Transcript:

Dr. Tea  0:52  

Hey there, this podcast is old enough to have a repeat visitor. And so who I have today is the one and only Dr. Grace Torres-Hodges, who was one of my early mentors in helping me decide whether or not I should opt out. And quite frankly, by the time I got a hold of her, I knew that I needed to do something different with my practice. And so I want you to go back and visit her original podcast that we had, I'll put it in the show notes. And this is kind of a follow up with just because she has such a wealth of knowledge that there's just so much for us to talk about. And today's episode really is going to focus on her newly published book, which I'm so excited to be able to share with you, because it will tell you exactly what you need to know about direct care. And the book is called Private Practice Solution: Reclaiming Physician Autonomy and Restoring the Doctor-Patient Relationship. I'm not getting any sponsorship with this promotion, I just really appreciate other doctors who are doing something showing us the way of what's possible, and how we experience medicine and how we function in our private practices. So please do check out her book, the link is down below. Give her some love on her social media account, interact with her, send people to her for advice and for her wisdom. And of course, as always, please do share this episode with the doctor who you think would benefit from learning about opting out of insurance in their private practice. Without further ado, here is our conversation and the promotion of her book, private practice solution. 

Dr. Tea  2:30  

I'm so excited to have you back on Grace, I really wanted to touch on your book, you just published a book for doctors and private practice. And it's all about direct care, right?

Dr. Grace  2:39  

That's correct. The book is entitled Private Practice Solution: Reclaiming Physician Autonomy and Restoring the Doctor-Patient Relationship. It was funny because I actually did a test run on my book title with both physicians and with the general public. And no one knew what direct care was, what I used that I put in the direct care solution was an original one. And then when I explained it, they came about both parties, both physicians and doctors. They both said, Well, you need to explain that this has to do with practicing medicine. And so it was kind of interesting to see that because sometimes when we're in our groups together, we tend to understand all the lingo, and the technobabble but direct care is still a fairly new concept to a lot of people. It's not a new way of doing things, but it's definitely a new term being used. And unfortunately, I think it's also being misused a lot of times. And so one of the reasons for writing the book was to educate people, number one, that particularly physicians that are in private practice that there are escapes from the mad, Mad World of insurance based medicine. We've spent too much time to get the degree, learn and train and have the ability and the opportunity to take care of patients. You know, you don't want to just give up on that and you know, you myself, so many others that are in the direct care arena, we found a way out and to still be able to practice. Second, this is not just for physicians, this is also for the late people, too. I say that in the sense that even though the majority of the book, more than half of the book is more of a how-to kind of manual. The first part I think people didn't realize the the the book rationing of health insurance and how it became tangled into our day to day. And it's not like we could see it coming because it was so insidious. And they were all good things first, as far as the reasons for insurance, it just got twisted along the way. And doctors and patients became victims in it. So, you know, with those two main premises in mind it is really educating people and getting word out that it's always about education. We're doctors, Doctor means teacher. And that's what we're always trying to do.

Dr. Tea  5:36  

I'm going through your book right now. And I love the title for chapter number one. Okay, so what's going on, because the world does not know what's going on. And even the physician world has no idea what's going on. And it actually took me a while to be able to tease out the model for private practice versus academia. And I know that sounds kind of silly, because if you think about it, our training now as a podiatrist, and I'm sure other specialists are predominantly in the academic setting, you know, residency is based in a hospital based institution, that's where the funding goes. But once we exit our training, we don't really see that there is a different opportunity for private practice owners to have and not function like an academic institution that has an endless amount of resources. And so I really, like that we were talking about, specifically, private practice, not all of medicine, because I think the misconception that happens in places like LinkedIn, or we're having a lot of this conversation is, well, we can't expect everyone to opt out, which is true. We need hospitals, we need facilities, we need academic centers to maintain that type of model. But when it comes to private practice, we are a totally different beast. Did that take you a while to see the difference? Or were you like, did you already know where you're already ahead of the curve?

Dr. Grace  7:01  

Well, I don't know if I was ahead of a curve, I definitely had a little bit of an advantage having grown up with physician parents that were in private practice. So I was surrounded with that growing up. My editor, who was actually a classmate of mine from college, but grew up in the same hometown was her father, was a colleague of my father's also. So, you know, we who I was so grateful that she was able to help me kind of put the words on paper properly, and organize my thoughts. With regards to advantage or not, I still had to learn how to private practice medicine once I got out. And I agree with you. Definitely, I Although ironically, you know, I finished residency in 2000. When did you, when did you finish? How many years are there between us with training?

Dr. Tea  7:56  

I finished podiatry school in 2011, and then my fellowship in 2015. 

