Triumph With An Awesome Direct Primary Care Practice

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Transcription PNC Podcast Episode 404

Triumph With An Awesome Direct Primary Care Practice

Interview with Dr. Ati Hakimi

John: I've been following the DPC movement for several years. And I've spoken about it here in the podcast, but actually today's guest is the first physician to join me on the podcast to talk about her DPC practice and why it might be the salvation of independent physicians and their patients. So Dr. Ati Hakimi, welcome to the podcast.

Dr. Ati Hakimi: Thank you, John. I'm happy to be here.

John: I think this is going to be good because I have this feeling that, you know, the people that listen to me, they're trying to get out of clinical medicine. They're looking for these nonclinical jobs. But I don't think they've, a lot of them have really fully explored this DPC thing. They've heard of concierge and they feel like that's, you know, expensive for patients. So just tell us a little bit about your background and then maybe segue into, you know, why you decided to start this particular type of practice.

Dr. Ati Hakimi: Yeah, definitely. So. My name is Ati Hakimi. I am a family medicine physician because we are the real doctors with all due respect to everyone else. That's why I chose to go into family medicine. I really wanted to know everything about everybody and how I could take care of the whole family. So that was my trajectory. I trained at Northwestern and I also did a little extra training at Rush University Medical Center. I got a year of geriatrics under my belt because we all know that medicine is geriatrics. So that was my calling in life. And I went on to actually work with the VA, which would have been the perfect fit, right? Because I just came out of a geriatrics fellowship and what have you. Unfortunately, it was not a good fit. And from there, I went to get an MBA. I have an executive healthcare MBA from UC Irvine because it had already started to become medicine was a business. Yeah. So I needed to learn how to speak the language. And that was the reason why I decided to get an MBA.

And so a caveat for your listeners as well is that you don't have to have an MBA to go into direct primary care. It was something that I chose to do to kind of give me more of the knowledge when I was actually in the insurance model of care because that's the care that is the business model, not what we do in DPC. So that's just a little caveat there. And so I actually went on to do more of the geriatrics practice in terms of post-acute care, things of that avail, and the primary care aspect was kind of put on hold until I came into DPC, even though I was trained in doing that outpatient primary care in my training.

So my story was that I was living in San Diego and I was with the Department of Defense there. Once again, not a good fit for me. And after doing my MBA, seemed Nevada became my calling. There was a gentleman who had actually became the president of one of the major HMOs out here. And if anybody knows any statistics about Nevada, unfortunately, we are number 47 in the nation in healthcare. There are just not enough of us here, specifically physicians. So he reached out and was like, we need doctors. And so I came out, it was a time in my life where it was a time for change and change is good. A lot of things that were going on were not good for me, but change was good. And California is very expensive. I don't pay state income tax here. So that was one of my major reasons to come out here. Quality of life was a little bit better for me. So it could have been worse, I guess. I ended up in Las Vegas. And I started working for that large HMO company. And at one time, it was an OK fit because they were physician run and operated. And they were called, can I say names?

John: Sure.

Dr. Ati Hakimi: I think names are OK. Health care partners, right? So they were physician run and operated, so it was a good fit. And once they started to go into the M&A world of mergers and acquisitions and sold and became DaVita, as you know, DaVita is a dialysis company with primary care, it was just not a good fit. And I really started to think that this was not for me because metrics started to become a thing in our world. And the metrics, unfortunately, were not attainable. There was probably at least 200 of us in the practice and like three of us would meet the metrics to get our bonus. So that was not what I went into medicine for.

And I decided that I needed to start thinking outside of the box, really. I actually left the company on my own accord when the metrics started coming because it was really egregious stuff, really egregious stuff and they had no answers for me when I had questions about these things. And I thought, you know, I'm a pretty smart cookie. Maybe there's other things I can do, right? But I'm a family doc. I love medicine. I love socializing with my people. I love taking care of people. I love preventing things from happen to them because that's my calling, right? My calling is to make a difference in your life before I leave this earth. It was a void. There was a void.

