Reducing Insurance Claims, Enhancing Patient Trust: Dr. Joseph Rotella

In this episode of "My DPC Story," host Dr. Maryal Concepcion interviews Dr. Joseph Rotella, who shifted his integrative-focused healthcare practice to a Direct Primary Care (DPC) model. Dr. Rotella highlights the transition from an insurance-based system to DPC to enhance patient-centered care. Dr. Rotella is a family medicine physician who earned his doctor of chiropractic medicine prior to medical school. He discusses the benefits of DPC, including improved accessibility, better patient relationships, and reduced administrative burdens. He recounts his challenges with the fee-for-service model, such as increased paperwork and the idea of "lower profitability" in the eyes of the insurance-driven world despite efficiency gains. Dr. Rotella’s multidisciplinary approach focuses on disease prevention, chronic disease management, and treatment of common ailments. Additionally, he offers services tailored to community needs and stresses the importance of consistent patient communication during the transition to DPC. The episode emphasizes the value of personalized care and the role of patient advocacy in DPC. 

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Transcript

Maryal Concepcion, MD: 1:02

Primary care is an innovative alternative path to insurance driven health care. Typically, a patient pays their doctor a low monthly membership and, in return, builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the My DPC Story podcast, where each week, You will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the Direct Primary Care model. I'm your host, Marielle Conception, family physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care, Direct Primary Care.

Dr. Joseph Rotella: 1:50

Direct Primary Care is being a personal physician to patients, a friend with a specialized knowledge. I am Dr. Joseph Rotella, and this is my DPC story.

Maryal Concepcion: 2:04

Dr. Joseph Rotella is dedicated to addressing the fundamental building blocks of health care, including disease prevention, chronic disease management, service delivery, workforce development, and leadership. With a passion for inspiring and motivating individuals toward a healthy lifestyle, Dr. Rotella believes in making a positive impact one person at a time. With extensive experience in health care, Dr. Rotella specializes in family medicine, I'm going to be talking about the the the the the the the the the the the the the the the the the the the the the the Recognized for integrity, problem solving abilities, work ethic, and analytical skills, has earned a reputation as a trusted professional in his healthcare community. He opened Direct Healthcare in the fall of 2021. Thank you so much, everybody, for tuning in. Find out more about DPC, including resources, discounts, my favorite tech tools, and more at mydpcstory. com. Follow us on your social media platforms at MyDPCStory and be sure to subscribe to our newsletter and of course the podcast feed so you won't miss when the next episode drops. With that, I am so excited to welcome another fellow Blue Jay. Welcome to the podcast, Dr. Rotella.

Dr. Joseph Rotella: 3:37

so much. Thank you for having me.

Maryal Concepcion: 3:38

So I absolutely geek out when anyone from Nebraska or anyone who went to Creighton is on the podcast. So I'm super excited that Another person who understands where Creighton was situated, and you don't have to be religious to understand this, the idea of mind, body, spirit was very big at Creighton. And I remember I talked to Dr. Andy Burkowski about this, who had gone through a history of Jesuit schools, but for me, not being Jesuit, just getting into medical school there. I was really inspired. during my entire journey in healthcare to take care of the whole person. And I really love that in your clinic, you've found a way to do that exactly. And you've done that under the DPC model after having experience in other models of healthcare. So I wanted to start with You have a history where you're not only an MD, but you have your doctor of chiropractic medicine. So tell us about your journey getting into your DC first.

Dr. Joseph Rotella: 4:30

Well, thank you for having me. it's not really a long story, but kind of goes like this. when I was at Creighton University, they make you take a lot of theology classes. So I had a minor in theology and philosophy and my major was chemistry. And I also worked at my family's bakery full time. Well, I shouldn't say full time, but on vacations, full time, part time. And then I also got on the soccer team to play division one soccer. My grades weren't, I wouldn't say stellar, but they were, I was persistently a good student, but it wasn't the best of students. My brother visited chiropractor and I always wanted to be a doctor ever since I was a little kid. So that was like, there's, there was no, question about that. I just, I knew I wanted to help people. And I remember going into a family physician's office and there was young persons and old persons. And I was like, I can just treat everybody. And it's kind of like this stuck with me as a little kid just to help be able to help everybody. So when I was getting to graduate and applying to medical school, my advisor told me that I didn't have good enough grades. So I was a little disappointed. And I decided to go to chiropractor school. So I went from Creighton University just down south to Kansas City, which I've loved the Kansas City Chiefs ever since then. I did miss a home game while I was there the whole entire time. We scrounged tickets every single game and back in the 90s and loved every minute of it. Today I'm a fan, even though I'm not on the bandwagon. I've been a true fan since the early 90s. And during chiropractic school, I got straight A's pretty much. And then when I was going to graduate chiropractic school, I realized there was a school in the Caribbean And I never really seen the ocean, believe it or not, because my dad worked in a factory and I worked with him and, played soccer as well as studied. So when I found out I was in the Caribbean, I immediately applied to medical school right after chiropractor school, hopped on a plane and begin my medical school and in St. Martin, American University of the Caribbean. A little to find out, you only do two years there and most of the teachers are, retired American teachers from America, obviously. And then when we came back here and I rotated through the United States in the last two years and took my boards and got a family practice residency at Scottsdale Healthcare. And that's where I, did residency at Scottsdale Healthcare. When I was there as I'm graduating after three years, they voted me the, to be the most successful entrepreneur. So when I was there, they gave me a stipend before back in 2005, well, 2002, three, four and five, they used to give stipends to open up practices rather than buy out a practice like they do today. So they gave me a stipend. To open up a practice being likely to be the most successful entrepreneur. So I started from scratch my own family practice in 2008 with zero patients. And I grew that clinic to four providers and a total of over, over 20, 25, 000 patients, something like that.

