A DPC In The Basement of Your House: Dr. Neal Douglas's Journey of Faith, Family, and Medicine

In this episode of the "My DPC Story" podcast, Dr. Neal Douglas, a family medicine physician from Heritage Family Medicine in Hood River, Oregon, delves into the intricacies of his Direct Primary Care (DPC) Heritage DPC. The episode explores Dr. Douglas’s personal journey of balancing career and family, stressing a prioritized life structure for fulfillment. He recounts transitioning to becoming a doctor and becoming a DPC physician following setbacks with Medicaid contracts, advocating for a patient-centered, membership-based model. He speaks about his innovative practice adaptations like the allergy services and shares about strategic hiring practices and overcoming financial challenges. Dr. Douglas discusses redefining "part-time" work for malpractice insurance based on patient panel size rather than contact hours. He highlights the importance of finding malpractice insurance companies that understand the unique dynamics of DPC practices. Emphasizing the resilience and adaptability of DPC amidst changing healthcare policies, Dr. Douglas shares his successful practice's reliance on community relationships and word-of-mouth marketing. Dr. Douglas’s narrative underscores the value of perseverance, gratitude, and faith in building a thriving DPC practice, providing actionable advice for fellow physicians. 

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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. Neal Douglas: 1:50

If I can run DPC out of my basement, you can run one anywhere. My name is Dr. Neal Douglas. And this is my DPC story.

Dr. Maryal Concepcion: 2:05

Dr. Neil Douglas is a family medicine physician at Heritage Family Medicine in Hood River, Oregon. Dr. Douglas is a native Oregonian who grew up on a farm in Boring, yes, Boring, Oregon. He developed a passion for medicine while serving on medical mission trips to Africa with his father. in 2017, he opened Heritage Family Medicine to provide affordable, convenient, and compassionate care to his community. Practicing out of his historic farmhouse, Heritage Family Medicine is a space where Dr. Neal and his wife, Christy, have created a space of healing and wellness that offers old world charm with old fashioned quality primary care. Welcome to the podcast, everyone. Thank you so much for tuning in. Find out more about DPC, including resources, my favorite tech tools and more, especially our 12 days of Christmas holiday discounts at mydpcstory. com. Follow us on your social media platforms at our handle at mydpcstory. 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 for this much anticipated interview with my dear friend Dr. Neal Douglas. Thank you so much for joining us and welcome.

Dr. Neal Douglas: 3:10

Thanks for having me, Mariel. This is been a long time coming for sure. I think we've tried to record this at least two, if not three or four times. And here we are doing it like, you know, it's happening this time.

Dr. Maryal Concepcion: 3:23

Yes, it is. this is true. You had come to California and were leaving the beach and we were like, well, this is a great time to record. And then I couldn't record at that time. And then another time we ended up talking about IVs and starting IVs under the DPC flag. So, uh, yeah, it's, fantastic and very timely that we are going to be doing this in the holiday season. I'm so excited So You were somebody who I met very early on in my DPC journey. In 2019, yourself, Dr. Tyndall Smith, Dr. Beckenhauer, Dr. Rossborough, Dr. Blackwell, Dr. O'Rourke, we're all at the point of care ultrasound course in Vallejo. And it was so, like, I knew that DPC was. an amazing community by stories, but that was really my first experience of really meeting DPC doctors and really finding people who were completely, having their senses on their shoulders and not living in this, you burned out world of fee for service any longer. So it's so exciting to be hearing your journey now even further in, because we're recording this in 2024. And two years ago, you did the keynote at the DPC summit in Minneapolis. And for those people who may have not heard that, I would really love if you could open this interview with how you even, found the calling to go into primary care.

Dr. Neal Douglas: 4:40

Yeah. Well, and I think, a big part of the reason we ended up naming the practice heritage family medicine is family medicine is truly my heritage. my grandfather tried to get into medicine and he actually, you know, wasn't able to and instead became a nuclear physicist. That's a very long story. But my father kind of followed on his footsteps and said, yes, I want to try to become a family medicine doctor did. And, you know, I grew up with, my memories of my father very much involved him taking care of patients and doing that in a new, in a really incredible way. And so, over the course of growing up, lots of experiences. I absolutely fainted at the sight of blood. That was terrible around medical experiences, but and you can listen to the full story about that on the keynote speech. But long story short, we did a series of medical mission trips and I got to see my dad at work. And to see somebody who doesn't understand necessarily the culture, who doesn't speak a language, but to be able to step off a plane from a very far away. Yeah. I mean, across the world, literally, and to be able to impact people's lives was something I could not shake. And I realized, that having that level of skill that you can take anywhere, but also being able to have a relationship with someone so quickly by meeting such a basic need, that is their healthcare needs. Just such a powerful journey. And I, decided pretty quickly in medical school because I loved every aspect that I was going to be a family medicine doctor. And I also realized pretty quickly how broken our system was. And especially in being trained and seeing how most residents getting out or kind of burned out by the time they started day one. And my goal was to always stay passionate and love what I did. Yeah, so that, I mean, that kind of catches you up to where I was at least, yeah, at the beginning of, well, towards the end of residency. And just realizing I, wanted to have control over my destiny. I knew I was never going to be a good fit for a big hospital system. Every one of my advisors said the same thing because I was, I don't know, I think the word rebel was used a lot when I was in residency.

Dr. Maryal Concepcion: 6:48

I do love that, though, especially when you have attendings who really know you and are able to call you out on things like your future is going to be much more important gonna be happier if you have, you know, certain things like certain people, Dr. Rachel Dirkson just shared how her advisor said, you shouldn't go to PA school, you should be a physician. for you to have mentors call out like, Hey, you know, this is the parts of you that you continue to live and show others that. are capable of doing and passing on to others as a direct primary care physician. I think it's really powerful. And I wanted to ask you, though, when it came to the fee for service system, I remember you talking to me about How the coding was working in your head and how you would have thoughts about, if I added this code, the 25 modifier, whatever, like there would be some extra incentive there. So can you talk to us about that? Because I think that that is really something that sometimes we don't necessarily recognize as we're going through the day to day and residency.

