Interview with Ron Barshop
In today's podcast, Ron Barshop explains how to save healthcare, satisfy patients, and fix physician burnout.
Ron Barshop is a serial entrepreneur with several ventures serving primary care physicians. His podcast Primary Care Cures presents thought leaders and CEOs of companies improving primary care and the majority of what's wrong with healthcare. And it has been featured on top healthcare podcast lists.
He has served as chairman of multiple capital campaigns as well as two angel networks. He has run ten marathons and received both local and national leadership accolades. Healthcare is Fixed is one of his books (soon to be released).
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What is DPC?
Direct Primary Care is a subscription-based program for connecting patients with physicians. It allows for immediate and continuous access to care. Most people might know it as concierge or “VIP” care. However, it has evolved to include a more grass-roots, scalable method for accessing care.
It enables doctors to provide medical coverage to a panel of 600 to 800 patients. And, instead of offering a six-to-eight-minute interaction with patients, DPC physicians spend 30 minutes or more with them during face-to-face visits. With DPC, coding and billing are no longer a concern.
Support for Independent Practitioners
Ron described four companies that support physicians in developing their DPC practices that have been featured on the Primary Care Cures Podcast. They are helping independent doctors start their own practices wherever they live.
- Episode 165 – Chris Habig, Freedom Healthworks. Doctors don't need to become entrepreneurs overnight. The company handles money, marketing, and all the backend work, and hiring is very much turnkey.
- Episode 21 and Episode 42 – Dr. Josh and Kirk Umbehr, Atlas MD. More than half of the independent DPCs in the nation were started with Atlas MD.
- Episode 25 – Dr. Paul Thomas, Plum Health. Paul Thomas established his own practice right after finishing his residency. He will shortly be launching his third practice. He explains how to launch swiftly using social media, and introduces other tools to help DPC start-ups.
- Episode 59 – Dr. Brian Forrest, Access Healthcare Direct. He has helped launch more than a hundred distinct DPCs.
Summary
Physicians who feel burned out should look into direct payment models. There is consulting support for starting up an independent practice. And there are large companies that will add you to their DPC networks. You can leam more about this growing phenomenon by listening to the Primary Care Cures Podcast. A list of all of the episodes can be found here: primarycarecures.com/podcast-episodes/
NOTE: Look below for a transcript of today's episode.
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Links for Today's Episode:
- Ron Barshop's Website
- Primary Care Cures Podcast
- Achieve Beautiful Balance as Medical Director and Concierge Physician – 234
Companies Mentioned in This Episode:
- Freedom Works – 165
- Atlas MD – 21
- Atlas MD – 22
- Plum Health – 25
- Access H/C Direct – 59
- First Stop Health – 130
- Proactive MD – 138
- Next Level Urgent Care – 126
- Nice Healthcare – 113
- Marathon Health – 164
- Medici – 118
- Medici – 58
- 98point6 – 62
- Crossover Health – 111
- Premise Health – 110
- Everside Health – 106
Value-based Care ACO Companies:
- ChenMed – 64
- Village MD – 84
- Catalyst Healthcare 45
- Nextera Healthcare – 28
- Redirect Health – 121
- Redirect Health – 29
- Redirect Health 6
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Transcription PNC Podcast Episode 256
How to Save Healthcare, Satisfy Patients, and Fix Physician Burnout
Interview with Ron Barshop>
John: Today's guest is not a physician, but honestly, it took me two or three of his podcast episodes to figure that out. So, why would that be? Well, because he so clearly describes the problems with our current system, most of which are driving physicians out of the system that I thought he had to be a physician. But no, he's not. He's awesome. He has a great podcast, he's written books. And the thing is he goes a step further. He offers solutions. And the solutions he describes if implemented, I think will fix healthcare as he claims. So, we're going to hear about that. With that, let me introduce Ron Barhop. Thanks for coming.
Ron Barhop: Thank you for inviting me. I'm looking forward to this.
John: Yeah, there's so much I'm trying to understand what you're talking about on your podcast and in your books. But before we get into that, why don't we just have you tell us a little bit about your background education and how you started to get this interest in direct contracted primary care?
Ron Barhop: Well, when I was an angel investor and I had an angel network, a gentleman came to me with a really interesting healthcare company, but it wasn't really fundable by early stage. But he and I became partners later in a business that helped physical medicine find its way into the exam rooms of primary care physicians and helped them add ancillary income.
He and I split up and he formed an allergy company and I formed an allergy testing and treatment C company. And it would turn out to be, I thought the solution for primary care to cure it, because it was broken clearly, was ancillary income. 15 years ago, is when I started the primary care supplement income company. But I started a podcast four years ago to "Sherlock" the crime scene. And the crime scene is "Why are we between Slovenia and Costa Rica in our outcomes with care nations?" And that's basically the GDP of Milwaukee.
John: Right.
Ron Barhop: And we're spending almost double Switzerland, our second closest competitor in spent. And then another question was "How come if the Fed is right, 51% of people are making under $20 an hour and 80% of workers are making under $30 an hour?" We have this backbone of hourly workers. And so, we have this Wealthcare-Poorcare system for them versus the others.
Basically, we have unfunctional uninsured about half of all workers. They have these high deductible plans they can't even use. They don't have enough money in the bank to access it. And then over half the PCPs are burned out. So, I've got this 51% under $20 an hour, 50% of doctors are unhappy in their jobs and they're supposed to be taking care of my health and my kids' health and my family's health. And I knew that if we had a cure for primary care, then we could cure overall healthcare because that's sort of the mouth of the river, if you will.
John: I guess I would just say, can you give us just kind of an overview of the best situation for what is DPC and what's the ideal situation for that way of providing care?
Ron Barhop: Well, most people might know it as concierge or VIP care, but it's not that anymore. It's scaling and there's sort of two flavors of direct primary care that I discovered on my show. Again, I was just like Sherlock Holmes, just trying to get my magnifying glass out and figure out what's the solution. And initially, I got what I call the Mount Everest, or maybe I should say the Mount Rushmore of the four DPC doctors that are the thought leaders on my show.
