Transcript

Dr. Tea 0:51
I'm very excited to share with you a dermatologist, in direct care. She's got a really cool story. She has two practices to separate entities, for dermatology, one is TELEDERM. And the other is a brick and mortar. And she's doing this all by herself. Oh, and I forgot to mention she has 40 states under her belt. She is licensed to practice medicine in 40 states. I think that is so cool to give access to people in so many different places. And you're going to learn so much in this episode, it takes you from where she used to be in a situation where she was contracting with a ton of insurance contracts to when she had to make a decision on whether or not to continue on that path. Or to dive into direct care. I think you'll know where the story ends. But I want you to tune in anyway and give her a shout out on social media and thank her for taking time out of her day to share her story with us. Let's dive right in.

Dr. Tea 1:54
Today I have Dr. Erine Kupetsky, who is a dermatologist talking about direct care and her business. Welcome Dr. Erin.

Dr. Erine 2:04
Nice to meet you. Thank you for having me.

Dr. Tea 2:07
Thank you so much for taking the time to speak with me about your practice. Why don't you give the listener a little bio about your professional life?

Dr. Erine 2:16
Sure. So I'm double board certified in Family Med and Dermatology. And I started my own private practice in New Jersey in 2018. I was taking insurances up until about June of this year. And then all the insurances went away. I was part of an IPO. So I had to make the decision of whether or not to drop all the insurances at once I didn't have the ability to cherry pick. And I made that decision. So now I am direct pay. With my practice in New Jersey, I also have a part time practice in Sarasota, a mobile dermatology practice. And that one has separate tax ID. So that one is direct pay from the start. It's about a year and a half old now. And that those are my two practices. I see kids, adults do medical cosmetic dermatology. I do a lot of virtual dermatology. And it's been it's been awesome.

Dr. Tea 3:21
Wow, that's incredible. So you've been doing this technically a year and a half, because you've started with your mobile dermatology. And then now you have in house you have a brick and mortar.

Dr. Erine 3:33
And a brick and mortar that's a little bit over five years, and been thinking about direct pay ever since I opened but like most people, it's scary when you have a lot of overhead, which is what I had when I first opened my practice, I own the building and the property. So of course, it's not the first thing to think about, but I was getting my feet wet. I was joining the groups I was listening. And slowly the seed got watered. And five years later, then I made the decision to make make the change.

Dr. Tea 4:10
I can't imagine what that might feel like they almost have to do all or none because you said you were part of an IPO so you can cherry pick those insurances to slip out of. How did you move from that mental space into I'm just going to do it all.

Dr. Erine 4:26
Lots of prayer. Lots and lots of prayer coffee, chocolate family time. No seriously though, It, I think that because I've wanted to do it since the beginning and just had a lot of fear driving me. I suppose I was just waiting for the right time and I was up against the renewal of the IPO. And the renewal the IPO was in June. In January I was saying this is it this year. I'm gonna make that decision. So I have to mentally prepare. And definitely not an easy one for sure. I don't think I don't think I'd recommend it to anybody, just to be honest with you, because especially, I mean, if you're renting a small space, and you have a micro practice, and you don't have a huge mortgage, a giant building, you don't have property taxes, utilities, you're responsible for everything. If you don't have that, well, then fine, no problem, you know, not a big deal, because the risk is not as great. And you don't have to worry about payroll, and that kind of overhead. But, um, you know, I think it was just time and I had a very supportive team, very supportive family. And like I said, it's been, it's been quite a journey, it's been very good. And I'm just, I'm just keeping my head up and keep going.

Dr. Tea 6:01
So you've had the seed planted for five years, when you started your practice? Is that right?

Dr. Erine 6:08
For, for being direct pay? Yes, yes, it's something that I wanted to do for a very long time. And, like most people in my position, both primary care and specialty care, you're driven by fear, you're you, you hear what people say, you don't know all the right answers, you don't know all the right questions. And mostly, you're just scared of not growing, you're scared of rejection. Also, I think it's demographic based, too, because direct pay is very well accepted in in in the South and the south. And I'm in New Jersey, in the Northeast. So if I were in the south, even if I did have a larger practice, or larger overhead, that's a little bit for some reason, it's just more accepted in the south. But in the north, not many people knew what I was doing and why. They're they, they were like, you're not taking insurances. Why? Why would you ever do that? How do you get paid?

