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  

I have Dr. Jill Farmer, a nationally recognized Neurologist, is here with me today to talk about her direct specialty care practice. Welcome to the podcast.

Dr. Jill Farmer  1:03  

Thanks so much for having me. 

Dr. Tea  1:04  

I noticed your website, it says, when a national expert becomes your neighborhood neurologist, I feel like that encapsulates exactly what direct care is, what it does, and it's, it's such a beautiful way to put the words together, you know. And I wonder, is this something that you kind of came up with yourself?

Dr. Jill Farmer  1:24  

I did. So my background is English, so I was an English major, and before I went into medical school, I worked in public relations at Scholastic publishers, so I have a little bit of a background in marketing and communications, things like that. When I was at Scholastic publishers, which is around the corner from New York University in New York City. It's in Soho, so I decided to go back and pursue my prerequisites for medical school. So that's sort of my long, convoluted way of how I got into medicine. But I still love a good turn of phrase and a nice creative, you know, marketing piece. So I came up with that and the name of my practice, and the tagline for my practice, all of that.

Dr. Tea  2:19  

Yeah, that's brilliant. So the reason why I loved it so much is because I think there's kind of a misconception about doctors who choose to opt out of insurance or some kind of reject rebellious like, we just don't fit the common, you know, like the status quo, right? I mean, that's exactly what we are. We don't fit the common status quo. But that doesn't mean that we're not qualified, right? 

Dr. Jill Farmer  2:44  

Absolutely, absolutely. Yeah, no, I was going to say I think that going into direct specialty care was almost the opposite of that. It was because I am an expert. I do have a lot of resources and education that I want to share with patients. I wasn't fitting into the mold. I wasn't able to practice the way that I wanted to practice, in the restrictions that an insurance based practice would allow me to do. 

Dr. Tea  3:17  

And I think the general public has an understanding, at least, they're starting to move into understanding that a lot of the qualified doctors are leaving insurance, and it makes them feel like perhaps they're getting abandoned. Have you had experience with patients? Who did you take insurance before

Dr. Jill Farmer  3:35  

I did? And so I am a Parkinson specialist, so the vast majority of my patients are going to be Medicare dependent patients, and one of the ways that I felt comfortable in switching over to a direct specialty care practice was that I practiced in the same geographic area for about 10 years. So it was almost like I had a 10 year interview with these patients. And when I left to start my own practice and create this model. It was my hope that they felt that the care that they had gotten over that 10 years was worth paying out of pocket for. And I don't know if I would have felt as confident doing it, to be honest, if I was a new grad, like coming out and just trying to start my own practice, I think that might have been a harder sell, but having had a relationship with these patients and being able to explain to them my rationale, it was one of the ways that I think made it a slightly easier transition. That's not to say that there weren't a fair number of patients that, just on principle, were, like, I have paid into Medicare my entire life, like I just can't do this. And I said, I completely understand that. And I helped them find another provider that was accepting insurance in their network, things like that. And I would say about a third of those patients that didn't necessarily come with me initially have since returned and said, Oh, I see the value. You and what you provide, and I am happy to do this, especially when they realize, and I think this was a learning curve that I didn't even know that I had to provide, was that it's just the office visit. So many of my patients thought if I opted out of insurance, that that meant that anything that I would prescribe for them, any lab tests that I would order for them, any referral that I would make for them would not also be covered. And once I explained that, and they realized that they really only see me about three times a year, the cost benefit analysis on their end was like, Oh, this is well worth it.

Dr. Tea  5:37  

That makes a lot of sense, because I would have to agree, when I was early in my transition, I didn't take the time to articulate that to patients, because I didn't realize in their mind, they meant they thought that everything I would recommend would end up being out of pocket. So that I think that's really important to know if, if you're new to direct care, that you do have to explain to patients why it's a benefit to see you, so that they can understand what they're paying into, but also give them the comforts or reassurance that if you were to recommend things, prescriptions, drugs, referrals, those sorts of things, that it's actually covered.

Dr. Jill Farmer  6:18  

Yep, no, I think. And once I started explaining that, it definitely made the conversations that much easier. And like I said, I only came to that realization after a couple of conversations where patients were really concerned, and then I when I kind of dug a little deeper and I understood what their concerns were, I realized that that part was an easy fix, like I can reassure them that this is what they would still be able to use their insurance for, and what they would not and it seemed a lot less intimidating.

Dr. Tea  6:51  

So you were in practice for 10 years before with insurance, before you decided to opt out. What actually made you like it? Was there a turning point? Was there an incident? What happened?