Maryal Concepcion: 7:10

It's just incredible. And I want to go back to this idea that you were given this entrepreneur honor, but also that, you know, how you went into using that funding, because, DPC movement are MDs, DOs without an MBA. And I'm wondering, was it. Anything in particular that you were recognized for to get that entrepreneurial award? Or was it because of what you were intending to do after because you had seen like how businesses run in your family's bakery and definitely how businesses run in the chiropractic world?

Dr. Joseph Rotella: 7:44

It's interesting. They call me Dr. Efficiency. everything that I used to tell the residency director that this wasn't very efficient. This wasn't efficient. This wasn't efficient. So I tried to do as much as I possibly could do to some policy changes to make it more efficient. and the most important thing in medicine is taking care of a patient, is to treat somebody, and I always said, like, family medicine is not treating age groups between young and old. Family medicine is treating somebody like you're a family member. So, we want to treat people like family members, treat them as our friends, and put them as a patient centric approach. And that was very difficult to do, even in residency, sometimes with all the rules, regulations, policies. and their, some of their procedural things that we have to do. so I found that very difficult, but I swore that when I get out, I was going to, when I did open up an integrative practice to put patients first, but little did I know that's very difficult to do and in the insurance world, because the insurance world, we all know there's host of issues that you have to jump through in order to put the patient first. Right. Right.

Maryal Concepcion: 9:20

So true and pretty much everyone who's listening to this podcast is probably nodding their head When it comes to how you use the funding were you given? Here's money and you have to achieve certain things Here's money and you have to prove or track your data in order to you know Earn this money so to speak like if somebody got a grant or Did you get the money and you were able to use it carte blanche? You

Dr. Joseph Rotella: 9:45

Well, the first thing that I did was set up a line of credit. So because they didn't give you money, they just reimbursed you. So there's a difference. So they didn't give me money, but I, had a spreadsheet. Basically. And then I had to figure out what needed to utilize my line of credit for it in order to start my practice. And then I would send every, all my payments and my payment stubs to Scottsdale healthcare. And then they would analyze it and figure out what their agreed according to their lengthy contract, what they would pay for. sometimes they didn't pay for some things that I wanted, like a decorative brick wall in my waiting room. They said no. Yeah. Okay. But other things, most of the things that it takes to run an office, they did. And then they give you, make sure you have a little bit of a salary for three years, and then, as long as you accept their insurance programs, I had to accept every insurance program for a certain period of time, I think it was 10 years or something, probably 10 years, then you can opt out. so the money was basically spent back then on the most inefficient things that I realized now, computer system, servers, staff, which is, you know, health benefits for your staff you know, a little bit of marketing and, equipment, stuff like that. I learned so many lessons. I mean, I almost wanted to write a book on just the lessons that I learned in the first 90 days of opening a practice from scratch in 2000 and, and eight when the market collapsed. Right. Switching to Obamacare. With the market, collapsing and then also the time where the opioid, crisis was, booming and you couldn't give out opioids and everybody was seeking opioids, but you couldn't give them and then you had to wean everybody off. And it was, it was kind of a chaotic mess at that time, but I mean, I persisted with the market crashing and all those, issues. And I realized that being efficient in medicine. Is being less profitable

Maryal Concepcion: 11:25

when you say that, can you give us an example of how in your clinic you've seen that demonstrated?

Dr. Joseph Rotella: 11:30

Oh, absolutely. When I was a medical doctor and a chiropractor, I had a chiropractic table with a room. I had my medical room with all, and I love sports medicine and and, and injections. So like right now I do, I'll just, I've got an injections for all my patients. I love, you know, I even got certified in Botox for migraines and And I just, I always loved doing injections, but back then the medical industry, as well as the medical legal industry with these attorneys, they said, mate, they said, Joey. You're a chiropractor and a medical doctor. You'd be great for MBA cases. And a lot of these pain management doctors, they would say, they would refer me to patients their MBAs. Attorneys would refer MBAs. So when I saw a patient in my office, I'd usually give them a chiropractic adjustment, evaluation, of course, you know, x rays, imaging as needed. You can give them a chiropractic adjustment. I would get out that a couple of trigger points on the sore spots and give them maybe just a little bit of muscle relaxer before they go to bed. Maybe some anti inflammatories. I gave him a chiropractic adjustment. I had some therapy. I gave him on a handout do home exercises and stretches. And, in the following weeks, my schedule was kind of bare. So we used to call these people up and I used to ask them, I said, are you guys coming back for follow up? And they're like, well, you gave me the home exercises. That trigger point really, really good. The muscle relax is working really good, and they don't need to come back. They don't need to follow up as much. And I said, Oh, okay. That sounds good. Then the attorneys called me up and they said, your claims are so low. Usually we can only file them in the thousands of dollars. But think, you know, I thought that you would do multiple visits for multiple trigger points or multiple manipulations or multiple visits. And I'm like, they got better in just a few. And so they, diverted away from me. And then I realized best doctors, the most efficient doctors to get the patients better had the least amount of visits. that would equate into less profitability.

Maryal Concepcion: 13:12

I just think about how residency is so, it's scheduled by other people. We show up, we have a certain amount of things that we need to do in whatever rotation we're on. Did you get the sense that, racket that we call fee for service was going on to this extent where you realize later on that really, if you're going to be more efficient, you're going to be less profitable.