I thought that was the answer as independent mom and pop Kool-Aid stands that are taking care of locals. And that doesn't solve the jumbo employer problem, which is a whole different flavor of DPC that is cropped up as private equity's been funding at the last really five to 10 years. And so, I suddenly discovered, "Wait a minute, you can have a jumbo solution and a mini solution all in the same model."
Just to take a step back, DPC - Direct Primary Care is a subscription base monthly payment per member per month. And what it allows for is an employer to access immediate care, but also let's take it from the doctor's perspective, because that's your listener. From a doctor's perspective, their panel is now 600 to 800 as opposed to triple or no quadruple that. It allows them to have instead of a six-to-eight-minute interaction with half that time typing. Now they can toss the EHR Bible out the window and not have to code and not have to bill, which is a massive regime of pre-authorizations and all the headaches that every listener knows. And it allows them to have a longer visit with a member. And the member now gets 30 minutes, 45 minutes on a second or third interview. They get an hour on the first exam, but more importantly, they have access with virtual care. So, they have an app that allows them to text synchronously tight with the doc at the same time or talk by chat or video.
Telehealth got this big boom in the pandemic to 40% utilization jump and DPCs had it all along. It's been part of it since 1998. It allows the physician to now have their calling come back into their life again, why they chose the calling. So, it's an amazing thing. This scaling has allowed an employer that has people in three or five or 10 states or three or five, 10 metros, or even in foreign countries to now have access to a primary care physician, which is really important for chronic care because that's 80% to 95% of their cost. And now they can get those folks in front of a primary care physician and head off in the past. So, they're not using that expensive downstream utilization of hospitals and ER and urgent care that are so costly and too late, frankly, for the chronic patient that needs lots of love and lots of attention now.
John: I sense that the devils in the details, to some extent. It's just hard to get my mind around "Okay, I'm going, I'm using an EMR. I'm working with insurance companies. Of course, I'm in my staff, I have to staff up like three or four employees just to handle the insurance and the rebuilding and so on and so forth." So, how is it that works where you're not having to code?
Ron Barhop: The problem with American healthcare that's unique and special about us, we're going to call it special in the short best sense of the word, is that we don't have access to inexpensive, immediately accessible primary care in America. And most primary care physicians would die to have three or four employees doing their billing and coding. But if you do the math, it's closer to eight or nine administrative types.
John: Okay.
Ron Barhop: These medical assistants aren't even giving to touch the patient. They're dealing with pre-ops and they're dealing with check in, putting stuff into a computer. They're dealing with the billing collecting, all of that regime. And when you have DPC, it's a monthly subscription. You're getting anywhere as low as 20 with one company as high as 120 or 150 depending on the services the employer wants. Now increasingly primary care is stretching like a rubber band to include behavioral health because that's what employers need. They need their people healthy and back at work. And generally, it's free. The ROI for DPC is one out of one year one, and it's as high as three or four on one year, two or three or four because of the downstream utilization that drops.
And the exciting thing about it is you only need maybe one assistant at the front to check people in. You're not coding anymore and you're not billing because there's no insurance company involved. So, we get these bloated expensive middles like PBMs out of the picture. We get these bloated insurance companies. 90% of the profits for insurance companies, core units have been federal. They're not seeing private employers anymore because they've fled long ago because they know that the incentives are maligned.
So, if you're a DPC doc and you're with a large scalable firm, they do all the backend for you. And there's three people that I'll introduce to this show that are helping independent doctors that want to start their own practice wherever they live, meet the patients, wherever they are. Again, as I said, there are two flavors. I'll try to carefully parse those out as we have this talk today.
John: I understand that there are, and I've heard either on your podcast or others, let's say talking to the really small company physician practice, and they just opt out of the whole system. They somehow have a tool or mechanism to receive the monthly payment. They have to deal with the high-cost items. I don't know if that's through reinsurance or some other method for the patients, not for them obviously. And then there's the other iterations that I think that you're going to get into, but if I was just finishing residency or early in my career decided to do this, how would I actually get started by doing it on my own or other companies I can reach out to, to help me?
Ron Barhop: Yes. I'll give you the names of three people that are helping people do exactly that. I just interviewed on my show number 165 Chris Habig, Freedom Healthworks. He basically does finances, does the marketing, does all the backend, does the hiring pretty much turnkey because doctors don't need to become entrepreneurs overnight when you have somebody like Chris that helps you get started.
There's another company. Dr. Josh and Kirk Umbehr with Atlas MD have launched over half of all the DPCs that are independent in the country today. That's episodes 21 and 42. And Josh the doctor, and Kirk the brother, are helping them get started in the practice with all the millions of questions and FAQs they've got to get it launched immediately.
I had another guest who is part of my Mount Rushmore, Paul Thomas. Dr. Paul Thomas has Plum Health and he's episode 25. He consults now with doctors that need to get started. And he came straight out of medical school, straight out of his residency and started his own practice and is now opening his third practice soon, where he lives. So, he will tell you how to rapidly start with social media and using all the obvious tools that are clear to a guy who's just getting started, how to launch quickly.
And then there's a gentleman named Dr. Brian Forrest, Access Healthcare, which is show 59. And he has launched probably over a hundred different DPC. And all of these gentlemen that I'm talking about have basically a hundred percent success. There are very few fallouts when you go there, if you want to go independent. If you want to go on a scalable, we'll talk about those a little bit later, but if you want to go scalable and go to work for somebody, these are the happiest doctors in America. They don't go to a convention and drink a lot of wine. They drink a lot of fresh water and they're happy. They're joyful because they don't have the burnout of the regime anymore of the insurance companies lording over them like a hot sweater in July.
John: All right. I'm definitely going to put those in the show notes. I'll make sure to put those podcast episodes in the show notes and the names and so forth. That's very helpful. I guess I wanted to comment too, as you're talking about this, I look at it from the perspective of the physicians being unhappy, but the other half of the equation is the patients are miserable because like you said earlier spending five minutes with a patient, spending 10 minutes documenting and trying to solve a problem. And now you're having them come back over and over, because you really only have time for one problem. You're not doing a comprehensive visit. Again, my audience, we kind of focus on the physician's side of this, but of course we all know that it's just making the patients as miserable as we are. So, if we can break that pattern, then this is going to be fantastic.