Dr. Jill Farmer  7:01  

 No there. There was no specific incident. It was just sort of an itch. I had been with the same practice through different practice styles for 10 years. So when I graduated fellowship, I started at a hospital based practice, and then this practice as a group moved into academic based practice, and then this practice as a group moved out of academics, because the hospital we were affiliated with Hanuman Hospital in Philadelphia closed, so everybody had to essentially scatter, and that then became a large sub specialty private practice, a neurology, neurosurgery mix. And so I had kept my practice and my patients afloat through these three different transitions, and I was starting to think, well, if I keep doing this and I've done it, well, I kind of like to just do it for myself. And I got incredibly fortunate where my prior practice was supportive of this, because I think they were looking to sort of change their focus and care, to maybe be more focused on the neurosurgical side of things. So I wasn't met with that resistance or that stress we have, you know, parted on very good terms, and it's not even parting. I still work with them and see patients through their practice a couple of times a month. So it was really amicable, which I know is not always the norm, but I was really lucky in that way.

Dr. Tea  8:28  

So you got the support. You had an itch. Did you have a mentor to kind of show you what to expect? 

Dr. Jill Farmer  8:35  

I did. So I am, I'm the administrator of a large Facebook group called the Women's neurology group, and it's got women neurologists in the group from residency through retirement, and one of the physicians in that group. Her name is Dr. Jennifer Werely. She's in Greenwich, Connecticut. She has been a big advocate for direct specialty care. And she did this herself 10 years ago, and she kept telling people like, who are curious about it and wanting to emerge like, it's really not that hard. When you opt out of insurance, you're able to have a much smaller footprint. You're able to have a much more manageable office structure and administrative structure, where you can really be a one woman, show and make it work, and her encouragement and her consistent reinforcement that this was possible really kind of was the part that brought me over the finish line to actually do this. The other things that came to pass was there was an office space in my town where I live that became available. So I'm like, well, if I'm going to do this, I could, I could move into this space, and that would be worth it. So things were starting to align. My contract with my prior practice was coming to an end, and I said, now it just seems like the universe is telling me it's time, and then you are helpful. Well as well. When I was putting out questions to the Facebook world, like, what do I do for electronic medical records? How about prescribing? And you chimed in with your experiences, and I ended up using the practice, the simple practice, and the I prescribe, and it's been really very, very easy.

Dr. Tea  10:19  

Oh, I'm so happy because, you know, I'm glad you bring this up, because I'm part of a group as well, a podiatry specialty group. And there's a lot of us, a few handful of us, who talk about direct care. Oftentimes we get shut down, you know, we get, like, the majority of people, saying, don't talk about money. This is not the form for that. That wasn't the question that was being asked. And it's like people want to shut us down when we are trying to share a brand new perspective. And so just hearing that you were able to get valuable resources from what I say, that's really wonderful. You know, we all are entitled to our opinions, of course, of course, yep, but I feel like direct care is the most open minded. I think it's because we've seen both sides and we're like, yeah, that's painful, but we don't have to continue to suffer. It's a choice, yeah. So I'm checking out your website. You've got simple practice. Are you? You realize that they added a medication prescription option. Now that's brand new. 

Dr. Jill Farmer  11:22  

I had it because I've just been kind of chugging along with my own thing, but I'll take a look at it and see, 

Dr. Tea  11:28  

yeah, I just learned about it. It took me a while to figure out it's a little bit more expensive than the standalone I prescribe, but depending on your needs and your desire for convenience, you can do that directly through simple practice. And this is not an ad, but it's a feature I actually wanted to talk about in a separate episode, but because I was actually looking for another platform, because I was doing I prescribe on my phone, and then, you know, I would have to get the effects and then have it uploaded to the chart so that things are consistent and it's just painful. Even though the volume of my practice is low, it's still work. So just check that out. Yeah, see how that works. 

Dr. Jill Farmer  12:07  

I will. Thank you. 

Dr. Tea  12:08  

You have transitioned into your directory practice. How long has it been?

Dr. Jill Farmer  12:12  

A little over a year. So I left my last practice December of 23 and I kind of opened up mine February of 24 so we're just, we just celebrated our one year anniversary.

Dr. Tea  12:28  

Congratulations. I That's gotta be a huge milestone. 