Dr. Joseph Rotella: 13:35

No, I didn't. think about that. I mean, I felt like now kind of relate to like my teenage daughter, you know, and she does some things that are kind of dumb and I'm like, Oh dear Lord, you don't understand the big picture. And I really did not understand the big picture. Especially being, you know, it's the big picture for, let's say procedure based specialties. It's a lot different than somebody who uses their medical knowledge. And in looking at somebody's lifestyle, there's an acronym that I always do for all my patients, I call it pencil, it's one of my, things that nobody really knows about. So I'm telling you, and you can share it because this is going to be live, but on most patients, I look at prevention for all aspects of their health, as well as their, their specific condition. For example, if an old man comes into my office and says he has low back pain and his wallet is empty. You know, three, three inches thick with credit cards and bills. I tell them to take out the wall and then the back pain goes away. But prevention, exercise, nutrition, counseling, motivational counseling, and setting up challenges, integrative medicine and lifestyle management. That's my pencil. So that's how I promote lifestyle medicine to my patients, as well as promote, trying to figure out what is the root cause of their particular disease. So I look at prevention, exercise, nutrition, motivational counseling, integrative medicine, and lifestyle management, which basically includes sleep and stress.

Maryal Concepcion: 14:52

And hard to cover those in a 15 minute or less visit. So my next question to you is how did you take this realization that efficiency is not going to equal more profitability and in fact could be less profitability as a result and then go into your journey to Direct Primary Care?

Dr. Joseph Rotella: 15:12

Well, the efficiency was geared towards, okay, I'll put it to you this way. There's a couple of sticklers that I have. One stickler is, primary care, just the word primary care. I like the word personal physician because primary care is more of a, which we need. There's no doubt about it because the other people understand that the community understands that but it translated into being a very efficient administrator. So as you know, and I know every single time I loved headaches. So I've been to the American Headache Society meetings like year after year. I've been to, pain management society meetings because like I want to learn about different types of injections and pain management. But every time that I go to a family practice one, it's about. CPT. It's about coding. It's about all these things, but not knowing on how to improve the life of our patient. So primary care basically turned into a big efficiency administrative asking pool of data collecting rather than putting a patient centric approach. so I'm fast forwarding a little bit, but have to say that one vision, I think, Every Direct Primary Care physician should grasp around. is reducing unnecessary insurance claims. The reason I say that is because we all need some level of insurance. We all do. I think that it's, I'm not saying about universal coverage. I mean, it can be a catastrophic insurance. You can have, even if you got bad insurance, at least you got insurance, you know, but thing is, like, does DPC replace insurance? No, but you need a friend outside the system. And a friend or a personal physician to reduce unnecessary claims, the cost of unnecessary claims, according to a few books that I read, 110 billion unnecessary care in the book. I said unnecessary care, but I say unnecessary claims. For example, we know big health systems who see a patient as primary care. They do, they're accountable they do their risk management, the RAF scores, all these things. They document, document, and document, and they don't have any time, so they refer out to neurology, they refer out to ortho, they refer out to derm, they refer out to OB. And what that basically means is claims, claims, claims, claims, claims. So Direct Primary Care is trying to reduce unnecessary claims, and I think that's a big step that we can wrap around to solve health care.

Maryal Concepcion: 17:17

It is beyond true, and I think that once you start thinking about DPC, even if one is not yet a DPC physician, I think that when you start thinking about it, Thinking about things under the DPC way to do things, you really, that, that truth really becomes so apparent. It's unbelievable.

Dr. Joseph Rotella: 17:35

One, so if you look at the first, idea in my particular vision, or the mission for my direct health care practices is increasing value for each particular patient in health care. So value and quality care that has access. and access means like they can call me or text me, as we all know, indeed, this DBC world. So increasing the value by having access to high quality care. And number two is reducing insurance claims. Now, if your goal is to reduce insurance claims. That means that you as a personal physician need to learn more, do more, be more for that particular patient. So we need to do specialized what I call AOIs, specialized areas of interest. Because in my group, I love migraines, you know, I've been doing migraines since 2008, well, a little bit earlier, but they'll refer me a migraine patient, or they do refer me a joint injection, you know, a lot of for my well woman, I refer them to somebody else, somebody in my office loves skin biopsies, we refer them, it doesn't cost patients anymore, so we can do family physicians who are personal physicians and have special areas of interest, is really important. So it's kind of like a match. Like a patient needs to know a family physician by what they do or what they have a specialized knowledge in because that's what makes us unique and that's what makes every DPC practice unique.

Maryal Concepcion: 18:46

And I think it really adds to this level of transparency and autonomy that we bring to the table because when we are, like you said, apart from the insurance driven world, we're able to look at things differently, look at claims differently, look at unnecessary care differently, I think that really feeds into the word of mouth and the trust that our patients have in us because we help them be advocates for their own healthcare journey.

Dr. Joseph Rotella: 19:07

Oh yeah. And you know, I love the lecture. I think, I don't know if you saw the lecture that was at the Hint Conference. last summer, but that word advocacy means so much that people don't really understand what true advocacy really means. mean, true advocacy means telling a patient, I don't know the answer, but I'm going to go home and research it. I'm going to call specialists up. I'm going to figure out a plan. You know, later tonight, and I'm gonna get a hold of you tomorrow. That's being a huge advocate, calling somebody and just seeing how they're doing following up with them. That's being an advocate, calling their loved ones or caregivers, you know, that we have permission to, of course, to check on the patients. That's being an advocate. Calling their pharmacy up, making sure that, you know, they get their medications on a timely manner. That's being an advocate. There's lots of different ways that a physician can be personal advocate to the patient, not just, being. president that office visit, but outside the office visit, there's a lot of things that we do that to advocate for our own patients behalf.

