10 Years of DPC in Bentonville, Arkansas

In this episode, Dr. Joel Fankhauser, board-certified in Internal Medicine and Pediatrics - delves into his successful transition from fee-for-service healthcare to Direct Primary Care (DPC) in Bentonville, Arkansas. Dr. Fankhauser discusses strategies for engaging potential patients before opening his clinic, emphasizing personal connections over online presence. He reveals how his clinic, initially cautious about financial risks, flourished by focusing on underserved populations like Medicaid foster families, without any advertising spend in a decade. The practice excels by offering zero-cost services and including low-cost lab tests in membership fees, enhancing patient satisfaction. Dr. Fankhauser also covers practical steps for physicians considering DPC, such as evaluating administrative skills and patient load management. He highlights the benefits of DPC for small businesses and shares anecdotes showcasing the practice’s patient-centric philosophy. The episode concludes with insights on recruiting and retaining compassionate, committed healthcare staff, critical for sustaining a successful DPC model. Tune in to learn more about how DPC can revolutionize patient care and physician satisfaction.

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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. Joel Fankhauser: 1:50

DPC is the way physicians and patients would design primary care.

Dr. Maryal Concepcion: 2:02

Dr. Joel Fankhauser is board certified in both internal medicine and pediatrics and has grown a very successful DPC practice in his now almost 10 years in. He practices in Bentonville, Arkansas, and he graduated from UT Southwestern Medical School. Then he completed residency at the University of Arkansas for Medical Sciences. He has successfully gone from opening with another physician to having now four physicians, including himself, and together they are running a very busy practice in an area of about 500, 000 people in Northwestern Arkansas. Thank you so much everybody for tuning in today. Find out more about DPC, including resources, discounts, my favorite tech tools, books, and more at mydpcstory. com. Be sure to follow us on your social media platforms. at our hashtag at my DPC story, and be sure to subscribe to the newsletter and of course, the podcast feed so you won't miss when the next episode drops. With that, I am so excited to break the walls into Arkansas on my DPC story. Welcome Dr. Fankhauser to the podcast.

Dr. Joel Fankhauser: 2:57

Thank you, Mariel. Thanks for having me. I'm glad to be here.

Dr. Maryal Concepcion: 3:00

So a little backstory. We spoke about this before I hit record, but when it came to my big mouth on Capitol Hill saying that I had interviewed someone from Arkansas, I went to the My DPC Story mapper and said, I actually met Alabama. And so, that was my bad. And so I said, we have to fix this. We have to have a voice from Arkansas to start the Arkansas story. And I'm so excited again to have you on the podcast. Now, something that many people might not know is that your clinic has been open, this January, we're recording in the winter of 2024. You are going into your 10th anniversary. So I'm so excited that you're bringing, not just knowledge about DPC, but experience because that's what I think really drives entrepreneurship is the experience that one goes through being a business owner.

Dr. Joel Fankhauser: 3:53

We're super excited to be approaching 10 years. You know, when we first opened, there weren't a lot of DPC practices to, talk with, to figure out, to kind of feel out, did this work, did that work? And so there was a lot of, uh, Early on trial and does this work for us or does it not? Why doesn't it work with Dr. Whedon, who is my original partner who has since retired and approaching 10 years with, the growth of the practice we've had. It's just fantastic and exciting. We're, super excited to continue doing this.

Dr. Maryal Concepcion: 4:25

So bring us back to just your, opening days and really wanting to open a DPC practice in this time that you describe when there weren't a lot of resources or ways to show that you could be successful. In the bio that I had read, I had mentioned that your area is around 500, 000 people. And would love if you could also talk about what the health care access was like at the time that you opened to help drive your decision to do DPC.

Dr. Joel Fankhauser: 4:52

Absolutely. So I went to work for a major hospital system right out of residency in 2010. And it didn't take long to realize how broken the traditional fee for service, especially in primary care was and within a couple of years, I was looking for a totally new profession outside of medicine altogether because I didn't want to do what I was doing what I had been doing for the rest of my career did not feel fulfilling. to me. So I thought to myself, what would a practice look like? if I were to sit down and design a practice as a physician and I were to ask my patients to design a practice, what would it look like? And I came up with this idea and I thought this should work. This should be a good idea. But then I realized I'm not the smartest person in the world. Someone is probably already doing this. So I started Googling basically, and I found at the time there was a group up in Washington called QLiants that existed, and there was another group called Medline that I think they've actually since closed their doors that existed. And I thought, these are things that we could probably duplicate in some way in Northwest Arkansas. And then I discovered Atlas in Kansas, and I went to one of my, partners in the clinic that I worked for, and said, Dan, this is not what you became a doctor to do. This is not how you want to do it. I can tell because you're behind by hours every day at the end of the day. Right? This is not how you would like to finish your career out. And he's, he said, you know what? You're probably right. I said, great. Let's go visit these guys in Kansas. and figure out if that's what you want to finish your career out like. So we went up and visited the folks at Atlas in Wichita and came back with sort of this idea that we could pursue this down here as well. So at the time was relatively small, but Bentonville is the home of Walmart. So the population has really exploded over the last 10, 15 years. Went from this sleepy town of 25, 000 people to now Bentonville itself is something like 55 or 60, 000, but it's got, big city amenities and lots of folks moving in regularly. We're pretty rapidly growing area.