Dr. Neal Douglas: 7:47

Yeah. You know, so immediately after residency, my path was pretty clear. I decided to join my dad's practice and what I consider to be my second residency started when I joined his practice, sat next to he, and along with seven, eight other family physicians who all did. extensive amount of mission work. The scope of practice in that clinic was absolutely above and beyond what you would find in most any other metropolitan, major metropolitan area. And I love that about that practice. But the other thing that I came to identify pretty quickly is that the practice was not financially sustainable, and in order for us to start to sustain where we had been and to maintain the lifestyle that the physicians were used to and the lifestyle that I had been promised, I realized pretty quickly that we needed to really change the way we were treating patients. Providing care we were starting to lose money in it was not it was either getting rid of staff or it was coming down to changing how we saw patients. So it was one of these things where I and I'm pretty good at putting on different hats and keeping myself separated and that was the way I really justified this. I was a business owner. I had bought into the practice and I had a percentage of the partnership. so, my business brain was constantly telling me we need to increase our BU generation. And I had done a bunch of work looking at, okay, how do I do that? how do we increase this? What's the national average in my space? we even went as far as to like have outside audits done. So we would understand what our performance was compared to other physicians in a similar space. And for those of you who work for big hospital systems, this is the pressure you're getting all the time. This is why you have administrators coming into your office and saying you need to see more patients, you need to do this, you need to do that. It's because there are metrics out there that are widely distributed that you can understand how productive you are. And it has nothing to do with relationships, obviously, has nothing to do with the quality of care that you provide, has nothing to do with anything other than how much are you able to generate. on a bill, on a super bill for providing to insurance companies to get reimbursed from. So there's a lot of little tricks that you could do. I mean, you could spend a little bit more time counseling patients. You can add a few chronic issues to the list and say that you reviewed medications. You can say that you've, you know, reviewed prior studies or what have you, whatever it is you want to do to start to gradually tick up those 99213s into 99214s you Or what have you 25 modifiers. Okay. Let's do some cryotherapy over here while we're talking about this issue. Let's make sure that we get, whatever kind of wound care that's set up that we're going to do and coding it this way. and then I always made sure that I had, a full procedure schedule and my RVU generation was phenomenal. It actually was. well above what most of the area was, and I took a lot of pride in that. And It felt terrible. I was like, wow, my business brain is really well satisfied right now. I am generating so much revenue for our practice. And that felt so good. And I would look at the employees and I would look at, okay, we've got a Christmas party coming up. And that's a big part of what I've done, but it never felt good. I could never fully justify it. And I tried, I really tried as hard as I could to be like, okay, I'm going to be the top revenue doctor, but I'm also going to hold on to the personal care piece in my practice. Once a lot of the doctors there started to retire, really the wheels started to fall off that bus, because then we realized I was one of the few people maintaining the practice because I was willing to see all the after hours people, to see all the, people walking in the door, and anyway, it became just untenable. But I also realized something way more important, and that is, I was. Despite what I was telling myself, I was not able to foster healing relationships with my patients. If I had a single patient come in with depression, my nurse knew. That's a 45 minute visit for me, and it's almost always scheduled at 15. So my day was always completely backed up. And then my notes would be completely backed up. So I was spending at least six and a half days a week to maintain that level of RVU generation. And it became really, really obvious. I was a great business owner. I was actually a pretty good doctor. But I was a terrible dad and I was a terrible husband and my wife just came to me and said, Neil, there has to be a balance here. You can be incredibly successful in your professional career, but that can't be at the cost of your family. Yeah. And that, that really started to change how I viewed my job and how I viewed my work. And I started to really think about. My structured priorities for my life.

Dr. Maryal Concepcion: 13:06

And tell us about that because I feel that. That is something very relatable to the listeners because when we're in this system, and you know, I've talked about this on the podcast with other guests before, but it is very appropriate to repeat it again that we go into medical school, we're told these are your rotations. This is when to be somewhere. what you're going to do, how many procedures you need to do in this category. And it continues in residency. So I'm just wondering when you started going down this path, and absolutely, it's wonderful that Christy was able to pull out and say like, hey, like, there's got to be some kind of balance here. What did you start? As going back to the heritage theme, like, what did you put at the foundation? And then how did you, create your tree? Cause that's your logo. Like, how did you create what comes next after this priority?

Dr. Neal Douglas: 13:51

Yeah. and I think, you know, I would encourage all of your listeners to do this. We are led down paths on our medical journey. I remember getting into medical school. It is delightful. It's amazing. Okay. Tell me when to show up for class. Tell me what tests I'm studying for. This is wonderful. You have people making almost every decision that you have. You might have an occasional rotation that you have a little bit of control over, but otherwise, I mean, you're just spoon fed a schedule and you're, going on a very specific path. Same with residency, you get into your residency program, you might have a little bit of control over what that pick list looked like, but you don't have a whole lot of control the moment you step in the door to your internship here. And people are telling you where to be, how to be there, what to do, how to do things. And it's part of that instruction model. It's beautiful, but we really are trained much like a military career is trained to answer to a certain level of authority. And I think there's nothing wrong with that. And in that journey, you need to have that structure because you really don't have the faculties to say like, Oh, what is my future going to be? You know, We all remember that, and if you're in that space, just know that we as established doctors recognize that's a hard place to be when you feel like you don't know what your future holds, you don't know what this looks like, but you have been led down a path, and you have had people who are constantly steering you in a certain direction, and one of the things that I think is It might be a little bit overstated or understated, I should say, is residency programs oftentimes lose lots of money. And the way that they make up for that, and the way that at the top level, they're viewed as an asset to any sort of a healthcare system is in physician recruitment. Recruiting physicians often takes a Sometimes it's millions of dollars to recruit physicians. And so there's a huge value. If you're in residency right now, you need to know, you have a giant target on your back. And there is a lot of people who want you to make decisions based on this trail that you've been following this whole time. And they're going to make a lot of these decisions feel like they're the easy decision because your malpractice is good because you have all of these pieces. You can sign a contract that guarantees a salary. That's kind of nice. You know what your vacation days look like. Hey, that's pretty good too. It feels so natural along that training. But I would just encourage you to take time at least a few times a month to just sit And zoom out and just take that camera that is just hyper focused on your next day's task and zoom out and zoom out even past like, okay, so I'm finishing up whatever part of my training, or if you're a doctor working in the system, zoom out past, okay, here's my next vacation coming up. Zoom out past Like, oh, I'm a successful doctor, or I'm a successful resident. Zoom out past that. Keep zooming out. Oh, I am a contributing member to society. Oh, I, and, and keep going until you get to the point where you're literally looking at your role with everything else in front of you, and what is, like, just the most basic priority list that you could create for yourself. It's what we do in business when you build a mission statement and you build a vision statement. And if you don't have that, I'd recommend you do that. You can, again, if you want to hear about, I've got a lot of that kind of built into that keynote speech, but it's really important to build that priority list. And then all those details and all those paths that you're following. When your nose is to the grindstone, when you have that mantra that you've built, it really helps you hold up a mirror and see what those decisions look like from a different perspective. So when I had, I realized, and I kind of woke up and was in a place where I was You know, a big part of this, I was commuting an hour from my home to get to my practice. The straw that broke the camel's back, there was a forest fire that turned my one hour commute into a three and a half hour, each way commute. And that absolute, well, it gave me a lot of time to think, honestly, that was kind of nice. I had like hours every day to think. And I was just like, okay, if I continue on this path, the natural conclusion is I will probably not have a successful marriage. My children will wonder where I was for most of their childhood, even though we will live a wonderful life. I mean, we'll be able to provide whatever they want. And I may be happy with my success business wise, but I would have to always tolerate the fact that my family life suffered because of the career path I chose. And that, I think that's a common lie that we tell ourselves. Well, we chose a career path, but that's just the way it is. And we tell family, and, well, I can't be there, I can't do this, can't do that, because, well, I mean, this is what primary care is. You just have to. To accept this is the way it is and it's really dangerous. But I was like, I wonder what would happen if I just decided to do things exactly the way I would and structured my life according to a priority list. And. That list starts, for me, the foundation is my faith, and so, foundation step number one was God, and making sure that I didn't have regrets about kind of the morality of practicing medicine, and the way that I incorporated the importance of spirituality into any of my patient practices. interactions and helping patients in that journey. So that was foundation number one. Number two was my marriage, making sure that I had time on a regular basis to spend with my wife and time that I could get away from. We had lots of little kids at that time, whole different story, family planning advice. I can give you lots, but just don't follow my example. We had five kids. So the priority list, I've got God, I've got my wife, I've got my kids, and then I've got my practice. And then lastly, I've got my hobbies and I've got lots. And anyway, that's a whole different, yeah. Thanks. So keeping those things in balance, that was my zoom. I zoomed all the way out and, and I got to this place where like, okay, if I am at the end of my life, if I had somebody and I just bullet pointed my life, what would I want people to see? If I had the people at my funeral say like, what were his priorities in life? And if people said, wow, he really treasured his faith. And he really was loyal to his wife and he really loved on his kids. And he was a phenomenal doctor. And if they prioritize it that way, I would, that would be my definition of success, a successful life. And I realized I had the entire thing upside down and that was a real. I mean, that, that just started to wear on me. And I realized I could, as successful as I wanted to be, as much money as I wanted to make, you know, as innovative as I wanted to start running our business and just doing all the things, I realized at the end of the day, I was compromising so much of myself. And had bought into this lie that to be a successful family medicine doctor, you have to see a certain number of patients, you have to be, have a certain amount of productivity that is measured in RVUs or whatever measurement you want. And and that it's okay to not be there for family events because we have such a strong sense of duty to our patients. Or so I thought those are all lies that now looking back, I'm like, oh my gosh, yeah, I'm such a better physician,, I'm so much more productive, even though if the system tried to measure it, they would laugh at me. I really don't care. and I'm so much more fulfilled and I'm not at odds with that list, that priority list every day I get to wake up and I'm so grateful. For where I'm at. So anyway, that's big picture. If you're not already doing that again, I hope if you hear anything from my story, I just really encourage you to look around you to zoom back, take a step back, take the time it takes to build a priority list and to structure your life around that because there's no amount of success. There's no amount of fame fortune that's going to make that priority list feel right. It needs to build your business, build your future around that priority list. And I'll tell you, you will be happy. And that's what helps you be successful and motivated to continue to stick to the really hard times. There's going to be a lot of really hard times when you're starting to be. That is, that's what it took for me. But