Dr. Tea 7:18
Funny, how that works? How do you get paid?

Dr. Erine 7:23
I was like, let me tell you. So, yeah, it's um, yeah, I think I think a lot of physicians have to thoughtfully and prayerfully, consider. If they started practice, if especially if they went traditional, just because they were scared, and they just went in the streamline of it all. They have to really think, count the cost, do the budget, do everything they need to do. And slowly water that seed because eventually it'll be the right time. I take that back. I'm sorry. It's never the right time, per se. But eventually your heart you'll just say, You know what, enough is enough. Let's let's do this. So for me, I was up against the deadline to renew the IPO. And I was like, three months prior. I'm like, let's do this.

Dr. Tea 8:14
Wow. So what resources did you lean hordes that helped you with that? That fear that you went through anyway?

Dr. Erine 8:24
Besides praying

Dr. Tea 8:25
I was just gonna say, it was probably a prayer? I knew that was gonna be

Dr. Erine 8:30
Oh my gosh, it was you know, just a lot of a lot of protective prayers, the prayers that you know, include that you know, God's got your back. Jeremiah 29:11, one of my one of my favorites. "The Lord has a plan for you a plan to you know, leave never leave you give you prosperity give you a future comes to mind" and I think besides that, because that's first I would say some of the Facebook groups have been extremely helpful. Some of the direct pay specialty groups the direct pay Doc's there are many different direct pay Doc's both there's like, physicians one and there's another one that's has physicians and and mid levels as well. So I joined all of them. And I read and I listened and I asked questions. Also for me as a business owner, understanding Explanation of Benefits understanding how insurance is paid, how they rejected and why. Things about deductibles, understanding all those things helped me have better answers to patients when I told them I was dropping insurances and why and be able to explain to them the little nuances in their insurances that they don't even they knew about most people don't know about co pays deductibles, co insurances, they had no idea so I had to learn those things to be able to explain to patients. Hey, did you know that my direct pay fee is about exactly what you owe after your deductible, before the deductible is even met, and you're regularly healthy person, you may never even meet your deductible by the end of the year. And your bill with me is going to be similar to my direct pay fee. So that kept a lot of patients on as opposed to turning them away. But it was understanding, doing like a deep dive and understanding those those nuances with insurances was another resource for me that I that I learned and had to learn. Um, gosh, those were the big three for me.

Dr. Tea 10:43
That's a really great way to look at it, because we're doing the work for them the cost comparison, and letting them know the value is the same, if not better, if they chose to work with you. So how do people find you? Are you doing marketing? Is it all word of mouth? What does that look like?

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So I actually do a lot of Facebook, Instagram marketing. And I find that that's how most people hear about me, I do a lot on Google, both practices. So for New Jersey, I market in New Jersey area, like within maybe a 3040 mile radius from where I am, which is Lawrenceville that's in Mercer County, right near the state capitol of Trenton. So I mark it all around there. And it even goes a little bit into Pennsylvania. And then for the Florida practice, I do the same around Sarasota, which is where the practice the mobile practices based. Virtually though, what's nice is that for both practices, and so I do so much TeleDerm, I'm able to well, I have about 40 state licenses. So I'm able to see my patients pretty much anywhere they are, I also mark it to some direct pay primary care doctors, on the groups letting them know that I am licensed in those states. And if they have patients who, for example, if they're not comfortable doing something with Derm, I can see the patient virtually. And that's a good add on service for their patients and the membership. And yeah, so so mostly social media marketing

Dr. Tea 12:17
I have so many questions with all of what you just said. So first, you have two practices in two different states. You have 40 licenses, and you've got you can practice in 40 states as well. So let's talk about why you have a practice in Florida and New Jersey. What was your motivation to do that? And are you physically in Florida? Or is that like your TeleDerm?