Dr. Maryal Concepcion: 7:01

And in terms of back in 2015, even with Walmart, cause Walmart's definitely been in existence for more than 10 years. Yes. What kind of access did people have? Because, from your perspective, I get it. The, scene from the physician side, don't want to do this. Don't want to end my career like this. Noticing that your partner, Dr. Whedon was behind ours. people are nodding their heads because that is the truth in fee for service period. It is very hard if you are truly seeing the amount of people that are pushed on our schedule the double bookings, triple bookings that we are pushed to see did the patients experience healthcare at the time when you were opening,

Dr. Joel Fankhauser: 7:37

so, because of the rapid The hospital systems have had a significant challenge with keeping up with the number of primary care physicians or specialists. I don't know what the wait time looks like to get into a typical fee for service doctor around here. Now in a primary care, if you're a new patient to a clinic, but it's measured in weeks, generally speaking. And then routinely I'll hear from, patients who have transferred from a fee for service practice to ours, that they just got tired of calling and waiting for days to be seen for something really basic, like a sinus infection, or months or months sometimes for, for things like physicals. So the, the wait time was pretty substantial when we first got here for the size of town that we were in, right? And then it's really the healthcare system has struggled to keep up with the explosion of population growth over the last 10 years too.

Dr. Maryal Concepcion: 8:34

And when it came to you going up to Dr. Whedon and saying, Hey, let's make a trip to Wichita. Were there any. Like, okay, you're crazy. I don't know what you're talking about. I'm too far into this to even make a change. What were, if you heard any hesitancies, what were those hesitancies before he jumped in the car?

Dr. Joel Fankhauser: 8:51

I'm sure he had them in his, in his mind and I'm glad he's not here to say them out loud. he probably thought to himself a little bit, okay, Fankhauser's crazy. he'll get beat into submission sooner or later. If he's bought those, he never really said them. Out loud. You know, one of the biggest concerns for both of us is we were both the primary wage earner for our family. So we had to make sure that whatever plan we put into motion had a high likelihood of success because there was no backup plan for either of us. So there was the usual like trepidation about what happens if this doesn't work. What happens if this takes longer to work than we're expecting. And we're both relatively fiscally conservative. Neither one of us wanted to have large Loans out because that, really hampers growth and what options exist. And so the biggest concerns after doing it were not so much, is this a thing we want to do, but is this a thing that we can do given the financial restraints in our personal lives.

Dr. Maryal Concepcion: 10:30

Totally. And when you guys opened how long was the transition time between your fee for service jobs and opening your doors?

Dr. Joel Fankhauser: 10:38

So, I want to say we spent a little over a year between when we first started having serious conversations about this model and when we actually opened our, doors those conversations included things like, You know, can we get the money we need for the startup costs without having to take out a loan? Can we make sure our wives are both on, board? Because that's, important parts of starting a business. What are our options going to be as far as non competes with our current employer, et cetera. And it took a little over a year to get all of our, Ducks lined up in a row.

Dr. Maryal Concepcion: 11:15

And what about the non compete? Did you guys have any clauses of non solicit in addition to non compete?

Dr. Joel Fankhauser: 11:22

So in Arkansas at the time, physician contracts routinely would have non compete clauses in them, but those clauses were not usually enforceable, even if they were limited in scope and time. There had been a few cases in Arkansas where a hospital system had pursued a physician for violating the non compete and they basically, the hospital system. Lost every time. So we were in good standing with our hospital system. We didn't leave them and any sort of like, we didn't leave them in a bind. We gave them a year's notice that we were going to do this and even said, Hey, if, you would like get on board, now's the time. if you would like to see if this is a model that's viable within your healthcare system, we're not leaving because of. The hospital system we're leaving because the model and so when we left, our system said we couldn't solicit employees but if an employee came to us and said they were interested, then we could potentially hire them if we wished and they actually gave us a little leeway on how we had them. Dressed our, plans with our, patients at the time. And so they gave us some options to do things after hours that I, we were a little surprising, honestly, it was, I guess, as pleasant a departure from a, job as you could expect to have.

Dr. Maryal Concepcion: 12:33

I'm glad that that was your experience because uh, had Dr. Rachel Dirksen on she was saying how she had to pay 50, 000 And a lot of stress and tears to get out of her non compete. And as we know, 50, 000 is enough to float a DPC for, a couple of years, if not more, depending on your model. And it really makes a difference you know, it's the David and Goliath situation for sure. when it came to you guys opening your doors, had you guys been entrepreneurs before becoming physician entrepreneurs? Yeah. Yeah.

Dr. Joel Fankhauser: 13:01

No, not really. I went straight from undergrad to medical school, to residency, to working for the hospital system. Dan essentially did the same. He owned the commercial building that our clinic was in. not our current clinic, but that a medical clinic was in. But apart from that, no, neither one of us would have gone out and defined ourselves particularly as entrepreneurial.

Dr. Maryal Concepcion: 13:23

Got it. And so when it comes to the marketing portion of entrepreneurship when you guys opened, how did you get the word out to your patients? Because there wasn't a non solicit for your patients that, hey, we're going to be here We're not retiring. That was what my patients understood when I left. That was the letter that was sent out by my corporation. How did you get people to not only, you know, understand what DPC is, but also invest in membership?

