Transcript:

Dr. Tea 0:52

I had the pleasure of meeting Dr. Lindsay VanDyke at the DPC summit that was hosted in Dallas, Texas, which you may not know was my ground for my fellowship training, which was the best training year I've ever had, but it was also a very challenging year for myself. So when I went back to Dallas to go to the DPC summit as a executive member for the DSC Alliance, it was really, really impactful for me, because it came to full circle as to what I thought my life was going to look like when I left fellowship to where I actually am almost nine years after the fact. We're here today to talk with Lindsay here to share her journey into the direct care space. And so I'd like to introduce you to Dr Lindsay VanDyke, welcome.

Dr. VanDyke 1:38
Thank you. I appreciate the opportunity to talk.

Dr. Tea 1:42
It's so exciting for me to talk with other specialists, because we only know what we know, and we don't know what we don't know. So it's always fun to explore what others are doing in the direct care space. Why don't you share with us why you decided to lead the insurance model and tell us what's going on in your practice right now?

Dr. VanDyke 2:00
Yes, so I would say, so I finished fellowship in 2018 and I'd always wanted to have my own practice, and so I didn't open one until January of 2021, and I had taken the conventional advice that I'd start with broad spectrum, traditional practice, take all the insurances, and then over the course of years, would walk my way down to cash. And I had kind of a ballpark 10 year timeline for that to happen, and I focused a lot on kind of revenue diversification, developing strategic alliances with other colleagues in allied health professions and stuff that would support diabetes, comprehensive care, and as was true in other practices that I'd been in, starting a new endo service line, you have this initial month or two period, which is kind of slow, and then things pick up. And then by about month six, you're full, and then by about month nine, you've got 70 people on your waiting list, and you have to close the schedule three months out, because nobody can take any time off. It's just this constant onslaught of phone calls and booking and that happened to us. And I had partnered with an independent physician association so that I could have some collective bargaining with our fee schedules and our contracts with the payers, and so everything was going well. About six months in, we were a little ahead of the forecasted schedule for revenue, and I was able to start drawing paychecks a little bit early, and that was lovely. And I thought, well, this is good. I'm not really even worried anymore. It's just going to continue to grow. And then in about month nine or so, seemingly without any warning, it's like the faucet turned off and we were still full. We were seeing 15 people a day or something, and the phones never stopped ringing, and the schedule was booked way out, but it's like the money was gone. So I had assumed somebody must be embezzling from me, but I couldn't find any evidence of that, and it took us several months to figure this out, but finally, we had gone back to the fee schedules, and found that they all had gone under Medicare rates. Every commercial PPO that we were onboarded with was paying us somewhere between 65 and 80% of Medicare for all of our EM codes.

Dr. VanDyke 4:58
And so I contacted. Impacted the IPA, and said, What are we going to do about this? Because this is not tenable. And they said, nothing, because the insurance company told us, take it or leave it. And I said, Well, if you're not going to do anything about it, I believe that I'm going to leave it, because I just feel that after 14 years of post baccalaureate training, I'm not going to take less than Medicare rates for anything that I do. And people had kind of said to me for months to years, and well, you probably could do a cash based endo practice. There's such a demand, I bet you would do fine with that. And so that was in the back of my mind, and I thought, well, first I'm going to try and fix the problem right. First I'm going to look at other IPAs, I'm going to look at ACOs, I'm going to look at the other options I have and just shift over to something new. But what we discovered is that every IPAs fee schedules were the same. And so the only option that we could try was to get into the Methodist ACO, and ultimately we just were not able to get admitted to their ACO. And so I really was faced with the decision of either get paid nothing and not being profitable, or dropping insurance and starting over, basically, and we tried to soften the blow for ourselves, and dropped a chunk of them, and then six months later, dropped more. And the results were incredibly dramatic. As soon as we made the announcement that we were dropping all of the commercial PPOs, the phones lit up and patients responded in one of two ways. The majority of them were inconsolable, just sobbing on the phone, saying, I don't know what I'm going to do. How am I going to how am I going to be okay if you're gone? And the rest of them were enraged, and they were calling us names and screaming over the phone and sometimes threatening. And that blew over in, I don't know, a month or so, and then we kind of did it again six months later, when we dropped the rest of the payers. And so now I'm down to traditional Medicare, which I'm perfectly happy with and direct, and I have learned a lot about the process, but ultimately, in a nutshell, We're all much happier now.

