Interview with Dr. Carl Peters
In today's episode, Dr. Carl Peters describes his transition from traditional practice to telemedicine, consulting and advising.
Dr. Carl Peters graduated from the University of Missouri-Columbia Medical School. Then he completed his Family Medicine Residency Program at the University of California, Davis. He is board-certified in Family Medicine and Urgent Care Medicine.
The first stage of the pivot was to learn everything he could about properly establishing a freelance telemedicine practice. Doing so enabled Carl to generate sufficient income working just 6 hours per day, 4 days a week. Once that was established, he focused on nonclinical activities to supplement his income.
A Family and Urgent Care physician with 25 years of experience and over 10,000 telemedicine visits, Carl is now offering his expertise in a variety of ways.
He previously provided direction and expertise as medical director for a network of 12 new urgent care centers. The health system he worked for opened all 12 in about 17 months. He is now the Director of Patient Operations and Lead Physician for Bow Tie Medical. And he continues to provide consulting services and occasional telemedicine visits.
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Telemedicine
Dr. Peters set up his telemedicine company as an independent contractor serving several telemedicine companies. These included large telehealth companies like MD Live and Teladoc.
He decided not to do block scheduling because he wanted to be efficient with his time. He generally works 4 days a week. That way, he is able to run errands and explore other employment and consulting opportunities on his off-days.
Here are some of the important steps Carl advises you take when creating a flexible non-employed telemedicine business:
- Obtain multiple state licenses (one in each U.S. time zone, if possible).
- Each telehealth company gives you the big population states of California, New York, Texas, and Florida. But you may want to focus on states such as Indiana or Utah, where there is often a greater need.
- Do business in a state that's part of the Interstate Medical Licensure Compact.
- That makes it easier to obtain additional licenses. You don't want to do more than four to six states, however. Spread them out geographically.
- You will need a decent internet connection with 2 carriers. You can use your phone's hotspot functionality as a third backup.
- Set up your connections to optimize your efficiency.
- Carl is generally working on one internet service using four monitors. The center monitor is his working monitor. And he keeps each telehealth company site open on an individual monitor so he can watch and select a patient that comes into a waiting room. He uses his own templates to improve his efficiency, dropping them into his notes as needed.
Preparing in this way allows him to interact with 6 to 8 patients per hour on most days.
Consulting and Advising
Once he felt confident that he could generate sufficient income through telemedicine, Dr. Peters actively sought nonclinical work. He signed on with a company that wanted to develop a new network of urgent care centers. As the medical director, he helped the company open 12 new clinics over a 17-month period in eastern Missouri.
He then looked for opportunities in consulting and advising other organizations. That lead to his role as Director of Member Operations and Lead Physician at Bow Tie Medical. Bow Tie Medical brings telemedicine services to employers to improve care, enhance quality and access, and reduce costs.
Dr. Carl Peters' Advice
When medicine is just not fun, it's frustrating, it's not fulfilling… the biggest thing is to research and learn and network and connect… Second thing, if you're not sure where you want to go, I'd say, keep it diversified a little bit. Maybe don't put all your eggs in one basket.
Summary
It can be more interesting and rewarding to diversify your job situation. By networking, you can find jobs that play to your strengths. Dr. Peters found the best networking opportunities on LinkedIn, Doximity, and Health Tech Nerds (HTN), or talking to old schoolmates, and co-residents.
NOTE: Look below for a transcript of today's episode.
EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.
Links for Today's Episode:
- Dr. Carl Peters' LinkedIn Page
- MD Live
- Teladoc
- Interstate Medical Licensure Compact
- Bow Tie Medical
- Doximity
- Health Tech Nerds
- How Do I Generate Awesome Income with Telemedicine Services? – 222
- What Is the Best Way to Leverage Telemedicine? – 181
- What Is the Latest Telemedicine-Supported Specialty? – 173
- NewScr!pt
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Transcription PNC Podcast Episode 249
How to Use Consulting and Advising to Find Freedom - Interview with Dr. Carl Peters
John: Today I have a fellow family physician who has responded to his frustrations with the current health system, as many of us have in his own unique way. And I thought you'd find it instructive. Hello, Dr. Carl Peters.
Dr. Carl Peters: Hello, John.
John: Hey, it's great to have you here. We had a chance to talk a little bit. And by the way, I didn't mention that you and I were linked up by Tom Davis. I think a lot of my listeners know who Tom Davis is because he's been on the podcast a few times and people know we partnered together on New Script. I was happy to be introduced and find a fellow physician that went through the process that many have. So, I'm interested in hearing your story.
Dr. Carl Peters: Oh, absolutely.
John: So, what happened? You were plugging along there doing family medicine. Tell us a little bit about your education and what led up to your practice, and then we'll get into what happened towards the end of that long clinical career.
Dr. Carl Peters: Yeah. Like a lot of us in family medicine, you do your residency and look at a career, lifelong career in family practice. And I did that for about 15 years or so, and kind of hooked up with a company in the St. Louis area that I was very pleased with. They were doing a lot of great things, but unfortunately, I joined them just as the ship was taking on water.
Within about 18 months I knew things were in bad shape. And by 24 months I left. By then I was getting a little frazzled with family medicine, just not the actual caring of patients, but just the business, some of the background stuff, the electronic health records, and all the things that get in between you and me as a patient and a doctor. The insurance stuff, all the games we have to play to satisfy that, to get paid the claims and billing, how much is driven by that, really not by actual patient care. So, I started rethinking a little bit. I've always enjoyed doing an occasional urgent care shift, so I was going to just temporarily do urgent care, maybe for a year, and rethink things a little bit. I started my urgent care career, which went on for the last eight years and really did enjoy it.
But then here we go, they started strategic plans that weren't being revealed to the doctor about, "Oh, we're going to start using mid-levels and goodbye doctors." We had targets on our back. I moved to another company and "Oh, yeah. No, no doctors will always be first and foremost." But then a new model starts to come up and it looks like we again have a target on our back. And so, that got a little frustrating too, even though I did enjoy it.
And then, part of the target on the back was an operation that was going to come in and take over these urgent care centers with this health system and they needed a medical director. And it's like, "Well, shoot, let's look at that." I had some management experience, and initially, it was very rewarding. It was something that had a very excellent team initially. And we worked really hard and we built 12 urgent care clincics from zero in 18 months. So, I went from just a handful of providers to 40 under me in that time period. And it was a very aggressive growth schedule, maybe a little bit too much.
John: Let me comment on that. That is really unreal. But it goes along with what I've seen because I've been in urgent care just in recent years. It's kind of a segue into retirement, more or less. You just hear about all these different buyouts and consolidations. So, I think you mentioned maybe two systems you were working for with urgent care. In the last one you became a medical director. Were those both health systems? Those weren't owned by private equity firms?
Dr. Carl Peters: Correct. They were large health systems that owned them, yes.
John: I think it's funny because I'm sure that most health systems lose money in urgent care. If they can break even, they're happy most of the time because they see it as a loss leader to get people into the doors. But there's always that struggle. And then at some point, they reach a point where we got to start making money and that means we're going to start using the mid-level providers and the things you talked about.
Dr. Carl Peters: Yes, yes. In a way, this was a transition into a nonclinical space as a medical director, and I really enjoyed it. But in watching the model over time, it was a very lean model, very lean. The leanest I've ever seen. And you really had to be hiring rock stars for your techs and stuff like that, your MAs and techs, otherwise, it just became apparent that "Ugh, this is pretty lean." And then the business team changed out a little bit to a culture that again, to me is part of the problem in medicine in this country that just looked at physicians as they really didn't care. It just was like, "Just do what we tell you to do, and we're not going to get your opinion on anything." Just the culture changed. And at that point, the job enjoyment really started going down. And actually, most of the leadership team left after this new management took over.