Dr. Joel Fankhauser: 13:49

Absolutely. So we were allowed after hours off site to host a series of meetings that would explain to our, patients what we were going to do. And in exchange for that, we promise to not spend time during the work hours telling people what we're going to do. Because obviously if, a patient gets a letter in the mail saying that Dr. Fankhauser is leaving, if they like me, One of the questions they might ask when they're in for their cold or whatever is, well, where are you going? Right? And we said, hey, we won't have big conversations that decrease productivity, that, increase the likelihood that patients are going to leave that meeting thinking less of the hospital system. If you'll just allow us to give them a card that has a link that says, this is where I'm going. And essentially. Our hospital system said, sure, it was really, really very surprising. It's not really the, you know, the like outcome that we were expecting. So we did that. We had several after hours meetings where patients could come up and ask us as many questions as they wanted to. And then we made the link to sign up as a patient live with the expectation that come January 2015 that they would be considered active patients the day we opened our doors. And so we opened day one with enough patients signed up from our previous practice that our overhead was covered from the first day we opened our doors. Because we. were fortunate enough to be able to spend the time to tell patients who already knew us. So we weren't having to sell our, you know, them on us as well as the model. We had enough time after hours and weekends to recruit those patients in ways that we weren't actively soliciting them.

Dr. Maryal Concepcion: 15:29

And I definitely would say I would expect that would not necessarily be as easy in 2024, you know, I just, the stories that we hear of people being so much more aggressive when it comes to companies really fighting non competes just to be, not in the patient's favor but just paints this picture of how. Under the we are in a lot of cases with these contracts going into employed fee for service medicine.

Dr. Joel Fankhauser: 15:52

You know, while that was fantastic experience for us, I don't know how I would relay that to the, you know, typical physician who has the typical hospital system non compete experience. combination of state law and the hospital system we had been working for who had just lost and paid pretty, heavily for it attempt at enforcing a non compete clause made it so they sort of said, here, y'all can do this, and it worked out pretty well for us, but I'm not sure how that would relate to the average individual physician living in the average healthcare system, unfortunately.

Dr. Maryal Concepcion: 16:26

Absolutely. And this is something that I literally just discussed with a person who is going to be opening DPC in January of 2025. The strategy that my husband and I had used mentioned this before, but for those of you who are listening or new listeners to the podcast, we had a website that people opted into. So we did not solicit patients and we. Were able to ask particular questions in that sheet that they opted into like why do you love dr Philo the questions that we could use for social proof on our website once he Transitioned over and so there's definitely ways to navigate the system even with those non solicits and non competes

Dr. Joel Fankhauser: 17:04

Absolutely.

Dr. Maryal Concepcion: 17:05

So when your patients then You Came to the clinic, how did you guys handle, you know, having patients already ready to go on day one in terms of the spigot, a famous episode that we talk about a lot is Dr. Kissy Blackwell, who had over 270 patients on day one because she transitioned her practice over and onboarding a DPC patient, onboarding when you're creating the workflows. It's a different experience. So how did you guys handle that?

Dr. Joel Fankhauser: 17:31

So we, did several things. One, we had a, RN who started working for us technically before we opened she started December of 2014. So she's approaching her, 10th year with us in just a few weeks. She would contact. Every perspective patient who signed up on our website and say, Hey, we, noticed that you, signed up on this website. 1, you understand what this clinic is. 2, were you already an established patient of Bankhouser or Whedon depending on who they chose? And then 3, can we set up A time after hours or weekend to literally sit down for 15 minutes with your prospective doctor for them to just make sure that they know that, you know, what you're signing up for 2014 really busy because we did our normal job and then after hours and weekends uh, This did our second job. And so it wasn't like January 5th. We had to, figure out where these 200, 300 patients came from. Right.

Dr. Maryal Concepcion: 18:31

That's awesome. And you guys on your website have videos, and I don't know at what point they were made, but where you guys are talking about DPC. So I'm wondering, was that the culmination of, like, multiple attempts at videos, multiple practices at the elevator pitch? Because I thought the videos were pretty awesome. Thank

Dr. Joel Fankhauser: 18:47

you. Those were actually more or less, like, live. Those were one of the meetings we, did, or usually, like, several of the meetings we did for prospective patients before we opened. And we just had a videographer. Record it and then edit it basically to make it a little more watchable and they've been up for 10 years We're not i'm not very good at Updating websites and things of that sort as you could you could tell probably as you go through there It's been my experience that people, you know, people don't choose a primary care doctor based off of social media ads or web presence. The web presence has to be there. They have to be able to find you, but people don't choose you based off of that. They're right. They choose you based off of who you are, who, what your clinic looks like to them, right? They, right. People sort of subconsciously have this, I got these positive feelings from this, or this negative feeling from that, and then they will make choices based off of that, rather than, you know, I saw a billboard, and it said Dr. Marielle is the best, so I'm going to go sign up with her. So we've, spent zero dollars on advertising in 10 years, because it doesn't really work that well for primary care physicians.

Dr. Maryal Concepcion: 20:01

And if you were in doubt, he's been open almost 10 years at the time of this recording and has four physicians at a full DPC. So those are definitely words to take to heart.

