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'm so excited to have a new guest today, Dr Troy Harris, who is practicing in Jacksonville, Florida. He is completely cash. As of October, 2024 welcome to the podcast.

Dr. Troy Harris  1:06  

Thank you. 

Dr. Tea  1:07  

It's so nice to have you here as another podiatrist, a fellow podiatrist, who is in the direct care space. And I wanted to know about your story. How did you decide that you're going to be direct

Dr. Troy Harris  1:19  

I did not plan for this. When I graduated from podiatry school in residency, I joined the military and served for three years in the Navy. And when I was on active duty, I've always had an entrepreneurial spirit. And when I was active duty, I decided I wanted to do house calls. So I gained permission from my command, and they allowed me to do that. And I started just doing some local advertising and seeing people in their homes on the weekends, and I got a call from the director of a local assisted living facility, and she said, We would like you to see our patients. And I said, no problem, but I'm self pay. And she said, Well, that's a problem. We need you to be on Medicare. And she said, this will be very lucrative for you if you can do it, and we'd like to have you. And so I looked into it and decided to take the plunge and enroll with Medicare and and all the associated learning curve to learn how to build toenail and callous care. And started seeing the nursing homes, and it was a good introduction to the rigorous requirements for Medicare billing, for for what we do as podiatrist, a lot of research, a lot of hours, a lot of consultations, to be sure I build this correctly and and then when I got out of the Navy, I started a private practice in Jacksonville, Florida, where I am now, and I did not plan on being cash pay. I called the main insurance companies, United, Aetna, Florida Blue, and asked them if I could have a contract, and they all told me, No, we don't need a podiatrist. Our networks are closed, so I enrolled with Medicare in Florida, and just proceeded with that. Did primarily house calls and and after doing that for several years, occasionally patients would say, we'd like to have an office to come to. Do you have an office? And I said, No, I don't. I just do house calls. And so eventually I opened a small office, and I thought, that'll be nice to have an office to do administrative work and paperwork, and if a patient needs to come in occasionally, I can see them there. So did that and and gradually, more and more people came into the office, and when they did, they were either on Medicare, and if they did not have Medicare, I just said, I'm self pay. I'm not on any insurance panels, but I'm happy to have you. So through the years, the practice evolved away from primarily house calls. I started with house calls, five days a week, and then down to 432, and one, and then as of one or two years ago, I was a good four days a week in the office, and it was about probably, the more that time passed, the the more the mix became more cash pay and less Medicare, until the point that I was about probably 60-40, 60% Medicare 40 cash. And at that point, I spoke to a podiatrist in Maine, Dr. Michele Kurlanski, and she has a cash practice. And I started thinking about it, and I thought, Is it possible to bite the bullet and just go straight cash. And she was a big encouragement. Gave me a lot of tips, and so October of last year, opted out of Medicare.

Dr. Tea  5:32  

And how do you feel?

Dr. Troy Harris  5:35  

I think it's the best thing I've ever done. Yeah, it was, it was naturally very scary. I had no idea what to expect. I didn't know if my patients would stay with me, the Medicare patients would stay with me, but talking to Dr. Kurlanski, she said, you know, you're already halfway there. You're basically half cash as it is, and you're halfway there. And so, yeah, she was a huge encouragement to make the switch. 

Dr. Tea  6:10  

That's a really good point that you make. When I started my practice six years ago, Medicare was about 50, 60% of my revenue, and so I was not halfway there. I was all insurance. So I didn't have the vision to think about leaving insurance until people were talking about it. And it sounds like you didn't have any idea that that was a thing until you met Dr Kurlanski. So it's funny how we can just plant the seed and then suddenly you ask such an important question, is it possible? You didn't say, No, I can't do it. No, my patients won't pay. No. You know, you didn't put barriers on yourself. You actually asked a legitimate question, and you found yourself the answer, is it possible? And here we are. We're saying it is possible, but it is scary at the same time. So how did you overcome the fear? Or did you just go through the fear and said, Whatever, whatever happens happened. 