So I actually joined a leadership group in our city and found a tribe of people that believed in me, supported me. And I started volunteering. And when I was volunteering and just not being a scribe, not billing, not coding, not those horrible words that have nothing to do with what I was trained to do, I realized I'm a pretty good damn doctor. I am a good damn physician, and I deserve to continue practicing. And so I started doing my own research and I was a little bit into the whole internet world and social media and things like that. And I ran across direct primary care. And I started following a group on Facebook, which was literally, I think it's called DPC docs. And I just started becoming a little bit of a troll and checking out what people were saying and their experiences. And it was just different, right? It was positive, people were helpful, people seemed happy themselves, and it just lit up all of my sensors. What the heck is DPC? What is direct primary care?

And I went online and I tried to find someone locally that was doing this. And I did find someone and he was an... He is an amazing person. I'll call him out Dr. Jimmy Hawks. He already had started his own DPC practice. He had about 400 or members at that time. And his story was he was a hospitalist. So he actually found there were so many people that had no one to follow up with. And so he created his practice from that source and was extremely successful, and the nicest guy in the world. I mean, you couldn't find a nicer person, I have to tell you. So he took me under his wings and he literally said, just come to the office, just come check out, follow, shadow, see what I do. And honestly, I was floored. I was floored. It was just good old fashioned medicine, right?

The model that he had constructed, and I think we all have that base of the same model that we have constructed. We all go off on our own in terms of what we think is fulfilling, not only for our members. I don't call my people patients because they're not sick. Right? I call people that are sick patients. My people are members. So we all create our own models when we start doing DPC. And his model was chronic disease management and it was amazing. And I really just started to finally believe in myself and think that there is a possibility of practicing for myself, not dealing with insurance, not dealing with all of that drama. And I am a solo female minority physician. And I would like to think I'm pretty successful. And I would think that if I could do it, anyone can do it.

But the moral of the story is it's nice to have a mentor because we can talk you through it. We can show you how it's done. And we are glad to do it. Listen, John, nobody in primary care should be working for anyone but themselves. We have found a way. And we, the rest of us are... We would love to help you get out a hundred percent, right? Because we deserve to do this for ourselves. You know, for every one of us that gets hired, they might give us like, you know, measly six figures somewhere, but they make two to three million off of each of us. Right. Seeing 40 or 50 people a day. That is not quality care. That stuff was killing me personally. Right. It wasn't just my members or my patients at that time, cause they were sick. It wasn't my patients that weren't getting the quality of care they deserved. I was struggling and hurting and it was hurting my soul. So to find direct primary care, it was very selfish. It was really about me. It was really about me. Yeah.

John: Let me ask a couple of questions just because when you first heard about it, maybe weren't aware of it at all, but just the beginning, it almost sounds too good to be true at the beginning, doesn't it?

Dr. Ati Hakimi: Yeah, for sure. Yeah. But it's all real. It's all real. And I think that, I mean, when I found out how much things really cost is where, you know, and having an MBA is where I was floored. I literally almost started crying when I found out how much things cost.

John: What were the surprises?

Dr. Ati Hakimi: The surprises for me, first of all, so let me just give you a quick spiel about direct primary care. This is the 32nd, you know, elevator speech.

John: Okay.

Dr. Ati Hakimi: So direct primary care is a flat fee healthcare membership. It is like the Netflix of healthcare, right? You pay us once and we are there for you. So for me, I am solo. So you call, me. You text, it's me. You email, it's me. When you see me, it's me. And I do a lot of telehealth still. So fun fact is that telehealth is going to be removed from that fee for service model again, because insurance just decided that's what they want to do, right? I don't work for insurance, I work for my members. So I get to do whatever I want. So that's fantastic.