Dr. Erine 12:40
So yes, I'm physically in Florida, used to be every month. And now since I dropped insurances in New Jersey. I'm more in my practice in New Jersey, that I'm in Florida. So I'm going down every other month now. I have patients that I see regularly, they're scheduled in advance and I go to their homes and I see them if they need some management similar to my practice in New Jersey, if they need management and I'm not physically there, I'm on vacation or I'm out of state. Telederm has definitely has been a great add on for my practice. And I do a lot of it. The licenses allow me to see patients anywhere, wherever I have a state license, including my patients who go off to schools, and I can see them take care of them. And it's not a problem.

Dr. Tea 13:31
I'm curious is with getting those many licenses. Is there like a unified are a centralized place to do that, or did you have to license for each and every state?

Dr. Erine 13:40
That's a good question. So there is an I believe I'm saying, I hope I'm saying it right. I am LCC. It's basically the state compact, that you go to their website. And they there's a state compact where you're able to apply for multiple state licenses at once. I think they only have I think they only have like maybe 20 or 30 states in the compact. And then every other state you have to apply separately. So before the compact you would have to like you said apply for each one, which is a little bit annoying. It's just a lot of work. But the compact has made it easy. And now more and more states are joining. They're just taking a long time. But I have a lot of non non-compact state licenses as well that I've applied for individually.

Dr. Tea 14:27
That's incredible. We would definitely need to have that and I don't think that exists yet for podiatrists because we have a DPM degree, but I'd have been hearing it for MDS and do that. I think it just makes sense because people want telemedicine access. Why not? Especially because everyone's moving all over the place anyway. So continuous care is always going to be important. So thank you for sharing that information. I'll find the link and I'll put that down in the show notes for everyone to take a look at. But going back to wow your plate sounds really full. You've got these two practices. Are you flying? Are you driving? Do you have a home in Florida? What is the like logistics of how it works for you and your family?

Dr. Erine 15:04
So yeah, initially, when I was traditionally based in practice, I would go down every single month, close the practice and just go down every single month, and we would drive to make it like a family thing in our minivan. And so now, dropping insurances. One thing I did not mention was that you lose a lot of volume when you drop all the insurances at once. And that's, I think, what the biggest, biggest scariest thing is for a physician who has all this overhead that doesn't decrease, payroll doesn't decrease, and yet your volume decreases. So you have to have some measures in place to cover that for me, that and the fact that I go to Florida every other month, so I just made it a little a little longer, enabled me to spend more time in my practice, at least until those volume, the volume bounces back. So in Florida, we have a home in Sarasota. And at the moment I've been flying down.

Dr. Tea 16:10
Do you recommend this for others?

Dr. Erine 16:14
To have two practices and fly down and then travel down with four dogs and two kids in a minivan? No.

Dr. Tea 16:20
No? It sound fun.

Dr. Erine 16:27
It is it is fun. It definitely you know, we did that like for two years before I started flying down, so but I it has been very fun. I have to tell you, especially with the dogs and the kids. But I think that thorough physician, definitely dropping one insurance at a time. If you want to go direct to PE definitely having a micro practice definitely not having a big building or making sure you maximizing all your rent space in the building. Those are kind of some of the three things I would those are my take home points. Those are the three things that I would kind of recommend for someone, both primary care or specialist,

Dr. Tea 17:06
Your patients. I imagine they love you. They love the access. They love the affordability. But in your words, why do you think patients are choosing you over? Let's say an insurance Network option?

Dr. Erine 17:18
Good question. So there's a lot of PE, dermatology companies around where I am. And they're everywhere. Actually, they're just not around here.

Dr. Tea 17:26
I was just gonna say Amazon was gonna roll something out too.