Ron Barhop: Well, the jumbo employers are using this to get free healthcare. So, when you take away the friction of finance, the friction of time, the friction of "Do I even have a doctor that cares about me or has information on me? I have to start all over again" goes away when you deal with these nationally scalable models that are now growing in all 50 states. Also, it's good to measure. If you're going to go work for one of those, what is their turnover with the employers? Most of them have 98% to 99% retention with their client, which is the employer who's paying the bill on that per monthly basis I was telling you about. And if you're measuring metrics, and doctors love metrics, what does that turnover and what is the employee satisfaction?
And there's two ways you can parse that out also. You can look at the NPS, the net promoter scores of most of these firms, and they're in the high 80s and low 90s. And some of them are in the high 90s. That means the patient is incredibly happy. And some of them will publish their Google ratings. I don't know why they don't, because that's a big question mark. For me, why wouldn't you be proud? But many of them have them in the mid four's, tons of fives and a few fours and obvious one or two. But Google ratings will tell you that the ultimate consumer, the patient is very happy. So, you don't have to guess when you go to work for these companies and you can look at the Glassdoor ratings. But Glassdoor is kind of like Twitter. If Elon Musk is finding out, it can be loaded with fake reviews in there.
I've seen companies that are at a two or a three instead of a five. And suddenly employees start jumping in, that are, I think, fake employees that are saying how wonderful it is to work there when all the rest previously were saying the truth of what it is like to work there. So, if you look at the Glassdoor of a hospital, a typical big system, it's not going to be very pretty. But if you look at the Glassdoor of a lot of these PCPs that are now getting, and by the way, most of these companies I'm about to talk about are all run by doctors. So that's a plus, right? But they're much, much higher rated, and I don't think they need to fake anything in there because the customer, the consumer, the member is genuinely happy.
John: No, that's the ultimate test, I think. Especially if all the stakeholders are really doing well and benefiting from it. Let's see, we're going to talk a little bit more about some of those businesses or the corporate side of things. To me, it sounds like that's kind of where this came from to some extent, because the big employers just decided, "Look, we're tired of number one, wasting our money. Number two, the insurance company is just billing, charging us to manage this thing and it's ridiculous." And so, they just took it over and started hiring doctors and putting clinics together, and that kind of thing, I imagine.
Ron Barhop: I'll talk about the small guys first that are regional and growing and maybe they'll be acquired by some of the larger ones, but we're talking about 20 million members. We're talking about 20,000 PCPs. And it's not just broad scope PCPs, although that's best, if you're a family doctor or DO or an internist and you have lots of scope in your practice. That's better than a gerontologist or a pediatrician, but there's plenty of those folks in this model too. But the gerontologists are getting snapped up by the Medicare advantage capitated plans. And I'll talk about those too, if you'd like, but I've had these guests on my show. Do you want me to just run through the list? Because it's about 10 or 15 companies.
John: Yeah, sure.
Ron Barhop: Okay. Small to bigs, First Stop Health. You'll hear the Patrick Spain interview on episode 130. Proactive, John Collier episode 138. Dr. Juliet Breeze is expanding big time in Texas. Next Level Urgent Care, that's episode 126. Nice Healthcare. I joked around. I can't believe that a name was still available a few years ago, but Nice Healthcare is Thompson Aderinkomi. He is the first guy I'm going to mention that's not a doctor. That's episode 113.
And now we're getting into the bigger voice here and it is the Dr. Jeff Wells with Marathon Health, episode 164 was just on our show. They're the most transparent I was able to find in terms of just getting all the metrics if you're a doctor and you want to go work there. But it's all on my show if you want to save the time.
Dr. Clinton Phillips, episode 118 and 58 with Medici healthcare is one of the largest virtual primary cares. But now that everybody's jumping in, basically Teledoc jumped in a few months ago. They have 11 fortune one hundreds. Medici has a third of the fortune one hundreds.
Brad Younggren with 98point6, episode 62. 98point6 is helping Walmart to do the virtual. And then Scott Shreeve with Crossover. It'd be hard to name a Silicon Valley big that's not using them, but that's episode 111. And so, Crossover is in all the Amazon fulfillment centers and they're expanding in LinkedIn and into it. The list goes on and on. Facebook.
Dr. Jami Doucette with Premise Health is the largest. They have 3 million members and that's episode 110. Premise Health, again, helps hundreds of employees, almost 800 employers across the country that are jumbos. And the one that I found first was Everside. Dr. Gaurov Dayal is their president. And Everside, not only helped the state of New Jersey save billions between primary care and pharmaceutical spend, which is the biggest amount ever by a state or county or anything. We had Chris Deacon on our show. Chris was the state treasurer. She was in charge of the program for that in pensions back before she left.
But Everside also helps the state of Colorado and big school districts all over the country. So, they're the second largest, probably over a million members. These are companies that I would probably look to. And I have not had on my show yet one medical, but they're a public company that does, with the purchase of IRA health, both the Medicare population and the employer population.Cityblock, I haven't had on my show yet, but they're doing a lot in the Northeast. Famhealth is a feminine female only business consumer. And then Firefly. There are a ton of them that are going after either employers or members directly that are worthy of looking at with this screen, I was giving you from a doctor's perspective.
John: With these companies, from the perspective of the physician, are they contracting with them? Are they employed by them? What's that relationship between the physician and their providing that service to the employers?
Ron Barhop: Yeah, they work for Crossover, get their paycheck from Premise. They get their benefits from Everside. They're not going out on their own. If you want to go out on your own, I would talk to those first four guests that can help you launch. But if you want to go, and it's not more stable, it's just different. But most of them will still give you a panel. You'll have your members that are coming to you, physically, because they're spread out all over the country. So, if you Google onsite or near site clinics, a lot of these companies will pop up. And they're either in the headquarters or near major employment manufacturing, or they're nearby. They're in the neighborhoods where the people live.