And so, at that point, I became very discouraged about everything. Where do I want to go next? And I ran across Dr. Tom Davis, who actually we've known each other on and off for years. He was, I believe, a resident when I was in medical school. And I was actually searching around looking at podcasts, just like what you have here. I don't know how I came across it, but I came across Dr. Heather Fork's website. And Tom had just done a podcast that she published. And I was like, "Wait a minute. I know that guy." And I just listened to it.
It was a big life-changer for me because I linked up with Tom. We reconnected. We hadn't talked to each other in years. And basically, we started looking at alternatives. And this was just before COVID, the telehealth space was really growing, especially in the acute care market. And so, Tom has done so many interesting things.
It's interesting, the people I've met that I had no idea knew Tom know Tom. As one person said, "All roads lead to Tom." But anyway, he does a lot of many different things outside of clinical medicine and business medicine. He's a very, very knowledgeable guy. So, we hooked up and he kind of showed me a path into the telehealth space and to build my own practice.
And by then I was like I just want to control my own shots. I am tired of answering the corporate needs and business people that are just taking over more and more in medicine. And part of that's our fault over the years, but whatever, I won't get into that. But Tom, we talked for a while and it just became really clear. So, I started a telehealth practice. Tom was my mentor and followed along and helped me build this up. And it was just immensely, I just loved it. I just really loved it.
John: I got to comment on that because you must have been in the right place at the right time. Because you're getting into telemedicine, but it was before the pandemics. You're getting set up. And I know Tom, basically, he's very passionate about taking back control for everybody in medicine that was kind of promised one thing. And even the patients have been promised one thing, which is to get good caring physicians that can spend time and take care of you. And now everybody's unhappy because the physicians can't spend time and the patients don't get the time and everyone's got paperwork. I've heard that telemedicine is a way to really get a little more control, particularly if you set it up I think the way that Tom has done it. So, tell us how you set that up. And what did that turn out to look like over the first year or two of doing telemedicine?
Dr. Carl Peters: Yeah. I think it would've been very successful regardless, but this was like buying Coca-Cola stock in the 1930s and hanging onto it. I've been doing this right before telehealth, it went gangbusters. But basically, I set up as an independent contractor with multiple companies. And there are large telehealth companies like MD Live and stuff out there like Teladoc. And I set up with multiple companies, first of all, to keep diversified, because at this point too, I knew diversification and Tom certainly agreed it was going to be key to my future. Not to have my eggs in one basket, one employer, if you will, whatever.
I contracted with at least four different companies. And then I gathered some extra state licenses. I only had one at the time. And so, it could be a three-month process. I gained some more state licenses and set up my home office, and basically did the onboarding with them, which is much more abbreviated than a standard onboarding with a large system. And also, the EHR programs used by these telehealth companies are much more stripped down and you're not having to put all this inane stuff in that has nothing to do with the clinical need. And then launched and built up from there. So, I would actually work with all four companies on a given day.
And the beauty, I decided not to do block scheduling. You have a couple of options there. You can do it on-demand. So, this is kind of what I call being the Uber in telehealth. Basically, you decide when you want to turn on things. I never set an alarm. Wake up when I wake up, have my coffee, read the news as I want to do, and say, okay, I'm ready. And by 8:00 or 9:00, I'm turning on my computer and I'm starting to see patients.
There was no schedule. I didn't have anything that I had to answer to. And I would just see patients until like, "Okay, it's time for a break, take a break anytime you want to." If I want to have coffee with my elderly mother for an hour or two, perfect, whatever. Go have lunch with my brother. It doesn't matter. You control time. And this was the first time in my career that I could control time. And it was beautiful. And you just decide, "Okay, after a while, I've seen 35, 40 patients" which goes pretty quick in the telehealth space. It's like, okay, I'm done for the day.
And I would just do that maybe four days a week. I'd take a day off just to run errands, chill, and relax. And it was interesting that I was able to make the income needs that I was interested in six-plus hours a day, four days a week. So, 25 hours, 30 maybe tops. And I was making the income that was actually pretty close to, not as a medical director, but as like in the urgent care centers.
John: Yeah. Well, that's not bad.
Dr. Carl Peters: I'm pretty happy with it.
John: You don't have anyone telling you what to do. And your liability. I haven't heard there's a huge liability in telemedicine as compared to other things. And the lifestyle is better. That few dollars cut and overall pay is not much to give up. Now I've heard some stories in the past, and maybe this doesn't happen anymore, but I heard of stories like some of the companies are kind of fly by night. You have a contract and then low and behold, they shut down. They don't pay you. Have you experienced any of that since you've been doing this?
Dr. Carl Peters: No because again, Tom mentored me. Tom has, I believe it's called the Institute of Telemedicine Mastery, ITM. And he mentors you. He's very careful because he understands that landscape really well and not getting hooked up with companies that look like they're just ready to flip from you and sell to some venture capitalists or what have you. And as a matter of fact, to this day, all four companies that I have worked with are still alive and well, and nothing's really changed other than one did sell. They were integrated somewhat, but they did sell to the insurance company Cigna, but there's really no difference in their process or care.
John: Okay. Any tips, tricks, or things to avoid to the listeners if they're thinking about getting into telemedicine?
Dr. Carl Peters: Yeah. The biggest thing is you want to have a certain number of state licenses. There are some folks out there that literally have 50 licenses, but that's a heck of a lot of work to manage and of course, cost and completely unnecessary. So, you do want to have multiple state licenses. Each telehealth company says, "Oh, we really want it. We'll give you the big population states of California, New York, Texas, and Florida." And I found that now there are actually what I call sleeper states that just don't have a lot of telehealth doctors with licenses in them. And you may find you get a lot of action out of Indiana or Utah or something like that. So really you want to query them about where there is more need, we're not interested as much in population but need. They have California well represented, don't waste your time getting a California license.
Also, it makes it really easy if you happen to reside, have a business in or reside in a compact state that's part of the interstate medical license compact. And if that happens, it's very easy to get licenses in other states. There are reciprocal agreements through about 35 states currently. Unfortunately, my state of Missouri is not in the compact and so I don't have that luxury and have to do full applications. But you don't want to do more than four, five, or six states. And that should be enough. Spread them out a little bit. Other than that, your office supply. You want to have at least a five megabytes per second upload and download capability. You got to have some kind of decent internet. I have two phone carriers I could hotspot if I needed to, but I've never had any problems.
I don't have two different services for my internet. You can if you want. Some minimal equipment to purchase. I use three monitors and my center monitor is my working monitor. And I keep all four of the telehealth companies on a separate monitor so I can watch. And if a patient comes into a waiting room on one, bam, I'll play whack-a-mole and grab it. You grab them or something like that. Because the way you get patients is a little different from company to company. But I keep all four tiled on one screen. And in my third screen, I keep and I do recommend this for efficiency reasons, again, the documentation piece is pretty simple, but I have many little templates for common illnesses and stuff. And I just bring them over drag and drop them into my note. So, I'm not typing full-blown notes each time. And that way my throughput is at least six people an hour. So sometimes you get up to eight and stuff by being efficient.
John: How long did it take you to get decently streamlined the way you're talking about? Did that take a few months? Was it pretty quick?
Dr. Carl Peters: Well, again, Tom was helpful and a lot of goals and tips and stuff with that. But really it just took two weeks. I was pretty comfortable. Because you would think, "Oh my goodness, we're all used to mega EHR systems that are built or set up for billing and claims and really not about patient care." So, we're used to Epic and Cerner and all the other ones out there. But the ones are so stripped down here. That was my biggest intimidation. Like, "Oh my God, I got to learn different platforms here." But they're really not. There is simple soap note-type stuff.
John: Okay.