Dr. Troy Harris  7:05  

You know, looking back, I don't know how I did it. Thank the Lord, I did it. But as far as what really did the trick, I think instead of overcoming the fear, I was probably so frustrated with Medicare in the last proceeding, my opting out in the last 18 months leading up to that, Medicare audited me 12 times they they did one audit, which was just a routine nail and callous care audit, which I understand they audited pretty much the whole state of Florida podiatrist, so, you know. But they asked for about 4D charts, and I submitted those, and they audited me another time for 25 modifiers when you do an evaluation and management as well as a procedure in the same visit, which they apparently don't like. And I did a lot of that because I saw probably 10 patients per day in my practice, and the visits tended to be a little longer and more comprehensive. And I legitimately built these 25 modifiers, probably more than the average, and I think that was a red flag. So they audited me. I think they asked for 30 or 40 charts on that and I passed that audit. I passed the toenail and Callis audit. But had started doing durable medical equipment, and that's where the other 10 audits came from. And with the DME audits, they audited me once, and I passed, and then they audited me again for the follow up on the same patient, and I did not pass. And that audit, that note, was very well written, very comprehensive with clinical photographs to substantiate the collagen dressing that was applied. And I left out two words light exudate were the two words missing, and they failed me on the audit. I asked for a clinical review with the doctor, and the doctor said, At this level, I can't pass you. He implied that if I carried it to an administrative law judge, I probably could pass. I talked to a consultant, Dr. Michael Warshaw, and he said, you know, if you read the guidelines, the Medicare says photographs can can substantiate his evidence in these situations, and I had evidence of the exudate, or light exudate, but anyway, I felt that audit, and they audited me eight more times, which I passed all eight of those. And I was spending so much time doing audits that I finally said, you know, life's too short. Work. I'm working all the time, coming in on the weekends, catching up on paperwork. And I would say that is probably the straw that broke the camel's back, that pushed me, pushed me over the edge to opt out.

Dr. Tea  10:14  

Every time I hear about the audits, I just feel like these are those little strings, those little threats that are intended to crush us as a private practice, because we it's just us. And if we're not with patients, we're dealing with paperwork. We're dealing with people who can care less about what we did for the patients, the lives that we saved and so on. And so it's hard to share with doctors the pain that you feel unless you've been through the audit yourself, and so it sounds like you had to go through that hardship yourself to actually take the leap, because it would have been probably worse and continued on if you continued to stay with Medicare. I don't know if you heard recently about Medicare reimbursement to physicians as well. This trend will not end. The trend of auditing, the trend of decreasing payments to the physician, the trend of making us work harder for the dollar. That doesn't go away with time. It's actually gotten worse with time. If you had not gone through the audits, do you think you would have stayed with Medicare?