So direct primary care has its benefits. And one of the benefits of course is access. You have your physician with you at all time. I pride myself on that being available, being accessible. Another part of that is labs. I can get an entire panel of labs from A to Z. I've actually got a relationship with LabCorp and it's something called client billing that we do. So basically LabCorp will give us prices that are pennies on the dollar, pennies on the dollar. The same labs that somebody would go in and say cash pay, if they do it through me because I pay LabCorp, so that prevents them from having to deal with billers and coders to run after everybody for all these ridiculous fees, they know that I'm going to be responsible for that bill.

So when I do that, it drops the prices significantly. My members compensate me afterwards, of course, but when they do it through me, it's probably a couple of hundred dollars, including all kinds of things, vitamin levels, not just your standard CBC, CMP, TSH. I can get all the vitamins in the world. I can get inflammatory markers. I can get it all, right? Pennies. Penny is on the dollar. That's one thing.

The second thing is imaging. I work with the local imaging center. So that's something that's city specific. You got to get out there and talk to your imaging centers, find out which ones are the ones willing to work with you. My people here, they'll give it to me for, I can get an x-ray for about $45. Walk in, I can, and that's with the read, that's with the radiologist read. There's not a separate fee that goes with that radiologist. So I can get that. I can get that x-ray. They will even do it for me for stat, same price. Same price. I can get a CT scan for probably three, $400. Those prices unfortunately just went up. It used to be less. And then I can get an MRI of any body part for maybe $500. Because nobody wants to deal with insurance. That third party model that we have in this country with everybody's hands in that pot is what is costing our healthcare system to be so egregious. There's too many hands in the pot. When you just go straight to the source, as with any business, everything drops tremendously, right?

And then the final one that I have for my membership, and this is specific to physicians as well as the state that they practice in, I actually order medications directly from the manufacturer. Every physician should know that they can do that for their people. You can create an account. I use Andameds. You can create an account if you have a DEA number and you can order medications directly to you. Right? So my blood pressure pills can be maybe $10, $15 for three months. My cholesterol pills, all my statins, they don't cost a lot anymore. They are all pretty much generic. I can get three months for $10, $15. Now I even put up a little markup there. That's with my little markup. So it's even cheaper than that. You understand? So that is another benefit. I have people that are in my practice that are making money off of me.

John: In what way?

Dr. Ati Hakimi: Because I'm saving them so much you're saving them.

John: Right. Yeah. Do you find that your patients are maybe on fewer meds? I see a lot of docs that basically every visit they come in, they're adding another med because of a side effect or something. So.

Dr. Ati Hakimi: Yeah, so that's an excellent question. I think once again, as a primary care or family medicine physician, also with that geriatrics training, right, that polypharmacy world is a nightmare. So when people do have access to their own physician and when they, what I like to do is check in on people once a month. That is my way of practice. My way of practice is about lifestyle medicine, which means I hold people accountable for how they sleep, what they eat, what they drink, how they move physically, what their mental health is, how their relationships are, because that is your base and foundation of healing.

So that's how I do my practice. But with direct primary care, you have the freedom to create it the way you want. There's nobody over your shoulder telling you to meet metrics, right? That's all gone. You create it. I have colleagues that literally have office spaces where they might have put a kitchen in there, classes about nutrition or yoga studios or have contracted with people to do such, right? It's what you want it to be. It doesn't just fulfill your patients' souls, it fulfills your soul, right?

So my onus, like I was saying before, that physicians, we are chosen. We're not made, we're chosen. And the current sick care model in our country has taken that away from us. And so people need to know that there is still a way to practice the art that you were chosen to do. And this is not just for primary care. I have specialists that have jumped on this as well. You know, we have direct specialty care now. It's a little more complicated when you have to do procedures, unfortunately. But there is a way for your members who don't have health insurance to actually bring on DPC in their worlds as well. And that's called a health share plan. I don't know if you've ever heard of that. Health share plans are perfect with direct primary care.

