Dr. Tea Nguyen (00:53.614)

I want to welcome Dr. Demetriou Aguilar from Total Pain Solutions here to the podcast today. Welcome. 

Dr. Demetrio Aguila III (00:59.938)

Thank you. It's exciting to be here. 

Dr. Tea Nguyen (01:02.242)

I've seen you a lot on LinkedIn, so I really wanted to get to know you because you offer pain solutions, but also it sounds like surgical interventions too. Is that correct? 

Dr. Demetrio Aguila III (01:12.178)

That's correct. And really the two are tied to each other because we offer surgical solutions for chronic pain, which I think is a... I'm a little reluctant to use the word novel because the idea has been around for decades. There just aren't that many of us that are trained to do it. You know, I'm sure as a podiatrist you're familiar with Lee Dellen. you know, so he's the one that trained me in peripheral nerve surgery. You know, there's probably, I don't know, three or four hundred comprehensive peripheral nerve surgeons in the United States of which maybe a dozen, maybe two dozen of us focus almost exclusively on surgically solving pain. And so I happen to be one of them. 

Dr. Tea Nguyen (01:53.932)

Yeah, do you happen to know Dr. Steve Barrett? 

Dr. Demetrio Aguila III (01:57.26)

I know the name, I don't know that I've met him. 

Dr. Tea Nguyen (01:59.8)

He was on the podcast as well. He has chosen direct care in his practice, but he's also on the leading edge of nerve surgery, microsurgery and things. And so it's really wonderful to hear more from doctors, from surgeons who are in this arena because me personally, pain stuff scares me. It freaks me out. I feel people's pain. And so it's, I don't know how you feel when you interact with patients, but for me, feeling patients pain is so severe. makes it hard for me to give complete care, because I'm in completely like, I'm absorbing their stuff. 

So when things don't go well, I'm there with them when things aren't going as planned, it's just been really hard for me. And so actually my favorite kind of patient are those who can't feel to be honest, because I can be their eyes for what they can't see. But nonetheless, I really do appreciate the services you provide. I want to learn more about how you started your practice and who are you? 

What was life like for you before you decided to have a direct care practice? 

Dr. Demetrio Aguila III (03:03.746)

So those are all great questions. I mean, my goodness, those are in their own way, they're kind of loaded questions, right? So I started out as doing a general surgery internship. I was in the Air Force and the Air Force wanted me to become a flight surgeon. And they said, hey, listen, would you be interested in getting into the astronaut program? Because we'd really like for somebody to go into the astronaut program as a physician. I said, that sounds awesome. 

How do I do that? They're like, well. Go ahead and start in general surgery, then we'll train you in aerospace medicine. And then after that, we'll go from there. I said, okay, sounds good. And so that's what I did. And I got, you know, I volunteered for a combat assignment, F-16s in Korea. And then that was fun. That was so much fun. You know, flying F-16s and practicing medicine. Mean You know, they're like, by the way, we'll pay you extra to do that. And I was like, you're going to pay me extra? Where do I sign? Right. But I realized pretty quickly that all the people that I knew that were trying to get into the astronaut program didn't even get the, don't call us, we'll call you letter from NASA. And I was like, well, if these people who have more letters after their name than they have in their name, aren't able to get in, well, you know, what does it take? 

So I did a little digging, it didn't take long for me to figure out that, you know, there have been more US Olympic gold medalists than there have been American astronauts. And there've been more U S presidents and there have been men on the moon. So I was like, well, that sounds like I should probably choose a different path, something a little bit more, a little bit more achievable. And I realized at that point that I missed the operating room. And so the air force was looking to send somebody for training and head and neck surgery.

Dr. Demetrio Aguila III (04:49.102)

 And I volunteered and you know, and so I got to do, you know, the Air Force sponsored my training at Mount Sinai in head and neck surgery. And during my last deployment to Afghanistan, I was doing a lot of head and neck reconstruction. And then the Air Force said, you know what, we're looking for somebody to further specialize in comprehensive reconstructive and plastic surgery all over the body. And so I volunteered again and they got my application mixed up with somebody else's and I got to go to Hopkins. I was very excited about that. And so then, you know, I did my plastic and reconstructive surgery training at Johns Hopkins. And it was there that I met Lee Dellen, who's kind of the godfather of peripheral nerve surgery. And he took me under his wing. He said, I want you to do my fellowship. And so I did. And of course, you know, when I left the Air Force, I figured, oh, peripheral nerve surgery will be maybe 5 % of my practice and the rest of it will be split between head and neck surgery and reconstructive surgery. 

Dr. Demetrio Aguila III (05:43.822)

And I started my practice in July working for one of the hospitals. And by Christmas of that year, 50 % of the patients that were coming to see me had pain problems that they wanted me to treat surgically. And so the rest of the practice has grown organically since then. And that was, what year was that? That was in 2014 that I, you know, that I left the air force. And now I do almost exclusively peripheral nerve surgery to treat chronic pain. And then, you know, as to direct care.