Dr. Carl Peters: So, it's pretty straightforward and you don't have to count all your HPI elements and review system elements, or waste your time doing all that. The eRx modules, the medication ordering is really simple and there are a lot of simplified rules that they're all pretty uniform between the companies. We're not prescribing narcotics. We're not prescribing lifestyle drugs.
John: Yeah.
Dr. Carl Peters: And stuff like that. There's a lot of uniformity between them.
John: It's interesting to me, as you're talking about that, that as family physicians, we went into it because well, we want to do a little bit of everything. But I think we've learned now what the specialists have learned. If you can narrow down what you're doing to just these 20 things or 80 things, whatever that number is, it does get a lot easier and you get faster, you get more efficient. Actually, I just kind of realized that while you were saying that, "Hey, we don't do narcotics. We're not doing (what did you call them) lifestyle drugs?"
Dr. Carl Peters: Yeah. Viagras and everything.
John: Yeah. That's a good point. I have a question. I've never done telemedicine, but there are certain, sometimes peak hours or maybe the opposite of peak hours, times when they can't get physicians. Is it possible to get a little higher payment level by going in at that time?
Dr. Carl Peters: Yes. Now, certainly of course, and they're not all the same, but some of the telemedicine companies will incentivize for after-hours and all that. But you got to understand, some of these companies will have thousands of doctors, but most of them are just doing this as supplemental work and they have a day job.
John: Part-time.
Dr. Carl Peters: I'm probably in a minority. It is a little different right now. But up until this last fall, when I was doing this at full steam, I was doing this as a primary income stream and I was doing a little expert witness. I was doing some minor advisor stuff, some other stuff, whatever. But mostly 90% of my income stream was coming from this and they don't have as many docs doing that.
But it's something that, I hope they're not listening to, the companies, that I wanted banker's hours. And the majority of patients will call between 9:00 to 5:00. Great advice I received is also to have states in different time zones. So here it is. I'm rolling in the Central Time Zone at 9:00 AM and stuff like that, but they're getting up real early on the West Coast and maybe before work, they want. So, I have a Washington state license. And vice versa later in the day, maybe the people out east are starting to get home from work. "I'm starting to have this burning when I urinate and I want to get in touch with somebody or this rash." Let's get this rash addressed. So, I could get some of the East Coast. In reality, I haven't seen a lot of trending where there's a wave across the country as the day goes by. It really just seems to be a hodgepodge. And there's a lot of people that just call from work. They go to a conference room or they go quietly.
John: Like they show you, they have shingles rash on their back.
Dr. Carl Peters: Oh yeah. Or go outside of work, out the back in the smoking zone or something like that. They're talking to you. And so, I never really found much of a trend with that. But by having six states and working through four companies, I pretty much stayed busy because the summers really get quiet. Now COVID of course, busted that, but still the methodology worked out really well to just keep volume. So, I didn't have to sit and twiddle my thumbs for 15 minutes. I just had a steady stream and I could just, "Okay, let me grab this patient, let me grab this patient." And so, it worked out really well.
John: All right. Well, it sounds like you've got that down and everything's done. You're good. You're going to just do that the rest of your life. What else is going on? We talked before that you got involved in some other activities, either to supplement that or just because it's interesting and maybe an opportunity for leadership. So, what happened next?
Dr. Carl Peters: Yeah. Well, this physician recruiter I know in my city, here. She's known me for many years. "Carl, you just want to build stuff. I know your mind. You want to build stuff and all that. I don't think this is going to telehealth or whatever. Yeah. You go do your thing." But I mean, I liked it. I really did. And there was a lot of bread-and-butter stuff you get bored within telehealth, like in the urgent care. You get your calls, UTIs and stuff, but then you get these curveballs coming your way. And it was interesting.
And the other really interesting thing I found about telehealth is if I was to predict before I started how many patients each day out of, let's say, I saw 40 people in a day. How many would I have to send for a hands-on exam? I would've sent over 25%. But in reality, remember they teach us in med school, the history is the most important thing. And by doing a real careful history and all that. And there's actually a lot. You can have a patient self-palpate, do different things or whatever. I really was astonished that I only would send one to two a day. And I still have never been sued. So, it's great news.
John: Nice.
Dr. Carl Peters: But I'm really astonished by doing a careful history. You could really take care of so much in the telehealth space. But then, I started thinking, "Well, God, you're really a family practice doc." And I didn't want my skills to get rusty. I've been doing urgent care all these years in primary care. Diabetes, chronic disease management, things like that. And I've kept my boards up, everything like that. But, again, Tom, linked me to O Thai medical in Cleveland, Ohio. And this is a newer thing building out virtual primary care, not acute care. Acute care has been done. It was going on way before COVID. Of course, COVID blew it up. But of course, there's more and more interest in virtual primary care.
It's like, "Well, wait a minute, we can do this with telehealth in their acute space. What about managing someone's diabetes? What about their hypertension and all these other things? What's the utility of putting our hands on them versus we could take care of a lot of this by ordering the right test, doing this, meeting up with them, and all that."
And so, the answer is actually a lot of it can be done. A lot of it. A lot of people are looking into space. And this is a little bit newer in this country right now. And so, I got linked with these people and started just doing a few consults with them and it was okay. A couple of operational things, nothing big. It's physician-led. This is what is really refreshing. This company is physician-led. We don't have all these business people that just look at doctors as little peons and stuff like that. And the vision of this guy, just matched everything. He and I have been kind of burned out over the years just seeing what's happened to the medicine and the waste that goes on, and the silliness.
Our vision matches on. And he goes, "Well, what do you really want to do?" And I said, "I want to build something." And it was right as this company is really starting to develop this virtual, what they call comprehensive care. Because we work with specialists, we can get second opinions from any specialists and all that. And get back to a model where a family physician should be able to take care of 90% who walk in the door.
And also managing the referrals. They do all this price shopping. They started off just taking care of people who had no insurance, but now they're developing their own insurance model. And so, there's a lot of aggressive price shopping because, heck, an MRI of the need can be $500 at a private facility. Or if you go to a big medical system thing, Cleveland Clinic, they may charge $3,000 for the same test. Blood work. A for-profit company like LabCorp charges $2.50 cents in my market for hemoglobin A1C or a CDC. So, we price shop this for people and get them the best prices. And I said, "Well, this is really cool." But they needed help in developing this so it could be scaled out.
And so, I'm really transitioned now mostly as the director of patient operations and lead physician for this company. And we currently see people across 35 states now doing virtual primary care. And we're building this up to scale into the tens of thousands of patient members. So, it's a really exciting time, with really nice people. The business team, they're not the types of folks I've run into in the past. They're all just really respectful, nice people, and work together. We all get each other's opinions and stuff and problem-solve together. And it's just been a really cool team and just kind of really got me stimulated again as like, "Wow, this is fun. I get to build something. Look at all the failures that we have in healthcare that we've been through all these years, and have a chance to sort of clean slate it and build something different."
And also look at it from the physician perspective too, John, because this intervention between you and the patient, that's slowly been growing, eroding the patient-physician relationship. How do we get that back? In this operation, you don't have to write all these notes. You don't need to count all these elements, anything. Get the meat of it down. Keep it simple. Let's give you tools. You don't need to spend all this time. And also, we're not going to have you do all this little stuff or whatever. We got care coordinators that'll take care of that for you. You are trained for your medical knowledge and that's where we want you just to concentrate on that. And not all the little nit-noid stuff that has nothing to do with patient care. So, it's pretty cool. And that's what I'm currently spending almost all my time doing now.
John: Now what kind of things do you do in that role? You're the lead physician and what is it? Patient care?
Dr. Carl Peters: Well, it's officially Director of Member Operations. They use the word "member" for a patient.
John: Okay. And so, are you supervising people? Are you creating protocols?