Dr. Joel Fankhauser: 20:10

what we actually try to do is identify our super patient, right? The sort of person that we thought to ourselves, like, this is what, This is why I get up in the morning and go to work, right? And whatever that person is for your practice, If you can get them to realize how important they are to what you do, they're going to tell people about you. They're going to tell people about how you went above and beyond. And so we, Dan and I, when we opened, we sat down and said, Hey. Who do you want? Like, what makes you happy to be going to work today? if you say, you know, I'm the young, healthy person who never goes to the doctor. Well, everybody needs some of those, but those people are not, they don't need you, right? And so it needs to be a group of people that some reciprocal need for you, that move the needle for you. And so in my practice, it was actually foster families. I would basically tell everybody in the community that would listen, if you have a foster child and you have Medicaid, good luck finding a PCP for them. it's crazy. It's so hard around here. It even got to a point. where routinely families with foster children, they couldn't get their foster child in to see the pediatrician that was seeing their biological children because they wouldn't take a new Medicaid recipient. And so we, got signed up as Medicaid PCPs in Arkansas and said, you know what, if you come to see me and you have a foster kid, that foster kid gets seen here, gets treated the same way as a privately insured person where if you need to call us after hours or weekend, they can see us if they need same day visits, they can see us just like that. And that was so unexpected and so out of the ordinary in our community that my practice just blew up and I was full within months.

Dr. Maryal Concepcion: 21:56

I love that. And I love that it really speaks to how people value you as a physician and also the quality of care that they believe in and invest in and they get returns on that investment. Tell me about, spoke to how your practice filled up, especially with foster families in particular. When you mentioned the Medicaid portion is there no issue with you being a Medicaid registered doctor and being a DPC physician?

Dr. Joel Fankhauser: 22:20

In the state of Arkansas, there really isn't for a few reasons. One, we wouldn't charge the Medicaid patients. So the foster kids were essentially like, I saw them. I never really got paid for them. Right. I did whatever Medicaid reimbursement was, which is so dismal that fee for service practices wouldn't take it. But it was nowhere near what, monthly fee for a privately insured child would take. So in that sense, we're sort of, hybrid ish. But also in Arkansas, there's a really robust TEFRA program. TEFRA stands for the Tax, Equity, and Financial Responsibility Act of 1982. And essentially, if you have a child who has disabilities that prior to 1982 would have routinely led to institutionalization the federal government said, well, this is not a healthy or cost effective way to do this. And so every state is allowed to make rules on basically. Medical need based Medicaid rather than financial need based Medicaid. And so if you have a child with a significant medical problem in Arkansas, they qualify for Tefra. And so we were going to sign up as Medicaid providers anyway because You know, if I had a child come to see me and I diagnosed them with leukemia and now they have a Medicaid secondary because every kid in Arkansas would apply for that, what was I going to do? Say, hey, it was nice taking care of you while you were well, and then send them out the door when they got sick. So it was always going to have to be a component of what we did.

Dr. Maryal Concepcion: 23:50

So when it comes to reimbursements, to be clear, you have your membership what people quote unquote call retail patients. I'm not a big fan of that. But then you have do you have adults as well as kids under Medicaid that you bill Medicaid for?

Dr. Joel Fankhauser: 24:04

So we Mario, we don't make a strong effort to build Medicaid because it's not worth the time, right? it's frustrating. we get denials all the time. I actually have a son who has pretty significant medical needs. And even on the patient side of things, I spend three or four months of the year with my kids. Tefra in limbo because it just, something went wrong somewhere. And so we don't spend a whole lot of effort on billing pediatric Medicaid, adult Medicaid in Arkansas, we can't actually bill cause you have to be a Medicare provider to do that. And we've opted out on the pediatric side, we. We don't charge Medicaid recipients the monthly fee because that's in violation of that rule. But we also don't usually make significant efforts to hunt down the, you know, 30 per visit or whatever that Medicaid pays in Arkansas.

Dr. Maryal Concepcion: 24:57

And you're speaking to Arkansas, but just the 30, I mean, that was less than people were charging The one time visit that a person would be charged for at Walmart health when it was open. So it's just blows my mind that you go to school, miss Christmas's weddings, all of these things to learn how to take care of others for 30 bucks. Fantastic. That sounds exciting. Yes.

Dr. Joel Fankhauser: 25:16

And you know, Walmart health just closed their doors because it wasn't a financially viable model for them. It's like, well, Medicaid's paying less. Than Walmart Health was charging, with more overhead to get there. So, it's clear, it's obvious to anybody who's paid attention that Medicaid as a fee for service model is not a viable option for primary care physicians.

Dr. Maryal Concepcion: 25:40

Definitely not at those rates. so tell me now with your panel, as well as the panels of the other doctors at your practice, what is the spread of patients in terms of ages, in terms of, people who are Medicare age beneficiaries so that people have an idea as to who comes and sees you at your DBC.

Dr. Joel Fankhauser: 25:58

Absolutely. So there are two of us who are board certified in both internal medicine and pediatrics. One of us is board certified in family medicine and pediatrics. Dr. Vo was insane and did two separate residencies, separated by several years. And then we have one physician who's family medicine. So we have our youngest patients are newborns. Probably our youngest one is a few days old at this point. Our oldest patient is 97, 96 upper 90s. We have a few upper 90 year olds. We have, generally speaking, Bentonville itself has a relatively young population. Benton County is unusual in that there are a lot of very wealthy people in Benton County because of Walmart, but we actually have a higher than average rate of uninsured and Medicaid people as well. So our uninsured population is about two fold what you'd expect if we just had sort of average demographics for the county. And our medic care population is maybe Maybe 10 ish percent of our, total patient panel, which is a little bit less than you'd expect for Bentonville and Rogers.