So the perfect health care model right now, I'll tell you, is a health share plan, which was started by the Christian faith once upon a time where people put money into a pot. So it's not faith-based anymore. There are several companies now that are doing this. And basically what they do is they take the onus of the catastrophes that happen, right? They work well with DPCs because they know we take the responsibility of preventing things from happening to them. So with the combination of a health share plan, a DPC and an HSA, which you can pay for your health share plan, which actually, you know, your money working for you, is honestly the ideal model of care in the United States when it comes to healthcare. Hands down.

John: Sounds awesome. Yeah, I think I did hear a podcast where someone was talking about like a crowd share kind of approach the pool for the big things. But I know one of the things my listeners are probably wondering about, like what is your day like practicing like this?

Dr. Ati Hakimi: So, I think for me, I am very, very outside the norm because what we have to do when we start a direct primary care practice or any type of business is you always have to first go back and evaluate what your needs are when it comes to your financial situation, your family, things of that avail. I have very, very, very, very, very little needs. So my overhead is non-existent. It's non-existent. I don't have a ginormous office space. Yeah, so I actually found one of my colleagues in a women physician medical society group that I'm a part of that when I approached this group and told them, hey guys, I'm done, I'm doing my own thing, one of my colleagues was amazing. She's like, I've got a huge office, like a huge office space, because she does infusions in a rheumatology clinic. So she has nothing but space. She's like, come rent one of my rooms. That's what I do.

So I literally pay her for a room. I don't need an office. I don't need front desk. I don't need any of that stuff. I can take my own blood pressures and weigh people myself for goodness sake. So I actually rent space from her. I go into the clinic once a week. My practice is very tiny. And that's because that's okay with me. That's what my needs are. So I have like a boutique practice is what I'd like to call it, right? I have about 150 people and I know them by name. I know their husband's name. I know their wife's name. I know their kid's name. Cause that's the kind of family medicine practice that I wanted to have.

So that's my practice. What my day looks like, it can vary. Honestly, I do a lot of telehealth because remember I told you that I like to hold people accountable. So we will jump online based on their needs or their times as to when they had that availability. I go into the office, like I said, once a week because I'm tiny. So I go into the office once a week and that's when I do the hands-on stuff that I need to do. The rest of it, honestly, this is my office. Is here.

John: I can imagine you see someone texting you or calling you. Well, you know in your head already who that person is. If they're on meds, probably. With that number, can, especially the people that have, maybe they got a chronic illness. And you said a lot of it's preventive as well. Do you feel like you're gonna stay at this about the way things are now? You gotta pretty much...

Dr. Ati Hakimi: Yeah, I think for me, my goal is just 200. That's my sweet spot. 200 is my sweet spot and then I'll tap out. And like I said, I have colleagues that have 400, 500 people. They've got this, you know, this whole beautiful office space they're paying $5,000 a month for, you know. But remember, our price point is also different for each practice, depending on what your needs are again, and how you actually construct that.

When I first started, I based it on age. Um, and now, um, and I also was doing a lot of house calls. Unfortunately, Nevada did something to us where our med mal practice, our legislation kind of messed us up. Um, they, they removed the cap on our med mal. So it's not, it's not for me anymore to, do the house calls thanks to the legislators. Uh, so anyway, um, I was doing that at one time too, because like I said, you can make it anything you want it to be. Now I've just had a flat fee. So I have a fee for my individuals, have a fee for my couples, and I have a fee for families. Listen, I charge $150 a month. That's it. I live in Las Vegas. If you go out onto the strip and have a couple of cocktails and a dinner.

John: Yeah, that's it. So what's the mix now then? I mean, is there a certain of the, you know, because you're talking about full spectrum from children all the way to seniors. Is there certain mix? Lot of women's health, lot of more middle healthy younger people.

Dr. Ati Hakimi: Yeah. So, that's an excellent question. I have everybody from the CEO to the Uber driver, right? The CEO, because their access is very important to them when they need something now, they have to have it now, and the Uber driver because they can't afford the nonsense that's out there. So there is no discrimination. It is affordable.