Dr. Maryal Concepcion: 22:03

let me ask you there, because, you know, we're in the holiday season when we're recording this. And absolutely. I mean, you just said there that you wake up and you're grateful for things. So I would love if you could speak to how you incorporate gratitude in your day to day, so that You can, you know, make it through if it's an easy day, if it's a tougher day because I think that one, you know, it's very holiday for me to say that, but also it's very much along the roads of how a business person needs to have certain tools to be able to cope.

Dr. Neal Douglas: 22:35

Yeah, I think, part of my story, and I'll tell you a lot of people look at my life. And look where it is now running a very successful practice out of my home. I have no qualms telling people I see patients scheduled three days a week. And I am with my family the other four days a week. And I also doctor those days. I'll run down to the basement and put stitches in on weekends if people need it. It's great. But the gratitude piece for me really started in the fact that I wasn't a shoo in into medical school, and it took me really humbling myself to a place of, okay, God, you've called me to do this, and I felt like my whole heart that I was called to be a doctor I was like, God, you got to make this happen because I pretty much screwed it up. My GPA isn't good enough. My MCAT scores were not great. I interviewed fine, but I got denied from almost every medical school that I interviewed with. And I was on my second year interviewing, same MCAT scores, same everything. And my application. There was an error in their system and none of my letters of recommendation made it to the actual database and all everybody's getting all their acceptance letters and everything. And I'm calling trying to figure out what's going on. Anyway, my 2nd year applying to medical school. I didn't get any interviews. And that one interview came because I had a mentor whose wife was the dean of admission at OHSU, Oregon Health Sciences University. And she said, Neil, your application is completely screwed up. And I was like, Oh my gosh, this is crazy. Long story short, that was an absolute miracle that we had somebody that we knew personally. Who is willing to stick their neck out and say, Hey, we're going to get this fixed. I sent them hard copies, even though everything was supposed to be digital, the letters of recommendation. And based on that, I got literally their last interview spot. I was put on the waiting list because it was so late in interview season. They had already chosen almost all of their students. I was on a mission trip in Africa, logging in, in this little, I mean, we are in like dusty, dirty streets. Internet cafe. It is dial up like the thing like hitting the refresh button and it takes about 20 minutes for the page to load whether I'm getting into medical school or not. And I'll never free. And I'm like, yeah, as we're, we were building a kitchen for an orphanage. It was, it was a wonderful experience, but I'm like, running down every day and checking that list to see. Am I on the, like, am I getting in? Cause I was waitlisted. And I, it was, I was like number 70. I was way up on the list. So I'm, I mean, it was all in God's hands. I was like, there's no way. And, and we'll see what happens. School was starting in two weeks. So if I was getting in, it was literally at the 11th, absolute 11th hour. I had no, I had no books. I had nothing. I was completely unprepared. I'm literally in the middle of, we're in Uganda at the time and just outside of Kampala. And I'm literally checking the internet to see if I get into medical school. And it was a miracle. Of course they did and showed up the first day of medical school feeling like the absolute least prepared, least qualified person to be there. So Yeah, when I say practicing gratitude, I feel like God knew that I'm, I could be a prideful person and really made sure that I knew that it was his calling. and there's just like, A lot of examples along the way where God's made it very clear, even with my practice here, it wasn't my genius idea that allowed this to happen. It wasn't my hard work and studying and all those things. I had to do those things to get here, but it was following a path that was again, different than the path that had been set by the system for me. And now it was not an easy path to follow. But that's where a lot of my gratitude comes from. So when I talk to patients about, people are like, how do you like your job? How do you like this? You know, what do you think? And my immediate response is, I am so grateful. I am just so grateful because I, tell people all the time, I would never in my wildest dreams, if you had told me, Like first year medical student Neil or second third year medical student Neil, you're going to be practicing out of your basement taking care of patients like it was like the 1800s and you're going to practice full spectrum family medicine and have four days a week with your kids. I'd be like, I have no idea what you're talking about. Like, that's impossible. So, practicing gratitude really helps you realize, no matter where you are in life, there's things that happen to get you to that place, and a lot of those things you don't necessarily have control over, and it's great. to kind of acknowledge that, for me at least, that there's a God out there who set that path for me. And it really helps with my anxiety, this, that, to not feel like I have that level of control. It's like, yeah, I just need to follow the path that's kind of set before me. And yeah, it makes a huge difference. And I think even if you don't have that faith aspect, Practicing gratitude is a great practice because you'll just be so much more content. We talked about, you know, you talked about small business owners coping. Owning a small business is like being on a roller coaster. You're going to feel like you're at the top of the world one minute and then the next minute, You're going to feel like you screwed everything up. Yeah. And it's, you know, that's okay. If you're grateful for where you are and for what you have, guess what? It's going to completely change the way you look at those situations. It doesn't change the situation, but it definitely changes the way you look at it. So yeah, I, I mean, I'll be the first person to say from the outside, it might look like I've got all this together and I'm like some, successful genius person, whatever, but I love talking to people. And that's why I hate social media, honestly, because I think that gets built up and it's like, that's not true. That's actually fake. What's true is I'm really humbled and honored to be where I am and to be able to practice the way that I do and be able to impact the community the way I do. It actually was God's plan, and it wasn't my plan. And. The more I lean into that the more faithful he is in blessing this practice and blessing how it runs. And just, I mean, my, even my business plans are completely different than what I would typically design for myself. Yeah. And a lot of that, again, is that just that practice gratitude. So anyway

Dr. Maryal Concepcion: 28:57

And tell us how, with this history of, you had exposure to your dad's practice with this history of gratitude for your journey into medicine from day one of medical school, you know, days before medical school, I really shouldn't say And also knowing that you were re evaluating your life from the ground up in terms of setting those priorities. How did DPC come into the picture and how did you decide that DPC was the way you were going to go?