Dr. Demetrio Aguila III (06:13.122)

The reason I got in direct care is because I was thinking about opening up my own practice because the hospital was making it harder and harder for me to treat the patients that I wanted to treat. And so one of my colleagues who he's a mentor of mine, he's been in private practice successfully for decades now. I said, how do I do this? Can you teach me how to do this? He said, yeah, I'll teach you how to do it. But what I want you to do first is go to the free market medical association conference. They'll teach you everything you need to know. 

Dr. Demetrio Aguila III (06:41.07)

I said, okay, well, I didn't know anything about the free market medical association and I went and I don't know if you've ever had this experience. Maybe some of your listeners have. got there and yeah, I was in the air force for almost 22 years. I felt like I was on a Navy base. You know, like when you're on one, when somebody like myself goes to a Navy base, all the signs look like they're in English and everybody sounds like they're speaking English, but I had no idea what anybody was actually saying. Yeah. was like, can this be? I consider myself a reasonably well-educated person. 

Dr. Demetrio Aguila III (07:10.87)

And I don't understand what anybody's saying. And I started to wonder, did I pick the wrong sessions to attend? Until finally, Ake Kempton, who's one of the founders of the Free Market Medical Association got up and he started talking about the cost of care to an employer, total cost of care to an employer for a total hip replacement at the University of Oklahoma versus the Surgery Center of Oklahoma. 

Dr. Demetrio Aguila III (07:33.262)

And this is in 2017 that I was attending the conference, right? So now you might be familiar with those numbers. I certainly wasn't familiar with those numbers at that time. And I was blown away when he said, yeah, total cost of care. In other words, what the employer pays, you know, whoever the insurance carrier, so the insurance carrier will then pay everybody else was $275,000. From the time that the patient identifies the problem until the patient's finally done with all their care. Compare that to the Surgery Center of Oklahoma who has subcontracts with all the same players and is able to provide care that is as good or better with the same surgeon and get better outcomes. The total cost of care to the employer is $15,000. And I was like, I literally had to stop myself from running out of the room and just vomiting all over the floor. had such a horrible visceral reaction to that because right away I realized the implications. wondered, well, how many of my patients have I done this to? 

Dr. Demetrio Aguila III (08:31.998)

How about all of them? And then of course you could argue, well, you didn't know, it's not your fault. You were ignorant. Well, guess what? I'm not ignorant anymore, which means now I'm morally culpable for every single person that I hurt financially moving forward. Now I know. And so now I'm responsible. And that was the genesis of my journey into direct care because as Keith Smith likes to put it, I did not want to be an accessory to financial rape any longer. could not, I couldn't fathom continuing to take advantage of my patients that way and really hurting them when these are the people I'm trying to help. 

Dr. Tea Nguyen (09:09.518)

This is such an important point that I don't think we talk enough of on this podcast because we really don't know the financial implications we put patients under when we ourselves don't know the cost of medical care. We may know that we have a protocol, we go through our checklist, let's say pre-op surgery, for example, everybody gets the EKG, everybody needs to go back to their primary for medical clearance or whatever they need. We just go through our checklist. 

Dr. Tea Nguyen (09:36.098)

But we don't know the dollar amount attached to that. We just assume insurance will pay for it. Something as simple as ordering a vitamin D. I don't know if a lot of doctors know this, but that's not covered by Medicare. And I think they bill out a hundred or so, a little over a hundred dollars for this one test that may or may not help us do the work we need to do. And now you're talking about the cost of medical care per person to the employers could be costing six figures. 

Dr. Tea Nguyen (10:04.344)

when you can get a way better deal and better care by totally eliminating the middle man. And I think that's just something that we really have to repeat over and over again, that what we do as direct care doctors is honest and is transparent, and it does give equal or better care. And I would argue it's better care because the doctor's not burned out. The doctor is working directly for the patient for a limited number of patients because that's our capacity. That is the moral thing to do is to have capacity and not treat ourselves as if we are a conveyor belt of medical care. And so I'm so grateful that you're able to share that with us to what turned on the lights for you. So from there, you learned about the heartaches that we all take part in, whether we choose to believe it or not. We are actively doing a disservice when we don't know the price of things and we choose to make those recommendations anyway. 

So from there, what did you do? 

Dr. Demetrio Aguila III (11:03.278)

So at that point, I said, you know what, I can't do this anymore. I need to figure out how I can get into private practice. Well, actually, let me back up. So when I realized the kind of financial impact I was having on the patients, right away I thought, okay, so how can we, number one, take care of patients who don't have much in the way of means in a way that's fair to them and that's fair to everybody else involved? 