So the difference between us and Concierge is that Concierge was once upon a time created for that access too, but they charge a large sum upfront and then they still bill your insurance. It's a double dip. So I'm not sure how they get away with that because with Medicare and things you can't. That's the difference between direct primary care and concierge. And concierge, sometimes they don't do all the other stuff of offering the labs and all these other things because they're going to bill your insurance and go through that fee for service model. They don't have the other things that are, I think, beneficial or options. They don't give people options, I think. So that's the biggest difference between us and concierge.

There was a time when I was interviewed by a local TV station and she said something about, well, it's cost prohibitive. You know, we are only taking care of people that have money. And I will dispute that all day, every day, because once again, I live in Las Vegas. So my fees, I think, are very affordable, very fair. And It's not the right concept or the right argument to even have with anybody when it comes to that.

John: You know, when Like where I am, our deductibles are so high that if my wife needed an MRI or an x-ray, I would just go outside the system and go directly to the freestanding clinic and get it done anyway.

Dr. Ati Hakimi: Yeah, sure. Cash pay it. And that's the other point is that we have forgotten that cash is still king. Um, so if people have insurance, can they do direct primary care? That's a major question that I get. Absolutely. Absolutely. Insurance doesn't take care of you. We do.

John: Right.

Dr. Ati Hakimi: When is that conversation going to be had? They do not take care of you. If anything, we are fighting them. If people are not paying attention to the world, we are fighting them every day to get you what you have been paying for every month. And every year it goes up. My fee for service family, every year Medicare goes down. We are the only profession that our salaries get docked every year. Right? That's a whole different conversation. That's because we are not part of the government and legislation. More of us need to get into that world if we're going to have any kind of change. We absolutely have to be a part of the legislator's lives and, you know, We should be in it ourselves. We should try to be elected officials ourselves. That's the only way is that if we are not at the table, we are going to be on the table. That's what's been happening every single year, especially in our state. So, I mean, that's a different conversation to be had. But once again, direct primary care, you don't have to worry about that.

John: OK, let me ask you this. Many years ago, I started my own practice. And this was not DPC obviously. Yeah, and I had to hire a ton of people and I haven't heard you talk about any employees. So do you have anyone doing anything at this point?

Dr. Ati Hakimi: What would I need them to do?

John: I don't know- I know the memberships they pay monthly or you know, but somebody might have to remind them. I don't know.

Dr. Ati Hakimi: Yeah, like QuickBooks. QuickBooks does my recurring billing? Doximity sends my faxes for free. I prescribe, I pay a yearly fee for my prescriptions. I'm primary care. I'm primary care.

John: Do you remember with your colleague that you talked to initially, Jimmy Hawks, I guess it was, Hawks?

Dr. Ati Hakimi: Hawks, yeah.

John: Hawks, yeah. Now he has a different practice. He has some employees or minimal?

Dr. Ati Hakimi: Yes, because he's huge, right? So he actually had somebody answering the phones and he had. He had nurses to assist him he needed. And he's a male, so pap smears and things like that. He needed to have somebody of that avail. But yes, so if you grow, obviously you know what you can and can't handle. But come on, like I said, we're used to 1,000, 2,000. I can handle 150. And so that's another question that my colleagues will ask me. And then the other one is, you feel comfortable giving people your phone number? Yes. Absolutely.

John: Yeah because its doable.

Dr. Ati Hakimi: It's peace of mind. When they have peace of mind, they will respect your time even more. I am so close to some of my members that my father passed away and they even came to his funeral. That's what it was about. That's what it is about. That's what I pride myself on because that's what I've created. It's something that fulfills me too. You know, we are always giving, giving, giving, giving, and we need to take back.

John: Yeah. I'm going to have a couple more questions for you, but first, tell us what your website is and maybe your LinkedIn profile.