Dr. Erine 17:29
I wouldn't be surprised if Elon Musk also rolled something out to everybody, everybody. So I think for me is that personable, I fluent in Spanish, the area where I'm at, there's a lot of Hispanic patients who, who had built that trust with because they speak their language and understand the culture. They will start with one family member and then you know, they bring their mom, their aunts, their uncles, and we we gained families in that sense, the patient's like the fact that I can see them virtually for any emergency to avoid the ER or avoid urgent care. I do telehealth appointments at all times. So like if someone has some issue, people have my cell number. And now let's say listen, I'm really sorry to bother you. But you know, I just jammed my finger. You know, I don't know if I need stitches, something like that. And I think people like that kind of access that it's just me, I'm very available. And they always have the ability to ask me any questions or for follow up care. You know, I have all all all these ways of texting and securing secure messages. So they can ask me any questions that they have. They also like the fact that they can get in next day, or same day depending you know, depending if we have availability that day. But a lot of patients are really excited the fact that there's not a three month waitlist around where I'm at, there's a three month four month waitlist and that's the Sooners practitioner or a PA to see a board certified DERM it's even much longer than that. And patients get very frustrated with this because they feel like they're not getting the care they need. And they they often just call around and see who's open or see who they can see. But when they come to my office, they're able to get in right away. The fact that also I offer transparent pricing patient knows exactly what they're paying from the moment they come to the office. The fact that I can bundle pricing in memberships to give extras or add on services patients like all those features.

Dr. Tea 19:41
Have you met other dermatologists with direct care direct pay practices?

Dr. Erine 19:45
I have Yes, there is a Facebook group called direct pay derms. And we do a lot of collaborating a lot of talking about our business models and those are those are all part of the Facebook groups that I belong to that have been very helpful.

Dr. Tea 20:01
That's good to know a lot of the work that I do as a podiatrist is like toenail problems. Nachteile feet fungus things. Yeah. So there is kind of dermatology component to that. But even like you said, the dermatologists out here to get access to them every six months or so. And even for myself and my daughter, I had to reach out to a friend. And even as a friend, he, you know, he can't see me for three months. It's kind of crazy. And he has built in the insurance model. And I just think like, there's so much more we can do. For people that we know people around us, I'm really grateful that you have direct access, especially with DERM. People freak out if they're, you know, they don't know if what they have is contagious. And if it is, we better not wait three months to figure it out, you know?

Dr. Erine 20:49
Yeah, yeah, no, you're 100%. Right, though. DERM is one of those blessed specialties where you see crazy stuff that you probably don't forget. But yes, I think patients find it very, very appealing that they can be seen right away. Or they can have even telehealth as an emergency. Even on holidays like I, during when I'm closed. For the holidays for the Thanksgiving or Christmas holidays. I will have emergency telehealth, I put it all over my Facebook group, like any patients who need to see me, you know, we're close. But if you have an emergency, you know, please DM me. So patients do appreciate that access. I think that's very unique. And that's what sets me apart from the practices around me. Plus, it's just me. And, you know, there's no other folks at the office that are provider. So I think that people know that I'm going to be their doctor, and that I'm going to deliver the care and that they can have that established doctor patient relationship.

Dr. Tea 21:58
Does your malpractice change when you have multiple states? Like you do?

Dr. Erine 22:02
No, my my insurance just needs to know what percentage of time I do in each state?

Dr. Tea 22:07
Okay, so that should be like an easy not a barrier to getting multiple state licenses?

Dr. Erine 22:12
No, I mean, depending like, depending on your insurance, I had a carrier that it's quite expensive. But they, you know, they they basically send you a sheet and then you tell them like what percent of your practice is telehealth in all these states? And then you kind of, you know, answer it. And it goes back to underwriting and then they approve it.

Dr. Tea 22:33
Good, as far as your business goes, what would you want to share that you would say has been maybe a mistake or something that you learned from or something that you wish you knew before venturing onto direct care? Well, what have you learned that you can help others prevent?