Dr. Carl Peters: All of it. Yes. All of it. Well, one part of the job is to supervise the providers, and also the guardian team. What we call guardians? These are the care coordinators that really are the main quarterback if you will. It's not you and me that's a quarterback. These guys are the quarterbacks. Now, they don't do clinical decision-making. They're the central quarterback that is the big patient advocate. And they would do all the heavy lifting for the stuff. But then when we need the clinical piece involved or whatever, then we get involved. And so, we're part of this team. But they're going to have many more visits with the patient than you and I would. And then what I did is develop all these care plans. There's a consultant in Tennessee that I worked with, Dr. Bill Bestermann, an internist down there. Using these current guidelines and cardiology and stuff for developing care plans for chronic disease management.
What are best practices for diabetes, heart failure, and chronic kidney disease, looking at these what we call optimal medical therapy. So, I designed these care plans that are care maps for both the guardians, but also for the providers for these various chronic conditions. And we're actually in the midst of going to start to digitize these, and everything too. So, it's care plans, managing the team, and then also how can we make all the workflows better? Everything's been re-looked at with this company and we've been doing a lot of redesigning. Taking this from a small mom-and-pop operation to something that could be scaled to tens of thousands of patients. So, very stimulating.
John: Now are they members with insurance, but high deductibles that are trying to have this stuff managed less costly way? Is it people without insurance? Is it a combination of that? Is it Medicare? How does that play out?
Dr. Carl Peters: Yeah. And that's right now ongoing, and product development is building out a health plan, basically. So, it started off as a direct primary care virtual. They actually did have in Cleveland, Ohio, an onsite brick and mortar DPC. That evolved and started to go into virtual space last year. And then we're taking that much further.
And so yes, initially there were patients without insurance. But what we're doing now is offering insurance like a captive model to employers. One we talked to recently, they're paying around $20,000 per employee for healthcare. And it's like, well, wait a minute. With our system here, we could come in and we are going to have family practice docs that are going to be practicing the full spectrum of care. They're not going to rein them in, we're going to remove all these barriers. We're going to tightly manage.
We've got a whole second opinion network. I could contact an endocrinologist or orthopedist and have nice feedback in 24 hours on that. Do we need to send that forward or can we manage it? They're just keeping these people out of the hospital as much as they can, following care plans and keeping them frankly away from specialists as much as we can until we really need them, or even co-managing, and we could keep the cost way down. And so, we are going to employers and say, "Well, we will do this for a fraction of what you're paying." This is a new product offering we're just getting into as part of our growth model or business development plan.
John: Now, this all sounds great because a couple of things I would say. Number one, talking about the MRIs, my wife is looking to get an MRI. We had this high deductible and it was going to be $2,000, but I just called around and I finally could get an MRI red, just walk in for $450 to the foot. That was it. It makes no sense to be spending $2,000 and $3,000 for imaging that's going to be one 10th of that.
Dr. Carl Peters: Yeah. And also, that actually can be cheaper than your co-insurance because a lot of advanced imaging like MRI and CT will have a co-insurance. It actually could even be cheaper than a traditional health plan, what your co-insurance one would be if you had to pay 20% of that or something like that.
John: Right. And I just told my wife, let's just get it and pay it out of pocket. Why even go down that route because the insurance is just so awful. And then the other thing you mentioned of course, you know this very well, but it always occurred to me when they're talking about, especially with all the requirements that Medicare was putting in place and the quality metrics and things is like, this stuff just needs someone to hold the patient's hand and figure out how to get them into the place to get what they need. It doesn't require a physician's order most of the time, number one, unless they have to be treated. And why would a physician have to spend 5- or 10-minutes figuring that out during a visit when you could have someone at a much lower skill level, just say, "Guess what? We got to check your blood pressure once a month and we're going to adjust your medication if you need it." That's it. And then the physician is overseeing that indirectly and if they have complications or something.
I mean, it's been out there. I don't know why it really hasn't taken hold yet, but it sounds like you guys are really trying to get on top of this. And the employers, I think they're driving a lot of it anyway. You're going to employers and offering this, but the big employers have already done it. They actually have their own health systems. The GMs and the big companies, they just hire physicians and NPs and put them in their offices and say, "This is our health system, screw the rest of you."
Dr. Carl Peters: Yes, indeed. And then that's precisely too, John, why we're targeting smaller employers.
John: Yeah, because they can't afford to do that.
Dr. Carl Peters: Right, they're paying full dollar if the company has 200, 300 employees.
John: The quicker we can get rid of the insurance companies, I think the better off we'll all be.
Dr. Carl Peters: Yeah. I actually have come to a point where it's sad. I almost see this as a failed model. At least the way business has been done. It's a money grab and there's just so much waste.
John: Yeah. You're just talking about a 15% plus or minus, and these are publicly traded companies and they make billions of dollars in profit and that's just money that's not going to the patients or to the medical provider. All right. Very interesting. We're getting to the end here, but it sounds like you did that telemedicine, it was a partial transition. I think you're probably still able to do telemedicine whenever you like.
Dr. Carl Peters: I'm still doing some. Yes.
John: At least, for now, you're involved in this completely new thing and it's on the cutting edge and hopefully this will continue to expand. There are other companies doing similar things. Yeah, I think it's great to have physicians like you involved and making it work for the patients.
Dr. Carl Peters: Yes. Yes, indeed.
John: Any advice for physicians who were maybe where you were 5, 10 years ago, whatever it was when you were just sort of saying "This is just not fun, it's frustrating. It's not fulfilling." Any words of advice for those listeners?
Dr. Carl Peters: Yeah. Number one, the biggest thing is to research and learn and network and connect. Because I didn't really realize, we get compartmentalized, "Okay, this is medicine. It's how it works. This is how it works in this country. And people jump from employer to employer." It's just something to really understand there are alternatives out there.
What you're doing, John, your site, your podcasts, how I found Dr. Tom Davis, Dr. Heather Fork, there are others out there too, to connect or at least to research, go through these podcasts, look at these things. And you'll see things like, "Oh, wow, I didn't realize we can do that." There are just all kinds of stuff out there that we could apply ourselves too that are even nonclinical. So, you got to research and connect. LinkedIn is a really good source. You want to make sure you have a nice profile built up. And then you don't want to be hesitant to reach out to people that have done alternative things and talk to them. I find most of us, John, are more than happy to talk to people and help them out. And so, reach out. Networking, some research.
The second thing, if you're not sure where you want to go, I'd say, keep it diversified a little bit. Maybe don't put all your eggs in one basket. Do a little of this. Acute telehealth is an easy transition to get into. It could get some income stream going on while you rethink things. Or maybe you want a lifestyle where you're doing 50% telehealth, and then you're doing some other stuff, whether it's medical writing or expert witness, whatever. I like to keep it diversified because you don't have the job security, I would say, that we did many years ago. This is a very evolving profession. But yeah, it's probably the most advice I would have at the moment.
John: Now, that's very good advice. Yeah. Diversification and just having different options to fall back on or just doing different things. We find it more interesting and stimulating. And networking. I used to think networking was going to a meeting and standing around with a drink in my hand, talking to people and as an introvert, it was never going to happen. But just talking to old schoolmates, co-residents, people, you'd be surprised what other people are doing. And if you just reach out, you'll get more ideas. So, I think that's really great advice.
Dr. Carl Peters: Doximity is another thing to get on because you'll search for and find your old classmates. "Oh, hey, I remember this guy, he's doing this. What? No." And you could reach out. So that's not a bad site too. And on LinkedIn, one other thing I would say is that you could create job search functions based on anything. You could say "physician medical writing" and throw that out there. And he'll just automatically send you stuff into your inbox every day and you could just screen through them. And sometimes those lead on a tangent.