Dr. Troy Harris  11:17  

I do. I do. I think I would still be in the rabbit race. You know, another incentive to opt out was what you just alluded to with the cuts and reimbursements. Isn't it two years in a row that they've cut? Is that? Is that right? I'm not sure. But anyway, they've, they've cut, they've cut the payments. And meanwhile, inflation in previous years has gone up so much and our reimbursements are being cut. And then on top of that, you have the MIPS and the MACRA documentation that you have to chart, and if you don't, you're going to be penalized for that. So for me, this became more than just about me. This became a business strategy. When you look at the let's just say, Take, for example, if you do toenail care through Medicare, you're probably going to net around $50 let's say for the visit. What do you have to do to get that $50 you've got to verify the patient's insurance. You see the patient, do the treatment, do the chart, and you better do it right, or you're going to get the club back and audit. And then you have to build Medicare and collect the let's say they don't have a patient that doesn't have a supplement. You collect 80% of that $50 and then you've got to mail an invoice to the patient and collect the 20% and then later, you may be audited for that visit. You have to submit that chart to the patient, so, I mean, to Medicare for the audit. So when you look at that, that's kind of an extreme example, but it's real, and you look at doing that, what kind of care are you going to provide for the patient? And if, if you're in your competition, or maybe that's not a good word, but if the podiatrist down the street is doing that, and that's their business model, and you transition to a business model that's more realistic, where people pay you directly, even they don't have to pay you that much, compared to Medicare, you're not doing all that paperwork, You're going to have more time to spend with the patient at a competitive advantage. And I think it's an advantage that you're going to need going forward. I think we're heading more to this, and I think we're heading away from quality care if you follow the traditional insurance model. And yeah, I mentioned earlier that I was not on, not allowed to join any commercial insurance networks. Well, after I was in business for a few years, I got a call from Florida Blue and they said, Would you like to be on our panel and be a provider? And I said, Well, what's the what are the terms? And she said, we'll pay you about two thirds what Medicare allows. And I said, No, thanks. And so how in the world can you do it on two thirds of what Medicare allows? And I said, Yeah, I can't do that. No. Thank you. And they said, Well, you can try to negotiate after one year. Not not we'll raise your fees after one year, but you can try to negotiate after one year. 

Dr. Tea  14:47  

That does sound like a very bad business plan. And I think a lot of doctors forget that when you run a private practice, these are business decisions, and oftentimes we feel very tethered or very loyal to patients who choose. Use this because of the insurance. So I'm wondering, did you ever have those feelings of abandoning your patients because you dropped Medicare, or did they all end up staying with you? How did that look?

Dr. Troy Harris  15:11  

I think the biggest feeling that I had, I've always tried to model my practice, is patient centered and what's best for the patient. And this was one of the first times that I did something that may not be good for the patient, at least financially, because these patients who were on Medicare, they have that Medicare either way, and if they continue to see me, they're going to pay out of pocket. And because I've opted out of Medicare, these patients are not allowed to file self-filing claims. So it was difficult for me to have to tell my patients, look, the doors open for you to stay with me. I want you to stay with me. You're welcome here, but you will have to pay and, you know, knowing the whole time that they've got Medicare, they can go somewhere else and use their Medicare and not pay. So there's really no financial advantage to the patient to stay with me. But a lot of the patients overlooked that and stayed with me. And I would say probably, well over 50% have stayed with me. I haven't checked the numbers. Sometimes it feels like over 60% that have stayed and I'm charging very reasonable fees, and a lot of them have stayed with me. So I just, you know, that's been nice. That's been very, very nice to have them continue with me, those that have and others, they're on a fixed income. They just can't pay the money. And I've referred them to other doctors nearby that they can go to so they continue to have the care. And I said, if you ever need another opinion or anything comes up, the doors open.

Dr. Tea  17:08  

Are you advertising for your practice right now? 

Dr. Troy Harris  17:13  

Well, when I opted out on October 1, I was busy. And then about two weeks before Thanksgiving, the practice dropped off, and I started getting worried, and I I had time to advertise. Leading up to that, I didn't have time. I was seeing patients. So as long as I'm seeing patients, maybe I should advertise, but if my clinic is busy, I'll focus on the patients, but those two weeks leading up to Thanksgiving, I started getting worried. And when you opt out of Medicare, you have 90 days you cannot back in. And after that 90 days you're locked out for two years. And to be honest, leading up to Thanksgiving, I was worried I might have to call MEDICARE back and say, I need to get back on Medicare, because things dropped off. And then after Thanksgiving, it picked up again. And so from then until I had a slow week, a week or two ago, maybe two weeks, and I was able to focus on some advertising at that point, but thankfully, the clinic sustained itself and been busy enough that I haven't had to advertise too much, but I do use a virtual assistant, and she does behind the scenes Instagram and She manages my website and other things. So I guess, even though, personally, I don't do a lot of marketing, she she does some marketing for me, and sometimes I'll if the clinic's slow, I guess is the short answer to your question,

Dr. Tea  18:56  

What do you think made this work for you? 