Dr. Grace  8:01  

Okay, so almost a 15 year 15 year gap between our endpoints in our residencies and, and your fellowship, there was a huge change. You know, because when I first started, we weren't in the EMR scenarios, it was still paper charts. And even my residency, one of the things that was really cool about it was number one, we were the only surgical residents at the hospital. So I got to, to scrub in on all cases, not just lower extremity podiatry. Number two, we had a lot of private practice physicians who we also shadowed in their offices. And anyone who's in residency right now, if you have that opportunity to meet doctors that are not part of the academic, like what you were saying that our hospital employed, by all means, take advantage of it, because I got to see that a lot. And there's also a difference in the way that as I've been teaching students, and working with residents, since I got out of school, and in residency, the question always comes up, you know, what do you want to do afterwards? It really was that everybody wanted to open up and hang their shingle and start, but as time went on, really in the 2010s, things changed tremendously. I don't, you know, I think a lot of it was managed, care driven. But yes, you know, when we're when we're in residency, academic medicine, that is seven years minimum, you know, four years med school, three years minimum residency, and if people go into fellowship afterwards, you're just surrounded by that. And there's a phrase that I used and quoted in the book that we were conditioned to conform. See, one do one teach one is a conditioning to conform kind of way to do things. They break you down, and they build you back up again. But you've learned how to rely on what others did ahead of you. And more and more and more. Each year, there's a survey that they do on fourth year and fifth year residents in the hospitals. Third, fourth and fifth year residents that ask what are you going to do afterwards, and I can't remember the name of the group that does it. But you can look it up. Because every year you can go back. And you'll see that the percentage of those that are employed by entities, whether it's hospital, private equity group, or even a group practice, went tremendously higher after the 2010s. So, yeah, so I directed this book, really to private practice, because there isn't anything out there that explains it. And thanks for the feedback on the first the first section, you know, we were little play on words a little bit, but it's, it's a good thing.

Dr. Tea  10:52  

I know I really enjoy it, and you know it. You and I know how important this book is. But why is it important for others who may not understand what's going on, like residents and students, and I know that you focus a lot of your efforts on the newer generations coming out into practice. Why is this book so important for everyone to get their hands on?

Dr. Grace  11:13  

I think autonomy is the biggest thing. That's one of the reasons why it's one of the part of the subtitle, you know, in medicine, one of the highlights of how, how we improve by ourselves or even, in any kind of societies critical thinking. medicine, science is always related on that and the ability to have that independence, to agree to disagree and rationally explain things and figure it out, I think it gets lost when we are in the midst of templates. The soap note that all of us learn how to do properly, is now all templated there's something to be said about nuance in medicine that we need to be able to continue with emphasizing, and I think because there's so much of an emphasis on trying to get as much information into the students and residents, they want to learn as much as possible, you have to take time to enjoy and actually listen to the patient, you have to take time to to really think through Am I not not following a protocol. And, and if we don't teach that at an earlier age, I think we're gonna lose it. Because people can become accustomed to it. And doctors are no different in any of our training in any of our teaching. You know, there's a lot of references that I don't think I've put it in this book that was maybe just written about it in blogs, or something like that. But education did a similar thing, when everything became protocol driven. Education began to, to diminish, because everything was being taught to the test. Whereas when you really wanted to have an open minded way of thinking, which then can progress that allow the allowing the individual to grow? I think that's one of the key things, and why we still need to have autonomy and why I emphasize the importance of direct care, you need to have that. You know, you want that second opinion, you want, you don't want everybody thinking certainly

Dr. Tea  13:40  

There's one core concept that I really want to dive into. And that is price transparency. And I'm guilty of this, you know, we all have protocols, because it just makes things a lot faster. So if I'm scheduling a surgery, for you out has a protocol, every patient over the age of 50 gets an EKG, regardless of my medical history. And so there are these templates put into place that will help staff members shift into gear and just get things done the way that it should be done each and every single time so I can understand where protocols provide efficiency. But there is also an area in which when we don't use critical thinking when we don't think of why we're doing what we're doing that can drive up expenses. And I don't think I realized it until later on that all the things I did per protocol was very costly to patients. And if patients filed for bankruptcy, we would never know it. As a physician, we would just never see them again. And I find this to be such a critical conversation that we must have this day and age, with inflation going up the cost of housing going up all the things that I think this really needs to be a topic in medical education. Are we actually getting patients the care that they want because patients will choose to not get a cure or treatment if they knew it would lead to them going bankrupt. So what is your perception about that?