Dr. Demetrio Aguila III (11:26.422)

And so I spent a lot of time praying about it, talking to my wife about it. And we came up with what we call the M25 program. And that's a program by which patients who don't have a lot of money can choose to volunteer their time at a local charity by investing their blood, sweat and tears into their own care so that they don't end up with crushing medical debt. And so I presented this idea to the hospital because I was working for the hospital at the time. I went to the CFO. I had a good relationship with him. He said, Great, that's awesome. It checks so many boxes. We can take care of our charitable causes. We can do all this other stuff. I said, okay, let's go talk to the CEO. We went to the CEO and the CEO said, that is crazy. What are you talking about? Why are you even considering this? We're doing just fine the way we are. Shut up and get out of my office. You know, we've got bigger fish to fry than that. And of course, I walked out of there thinking to myself, well, if you've got bigger fish to fry, then I'll just fry the fish myself. 

Dr. Demetrio Aguila III (12:22.414)

You know, and so I said, okay, how can I do this and try to thread that needle and navigate, you know, all these concerns regarding insurance? How do I talk to patients about it? So forth and so on. Well, I discovered something interesting that the only way that I could reasonably offer the M 25 program or some other type of charitable program like that to my patients was to get out of the insurance game. Because if I said to a patient, let's say I had a contract with, we're not going to name any names here. So we'll say United WealthScare. Okay. I have a contract with United WealthScare and my patient happens to have that insurance. And I say to the patient, you know what? I want you to volunteer some time at the Least of My Brethren, which is a charity that helps homeless people get off the streets into their own homes and helps them get jobs and retrain and so forth and so on. They do awesome work. If I offer the patient, go ahead and volunteer some time with them. Guess what I've just done? I've just violated my contract with United WealthScare which means they're going to claw back a whole bunch of stuff. might be subjected to fines. 

And then of course, if I offered that to a Medicare beneficiary and I had a contract with Medicare, well, not only did I just violate my contract, I just broke the law. I don't generally like wearing stripes. So I figured, you know, that's probably not a good thing to do. And so the irony is in order for me to help the people that are most vulnerable, I had to get out of the insurance game, which everybody assumes is the best way to help people who are vulnerable. 

Dr. Demetrio Aguila III (13:49.344)

And you know, I discovered along the way that there was a lot of brainwashing that I had to undo and really rethink my paradigms in order to get to where I am today as a peripheral nerve surgeon doing direct care. 

Dr. Tea Nguyen (14:02.552)

That's crazy, you just gave us a load of information because you're basically saying what we were all believed to be true is that the best way to give best care to patients is to take insurance. But we're sitting here in defiance and saying, actually, no, that is not the best way to give medical care. The best way is to walk away from contracts that are so restrictive and punitive on top of that. want to do good, but we'll get punished for doing more good than the contract allows, we're able to do better with direct care. 

Dr. Demetrio Aguila III (14:37.55)

That's absolutely right. That's absolutely correct because direct care does, and of course, you know this just as well as I do, direct care puts the patient back in the driver's seat, right? It gives the patient, it respects the patient's dignity. It restores the patient's autonomy. And most importantly, it restores the doctor-patient relationship. And so, you know, if I did things the way I used to do them and I said, you know, you need surgery, well, who has to give prior authorization? Well, the insurance company does. 

Dr. Demetrio Aguila III (15:06.51)

In our model now, who has to give prior authorization for the surgery? The patient. The person who's actually gonna deal with the consequences of the surgery is the one that makes the decision about the surgery. Not some person in an ivory tower, a thousand miles away, who's never met the patient, doesn't really care about the patient, and doesn't know anything about the patient. 

Dr. Tea Nguyen (15:29.28)

So how did you get to this realization? I mean, from start to finish, you know, you went to a conference, you were bewildered, and then you drank the juice. And then you're like, let's do this. You found some help, somebody who is experienced, and then you decided I'm going to do this. What was the trajectory of that process? How long did it take you from going from that idea to now I have my practice and I'm just going to do it my way?

Dr. Demetrio Aguila III (15:54.808)

Sure. So I'd love to tell you that it was quick and easy. just turned a key, I flipped a switch and boom, there it was. Everything was perfect. That would be a lie. Okay. And so for anybody out there that's thinking about this, it's thinking, you know what? There are turnkey solutions. There might be, but I would highly recommend that you don't do it the way I learned every single lesson along the way, the hard way. And so I'd like to share those lessons so that your listeners don't have to do it the hard way, right? 

Dr. Demetrio Aguila III (16:22.99)

So the first thing I did was I said, okay, I'm going to come up with a practice model. I'm going to hire this many people in these roles. I'm going to open up the doors. got a loan from the bank. I opened up the practice and what I discovered, so, and you'll be horrified by this, you know, as a direct care surgeon. I started out with nine full-time employees and four 1099 subcontractors. 

Dr. Demetrio Aguila III (16:49.998)

and you're thinking to yourself, holy crap, you're a direct care surgeon. What are you doing with all of those people, right? For one surgeon. Well, that's nothing compared to one of my colleagues here in Omaha who's an OBGYN who runs a conventional insurance practice. He has 11 coders and billers working in his office, four of whom are dedicated just to Medicare claims. So I figured, oh, well, I'm way ahead of him. Look at me, Dr. Innovative. 