Dr. Troy Harris  19:02  

I think probably that it was not a flip the switch situation. I think it took a lot of years to build up the patient babies, to build their relationships. I think if I had just come right out of school and opened practice self pay. I don't know if it would have worked or not, but I definitely had the advantage of about seven years in practice in this location to build relationships around town, where you get repeat patients. You get their family members, their friends, and I think without that, it may have turned into it may not have been as successful as it has been so far. 

Dr. Tea  19:55  

Take this behind the scene to what your practice, day to day looks like. Operations. How many patients do you see? Are you there full time? Do you still do home visits to see how many employees you have? 

Dr. Troy Harris  20:09  

I have never had employees other than a virtual assistant who's based in the Philippines, and then my wife did some of the billing tasks for me. At some point in my medical training, I learned about the concept of a micro practice, and that really intrigued me. And it was, I guess, mostly primary care doctors that did this, and they utilized computer technology to reduce their staff, oftentimes where the provider is the only employee of the practice. And I modeled that thinking when you don't have as many employees, your tax filing is simplified, your OSHA requirements are simplified. So many, so many things are simplified. Before I was a podiatrist, I've sold insurance and to small businesses, and I did that for about seven years with a with a Family Insurance Agency, and I, and all the small businesses that I sold insurance to, the number one headache and complaint of all the business owners was human resources, management, turnover, staff, dealing with staff. And I guess that stuck with me, and my goal in the practice has been to keep overhead as low as possible, to provide the patients what I would want if I was a patient, and what I would want is a streamline, easy access to the practice with the lowest cost possible. And so I've modeled my practice that way the whole time, and so the overheads have been very low. When I was active duty in the Navy, we saw about 15 patients per day, so I kind of got used to treating people at that pace, and I did work part time for a couple of podiatrists when I got out of the Navy and they were seeing many more patients per day, and that just didn't work for me. I felt like I just couldn't do that. So my practice now, I typically see about 10 patients per day, and just recently discontinued the house calls. I had probably 10 to 15 long time house call patients who stayed with me after I opted out of Medicare, and unfortunately, a few of those have passed away in recent months, so I just didn't have enough house call volume to continue, but I was doing house calls one day per month, so now I'm in the office exclusively, and a typical day when a patient calls, they I answer the phone when they call, a lot of people are really they're kind of taken by Surprise if they don't know me, and they're like, Wait, you're the doctor. You're answering your phone. And I say, Yes, this, this is me, you know, how can I help you? And that way I can kind of pre screen them and give them an idea what to expect, what the costs are going to be, and kind of develop a little, a little bit of a relationship with them right off the bat before they even come in. So when they schedule, they come into the office. It's a two room office. There's a waiting room and a treatment room, and the treatment room has my desk in it, and it's very well equipped. We have digital X ray, we have PRP, centrifuge, ultrasound, shock wave, laser, autoclave. You know, we can do a lot. I can do a lot in this small office. And so when they come in, they're greeted by me. They sign in, and I just welcome them here and walk them back. And it's a very personal experience for the patients. And we're not in a hurry, you know, we are a new patient. We may spend an hour with them. We'll do the X-rays, ultrasound if we need to exam and go over in detail, and again, I think that that's going to be really hard to do in a traditional practice. I don't know how much time we have, and I'm probably going to reach our time limit, but I can get on my soapbox about a lot of. Things You know, one of those is if, if they have commercial insurance, they're paying the insurance company for their medical care. And for these small visits, you know, a lot of the reason I can do this is not major brain surgery, cancer treatment, these are lower fee services that I provide. And for these small visits, if you use insurance, you look at the inefficiency of it, the money that they pay to Florida, blue or United, how much of that money is going to the claims processors, to their legal team, to their advertisements, to their building downtown, to their pre approvals and all the staff that goes back and forth with claims for doctors offices and how much is left for their medical visit. And so my philosophy is for the healthcare dollar for my patients to be used efficiently, where it's not being diverted to all these different expenses, and they get a more efficient, more bang for their buck medical visit. 