Dr. Maryal Concepcion: 27:06

And have you guys ever considered not opting out of Medicare the opening part of your DPC journey?

Dr. Joel Fankhauser: 27:12

No, we made that decision pretty early on because Dan's patient population in his fee for service practice skewed older because he had been in practice in Northwest Arkansas for approaching 20 years at that point and that would have closed the door. to a fair number patients that he expected and hoped would continue to see him after we transitioned.

Dr. Maryal Concepcion: 27:36

Definitely makes sense. And when it comes to your patients, I would love if you could tell us some amazing stories about because you are DPC, your patient got blank level of care that they couldn't have had, had you been in your fee for service clinic?

Dr. Joel Fankhauser: 27:51

Absolutely. I actually had a sort of like little mini documentary made about me. like four minutes long. It's really short. So I'll reference what I know is in the documentary so I can make sure I'm not violating. I had a young lady come to see me in 2015 and she had been having pretty severe headaches. She had been going to a neurologist, even seeing a headache specialist, and these headaches were debilitating for her. She's a young mom. She's 30 something years old, had early elementary age kids. and just was in so much pain that she couldn't do very much through the course of the day. And I said, Hey, well, you know, that's pretty unusual. Like, these are not normal migraines. Let's come talk to me about what's happening here. And she told me this story and I thought, you know, migraines don't usually get worse when you, stand up this is something different. let's look into this. There's gotta be a headache subtype that gets worse when you stand up, right? She had never had an LP, because that was the first thing that came into my mind. I was like, well, maybe she had a spinal leak. but she hadn't really had a LP. I can't recall if she had epidurals with her kids, but her kids were Early elementary age at this point. So I said, well, Hey, I think you might actually have something called spontaneous intracranial hypotension. This is really hard to prove. I don't even know that I can do the tests that I need to prove to do it in the state of Arkansas. She had been on so many medications, she was really hesitant to do anything more. She'd been through the medical ringer, right? She was like, kind of resigned to the fact that this was her new existence, that she had to lie down for hours a day. And so I spent a fair amount of time convincing her and her husband, like, Hey, we really shouldn't do these. test. This is what we really need to get done. And ultimately finally convinced her to go see there's an expert on this particular condition in Los Angeles. it's a pretty relatively uncommon condition and finally got her to go see this person. And you know, this doctor said, well, yeah, absolutely. This is what you have and we can fix this. And she had a simple outpatient procedure and went from incapacitating daily headaches. to living a normal life because I had, the time to sit down and ask her all the questions that the neurologist had never really asked her. They just assumed migraine headaches are common. Your headaches seem migraineous. Here are all these migraine medications and none of them really ever made the headaches go away.

Dr. Maryal Concepcion: 30:09

That's just incredible. And I can't imagine just the overwhelm with gratitude that that patient must have had, especially, as a mom with two young kids, that's a hard job, I could totally see myself having mom guilt. In not being able to participate in my family's, whatever, Pokemon card game is the latest situation here because I couldn't get up like I mean that I can't imagine what she had gone through emotionally. And so that is incredible to hear that. even in somebody who doesn't necessarily have a lot of diagnoses, like hypertension, diabetes, was able to have this care.

Dr. Joel Fankhauser: 30:43

Yeah, it was it still is probably my favorite, patient experience and my

Dr. Maryal Concepcion: 30:49

when patients think about what value they're getting in DPC, sometimes early on patients, they're still really unsure about what it is they do. And even with your nurse and you and Dr. Whedon doing, you know, like, okay, so this is what we really do, like, just to make sure you understand that conversation. You guys had early on this offering for your patients to have the annual labs Included in your membership. So how did you guys think about that? And how did that work financially as you guys continue to grow?

Dr. Joel Fankhauser: 31:17

So, the actual cash price, not the fake bloated healthcare price, but the actual cash price for labs. It was so low that as we thought about it, I thought to myself, I don't want to spend the time chasing down four dollars. I don't, that's not worth my time to chase down four dollars. So We knew from the start that there were going to be some labs that we included, essentially because one we didn't want to, our patients to feel like they're being nickeled and dimed, right? It's annoying to get a bill for 4, right? As a consumer and whatever, or as a patient, you get a bill for 4 in the mail and you're like, come on. And so we didn't want. Any of our patients to think I just feel like you guys are you say this price But then you add this three dollars and that four dollars and that six dollars we didn't want anyone to feel like that and we didn't want to have anyone spend hours At a time doing that, paying someone to track down those, those dollar bills. Right. And so we have good enough pricing on labs that it was a viable option for us to just say, okay, if we get a lab that's below X amount, we're just going to include it. And that doesn't mean that, you know, you could come in as the patient and say, well, I want labs one, two, and three, and because they're under 10, you'll pay for them. if we decide that they're medically necessary, and they're below a certain cost, we don't want to have to track down single digit dollars at a time. And that's been just fine. I think there are clinics who obviously do it differently, and they seem to be doing just fine there, too. But for us, no one in our clinic was the sort of person who was like, you know what I really want to do? I want to spend more time in the minutiae of single dollar medical billing. None of us wanted to do that, and so we just said this is, we'll work this into our cost. We'll do the math and figure out what we expect people to need, and if it works, then we win, and if it doesn't work, then we can revisit that. It's one of the many things that we tried, but it's worked really well for us. It's made it really easy to just be able to tell patients when they say, well, how much is that going to cost? it costs you zero dollars. Right. That's, to me, for a lot of patients, that feels like looking at their expression on their face more surprising than anything we do. When they say, well, how much do I owe you for that lab? And I was like, you don't owe me anything for that lab. Like, really? Well, why? It's like, because it cost us 2 to do it, and I don't want to send you a bill for 4.