Dr. Tea Nguyen (17:15.328)

More is better. 

Dr. Demetrio Aguila III (17:17.93)

And I found out really quickly that overhead was killing me. Not only that, not only did I hire too many people, I hired some of the wrong people, in which case I was leaving six and seven figures on the table in terms of, you know, because what we decided to do is, to make this more palatable to patients, we're going to say to them, listen, you pay us cash, but as a courtesy, we'll submit the bill to your insurance company on your behalf, and then you're responsible for chasing it down. 

Dr. Demetrio Aguila III (17:46.798)

Well, what I discovered was that when you offer to do any of that stuff on behalf of the patient, the patient expects you to do all the rest of it too. And there's no chasing down that's done by the patient, which means that you're in the same pickle you were in originally, except now you have a different jar. Exactly. It's a different jar. And the patients are asking, well, where's my money? You know, because I already gave you money. Why aren't you chasing after the money from the insurance company? And so it took me a while to figure out, you know what we need to, we need to do, we need to get out of the game completely. 

Dr. Demetrio Aguila III (18:16.172)

You can't sit on the fence. When you sit on the fence, you know, it hurts your crotch. That's really, it's that simple. It's really men and women. And so, yeah, you got to decide which side of this fence am I going to be on? Am I all in or am I all out? And when we finally decided to go all in or all out, if you will, with respect to insurance, which was about three years ago, we finally cut the last cord. We cut down to three full-time employees, myself included. 

Dr. Demetrio Aguila III (18:46.222)

and one 1099 subcontractor. And so we reduced our payroll significantly, which gave us the flexibility to be able to do all kinds of other stuff. And now this past September was the busiest month in terms of surgical volume that we've had since my practice opened in 2017. And October was almost as busy, what will be almost as busy, the schedule is mostly full. 

Dr. Demetrio Aguila III (19:13.174)

And then November, if it weren't for Thanksgiving, November would actually be the busiest month of the entire practice in our history. 

Dr. Tea Nguyen (19:21.24)

Wow, that's a huge change. Because I'm thinking you got to cover their health insurance. You've got to pay for the stress you have to endure to juggle the schedule. Yeah, and being able to reduce that down. I mean, I know how good it feels to buy back your time. I mean, and your sanity and the financial risks involved in all of that. So I wanted to kind of just pivot a little bit because I want to understand how patients find you and then choose pay out of pocket at this point since you don't contract with insurance. Sure. 

Dr. Demetrio Aguila III (19:53.368)

So one of the things is, if there's any one thing that I would wanna share with your listeners who are thinking about making the switch, it's this. And you probably had a similar experience, just about everybody else I've spoken to has said the same thing. When you decide you're gonna step outside the system and move into direct care, everybody that used to refer patients to you thinks you're dead. 

Dr. Demetrio Aguila III (20:20.27)

Like they treat you as though you don't exist anymore. None of the referrals show up any longer because they don't want to deal with the questions that are associated with having to deal with the practice because they don't know how to answer those questions and they're not familiar with those things. And so those referrals go away. And that was something that was really painful for us at the beginning. Thankfully, we had cut back on our overhead initially, not as much as we have now, but we had cut back on it enough that we could survive on a smaller portion of the revenue than we had originally dealt with initially.

 Anyway, what we started doing, I started talking to other physicians. I would go to their office, I'd bring them lunch, I would do all the usual stuff a sales guy typically does, right? Because when you're in direct care, you have to be able to talk about your practice. You have to be able to tell people, this is what we do, this is why we do it. This is why you should come see us, why you should send patients to us. Well, mostly it fell on deaf ears. And what I discovered was that direct to consumer marketing was the key. 

Dr. Demetrio Aguila III (21:17.742)

In other words, I needed to know who my audience was, and in this case, it was the patients, and help the patients understand why this was better for them. Because if we're going to cut out the middleman from a financial standpoint, then let's just cut out the middleman from a communication standpoint as well. Right? And so we started doing direct to consumer marketing primarily through Facebook and through YouTube. At first, we didn't pay any money for any of it. You know, we would just put posts on Facebook at least two or three times a week, sometimes multiple times a day. And then YouTube started collecting video testimonials. And here's another thing about video testimonials. So at first, when we started doing this, I thought, well, they got to have the perfect story for me to share. And what we discovered was that if the patient's not pissed off, just ask the question, will you share your story? Because if a patient is willing to say yes, they're not going to bad mouth you in that story, right? 

Dr. Demetrio Aguila III (22:13.622)

If you have somebody that knows how to edit out all the ums and the uhs and the, you know, and stuff that's awkward and you can, you know, pare it down to the, to the core story, then that can be really compelling. So on our YouTube channel, we've got over 400 videos now, most of which are video testimonials, patients talking about their experiences. And so then again, what do we do? We offer the patients our expertise and our time, and then we leave it up to the patient to decide whether or not their problem is worth the same thing. 