Dr. Grace  15:07  

I know, I agree with you the price transparency is definitely a must. And that is a key element in direct care. But one of the things that which makes it difficult to have the conversation of price transparency is that there's this conflation of terms, health care, and health insurance, the delivery of the health care really has to be separate from the way that it is, is paid for. And unfortunately, because of the oversight and the control that insurance companies have have taken on in medicine, they have taken over both sides. You know, it's become a game to them, because they're playing both sides of the both sides of the of the game. They're working on the doctor side. And this is why, you know, once we're out of it, they work on the doctor side to determine how much things you know, how much you're going to get paid for, and how much your procedures are worth. And then they also work from the patient's side, because they're controlling the premiums, and they're determining whether or not a service is needed. I think the one of the biggest things to do first is price transparency, which actually allows people to differentiate that health care and health insurance are two different things. I agree with you, I I think I hope the book opens up ideas to have more conversations like that that's, you know, because it will make if anything, what this book does, it makes you think about different aspects, not one thing specifically, but just different aspects of the entire healthcare journey for for a patient and for a physician that's practicing it. But until, until people see that, and I try to use examples in there that, you know, it's it's almost like a monopoly that the insurance company has, and that's why you're it's it's difficult to win when patients have just been as much conditioned to conform, it makes it difficult to have to have that to figure out how to get out of it. Does that make sense?

Dr. Tea  17:28  

I know it makes sense to me, because it's hard when you don't stop and think about why we're doing what we're doing. Right? Right. If we're following a protocol, we don't care how much an EKG is going to cause from one doctor to another, we just know it needs to be done before we do the surgery, right? Or whatever their protocols are. And even when we go to educational conferences, and we're having these lively academic debates about which product is better, versus another one of the conversation sometimes is talked about is the cost of the thing. Like there are instances where physicians function in a rural area. And so we must be economical in our decisions. Agree here as if we're in different parts of the world. You know, we some places are just more privileged than others. So I think it's just that it needs to be in the top conversations before we even offer patients options that they must know what it's going to cost, whether it's out of pocket expense for them, their deductibles, their premiums, you know what to agree to paying and stuff. It's just, I've never thought about medical health in that way. Because we've never had to, we've been cushioned by it. And we've been restricted by talking about what our insurance contracts are. 

Dr. Grace  18:44  

Right. Right. Because you know, each one people don't what people don't understand is that we'll use the codes, the codes that are controlled by insurance 99214 paid to podiatrist is one is one amount and then I do one for paid to an internist or to an orthopedist, isn't it a different amount? And that 99214 is not the same amount in different areas? You know, so? Yeah, I agree with you with that. The thing going back with protocols, though, there's a difference between protocols because that is the guideline, the fundamental. So, you know, it's the it's the first nature of rather than saying second nature, it's the first nature. So we know that when it comes to a code ABC is the first thing that we think about, you know, airway, breathing, circulation, you know, it's immediate, all of us know how to do that we know how to do a triage, you know, nature, and duration, location onset, you know, we'll go through and I'll do cat, whatever our acronym is that we use. Those are fundamental. Those are, those are our, our protocols in our heads. I'm talking about, you know, the ones that you're talking about also that ended up being money driven our protocols, almost like privileged protocols, because the insurance companies have said to do that, and why do we do that? To protect ourselves from, you know, from lawsuits? You know, do we really need it if I'm looking at and this was one of the examples that I used, that got me really thinking about why is the insurance company making me do this? You know, I had you and I've seen these and then these patients that are diabetic, they Nick their Shin, and I'm looking at it exposed into your tube tendon. And I know I need to debris that but you know, what I also want to know is how extensive Is it because the patient's coming into a dried wound? You know, is it in the bone? You know, the protocol is bone scan, but we know we're not going to get a good quality con that it's, you know, we'll just get we know it's impacted. Okay, good. But how extensive it is, is it? You know, I remember early on trying to get an MRI on that. And they wouldn't want to do it because they said, No, you have to go through wound care first. And then you have to do an x ray, did you do an x ray? Well, what do I need an x ray when I could see the whole thing, but I get it because that was what the insurance did. But once I was out of that you didn't have to worry about following that protocol. So that protocols are a little different. And I think that's where, you know, the insurance companies understand that it's such a miss, it's misaligned incentives is what it comes down to. As a physician, as a patient, I want my patients to get better as a patient, the patient wants to get better as a insurance company that's interfering in the middle of they're the third party payer that is become the intermediary. They want to increase coffers for their stockholders. Totally different incentives. So yeah, no, I agree with you. 100%. But yeah, this is ongoing. And this is a beginning conversation. And yeah, I think the more and more of those of us that can have been practicing in it, and have been able to to see and one of the ways that why I wrote this book was that I was slightly frustrated, I guess probably his best word. I couldn't figure out why when I was first starting direct care why out it made sense to me. I was completely blown away by my first conversations, and first meetings with direct care that I could even opt out of Medicare that was even so foreign in my head back in 2013. And then going through the whole transition. And I would explain to them, like yourself, when I remember when you called me up and asked how do you do this and trying to you know, explain it to you. We all get into those periods of doubt. And even today, their tastes and I'll go through I think that's a misconception a lot. People think that it's like, once it's done, you know, once you do it, it's one and done. No, you're constantly on the move, and you're constantly adapting. And that's what's so cool. You assess and you adapt, and you readjust assess, you know, and so it's very fluid in the way that we practice now. And you have to work off of your patience and the community that you're in the market that you're in the economy that we're all living in right now. So it's a good, it's a good, it's a good motivator, but I got one of the reasons for writing this was that actually, I wanted to put it in terms that maybe made more sense to people. So you'll see throughout the book that I'll use examples like a restaurant, you know, because people can understand restaurant Protocol, or protocol activity, a restaurant example. I use a hotel when I'm explaining the revenue cycle, because it's the same as what we would do in revenue cycle in our own practices. But, again, we didn't learn a lot of this in school because our minds were set on other things. And so if this will help that doctor, get past that point, that's a good thing.