John: It's a little overwhelming, although it's been kind of bubbling in the background for a long time, it sounds like. And you have mentioned on the podcast that they've been very successful. Like you said, the dollars look good. The physicians are happy. The patients remain with the physicians, the old model of the primary care doing most of the initial management and being that, not just really a gatekeeper, but really that one-on-one physician and managing things. It seems to be almost Nirvana. So, what have we missed now? Are there some other types of companies that are doing this, that we haven't discussed so far?
Ron Barhop: Well, it's an ecosystem. Again, if you're helping an employer, they need access to wholesale pharmacy. A lot of them are contracting either direct with a pharmacy, sometimes the gross is in that town, and they're negotiating rock bottom prices, or there are wholesale mail order firms. I had ScriptCo on the show, their average fill is 4 cents per pill. You don't need a PBM if you got 4 cents per pill. So, they're in 47 states now. I just had Zach Zeller back on the show. You'll see him pop up in last week's episode. And it's not just pharmacy. It's got to be, how do you contract with surgery, labor and delivery being the biggest one?
Well, the Surgery Center of Oklahoma was the OG, the original gangster that started back in 1993. And there's now 60 independent free market surgery centers that are owned by surgeons and doctors that are in pretty much every state. So, if you're willing to travel just a little bit, surgery is 60% to 80% less. And then there's 1,700 independent imaging centers with green imaging. Kristen Dickerson was on one of our shows. And those imaging centers are, again, 20% to 40% of the cost of imaging centers owned by the bigs that had these facility fees and these outrageous prices built into a simple X-ray or MRI or ultrasound. And furthermore, it's not just pharmacy, it's not just surgery, but you've got to access sometimes a hospital. You got to do a deal, sometimes you just got to go there. As much as we don't want them to, and they don't need to, hospitals are going to be contracted within those cities as well, independently through the third-party administrator.
Now you mentioned stop-loss. On a contractor basis with jumbos, they have stop-loss built into these plans by the plan designer, the benefit designer. But if you're independent and you're going to find these docs on your own, in your own town, in your neighborhood, you will buy a company called Sedera Health or Zion Health. And they have these, I guess, they're sort of like stop-loss, but they are low deduct. They can't call them insurance because they're religious plans, but they are allowing people to take care of that scary cancer car accident or cardio incident that could bankrupt them. And those companies pick that up.
And then there's another company that just came into the market from Austin that's called Crowd Health. And I had Andy Schoonover on my show. It's kind of the same idea, but it's just crowdsourced funding of your large healthcare expenses.
I've had it for four years. I had Sedera for four years. I had Redirect Health handle my primary care. Anywhere I want to go, I would show QR code and I would get out no cash. I'd just pay them a monthly fee to access. And it's not their doctors. It's any doctor I want to use. Any labs free, any physical medicine free as part of my monthly. But now Redirect Health is now offering a stop-loss, if you will, with $2,000 deductible in any hospital spend. So, they haven't built into their model too. So now I'm using them fully, not some of these other religious.
John: This is something that I think my listeners would like to dig into a lot more because it's an option if they're really feeling frustrated and burned out. You have a book called "Healthcare is Fixed." Is that out? Is that available for pre-order? Because it goes into these details from what I know. I've not seen the book. So, tell us about that.
Ron Barhop: I wrote it in 2019. I recorded it right after that and I've been sitting on it. And John, I don't know why. I don't know what I'm afraid of. I hope to pick with Healthcare is Fixed and you can go to healthcareisfixed.com, but I hope to go pick a company every year and identify what I think are the best. So, I'm going to write another book about hopefully the new ecosystem in Alaska, which is doing amazing things at half the price in primary care for the Alaskan native population.
I hope to write a book about RosenCare, but I think Mr. Rosen and his daughter or granddaughter are going to write a book. But RosenCare again, for less than half the cost, is delivering healthcare so much so that they have no debt on 6,000 room hotel resorts around our Orlando convention center. And they're funding a school district that used to be crime ridden and drug ridden. Now they're paying for all the college for any student that graduates high school. Community college, vocational school, full boat, PhD level college. Medical school, whatever they want to go to. And some of the doctors that started out as students there 20 years ago are now serving their population of their employees.
John: Nice.
Ron Barhop: There's amazing companies out there doing incredible things that are literally eliminating crime in neighborhoods. There are no gangs in this school district and they just adopted a bigger one. The best way to measure is who wins in this model? And if the employers are winning, because they now have a ROI of one on one or two on one or three on one. And if the consumer, we don't call them patients in this world, we call them members. But if the consumer's winning, if the doctors and nurses are winning, they have low turnover rates. If the shareholders of those companies are all winning, if the communities are winning, like the Orlando community has gotten rid of crime and these giant school districts, if costs are dropping 20% to 60%, and if outcomes are rising measurably, we don't have a triple aim problem or quadruple aim problem anymore. We have an octupole aim and then we're accomplishing them all eight. Those are passe to talk about quadruple aim. You can have three out of four, but not all four. No, that doesn't work anymore. We have direct contracting with a large ecosystem with primary care as the foundation, John, is the answer.
John: Well, I could get behind that 100% for sure. For my listeners. This is going to be overwhelming. So, you want to go to primarycarecareers.com because you can find out about the podcast and start listing the episodes. And then you can go to healthcareisfixed.com where actually there's a lot of information that you've described. And that book when it's available is going to be there for us. So, we'll look for that. Any other big points, as we want to get to before I start to wrap up our interview here? Did we hit the high points?
Ron Barhop: Yeah. The system is clearly broken. We don't need to talk about that. You do a lot of that on your show. But there are happy doctors out there that have opted out. And this is the most important point that there is a downside. You have to opt out of anything federal. You can't no longer take Medicare, Medicaid. You can't take TRICARE defense health. So, you can't go moonlight at the VA on the weekends and you can't be a medical director if you will, for a company that takes Medicare Medicaid. So, you have to step out and that's again, a glitch in the law that allows the bigs to sort of lord over this model. But once you opt out, it doesn't mean you can't opt in again, but you just no longer are participating in things.