Dr. Demetrio Aguila III (22:42.1)

I think the challenge, there's a paradigm shift that needs to happen when we switch into direct care. Most physicians aren't accustomed to the idea of judging the value of their time and their expertise. And so as a result, they're not comfortable having these conversations with patients that have to do with money. And so what we did is we turned that around and I said, yeah, and I still say this to patients. I don't have to say it nearly as often now because they get it. But generally speaking, I'll say to the patient, what is your problem worth? because I have no idea what your problem is worth to you, how it affects you, what the impact of that problem is on you. I don't know what that impact is. And I wouldn't presume to tell you what your problem is worth, but your insurance company wants to tell you what your problem is worth. The insurance company wants to tell you what you're worth. I'm not gonna try to step into that because I'm not in a position to be able to tell you that, only you know that. But what I can tell you is what my time and my expertise are worth. 

Dr. Demetrio Aguila III (23:39.744)

And here it is. And if that meets with what your problem is worth, then let's move forward together. And if it doesn't, well, then let's shake hands and move, go our separate ways, no hard feelings. And that kind of a frank, upfront, transparent discussion, I think is really refreshing for some patients. Some of them it's kind of shocking, but when they get over the initial shock, they realize, you know what? I've treated them with dignity. I've treated them with respect. 

Dr. Demetrio Aguila III (24:07.47)

I treat them as the intelligent human beings they are. I don't say to them, oh, it's too complicated for you to understand. I say, no, this is simple enough for you to understand. Here's how it works. You decide. You decide what your time, your money, and your problem are worth, and then let us know. And we put the patient back in the driver's seat, just where they should have been the whole time. 

Dr. Tea Nguyen (24:31.906)

That's a really great way to frame the conversation to empower the person to choose rather than just saying, well, your insurance thinks this is fine. We'll do that instead, you know, especially for pain insurance that pays for the cheap stuff, right? They'll pay for the steroid injections. They'll pay for an amputation, everything else in between, you know, balls to the walls. You did, it's not going to be covered no matter what your premium is. So I really liked the way that you frame that. And I wanted to ask you because it's not often we get a direct care surgeon in-house because there's a perception that surgery should be covered by insurance. And I get that. And I myself have reduced my surgery significantly because it's just a lot of processes. You know, when I schedule a patient for surgery, they are either going to the facility or hospital. And then I have to deal with that entity who has to then deal with what the patient's responsibility is and what their estimated costs are. So I'm wondering what that looks like for you and what you do.

Dr. Demetrio Aguila III (25:34.518)

Sure. So that's a great question. So there's the way it looks today and the way that we were hoping it's gonna look 12 or 18 months from now. So I'll start with where we are today. Right now, there are a few facilities that we work with where those are two separate conversations. We have the conversation with the patient about the cost here in our practice and we give it to them in writing in advance. We say, this is exactly how much it's gonna cost. 

Dr. Demetrio Aguila III (26:01.728)

No questions asked, no hidden fees, no surprise bills later on. And if I end up having to do more surgery than this, well then that's not your responsibility, that's mine. As a surgeon, I should be able to plan out for these elective procedures exactly what it is I'm gonna do. And if I end up having to do more, well that's poor planning on my part, the patient shouldn't have to suffer for that. And then we have the patient have a discussion with the financial people at the surgery center about what those costs are gonna be. Now we've done this enough times with the two surgery centers we work with that they've gotten accustomed to having those conversations. And so it can go relatively smoothly, certainly compared to the way it used to be. What we would like to do though, is a model similar to the Surgery Center of Oklahoma, where you have one bundled price and the patient doesn't have to worry about, wait a minute, you mean I gotta pay a facility fee, I gotta pay an anesthesia fee, I gotta pay a professional fee, and that can be really confusing for patients. 

Dr. Demetrio Aguila III (26:58.104)

You don't go to McDonald's and say, okay, I want a Big Mac. they say, well, you got to pay this person for the bun. You got to pay that person for the meat. You got to pay this person for wrapping all of it together. You just want to pay one price. And so that's our goal is to eventually get there. And so we're working on a mechanism to do exactly that, to bundle it all together here in the Omaha area in a way that's simple, predictable, transparent, affordable. 

Dr. Demetrio Aguila III (27:27.114)

and easy for the patients to understand and wrap their heads around. And we're hopeful that we'll be able to work out those details here in the next year to year and a half. Theoretically, it's possible that we might even have a mechanism in place by March of 26. Although I think that's probably a little bit ambitious, but regardless, it's being done in other parts of the country. We see it happening in Wisconsin at places like Renova Health. We see it being done at the Surgery Center of Oklahoma. We see it being done at the Texas Free Market Surgery Center, obviously in Texas, right? 