Dr. Neal Douglas: 29:27

So one of the justification methods, and do feel like A lot of these big systems and even private practices are very good at saying, well, you know, we are a for profit company or whatever it is, or even if you're a non profit. had a contract with a state health insurance so for those who don't know in Oregon, we have Medicaid program that's very robust and it's actually great for families who meet that qualification to get excellent healthcare provided through contractors of state funds. And. That population of people I love to serve because those were the people who had no other access to care. They had no other access. their understanding of their health. And just educating those patients was so important. Unfortunately, that contractor we worked with, that insurance company that we worked with, put almost all of their funding into primary care. And that was the reason we were able to contract With that insurance company and they were at the forefront of doing a lot of studies that were proving that the emergency room rates, the admission rates, that the bounce back rates in the hospital, that everything was pointing to the fact that if you pay primary care doctors more of this percentage of a Medicaid allotment, the amount that they're given It saves the state money. A lot of money. It became very political with a lot of the big health systems in Portland, and that health care plan was dropped by the state because of their focus on primary care. And because there was so much lobbying against that practice of allowing primary care to have a much larger portion of the pie. For providing. So we lost that contract and that was the only contract we as a private clinic could really justify having. And so we lost access to about a third of the patients that I took care of because I love taking care of those Medicaid patients. And. I was heartbroken. My patients were heartbroken. We had developed a relationship over the past four years, three, four years, and suddenly we had to send them all letters that said we can't take care of you. And that felt so criminal to me that we would put, you know, the well being, even as a business owner, I said, there has to be a better way to allow these patients access to us. We can't just rely on the card that they get issued by the government to get them access to their doctor. And it's so frustrating that that is the way it needs to be. So I started to research else could a patient who doesn't have insurance access me as a doctor. And that led me to finding direct primary care model, a company that was, I don't think they exist anymore, but they were basically going into clinics that were established and setting up a DPC type structure. Managing the roster in hindsight, I look at that and I'm like, Oh my gosh, I can't believe we even entertain that because of the overhead that we were running like there's no way with every nurse and like, yeah, but what it did is it allowed me for, it was like a year and a half to care for a list of patients. They were all my patients because I sold them on it. I was like, 80 bucks a month. You can see me for anything you need. You have access to our X. We had an extra machine. We had a lab. So they got all that stuff for 80 bucks a month. It was an incredible steal of a deal. And a lot of them, that was a ton of money, but they prioritize that relationship with me for that 80 a month. And I was like, this is transformative. These are patients who normally get health care for free, and they're choosing to spend a little bit of their disposable income to continue to have access with me and the relationships I built with those patients were just like me. second to none because they were investing in me in a lot of ways. And that, I mean, that really, once I got a taste of that, even in my fee for service practice, so I've got like a regular fee for service practice, but now I've got this list of patients and I would check that list and I'd be like, Oh my gosh, so and so called for my partner who was on call. And I just realized that like, it just felt like those patients were rooting for me. For us and like rooting for me and I knew it was such an organic, the business part of it aligned with like the medicine part. And now my business brain is like, Well, why, why are we dealing with these insurance companies like this is what they have complete control over how our practice runs how it works. This is the reason my schedule looks the way it does is because there are view requirements because they keep trimming off there. They used to give us 10 percent on Medicare rates and now they're giving us 8 percent and now, and they can just keep trimming it down and now we've got all these incentives and single patient goes to the emergency room and our entire care. bonus structure is destroyed because we missed it by one single stupid patient at ER visit. And I'm like, why do they have so much control? the moment we have that fire, and the moment I went to my wife and said, it's time to do something drastic, I knew beyond a shadow of a doubt that I was going to do something membership based. I had no idea that there were established practices. I had no idea that that, that it was even existed outside of, that one company that came and helped us. They had since gone out of business. So that wasn't even an option. So I was like, okay, there has to be people who have figured this out. And then ultimately that led me to Rob Rossboro's door. That walked into his practice. The rest is, I mean, yeah, we went out to lunch, still my best friend to this day. rest is history.

Dr. Maryal Concepcion: 34:54

Beautiful and incredible. And It's interesting how we all come to this journey of DPC, but I think that it is so cool that, Rob had been open, he transitioned from his own practice. I think it's maybe episode 69 or somewhere in the late 60s. If you haven't heard that, go back in the catalog. But This is why I think it is so important to see and hear other people like you because it's like we come from this similar culture of you know, we were talking about how medical school and Residency and just even being attending that mindset of like you're told what to do you are a cog in the system pretty much from day one and when you can preserve the relationship focused part of you and when you can find a practice that is similar to you in terms of like dealing with the same state regulations and the same population health issues that you might be facing. I think it is so empowering to see someone like you and I think it really helps push people towards the I can do this versus I can't do this mindset.

Dr. Neal Douglas: 35:55

Well, and I think. to me that the purity of that relationship with patients became my new standard of care, and it really anything outside of that just, it wasn't, it didn't feel right. It didn't check those boxes of, am I doing no financial harm to my patients? Am I providing the level of care that they need? Am I structuring my practice in a way that actually allows them that incentivize them to access me when they need me and I'll just tell you, I think, my story for people out there who would say, well, if I own my own practice and I could run it the way I wanted to, or I could run a blended practice and do fee for service and DPC. I'll tell you, you know, having been there and having done that, making the switch to pure DPC has absolutely just transformed my career and the way I look at my job, honestly because to know that I'm fully sustained by my community and by the people who I've built relationships with over the years. it's such an empowering feeling. And then to go into COVID and to know that we had established such a good rapport with our community, even though we had only been open for a year and a half, two years, I knew I had farmers who would drop groceries or vegetables off at my doorstep in exchange for healthcare. I told my wife, I was like, we're going to be fine because. We have a community that will take care of us because we can take care of that. And not, I can't imagine that level of security in my old job. So I'll just tell you my life priorities have just been completely restructured as far as, I get a wild hair now and then I'm like, Oh, I'm going to open up six new DPC practices. We're going to take up the world. And it's funny because I'm always humbled. And that doesn't happen. Thankfully. So another story I'd love to tell is bringing on our second physician here. This will highlight that very well. I've had a very good practice now. I've got a nurse who is wonderful. She's been with me for two and a half years now. And yeah, that was, I mean, that was a miracle in and of itself. Basically, like, didn't put out any sort of a job job description. I didn't even post the job and my buddy is like, Hey I've got a friend and his girlfriend's a nurse. She, maybe she could come see what you're doing over there, interviewed her. And I was like, well, Sarah, I don't have a position open for a nurse. I can't really pay a nurse salary. I absolutely am going to hire you because you are the right person to be here caring for my patients. And I can teach you how to be a medical assistant, but I want you to do as much nursing as possible because you are such a phenomenal person. And that has been such an incredible decision to have somebody Yeah, to work alongside a nurse. I mean it, I again, I'm like, I cannot believe it's really the way it was designed to be. And for those of you who are like, have been working with a medical assistant, or if you're thinking about like, Oh, do I hire a nurse or hire a nurse? It's amazing. I'm just absolutely blown away. Yeah. So grateful that I have her.