Dr. Tea  26:12  

That's such a good point about the inefficiency there is in such a big institution, because they're supporting the infrastructure. They're not really supporting the patient or the physician. And I think we don't know that when we're in training, we're in school, even our first couple of years of practice, we don't realize what's happening to the money until you become a business owner and you're wondering why a 30 minute visit paid out $12 when we have malpractice insurance to pay for when we have to deal pay out our liability insurance for our facilities and so on. And I do think this is something that we need to continue to share and let people know that insurance expenses are inefficient, and if people are unhappy with that, many are realizing that it is inefficient. That's why direct care doctors exist. We don't replace insurance. We're just here to supplement what's missing. So if you're not getting enough quality time with your doctor, with your current options, seek out a direct care doctor who takes away the inefficiency, like how you're having people just walk straight into your door, meet you and get the treatment, and that's all there is to it, versus what we are accepting experiencing you have to call for a referral. You get on a phone with somebody who doesn't like their job. They mess up on the administrative work and the paperwork, which has to be redone, they get greeted by a room full of people who have been waiting for a long time for their appointment. They're not seen on time, and they get to a doctor who's rushing throughout the appointment because now they're backed up

Dr. Troy Harris  27:50  

exactly. Yeah, and I was sometimes I worry, what are people going to think when I don't have someone to answer my phone? What are they going to think when they come into my office, and it's very small, and I really don't think it's been a problem. What matters is the equipment in the office and the care that you get in the office.

Dr. Tea  28:12  

Totally. I have the exact same practice. It's a micro practice. It's just me, a part time employee, a virtual assistant. I have all of the latest technology to help assist the diagnosis and the treatment, get them in and out quickly without having to fuss around with asking permission to do my job to get paid by somebody who can care less about the patient physician relationship. So I really do appreciate you sharing your story with us here, so there's a doctor listening, and they're very curious, or they're very scared about making the transition. What would you advise them?

Dr. Troy Harris  28:47  

That's a tough one. I guess it all depends on the individual situation. I thought you may ask this question, and I think the most practical advice is to realize the competitive advantage that you will have if you're not like the normal corporate driven, insurance driven practice, and focus on being efficient and providing your patients with that, with that quality care that they may not or that maybe instead of quality care, I should say giving them more attention and time than than the typical practice allows. And I think practically, the thing to do is to do it gradually and opt out of one at a time. So if you're a completely insurance based practice, I don't coach this. I know you. You probably have been doing this longer than me, and you probably know better than me, but my gut feeling that I would recommend generally to practitioners is to maybe drop one plan and then drop another plan and then drop another one, and. And aim for a hybrid practice. And then when you get enough stability and patient loyalty, then perhaps you could even take it all the way, like I did, and drop Medicare.

Dr. Tea  30:12  

That's stage advice. I say the same thing. Don't do it cold turkey, because you will see a drop in your revenue. It's going to give you a heart attack. So if that doesn't kill you, the trend of it going upward is actually very slow, depending on your resources. Of course, you know, if you're very savvy in ads and things like that, you can definitely pump it up faster. But I think that's very safe advice for anybody who's considering direct care. So thank you so much for sharing your experience. Any last words for the listeners?

Dr. Troy Harris  30:43  

No thank you for having me on. I think what you're doing is great, and it's good for patients. And it's not just good for doctors, it's good for patients as well. A lot of patients have asked me, Can you find me a doctor that works like you do? Can you find me a primary care doctor that works like you do? Do you know anybody? So I think the need is out there.

Dr. Tea  31:06  

I could not agree anymore. Thank you so much. Dr Harris, so nice to hear from you. You

Dr. Troy Harris  31:11  

Too. Thank you.

Dr. Tea  31:15  

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