Dr. Jill Farmer  12:32  

It was, it is, and it is, what has been even more reassuring for me is because my office space that I had found in my town is still under renovation. I've been doing, I pivoted a little bit, and I've been doing a lot of home visits and a lot of telemedicine. I'm a big advocate and proponent of telemedicine, particularly in my world of movement disorders. I find it incredibly helpful and very useful, you know, very utilitarian, for both patient and Doc, and it's worked well, and the majority of my patients have been my follow ups that have been part of my practice for 10 years. But over the year, word of mouth is a nice thing, and people new patients have found me, and I haven't really had to do any advertising, because I didn't want to explain the whole rationale for why I was doing home visits in telemedicine and didn't have a practice space and blah, blah, blah, and I was planning to open that up to advertising when the office opens, which will hopefully be by the end of the summer, but watching it kind of grow organically has been incredibly reassuring that it was a good decision like that. I waited and calculated and did my research panned out, and it was, it's been something that I've been very relieved by, because you take this leap and you don't know, and it is concerning. You know what's going to happen, but it's been working out. Okay. 

Dr. Tea  14:05  

This is a totally different trajectory than what I've experienced. And so I really enjoy hearing that you were already in your community for 10 years, so you already created that rapport, that trust, and you said, you said, that patience just ended up following you. So in your specialty, Parkinson's disease, you said that most of the people you see have Medicare. That is that correct? Yes, that's correct. So you, did you expect that they would stay? Or were you prepared to know that some many will not stay?

Dr. Jill Farmer  14:40  

I was prepared to know that many would not stay and I price. My price point was considered based on trying to be as enticing as possible. So I did not want to, you know, make it too low to underscore and under. Anybody else in the area doing direct specialty care. But I also didn't necessarily follow a concierge model or things like that, where it's a large buy in and there's some higher upfront cost, it's free for service. So it's like, I tell patients like, think of your dentist or or think of a psychiatrist, or think like, think like that. And I based it just a little bit above what the Medicare reimbursements are for new patients and follow up visits with a different pay structure for patients that do have out of network benefits and are able to get reimbursed. So basically, commercial insurance without network benefits is one fee for a follow up, a new visit, and anybody who can't submit for out of network benefits gets a 20% discount off of that fee. And I did that again, as a show of good will to my patients, to be like, I'm not trying to do this to price gouge you or to you know, rake in excessive funds or anything like that. I'm just trying to do this to have a smaller patient panel that will allow me to practice medicine the way I want to practice and give you the care that I want to give you, so that you can be as successful as possible in managing this chronic neurodegenerative condition. And like I said, not everybody was on board. More people were than not, and they also realized that they don't. Again, they only need to see me about two to three times a year, so it's not a the expectation was that, because I'll have the smaller patient panel, I'll be able to answer emails or have, you know, a conversation on the phone or something like that, without doing it begrudgingly, because I'm trying to add that in on top of a full day of patience, like I have the luxury of time where I can do that in between. So it saves them from having to see me, and it allows me to manage things much more, much more gracefully than I would have had to do in my prior practice. Models.

Dr. Tea  17:08  

This is interesting, because I know another Parkinson's specialist, and she has a membership model, and you're saying that you have a fee for the service model. How did you decide one direction or another?

Dr. Jill Farmer  17:19  

So I don't like stress. And for me, the idea of a membership model made it so that I didn't want to feel like I was constantly on call, like I am essentially constantly on call. But the expectation is I don't have to call you back right away, whereas, for membership models, the expectation is like, is when I reach out, like I'm going to get a return phone call, so I have the luxury of my outgoing voicemail message says that if messages come in for me after 3pm like, expect that they will be returned the next business day or the day after. Like, I don't have that expectation of being on call 24/7 like, on the weekends, I'm not going to reply unless it's like, truly an emergency or something like that, where I feel that the membership models and the concierge models are a little bit more hands on more consistently, and that's not what I wanted for myself.

Dr. Tea  18:10  

For those who are in neurology, are there certain specialties that you feel would be more fitting for direct care versus another? 

Dr. Jill Farmer  18:18  

I do. I definitely think about things that have chronicity. So stuff like neuro immunology, like multiple sclerosis, or again, anything within the movement disorder world, Parkinson's disease, dystonias, ataxias, things like that. For a different model, like, if it's not chronicity, but it is something like migraines, can be very nice for direct specialty care, simply because they are procedure based. But those procedures, since most of those patients have commercial insurance, have the ability to still have their medications and things paid for through their specialty pharmacy benefits and patient co-pay assistance programs. So those also could be attractive as a direct specialty care model.