Dr. Maryal Concepcion: 38:58

So talk to us about this because, with you being a business owner and a successful business owner with productivity and the fee for service model, and then transitioning over to DPC, I'm guessing you had to have saved up some and also saved money because your practice is in your basement. But how did you approach one financially? being at a level where you could open a DPC. And then how did you approach financial decisions like hiring Sarah and like hiring your second physician?

Dr. Neal Douglas: 39:25

No, I think that's a really good question. So the financial side of things was we took a huge leap of faith. you know, if you've heard Kissy's story, she sold her car. I've heard people selling vacation home or whatever it is, or, subletting and space, there's a lot of, ways to do that. we had just purchased our home. We hadn't sold it. Little to nothing in savings because we had just used it on a down payment and I just went to my wife and I said, I think God's calling this direction. We asked for an open door and that door was just open. We're going to step through it and we pulled our kids out of their little three day a week private homeschool. That was an extra cost. We pulled them out of a lot of the high, right? You know, the sports things that cost more money and I started doing some hospice work. That was the only way I could sustain and yeah, and then we basically went, that would have been a decrease of, yeah, we were living off of 20 percent of my previous salary. And it was borrowing food from my parents freezer, like meat from their freezer. I grew up on a farm and we raised beef and chickens, I think, all that stuff. So we raided the freezer. They were fine with that for the first year. It was just really humbling. We, it was just, we had to just basically scrimp and save. And there were months we didn't think we were going to make the mortgage. And we pray. And suddenly, There'd be something that would happen like a bonus from hospice that I never knew even existed or an uncashed paycheck from two years ago at my old practice that, that, that happened. The gal called me and she's like, you didn't cash one of your paychecks from two years ago and I was like, that's like a third of my salary now. Um, That was a huge one. Man, I haven't thought about that since. Anyway, I'm going to tear up now. Yeah, there were just a lot of things that took faith and really just stepping out to a place where we had next to nothing. And to build out my clinic. I called my brother and just said, Hey, you have any old construction equipment we can, or materials we can use to help patch this thing together. Anyway, it was incredible. My family came out, supported us. We had yeah, looking back on that now without that journey, again, that gratefulness, that kind of place of just feeling like this really was grown out of something much bigger than myself. I think it, had it been easy, I would fall into that trap that it had just been because I was able to do it or whatever. So,

Dr. Maryal Concepcion: 41:48

It embodies that picture of a rollercoaster that you were talking about earlier.

Dr. Neal Douglas: 41:52

yeah, yeah, major ups and major downs and, you know, such an important journey though. And again, it makes me feel very, very blessed to be where I am today. the other development that happened. We had an allergy clinic here in Hood River. We're about an hour away from any sort of major metropolitan area. There was one clinic here that was administering allergy shots and doing allergy testing. Which is a very, very bread and butter, very gold standard, very cookbook medicine, about as cookbook medicine as it gets to be honest service that you can provide and a lot of primary care providers, I encourage them to look into that if they want some subsidiary way of income, but we have an immediate need in the for that. So I had the previous office administrator came to me and we partnered together to start a new business to do allergy care. And that did help quite a bit to alleviate some of the financial strain that we were under. It also allowed me to build the DPC practice. In a little bit more of an organic way. It also helped me to be able to hire somebody to actually help me with the work because I was at about 220 patients and it was really challenging to, to do that by myself. I think, with hiring Sarah, it really was. giving her a business proposition that said, here's what I can afford. I did have to take a pay cut personally to be able to do that. But really I saw so much value in having patients be at, be able to access like nurse level care and then her ability to come in I was doing IVs and doing some of those things, but to have somebody else who was able to do that while we were providing the other care, it just really freed up the schedule, and it made it so much easier to be able to add new patients to practice. So, yeah, so I gave her an incentive, every patient that signed up, she got, 50 percent of the enrollment fee that we charge. And then some other bonuses that were tied into the allergy practice as well. So she gets something along those lines and then just told her, you know, every 6 months we're going to reevaluate and we're going to make your job better. I know I'm paying you. well under the market value, but I really want you to feel like this is a great place to work. And I'm going to work with you to be on vacations that you have set up. And she did, she was like, Oh, I've got these, Three big trips coming up with this summer and I'm like, that's great. I was like, I've been working by myself. So yes, you, you may have every one of those trips and I will, yeah, I'll give you paid vacation for a few of them too. So, yeah, that think that was, and I learned that from Rob, it's like, just be as giving as possible to your employees and they will, do. Whatever they can for you. And if you can't do that financially, there's a lot of other ways that you can incentivize people to do some of those things. So, yeah, she's got, I mean, now she's almost at the level that she was getting paid before. So I've really kind of paused my income track and really built hers to make sure that she stays. And her responsibility list has just continued to grow as she manages. Sort of both she's both office manager now and nurse for both practices. So yeah, it's been that has worked out incredibly well. That way, so

Dr. Maryal Concepcion: 45:00

incredible, absolutely incredible. And when it comes to. You have now added on a second physician like that definitely was not the case back when I met you in 2019 And I think about how it's a big challenge for people To grow their practice if they wish to find another physician to join on So tell us about your journey in not only the financial part of adding your second physician, but also how did you guys connect?