Dr. Maryal Concepcion: 33:49

Right? Oh, it's just so silly. makes me think about how during the SAG AFTRA strike, it was like people were talking about how they would get residuals of like 0 on a check, and the stamp costs 0. 56 or whatever it does to send it. We think about budgeting and what's your P& L when you do things like that, you know, but it's so for us where we're community based, we're community driven. I love that. You've approached it in this way. And also that it's really, been these jaw dropping experiences for patients. I mean, that's, incredible. And I'm sure that you also get more of that from the people who are coming in because they've heard about that from another patient.

Dr. Joel Fankhauser: 34:30

One of my favorite stories. Obviously, this is not the way that you could grow your practice entirely. But one of my favorite stories is, I had a patient sign up to see us, because he got sent to collections over seven cents. Seven cents! And he's like, you know what? This organization clearly is not interested in me as a person or my well being. You guys sent me to collection over seven cents. I'm going to go somewhere else. So, the difference, there is just like startling to him when he was like, well, what about, and we're like, nope, that's. It's not a thing. You don't even have to worry about that here.

Dr. Maryal Concepcion: 35:06

Oh my gosh. just so, so silly. Oh

Dr. Joel Fankhauser: 35:11

my gosh. It was very silly. But one of the things that we try to do here that all of our team tries to do is we want our patients to think, I got more. than what I was promised, right? we don't have any binding contract. It's our contract renews month to month because we don't want people to think they're stuck here. And they didn't get what they were promised. And so we just tell folks, this is your thing, stick around. If it's not your thing, that's okay. And we try to make it their thing as best as we can. And that usually means treating people at the sort of, I don't know, respect and that sort of generosity. That, you know, you and I would want to be treated with in most scenarios.

Dr. Maryal Concepcion: 35:50

Totally. And, I just think also about how this is in this season. I mean, we're not yet necessarily to December, but in this house, we're already playing the Christmas carol game and reading a Christmas carol. So it's very Scroogey of the seven sons company. Um, So when you talk about your team I love that you guys have, I mean, props to Dr. Vaux. I don't, I could not have done another residency after family medicine unless it was a fellowship. oh my gosh, to be an R1 and to be like I'm already an attending.

Dr. Joel Fankhauser: 36:20

Right.

Dr. Maryal Concepcion: 36:21

And now I'm doing R1 stuff again, props to her. But when it comes to your team, please tell us how you were able to get such an awesome team to come on over your nearly 10 years in practice.

Dr. Joel Fankhauser: 36:34

Absolutely. Our non physician staff members have all come to us by essentially. Word of mouth. We've sort of put out to people we know this is the role we're trying to fill and then people just come because our work environment is so much, pleasanter than office, right? Even if you have a, great physician and a fee for service office, if you're trying to see 30 plus people a day per physician. It, can easily become an unpleasant work environment. We're you know, intentionally slow. We ask our staff members, like, hey, if there's a person that you feel like some, connection to, feel free to, like, reach out to them like humans. Ask them, right? Ask them, but feel free to interact with them like humans. Like a regular person, not just a, you know, patient that you have 30 seconds before I'm ready to come in. So our staff members will talk with and interact with our patients in ways that could never happen in a traditional office. And that creates a working environment, coupled with how we interact with each other as a team, creates a working environment that I think fosters goodwill. And so we've had zero turnover in the ten years. We've had Dr. Weeden retire, we had a nurse retire, but we've had nobody that we've Left on poor terms. Hiring. Our first position was Lynn Davis. That was hard to find someone because we were a small practice. we talked to recruiting companies and they wanted, insane amounts of money. And so, honestly, we found Lynn by it would have been 2017 by putting on Facebook. We'll pay you a thousand dollars if you recommend a physician. We hire him or her and they stay for a year. And so one of, my friends from residency said, Hey, I know, a person and recommended Dr. Davis and we hired her and she's been great. She's been here for seven, almost seven and a half years now. And then when the year came around, I offered to send the person who recommended her the thousand dollars that we promised, he said, no, I just wanted y'all to succeed. So cool. Yeah, so we crowdsourced recruiting services instead of paying, you know, like most recruiting services want 25 percent of the annual salary. It's like, well, that's a big chunk of change if you're uh, independent practice. So we crowdsourced it and that's how we found, basically Dr. Davis. And then, honestly, I don't totally know how Dr. Ivy decided to reach out to us, we've had this sort of orbiting, we've known each other, sort of, and we have several, members of the community in common, but I don't know what finally, like, moved the needle, I probably should ask her this question, I probably should have asked her this question before the interview I don't actually know what made her, you know, reach out to us. And then Dr. Vo, who is our most recent addition, she started in August. She had been working for a healthcare system here for a while and was also at a point where she's I'm tired of doing fee for service. Didn't necessarily want to do all of the administrative and entrepreneurial sides of things. And so she just, you know, reached out to us because she, we have several mutual friends in our community and asked if we happen to be hiring and I said, well, yeah, actually we're almost always hiring the right person if we can find them. So, yeah.