Dr. Demetrio Aguila III (27:56.29)

We see it being done at Veritas surgery in Idaho. I mean, it's happening all over the country across multiple time zones. And the reality is, you know, a lot of people have this idea that, well, you know, direct care, this is a new idea. That's a, that's a lie. That's the biggest distortion of the truth that you could possibly have in medicine. Direct care is the way medicine was practiced successfully for thousands of years. 

Dr. Demetrio Aguila III (28:23.712)

all around the world until the mid 20th century here in the United States, when somebody decided, hey, let's introduce this health insurance idea, which effectively is an experiment. And now we can see largely a failed experiment. And so what are we trying to do in the Free Market Medical Association? We're trying to recapture what we know is tried and true, what has worked for centuries around, millennia all around the world and is working again in certain parts of the United States. We're trying to recapture that. 

Dr. Demetrio Aguila III (28:51.766)

and then add some modern flourishes and refinements, and then just say, look, here it is. Here's the future of medicine. 

Dr. Tea Nguyen (29:00.664)

That is really great. I used to say the same thing. It's what medicine is supposed to be between the patient and the doctor. That's all it really is. Everything else is just extra paying for people to have a job, basically. And you know, for surgeons like myself, I had to find alternative ways to provide care. And so what I get to do is perform procedures in my office. Now I know some states have restrictions around that. So if a patient can be under local anesthesia, then that's... 

Dr. Demetrio Aguila III (29:11.532)

Right. Exactly. 

Dr. Tea Nguyen (29:29.814)

a viable alternative, although you need to develop the skills and the setup to make that happen. I wonder for you, are there procedures that you now bring in-house or is everything under anesthesia? What does that look like for you? 

Dr. Demetrio Aguila III (29:43.458)

That's a great question. So, you know, I do a lot of carpal tunnel surgery. We do that in the office under local anesthesia with ultrasound guidance. Patients are back to work the very next day without any activity restrictions, which is a significant improvement compared to the way I used to do it when we did a mini open procedure and it was three to six weeks before those patients are back to work. I mean, a lot of our patients drive themselves home after their carpal tunnel surgery because there's no sedation. It's strictly local anesthesia. You know, we do trigger fingers the same way. 

Dr. Demetrio Aguila III (30:12.258)

You know, 50 % of my practice is patients who have post-herpetic neuralgia, chronic pain after shingles. And for those patients that come in that have it isolated to certain parts of their face, a lot of those procedures we could do in the office under local anesthesia also, and they feel better walking out the door than they did when they came in. And so I'm a really big advocate of doing procedures under local anesthesia when it's appropriate to do so, because number one, it's safer for the patient. Number two, 

Dr. Demetrio Aguila III (30:39.094)

It's more convenient for the patient. Number three, it's more convenient for us because we have fewer schedules that we need to coordinate. And then it's more affordable for the patient. The patient can ask questions in the middle of the procedure if they want to. Doc, know, what are you doing now? Or we actually have a monitor on the wall so that patients can ask questions about what I'm looking at and they can point to the wall and say, what is that over there? What's this over here? While we're doing the procedure. And so it's an opportunity for greater education along the way as well. 

Dr. Tea Nguyen (31:09.934)

I want to shadow you some days. I want to be like you when I grow up. 

Dr. Demetrio Aguila III (31:12.728)

You're welcome to come out. 

Dr. Tea Nguyen (31:18.412)

We have really advanced so much as far as pain relief for patients doing a lot more under our local imaging. And I just feel like it's such a sexy thing to do, to do as least as possible to get the maximum benefit. Whereas I feel like in the olden days, where we open things up and we put a bunch of screws and plates in, that is going on the wayside for some things, not everything. And so I'm really excited about this, the field of being able to perform surgeries minimally invasively. 

Dr. Tea Nguyen (31:47.466)

in the office for all the reasons you listed. It's good for me. It's good for the patients. It's good for the ecosystem of healthcare. We're not wasting money. We're not wasting time or dollars. 

Dr. Demetrio Aguila III (31:56.598)

Exactly. And we're not putting patients at undue risk. I mean, you know, when I first got introduced to this idea was, you know, when I was a head and neck surgeon and I would fix a lot of broken noses. And so a lot of people take those patients to the operating room, they put them to sleep and they straighten out their nose. And it's not like you see on TV where, you know, you got some football coach who goes, okay, okay, look over that way, crack, you know, it's not like that. It's actually, it's a very gentle procedure if you do it properly. And what I discovered was that if you adequately numb that person up, 

Dr. Demetrio Aguila III (32:25.666)

and then you give the local anesthetic time to work, you can, I mean, you could effectively chop somebody's nose off and they wouldn't know it other than the fact that they could see that it's not there anymore, right? So it's possible to make those patients really, really comfortable. And I discovered, you know what, if I restructure my day so that I can accommodate those things, you know, so I'll see one patient, numb that patient up, I'll go and see another patient while I'm waiting for that patient to get ready, you know, then we're utilizing our time more effectively. 