And if you think about it, it is kind of logical. CMS does not want to write a check to Dr X and then write her another check. So, you get another check from her employer at Eversite or Premise or Medici. It makes sense a little bit, but the opt out is there's no reason folks shouldn't be able to consult on the weekends and help out other folks that are in need with this giant shortage that's looming.
John: Maybe at some point they'll figure out how to make that work. So, what's the best way for listeners to find you? Just one of those two that I mentioned?
Ron Barhop: Yeah. You and I found each other on LinkedIn and I'm easy to get to and I am happy to respond and talk to anybody and send them in the right direction. But if they listen to these 12 or 15 shows, they'll get to meet the CEOs that are making the changes. They'll get to talk to or hear the metrics of what drives these models. And they'll start hearing the same thing over and over again, which is, this is really healthcare fixed. This is really primary care cured. And that's why I named the show "Primary Care Cures." And that's why I named the book "Healthcare is Fixed."
John: If we can just get that to be adopted across the board, it'll be in great shape.
Ron Barhop: It's going to grow no matter what happens, it's an unstoppable movement.
John: All right. Now is the time to jump on the bandwagon. This has been very interesting, Ron. I really appreciate you coming and explaining this to us and describing this. This has been really an eyeopener. Even though I promote a lot of the nonclinical careers for people that are burned out, I would definitely encourage you if you want to continue to practice, you definitely have to look at these direct payment models and DPC and some of these companies that are supporting this. It's fantastic. All right, with that, I guess it's time to say goodbye. Thanks Ron. Bye.
Ron Barhop: Thanks John for inviting me. I appreciate it.
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Transcription PNC Podcast Episode 256
How to Save Healthcare, Satisfy Patients, and Fix Physician Burnout
Interview with Ron Barshop>
John: Today's guest is not a physician, but honestly, it took me two or three of his podcast episodes to figure that out. So, why would that be? Well, because he so clearly describes the problems with our current system, most of which are driving physicians out of the system that I thought he had to be a physician. But no, he's not. He's awesome. He has a great podcast, he's written books. And the thing is he goes a step further. He offers solutions. And the solutions he describes if implemented, I think will fix healthcare as he claims. So, we're going to hear about that. With that, let me introduce Ron Barhop. Thanks for coming.
Ron Barhop: Thank you for inviting me. I'm looking forward to this.
John: Yeah, there's so much I'm trying to understand what you're talking about on your podcast and in your books. But before we get into that, why don't we just have you tell us a little bit about your background education and how you started to get this interest in direct contracted primary care?
Ron Barhop: Well, when I was an angel investor and I had an angel network, a gentleman came to me with a really interesting healthcare company, but it wasn't really fundable by early stage. But he and I became partners later in a business that helped physical medicine find its way into the exam rooms of primary care physicians and helped them add ancillary income.
He and I split up and he formed an allergy company and I formed an allergy testing and treatment C company. And it would turn out to be, I thought the solution for primary care to cure it, because it was broken clearly, was ancillary income. 15 years ago, is when I started the primary care supplement income company. But I started a podcast four years ago to "Sherlock" the crime scene. And the crime scene is "Why are we between Slovenia and Costa Rica in our outcomes with care nations?" And that's basically the GDP of Milwaukee.
John: Right.
Ron Barhop: And we're spending almost double Switzerland, our second closest competitor in spent. And then another question was "How come if the Fed is right, 51% of people are making under $20 an hour and 80% of workers are making under $30 an hour?" We have this backbone of hourly workers. And so, we have this Wealthcare-Poorcare system for them versus the others.
Basically, we have unfunctional uninsured about half of all workers. They have these high deductible plans they can't even use. They don't have enough money in the bank to access it. And then over half the PCPs are burned out. So, I've got this 51% under $20 an hour, 50% of doctors are unhappy in their jobs and they're supposed to be taking care of my health and my kids' health and my family's health. And I knew that if we had a cure for primary care, then we could cure overall healthcare because that's sort of the mouth of the river, if you will.
John: I guess I would just say, can you give us just kind of an overview of the best situation for what is DPC and what's the ideal situation for that way of providing care?
Ron Barhop: Well, most people might know it as concierge or VIP care, but it's not that anymore. It's scaling and there's sort of two flavors of direct primary care that I discovered on my show. Again, I was just like Sherlock Holmes, just trying to get my magnifying glass out and figure out what's the solution. And initially, I got what I call the Mount Everest, or maybe I should say the Mount Rushmore of the four DPC doctors that are the thought leaders on my show.
I thought that was the answer as independent mom and pop Kool-Aid stands that are taking care of locals. And that doesn't solve the jumbo employer problem, which is a whole different flavor of DPC that is cropped up as private equity's been funding at the last really five to 10 years. And so, I suddenly discovered, "Wait a minute, you can have a jumbo solution and a mini solution all in the same model."
Just to take a step back, DPC - Direct Primary Care is a subscription base monthly payment per member per month. And what it allows for is an employer to access immediate care, but also let's take it from the doctor's perspective, because that's your listener. From a doctor's perspective, their panel is now 600 to 800 as opposed to triple or no quadruple that. It allows them to have instead of a six-to-eight-minute interaction with half that time typing. Now they can toss the EHR Bible out the window and not have to code and not have to bill, which is a massive regime of pre-authorizations and all the headaches that every listener knows. And it allows them to have a longer visit with a member. And the member now gets 30 minutes, 45 minutes on a second or third interview. They get an hour on the first exam, but more importantly, they have access with virtual care. So, they have an app that allows them to text synchronously tight with the doc at the same time or talk by chat or video.
Telehealth got this big boom in the pandemic to 40% utilization jump and DPCs had it all along. It's been part of it since 1998. It allows the physician to now have their calling come back into their life again, why they chose the calling. So, it's an amazing thing. This scaling has allowed an employer that has people in three or five or 10 states or three or five, 10 metros, or even in foreign countries to now have access to a primary care physician, which is really important for chronic care because that's 80% to 95% of their cost. And now they can get those folks in front of a primary care physician and head off in the past. So, they're not using that expensive downstream utilization of hospitals and ER and urgent care that are so costly and too late, frankly, for the chronic patient that needs lots of love and lots of attention now.