Dr. Maryal Concepcion: 39:37

So talk to us about the right person, so to speak, because that is something that a lot of people are thinking about right now, especially as this movement grows, and especially because people after a residency, they might not want to just like Dr. Vo do the entrepreneurial stuff, open a DPC from the ground up. So how do you think about the right person for your practice?

Dr. Joel Fankhauser: 39:58

So the first thing that I would suggest is oftentimes subconsciously, we think of the person who's like us as the right person, right? The same personality type or whatever, right? That's, almost never the best way to do it. So you have to, we have to spend the time to think, okay, Dr. Vo and I do not actually have a lot in common as far as our personality. She's pretty straightforward. Whereas I tend to be a little like surrealist sometime in my conversation. And sometimes she'll look at me like, what are you talking about? And then I'll just kidding. Nevermind. We'll talk about something concrete. What we had to figure out is, okay, she's not like me in the sense that we don't have the same sense of humor. We don't watch the same movies or whatever, right? But she clearly has a gentleness and a generosity about her that is appealing to people, right? So partly, finding the right person and saying like, okay, what, am I actually looking for in a physician? I don't want little clones of me because then we're all going to have the same problem, right? I want people who care about being thorough, care about being kind and generous and taking care of the people that are put into their lives for them to take care of. And then the personality type is mostly irrelevant, right? Whether that's our nurses or physicians, right? If they don't have the, sort of intentionality to care well for the people that are put in their lives, I can't train them to do that. Right. I can help people become better front desk staff or better nursing staff or better physicians if they're interested, but I can't make them care about doing a job well.

Dr. Maryal Concepcion: 41:34

Oh, totally. And when it comes to these physicians coming on, Dr. Davis coming on first of the remaining three, and you're the fourth physician, how were their patient panels? From the get go, did you guys build a wait list and then they came on or did they start from day one with zero patients and work from there?

Dr. Joel Fankhauser: 41:55

So when, Dr. Davis joined, but we, what we told her is from the day she signed the contract, every new patient excluding family members of established patients would be transitioned to her care the day she started. So she had functionally no wait list when she signed. the contract, but then we had that like, three ish month window, four ish month window from the time she gave her notice at her, previous employer to when she started with us, where every new signup would be transitioned to her care. And we told them that, you know, when, the new patient would show up and sign up, we'd say, hey, just to be clear, today you're going to see, You're going to see Dr. Fankhauser, but come July of 2017, you're going to see Dr. Davis, and she's going to take over from that point on. And the vast majority of people were okay with that, and it worked out just fine. So she came on with Definitely not enough patients to, pay the bills for her if she had started it on her own, but very quickly grew. When Dr. Ivy came on, she just mostly took over Dr. Whedon's practice because he was retiring, and then brought some of her own patients with her. And then Dr. Vo came on with a much smaller wait list, but is growing at a rate. That we're totally pleased with, so.

Dr. Maryal Concepcion: 43:10

Amazing. Now, when it comes to their employment agreement, are they W 2s? Do you have benefits for them? How does it work?

Dr. Joel Fankhauser: 43:17

So they're all W 2. We offer, insurance benefits high deductible plan, health dental vision, and a retirement benefit as well.

Dr. Maryal Concepcion: 43:26

Very cool. Now, when it comes to benefits, the next question I want to ask is about employers, because in Bentonville, where Walmart is, you know, where it is centered. I think about how you mentioned how there's a lot of wealth and there's a lot of people who are not so wealthy. And when it comes to employers, You have employers who have chosen to get their employees care through you. What has been the journey with employers at your practice and why do these employers continue to find your practice the way to go for their health care?

Dr. Joel Fankhauser: 43:57

So the initial employers that signed up with us were people who we had cared for someone in their, decision making tree individually. And they went to whoever else was involved in the decision making in their organization and said, Hey, this is the thing I'm already doing. This works out great. These are this is why it works out great. Can we talk about this with our employees? So we actually didn't really go out of our way to initially attract employers just because we haven't steady enough flow of, private individuals. But then a few employers came to us and said, Hey, is this a thing that you could do? Because, so and so at our company already sees you, or these people already see you. What would it look like for us to offer that to everybody? And so we have this sort of like process we go through where we say, hey, whoever is going to be involved in this decision making process in whatever way makes the most sense, let's sit down, let's talk to them about this is what this looks like, this is what this includes, this is what it definitely does not include. This is what it definitely does not do for you, right? Because we want to make sure whatever organization is looking at us that they understand that we are not an insurance plan, right? And then we, once they've done that, we say, Hey, these are the questions that you need to have answered before we talk to anybody else in your organization. We need to know who you're going to pay for and what percent are you going to pay for? So we don't say anything that we have to walk back later because we misspoke and, what start date and things of that sort, right? The sort of boring logistics. And then we ask everyone to. Allow their employees to opt in. We have no like we're going to cover 100 percent of people, whether they want to be or not, because that ends up wasting the employer's money, right? They have people that they're paying for that literally will never come see us. And so far, that's worked really well for us. We still don't spend a ton of time trying to actively recruit. Employers because we have so many just private individuals that are still coming through the door, but we have about a dozen employers or so that have signed up with us.

Dr. Maryal Concepcion: 45:52

That's great. And in terms of the employers that have invested in your practice for membership for their employees, have you heard about what they've been able to do with their savings?