Dr. Tea 8:00
That's insane, just to deal with people who are frustrated with the system that we did not create. We did not create those low fee schedules. That was a unilateral contract. There was no room for negotiating. But we are the ones carrying 100% of the malpractice. We are the ones helping patients get what they need, but then there's this constant roadblock. So not only were you getting paid less than Medicare, which has traditionally been the lowest payer, you didn't have the opportunity to do much else. It was either their rates or you left. And I think it's incredible to hear that you chose to leave What gave you that security to do so

Dr. VanDyke 8:45
Well there was zero security whatsoever. Decision to make because I knew one way or another, it was going to be a nightmare. Now I took a lot of comfort in knowing that I had a very strong reputation in the community and I'm lucky, because in my town, there's only one other endocrinologist in this general mid Cities area where we live, between Fort Worth and Dallas. There's just a few. And the waitlist to get into everybody's months long. And so I knew the demand was there, but more importantly, I had this huge referral pool of primary doctors that I knew fairly well, and hospitalists and ER docs and everybody in this area, and we just kept getting the same feedback over and over from multiple physicians, saying things like, you know you're the only one I'll send to if I have a complicated case, it's going right to you. You're the one who I can count on, because you send back your documentation, I know what's happening. And I said, Okay. This is terrifying, but I've worked hard to this point, and I believe my reputation will carry me through. And that is false, because as soon as the phrase out of network leaves anybody's lips, the conversation is over. Nobody cares how good you are. Nobody cares how well your patients do. Nobody cares what your bedside manner is. All they hear is that, and they're dead to you and so it really was sobering. When we were, say, three months into this decision, and it was just dead around here we would see, you know, a couple of patients a day, I was starting to freak out, like, what was I going to do to bring new cases in? This was not a problem I'd ever had to deal with in endocrinology before. Normally, people just flood you, and so I had to embark on marketing strategies, but I knew that it wasn't just your normal marketing, because this wasn't a normal insurance based practice anymore, and so we did everything. We sponsored community events, we hosted networking events, we started a walk with the doc chapter so that we could get some community interest. We revisited all of our referring physicians that we knew really well and brought them things and said, we're still here. Don't forget about us. We did an extensive mailing campaign to remote areas of Texas where we knew there would be really no endo coverage to speak of, and invited primary doctors, dialysis centers, cardiology teams, hospitalists, etc, to refer for telemedicine so patients could be seen quickly. We joined the Chamber of Commerce, we hired a social media team, and none of it did anything.

Dr. VanDyke 12:33
We were just getting really no traction to speak of, and it was shocking and confusing and stunning. When you look around at all of these, you know, med spas and hormone expert clinics on every corner, it seemed and nobody had any qualms about going there and paying cash. But to come to a board certified endocrinologist was just what nobody, nobody was ready for, I guess. And so now it has been, has to be about, well, I guess it's about 18 months that we pulled the plug on all of the payers, and it's just been in the last about maybe three months that we seem to have found a tipping point, and all of a sudden people are finding us. And it's a little puzzling, because I'm not even sure why, why now they're finding us and coming and asking for consults and and even our Medicare referrals all of a sudden have gone up, and we're not even really doing anything special right now for that marketing, and it's just started to come in.

Dr. Tea 13:56
I can postulate why now if, if you will, entertain me. It takes eight to 23 touch points for someone to even pay attention to you, to the problems you solve. So it's not like you do the marketing one day, they come the next day, there is a lag time, and I'm seeing it for myself as well. I've opted out close to two years too, and it's only now I'm starting to feel steady under my feet that things are kind of on autopilot. And this is something I want to educate the community on, is that it does feel like you're drowning from time to time, and there's no lifeboat, but continuing to do what you have to do, not measuring the daily outcomes, but realize that it will become something you plant the seed 18 months ago, and it's showing its fruits today. So that's how long it takes for your marketing efforts to mature, and that is my best educated guess as to why. Now for you and every specialty is going to go through there. A wave, depending on the community's needs. But I think it's important to understand that even if you're doing all the things and it feels like nothing, it's happening. It's happening as you're sleeping, people are thinking about you. They're not quite ready. Maybe they had to go through some bad experiences first, and then come back around and say, You know what? I'm going to give that doctor a try. I've seen her enough. I've heard about them enough. I feel comfortable now. I went through all the traditional options. They are not giving me what I need, and I think that's where direct care fills the void. But it does take a lot of time for us to finally get a grip underneath us and see that it's definitely working, and I sure hope that this continues to be an upward trajectory for your practice, because we need you. We need you in medicine. We need your talents. We need your skills. And I am such a strong proponent for physicians just like you, who go through the ways without really knowing what to expect, but now that we are past the point, we can show others that this is actually completely normal, the fear that you had, the downs that you experiences, the surprises you had, where those doctors who heard you were out of network suddenly created themselves a barrier, not providing you as an option, even, which I think is a disservice, but nonetheless, they ended up finding you anyway. So it's all working the way it's supposed to.

