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  0:53  

What is the mindset shift from owning an insurance based practice to having a direct care practice? I started my practice with insurance because that's what everybody else did. And so you're going to learn through those lenses. And I really admire those doctors who, straight out of training, decide to open their own direct care practice, and they are killing it. It's like a whole new world out there. So I'm so excited to see what the new generation are doing now that they are empowered, and now that they have this information to know that there is a choice. But for me, when I had graduated at a fellowship, after three years of surgical residency, I hopped into a fellowship. After that, I was so ready for academic medicine, that was my training, that was my area of interest. But then I was married, and I had to make decisions as a couple, right? And so I never really went into academic medicine. I took a job with a group here in California, and it was great in the beginning. You know, there's that honeymoon phase where you're excited, you feel like you've made it, you got a paycheck every two weeks. Feels really comfortable. It's very cushy. And not to mention that I also live by the ocean now, which is very different from places I used to live in the past decade, which was Iowa, Michigan and Texas. So you would think, if I were to complete my story and say that was the end, that that was a happy story. But then, as many of you know, I got pregnant, and at first I was excited because my boss was supportive and saying, you know, it's okay if you get pregnant, we'll just accommodate you. But then something changed, and I don't know what it was, but the tone changed, and I found myself not having control in my schedule, and ultimately it just didn't work out. And so we parted ways, and I was kind of put between a rock and a hard place, meaning I had no idea that I wanted to own my practice. It was kind of like I had no other option, because in the small community of Santa Cruz, California. It's kind of like an island. It's a city on its own. But we had moved here, and my husband has a job here. He's a general surgeon, and he's stayed with his job ever since, so things were nice and steady for him and for me, I didn't know what to do. There weren't a lot of job openings for podiatrists, and the only private group that existed was the one I left. So what I do from there? Do I just take a job and have to commute out of town like lots of other people do? I had a little one at the time, and so I felt like I truly didn't have a whole lot of options left. There wasn't a job to pick up. It wasn't like it was posted on Indeed, there wasn't a lot of saturation for job opportunities for podiatry out here. And, you know, sometimes I daydream about being a stay at home wife, but I'm a little bit too antsy. I don't think I would have really done well in that. So then I was like, Okay, what's the next best thing? 

Dr. Tea  3:58  

What can I actually try to do at this point to make my whole life situation work, because of this huge change, I was bringing in the baby to the world, and then I left a job that we were both unhappy, and, you know, employer and myself, and so it was like, why do we need to torture each other if we're both unhappy? So I was like, Okay, fine, I will just open my own practice. And that was it. I made the call, and I said, Okay, I saw what I saw in that business. I saw things that I wanted to improve upon. I think I can do it better. I think it could be more efficient. How hard can it be, right? The most dangerous words any less can say, how hard can it be? Turns out, it's pretty hard. So yes, I didn't go too far from my existing practice to open my own practice, and it was hard, but at the same time, in the honeymoon phase, it's exciting, you know, I'm thinking about what I want to build, and I'm actually building it. I'm seeing things come to life. I'm picking out the paint. I'm talking to the landlord about walls to put up, things to take. Down, and then eventually patients show up, and I'm like, holy cow, I'm actually doing it. So then at this point, I'm taking all of the insurance, because that's what people told me to do, because no one ever gave me a different option. I don't think I've ever met another podiatrist who did not take insurance, and that's unfortunate, because they exist. They just didn't exist in my little sphere, in my connection. So I did the thing, got all the consultants, and then soon enough, I found that my overhead was beyond the money I was bringing in. And so I had a doctor ask me if I had held out a little bit longer to see my business mature? Would I have stayed with insurance? Because I hopped out of insurance, probably about, I would say, a year and a half I was already thinking about it, and then after two years I started to slowly drop one by one. And I appreciate this question, because it was pretty thoughtful. 

Dr. Tea  5:58  

You know, when you own a business, you don't really know when you're going to break even, especially when you're taking out a chunk of money to invest in making it really nice, and to get all the things and to have capital for your equipment and to make sure you have some money for your staff. But I remember thinking, it's not just about the money. When you're bound to insurance. You are bound to their rules, their regulations. And there was a risk in my mind about it too, because once I render the service, they have all the right to reclaim it back. They have all the right to dispute it and say, we changed our mind. We are no longer covering the service. And this has happened in many specialties where surgery was pre authorized, the surgery was done, and then months or years later, the insurance decides to do an audit, and they say you don't have enough documentation, or they say this is not a COVID service without any other reason, they have no accountability whatsoever to patients. So then what happens? Well, then the patient gets stuck with a bill they probably wouldn't have had if they knew insurance wasn't going to pay for it, right? 

