even see each other in the right podiatry ear people like we never hang out. And so I'm so excited that you're here, because I've learned so much just on your social media about the things that you do when I had trained back in Michigan, and I did work with some ENT docs, a lot of them were doing like Facial Esthetics and things, and I had no idea what the scope of practice is. So how did you start your private practice journey?

Dr. Ashley Agan  2:22  

Yeah, no, you're right. We're, we're ENT is kind of one of those specialties that not everybody knows what we do. And I think it's, it's because it's, we're, like, not part of the core rotation. So you wouldn't necessarily know that head and neck cancer is, is an ENT thing, or that, you know, facial plastics or reanimation is part of that, but yeah for me, so I was in academic practice for almost eight years, and I had always had kind of the that, that itch to have my own private practice, even when I started medical school, I just kind of always saw myself, you know, hanging my shingle, as they say. And I was kind of, you know, at eight years in, I was feeling more mid-career, kind of looking for, like, what's next for me? I got promoted, and I think I started thinking about, you know, this, going into private practice, as something where, if I don't do this right now, if I don't, if I never do this, I'm going to look back and always wonder what, what would have been, what could have been, and then, and then, as I started kind of planning that I met people in direct care models, and I had heard about, kind of like the the concierge primary care physician, you know, many years ago, and was kind of intrigued by that model, but then the more I met people and learned about direct primary care and direct specialty care, and I met Jerry Gianoli, who's in New Orleans, who's an ENT doing direct care. Because I think a lot of people think, oh, you can't be a specialist and do direct care. And so I was also kind of like, Oh, that's cool, but I could never do that. And then when you meet somebody who's doing it, you're like, Oh, well, maybe, maybe this is possible. And, I was just so drawn to everyone that I had met who was practicing in a model that was out of insurance. What struck me is that all of these people were so happy in their work life and talking about, you know, being able to just kind of continue to work forever because they just enjoyed their work set up so much. I. Um, whereas, you know, some of my other colleagues who were practicing in a traditional private practice, taking insurance, when they heard that I was going to go into private practice, they were like, What are you doing? Like, are you crazy? This is not, you know, we're, we're, this is not sustainable anymore. We can't, you can't be in private practice anymore. You need to, you know, stay where you're at so, so ultimately, I, I made the decision to open a direct care practice, and that was in March of 2024

Dr. Tea  5:33  

I love how fresh you are in this because it feels like the honeymoon phase, but also like, but also like, you're going straight downhill from time to time, I'm sure. Go up, we go down. And I totally still feel that. You know, I've been doing this for two years out of insurance, but six years in total, in my practice, every year is different. There's something new to overcome. There's something revealing about our weaknesses that we have to figure out. And so being so new to direct care, what has surprised you the most? 

Dr. Ashley Agan  6:09  

Maybe a few different things. I think what one big surprise in the beginning was I, my plan was to be able to do, to do some locums gigs here and there to kind of help supplement my income while I was growing and then learned that with Medicare, you need to be opted out if you're going to be able to see those patients in a direct care model. And if you opt out of Medicare, then that alters your ability to do locums. And so that was, like a big surprise when I was kind of like planning everything out, like, where all of a sudden it was like, Oh, wait, you're, you can't, you can't really do both of those things, be being, you can't be opted out of Medicare, and also be able to take a locums gig here and there every once a while, or at least not in general, I have met some doctors since then who have found some opportunities where it doesn't require to be opt into Medicare. But that was a big when I learned that it was it was a big surprise, because it did change how I thought about just my backup plan and being able to support myself while, you know, things were getting going, because I I anticipated that it would be a slower start than if I was, you know, taking insurance

Dr. Tea  7:33  

so you didn't have the opportunity to do locums. 

Dr. Ashley Agan  7:36  

So in the beginning, this has been kind of a roller coaster up and down. So I apologize for a story being longer that needs to be in the beginning, I was not opted out of Medicare, and therefore I was not doing any locums I could have. But I was like, for my first few months I was just solely focused on the business. I had a really unpredictably amazing first three months, and decided to opt out, because I felt like, if this is the trajectory, then things are going to be fine. I don't need to rely on this backup plan so much. And then the bottom kind of fell out of everything. I had a very, very slow summer. And luckily, when you do opt out of Medicare, you have the first time you do it, you have a three month grace period to where if you want to opt back in you can. And so I ended up opting back in so that I could do some locums, and have recently done some locums in as a side, while my business is building, but it changes the way I see Medicare patients now. So now, if I do have a patient who is Medicare, at first, I was just taking a wait list and not seeing Medicare patients at all, just for from a simplicity standpoint, but now I just for, for Medicare patients who want to see me, I'm learning how to bill Medicare for that small group of patients. 

