How to Be Happy and Appreciated: Thrive with Direct Primary Care – Part 2

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Transcription PNC Podcast Episode 407

How to Be Happy and Appreciated: Thrive with Direct Primary Care

Part 2 with Dr. Josh Umbehr

John: You have not been sort of sitting on your laurels and just resting on your laurels, is it? And so you had this great practice. You got a lot of people around you. And so I think you felt, well, you could even contribute more. So you created some new things. So I want to hear about that because I think our listeners, if they're interested in this, are going to want to hear about it.

Dr. Josh Umbehr: Yeah, I think my wife would agree with this sentiment. I heard a quote, success is mental illness weaponized. And so my mental illness is I probably can't shut my brain off. I'm a little eager beaver. I was thinking, thinking, thinking. And so that made it easier, fun to take each project and keep running with it.

So once you had the clinic model, well, if you have kids, there's a whole series of books. Like if you give a moose a muffin, or if you give a mouse, a pig a pancake or something, and they're going to want another and another and another thing. And so you start the practice and then you figure out wholesale meds and labs.

Then once you do that, you realize, well, now we have nine different software systems running. We better fix that because we can't show other doctors how to be successful with their wives or their husbands doing QuickBooks in the basement for hours and hours every month. Well, then we found a local software developer, Joe and Intermotion.

And then they helped us out by being great at what they do, but they had never done healthcare software before. And I was like, great, because I've never found healthcare software I like. So you don't have any bad patterns and then just keep fixing problems.

And to this day, we have more irons in the fire than fire. It feels like if you tried to stop running downhill, you'd fall over, but we're very excited to have probably the number one EMR program for direct care, Atlas MD. And we do all of our consulting for free for anyone in the movement because number one is growing the movement, rising tides, raise all ships.

But eventually then the next biggest problem that doctors or patients ourselves saw was we had some options to make custom insurance around direct care clinics in some states and for some employers, but we needed something more extensive overall. So March or December 3rd of 2024, we launched a health insurance product just for direct care and their patients. And let's fix that or let's fix it is our tagline because that implies community, that implies that there's a lot more work to be done, but we do it together.

John: That's interesting, because you've sort of opted out of insurance and yet you're saying, well, but we need a special kind of insurance. Now I've heard of crowdfunding and things like that, which I assume is not what you're talking about, but maybe it is as a way to put money aside proactively so that when you need it, it'll be there if you have to opt out of the DPC or see a surgeon or something. So explain more about the health insurance.

Dr. Josh Umbehr: I'm on this big kick now. I think once you start seeing this, you'll see this everywhere, but the parent company for the insurance is called NHI, not health insurance. And so, Elon had not a flamethrower and there's all these versions of this, not first class or not, but something else or something better.

Because we definitely wanted to do a different type of health insurance because we had to, you're remembered for the rules you break. Every ACA enabled plan does the exact same thing in the same broken way. And then Einstein's quote of insanity is doing the same thing and expecting a different result.

The solution to the broken health insurance program is less insurance. And there's so few times where people acknowledge the solution is less of something, not more of something. We keep trying to add more red tape to a broken bureaucracy and we're surprised that it grows. Again, if you say that direct care can make 80 to 90% of healthcare too cheap to insure, what's left? Actuarily, not a whole lot. Car wrecks, cancers, heart attacks, ER visits, things like that.

We worked with the best people we could find in insurance fields to say, help us thread this impossible needle. This Gordian knot. And you kind of have to become the villain, I think, in your own story because the insurance free guys are now insurance licensed agents in 18, 19 States.

You got to have your foot in both worlds. But so it's a fixed indemnity product where it is not a ACA plan, proudly, because then we don't have to play by the same rules and we can carve out everything that direct care does well and try to cover the rest. I will say like any good agent, asterisks, it's not the right insurance for everybody, but the kind of nervousness.

Nirvana fallacy is that if you don't fix everything, you don't fix anything. And people will often tell me, well, in family medicine, but you don't treat cancer. The hell I don't. I cure skin cancer quite frequently with biopsies or 5FU or different things and all of that skin cancer. Oh, well, it's still I had a patient with a glioblastoma, her chemo was going to be 26,000 a month that we could get for 1200 a month. Not because I knew anything other than how to type in the wholesaler's page and be like, well, what medicine are you on? Well, it says here it's 1200. Every doctor should do that. It's not a skill. It's an option. It's a commitment to do the best thing for the patient. You start carving all those big things out.

The rest is very simple. And a fixed indemnity product gives the money back to the patient. So now you don't have a copay, a deductible, or a network.

The money goes to the patient. If they're in a model like this, they qualify for uninsured or self-insured discounts at our local HCA hospital, uninsured or self-insured patients on the HCA website are eligible for a 92% discount. It's ridiculous. We're insuring the wrong number. And that's not because doctors are bad or insurance companies are bad specifically. It's because of a bad system.