Dr. Tea  7:11  

And so it became this whole ethical question. It became a very global issue for me, thinking about what is actually right? Is it really right that patients don't know the price of things. It didn't feel good to me if I did a service saying that, hey, we got the prior authorizations, and then later on, insurance changed their mind for whatever reason, those things were out of my control, and I deeply hated not having that control. And so we end up being the doormat for insurance. For insurance. So that's the issue here. So the answer to the question that the kind doctor had asked me, you know, if I held out long enough to I think I would have done better. I think my answer is still no, because I would have lost my mind. I would not have been happy. I would have been a whole nother version of myself, I would have been hustling for the pennies, fighting for every little dollar that seemingly was dripping through. I don't think I would have survived mentally, and I had a little one, and I had other responsibilities, and I was like, I really just wanted to practice medicine, pay my staff. I wasn't even paying myself at the time, and I just want to make this work. Like, is it really that hard to just tell people that I'm trained to do the thing that they want me to do and then get paid for it? Like, if you think about other service industries, you want to get your hair cut, you want to get your nails done, you pay done. There's no middle man to negotiate with only in medicine, and that's wild, because we have all come to accept that that is just the way it is, which makes it very difficult for doctors to feel empowered that there is an option. But I'm glad you're here, because you know that there's an option. So I wanted to take away that feeling of disempowerment, and that's why I walked away from insurance. It was so suffocating to have to deal with the claim denial with a wrong code, with a wrong diagnosis, with the patient saying you're not billing correctly, therefore I'm not going to pay you. Blah, blah, blah, blah, blah, you know, it's a whole thing. I just wanted a simple business where I was respected for the work I was doing, for the training I had undergone to take care of people. So we have, somewhere along the way, normalized seeing 20 to 30 patients a day. It's kind of wild. Talk to a non medical friend and just tell them what it's like to run a practice seeing 20 to 30 patients a day. It's like meeting with 20 or 30 of your friends, but each time you have to write a note and summarize what that meeting was about, you do this day in and day out. It's kind of crazy, right? And then we normalize that these visits are very short. They're not like an hour long. 

Dr. Tea  9:55  

They're down to seven minutes on average. And in many instances, we have. Realize that it's okay for patients to wait weeks or months, and I've even seen arguments as to other countries where they have universal health care and it takes them nine months to get an MRI. But listen, we're not in other countries. We're here in the United States. So I'm not arguing about other countries. I'm not even arguing about universal health care. I'm talking about owning a private practice that's easy, so we can't compare apples to oranges. Okay? It's not okay for my patients to have to wait months to see me, because that can mean a difference between having a little infection to a full blown out baloney amputation. That's not okay for me, that's not efficient, that's not kind, that is not accessible medicine, and that happens even when people have insurance, unfortunately. So my purpose has always been to advocate for people to know their choices, patients and doctors, and for them to decide what to do with that information. So in this insurance model, we are functioning in a way, in a pace that's consistent with it, right? It's volume based, the more you see, the more money you make. That also means that when your schedule is tightly packed and somebody shows up late, or somebody asks more questions, or somebody you know just needs more time, it will shift your entire day, and then suddenly you have a line full of pissed off people who are like this doctor is never on time, and then you get yelled at. You feel the consequences. You get the negative Google review. This is not your fault. This is a systems problem. And until we can see that it's a systems issue, that no matter which way we code, how we do, what do they call it creative billing to make more money, whatever, you know, like that. First of all, that's illegal. Okay, I'm not advocating for that, but we can play the rules, but the rules will continue to change. That's why I left insurance. It wasn't just the money, it was the fact that I couldn't do what I needed to do for my patients. I lost my autonomy, I lost my sanity, and I know a lot of you are feeling the pain too. So now let's talk about moving into a direct care practice when you make the decision to increase your cash flow, I want you to think about opportunities where you can increase non covered services now that could be introducing a technology that insurance doesn't pay for. So in the musculoskeletal realm, there are things like laser therapy, shockwave therapy, regenerative medicine, that's not covered by insurance, and it's legitimate science. It works. So you can start increasing that, learning more about that, and adding that into your services to increase your cash flow. You educate your patients. Here are your options. Here's the cost. That's very typical for podiatry. 

Dr. Tea  12:47  

What I realized also in podiatry, that it's not very common in other specialties, because they also help other specialists build their direct care practice, is that we sell a lot of stuff. We make a lot of recommendations. I'm often sending patients to Amazon to buy things, which is nice because it's exactly the product I recommended, and it gets delivered to their door, you know, the next day or whatever, whenever it gets there. But it's pretty fast. Or I sell it in the office, they can just grab it and go, such a huge convenience. And patients get the exact thing you told them to get, whereas in other specialties, there's a lot of hesitancy, because they're not used to selling stuff in the office. So I think it's pretty cool that we can cross share what works for our practices amongst other specialists, which is why the podcast is called for specialists, because we can learn so much from one another. There is such diversity that we can pick and choose what's going to work for us so you can increase your cash flow by offering non covered services. You can sell products you already recommend. It's not sleazy, it's totally normal. You already tell them what you recommend. You might as well either choose to sell a higher end product in your office or create an Amazon storefront and to send them that way. Whatever you can do to make their life easy, they will appreciate it. So doing it this way will help bridge the kind of the knowledge gap between how to sell to a patient, how to market yourself, and then finally, help patients with what they truly need. 