Maryal Concepcion: 19:58

It's so true. it's so ironic that we're talking about this because literally I was talking to a staff member at one of the local assisted living facilities about a patient that I have who's living there. And the discussion was about, you know, how do we increase water intake? This patient in particular has dementia. And so one of the things that I was talking to the staff member about was, research that I've been doing to try to increase. Hydration and she was like. is this a person who's with you right now, or like you were just reading and literally, you know, this is just what we do to, illustrate your point is because we have the ability to just be doctors. It really frees up how we can be the doctor and advocate for our patient. And so I do have also patients who are like, I haven't talked with you in like two weeks and you just randomly emailed me about this thing that you read about some study on cardiovascular health or whatever. And they're like, Oh my God, they're thinking about us even when we're not there. And it's so funny because, this is what. At least I could never really get into at the level that I would have liked to while in fee for service because it was notes are never done. It was you're an hour and a half behind. It was all of these things. So I don't know if You know, that resonates with you and your patients, but that's definitely what it's ironic again, because I had that conversation. I mean,

Dr. Joseph Rotella: 21:12

I have two stories. I can tell you two quick stories. One story is a patient that doesn't necessarily have dementia, but Parkinson's and he does forget to drink. He has hypotension labs are a little bit off. He's a cardiologist. They try to put him on some medications. Let's just say, and you know, I go along with it. One of, one of my nurse practitioners that works here does IVs. So I just gave him an IV and his blood pressure picked back up, his coloring perk back up. So they come in once a week for an IV and the hypotension is improved. His exercise tolerance is improved because he likes to golf. Maybe that's why he's dehydrated, goes out in Arizona sun and golf all the time. But I can't limit that, you got to do what you got to love to do. The other story is my best friend in Arizona is a nephrologist and we were watching a boxing match one night as a famous boxer from Omaha, Nebraska. And I told him, I said, and I went to commercial break. And I said, you know what? I got a really interesting case. I can't figure this thing out. I said, I worked up as much as I possibly can. His labs are completely abnormal for the most common conditions. And he's like, well, you need to do a CT of his adrenals. And I did. And he's like, well, you need to do this. I go, I did. And then he looked it back up. He's like, hold on a second. And he was Googling a little bit. He's like, this was on my boards. This is little syndrome. He's like, I've never seen this before. So this guy's on four different blood pressure medications, can't control the blood pressure. And we diagnosed him with little syndrome. I called the patient up eight 30 at night and told him he was kind of like, what are you talking about? Right. He had no idea. But anyway, we put them on the new appropriate blood pressure medication, just one been controlled ever since. And his mother passed away from a stroke because of uncontrolled blood pressure. And so it was really interesting how you said, you're right. We think about our patients outside. And then as patient advocacy, to its fullest extent, what you do, what we do what a lot of physicians do outside of DBC, but at the same time, you know, we have the ability to spend a little bit more quality time to try to find the root cause of problems.

Maryal Concepcion: 22:52

So with you realizing that, quality patient care advocacy, being a personal physician matters. When did you decide that you were going to leave your fee for service? way of doing things and transition to Direct Primary Care.

Dr. Joseph Rotella: 23:04

I think when my daughter was a freshman high school, she got into soccer. I was a soccer player. And then during her practices, I remember pulling up my car, getting my laptop out, and then I would log in, and I was doing all my patient notes. And all the parents were outside talking, you know, and watching their kids. And then my daughter was like, did you see me practice? Did you see me? Did you take any pictures? I was like, no, I was doing my notes. And then I'd go back home, finish dinner, and then I would finish my patient notes, and then repeat that process. And I don't have to say that at first I thought that was normal. But then I started to realize that This is not normal workload. And then when I looked at my practice, as I was getting bigger and bigger, the more people that I hired, the more administrative work that I did, the more health benefits that I had to offer. My staff, I was making less money actually growing my practice than did as just having me and a couple other providers. knew that this wasn't normal. Just constantly waking up in the morning, doing charting my lunch during charting soccer practice, my daughter spending, not quality time with my daughter. I just said, this is, this is not normal. And when I went to the meetings from the primary care groups and for like the accountable care organization or the, it was just more and more documentation and the more and more steering away from patient care. And I remember telling myself, I wouldn't mind doing this if I was getting paid. Okay. But I'm getting, I'm not getting reimbursed and I'm doing extra work on top of it. And I'm not spending quality time with my daughter. There has to be another way. And I said, I mean, I love taking care of patients, but you can't live like this. it's not normal. I mean, one of my dad's saying is if you retire, you expire, you know, you really want to find something that you have passion about, that you love about. And I think one of the. things that I, don't really appreciate with the system is that you see a lot of high quality, highly trained, super smart people retire early. And I said, I don't want to retire early. I want to be able to have a career that I love and then has longevity. You know, I want them to kick me out of my practice rather than me retire. I said, there has to be a different way. I had meetings with the, MDV IP. Group met with me a few times, knew the guy and his son plays soccer. I play soccer. My daughter plays soccer. So we talked and I didn't like that aspect of medical legal complications with accepting insurance and cash at the same time. Plus I thought that was a little bit of high fee. So I decided to look at other avenues and that's when I discovered the Direct Primary Care movement. And I researched its history. And then I kind of said to myself, this makes sense. So I went, I bought the books and then I bought a book for every one of my staff members and we all read it. And then one of my providers, she's amazing, Dr. Barker. She's like, this makes sense. And she's a Brown graduate, super smart. and she came along and she didn't want to do concierge, but she agreed to this. And we set up a timeline. Our timeline was right around, I would say we were shooting for six months, but we did nine months. So we did a lot, a lot of preparation. A lot of people, you know, think, Oh, I'm going to go switch my practice. Well, you can, but it does take a deep dive into the amount of patients that you have, how are you going to communicate your message, what your message wants to be, et cetera, et cetera, as you know, and to make that final switch. was difficult. There's no doubt about it. But once we did, then it became streamlined because at first you care about it so passionately about it, but then after a while, it seems like once you get your volume of patients up that you don't need to explain yourself so much. And if you just tell somebody if you want access to high quality health care at a dime, you got it. If you don't, it's not the place for you. And. Most, I would say a lot of my patients that didn't choose to sign up with me, they came back, they did come back. so, you know, there is a, there is a waiting period for them to try out the other models, try out other doctors and see the difference. So I think that's, important, but it's also important to know that it is a process. It's not like something that you can just do overnight. It takes time, especially converting a whole group, right? And so we, we staggered it. So we staggered me transisting first. Dr. Barker transitioned three to four months later, then Dr. Summers transitioned three to four months later, and then Catherine, our nurse practitioner, she was doing a little bit of both, but she also runs a little bit of the wellness on the side. So some of the cash pay services that we do offer outside of the kind of the DPC model that she does.