I had someone contact me and say, "Hey, we need a medical director for a COVID testing facility." I was like, okay, part of diversification. So, I did that for a little while. And so, you don't know who will contact you. Of course, most of them are just standard recruiters for standard family practice jobs and whatever, but you could tailor your searches to look into alternative things. You could say acute telehealth, you could put in a search for whatever. And then sometimes those will jog your mind. It's like, "Oh, I never thought about this." And even if you don't want to pursue it, you could at least talk to them a little bit and better understand it. So, I found that to be useful.
John: Good ideas, yeah, with the searches out in LinkedIn. I've not done much on Doximity lately, although I've always had a profile there. But I think I need to spend a little more time to see what's going on there based on what you're telling me.
Dr. Carl Peters: And there's another site too. Another site called Health Tech Nerds, HTN. A lot of it will have nonclinicians on there too, but occasionally you'll have physicians on there looking at if you're more into the tech side of things like software development. There are a lot of start-ups out there and occasionally they do need a physician advisor or something. So yeah, once you get the ball rolling, you start just going off in these different tangents and pretty soon you build up some ideas for yourself and where you want to go.
John: Yeah. I always get people asking me, "Well, where do I start?" Well, these sound like some really good places to start. Okay, Carl, we are out of time. I know some of the people will want to get a hold of you, so I think they can find you on LinkedIn for sure. Just put your name in there. Should we put your email address out there or I can put it in the show notes too, but if someone wanted to get a hold of you?
Dr. Carl Peters: Yeah, I'd be more than happy. That's fine. Sure.
John: All right, we'll do that. And just to tease you a little bit, I think it's saya@att.net. So that's kind of cheeky. I like that.
Dr. Carl Peters: say.a@att.net. Don't forget the little dot.
John: Don't forget the dot. We'll put that in the show notes. All right, Carl. This has been a lot of fun. I've learned a lot and I know the listeners have too, so I really am glad to have you here to explain your recent career journey. It's been very interesting.
Dr. Carl Peters: I appreciate it, John. Thank you kindly.
John: You're welcome. Bye-bye
Dr. Carl Peters: Bye.
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Transcription PNC Podcast Episode 249
How to Use Consulting and Advising to Find Freedom - Interview with Dr. Carl Peters
John: Today I have a fellow family physician who has responded to his frustrations with the current health system, as many of us have in his own unique way. And I thought you'd find it instructive. Hello, Dr. Carl Peters.
Dr. Carl Peters: Hello, John.
John: Hey, it's great to have you here. We had a chance to talk a little bit. And by the way, I didn't mention that you and I were linked up by Tom Davis. I think a lot of my listeners know who Tom Davis is because he's been on the podcast a few times and people know we partnered together on New Script. I was happy to be introduced and find a fellow physician that went through the process that many have. So, I'm interested in hearing your story.
Dr. Carl Peters: Oh, absolutely.
John: So, what happened? You were plugging along there doing family medicine. Tell us a little bit about your education and what led up to your practice, and then we'll get into what happened towards the end of that long clinical career.
Dr. Carl Peters: Yeah. Like a lot of us in family medicine, you do your residency and look at a career, lifelong career in family practice. And I did that for about 15 years or so, and kind of hooked up with a company in the St. Louis area that I was very pleased with. They were doing a lot of great things, but unfortunately, I joined them just as the ship was taking on water.
Within about 18 months I knew things were in bad shape. And by 24 months I left. By then I was getting a little frazzled with family medicine, just not the actual caring of patients, but just the business, some of the background stuff, the electronic health records, and all the things that get in between you and me as a patient and a doctor. The insurance stuff, all the games we have to play to satisfy that, to get paid the claims and billing, how much is driven by that, really not by actual patient care. So, I started rethinking a little bit. I've always enjoyed doing an occasional urgent care shift, so I was going to just temporarily do urgent care, maybe for a year, and rethink things a little bit. I started my urgent care career, which went on for the last eight years and really did enjoy it.
But then here we go, they started strategic plans that weren't being revealed to the doctor about, "Oh, we're going to start using mid-levels and goodbye doctors." We had targets on our back. I moved to another company and "Oh, yeah. No, no doctors will always be first and foremost." But then a new model starts to come up and it looks like we again have a target on our back. And so, that got a little frustrating too, even though I did enjoy it.
And then, part of the target on the back was an operation that was going to come in and take over these urgent care centers with this health system and they needed a medical director. And it's like, "Well, shoot, let's look at that." I had some management experience, and initially, it was very rewarding. It was something that had a very excellent team initially. And we worked really hard and we built 12 urgent care clincics from zero in 18 months. So, I went from just a handful of providers to 40 under me in that time period. And it was a very aggressive growth schedule, maybe a little bit too much.
John: Let me comment on that. That is really unreal. But it goes along with what I've seen because I've been in urgent care just in recent years. It's kind of a segue into retirement, more or less. You just hear about all these different buyouts and consolidations. So, I think you mentioned maybe two systems you were working for with urgent care. In the last one you became a medical director. Were those both health systems? Those weren't owned by private equity firms?
Dr. Carl Peters: Correct. They were large health systems that owned them, yes.
John: I think it's funny because I'm sure that most health systems lose money in urgent care. If they can break even, they're happy most of the time because they see it as a loss leader to get people into the doors. But there's always that struggle. And then at some point, they reach a point where we got to start making money and that means we're going to start using the mid-level providers and the things you talked about.
Dr. Carl Peters: Yes, yes. In a way, this was a transition into a nonclinical space as a medical director, and I really enjoyed it. But in watching the model over time, it was a very lean model, very lean. The leanest I've ever seen. And you really had to be hiring rock stars for your techs and stuff like that, your MAs and techs, otherwise, it just became apparent that "Ugh, this is pretty lean." And then the business team changed out a little bit to a culture that again, to me is part of the problem in medicine in this country that just looked at physicians as they really didn't care. It just was like, "Just do what we tell you to do, and we're not going to get your opinion on anything." Just the culture changed. And at that point, the job enjoyment really started going down. And actually, most of the leadership team left after this new management took over.
And so, at that point, I became very discouraged about everything. Where do I want to go next? And I ran across Dr. Tom Davis, who actually we've known each other on and off for years. He was, I believe, a resident when I was in medical school. And I was actually searching around looking at podcasts, just like what you have here. I don't know how I came across it, but I came across Dr. Heather Fork's website. And Tom had just done a podcast that she published. And I was like, "Wait a minute. I know that guy." And I just listened to it.
It was a big life-changer for me because I linked up with Tom. We reconnected. We hadn't talked to each other in years. And basically, we started looking at alternatives. And this was just before COVID, the telehealth space was really growing, especially in the acute care market. And so, Tom has done so many interesting things.
It's interesting, the people I've met that I had no idea knew Tom know Tom. As one person said, "All roads lead to Tom." But anyway, he does a lot of many different things outside of clinical medicine and business medicine. He's a very, very knowledgeable guy. So, we hooked up and he kind of showed me a path into the telehealth space and to build my own practice.
And by then I was like I just want to control my own shots. I am tired of answering the corporate needs and business people that are just taking over more and more in medicine. And part of that's our fault over the years, but whatever, I won't get into that. But Tom, we talked for a while and it just became really clear. So, I started a telehealth practice. Tom was my mentor and followed along and helped me build this up. And it was just immensely, I just loved it. I just really loved it.
John: I got to comment on that because you must have been in the right place at the right time. Because you're getting into telemedicine, but it was before the pandemics. You're getting set up. And I know Tom, basically, he's very passionate about taking back control for everybody in medicine that was kind of promised one thing. And even the patients have been promised one thing, which is to get good caring physicians that can spend time and take care of you. And now everybody's unhappy because the physicians can't spend time and the patients don't get the time and everyone's got paperwork. I've heard that telemedicine is a way to really get a little more control, particularly if you set it up I think the way that Tom has done it. So, tell us how you set that up. And what did that turn out to look like over the first year or two of doing telemedicine?