Dr. Ati Hakimi: So LinkedIn is just my name. A-T-I is my first name. My last name is H-A-K-I-M-I, Hakimi, M-D-M-B-A, and I'm on LinkedIn. And then my practice is called Vegas Direct Primary Care. The website is VegasDPC.com. And I'm also on Instagram. I'm trying to learn that world a little bit. I'm on Vegas Direct Primary Care on Instagram as well.

John: OK. I'll put that in the show notes too and the emails that I send out. Let's see, questions. So what if someone's listening now? Are my listeners, maybe they're looking for other things and they hear about this? What's kind of the first or second step they should take if they really want to learn more?

Dr. Ati Hakimi: So the first step you should take is get online and look up direct primary care in your city. Find one of us. Find one of us, reach out to us, make yourself known that you want to do this. They also have, we also have, you know, there are professional associations with direct primary care as well. There's something called DPC Alliance and there's a couple of OGs that have been doing it for a while, Dr. Paul Thomas, things of that avail, that are also very helpful. But if you get on Facebook and get on that DPC docs group, that is one of the places that I initially started going on and doing my own research. And you will find that we are a very supportive community.

I didn't find that in the fee for service model. I found it a little bit competitive and I don't know why because we have 2 million people in our city now. There's plenty to go around. So that was the other uncomfortable thing about fee for service. But I think that those docs are just so stressed, right? And so they weren't as receptive. I'll tell you something else. I did look into taking on insurance when I first started. They weren't going to deal with me. Insurance will not deal with you if you're a one person show. They want groups now to come on because they want to negotiate paying you crap. Yeah. So that's another reason that I had to go direct primary care. They weren't willing to even bring me on. So, you know, that was the other thing. And thank God they did not.

John: It's worked out great. Okay. Last question. You know, I have listeners and they are calling me sometimes and email me about, well, I'm miserable. I just can't stand it. I have this corporate medicine BS is from birds and I'm, should I retire early? Should I go look for a job in pharma? Why should I do what you're doing?

Dr. Ati Hakimi: Because it will save your soul and you deserve better. And you have worked so hard to be where you are. Stop working for others, work for yourself. Don't let the corporate systems, the private equities. They don't give a crap about us, you guys. And they will never. That is what they are made to do. We can't blame them. Their model is about the bottom line. Their model is about making money. Now, if you choose to work in that environment, you are going to be a slave to their model. That's all it is to it. And this is not disrespect to any of these things, to anybody or corporations. It's not disrespect. It's just how that model works. It's not made for any of us, honestly, I don't think.

It's not humanly possible for you to see 40 and 50 people. And I even have residents that are coming out saying that they're giving them two to 3000 and they're already thinking of looking for another career. We went to school for so many years. We jeopardized things and sacrificed our lives to be who we are. Don't let them take that away from you. Listen, I did clinical trials. I was a PI for things. I did all of those things. There is nothing as fulfilling as being a physician with all due respect to I don't know if you're still practicing, John, but I mean, once you're ready to retire, that's fine. But don't let anyone else take it away from you. This is the way to go.

It's not hard, you don't need an MBA. Please, I mean, my number is online. If you get online and see my number, call me, text me, I'm totally happy to help. We all are, honestly. I'm in Vegas, that's fine. You can emulate this model everywhere, right? It's absolutely reproducible. And it's not hard, you guys, it's not hard. I did a whole thing for the Small Business Association about how to start your own practice, but it's even easier with DPC because you don't have to deal with all those insurance things and having this number and that number and coding and billing and none of it doesn't matter. That's not what we were trained to do. We went to medical school. We didn't go to billing school. We didn't go to coding school. You don't need to do that. Just be a physician and make a difference. That's what you're meant to do and you can do it. Get out. DTFO.

John: All right, that was fantastic. I really appreciate you, you know, sharing your experiences with us. I think it's gonna be great to look at. I love this. All right. With that, I'll say bye.

Dr. Ati Hakimi: Okay. Thank you, John. And let me know how else I can help.

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