Dr. Tea  24:15  

Last question for you Grace. What inspires you to do this, because you're active on social media, you're very active with your email, you've created a book What's next for you? What's inspiring you to move forward?

Dr. Grace  24:28  

My patients, my patients actually are probably the end my kids because you want to leave this legacy that we're doing now. You know, my kids, I want to leave them in a good, good world ahead, you know, leave it better than you found it. And my patients, you know, every patient that comes to you, it's so humbling because they ask for your help and they want the they trust you. And that's, it's, it's daunting, because you feel terrible if you can't figure it out. But, you know, I always say, my mom, my mom always told me this. And she goes and says, you know, your job as a physician is not to always just fix, what it is, is to listen. It's there to advise, you have the know how to advise them to move in the right direction. And so I don't know what what's my next move.  I don't know yet. I am new right now, I'm still working on trying to get the book out there. I'm going to start talking a little bit more. I'm really excited that I've had a lot of residency directors contact me, so I'm doing some zoom, morning meetings with them with their residents. And so I think that will be a spark in our hopefully in all of our education. At least from the residency, I'd love to get a little bit earlier, into it also in the student years, but we'll see what happens. 

Dr. Tea  25:59  

That's amazing. I'm so happy that you got your book out there, you left a legacy, and it's only going to build for future generations. I know you've had a huge impact in my decision to opt out as well. I'm sure people want to know, do you have any regrets opting out of insurance?

Dr. Grace  26:14  

No, non zero.

Dr. Tea  26:16  

So easy. 

Dr. Grace  26:18  

I'm very quick to answer that one. No, I you know, and I want a lot of people to understand that this is not like an us versus them game. You know, I think sometimes there's this misconception that, you know, I'm not trying to bash health insurance, health insurance, we need that. So I encourage patients to still get health insurance, but understand what kind of health insurance you're getting. The most common ones that everybody knows which we affectionately call the BUCAs, the Blue Cross United, Cigna, Aetna and Humana. They're not the only players in this game, you know, and I think a lot of people are now beginning to realize there are other modes of payment. Again, health care is what doctors render. Health insurance is a risk management tool to protect you from having catastrophic financial distress from health care expenses. It is a tool and a method of paying but not the only method. In the ecosystem that we're currently living in didn't happen overnight. We need to, you know, early on when health insurance and if you read the book actually goes through health insurance was used, like car insurance before for major, major medical, once, if we can get it away from doing the normal, routine things like, imagine if gas and oil changes and tires. Were all covered by insurance, you know, car insurance would be up the alley was it? You know, so it's just getting back to the way it's supposed to be done. It's as much important that health insurance folks also start working on this too. So, you know, I think a lot of people who are in health insurance, and I can attest to this, because my husband is in that field. He's just as upset with some of the books as well, because he finds the way that he educates others and benefits benefit folks, is by showing them alternative means of payment.

Dr. Tea  28:34  

That's great. Well, thank you so much for talking to me about your book and I'm excited to help you promote what you've written into books, which we've had many conversations in the past by phone, and now it's tangible. And now it's something that we can reflect on and share with future generations about how else we can practice medicine and change our experience in it. Any last words, Grace, before I let you go?

Dr. Grace  28:57  

I want to say thank you again for having me on. And I want to encourage you to continue on because you are asking who inspires me, you inspire me, because it's like, you know, because you you've, I've watched you grow through this. And if every one of us can do that to somebody, each one that we touch, and, and can and can have them grow also. It's a beautiful thing. So, so keep going. I am rooting all the time. And I want you to know, we're all that's the beautiful thing about direct care. We all root for each other. It's fantastic. It's it we understand it's a win win for everybody, both doctors and patients.

Dr. Tea  29:38  

You inspire me too, Grace. Thank you so much for your kind words. I appreciate you so much. Let's get people talking and thinking about a different way to experience medicine for ourselves and for our patients. I will catch you next week with a new episode. I'll see you then. Take care everyone.