Dr. Tea  9:14  

I bet you a lot of doctors want to know how to keep that type of system in place, because there's always that fear that when we're building the business, we just won't get the revenue that we need to sustain a practice and to pay ourselves. So what would you advise a doctor who is just thinking about this hybrid option? Is that something for you? Is it long term, or is this temporary? 

Dr. Ashley Agan  9:39  

My plan right now is for it to be temporary, because ideally, my goal is to be full time in my practice. Being able to do locums is really great, because it does help a lot. But the problem. Is, is that it takes me, it takes me out of the office. So for you know, for a week at a time, I'm out, and for me, one of the, one of the big things that one of the reasons why my patients love, love seeing me, is because my availability is really nice, like, typically, patients can call me or text me and say, like, Hey, can you see me today or tomorrow? And typically the answer is yes, and so you know, if I'm out of the office for a locum assignment, then that makes it difficult to meet that that level of customer service that I really like to be able to provide. But on the other hand, the silver lining about, you know, doing locums is that it keeps my skill set up with, you know, things that we see in the hospital and ENT tend to be very different than the things that we see in clinic, because we're, you know, you're seeing more acute types of problems. And so, on the flip side, it's nice because it keeps me, you know, up to speed and keeps my skill set up as far as, like, practicing hospital type of, you know. ENT,

Dr. Tea  11:14  

so in the model that you currently have where you're doing a little bit of locums, you're building your practice, you opened up earlier this year. How has the patient load grown or changed from then to now?

Dr. Ashley Agan  11:29  

Yeah, the my my schedule typically on a normal week, at least with, you know, probably, if I'm just thinking about the last couple months, I might look at my, you know, next week's schedule on the Friday before, and it'll be maybe 25 to 50% full and and, you know, I, I used to think, okay, it's going to be slow next week, and then by The following Friday, I will look back at the schedule, and it it's, you know, filled to, you know, sometimes 100% sometimes 75% and so it's pretty cool to have gone, you know, if I think back to May, I should probably look at what the schedule looked like back in, like March and like in the spring, where there were, you know, weeks where you would see, I would have some days where there were no patients. And then now, you know, pretty consistently the week gets, you know, at least 75% full and and sometimes that happens as the week is happening. And so, like, actually, even this week, we're full. You know, at the beginning, this morning, I had several spots available this week, and now this evening, we're pretty much full for the week. So it's kind of cool. It's exciting that the word is getting out, and that, you know, patients are telling their friends and family, and we're starting to get busier.

Dr. Tea  13:07  

What does your model look like right now? Are you just paying a fee for service, which apparently is a bad word, because it comes from insurance, but it just means, hey, as you go, Yep. Do you also offer a membership? What does that look like? 

Dr. Ashley Agan  13:22  

Yeah, good question. So when I opened, I had an option for a membership, or just, you know, pay for your appointment. If you just want to come one time, you can pay one time. And the membership was just not super popular. And so I have a handful of patients who are on membership, but most patients just pay as they go, um. And it makes sense, because a lot of the things that patients are coming to see me for are very particular problems, um, that they just want fixed. And, you know, typically, with surgeries or procedures, we're gonna, we're gonna know within a couple of visits, okay, it seems like it's a good idea for us to proceed with surgery for this or that, or an office procedure and, and so that works well for most things.

Dr. Tea  14:27  

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Dr. Tea  15:53  

Are you doing any home visits or video visits?

Dr. Ashley Agan  15:57  

I have not done any home visits. ENT, or at least for me, my visits are kind of equipment heavy like so I'm frequently looking in the nose with a scope, or looking in the throat with a scope. I have a microscope that I use to look at the ears, so all stuff that would be hard to kind of travel around, although I do think that, you know, maybe, maybe in 2025 I need to figure out a way to offer something for home visits. I think some of my equipment is portable. It's just the the quality of the interaction would be different. So for example, when patients see me in the office and I do a scope, I can play back the scope and show them what their nose looks like, what their throat looks like, everything like that. If I were doing it like a home visit, I would be using a scope that I used to look through with my eye, and so I would just be seeing it, and wouldn't be able to kind of have that playback for them, which for some patients, they might, they may not. You know, I have some patients who are like, Oh no, no, I don't need to see it. Like, you can just tell me I don't need to see the inside of my nose. And so I am there. There probably is an opportunity for people who would just really appreciate you to come to them, or for me to come to them. So perhaps I am doing virtual visits, though I do for especially because I have a lot of patients who travel and so I will typically do, you know, we can do a virtual visit on the front end, and make sure that they kind of help them decide if they want to travel to see me. And then if we know, if once I see them in the office, if we need to follow up and see how they're responding to treatment, we can do that virtually. So the the virtual option does work Well,