Maryal Concepcion: 27:17

Got it. And in terms of transitioning, we've heard statistics like five to 10 percent of a person's fee for service practice will follow them. Did you find that to be true between your practice and your other physicians practices and Catherine's practice? Yep. Yep.

Dr. Joseph Rotella: 27:31

Yep. I mean, sometimes statistics don't lie, right? So, you know, they always say, like, if you have a startup company, it takes three years, kind of see some fruition and those statistics were spot on. I mean, the statistics out of the books that I've read were spot on. I think that we had around, let's say 15, 000 letters we mailed out, we got 10%, 1500 patients. So there it was spot on. And then the books also say like, you know, the amount of phone calls you get is like double of what your patient schedule is. So if your schedule has like four patients on it, you get eight phone calls. And so you usually get, you know, 10 15 percent of your patient visits for your volume. But it also depends on. you as a physician as well. So if you want your patients to follow up more, I mean, you can be busier if you want your, if you try to gear your pay, your practice towards like a lot of patient handouts, you just call me and do a lot of check ins this way. Then you'll see a lot less patients during the day. So you can, as you know, you can structure a DPC practice that any which way you want to structure it. I mean, and you can have a type of practice with, your. patients that you like to see anyway. So, and then those patients will refer patients that feel the same way that they feel about their provider and the list goes on.

Maryal Concepcion: 28:35

I 110 percent agree with that. You earlier mentioned how, as part of your residencies reimbursement of your opening a practice part of that was tied to, you had to accept the insurances that were accepting as well. So did you have to Before you opened your private practice, sign independent contracts with these, you know, BUCA insurances? Or did you have an easier time transitioning to DPC because your name was just continued on with the residencies, insurance programs, and you did not have to unenroll in any BUCA plans?

Dr. Joseph Rotella: 29:07

the residency. The reimbursement had really kind of nothing to do with my practice other than just a little bit of a reimbursement. So I had to contract with access, which is our Medicaid. I contract with Medicare. I contract with all the book. We had literally three boxes of health and health insurance plans that we had to cancel. And the irony, the funny thing was, is that the first time that we, the one that we canceled, we tried to renegotiate rates for like, I don't know, three or four times with Aetna. As soon as I canceled that, now the representative was at my doorstep the next day asking if they could renegotiate our contract. I'm like, I've been trying to renegotiate my contract for like three or four times with you guys in the last 10 years. Now, see what people don't understand sometimes Is that when Medicare cuts their reimbursement, you know, a lot of people at that level in Congress, they'll see the hospital system. So the hospitals are making too much money or the hospitals of this, or, but you know, when they'll cut their reimbursement rate and all of a sudden, like, what about us little guys? Because when you go into a hospital, you know, you get a cup of coffee, you get lunch, the heater or the electric or the ACs on the lights are on, but in our independent practices, we have to pay for all of that. Right. And so you're going to cut reimbursement. might. Dent a hospital a little bit, but you're crushing independent but to your original question, I do think that, I had to cancel each and every contract and we had my office manager scrub every single contract that we canceled.

Maryal Concepcion: 30:22

Yeah. And that's, what my next question was, Any strategy tips that you have for those people who are looking to transition a fee for service clinic into a DPC when it comes to unenrolling one's self or one's practice from the insurances?

Dr. Joseph Rotella: 30:35

I think the best way to do it is, almost the exact same way that you signed up for insurance. One at a time, slow process, and reap the benefits of the money coming in that are Delayed payments, as well as making sure your billing, is looking at your accounts receivables and making sure that you're receiving all those payments and copays and that weren't collected one insurance at a time. That's how my recommendation is. If you do it all at once, then it's, it can get very cumbersome. I mean, we see it now more than ever, where you call up an imaging place or you, where you call up this place and they're like, Oh, we don't take United Healthcare anymore. We don't take Blue Cross Blue Shield anymore. Well, so when you say that we don't take Blue Cross Blue Shield anymore, they're not, nobody's like really shocked anymore. Right? So I would just do one at a time. slowly, consistently, and have a timeline, but when you opt out, you make sure that you're collecting all your receivables, you're calling all the patients, you're, you know, sending them out letters, videos, texts, etc, etc, to tell them what you're doing and why you're doing it. And then the reason why you're doing it as well as. That's what makes you the best doctor for that particular patient.

Maryal Concepcion: 31:43

Awesome. And when it comes to your staff transitioning to a Direct Primary Care clinic, did you have any staff turnover in terms of you know, not needing billers and coders anymore? Did you have any people who were no longer going to be in one role, but could DPC practice?