John: I sense that the devils in the details, to some extent. It's just hard to get my mind around "Okay, I'm going, I'm using an EMR. I'm working with insurance companies. Of course, I'm in my staff, I have to staff up like three or four employees just to handle the insurance and the rebuilding and so on and so forth." So, how is it that works where you're not having to code?
Ron Barhop: The problem with American healthcare that's unique and special about us, we're going to call it special in the short best sense of the word, is that we don't have access to inexpensive, immediately accessible primary care in America. And most primary care physicians would die to have three or four employees doing their billing and coding. But if you do the math, it's closer to eight or nine administrative types.
John: Okay.
Ron Barhop: These medical assistants aren't even giving to touch the patient. They're dealing with pre-ops and they're dealing with check in, putting stuff into a computer. They're dealing with the billing collecting, all of that regime. And when you have DPC, it's a monthly subscription. You're getting anywhere as low as 20 with one company as high as 120 or 150 depending on the services the employer wants. Now increasingly primary care is stretching like a rubber band to include behavioral health because that's what employers need. They need their people healthy and back at work. And generally, it's free. The ROI for DPC is one out of one year one, and it's as high as three or four on one year, two or three or four because of the downstream utilization that drops.
And the exciting thing about it is you only need maybe one assistant at the front to check people in. You're not coding anymore and you're not billing because there's no insurance company involved. So, we get these bloated expensive middles like PBMs out of the picture. We get these bloated insurance companies. 90% of the profits for insurance companies, core units have been federal. They're not seeing private employers anymore because they've fled long ago because they know that the incentives are maligned.
So, if you're a DPC doc and you're with a large scalable firm, they do all the backend for you. And there's three people that I'll introduce to this show that are helping independent doctors that want to start their own practice wherever they live, meet the patients, wherever they are. Again, as I said, there are two flavors. I'll try to carefully parse those out as we have this talk today.
John: I understand that there are, and I've heard either on your podcast or others, let's say talking to the really small company physician practice, and they just opt out of the whole system. They somehow have a tool or mechanism to receive the monthly payment. They have to deal with the high-cost items. I don't know if that's through reinsurance or some other method for the patients, not for them obviously. And then there's the other iterations that I think that you're going to get into, but if I was just finishing residency or early in my career decided to do this, how would I actually get started by doing it on my own or other companies I can reach out to, to help me?
Ron Barhop: Yes. I'll give you the names of three people that are helping people do exactly that. I just interviewed on my show number 165 Chris Habig, Freedom Healthworks. He basically does finances, does the marketing, does all the backend, does the hiring pretty much turnkey because doctors don't need to become entrepreneurs overnight when you have somebody like Chris that helps you get started.
There's another company. Dr. Josh and Kirk Umbehr with Atlas MD have launched over half of all the DPCs that are independent in the country today. That's episodes 21 and 42. And Josh the doctor, and Kirk the brother, are helping them get started in the practice with all the millions of questions and FAQs they've got to get it launched immediately.
I had another guest who is part of my Mount Rushmore, Paul Thomas. Dr. Paul Thomas has Plum Health and he's episode 25. He consults now with doctors that need to get started. And he came straight out of medical school, straight out of his residency and started his own practice and is now opening his third practice soon, where he lives. So, he will tell you how to rapidly start with social media and using all the obvious tools that are clear to a guy who's just getting started, how to launch quickly.
And then there's a gentleman named Dr. Brian Forrest, Access Healthcare, which is show 59. And he has launched probably over a hundred different DPC. And all of these gentlemen that I'm talking about have basically a hundred percent success. There are very few fallouts when you go there, if you want to go independent. If you want to go on a scalable, we'll talk about those a little bit later, but if you want to go scalable and go to work for somebody, these are the happiest doctors in America. They don't go to a convention and drink a lot of wine. They drink a lot of fresh water and they're happy. They're joyful because they don't have the burnout of the regime anymore of the insurance companies lording over them like a hot sweater in July.
John: All right. I'm definitely going to put those in the show notes. I'll make sure to put those podcast episodes in the show notes and the names and so forth. That's very helpful. I guess I wanted to comment too, as you're talking about this, I look at it from the perspective of the physicians being unhappy, but the other half of the equation is the patients are miserable because like you said earlier spending five minutes with a patient, spending 10 minutes documenting and trying to solve a problem. And now you're having them come back over and over, because you really only have time for one problem. You're not doing a comprehensive visit. Again, my audience, we kind of focus on the physician's side of this, but of course we all know that it's just making the patients as miserable as we are. So, if we can break that pattern, then this is going to be fantastic.
Ron Barhop: Well, the jumbo employers are using this to get free healthcare. So, when you take away the friction of finance, the friction of time, the friction of "Do I even have a doctor that cares about me or has information on me? I have to start all over again" goes away when you deal with these nationally scalable models that are now growing in all 50 states. Also, it's good to measure. If you're going to go work for one of those, what is their turnover with the employers? Most of them have 98% to 99% retention with their client, which is the employer who's paying the bill on that per monthly basis I was telling you about. And if you're measuring metrics, and doctors love metrics, what does that turnover and what is the employee satisfaction?
And there's two ways you can parse that out also. You can look at the NPS, the net promoter scores of most of these firms, and they're in the high 80s and low 90s. And some of them are in the high 90s. That means the patient is incredibly happy. And some of them will publish their Google ratings. I don't know why they don't, because that's a big question mark. For me, why wouldn't you be proud? But many of them have them in the mid four's, tons of fives and a few fours and obvious one or two. But Google ratings will tell you that the ultimate consumer, the patient is very happy. So, you don't have to guess when you go to work for these companies and you can look at the Glassdoor ratings. But Glassdoor is kind of like Twitter. If Elon Musk is finding out, it can be loaded with fake reviews in there.