Dr. Carl Peters: Yeah. I think it would've been very successful regardless, but this was like buying Coca-Cola stock in the 1930s and hanging onto it. I've been doing this right before telehealth, it went gangbusters. But basically, I set up as an independent contractor with multiple companies. And there are large telehealth companies like MD Live and stuff out there like Teladoc. And I set up with multiple companies, first of all, to keep diversified, because at this point too, I knew diversification and Tom certainly agreed it was going to be key to my future. Not to have my eggs in one basket, one employer, if you will, whatever.
I contracted with at least four different companies. And then I gathered some extra state licenses. I only had one at the time. And so, it could be a three-month process. I gained some more state licenses and set up my home office, and basically did the onboarding with them, which is much more abbreviated than a standard onboarding with a large system. And also, the EHR programs used by these telehealth companies are much more stripped down and you're not having to put all this inane stuff in that has nothing to do with the clinical need. And then launched and built up from there. So, I would actually work with all four companies on a given day.
And the beauty, I decided not to do block scheduling. You have a couple of options there. You can do it on-demand. So, this is kind of what I call being the Uber in telehealth. Basically, you decide when you want to turn on things. I never set an alarm. Wake up when I wake up, have my coffee, read the news as I want to do, and say, okay, I'm ready. And by 8:00 or 9:00, I'm turning on my computer and I'm starting to see patients.
There was no schedule. I didn't have anything that I had to answer to. And I would just see patients until like, "Okay, it's time for a break, take a break anytime you want to." If I want to have coffee with my elderly mother for an hour or two, perfect, whatever. Go have lunch with my brother. It doesn't matter. You control time. And this was the first time in my career that I could control time. And it was beautiful. And you just decide, "Okay, after a while, I've seen 35, 40 patients" which goes pretty quick in the telehealth space. It's like, okay, I'm done for the day.
And I would just do that maybe four days a week. I'd take a day off just to run errands, chill, and relax. And it was interesting that I was able to make the income needs that I was interested in six-plus hours a day, four days a week. So, 25 hours, 30 maybe tops. And I was making the income that was actually pretty close to, not as a medical director, but as like in the urgent care centers.
John: Yeah. Well, that's not bad.
Dr. Carl Peters: I'm pretty happy with it.
John: You don't have anyone telling you what to do. And your liability. I haven't heard there's a huge liability in telemedicine as compared to other things. And the lifestyle is better. That few dollars cut and overall pay is not much to give up. Now I've heard some stories in the past, and maybe this doesn't happen anymore, but I heard of stories like some of the companies are kind of fly by night. You have a contract and then low and behold, they shut down. They don't pay you. Have you experienced any of that since you've been doing this?
Dr. Carl Peters: No because again, Tom mentored me. Tom has, I believe it's called the Institute of Telemedicine Mastery, ITM. And he mentors you. He's very careful because he understands that landscape really well and not getting hooked up with companies that look like they're just ready to flip from you and sell to some venture capitalists or what have you. And as a matter of fact, to this day, all four companies that I have worked with are still alive and well, and nothing's really changed other than one did sell. They were integrated somewhat, but they did sell to the insurance company Cigna, but there's really no difference in their process or care.
John: Okay. Any tips, tricks, or things to avoid to the listeners if they're thinking about getting into telemedicine?
Dr. Carl Peters: Yeah. The biggest thing is you want to have a certain number of state licenses. There are some folks out there that literally have 50 licenses, but that's a heck of a lot of work to manage and of course, cost and completely unnecessary. So, you do want to have multiple state licenses. Each telehealth company says, "Oh, we really want it. We'll give you the big population states of California, New York, Texas, and Florida." And I found that now there are actually what I call sleeper states that just don't have a lot of telehealth doctors with licenses in them. And you may find you get a lot of action out of Indiana or Utah or something like that. So really you want to query them about where there is more need, we're not interested as much in population but need. They have California well represented, don't waste your time getting a California license.
Also, it makes it really easy if you happen to reside, have a business in or reside in a compact state that's part of the interstate medical license compact. And if that happens, it's very easy to get licenses in other states. There are reciprocal agreements through about 35 states currently. Unfortunately, my state of Missouri is not in the compact and so I don't have that luxury and have to do full applications. But you don't want to do more than four, five, or six states. And that should be enough. Spread them out a little bit. Other than that, your office supply. You want to have at least a five megabytes per second upload and download capability. You got to have some kind of decent internet. I have two phone carriers I could hotspot if I needed to, but I've never had any problems.
I don't have two different services for my internet. You can if you want. Some minimal equipment to purchase. I use three monitors and my center monitor is my working monitor. And I keep all four of the telehealth companies on a separate monitor so I can watch. And if a patient comes into a waiting room on one, bam, I'll play whack-a-mole and grab it. You grab them or something like that. Because the way you get patients is a little different from company to company. But I keep all four tiled on one screen. And in my third screen, I keep and I do recommend this for efficiency reasons, again, the documentation piece is pretty simple, but I have many little templates for common illnesses and stuff. And I just bring them over drag and drop them into my note. So, I'm not typing full-blown notes each time. And that way my throughput is at least six people an hour. So sometimes you get up to eight and stuff by being efficient.
John: How long did it take you to get decently streamlined the way you're talking about? Did that take a few months? Was it pretty quick?
Dr. Carl Peters: Well, again, Tom was helpful and a lot of goals and tips and stuff with that. But really it just took two weeks. I was pretty comfortable. Because you would think, "Oh my goodness, we're all used to mega EHR systems that are built or set up for billing and claims and really not about patient care." So, we're used to Epic and Cerner and all the other ones out there. But the ones are so stripped down here. That was my biggest intimidation. Like, "Oh my God, I got to learn different platforms here." But they're really not. There is simple soap note-type stuff.
John: Okay.
Dr. Carl Peters: So, it's pretty straightforward and you don't have to count all your HPI elements and review system elements, or waste your time doing all that. The eRx modules, the medication ordering is really simple and there are a lot of simplified rules that they're all pretty uniform between the companies. We're not prescribing narcotics. We're not prescribing lifestyle drugs.
John: Yeah.
Dr. Carl Peters: And stuff like that. There's a lot of uniformity between them.
John: It's interesting to me, as you're talking about that, that as family physicians, we went into it because well, we want to do a little bit of everything. But I think we've learned now what the specialists have learned. If you can narrow down what you're doing to just these 20 things or 80 things, whatever that number is, it does get a lot easier and you get faster, you get more efficient. Actually, I just kind of realized that while you were saying that, "Hey, we don't do narcotics. We're not doing (what did you call them) lifestyle drugs?"
Dr. Carl Peters: Yeah. Viagras and everything.
John: Yeah. That's a good point. I have a question. I've never done telemedicine, but there are certain, sometimes peak hours or maybe the opposite of peak hours, times when they can't get physicians. Is it possible to get a little higher payment level by going in at that time?
Dr. Carl Peters: Yes. Now, certainly of course, and they're not all the same, but some of the telemedicine companies will incentivize for after-hours and all that. But you got to understand, some of these companies will have thousands of doctors, but most of them are just doing this as supplemental work and they have a day job.
John: Part-time.
Dr. Carl Peters: I'm probably in a minority. It is a little different right now. But up until this last fall, when I was doing this at full steam, I was doing this as a primary income stream and I was doing a little expert witness. I was doing some minor advisor stuff, some other stuff, whatever. But mostly 90% of my income stream was coming from this and they don't have as many docs doing that.