Dr. Joseph Rotella: 32:01

Well, unfortunately you have to, Let people go. It's just the way that it is. Technically speaking, if you wanted to say a patient, I mean, this is a hypothetical. If you wanted a patient panel of 250 patients, right? basically can just open up your door, see a patient every hour and don't really need any staff at all. you want to have a busier practice doing more ancillary services, more procedures, you'll need a medical assistant. You'll need a front office. So we had to let go. I think about five people. So most of those people that we had to let go. we actively pursued job replacement. So we actively called all the colleagues that we know, trying to find them a job. Okay. I gave them a little bit of a severance package for their hard work and helping us through this transition. So I didn't cancel their health insurance until the 90 days afterwards. So they didn't have to get health insurance or the other benefits. their day that they'd allow, I extended that to 90 days. So I did a lot for my staff that stuck through it. But it is, a sad moment. But there is a time when you have to take care of yourself in order to take care of other people.

Maryal Concepcion: 32:59

So true. I absolutely have said that on the podcast before, because that's something I learned. I think even, yeah, it was even before I went to medical school. I think that's so true and it resonates. And if that is a motto that helps you get through any overwhelm entrepreneurship is not a smooth road just with, no bumps. And so I think that that's something to keep in mind as you go forward. And now I want to ask about the people who did stay. So you mentioned your physicians who transitioned, like dominoes after you, as well as Catherine Stang. How did you transition their practices to DPC when it comes to finances? Did you have them stay on as your employees or did they open up their own businesses under your practice name? How did that work out financially?

Dr. Joseph Rotella: 33:40

Well, I would say that when we transitioned the group practice, and we also transitioned. slowly executing the contracts to erase these contracts, I would have to say that, our patient panels of her DPC were slowly increasing for each provider. And I think while we're doing that, the tricky part was trying to get each provider, the DPC patients in first, versus the insurance because they're like, wait a minute, you know, there was a little, a little confusion there at first, but luckily, my practice filled up really fast. Dr. Barker's practice filled up really fast. she had 500 patients within like three months. So we really had to close her panel. And then Dr. Summers was the last one and he was a relatively new employee. So panel didn't fill up as fast, it's 90, 90% full now, but it took about a year or two to, for that to fill up. So I would say that I had to use some of my income to pay his salary just for a little bit of time. Until he ramped up but that's an investment on my part, because what I normally see is that a physician who is happy with good benefits is not going to leave.

Maryal Concepcion: 34:38

Totally. when it comes to the structure that you guys have, Dr. Barker, Dr. Summers, and Catherine and Kathleen now, I think, is also a nurse practitioner at your practice. Are they all W 2s now?

Dr. Joseph Rotella: 34:50

Yeah, they're all WTs.

Maryal Concepcion: 34:51

Got it. Continuing your team as employees, as W twos, did you change benefits at all for them in terms of, did you switch to different offerings that were still as good quality? When you transitioned to DPC or did you just maintain the benefits that you had previously? I,

Dr. Joseph Rotella: 35:08

nothing was changed. Not to say that I'm not going to change anything in the future, but nothing was changed. mean, I provide everybody, with good health insurance, dental, vision. I provide people with a bonus at the year. I provide people with a 401k plan. So nothing's really changed.

Maryal Concepcion: 35:22

Awesome. And any tips on setting up a 401k option for your employees? Because that's something that I know a lot of DPC doctors want to do but they're not necessarily sure how to go about it because they've not been a small business owner before.

Dr. Joseph Rotella: 35:35

401Ks are kind of strange because they're complicated, right? So I had an employee and they said that one time, this is a funny, this is a true story. I had a physician one time, but he left to be, it while back, but he left to go to the ER room and become an ER physician at the VA. But, told him that I give people 401k benefits and then you talk to either your financial advisor, you can ask your banker but they'll give you, really good advice. On how to set that up, and you don't need to take their advice. You can get a couple of different options and then kind of look at it all together at a table what you want to match and what you don't want to match. So there's a lot of options to do it. But what I didn't realize, though, this is that You know, if they leave in a certain amount of time, that money goes back into the 401k pool for the rest of your employees, doesn't necessarily go back to you personally, but it goes back into the pool. I mean, it's not my area of expertise, but we did have talks on it. We did have a couple of people from our 401k plan, kind of educate our staff about that. And so I encouraged everybody to do it because. Is that you don't necessarily see the money you don't have. So you don't spend the money that you don't see. So, and over time it accumulates, I know and most of my, employees have been with me for a very long time. And, their 401k is substantial now. So, and you can, as an employer, you can match, you know, 1%, 2%, whatever you want. And you've been, you can go higher if you want, you don't need to offer it. Some people just give people bonuses if you want at the end of the year, it all depends, but the only suggestion that I would tell a DPC doc that doesn't have an MBA is that it's not difficult. Take care of your staff that takes care of you. if you love your staff and you want them for a very long time, you've got to give them great benefits.

Maryal Concepcion: 37:09

Awesome. Now, As people were making the decision, I'm talking about patients, to stay or to go initially, when you transitioned to DPC in those first, you know, 90 days, who were the people who transitioned over? Just

Dr. Joseph Rotella: 37:23

like the books that you read. The people that you don't think are going to transition to DBC, they do the people that are bragging about their money and their houses and their finances and driving fancy cars, they usually don't. So you're like, what? I thought this guy had a ton of money, so to be honest with you, I would say that. Most people who want access to high quality health care and have a chronic condition, those people transition pretty rapidly over, you know, they don't want to lose the rapport with you as well as you're managing their chronic care and you know them very well. So those were kind of like, yeah, you know, they need to stay here. And some people are surprised because they just, they like you and they know you're a good doctor and they trust you. You know, it's the whole saying, you know, no, like, and trust. So that's important for people who, sign up for your DPC practice.