I've seen companies that are at a two or a three instead of a five. And suddenly employees start jumping in, that are, I think, fake employees that are saying how wonderful it is to work there when all the rest previously were saying the truth of what it is like to work there. So, if you look at the Glassdoor of a hospital, a typical big system, it's not going to be very pretty. But if you look at the Glassdoor of a lot of these PCPs that are now getting, and by the way, most of these companies I'm about to talk about are all run by doctors. So that's a plus, right? But they're much, much higher rated, and I don't think they need to fake anything in there because the customer, the consumer, the member is genuinely happy.
John: No, that's the ultimate test, I think. Especially if all the stakeholders are really doing well and benefiting from it. Let's see, we're going to talk a little bit more about some of those businesses or the corporate side of things. To me, it sounds like that's kind of where this came from to some extent, because the big employers just decided, "Look, we're tired of number one, wasting our money. Number two, the insurance company is just billing, charging us to manage this thing and it's ridiculous." And so, they just took it over and started hiring doctors and putting clinics together, and that kind of thing, I imagine.
Ron Barhop: I'll talk about the small guys first that are regional and growing and maybe they'll be acquired by some of the larger ones, but we're talking about 20 million members. We're talking about 20,000 PCPs. And it's not just broad scope PCPs, although that's best, if you're a family doctor or DO or an internist and you have lots of scope in your practice. That's better than a gerontologist or a pediatrician, but there's plenty of those folks in this model too. But the gerontologists are getting snapped up by the Medicare advantage capitated plans. And I'll talk about those too, if you'd like, but I've had these guests on my show. Do you want me to just run through the list? Because it's about 10 or 15 companies.
John: Yeah, sure.
Ron Barhop: Okay. Small to bigs, First Stop Health. You'll hear the Patrick Spain interview on episode 130. Proactive, John Collier episode 138. Dr. Juliet Breeze is expanding big time in Texas. Next Level Urgent Care, that's episode 126. Nice Healthcare. I joked around. I can't believe that a name was still available a few years ago, but Nice Healthcare is Thompson Aderinkomi. He is the first guy I'm going to mention that's not a doctor. That's episode 113.
And now we're getting into the bigger voice here and it is the Dr. Jeff Wells with Marathon Health, episode 164 was just on our show. They're the most transparent I was able to find in terms of just getting all the metrics if you're a doctor and you want to go work there. But it's all on my show if you want to save the time.
Dr. Clinton Phillips, episode 118 and 58 with Medici healthcare is one of the largest virtual primary cares. But now that everybody's jumping in, basically Teledoc jumped in a few months ago. They have 11 fortune one hundreds. Medici has a third of the fortune one hundreds.
Brad Younggren with 98point6, episode 62. 98point6 is helping Walmart to do the virtual. And then Scott Shreeve with Crossover. It'd be hard to name a Silicon Valley big that's not using them, but that's episode 111. And so, Crossover is in all the Amazon fulfillment centers and they're expanding in LinkedIn and into it. The list goes on and on. Facebook.
Dr. Jami Doucette with Premise Health is the largest. They have 3 million members and that's episode 110. Premise Health, again, helps hundreds of employees, almost 800 employers across the country that are jumbos. And the one that I found first was Everside. Dr. Gaurov Dayal is their president. And Everside, not only helped the state of New Jersey save billions between primary care and pharmaceutical spend, which is the biggest amount ever by a state or county or anything. We had Chris Deacon on our show. Chris was the state treasurer. She was in charge of the program for that in pensions back before she left.
But Everside also helps the state of Colorado and big school districts all over the country. So, they're the second largest, probably over a million members. These are companies that I would probably look to. And I have not had on my show yet one medical, but they're a public company that does, with the purchase of IRA health, both the Medicare population and the employer population.Cityblock, I haven't had on my show yet, but they're doing a lot in the Northeast. Famhealth is a feminine female only business consumer. And then Firefly. There are a ton of them that are going after either employers or members directly that are worthy of looking at with this screen, I was giving you from a doctor's perspective.
John: With these companies, from the perspective of the physician, are they contracting with them? Are they employed by them? What's that relationship between the physician and their providing that service to the employers?
Ron Barhop: Yeah, they work for Crossover, get their paycheck from Premise. They get their benefits from Everside. They're not going out on their own. If you want to go out on your own, I would talk to those first four guests that can help you launch. But if you want to go, and it's not more stable, it's just different. But most of them will still give you a panel. You'll have your members that are coming to you, physically, because they're spread out all over the country. So, if you Google onsite or near site clinics, a lot of these companies will pop up. And they're either in the headquarters or near major employment manufacturing, or they're nearby. They're in the neighborhoods where the people live.
John: It's a little overwhelming, although it's been kind of bubbling in the background for a long time, it sounds like. And you have mentioned on the podcast that they've been very successful. Like you said, the dollars look good. The physicians are happy. The patients remain with the physicians, the old model of the primary care doing most of the initial management and being that, not just really a gatekeeper, but really that one-on-one physician and managing things. It seems to be almost Nirvana. So, what have we missed now? Are there some other types of companies that are doing this, that we haven't discussed so far?
Ron Barhop: Well, it's an ecosystem. Again, if you're helping an employer, they need access to wholesale pharmacy. A lot of them are contracting either direct with a pharmacy, sometimes the gross is in that town, and they're negotiating rock bottom prices, or there are wholesale mail order firms. I had ScriptCo on the show, their average fill is 4 cents per pill. You don't need a PBM if you got 4 cents per pill. So, they're in 47 states now. I just had Zach Zeller back on the show. You'll see him pop up in last week's episode. And it's not just pharmacy. It's got to be, how do you contract with surgery, labor and delivery being the biggest one?
Well, the Surgery Center of Oklahoma was the OG, the original gangster that started back in 1993. And there's now 60 independent free market surgery centers that are owned by surgeons and doctors that are in pretty much every state. So, if you're willing to travel just a little bit, surgery is 60% to 80% less. And then there's 1,700 independent imaging centers with green imaging. Kristen Dickerson was on one of our shows. And those imaging centers are, again, 20% to 40% of the cost of imaging centers owned by the bigs that had these facility fees and these outrageous prices built into a simple X-ray or MRI or ultrasound. And furthermore, it's not just pharmacy, it's not just surgery, but you've got to access sometimes a hospital. You got to do a deal, sometimes you just got to go there. As much as we don't want them to, and they don't need to, hospitals are going to be contracted within those cities as well, independently through the third-party administrator.