I'll say it again systems and when they fail is we should understand this more. The Affordable Care Act for all it's good and bad created a system where insurance companies were punished if they decreased the cost of care because the 85% corridors and these things that even if they were innovative, they would still get punished. So they're legally anti-incentivized or anti-allowed, but the pie only gets bigger.

So you had to come out with a different insurance company or model that says, all right, the national average for a cash rate for hospitalization, I think is around 2,800, if I recall, depends on your search terms. We reimbursed the patient $3,700 per day. But at a 60 to 90% discount, depending on the website, it's structured so that some people will make money on this.

And we've seen that example play out throughout time. Recently, we just launched the insurance. So we don't have a lot of actual examples, but we have lots of patient examples who went to the hospital. What was their bill? How did we get it down by 90%? So what would that look like in the insurance reimbursement?

To the point that Atlas EMR has recently partnered with a company called Goodbill. And so that every clinic using Atlas EMR gets free help with hospital bills for their patients. So now they have free help getting information about where they qualify for discounts, their local hospitals based on non-for-profit status.

But then they'll also help negotiate a hospital bill down afterwards and just take a fee of the savings. So, it's a win-win for everybody. It's become so ridiculous in a broken model that the solution seems hard to believe.

The problem seems hard to believe to me. But this fixed indemnity product, again, may not cover everything, but either does Medicare. One of the fun facts you learn along the way of getting insurance licensed is Medicare has a deductible. That's exactly what they call it. They don't pay for the first three pints of blood you get in the hospital. Those are on you.

John: After that, anything goes.

Dr. Josh Umbehr: After that, hey, Uncle Sam's got it. But they don't do dental or they don't do vision or they don't do a lot of stuff and no insurance pays for everything. So we do hope the model will crawl, walk, run as it picks up momentum.

But direct specialty care is popular. Cash surgery centers are amazing. All these sort of things that now less insurance is the obvious answer. It's better for patients. It's better for physicians. It's better for employers.

It's really even better for the insurance companies. I hope one of those big companies comes in and out-competes us on this model. I don't think they'll be able to because we're just so amazingly cheap.

The national average for a family of four under 45 is $2,500 a month for an employer. Our prices are under $500 a month for a family of four. So that's an 80% savings right there even before you get to no deductible, no copay, and you might get money back.

There's a lot of room in this insurance, and you might not, but somebody has to come along and innovate. The two biggest pieces of the puzzle that we've been asked for 15 years is how do I get health care and how do I get health insurance? Normally, they feel like they're very separate, but if done well, one complements the other.

Then your insurance underwriting is so much easier because if you have hypertension in a traditional insurance model, you're high risk because they've got to pay for every doctor's visit and meds and labs. But when your amlodipine is 0.8 cents and your metabolic panel is $2.50, well, you just don't insure that. Now, what was expensive is no longer expensive.

There's a great analogy I like to this from history, two actually, whether they're true or questionable, but Napoleon's egg, I'm sorry, Napoleon's aluminum and Christopher Columbus's egg. Are you familiar?

John: I don't remember hearing about those.

Dr. Josh Umbehr: No. Christopher Columbus's egg, long story short, he discovered the new world, comes back, and they say, well, you're not special. We already kind of thought the world was round.

And so he takes the egg, asks all the king's horses and all the king's men to make the egg stand up. And of course, they all try and they all agree, we can't make an egg stand up. It's designed to wobble.

He takes the egg, crunches the bottom, egg stands up. It's like, I didn't say you couldn't do anything to the egg, but that's how we think of problem solving. Then Napoleon's aluminum, it was so rare that if he wanted to impress dignitaries, his generals ate off silver, he ate off gold and they ate off aluminum.

And then introduced electrolysis. And now we have tinfoil that's so affordable, we throw it away. Capitalism brings the comforts of kings to commoners. It's insane. Not that we want healthcare to be throwawayable, because it's still always valuable, but there's no reason to ensure the most affordable version of healthcare. And family medicine can cover such a broad version of that.

That's the part that's hardest for doctors to wrap their head around. I think often patients get it easier than doctors do, because doctors hear HIPAA and Medicare and MACRA, MIPS and reporting and all this other stuff. And all patients hear is, and I think Jeff Bezos or Peter Thiel, what won't change in the future.

People, what won't change is people will always want it better, faster, cheaper, easier. If you do that to healthcare, you do that to movies, you get Netflix. You do that to hotels, you get Airbnb.

You do that to phones, you get Apple. If you do that to healthcare, you get direct care. So it's an exciting time. Hopefully it feels obvious after the fact, but right now still a lot of work to convince people.

John: Yeah. It's such a different way of looking at things that some people just cannot even imagine it unless they really sit down and study it to some extent. Well, if I have colleagues and listeners, this podcast who are basically they kind of hate what they're doing because of the way the system, and they know there's the system's broken, there must be another, what advice you have for them, how to get started or how to even understand that there is a better way?

Dr. Josh Umbehr: Yeah. First and foremost, everyone's welcome to reach out to me. My email is drjosh@atlas.md or hello@atlas.md. We have live chat on our website. For the doctors, we have all of our consulting is free, just that way anybody can come and ask and learn whatever they want to learn.