Dr. Joel Fankhauser: 46:03

Yeah, so, mostly the employers that have signed up with us are under that 50 employee mark where they're not required by law to offer health benefits. So a fair number of Employers will sign up their employees more as like a, perk for their employees. Cause it's, a competitive job market right now. And to be able to tell someone, you know, I'll pay for all of your primary care needs and have, be able to do it for under a thousand dollars, the promise of I'll pay for your primary care needs versus the cost of under a thousand dollars is like most. People aren't used to thinking like that. And so an employee was thinking, Oh, this is costing them 12, 000 a year or whatever the health insurance cost is. And so for most employers, most small employers it's a combination of. Their employees get easier access to us. So they miss less days of work. And it's a apparent big perk with a small price tag.

Dr. Maryal Concepcion: 46:57

this is what I talked about. When I had gone to a Calaveras chamber of commerce event that. When I was amongst other people who are small business employers, people really got that, oh my gosh, if restaurant A and B are on the same street, and an employee is looking at Where should I work? And you have this added benefit of, you know, 75 to 100 a month to be able to offer, hey, if you have a rash, you don't actually have to not get tips and not work. You literally could see if it's a problem first before you decide if you can come to work and you didn't have to, you know, drive, take time off, find a babysitter, all these things. And so it's definitely something that we've seen at our practice in terms of that understanding of. How DPC is so valuable even for like you're saying businesses with 50 employees or less

Dr. Joel Fankhauser: 47:41

we actually do have a employers that offer a variety of different insurance plans and they have discovered that if they can move employees towards the higher deductible plan and still subsidize a portion of our monthly fee, they're still saving the company usually several hundred dollars a month to based off of the, you know, the premium for the insurance plan while simultaneously improving their employees patient experience in a primary care setting. So the few employees we have that are big enough that they can offer multiple tiers of insurance from the like very expensive comprehensive plan to the higher deductible plan with some subsidy for seeing us we've seen, we don't usually ask employers, like, tell us your specific numbers, right? Because that, feels odd but clearly they have a financial incentive to push people towards a model that ends up working better for the patient anyway. So we've had a couple of employers who have started this idea of like, okay, look, you have this option for insurance and yeah, you're at out of pocket max might be higher, but do you ever meet your out of pocket max? anyway and most people don't because around here, you know, like my family out of pocket max is, I don't know, 10, 000, 12, that's high enough that I don't even, it's like, feels like monopoly money, right? That it's like, that's not a number that most people pay for healthcare on any given year anyway. And so for those, employees, They're actual like cost savings and their people have obviously done that math or they wouldn't continuing to offer and even push people towards our model apart from the, patient experience side of it.

Dr. Maryal Concepcion: 49:16

Gotcha. Now, when it comes to speaking to the greater audience who's listening, especially for those people who either looking to start DPC or can Really in the, throes of, is this a thing? You know, maybe they're not going to get into a car as fast as Dr. Whedon did, but because you have. three other physicians who have joined you. What would you say to those physicians who are thinking about DPC? Your opening statement definitely was, powerful in terms of though, things that you would say specifically to that group of people, what would you say to them about DPC?

Dr. Joel Fankhauser: 49:51

Absolutely. So If a physician who is a considering DPC came and wanted to speak to me there'd be some of the like boring logistical sides of things. Like, do you want to be the person responsible for payroll, for advertising, for all those things? Because if, you don't feel confident to get in front of people and tell them why you're worth giving money to, you shouldn't run a DPC. You could work at one, potentially, right? But if you're not willing to sell yourself as a, positive experience for someone in a way that is, honest to them. you shouldn't be the starter of that clinic, right? Because for better or worse, individual DPC practices mostly until they get to be relatively large or survive or, or fail based off of the individual physician. if I came across as a sort of person that patients were like, I don't trust that guy. I'm not going to give that guy any money. It could be the best idea in the world. And it's not going to work. So first question that a prospective DPC doctor needs to answer is, Am I that person? Do I have that? Am I willing to, take those steps to have those skills? And then the next thing I would say is you have to do some really boring math and figure out how much do you need to charge people to make the amount of money you need to make? And how many patients will that take? does that seem viable to you? And we made a hard and fast rule about 800 patients per doctor. None of us can go above that. Because years ago, I don't even remember how long the study was. 15, 20 years ago, the American Academy of Family Physicians published some data that talked about how many hours per day primary care physicians should work. And it was something like one hour per every 100 patients. And I said, well, why would I intentionally make my day longer than eight hours regularly? So we have a hard and fast cap at 800, but none of us want to be at that cap. We're all below it. And so that's the next question that a prospective DPC doctor needs to answer is, if I do the math where I live, how many patients do I need to make the amount of money that I want to make to make this worth my time? And then after that, the only real question left is why aren't you doing it yet? Because working in a fee for service office where you're seeing 30 plus people a day to make of what your specialist friends make. that doesn't feel like the sort of choice that's, that intelligent people would intentionally make, right? And intelligent people have intentionally made it, right? I'm not, I'm not trying to, to belittle people, but on the front end, if I said, here, you could have this job that pays half as much for a lot of daily headache. You would think to yourself, Fankhauser is insane and I don't want that job. But this is what a lot of primary care doctors have done in the fee for service world.

Dr. Maryal Concepcion: 52:31

Absolutely. We are going to be talking about the experience and looking back on almost 10 years of practice in DPC. thank you so much for joining us today.

Dr. Joel Fankhauser: 52:41

Thank you, Mary. It was nice to meet you.

Maryal Concepcion, MD: 52:45

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.