Dr. Tea  18:00  

I am one of those people who could live life without seeing the sinus. And yet I found myself learning about the sinus because I was doing, like a I had worked with a micro surgeon who was like, enucleating an eyeball, which was pretty cool, but then he had also like, clear out the sinus, and I just saw this gob of goop, and I was like, I'm really happy to be at the feet, so I'm grateful that you can do what you do, and you're joyfully doing it. But I'm sure people say the same thing about feet, so for sure. All right, let's talk about your marketing efforts, what's working, what's not working. Help us save some money here. 

Dr. Ashley Agan  18:46  

I know. So I've, I've spent money on various types of marketing, like, like, for example, print, you know, magazines, local magazines, the but the best marketing has been other patients. Like, to be honest, like it's, it's word of mouth, it's other colleagues in town, my former colleagues will still send me patients. It's, and so I'm always, it's always interesting to me when I ask patients, how did you hear about me? And it's, it's usually word of mouth. I've had some, I have a social media presence that I've maybe slacked off on a little bit recently, but I'm on, you know, Facebook, Instagram, LinkedIn, and I, I've had patients who, you know, I remember this one patient specifically who like, heard a video, like, I don't know, I did some video on something on Facebook, and they were like, I heard your video, and I just could tell that I liked you, I trust I'm a good judge of character, and I could tell that I liked you. So they, you know, came to see me based on that. And. So I think the other things I'm doing, you know, I've been pretty active in my local Chamber of Commerce, and so meeting other people, you know, who are in small businesses, and I think that's been helpful. And what else, yeah, it's, it's kind of, I think ultimately patients are finding me because, oh, Facebook groups. I've, I've had more than one patient tell me that they're, they've someone on a Facebook group recommended me to them. And so it's, tends to be the things you know that are a little harder to control. I guess, like it. But, you know, just, just keep trying to, like, take good care of my patients and and then, you know, hopefully the word will get out.

Dr. Tea  20:52  

What's your competitive advantage? Do these people come with you with insurance, or are they uninsured? What does that look like?

Dr. Ashley Agan  21:00  

Yeah, it's a mix. I think that's another thing that's been surprising. You know, we talked about what, what surprised me. I wasn't really sure what to expect, as far as, like, who, what kind, who my patients would be. And I think from the outside, it's easy to assume that, oh, or you're only going to, you're just only, you're only going to see patients who have money if you're not taking insurance. And I found that to not be true. I think there are lots of patients who who they work and they have jobs, but they just don't have insurance, and they're looking they have to be a lot smarter with how they spend their health care dollars, because it's coming out of their savings, and because I'm not contracted with insurance companies, my prices tend to be better. So I have had patients who are just savvy and have sought me out because my pricing is better. The I think a couple of things that have been helpful are and as far as offerings for patients, I guess one. You know, when I was at UT, southwestern my my niche area of expertise was in Eustachian tube disorders, and particularly a disorder called patch of Eustachian tube, which is a more rare disorder that most people have never heard of. But that's that I kind of was known for, that there, and that has followed me so a lot of patients who had seen me there for their patchel Association tube or had been referred to me and I wasn't there anymore, they followed me to this practice just because it's, it's one of those conditions that not a lot of ENT doctors treat. And so, and the the condition is, it is very annoying for patients. It's, it's a big quality of life issue and so and so those patients have sought me out for that specifically

Dr. Tea  23:13  

In your community where you're at is direct care popular?

Dr. Ashley Agan  23:19  

I would say, yes, I mean, there's, there's, I'm in, you know, Dallas, and so if you look at kind of DFW broadly, there are lots of doctors practicing, like in the DPC, direct primary care model, as well as like in the concierge medicine model. As far as direct care specialists, I would say that's still kind of the minority, but I've had a lot of referrals from patients coming from other direct primary care type practices, and those are great referrals, because those patients are already accustomed to the model and that and that, those have been great referral partners, too. 