Dr. VanDyke 16:24
It is slow, and in my specialty, it's weird that it's this slow. Like I said, we're used to kind of this explosive growth, because the demand is not just high, but ever increasing. So I would say to somebody who's thinking about dipping their toe in this, if I could do it all over again, I would have grown a pair and chose to go direct from the beginning. And I thought about it. I thought about it, but I didn't want to do something rash. I didn't want to do something too bold. And I took that wisdom from business advisors, from other practices, from colleagues, from friends, whatever, to do it the safe way. But if I'd had the cojones to embark in that unknown as a direct care from time zero. I could have started with essentially zero overhead, and I might only be in the growth position that I currently am in now, but I would not have had to go through all of the horror show of having to take what's your normal workflow and overhead and personnel and and materials from a traditional practice and cut it all down as thin as you can get it to try and make this direct process work, it would have been maybe equally difficult, but less painful to have started from scratch as a direct care

Dr. Tea 18:10
Good wisdom, because it is starting all over. You started their insurance practice opting out. You're starting all over with the new demographics in your direct care. So tell me how your practice was like in the insurance practice, as far as workflow, how was your how many staff? What was your overhead? What it looks like now, even office space,

Dr. VanDyke 18:32
Yeah, so I took the plunge back when I opened to buy my building instead of renting something, because with a Small Business Administration loan, the cash flow pencil that better, and month to month, I was spending less and gaining equity, because the opportunity just happened to be there to do that, and I knew that if I crashed and burned, that I would have this asset still, and and I do, and it's a large asset. So in all this building is something like 4300 square feet. When we were at our peak under insurance, we were using about 3200 square feet and subleasing the rest to a podiatrist, which was a fantastic collaboration. When I went direct, it became clear quickly that I was really only going to need one or two rooms, and when we were at our peak, I had two virtual assistants, a full time nurse, a full time blended front desk and managerial person, and then a part time Front Desk. Person, and today we have one virtual assistant, still my same nurse, and still my blended front desk manager person. And if I'm honest, I believe, because we work so tightly together, I believe we could get by with just my two ladies who work in the building with me, and we could get away with not having a virtual assistant.

Dr. Tea 20:28
What are you most happy about in your direct care practice, Now?

Dr. VanDyke 20:33
I will tell you that we had so many problems with aggressive patients with threats of violence in one way or the other, such that it was almost a daily occurrence that somebody would be screaming at us for something, and we would have to discharge them for misconduct. And when we made the announcement that we were going Medicare only, otherwise cash. All of that went away, and it was almost instant we had gotten to the point where we had to put locks on certain doors. We had to put glass up at our front desks, because we were worried about what people would do. And it wasn't just and every one of us had a panic button on our little rolling desk and all that stuff, and we had to use them. We'd have to use that panic button periodically, and the cops would come, and I can count on one hand in the last 18 months, how many one finger actually, how many episodes we've had to deal with since dropping insurance.

Dr. Tea 21:50
Wow. And I remember living in Texas, it's a carry and conceal state, so people are packed compared to, I mean, California, you know. So I can understand the fear is very real, especially when we hear in the news a disgruntled patient, for whatever reason, comes in and attacks physicians. So that's incredible, that you pushed through it. So moving forward into how you project your practice, where do you think things are headed for you.