But it's something that, I hope they're not listening to, the companies, that I wanted banker's hours. And the majority of patients will call between 9:00 to 5:00. Great advice I received is also to have states in different time zones. So here it is. I'm rolling in the Central Time Zone at 9:00 AM and stuff like that, but they're getting up real early on the West Coast and maybe before work, they want. So, I have a Washington state license. And vice versa later in the day, maybe the people out east are starting to get home from work. "I'm starting to have this burning when I urinate and I want to get in touch with somebody or this rash." Let's get this rash addressed. So, I could get some of the East Coast. In reality, I haven't seen a lot of trending where there's a wave across the country as the day goes by. It really just seems to be a hodgepodge. And there's a lot of people that just call from work. They go to a conference room or they go quietly.
John: Like they show you, they have shingles rash on their back.
Dr. Carl Peters: Oh yeah. Or go outside of work, out the back in the smoking zone or something like that. They're talking to you. And so, I never really found much of a trend with that. But by having six states and working through four companies, I pretty much stayed busy because the summers really get quiet. Now COVID of course, busted that, but still the methodology worked out really well to just keep volume. So, I didn't have to sit and twiddle my thumbs for 15 minutes. I just had a steady stream and I could just, "Okay, let me grab this patient, let me grab this patient." And so, it worked out really well.
John: All right. Well, it sounds like you've got that down and everything's done. You're good. You're going to just do that the rest of your life. What else is going on? We talked before that you got involved in some other activities, either to supplement that or just because it's interesting and maybe an opportunity for leadership. So, what happened next?
Dr. Carl Peters: Yeah. Well, this physician recruiter I know in my city, here. She's known me for many years. "Carl, you just want to build stuff. I know your mind. You want to build stuff and all that. I don't think this is going to telehealth or whatever. Yeah. You go do your thing." But I mean, I liked it. I really did. And there was a lot of bread-and-butter stuff you get bored within telehealth, like in the urgent care. You get your calls, UTIs and stuff, but then you get these curveballs coming your way. And it was interesting.
And the other really interesting thing I found about telehealth is if I was to predict before I started how many patients each day out of, let's say, I saw 40 people in a day. How many would I have to send for a hands-on exam? I would've sent over 25%. But in reality, remember they teach us in med school, the history is the most important thing. And by doing a real careful history and all that. And there's actually a lot. You can have a patient self-palpate, do different things or whatever. I really was astonished that I only would send one to two a day. And I still have never been sued. So, it's great news.
John: Nice.
Dr. Carl Peters: But I'm really astonished by doing a careful history. You could really take care of so much in the telehealth space. But then, I started thinking, "Well, God, you're really a family practice doc." And I didn't want my skills to get rusty. I've been doing urgent care all these years in primary care. Diabetes, chronic disease management, things like that. And I've kept my boards up, everything like that. But, again, Tom, linked me to O Thai medical in Cleveland, Ohio. And this is a newer thing building out virtual primary care, not acute care. Acute care has been done. It was going on way before COVID. Of course, COVID blew it up. But of course, there's more and more interest in virtual primary care.
It's like, "Well, wait a minute, we can do this with telehealth in their acute space. What about managing someone's diabetes? What about their hypertension and all these other things? What's the utility of putting our hands on them versus we could take care of a lot of this by ordering the right test, doing this, meeting up with them, and all that."
And so, the answer is actually a lot of it can be done. A lot of it. A lot of people are looking into space. And this is a little bit newer in this country right now. And so, I got linked with these people and started just doing a few consults with them and it was okay. A couple of operational things, nothing big. It's physician-led. This is what is really refreshing. This company is physician-led. We don't have all these business people that just look at doctors as little peons and stuff like that. And the vision of this guy, just matched everything. He and I have been kind of burned out over the years just seeing what's happened to the medicine and the waste that goes on, and the silliness.
Our vision matches on. And he goes, "Well, what do you really want to do?" And I said, "I want to build something." And it was right as this company is really starting to develop this virtual, what they call comprehensive care. Because we work with specialists, we can get second opinions from any specialists and all that. And get back to a model where a family physician should be able to take care of 90% who walk in the door.
And also managing the referrals. They do all this price shopping. They started off just taking care of people who had no insurance, but now they're developing their own insurance model. And so, there's a lot of aggressive price shopping because, heck, an MRI of the need can be $500 at a private facility. Or if you go to a big medical system thing, Cleveland Clinic, they may charge $3,000 for the same test. Blood work. A for-profit company like LabCorp charges $2.50 cents in my market for hemoglobin A1C or a CDC. So, we price shop this for people and get them the best prices. And I said, "Well, this is really cool." But they needed help in developing this so it could be scaled out.
And so, I'm really transitioned now mostly as the director of patient operations and lead physician for this company. And we currently see people across 35 states now doing virtual primary care. And we're building this up to scale into the tens of thousands of patient members. So, it's a really exciting time, with really nice people. The business team, they're not the types of folks I've run into in the past. They're all just really respectful, nice people, and work together. We all get each other's opinions and stuff and problem-solve together. And it's just been a really cool team and just kind of really got me stimulated again as like, "Wow, this is fun. I get to build something. Look at all the failures that we have in healthcare that we've been through all these years, and have a chance to sort of clean slate it and build something different."
And also look at it from the physician perspective too, John, because this intervention between you and the patient, that's slowly been growing, eroding the patient-physician relationship. How do we get that back? In this operation, you don't have to write all these notes. You don't need to count all these elements, anything. Get the meat of it down. Keep it simple. Let's give you tools. You don't need to spend all this time. And also, we're not going to have you do all this little stuff or whatever. We got care coordinators that'll take care of that for you. You are trained for your medical knowledge and that's where we want you just to concentrate on that. And not all the little nit-noid stuff that has nothing to do with patient care. So, it's pretty cool. And that's what I'm currently spending almost all my time doing now.
John: Now what kind of things do you do in that role? You're the lead physician and what is it? Patient care?
Dr. Carl Peters: Well, it's officially Director of Member Operations. They use the word "member" for a patient.
John: Okay. And so, are you supervising people? Are you creating protocols?
Dr. Carl Peters: All of it. Yes. All of it. Well, one part of the job is to supervise the providers, and also the guardian team. What we call guardians? These are the care coordinators that really are the main quarterback if you will. It's not you and me that's a quarterback. These guys are the quarterbacks. Now, they don't do clinical decision-making. They're the central quarterback that is the big patient advocate. And they would do all the heavy lifting for the stuff. But then when we need the clinical piece involved or whatever, then we get involved. And so, we're part of this team. But they're going to have many more visits with the patient than you and I would. And then what I did is develop all these care plans. There's a consultant in Tennessee that I worked with, Dr. Bill Bestermann, an internist down there. Using these current guidelines and cardiology and stuff for developing care plans for chronic disease management.
What are best practices for diabetes, heart failure, and chronic kidney disease, looking at these what we call optimal medical therapy. So, I designed these care plans that are care maps for both the guardians, but also for the providers for these various chronic conditions. And we're actually in the midst of going to start to digitize these, and everything too. So, it's care plans, managing the team, and then also how can we make all the workflows better? Everything's been re-looked at with this company and we've been doing a lot of redesigning. Taking this from a small mom-and-pop operation to something that could be scaled to tens of thousands of patients. So, very stimulating.
John: Now are they members with insurance, but high deductibles that are trying to have this stuff managed less costly way? Is it people without insurance? Is it a combination of that? Is it Medicare? How does that play out?
Dr. Carl Peters: Yeah. And that's right now ongoing, and product development is building out a health plan, basically. So, it started off as a direct primary care virtual. They actually did have in Cleveland, Ohio, an onsite brick and mortar DPC. That evolved and started to go into virtual space last year. And then we're taking that much further.
And so yes, initially there were patients without insurance. But what we're doing now is offering insurance like a captive model to employers. One we talked to recently, they're paying around $20,000 per employee for healthcare. And it's like, well, wait a minute. With our system here, we could come in and we are going to have family practice docs that are going to be practicing the full spectrum of care. They're not going to rein them in, we're going to remove all these barriers. We're going to tightly manage.