Dr. Tea  24:10  

I told you I used to live in Dallas, right? That was like my (I think I remember) sweetheart town. I was there for my fellowship. So when you say out southwest, it's kind of like hearing a gold crush. You're like, oh yes, those are fond memories. I had such a wonderful time there. And I do think that community supports what you're doing. So I'm happy to see that you're doing well, and it's just fitting perfectly, especially when you're coming from academia, you have all this knowledge, then you're shoved into this hole of private practice, and you're like, Okay, what do I do with all this? And then there's more. There's so much that maybe we didn't know. Coming into opening our practice, I know you talked to other direct care doctors. Do you also have an MBA? (I do Yeah) , how do you get that.

Dr. Ashley Agan  24:57  

So during i. Let's see here, I was supposed to graduate in 2020 I say supposed to because, you know, nobody had a graduation in 2020 but I was, I was done in 2020 and it was a two and a half year program. So I guess I started in like 2017 and it was a healthcare specific MBA and so I learned a lot about it. It definitely kind of helped fill in some knowledge gaps as far as things like managerial accounting. Although, you know, I was a I was an engineering major in undergrad, and so I've always kind of loved a spreadsheet, just, you know, at baseline,

Dr. Tea  25:48  

That is the nerdiest thing I just heard right now. I love that.

Dr. Ashley Agan  25:55  

I mean, numbers are just, you know, black and white, right and wrong, whereas medicine is so the opposite of that sometimes. And so there is a part of my brain that really loves, like, you know, just the cleanliness of a spreadsheet and numbers. And this is how much of you know, it adds up. This is what you need to make to cover your expenses, those types of things. And so that was really helpful when it came to trying to figure out how you're going to, you know, how much do you need to make to be able to cover your overhead expenses, and how much working capital are you going to need? And, I mean, it's really challenging to try to, I mean pricing, pricing by itself, I found to be challenging because it's, you're looking at, you know, the different things I would look at when I was trying to price services or appointments is, you know, looking at, looking at, like, what? What would Medicare reimburse for this, you know, as as one input, but then also what value is being provided beyond what a patient could expect going to a traditional clinic. And, you know, it's hard to put a number on that, because it's a lot of it is like thinking about your time and how much, how much you've trained to know what you know, how much of an expert you are, how many people are there that know what you know about this one subject and so and that was challenging, and continues to be a challenge, because I think there's a sweet spot of making sure that you're valuing the service that you're providing, but also being, you know, reasonable for patients to be able to come see you. And so that's something that I'm still learning and struggling through, but, and I'm probably priced too low, because most of the time when patients, you know, hear how much a surgery or something is going to cost, they go, Oh, well, that's not as much as I thought it was going to be.

Dr. Tea  28:14  

We can talk about pricing later if you want. I'm i This is my favorite topic, because it's not something that we were taught to do, and in fact, we were shunned to talk about it, because with insurance, there's this contractual obligation to not share, and therefore that's how they're able to control the cost of things, and that's why it's 10 times more than any of our private practices would ever charge. So it is a weird it's still a weird thing for me. You know, we're, we're nearing, you know, a time where we need to refresh our prices. I try to do this almost every year, just to make sure it reflects the level of expertise I provide. And you're right, it's, it's so subjective, there is no right way to do it, but you are pretty good with your prices. It sounds like, right?

Dr. Ashley Agan  29:07  

Yeah, I haven't, I haven't had any patients, you know, tell me that they weren't going to see me because of my, you know, my pricing being too high. Most of the time it's because they want to use their insurance. And I, I think my relationship with that reply used to be almost like feelings hurt, right? And now it's more like, okay, that's, I, you know, that's, that's fine. And I mean, I think it's just like understanding how people want to spend their money, and I think everyone's different, and it's kind of like buying a car or spending money on a nice vacation, like people will will spend money. On where they perceive there is value, on what they want and and some people would rather just, you know, they would rather have kind of a typical, standard doctor's visit and use their insurance and just have their co pay than to spend a little more to get a little more, I guess. And most of the time when I have patients who have never seen a doctor outside of insurance, almost. I mean, not 100% of the time, but a lot of the time when we're finishing the visit, they go, Oh my gosh, this was so great. You know, they're just the fact that we aren't rushed through our visit, and that they, you know, I have time to kind of answer all their questions. We we have time to get to know each other more like I feel like I have, I'm developing relationships with my patients, and I know about, you know, their daughter's upcoming wedding, and it's just more for me, this is a more fulfilling way to practice medicine, and I think for some patients, it's worth that extra spend to be able to have that kind of relationship with their doctor. And for the ones who don't want that, or don't need that. I totally understand that too, and I think I'm at a place now where it's less I don't, it's not about me, right? Like I don't, I don't get my feelings hurt that they didn't pick me. It's more like, oh, they just, they're they have a different preference for how they spend their money on health care, and that's okay. I'm not that. That means I'm not for them, if that's how they want to interact with the healthcare system. And I think that's for me. That's just kind of a healthier way to think about it.