For patients, we have atlas.md/map, which is growing daily so they can look for direct care practices around them. But any direct care doctor would probably be more than happy to have local physicians reach out to them. Again, I think it's the happiest group of doctors you'll find is they are so free of that burnout.

Not that medicine isn't stressful. It's still a very empathetic career. But they understand that they're in a spot that they'd never get the luxury of if they were doing regular. I don't see 30 patients a week. Most doctors are seeing 30 a day. Now, I always like to add on the criticism to that is that direct care makes the doctor shortage worse, which I would say that's a fallacy.

Well, too bad is true because that's the ship blaming the iceberg on some level or vice versa, I guess, is that the current system is sinking on its own. It doesn't need to blame us to speed up that is sort of silly. But the inefficient, we don't have a physician shortage, we have an efficiency problem.

There's a great Dr. Antonio on Twitter does research on this and had a great example. It was 63 clicks for a resident to order an MRI in Epic. We have a clicking problem. AFP did a study on this years ago, the most conservative version of this was that just 22% of a doctor's time was wasted on paperwork.

John: Exactly.

Dr. Josh Umbehr: But 22% times the physician workforce would be 165,000 full time equivalents back. And the AMA is about the same noisy stat that we're going to have in like an 80 to 150,000 doctor shortage in 10 years. It's always a wide number.

And it's always in 10 years. If you're that far off, you don't know what the number is, right. But we have roughly 500,000 primary care doctors, 600 patients each, that's 300 million people, we have no problem covering all the patients, we have an efficiency issue where docs are spending in a broken system, they're not doing what they're supposed to do, they're doing what the system wants them to do.

They're doing paperwork for an insurance payment model when they should be working directly for the patient, then I guess I see on average, three or four patients in the office a day, I can double that if I need to, if that means solving the patient access problem. But just more doctors doing this and avoiding suicide and burnout and early retirement and administrative. That's the funny thing.

We do a lot of debates at med schools. Professors love to hate on us for choosing our own lifestyle here and taking care of fewer patients. But they applaud any doctor that leaves clinical medicine for administration. At least I'm still taking care of patients. That's the funny thing is so they have this weird do as I say not as I do mentality when it comes to healthcare.

John: You just mentioned the AMA, I think. Now, I think the family medicine organizations have endorsed DPC, correct? AFPA, ABMF, or whatever, family medicine. What about the AMA? Do they have an opinion?

Dr. Josh Umbehr: I don't recall the AMA. The American Academy of Family Physicians has done a great job because they sponsor one of the conferences every year. The Board of Internal Medicine has had a love-hate relationship with them. Dr. Lee Gross had a very productive presentation at one of their conferences just last month or two. They're coming around. I think that's in part because their internal medicine is so much more specialty based.

So my joke is that the specialists are 10 years behind the family docs on frustration. When I was in training, they had an easy life and great reimbursements and never had to do Pryor-Ross. It was just sunshine and rainbows. And I love this cardiologist, but I remember vividly as a third year resident, we were in with him and a patient asked about diabetes and he put his hand on their knee and said, oh, ask your family doc. Is that what you guys do in here is just put everything back to us? No wonder you can see so many patients, but it's caught up with them.

And that's why more specialists are doing a direct care model as well because the current model is just unsustainable. It's a cold war that I still blame doctors on. There's a great book, Sunsetting Laws. I'd have to check the title, but they interview forever ago, the founders, the writers, the architects of Medicare.

And those architects went out into the medical field a year or two later to see how it was working. And they were shocked at how different doctors were practicing medicine. Before they just did things because it was supposed to be done and there was no box to check.

Once you gave them boxes to check, they became very good at maximizing revenue because you told them, here are the rules to the game, check these boxes. Which is a systems problem. It's a gamifiable issue. So when you remove that, guess what? Doctors still do the right thing. They just don't have to worry about checking the boxes.

John: The general internists too are adopting DPC pretty aggressively, are they, or not as much as family docs?

Dr. Josh Umbehr: Yes. As they get burnt out and they see more and more successful examples of this working, the Delta between DPC is getting better all the time and the current model is getting worse. So the friction to change is less. Now I'm guilty of saying that for the past 15 years, but at some point the dam breaks and no one wants to be the last man out of Vietnam.

John: All right. Well, we've gone, I don't know that we've gone over, but we've gone taken enough of your time, Josh. So I really appreciate it. Yeah, this has been eye opening and I think it's exciting. And like I said at the beginning, you're one of the pioneers. I guess a great resource too, if someone's interested to contact you. I'll put those links in and with that, I'll say goodbye. Any last words of wisdom before I let you go?

Dr. Josh Umbehr: No, thanks for having us on. We'd love chatting with anybody. And again, open invitation to anybody that wants to learn more patients, employers, insurance, doctors. We'll talk to everybody. This is our favorite topic.

John: Awesome. All right. Take care.

Dr. Josh Umbehr: Thanks.

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