Dr. Erine 22:49
So that's a very good question. I kind of alluded to it earlier, when I was saying how you have to always count the cost when you transition to direct pay. If I could go back in time, and I was looking at the real estate of my practice and the building that I got, I bought it from a retiring GYN in New Jersey, and it was on the market for two years before I bought it. So talk about providence, right. But if I can go back in time, and say you're going to be direct pay, so you don't want to buy almost a million dollar building. So I'd probably go back to my younger self and say, Yeah, that's a nice building, but you probably just want to rent for maybe a primary care doctor like a room and kind of grow that way. So that your overhead is not overwhelming. So even if I was traditional practice, I feel that it's a lot less stressful. When you start small. Like even if you buy let's say a mixed residential, commercial, and then you rent the top to a family and then that pays the whole mortgage. If you start off small like that, I think that's very smart as an entrepreneur, physician, whether you do traditional or direct now, if you go traditional, yes, you have a ton of more volume, because you're taking insurances, but if you go direct, it's even better because then you have a lower cost of overhead, you have no Biller, depending on if you're not involved with Medicare either. And you also don't have all the craziness that's involved with the billing, the insurance, the calls and denials and all that stuff. So in that sense, it's better because then you can take profit, you'll make profits sooner and you can take the profit and apply it to getting a larger space, or getting a medical device or getting, you know, nicer chairs, whatever you want. Right but definitely starting small is the first thing I would do. And then the next thing I would do is if you're traditional just because you were scared, take the plunge and drop one insurance About time about every six months or so. And then this way, you don't feel that drop in volume so acutely, and you're able to introduce the idea of direct pay to some of your patient populations slowly get it in. So that's another thing I would do to my case, I didn't have that choice was because I was part of the IPO, I could not cherry pick. And those are the two major things that I would change. If I could go back to a younger me for the most part. I think that besides those two things, just making sure you're have an excellent CPA, a really good bookkeeper who goes over your profit, your loss, your budgeting helps you for cast, where you can go and take a little bit of risk and where you can go and spend more money. Someone like that is in valuable to me, I have a really good accountant and bookkeeper that helped me figure all this out, then they helped me actually sit down about three months prior to dropping insurances and calculate, okay, how does this change? If let's say your medical expenses decreased by 25%? What does that mean for your take home for this for payroll for all those things, all the numbers that trickled down from it? What does it mean if you drop 50% of your volume, and so on, and so forth. And you can kind of get an idea of just where you have to be able to save if you need to look for new vendors, if you need to start thinking outside the box, or if you can just do away with certain vendors, for example, if it doesn't make financial sense. So I think a lot of it is knowing that you're an entrepreneur, first, you're a physician. Second. I think if you understand that role, you're going to be successful, and a solo practice. As a solo practice owner, if you're a physician, first and entrepreneur, second, you're going to make a lot of financial mistakes.

Dr. Tea 26:55
Thank you so much for sharing all of that. Any last words you want others to know before I let you go?

Dr. Erine 27:03
If you feel it's time to drop insurances, and you've calculated the cost, and you have a lot of support, and you feel it's the right move. There's no better time than today. Because there will never be a really good time for anything like that. You either do it and you move your practice in that direction, and you just do what you have to do, or you don't. So those are my last words. I encourage everyone who is motivated to end the third party payment system that is unfortunately destroying the solo practice owner in this country to just do away with it. Eventually, however they decide to do it. There are tons of resources for health, including me.

Dr. Tea 27:44
Awesome. And by the way, how can people connect with you?

Dr. Erine 27:47
Sure, so Facebook, Instagram, my Facebook company in New Jersey is Wellness Dermatology. And we're in Lawrenceville, New Jersey. I'm Patriot Dermatology in Sarasota, and Facebook and Instagram instant messaging are probably the easiest way to get a hold of me. Other than that I can be direct message and we can you know exchange numbers and have conversations with with colleagues and make sure that they get all their questions answered.

Dr. Tea 28:17
Thank you so much for your time. I've learned so much from you today. And I'm so glad that you're here listening to the podcast with us. I'll put all of that information down below in the show notes. Please give her a warm thanks for her time by following her on her socials and thinking about her when you need a dermatologist in any of the 40 states she participates in. That's all I've got for today. I will catch you next time. Take care everyone.