Dr. Tea  14:15  

That's the steps you need to take to develop a direct care practice so you can start introducing new things into your practice and start having those really awkward money conversations, especially if you've never been comfortable doing so, and especially if you think hiding behind a staff member will save your practice. Now listen, I know there are a lot of doctors who think that they should not be having money conversations with patients, and I feel, I feel that, like I get that it's, it's not something we're trained to do. It feels really weird, maybe even icky. And if you're not comfortable, it's going to come off really weird to the patient too. And so you might end up not selling something because of how you feel about the situation. So I get that, but let me just tell you, I. You tell my patients what things cost, and it allows me to practice being uncomfortable, and it also helps bridge the trust. When I can look them in the eye and I tell them the price of things, they get it, they're like, Well, yeah, you know, you're an expert, you know stuff, and I understand. And it's not uncommon that I tell a patient, you know, this is what you would get for $3,000

Dr. Tea  15:25  

and they either pause, they gasp, like it's crazy expensive for them, or they agree. And so you mentally prepare yourself to expect one of those three responses. So you know, it's something to learn. Say what you need to say. It's uncomfortable. But in doing so, I feel, I deeply feel this. I feel like it is the most honest thing that we have to offer in medicine to build that trust again, to not hide behind another staff member about the price of things, to truly be there with the patient and say, I know this sounds like a lot, but it costs what it costs. Don't try to price yourself to be the bottom of the barrel. Pricing doctor. Nobody wants surgery that is the cheapest, right? What does that imply that you're not going to have good quality? And yes, there are people out there who want the cheapest surgery, fine, but that's not how you want to build this practice. You really want to price it in a way that respects the work that you do and the knowledge that you have, and it also elevates the entire profession when you do that. So not only is it great for you, but you're elevating the medical experience for others as well. So I feel that it is very important to be able to talk about money in an honest way. It's really uncomfortable. I totally get that. I often catch myself feeling that discomfort too, and that's when I know I haven't practiced enough, or I haven't conveyed the value clearly enough. But over time, you will get better, and you'll see that patients do appreciate that transparency, and you build that relationship with them, and then you see that they respect you for that. Now I do know practices who do offload the financial conversation to another staff member. I'm sure it works, and if it does, great you've got a system going for you, but for me, I'm okay with telling people my prices. I'm actually very proud of the progress I've made to be able to get to that level. It's not always been that easy for me to talk about what things are going to cost, but then I got over it, and then I realized the people who really want my service, who really need it, they'll find a way to pay and how they view the situation is all in them. I have nothing to do with that. I just provide the options and they can decide. So once you go through the process of increasing your non covered services, maybe it's musculoskeletal pain relief, maybe it's esthetics, something of that variety, then you start having those money conversations. Then you start seeing how people interact with you, and you start cataloging how people respond to their objections, and then you start practicing how to deal with those objections. A common objection is, Oh, that's too much money. And you can respond and agree and say, I get that, and that's it. You just agree with them. And I know that's not hard to do, because you probably feel it's high too. But listen, if you want the thing, this is what it costs, period. So anyway, if you want to do some of that training, you can send me a DM. I'm happy to get on a call with you and help you through the dialogs that I've had to go through myself in order to get to where I'm at, where it's very easy for me to ask patients to pay me for the services they're looking for. So the mindset shift from owning an insurance based practice into direct care is learning key skills. 

Dr. Tea  18:51  

One of them is marketing, how to sell your stuff. The other is having weird money conversations, which takes time for you to get used to. Once we all start to do this. We normalize that this is just business. We depersonalize it. We don't make it a thing like if they don't pay for our services. We don't take it personally, just the business transaction. There are many more where people will choose to pay. Just realize that it's all a numbers game. If not enough people know about you, you gotta go find them. If not enough people are buying your stuff, then maybe it's a communication issue. All of these things you can learn, but it just takes for you to be willing to take that first step, to be uncomfortable and learn what you need to learn in your business. Tell people how you can help them. Ask for the money. Start practicing now, start offering things, start raising your prices a little bit. Get to a place where it does feel uncomfortable, and then you will see that you will eventually turn into the person who owns a very successful direct care practice that makes money. And then you can do whatever you want with that money. You can give it to charity. You can put it back in your business. You can give your staff bonuses, whatever you need to do with that money, do something nice with it, because you deserve it. That's all I've got for today. I'll check back with you next week. Take care.

Dr. Tea  20:14  

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.Bye