Dr. Neal Douglas: 45:25

So had you asked me, yeah, like two and a half years ago, like, am I going to hire a new doctor? I'd be like, no, I'm perfectly happy. We have, 400 DPC patients. We have around 600 allergy patients. They're a lot less complicated than the DPC patients. And yeah, and I've started to do PRP and, you know, that we get some community members pay cash for that. And. still doing vasectomy, cash, and all that stuff. So things are great. I was like, I was happy with where the practice was at. But this is again, totally a God thing. So I get a call from my mother who's like, Hey, I want you to call. This person, name's Claire. And because I've been talking to this woman in my Bible study and her daughter in law is a family medicine doctor and lives in the Dalles and she doesn't like her job. And you guys should just talk to each other. I'm like, mother, that is the most awkward thing you could ever do. Like set me up on some blind date with a doctor who I don't know. mean, I've heard of this person, but I don't know her and I'm like, that just sounds terrible. What am I going to do? I'm going to call her and be like, Hey, I heard your job sucks. And I love my job. So maybe you should come like that. Just, it doesn't sound. And Oh, I'm not hiring anybody, but I just was calling you to see how bad your job sucked. Like there's not like, there was no conversation. I'm like, mom, Thanks. But no, thanks. Like, I appreciate that. But if she wants to call me and talk to me, like, whatever. So like, if you like, I think like three or six months go by and my mom is still just like, you know, you gotta call Claire. You gotta call Claire. I'm like, mom, this is like, okay, whatever. So finally, I get a call. And it's Claire. She's like, so my mother in law will not stop badgering me about calling me. I'm like, well, that's really funny because my mother won't stop badgering me until I talk to you. She's like, well, good. I think we're going to accomplish something with this phone call. And that's really where it started. I'm just like, Hey, like this is what I do. You're welcome to come and see what that's like. I was like, I'm not hiring anybody. I have no idea what a partnership or what any of this would look like. I'm like, I work in my basement. you might want to work in my base. I don't even know. Don't know. Do you want to do DPC? Just come check it out. So Claire came, we had amazing time. I realized, Oh my goodness. Having a colleague. Like a doctor colleague to bounce ideas off of it was incredible. I was like, I forgot how nice that was to not feel like you're on this complete island by yourself. And I think God just knew that it was time for that to happen. So she's like, well, I've got a really young kiddo and her husband's an internist. He's two weeks on two or one week on one week off. And she was working very part time and she was like, I want to join your practice. And I'm like, awesome. That's great. No idea how to pay you. No idea how to make any of this work. I'm like, you know, I'm not here most Thursday and Friday. So if you want to work Thursday and Friday, she's like, that sounds perfect. And I'm like, well, I'm happy to cover any vacations you have, because I've never had anybody for my vacation. And she's like, that sounds perfect. And I'm like, well, let's come up with a plan. And that, it really was like that organic and I'll never forget, we went to dinner with them and her husband is like grilling me about DPC like all the questions like how is it financially sustainable and how you do this and that anyway, it's great conversation But at the end she called and she's just she just said neil, you know I prayed about it and I have a total peace and god's called me to practice at your clinic and I was like, okay Well, that's it. We're gonna come on in and we'll figure out how to get you paid and go from there So she started with zero patience and she's up to She's really growing it slowly because she's, mostly mom, but she's also loves doing the family medicine. So she sees maybe two to three patients Thursday and two to three patients on a Friday. And she has, I think, 50 or 60 patients now. And she's growing that slowly. But man, to have her to bounce ideas off of and to talk through cases has just been, oh my goodness. It's just been so amazing. And then I can go on vacation. Oh my goodness. It's crazy. Like in the middle of nowhere and not feel like my patients only have access to the emergency room here in town. So it's great.

Dr. Maryal Concepcion: 49:32

That's awesome. How do you guys address the nuances of this partnership because you already had an established DPC.

Dr. Neal Douglas: 49:39

yeah, I think, that's a great question because it is not easy and it takes the right relationship with somebody. I mean, if we rewind, I got completely burned by that office manager who we went in and did our business together. That's a whole different story. But kind of salvaged that practice and now it's thriving But I had been in a business relationship that I Just, it was not healthy as far as just the way it was run. So I realized I was not in the market for a partner. I did not want anybody else to have any skin in the game, especially because being run out of our home. There's just a lot that would go into that. If something. Anyway, there it's too much me to let anybody else have partial ownership of the practice. So I knew that was the case. And I also knew she wanted to be very part time, but I also knew that bringing on another physician, the overall cost to me besides the EMR was very nominal. I mean, the supplies that she uses, supplies are not expensive. I already have a fully stocked clinic. So really the only overhead item that I noticed was that EMR bill. And so I told her, I was like, I'm okay with giving you the majority. In fact, more than the majority. of what you bring home, so you feel like this is worth it. Because to me, having you here improves the quality of the practice so much, and the quality of what we provide patients and this community, that it is really worth it. for me to have you as a little bit of a loss leader, especially in the beginning. I was probably too generous for her. We did a 90 and it was going to take 50 patients for her to even make up the EMR version. But she was so grateful for that and that kind of like that vote of confidence and what she was bringing to the practice that I think, I don't know if I would do it that way, just because it has taken a while for her to build their practice. But now everything's breaking down. Even at least for me, I'm not making a profit off of her, which is okay with me too. But really the value add all the intangibles have been phenomenal. And so just having her here, having the vacation coverage. Having somebody else who can manage my patients, my female patients who aren't comfortable seeing me for a lot of those issues. she's actually taken on a fair number of the female patients in that space. And it's worked out just incredibly well where her skillset now is like very, very complimentary to my skillset. So she sends me a lot of her sports medicine patients and a lot of the people who need, that. Level of care. it's been phenomenal. And again, business wise, did I make the best business decision? Maybe, maybe not. But again, Rob being my mentor, I just hear his voice every time I make these decisions and he's like, just keep your people happy and you will be happy. Like if you try to cut corners or if you try to like profit off of these relationships, just know, it just. it introduces just a different, kind of a different context to that. Now, I will say I am planning to recoup that. So once Claire gets above a certain number we are changing that to the more traditional 60%, 40%. So she'll take 60 percent of membership and I'll take 40 percent for the additional patients that go above and beyond that. initial number. So that's where we're at, but it's hard to, cause she gets paid almost the same as I do for the DPC side of things with 50 patients. But anyway, that's my issue and that's running a business out of your house. And there's lots of discussion I could have about, you know, making sure I don't pay myself too much because anyway.

Dr. Maryal Concepcion: 53:18

Well, I think it's so important to hear because even with you just saying that, I'm sure there's people out there who are like, how does that even make sense? 50 patients and, making, if you think about even a salaried full scope primary care physician. at the time that we joined where we were at Incorporate, it was probably around two 20 was what we were bringing in as, as two halftime doctors doing we were doing job share at the time So when you think about it, it's like those people who have on the podcast talked about, you know one way is to start with what is your ideal salary and then work backwards from that. And then I thought it was very good of Dr. Julie Gunther to mention, you know, increase that overhead percentage to probably like from 10 to 15 to 30%, just like over plan for overhead, because in DPC, I think, especially when we're. MD, DOs, budding entrepreneurs that have not necessarily run businesses before you're going to make mistakes sometimes, or you're going to spend a little more than, if you had glasses and you could look back and save on certain things. And so that is totally normal. But I think that it's really good for people to hear that because you literally have the ability to, craft how your income is going to be made, even with doing side gigs like the allergy clinic in your case.

Dr. Neal Douglas: 54:32

So

Dr. Maryal Concepcion: 54:33

let me ask here because, you know, one of the biggest fears in going to DPC is how are you going to cover your malpractice? Because we have. malpractice, like you said, Oh, we'll cover your malpractice. We'll give you a salary. We'll cover your tail, all of these fancy things that are the golden handcuffs, especially in corporate medicine. How did you guys address malpractice for yourself and then adding a second physician on?