Dr. Tea  19:13  

Have you come across anything that surprised you along this first year in your direct special care practice? 

Dr. Jill Farmer  19:19  

So I do do a fair amount of injections, whether it's for spasticity, for dystonia. I have inherited a few migraine patients from my prior practices, just because, if you inject for one thing, you inject for all kinds of things. But I was pleasantly surprised that Medicare has a specialty pharmacy benefit, and some of my patients that I thought I'd have to give up injecting had a fairly reasonable co-pay for their toxin, and I was still able to inject them. I was expecting to have to give up all of my Medicare, because in the insurance based world, it's a buy and Bill scenario. Where are you at ? The provider has to take on the onus of purchasing all the toxins then submit and get reimbursed on the back end. But since Medicare does have a specialty pharmacy benefit, I don't have to do a buy in bill, and it is again taken care of by the patient's insurance.

Dr. Tea  20:18  

I've not heard this term before, so I'm not, I don't even understand what this means. So when you need the toxin, you write the prescription and the patient picks it up, and then you inject it. How does that look?

Dr. Jill Farmer  20:30  

Yeah, so I can go to the patient. Usually I have it shipped to me, but I will write the prescription. I will send it to a specialty pharmacy, like a Walgreens specialty pharmacy or a CVS specialty pharmacy, and they will work on getting approval and co pay assistance if needed for the toxin, whereas, if you don't go that route, if you Don't do it through a specialty pharmacy, then the for someone who is on government insurance, whether it's Medicare, Medicaid, TRICARE, whatever it might be, you are responsible as the doctor for buying that toxin and then billing the insurance yourself to wait for the reimbursement on the back end,

Dr. Tea  21:20  

So you're saying you would write the prescription to a specialty pharmacy. The pharmacy will process the insurance, whether it be a prior authorization or collect the copay. Then where and the medicine gets sent to you? Or does you mean, 

Dr. Jill Farmer  21:35  

Yep, the medicine, the medicine gets sent to me? Yes. 

Dr. Tea  21:39  

Okay, that's cool. I had no idea, actually, so thank you for sharing that.

Dr. Jill Farmer  21:46  

Yeah, no, it was something I learned on the way, because I really didn't want to give up doing my injections. I really enjoy doing injections. I find them incredibly beneficial, incredibly therapeutic. And from a, you know, practicing point of view, they're fun to do like it's nice to do something hands on to a patient that you know will give them benefit. And I was really happy it didn't work for everybody. There are some patients where the copay is either just too high or they don't have a specialty benefit that covers toxins. And then in that case, I again, will happily refer them on to somebody who's in the network, because otherwise it's just too astronomical, and it's not something that I would ever feel comfortable charging a patient to do. 

Dr. Tea  22:31  

How would you know if the patient has that benefit? Is it like a Plan D or something?

Dr. Jill Farmer  22:36  

Yeah, so far, that's where the Specialty Pharmacy comes into play. They will, they will see and they'll let me know. 

Dr. Tea  22:42  

Perfect, because I was like, I can do less. I don't want to do more. Yeah, great. Has there been something that surprised you along this journey? 

Dr. Jill Farmer  22:52  

Again, I've been pleasantly surprised by the patients that are so supportive of it, like you're asking patients to pay. And many of them in my world are on a fixed income, or, you know, social security and things like that. But when they encourage you and see the value, and they say, this is especially when I do the home visits, when they say, this is just unbelievable. This is as much as we pay to go out to a nice dinner like it was. It makes it feel like I am not doing something that is more of a hurdle. It's reinforcing that I'm doing something to try and bring care. And part of my process of actually taking the leap, I did have to come to terms to realize that I was self selecting a certain population. I I knew that I wasn't going to be able to continue to see everybody, and not everybody would be able to continue to see me, and that took me a while to get comfortable with. What I have also realized, and it's been pleasant, is if this continues to grow, then I will be able to incorporate some patients that either need a payment plan or that I need to offer charity care to, or things like that, and I get to make those decisions, because it's my practice. And again, I don't have to go through the hurdles of administration or, you know, bureaucracy, of saying I can't see or have to refer somebody on to somebody else, if I choose to make the decision, then it's something I can do.

Dr. Tea  24:26  

What do you think is the biggest challenge for somebody who is within your situation and coming from an employed or insurance based practice and wanting to start their own direct care practice?