Dr. Tea  31:51  

I love that transition. We took it away from personalizing or you don't want to spend on me to you do what you went with your money, not my not my deal. Yeah, exactly. Awesome. What a great reframe. What is something people may not know about you that you want to share? You? Like spreadsheets.

Dr. Ashley Agan  32:10  

I like spreadsheets.

Dr. Tea  32:13  

I hear the freak in the sheets.

Dr. Ashley Agan  32:19  

I let's see I, I have a three year old, and so these days, life outside of work kind of revolves around her, and you know her going, you know her activities and everything like and that has been one nice thing, being my being my own boss, and having my own practice is, you know, if I get, if I get an email from daycare that there's going to be, you know, a Valentine's party next week, I can, I can make plans and close my schedule and go be there for that, whereas previously that would, you know, usually I would be booked out already. Like, a week's notice is usually not enough when you've got a full busy practice, and so that's been nice to be able to accommodate, you know, schedule changes like that, to be able to show up for things like that, for her activities. 

Dr. Tea  33:27  

There's something about these schools that likes to tell us things at the last minute. All of December has been like that where, oh, she won an award, or there's an assembly and there's a peace thing to do. And I'm just thinking, who is just laying around the house waiting for these emails to come through. But yes, I too, have been able to rearrange my schedule to make it all every single one, and go on a field trip. And she volunteers for me, my six year old. So she's like, mom, and you're gonna you're coming, right? And that's like, you know, three days ahead of notice. So anyway, that is a luxury that I will never want to have taken away.

Dr. Ashley Agan  34:08  

Yeah, these years will fly by, and so it is right now, it's, it's, you know, it's, it's nice to be able to, to be able to show up and be there for those things.

Dr. Tea  34:19  

Thank you so much for sharing your experience with us. There's a doctor out there who's like, It must be nice. It sounds really nice. And they're just listening and consuming. We're not doing a whole lot of movement. What would you do? How would you encourage them to take some action, to make a change. 

Dr. Ashley Agan  34:41  

If you're thinking about direct care, then, you know, go be a direct care patient. You know, find a direct care doctor and experience it. Because I think that that, you know, being on the. Their side of it also can kind of help paint the picture of how it's just different all the way around. I think it's, it's different from the doctor side of it, it's different from the patient side of it. It's just so different from traditional medicine. And it might, it might help persuade you one way or the other, and not, not that there's a right or wrong way. I just think that, for example, for me, I think of this as providing another option for patients, and I still have lots of great colleagues who are working in like a traditional practice that accepts insurance and I, if they're in, they're great. And for patients who ask me, like, would you recommend, you know someone who takes insurance because I really want to use my insurance, I recommend those people all the time. And then they have patients who are looking for something different, and they send patients to me all the time. And so I think that this is about enough, you know, giving people another option and and so it doesn't have to be, you know, one is right or one is wrong. And if you're thinking, if you're intrigued, and think that this might be a practice model for you. Then, you know, kick the tires a little bit and experience it for yourself.

Dr. Tea  36:27  

That's a great one. I've not heard anyone say it like that before experiencing it yourself. Because I have to tell you, I see my friends who all take insurance, and I love them, but it's a pain, because they are always running over time. They're always trying to squeeze me in during their lunch period. And I'm like, Look, I'm not trying to take your personal time. I want to be a regular patient, but I also want your attention, and I would absolutely pay extra for that. And I do, I do that when I get a massage, I will go all out to get a massage, not just massage, but the environment, and we do the same thing in direct care. Well, thank you so much for your insight. I'm so excited to see where you'll be a year from now. I know it seems like an eternity, but I think we learn something new every single year we're in the business.

Dr. Ashley Agan  37:16  

Yeah, yeah. Thank you so much for having me, and for and for being, you know, for being a mentor to me and someone to look to, to learn from. I appreciate it. 

Dr. Tea  37:28  

Oh, you're welcome. This is my calling, my pride and joy, to talk to doctors like you, who is just so screwed. Let's just do it. I'm here for it. 

Dr. Ashley Agan  37:38  

Thank you. 

Dr. Tea  37:39  

If you enjoyed this episode, please give it a review and share it with a friend so more doctors can learn about direct care. Let's keep the conversation going on LinkedIn so we can help more doctors escape insurance and thrive in private practice. Thanks for listening. I'll talk with you next time take care you.