Dr. Neal Douglas: 54:56

Yeah. And I think that's, one of the biggest hurdles for people, it's certainly like the biggest, check that you're going to write outside of like a lease to get a practice started for me, at least, you know, running the space out of my home that is our biggest expense every single year is, the malpractice. You know, this is an issue that's been around for a long time. I think, physicians realize that. Obviously, it's critically important to have malpractice insurance. It's critically important to have coverage. Personally, I have both malpractice insurance. I have an umbrella policy that covers our home and covers our family, and then I have business insurance. But the malpractice, insurance piece specifically, I was really interested in because one of the things that is, I mean, DPC is so innovative in the way we care for patients and in the way we, build relationships with patients that, to me, there really should be compensation for that. There should be some offset because we are putting in the time and effort to make the right decision and to provide care in a way that's accessible and to provide better care. And I would stand by the fact that I provide better care in my DPC than I ever could have in my fee for service practice every day of the week. There is no comparison. So, But that really has implications when it comes to a malpractice insurance and a company. So, rewind and if we go back to, I think this would have been, 2020. I was recently, well, maybe 2021. Anyway, I'd recently be then put it on to the board of directors for the direct primary care alliance. and one of the topics was, well, we found this in an insurance broker who's really interested in working with us. And I mean, it kind of makes sense if you have a group of doctors who practice very low risk medicine, and you're making a commission off of every doctor that you sign up. Interfacing with a big doctor corporation or something that could have potential to grow very quickly would be very lucrative, right? So, I realized and yeah, so anyway, I was the guy whose hand was raised at the end of the meeting saying like, yeah, I'll take that on. That sounds great. I had no idea what we were getting into. I realized pretty quickly that talking with a broker was not the right person because the first question I asked is how are you getting paid and the answer is I get paid for every doctor that I sign up. And I said, okay, so you're taking a percentage of our, Malpractice fees, whatever it's called. And that's the way traditionally that that's worked. But I realized, rather than working directly with this middleman, who is essentially what a insurance broker is going to be, What if we found like an actual insurance provider who was willing to see the benefit of direct primary care, and when it comes to their underwriting, and when it comes to like building their policies, when it comes to actually interfacing with the doctors that they would automatically understand the style of practice that we have and what we do. So I was really looking for a relationship with a company that would allow us to not have to constantly justify what we do, how we do things, but rather a company that would be like, Hey, we're willing to we see you, we know who you are, we know what you do, and here's what we can do. that led us and, you know, Dr. Cloda Ryan was part of the board at the time, and she said, you know, I've got a decent contact for that. I've got someone that I work with who seems really reasonable. You might reach out to this company. And we did. It was, yeah, we started a conversation and really, as the DPCA, we're able to grow a relationship with a company and not just a company, but people who represented that company who really understand in a pretty foundational level what we do in DPC and understand. Why we do what we do, but more importantly, we're willing to give us significant discounts on that rate because they realized how much better. Our care was going to be and how much lower risk we are going from, say, caring for 4, 000 patients down to caring for 400 patients.

Dr. Maryal Concepcion: 58:58

I think that's really important because I think that, there's so many stories of you know, people being afraid of starting relationships or partnerships with people who are in the healthcare ecosystem, the direct primary care ecosystem because of experiences that we've had in the past with corporate medicine, etc When I heard that somebody had spent thousands of dollars on a website for their DPC clinic and spent their seed money on there and then had to pay another person money to fix the copy because the original copy did not portray DPC at all, these are the low points of the roller coaster journey when you're like, I had seed money and now I don't have that seed money and I still don't have something to show for it. So when it comes to, finding and building relationships out there with like minded people who understand what we're doing, think that's wonderful that you found this in a malpractice company. how did you continue that conversation? Ended with you getting a malpractice policy that you could afford, because a lot of doctors out there are thinking that malpractice is never something that I could afford, and I don't even know where to go to look for one.

Dr. Neal Douglas: 1:00:05

You know, really the interface was just trying to find people who understand, what we did to start with. And then the other thing that really, drove this home, my first question I ask anybody interfacing with me now is how do you get paid? How do you get paid? If the answer is, well, if I sell you this product, then I get paid. That doesn't feel great because. that's not ideal. The initial agreement that we had with the malpractice carrier that we, initially formed our agreement with was that the, rather than working through a broker to a middleman to interface with that insurance company, that's an additional 10 percent on your rate right there. This. malpractice carrier was willing to interface directly with the doctors and that would save immediately 10%. So the person getting us enrolled was part of the company and pay was not tied to whether we signed up or not. That felt very organic. It felt, you know, the, our representative was growing her company, but at the same time, wasn't getting paid a commission for getting us that worked out that that relationship ended up working very, very well. The only challenge was we have doctors in 50 states and that insurance only covered eight states. So we really needed as the need for more affordable malpractice insurance, and you know, right, right off the top, anybody in those eight states was getting a 20 to 25 percent discount on their rate. And that's like huge, for me, you know, going from 8, 000 a year to, to around 6, 000 a year. That's, you know, that's, that's real money, right? That's, that's a big deal. Especially with a mature plan. So, But the challenge was, and for me, it was a bummer because they didn't cover that state. So we ended up having to shop for other companies that were willing to provide policies under the same agreement now and knowing that they weren't going to get commission fees, knowing that they weren't going to get those things that they needed to provide similar discounts. And that really grew a whole nother discussion and caused sort of a pivot in what we decided to do As far as the direct primary care alliance was concerned and how we were going to address that problem of getting affordable insurance in the door, and really what it boiled down to was working with the right people and getting to building relationships with people that. Again, we could, really trust to provide the level of care that we needed and, the type of product that the average DPC doc would need to be confident in opening a practice in a basement, even if they wanted to.

Dr. Maryal Concepcion: 1:02:43

Literally, not figuratively. I love that. I love that. And in terms of, when you brought Claire on did she come with a policy that you guys had to participate in paying off tail or did that get worked out with this malpractice company and that's assuming that she also signed on to that company versus staying with her other?

Dr. Neal Douglas: 1:03:05

Yeah, she signed. So, we have been waiting for, almost two to three years for Oregon to be on the covered state list because it takes time for them to jump through all the hoops to get coverage in different jurisdictions. But yeah, it's funny but Claire actually got her policy with the DPC Alliance. vendor before I did, because she's also much more organized than I am. she's very good at getting papers in and all of her ducks in a row, which I appreciate about her, but I'm just not so good at that. Anyway, she transitioned her malpractice over and. I don't know exactly. I know for her it was a huge savings. She was already part time with her old malpractice insurance provider. But I mean with the savings that she had with the direct primary care alliance, so she signed up for the membership with the alliance and then got the alliance based quote and it was still so much better than what she was paying before. So for her, she really felt like even though she was starting with zero patients, it was worth carrying that malpractice insurance. And it also covered her moonlighting work. She's still doing some pediatric call work for the hospital nearby. So, Yeah, it ended up being a very good fit for her and wasn't a huge barrier, fortunately.

Dr. Maryal Concepcion: 1:04:19

That's great. And it's really cool to hear also that it covers, her work in addition to DPC at the hospital. I think that's so important because people are definitely thinking about, do I opt in, do I opt out? Can I do a side gig? Can not do a side gig? And what do I need for both DPC and side gig to survive? So what would you recommend for those doctors, especially those who are planning on opening because we're approaching 2025, if they're looking for malpractice, and they're either with no policy yet because they're coming from residency, or they're transitioning off of a malpractice plan to switch to one similar to yours?