Dr. Jill Farmer  24:38  

I think the biggest challenge is to feel comfortable juggling many hats like you become the administrator. You become the marketer. You become the clinician. I like many hats. I like having it not being the same exact thing every single day. Right? So that was appealing to me, but for somebody else, that might not be appealing. The other thing is to be creative. And if you are concerned about revenue, and you know, if you are the primary breadwinner of the family, and this is going to be a big financial risk, look into making sure you have other revenue streams that can help supplement and support whether that's consulting or being working with pharmaceutical or industry or something like that. And again, that's something that might not be appealing to others, but for those that it is, it can be very rejuvenating and invigorating to feel like you're in control of your destiny of how you want to practice medicine and shape your practice.

Dr. Tea  25:51  

If there's one thing you can change about your career trajectory into direct care, what would that be?

Dr. Jill Farmer  25:59  

I wish I would have done it sooner. I, yeah, I really was not feeling compelled to, you know, continue in medicine like after the pandemic, and, you know, dealing with so much of the culture of medicine that I felt was outside of my control. And, you know, it was, it really re-invigorated my enjoyment of the clinical practice and it, and I get that this isn't necessarily for everyone. I'm in a nice payer mix. I am not in a low cost of living or, you know, gentrified area. So I am well aware that this is something that is not going to be feasible for everybody, and I don't want to say that it's the panacea for all people who are disgruntled in their current practice. But if it is something that you're truly looking into then do yourself the favor of at least exploring how it may be something that you could transition to, or incorporate some principles into what you're doing. 

Dr. Tea  27:13  

So you like to wear a lot of hats, and so I imagine you like to do stuff outside of your clinic. Do you want to share some of the things that you enjoy, 

Dr. Jill Farmer  27:23  

sure, so I'm a big educator. I really, really enjoy doing patient education and provider education. So I am on the board for New Jersey, New York. I'm sorry, New Jersey Pennsylvania, Parkinson's foundation. I am on the board for rock steady boxing International, which is an exercise regimen program for patients with Parkinson's disease. I do a fair amount of consulting with pharma, and I do education for nurse practitioners and physician assistants through AMDAPP, which is a new organization specifically for movement disorder nurse practitioners and physician assistants. 

Dr. Tea  28:17  

So not all of that is paid,

Dr. Jill Farmer  28:21  

so that all of that is paid, so it's not like that's where I'm making, like all of my money, the pharma consulting stuff is but the rest of it is volunteer work, and I wouldn't be able to do it if I didn't have the flexibility over my time and my schedule.

Dr. Tea  28:34  

Yeah, and I think that's what a lot of us crave, is just that. I call it creative freedom, just the free will to do what we want to do, absolutely wonderful. Do you have any last words of advice or encouragement for the listeners 

Dr. Jill Farmer  28:48  

Like I said, if this is something that you are toying with, I would try to seek out people who are in your specialty, who have done it before, and get as much information as you can because it really is not as hard as you think, and there are ways to position yourself for it to be successful. So I would just encourage people to follow their dream of practicing medicine the way they want to practice.

Dr. Tea  29:17  

So in case, do you guys miss two key points that were made about direct care. The first is, do it sooner. And the second is, it's not as hard as you might think it is. And I have to agree with those two things. Well, thank you so much for your time today. How can people contact you?

Dr. Jill Farmer  29:35  

Thank you. So my website is www.boroneuro.com that's B-O-R-O-N-E-U-R-O dot COM that is, you can send an email or anything through that website, but if you did want to email me directly, you can email info@boroneuro.com 

Dr. Jill Farmer  29:36  

What is BoroNeuro? What does that mean?

Dr. Jill Farmer  30:02  

So borough is where the practice is, in Hopewell Borough, New Jersey, and in town there are things like Borobean and borocollision and boro like. It's just sort of a prefix for some other businesses, and it rhymed with neuro. So that's why we liked boronaro. My husband came up with that, but then I came up with, since it's in Hopewell, New Jersey, I came up with, move, well, live, well, hope. Well, 

Dr. Tea  30:30  

That's perfect. I wish I lived in a town that rhymed with podiatry. But anyway,

Dr. Jill Farmer  30:36  

That's a little harder. Yeah.

Dr. Tea  30:39  

Well, I thought about podiatry by the sea. And I was like, I don't want to change my business name anymore. I'm over it. Well, thank you so much for your time. I look forward to talking to you again and seeing how life progresses for you and your direct care practice in the next couple of years, anytime.

Dr. Jill Farmer  30:57  

Thank you so much for having me. This was fun. 

Dr. Tea  31:02  

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.