Maryal Concepcion: 38:05

Totally. And it goes back to those people are going to tell people who are usually like them about your practice. And One because They know the people that they're talking to and two, they're probably hanging out with like minded people who value similar things, access, trust, all of these things that we bring in DPC. I absolutely see that, feeding into why word of mouth is a massive way that we grow our practices. so true. So now I want to transition to the fact that you offer a lot of services at your practice. And you talked about this earlier in terms of, you know, you've taken care of migraines beyond, Immatrix, but since before 2008, but you have quite a significant Okay.

Dr. Joseph Rotella: 38:43

I was big into integrated medicine or aspect of in the nutraceutical aspect of migraines. I worked with a headache, a migraine specialist and we developed nutraceuticals for migraines back in 2008, nine, 10. That was fun. but I do think that a lot of doctors, I mean, physicians can provide a lot of services. I mean, we did a lot in our training. This is the unfortunate part. We did so much in our training and then as soon as we transitioned out to private practice, it's like, okay, these are all the checkboxes, so it's like, you know, but if we do the things that we did in our training in the real world, I think we can all do a lot of procedures, but go ahead. I do, I try to do as many services as I possibly can in my office to try to reduce insurance claims if possible, unnecessary insurance claims.

Maryal Concepcion: 39:19

Absolutely. And it goes into my question about how you found those services to be helpful to your community because I'm wondering looking at your services on your website, did you put these services because you either were already offering them or wanted to offer them Or did you add certain things because your community was asking for them?

Dr. Joseph Rotella: 39:38

Well, so I have a different view for primary care than a lot of people do because when you learn about family medicine in residency in a hospital based system, you are a part of that ecosystem of what they need you to be. So you need to do the things that you did in residency to be a part of that ecosystem. In the outpatient world, we have to learn how to take care of the most common ailments. And that's where my chiropractic degree really helped me out as well. Because like, the most common complaint is back pain. So if you're not a master of back pain, you know, we need to take seminars on on how to treat that. Migraine headaches, it's the number one disability, for like work force on you know, missed absences. It's the cost is huge. I mean, so you've got to know headaches, migraines. it's common. Skin lesions are common, doing preventative measures is common. You know, everybody works out and they go to the gym to do the CrossFit and you got to know your sports medicine kind of things you know, to treat that, and then injections are simple. I mean, you really, they're not hard once you kind of learn, the gist of them. So I just try to look at the most common elements that people come to see a physician for. I mean, weight loss, it's huge. I mean, everybody should do a little bit of weight loss because it's so common. So these are the things that we should just get into is just like, look what's inside the community the most common elements and really master those. you know, and that's why, health care is different. in each different state, because every state has their own set of unique circumstances and unique disease states, you know, there's that occurs, you know, when you go to Hawaii and you get, Dung by a, some type of fish, they call me up on the phone. I'm like, I don't know, you know, you might want to go to urgent care on that one, cause I'm not really familiar with that type of patient. You're showing me a picture of, you know, in Arizona, we might have, we have to check for Valley fever more, you know, you know what I'm saying? So it's all unique, but at the same time, you got to look at the most common circumstances, you know, the most common elements that people come into seeing, we should master those. I mean, you also have to look at you know, what's kind of around you as well, and and what you can refer people to, because I always try to refer somebody that can do a better job than me at something, so, you know, I think that's also important to know your, limitations for your particular standard of care.

Maryal Concepcion: 41:39

Absolutely. And I think that goes back to the trust, like you mentioned earlier, being completely transparent and saying, you know, I'm not actually sure I'll get back to you and following through with the, I'll get back to you part. And then either saying to the patient, I can help with this, or I can help to a little bit more extent before you have to go see somebody else or I need to send you to somebody else. And that absolutely is really appreciated. I know that from my patients because we're so rural and access to specialists is so tumultuous and the weights are so long. And so, the idea of maximizing what you can do under your training and what you're confident in adding to your repertoire of, you know, your, to your toolbox It just compounds so much in DPC when it comes to your. offerings for non members. I want to ask about this as well, because some people ask about, you know, how do you maintain finances if you're transitioning or if you're out of residency and you're not sure how to bring in income. For you, you have different tiers for direct pay non members as well as your DPC patients. So how did you go about deciding what services were going to be offered for direct pay non members and how did you decide pricing for those people?

Dr. Joseph Rotella: 42:46

Well, I would say that it's a good question because we did that. What we're trying to do is make everybody members because they're going to get the most bang for their buck. However, some people need just one offs, right? Which I don't love to do one offs, but because, there can be complications because they don't particularly follow up, you know? So somebody comes to you and say, Oh, I have this. And you're like, okay, haven't a plan. I'm going to try these four things, but we got to try this one first. And then they go, that one didn't work. I, you're a horrible doctor. I'm getting out of here. Like, wait a minute, you got to have follow up. you know, it's personalized medicine. And the fact that you got to, try to cater to you and try different things to find out which one best works for you. But anyway, so it all kind of basically started with the premise of a lot of plastic surgeons in Arizona wanted pre ops, so we did pre ops and so we bundled our service or a lot of our one offs are our pre op visits from relatively healthy humans that need plastic surgery. Then we, basically try to shift cash paying price. Unfortunately, we shifted a little higher because of the fact is that like, I value my time. So you're going to pay a lot of money for one visit. And a lot of money for follow up, or you can pay a really relatively reasonable fee for, a monthly membership for us, so most people realize they just sign up for the monthly membership. So the other ones that are more of the nurse practitioners and other doctors, if they have a special area of interest. Again, the AOIs that I call, I could call them, I give them free reigns to do anything they want to do. They're physicians, they earn their degree. So if they want to do some cosmetics, go ahead. If they want to do lifestyle management or weight management, go ahead. If they wanted to do OMT, you know, go ahead. We usually limit our OMT to one or two per month for DPC and anything above that, we charge a fee. This seems only fair. But every physician, I give them autonomy in the practice that they can do anything they want to do. but, For the most part, I mean, that's how it kind of went there. And we start off with the, everybody's coming in for these pre ops. So we charging them for that. And then we also say like, we want people to sign up for our membership. So this is our membership fee. And then everything else is a little steeped, a little pricier. So, cause we want people to sign up. We want more members. We don't want to go for a, another fee for service type of places. It's kind of. That's how we worked it.