Now you mentioned stop-loss. On a contractor basis with jumbos, they have stop-loss built into these plans by the plan designer, the benefit designer. But if you're independent and you're going to find these docs on your own, in your own town, in your neighborhood, you will buy a company called Sedera Health or Zion Health. And they have these, I guess, they're sort of like stop-loss, but they are low deduct. They can't call them insurance because they're religious plans, but they are allowing people to take care of that scary cancer car accident or cardio incident that could bankrupt them. And those companies pick that up.
And then there's another company that just came into the market from Austin that's called Crowd Health. And I had Andy Schoonover on my show. It's kind of the same idea, but it's just crowdsourced funding of your large healthcare expenses.
I've had it for four years. I had Sedera for four years. I had Redirect Health handle my primary care. Anywhere I want to go, I would show QR code and I would get out no cash. I'd just pay them a monthly fee to access. And it's not their doctors. It's any doctor I want to use. Any labs free, any physical medicine free as part of my monthly. But now Redirect Health is now offering a stop-loss, if you will, with $2,000 deductible in any hospital spend. So, they haven't built into their model too. So now I'm using them fully, not some of these other religious.
John: This is something that I think my listeners would like to dig into a lot more because it's an option if they're really feeling frustrated and burned out. You have a book called "Healthcare is Fixed." Is that out? Is that available for pre-order? Because it goes into these details from what I know. I've not seen the book. So, tell us about that.
Ron Barhop: I wrote it in 2019. I recorded it right after that and I've been sitting on it. And John, I don't know why. I don't know what I'm afraid of. I hope to pick with Healthcare is Fixed and you can go to healthcareisfixed.com, but I hope to go pick a company every year and identify what I think are the best. So, I'm going to write another book about hopefully the new ecosystem in Alaska, which is doing amazing things at half the price in primary care for the Alaskan native population.
I hope to write a book about RosenCare, but I think Mr. Rosen and his daughter or granddaughter are going to write a book. But RosenCare again, for less than half the cost, is delivering healthcare so much so that they have no debt on 6,000 room hotel resorts around our Orlando convention center. And they're funding a school district that used to be crime ridden and drug ridden. Now they're paying for all the college for any student that graduates high school. Community college, vocational school, full boat, PhD level college. Medical school, whatever they want to go to. And some of the doctors that started out as students there 20 years ago are now serving their population of their employees.
John: Nice.
Ron Barhop: There's amazing companies out there doing incredible things that are literally eliminating crime in neighborhoods. There are no gangs in this school district and they just adopted a bigger one. The best way to measure is who wins in this model? And if the employers are winning, because they now have a ROI of one on one or two on one or three on one. And if the consumer, we don't call them patients in this world, we call them members. But if the consumer's winning, if the doctors and nurses are winning, they have low turnover rates. If the shareholders of those companies are all winning, if the communities are winning, like the Orlando community has gotten rid of crime and these giant school districts, if costs are dropping 20% to 60%, and if outcomes are rising measurably, we don't have a triple aim problem or quadruple aim problem anymore. We have an octupole aim and then we're accomplishing them all eight. Those are passe to talk about quadruple aim. You can have three out of four, but not all four. No, that doesn't work anymore. We have direct contracting with a large ecosystem with primary care as the foundation, John, is the answer.
John: Well, I could get behind that 100% for sure. For my listeners. This is going to be overwhelming. So, you want to go to primarycarecareers.com because you can find out about the podcast and start listing the episodes. And then you can go to healthcareisfixed.com where actually there's a lot of information that you've described. And that book when it's available is going to be there for us. So, we'll look for that. Any other big points, as we want to get to before I start to wrap up our interview here? Did we hit the high points?
Ron Barhop: Yeah. The system is clearly broken. We don't need to talk about that. You do a lot of that on your show. But there are happy doctors out there that have opted out. And this is the most important point that there is a downside. You have to opt out of anything federal. You can't no longer take Medicare, Medicaid. You can't take TRICARE defense health. So, you can't go moonlight at the VA on the weekends and you can't be a medical director if you will, for a company that takes Medicare Medicaid. So, you have to step out and that's again, a glitch in the law that allows the bigs to sort of lord over this model. But once you opt out, it doesn't mean you can't opt in again, but you just no longer are participating in things.
And if you think about it, it is kind of logical. CMS does not want to write a check to Dr X and then write her another check. So, you get another check from her employer at Eversite or Premise or Medici. It makes sense a little bit, but the opt out is there's no reason folks shouldn't be able to consult on the weekends and help out other folks that are in need with this giant shortage that's looming.
John: Maybe at some point they'll figure out how to make that work. So, what's the best way for listeners to find you? Just one of those two that I mentioned?
Ron Barhop: Yeah. You and I found each other on LinkedIn and I'm easy to get to and I am happy to respond and talk to anybody and send them in the right direction. But if they listen to these 12 or 15 shows, they'll get to meet the CEOs that are making the changes. They'll get to talk to or hear the metrics of what drives these models. And they'll start hearing the same thing over and over again, which is, this is really healthcare fixed. This is really primary care cured. And that's why I named the show "Primary Care Cures." And that's why I named the book "Healthcare is Fixed."
John: If we can just get that to be adopted across the board, it'll be in great shape.
Ron Barhop: It's going to grow no matter what happens, it's an unstoppable movement.
John: All right. Now is the time to jump on the bandwagon. This has been very interesting, Ron. I really appreciate you coming and explaining this to us and describing this. This has been really an eyeopener. Even though I promote a lot of the nonclinical careers for people that are burned out, I would definitely encourage you if you want to continue to practice, you definitely have to look at these direct payment models and DPC and some of these companies that are supporting this. It's fantastic. All right, with that, I guess it's time to say goodbye. Thanks Ron. Bye.
Ron Barhop: Thanks John for inviting me. I appreciate it.
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