Dr. Demetrio Aguila III (32:53.068)

And then I started doing the same thing for carpal tunnel surgery. We started doing the same thing for various other procedures on the face. I mean, there are certain types of sinus procedures you can do in the office under local anesthesia, which is like 15 years ago, that would have been unheard of. People would have said that was malpractice. And now in many parts of the country, that's the norm. Now, somebody needs a balloon sinuplasty because they've got chronic sinusitis and their maxillary sinus. You can do that endoscopically with a balloon and 

Dr. Demetrio Aguila III (33:19.842)

wide awake and the patient will tell you the moment that it gets better. I remember the first time I did it and the patient was like, doc, what did you just do? I feel amazing. All of a sudden I was like, well, I said, good, you know, I hadn't expected that, you know, the patient was like, that's awesome. Can you do that on the other side? I'm like, well, that's the plan. You know, let's switch over to the other side and do that for you. 

Dr. Tea Nguyen (33:41.57)

I love telling patients when they feel good. Like, I didn't expect that. 

Dr. Demetrio Aguila III (33:45.026)

Yeah, exactly. So I tell them, well, I'm glad because that's what the YouTube video said you were going to say. 

Dr. Tea Nguyen (33:51.436)

Right, we got it right this time, 

Dr. Demetrio Aguila III (33:54.328)

You know, of course then I tell them, yeah, well, most of those YouTube videos on this procedure were done by me anyway. So at least I'm listening to myself, right? 

Dr. Tea Nguyen (34:03.224)

That's so wonderful. My gosh. I know there's so much more to share about your type of practice, about surgery, about the business aspect. And I don't want to take up any more of your time. So I wanted to ask you, what is the one thing you would recommend to the doctor who's on the fence about direct care? 

Dr. Demetrio Aguila III (34:21.25)

The biggest recommendation I would have, it would be one of two things. Either one, go to the next free market medical association conference. Okay. I don't know if it's going to be in Oklahoma city or they're, they're toying with the idea of maybe going to Nashville for this next one, because we've run out of space every year. There's more and more people attending the conference and I suspect I'll be speaking at the conference again. That'd be my like third or fourth year in a row speaking at the conference. So, and I usually talk about exactly what we've talked about. 

Dr. Demetrio Aguila III (34:50.2)

How do you start and run a successful direct surgical care practice? That's one of my passions and one of my big long-term goals is to raise up the next generation of direct care surgeons. So that would be my first, my highest recommendation. If you're not sure whether or not you could do it or whether or not you wanna invest the time and energy and money into going to that conference, then find the local chapter of the Free Market Medical Association and attend their meetings.

Dr. Demetrio Aguila III (35:19.148)

Most of the time, most of the chapters don't charge anything. You just show up and meet people and learn about direct care. Because what you're going to discover when you go to these meetings is that there's all kinds of people at various stages of this transition from conventional insurance-based medicine to direct care medicine. And there are different phases of that journey. And there's lots to be learned from each of those people about where they've been and where they're going. 

Dr. Demetrio Aguila III (35:46.158)

And even for somebody like myself, I've been doing direct care now in some form for the last eight years. I learned stuff from other people who are on this journey because they'll say something. I'm like, that's a really good idea. Yeah. I'm going to incorporate that into what I do. And then finally, the last thing I would say is don't be afraid. No, we've all been taught to be afraid of the risk associated with this with the unknown. But I tell this to surgeons all the time. If you're an MD, I'm not familiar with the statistics for other degrees, but if you're an MD, when I applied to medical school, there were 45,000 applicants nationwide for 15,000 spots. That meant two thirds of the people that were applying failed. Did that stop those people from applying? No, they weren't afraid of that kind of failure rate. I went to Boston University and the last day of orientation, they gave us a whole bunch of statistics. 

Dr. Demetrio Aguila III (36:37.454)

And they said one of the things that stood out in my mind, there were 15,000 applicants for 150 spots. That means 99 out of 100 people who applied failed to get in. They just got me mixed up with somebody else and I got in. So I was very thankful for that, right? When I applied for plastic surgery, there were 2000 applicants for two spots. Those are really daunting statistics and those are daunting odds. 

Dr. Demetrio Aguila III (37:06.402)

The likelihood of failure there is greater than 99%, but the likelihood of failure when you go into direct care is significantly smaller than that. As a matter of fact, I struggle to think of somebody that I know that went into direct care that wasn't able to make it work. It is possible. Is it scary? Yeah, it is scary. But you overcame great fear to get to where you are today. Why turn your back on that legacy and get into fear now? 

Dr. Tea Nguyen (37:34.358)

I completely agree. I can only think of maybe a few people who I wouldn't necessarily say failed direct care. They just had to pivot before they became financially stable to make the decision. And so I'm with you. Once people go direct care, they really don't go back. 