Dr. VanDyke 22:21
You know, we're pretty consistently seeing eight patients per day. Our goal is 12 in a hybrid practice like this, 12 is comfortable. 12 is doable. 10 would be nice. And ultimately, I want to be able to take enough time with a complicated diabetes case for them to walk away from that consultation going I feel like even if I don't have mastery of what's going on right now, I feel comfortable knowing that this team is my guide through the process, and that is what I want my reputation and my legacy to be, that our patients are able to thrive because we're able to spend the time and energy with them that they require, whether that is required for one visit or 10 visits, whether their mastery of their disease happens in the course of a month or six months. But I want my name to be associated with the gold standard in diabetes, comprehensive care. The other thing that I want to be known for is technological innovation, and it's nice that diabetes is actually a very tech heavy specialty right now, and we really embrace that, and there's better quality of living because of embracing technology. But it's not limited there. You know, radio frequency ablation of thyroid nodules. This is catching on. It's been available in the United States since 2018. We've offered it since 2021 and people are finally wising up to the fact that if they've got this big goiter, they don't necessarily have to have it cut out. And so we were, we were the first clinic to offer that procedure in the DFW Metroplex at a time when there were only 70 providers across the country. And so that's what I want my reputation to be as an innovator and a thought leader and to bring excellence in diabetes care. Now, where do I see my practice going? I hope that I get to expand. I've thought about reactivating my licenses. New Mexico and the state of California as well, and starting to see people remotely in those locations, because I know the demand is monstrous, and that may translate to other locations, in those places, and that would be lovely, because I enjoy all of those places. But honestly, I look forward to the stability that a direct care practice brings, because there can be no more nasty surprises. There's no more surprise your fee schedule is different. Surprise, you've been dropped from this network. Surprise, this isn't covered anymore. Surprise, we coded this down. It's just what it is, and the only thing that matters is, are you doing well with your patients, and are your patients benefiting from what you do?

Dr. Tea 25:59
That's beautiful. I know I have so much to learn from you as a podiatrist myself and you as an endocrinologist, I did my fellowship in wound healing and limb preservation, and boy, it was like a revolving door. You come in and lose a toe, one day, next day you're losing a leg. And it was painful to witness and it was painful to see that the structure to support those people before, during and after, it just wasn't there. And so if I was in Texas, I wish I was close to you. I wish I was in your space to be able to help, be part of the problem solution. But instead, we're having health care problems where it's really just treating them as fast as you can until the next problem pops up. And often that's not no no sooner than a week or so, you know, unfortunately, and that's what keeps people busy and stuck in the conventional way of medicine. So thank you so much for showing us a new way of practicing endocrinology medicine being at the forefront of diabetes and technology. Is there anything you want to share with the listeners who might be on the fence about direct care and they're struggling to make the leap?

Dr. VanDyke 27:11
Yeah, I think no matter which way you crack this nut, whether you start from scratch or you convert from a traditional practice, it's tough. If it wasn't, everybody would do it. But I kind of see that as a moot point. Anybody who's listening to this and has been through medical training, okay? So you can do hard things. We've all done really, really hard things. And this doesn't compare to being awake for 30 hours at a stretch and being responsible for, you know, keeping someone alive in the middle of the night when you're an intern in the ICU for the first time. Okay, that's as hard as it gets. This is different. This is even if it's hard, even if you are working more hours at first than you ever did before. It's your freedom.

Dr. VanDyke 28:14
It's your freedom to use your mind the way that you were trained to use it and and say enough is enough to these rules that have been developed by, let's face it, just CEOs and are designed to enhance a profit margin, not enhance outcomes. And we're all better than that. Every one of us is better than that, and our patients deserve better than that. And what I think kind of to your point about how maybe 18 months down the road, the thought process is changing in the population that we're targeting. I really believe there has been a sea change in what patients are willing to tolerate anymore, and I think that there is a backlash this year in people saying, Man, I can't get into anybody for months. I can't get anything covered. I can't get better. I can. They're just so frustrated and fed up that the concept of paying outright for a one hour consult where they actually get to see a doctor and not think they're seeing a doctor, but end up seeing a mid level or something that's worth it to them, and for everybody who's trapped in a high deductible plan, because every one of them is high, high deductible. Now they're saving money when they do this every year. I think about my worst diabetes cases. These are the people where we have to have eyes on them every couple weeks, every month, something like. That even if they paid the subscription fee for an entire year, it's going to come out to on the order of $2,200 or something, for an entire year's worth of comprehensive diabetes management. That is a fraction of what their deductible would be. They're saving money,

Dr. Tea 30:22
Saving money, saving lives, all at one (yes), and saving positions direct care. does it all it's going to save positions too well. Thank you so much again for your wisdom. I look forward to seeing what else you got hidden up your sleeve, because I know you've just got a whole bunch of years ahead of you, and I'm so grateful to be here with you.

Dr. VanDyke 30:45
I'm so grateful for the opportunity. It was a pleasure to meet you over the weekend, and I'm so happy that you do this podcast.

Dr. Tea 30:52
Oh, thank you. Thanks again to everybody else. I'm going to catch you next week. Have a great one.