Maryal Concepcion: 44:48

And I definitely would say, it's very clear as day we'll link your website to the blog accompanying your podcast, but you even have your direct healthcare membership menu that lists exactly what the tiers are and it lists the membership. And, if someone is looking at this. From a financial perspective and understands not only having access to a physician, but also having that higher accessibility when you actually need it. With someone who knows you, it's, pretty awesome.

Dr. Joseph Rotella: 45:17

one more point to that, because when I transitioned my practice, The community doesn't realize what they have with DPC until they use it, and it's very difficult to place value on that until they see it. So, for example, one of my elderly patients said, why do I need to pay you money when I already have Medicare? And I told him, you don't, you can go to another physician, but if you want access to me and talk to me and call me, He's like, well, I only come in once a year, which he came in more. But anyway, they all say that, right? It's like, their thing. I only come in once a year. Okay. Well, sir, I said. I've got five visits over here and I got you already call like, a dozen times with her, but okay, you see me once a year, I'm not going to argue with you, but anyway, so as soon as he said, fine, I'll do it. So he became a DPC. I mean, he calls me, you know, every other week, you know, he checks in with me, he goes, he's another specialist, he makes sure I gets the notes that he has. An issue, you know, he calls me and then he came to me a couple of weeks ago and he said, I didn't realize how much I can utilize your services. And a lot of people do that. They'll call me up with their supplements. So they'll call me about something that specialists said, and they want to check in because the specialist prescribed the medication, but they're already taking another medication. They want to see if they have any drug or drug interactions. All these little things that people are calling even now for, just to make sure, and they're not in a very long visit, they're just quick questions or whatever. And they said, I never had the opportunity to do that before with a doctor. Like, that's what direct medicine, that's what direct health care, Direct Primary Care is. It's like, you have access now to make sure that your health is on point. So, it's difficult to try to tell people in the insurance model what it's like to have a personal physician. Until they have it.

Maryal Concepcion: 46:47

so true. Let me ask you here when it comes to the fact that you are a personal physician, you are able to take care of a person on so many levels and use your pencil model. for Those people who especially are already with a private practice and they're using insurance to bill for their care exclusively, what would you say to those doctors to really make them think about How they're practicing and you've, mentioned so much already, but in terms of a takeaway message for those people in particular, what would you say to them to really think about as they decide to continue fee for service or do DPC in the future?

Dr. Joseph Rotella: 47:20

I think that, in all honesty, we need both. There's no doubt about it. We can't be all or nothing. We do need both. I'll put it to you this way. we need physicians outside of the system to reduce unnecessary claims, to do more and be more for their patients, like I said before, to reduce inefficient care. We need somebody, outside the system to decrease the excessive administrative costs. We need somebody outside the system to avoid, fraud, as in all these referrals to all these other doctors and you don't know where your patient ends up because you're too overwhelmed, but you lose track of them. We need somebody outside the system to be a friend. with the special medical knowledge to each patient. So they have somebody to refer to ask if they're doing the right things all the time. But we all know as a DPC doctor, I'm sure that you've got calls from patients and say like, my pain doctor wants to do this injection or the surgeon wants to do this. Should I do it? That is just double checking and triple checking, you know, everything or their medication. So you need somebody in in the system outside the system to help with that aspect. Now, If a physician wants to go into a DPC model, there are soon enough. I mean, not exactly like I would say, like right now, but soon, very soon there will be group practices. They're going to be hiring them. They are now, but they're not, as well as vast as, the insurance model, but there's going to be group practices. They're going to be hiring. And then what these physicians need to know is that when you're in the insurance model, You're constantly going to see, you know, new and different people all the time and have to fill your schedule in order to make your paycheck. The DPC is basically you have to get to your four to 500 patient mark. And then you're basically done because your attrition rate, as some people fall off that same amount of money, the same amount of people reinstate with your DPC model. So you really need just going back. I'm having another little moment here, but going back to your 401k, right? The doctor who chose you to do DPC is like a 401k because it's an investment. You invest one or two years. I'm not making a lot of money to gather your four to 500 patients. You're basically invested for life.

Maryal Concepcion: 49:20

it's so streamlined and so easy to understand. So I love that. So thank you so much, Dr. Rotella for joining us today. We are going to be geeking out about efficiency and how efficiency in fever service versus DPC is different and is not different. So join us over on the Patreon community for that. And again, thank you so much for sharing your story today.

Dr. Joseph Rotella: 49:38

No, thank you. Thanks for having me. Appreciate it.

Maryal Concepcion, MD: 49:43

Thank you for joining us for another episode of My DPC Story, highlighting the physician experience in the world of direct primary care. I hope you found today's conversation insightful and inspiring. If you want to dive deeper into the direct primary care movement, consider joining our My DPC Story Patreon community. Here you'll have access to exclusive content, including more interview topics and much more. Don't forget to subscribe to My DPC Story on your podcast feed, and follow us on social media as well. If you're able, I'd greatly appreciate if you could leave us a review. It helps others to find the podcast. Until next time, stay informed, stay healthy, and keep advocating for DPC. Read more about DPC news on the daily at dpcnews. com. Until next week, this is Marielle Conception.