Dr. Demetrio Aguila III (37:49.814)

Right. And the same thing is true for patients. So, you know, in our practice, for instance, my, you know, the two staff members that I have, my team members, I don't refer to them as staff members. That's another thing, you know, you got to change your mindset also about the people you work with. But that's another discussion for another day. You know, I told them, said, you know, if we're going to, if we're going to talk the talk, we got to walk the walk. And so I didn't offer them insurance. What we do instead is 

Dr. Demetrio Aguila III (38:17.982)

I have each of them plugged in with a direct primary care subscription. I pay for that. And I also pay for a subscription to a health share. And they understood this stuff conceptually, but until they started to use it, they didn't really understand. Now they're like, doc, we could never go back. I'm like, see, I told you. And they're like, this is way better care than we ever got the old fashioned way. And they're like what we like to call true believers now. You know, they're some of the greatest evangelists there are. Once you get somebody  into the direct care system, they're not gonna wanna go back. 

Dr. Tea Nguyen (38:50.966)

Yeah, you're completely right about that. Some people just feel like what they have with their insurance option is good enough and they've accepted that to be normal. They think that, yeah, it's like, it's normal that I can't be seen for eight months, although my foot's falling off. Like, I guess there comes a point where, hey, that's not right. 

Dr. Demetrio Aguila III (39:01.614)

It's Wink Home Syndrome. 

Dr. Demetrio Aguila III (39:11.886)

Yeah, well, and then on the financial side, like if we think about my practice, I mentioned I do carpal tunnel surgery. So the average cost for carpal tunnel surgery, unilateral under general anesthesia here in the Omaha area is about $20,000. Now, let's say the average deductible for a family of four in the United States is about, I think it's $8,500 now, but let's say you have good insurance, right? And your deductible is only $5,000. 

Dr. Demetrio Aguila III (39:37.934)

Out of that $20,000, right away you're gonna pay $5,000. This is for one hand, right? You're gonna pay $5,000 right away. And then you got the 80-20 split, right? So you're gonna be responsible for 20%, the insurance companies are gonna be responsible for 80 % up to a certain amount. So what's 20 % of the remaining 15,000? I'll do the math for you, $3,000. So that's eight grand right there that you're gonna pay out of pocket for the privilege of using your insurance, right? Or, 

Dr. Demetrio Aguila III (40:04.802)

You can come see me here in Omaha. can do both hands under local anesthesia. You can drive yourself home. We don't use insurance and it'll cost you less than half that much for us to do both hands and you're back at work the very next day. 

Dr. Tea Nguyen (40:19.982)

What a great pitch. I love that. We know so many people who need that. So that's a great one. Awesome. Well, thank you so much for your wisdom today and for sharing yours, is it seven years, eight years long of experience now? 

Dr. Demetrio Aguila III (40:33.358)

8 years now.

Dr. Tea Nguyen (40:40.982)

I've been in practice. I've owned my practice for seven years. So I'm just cruising alongside you, except I was in direct care for more like three years. It took a little while to get there. 

Dr. Demetrio Aguila III (40:43.564)

I know that feeling. 

Dr. Tea Nguyen (40:44.582)

Well, thank you so much. How can people get in contact with you? 

Dr. Demetrio Aguila III (40:48.088)

The easiest way to get in contact with me is to email us at totalpainsolutions.net. You can also check out our YouTube channel, it's Total Pain Solutions. You can also find us on, me on LinkedIn. Obviously you know I'm pretty active on LinkedIn. I know you are, because I see your posts. We're also on Facebook. Or you can just swing by, we're right here in Omaha. Just Google us and you'll find our practice. We've got some videos showing, we got this drone that hovers over and shows people, okay, this is what it looks like, this is how you find us, know? Kind of fun. Yeah, doing that was a lot of fun. But yeah, I mean, we're happy to help. If you're a doctor out there that's thinking about doing this, you wanna learn more about it, come check us out. Oh, one last thing. I also have a podcast that talks about direct care. I'd love to have you as a guest, as a matter of fact. And the podcast is called the Direct Care Movement. And you can find it on 

Dr. Tea Nguyen (41:21.326)

That's pretty cool. 

Dr. Demetrio Aguila III (41:44.558)

I know we were on YouTube. I'm pretty sure you can find it on Spotify and Apple podcasts as well. 

Dr. Tea Nguyen (41:51.874)

Yeah, I'll check it out and I'll put all the information down in the show notes so that people can get more resources on how to do this because we're not turning back. We're in it for real. 

Dr. Demetrio Aguila III (42:02.862)

For sure. Yeah, we're excited. 

Dr. Tea Nguyen (42:06.606)

Cool, thanks so much. One last thing, if you took anything from this episode, whether it's a small dose of inspiration or even an aha moment, could you please share it with a friend or post it on LinkedIn? The direct care community depends on doctors like you because no one is coming to save us. So it's up to each and every one of us to keep the conversation going to a point where direct care becomes a normalized path for private practice. 

Dr. Demetrio Aguila III (42:07.96)

Thank you.