We've got a whole second opinion network. I could contact an endocrinologist or orthopedist and have nice feedback in 24 hours on that. Do we need to send that forward or can we manage it? They're just keeping these people out of the hospital as much as they can, following care plans and keeping them frankly away from specialists as much as we can until we really need them, or even co-managing, and we could keep the cost way down. And so, we are going to employers and say, "Well, we will do this for a fraction of what you're paying." This is a new product offering we're just getting into as part of our growth model or business development plan.
John: Now, this all sounds great because a couple of things I would say. Number one, talking about the MRIs, my wife is looking to get an MRI. We had this high deductible and it was going to be $2,000, but I just called around and I finally could get an MRI red, just walk in for $450 to the foot. That was it. It makes no sense to be spending $2,000 and $3,000 for imaging that's going to be one 10th of that.
Dr. Carl Peters: Yeah. And also, that actually can be cheaper than your co-insurance because a lot of advanced imaging like MRI and CT will have a co-insurance. It actually could even be cheaper than a traditional health plan, what your co-insurance one would be if you had to pay 20% of that or something like that.
John: Right. And I just told my wife, let's just get it and pay it out of pocket. Why even go down that route because the insurance is just so awful. And then the other thing you mentioned of course, you know this very well, but it always occurred to me when they're talking about, especially with all the requirements that Medicare was putting in place and the quality metrics and things is like, this stuff just needs someone to hold the patient's hand and figure out how to get them into the place to get what they need. It doesn't require a physician's order most of the time, number one, unless they have to be treated. And why would a physician have to spend 5- or 10-minutes figuring that out during a visit when you could have someone at a much lower skill level, just say, "Guess what? We got to check your blood pressure once a month and we're going to adjust your medication if you need it." That's it. And then the physician is overseeing that indirectly and if they have complications or something.
I mean, it's been out there. I don't know why it really hasn't taken hold yet, but it sounds like you guys are really trying to get on top of this. And the employers, I think they're driving a lot of it anyway. You're going to employers and offering this, but the big employers have already done it. They actually have their own health systems. The GMs and the big companies, they just hire physicians and NPs and put them in their offices and say, "This is our health system, screw the rest of you."
Dr. Carl Peters: Yes, indeed. And then that's precisely too, John, why we're targeting smaller employers.
John: Yeah, because they can't afford to do that.
Dr. Carl Peters: Right, they're paying full dollar if the company has 200, 300 employees.
John: The quicker we can get rid of the insurance companies, I think the better off we'll all be.
Dr. Carl Peters: Yeah. I actually have come to a point where it's sad. I almost see this as a failed model. At least the way business has been done. It's a money grab and there's just so much waste.
John: Yeah. You're just talking about a 15% plus or minus, and these are publicly traded companies and they make billions of dollars in profit and that's just money that's not going to the patients or to the medical provider. All right. Very interesting. We're getting to the end here, but it sounds like you did that telemedicine, it was a partial transition. I think you're probably still able to do telemedicine whenever you like.
Dr. Carl Peters: I'm still doing some. Yes.
John: At least, for now, you're involved in this completely new thing and it's on the cutting edge and hopefully this will continue to expand. There are other companies doing similar things. Yeah, I think it's great to have physicians like you involved and making it work for the patients.
Dr. Carl Peters: Yes. Yes, indeed.
John: Any advice for physicians who were maybe where you were 5, 10 years ago, whatever it was when you were just sort of saying "This is just not fun, it's frustrating. It's not fulfilling." Any words of advice for those listeners?
Dr. Carl Peters: Yeah. Number one, the biggest thing is to research and learn and network and connect. Because I didn't really realize, we get compartmentalized, "Okay, this is medicine. It's how it works. This is how it works in this country. And people jump from employer to employer." It's just something to really understand there are alternatives out there.
What you're doing, John, your site, your podcasts, how I found Dr. Tom Davis, Dr. Heather Fork, there are others out there too, to connect or at least to research, go through these podcasts, look at these things. And you'll see things like, "Oh, wow, I didn't realize we can do that." There are just all kinds of stuff out there that we could apply ourselves too that are even nonclinical. So, you got to research and connect. LinkedIn is a really good source. You want to make sure you have a nice profile built up. And then you don't want to be hesitant to reach out to people that have done alternative things and talk to them. I find most of us, John, are more than happy to talk to people and help them out. And so, reach out. Networking, some research.
The second thing, if you're not sure where you want to go, I'd say, keep it diversified a little bit. Maybe don't put all your eggs in one basket. Do a little of this. Acute telehealth is an easy transition to get into. It could get some income stream going on while you rethink things. Or maybe you want a lifestyle where you're doing 50% telehealth, and then you're doing some other stuff, whether it's medical writing or expert witness, whatever. I like to keep it diversified because you don't have the job security, I would say, that we did many years ago. This is a very evolving profession. But yeah, it's probably the most advice I would have at the moment.
John: Now, that's very good advice. Yeah. Diversification and just having different options to fall back on or just doing different things. We find it more interesting and stimulating. And networking. I used to think networking was going to a meeting and standing around with a drink in my hand, talking to people and as an introvert, it was never going to happen. But just talking to old schoolmates, co-residents, people, you'd be surprised what other people are doing. And if you just reach out, you'll get more ideas. So, I think that's really great advice.
Dr. Carl Peters: Doximity is another thing to get on because you'll search for and find your old classmates. "Oh, hey, I remember this guy, he's doing this. What? No." And you could reach out. So that's not a bad site too. And on LinkedIn, one other thing I would say is that you could create job search functions based on anything. You could say "physician medical writing" and throw that out there. And he'll just automatically send you stuff into your inbox every day and you could just screen through them. And sometimes those lead on a tangent.
I had someone contact me and say, "Hey, we need a medical director for a COVID testing facility." I was like, okay, part of diversification. So, I did that for a little while. And so, you don't know who will contact you. Of course, most of them are just standard recruiters for standard family practice jobs and whatever, but you could tailor your searches to look into alternative things. You could say acute telehealth, you could put in a search for whatever. And then sometimes those will jog your mind. It's like, "Oh, I never thought about this." And even if you don't want to pursue it, you could at least talk to them a little bit and better understand it. So, I found that to be useful.
John: Good ideas, yeah, with the searches out in LinkedIn. I've not done much on Doximity lately, although I've always had a profile there. But I think I need to spend a little more time to see what's going on there based on what you're telling me.
Dr. Carl Peters: And there's another site too. Another site called Health Tech Nerds, HTN. A lot of it will have nonclinicians on there too, but occasionally you'll have physicians on there looking at if you're more into the tech side of things like software development. There are a lot of start-ups out there and occasionally they do need a physician advisor or something. So yeah, once you get the ball rolling, you start just going off in these different tangents and pretty soon you build up some ideas for yourself and where you want to go.
John: Yeah. I always get people asking me, "Well, where do I start?" Well, these sound like some really good places to start. Okay, Carl, we are out of time. I know some of the people will want to get a hold of you, so I think they can find you on LinkedIn for sure. Just put your name in there. Should we put your email address out there or I can put it in the show notes too, but if someone wanted to get a hold of you?
Dr. Carl Peters: Yeah, I'd be more than happy. That's fine. Sure.
John: All right, we'll do that. And just to tease you a little bit, I think it's saya@att.net. So that's kind of cheeky. I like that.
Dr. Carl Peters: say.a@att.net. Don't forget the little dot.
John: Don't forget the dot. We'll put that in the show notes. All right, Carl. This has been a lot of fun. I've learned a lot and I know the listeners have too, so I really am glad to have you here to explain your recent career journey. It's been very interesting.
Dr. Carl Peters: I appreciate it, John. Thank you kindly.
John: You're welcome. Bye-bye
Dr. Carl Peters: Bye.
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