Dr. Neal Douglas: 1:04:54

Yeah. I mean, the first question you would always ask anybody who's offering you a malpractice insurance product is how do you get paid? And if they're getting a significant commission and you can ask them, what is your commission that you're going to get paid on this? Just know that you are paying them literally that commission you, that comes directly from your pocket. They're not getting, and a lot of these brokers are paid only on commission. That's the only way that they make money, but they're going to get 10 percent of your malpractice benefit. dollar every single payment. And to me, when you're making a sale and you're getting 10 percent of every payment, that doesn't quite feel right. It would be like hiring somebody to recruit DPC patients and they get forever a portion of the patient's membership because they brought them to you. Again, that's not where the relationship lies in my opinion. So I would encourage people at that stage To look for a company that you can interface with, or looking for a broker who specializes in getting DPC insurance, looking at, is it worth, Some people have decided, Oh, if I get a big enough discount from the DPC Alliance, I'll join the DPC Alliance. And then that'll give me access. Other people say, you know, I, I think I can interface and I can get a really reasonable deal. And that is true. I mean, we are, DPC has grown to the point where some malpractice companies do identify what they're doing. those reduced risks look like. So asking around finding out, who those brokers are that are trusted or finding out what other doctors are using. And then, you know, ultimately again, asking that question, how are you getting paid to whoever it is who's signing up for that insurance is a really important question to have. I've even, talked with some insurance brokers where I say, hey, can I pay you 500 bucks to find me a really good malpractice insurance plan? And then you're not taking a 10 percent commission for the rest of the time I'm on this malpractice carrier. Sometimes that's legal. Sometimes states have regulations around that, but anyway, I would just say, shop around and see what you can find. And again, for some people that there are companies out there that do recognize what we do and they give us a substantial discount for that. There's one of the big conversations that's been happening at least for the company that I've worked closely with for the last four years. One of the big conversations we had is what is part time? How do you define part time when it comes to a malpractice policy? So traditionally part time means that you spend less than 20 patient contact hours. The problem with DPC is you can spend 20 patient contact hours by seeing five really sick patients or whatever it is. And we don't base our risk really doesn't reflect the amount of hours we're seeing patients and talking to patients. I see patients three days a week. Strictly, I wouldn't meet that 20 hour criteria. But, If you looked at my schedule being one tenth of what it was when it I had four to 5, 000 patients on my roster. Now I have 400 patients. That's a big difference. And, Again, finding a malpractice company that identifies that difference is really, really important. That is like an entire culture shift away from the way they've usually identified part time practice. So if you can find a carrier that does allow, that does identify that, yes, your patient panel size reflects your risk more than the actual hours worked, that plays hugely in your favor. Totally.

Dr. Maryal Concepcion: 1:08:11

Totally. And. As you look for malpractice as a DPC doctor, it's definitely something that those people who understand that DPC is different and that even DPC is different than concierge medicine. It's so interesting to hear those conversations when one can get so used to, you know, what's your claims data. And some of that can be it can be very refreshing to have those conversations. So I definitely echo that talk to people who are in your state, talk to people who are around you, who are already in your, cohort as you go on your DPC journey. So wonderful. Now, in closing, I want to ask about going into 2025, we're going to have a different administration on Capitol Hill. What is the feel around Hood River in terms of when it comes to healthcare in particular at your practice, because, you know, I look at how DPC rode the wave of COVID and I definitely see. Because we are built local, because we are funded by our members and we are not funded by people who can change rates and whatnot, that it gives us a little less stress going into the future. But I wanted to get your thoughts on that.

Dr. Neal Douglas: 1:09:17

Yeah. I'll tell you from my standpoint, having DPC practice and owning a DPC practice is. The best long term investment that you could make because your market are people that you interface with and care for daily. And regardless of what happens, and I've, been talking about this for years now. I mean, really, I love thinking in extremes. I love that zoom out. I'm definitely a big picture person. And if you look at like what are the two extremes that we can watch our healthcare system move in? If we're moving towards a system that looks much more like Canada, or if we have more socialized medicine, whether you believe that's the right thing to do or not, I If you have a direct primary care clinic that is established, and if you've worked to ensure that there are some protections in your state and your area around direct primary care really, you would be in a phenomenal place, because even in places with socialized medicine, there are private practices that care for people outside of the system and provide excellent care. But we're already doing that. And so, even if something were to shift that direction, we know. Direct primary care would always have a place, now look at what could happen if we go full corporate medicine, kind of the path that we've already been on. And we're watching that, you know, the profitability of medicine has increased. Tenfold in the last, you know, several decades, and it's probably just going to continue to ratchet up over time as far as the cost to our society for health care, the cost to the consumer to get health care, again, direct primary care is the absolute best place to be. Because while insurance rates are raising at a significant rate, my overhead isn't raising at nearly that rate. And so, it becomes more and more affordable, the less affordable, the insurance practices get. So, really, The way I see it, direct primary care, kind of this solid foundation, this ground where we are insulated from a lot of the outside pressures that come from changes in administration, that come from changes in a lot of these policies that come through. That come from the massive lobbying that happens at the state and federal level to ensure that our system stays the way that it is. We're really bypassing all of that and just saying, you know what, at the core and at the center, we care for patients. That's what we do. And we can prove that we do it well, if there were a bill that were going to be passed that would threaten direct primary care, I could have at least 100 of my patients would be driving down to our state Capitol building with me to sit there and tell their stories about why that would be a terrible decision for our state. So that. to me that that's very powerful. And when you get into a community, and for me, it's a small community where you're making such a big impact in lowering the price of health care. We have, we have families who come in and I mean the primary reason they're here is because they've had such terrible experiences with their insurance and with the way that's worked. I don't, I, they, they, they find that it's all word of mouth. I do know marketing now and we are growing. Substantially, it is 100 percent word of mouth, but it feels so good to have patients who have that immediate need. They see how broken the health care system is, and they're coming to us. And again, for me, whether no matter who's in charge of our country direct primary care has the staying power. to provide exactly what people want with having a relationship with their primary care provider, with being able to access that care. I don't see it changing anytime soon. And for me, I can sleep at night regardless of where that's going, because I know Worst case scenario, the farmers I take care of are going to bring me their vegetables, the people who own the yeah, I mean, we've got, yeah, I've got a guy who does our yard maintenance and takes down our trees and we do that for trade. I've got people who are doing my cement work and making sure that. We've got our, you know, our, anyway, like all of our dirt work and cement work is all done for trade because had our house that was painted for trade. Our community is literally investing in the small business owners that I care for are so. So excited about the care that we provide them that they would gladly trade their profession for my profession. And that feels like you're insulated from anything. So I, you know, if you're, if you're one of these people, whether you feel stressed or, you know, whatever it is about what's coming down the pike. Yeah. And you're on the fence about choosing whether DPC is a good fit, I'll just tell you, there's no better time to get into direct primary care. You have a degree in the most important field in our nation, in that we spend more money on healthcare than any other country in the world. Than any other dot line item for our country. You have a primary care degree, you, yeah, look at the guy who runs the plumbing business, look at the guy who runs the HVAC business, look at these people who have, don't have a professional background that we have, who aren't in fields that have so much money that's out there. And now look at the value you have to be able to provide primary care to know that that is valued and to know that it just takes that little bit of work to do what all those other people out there with those blue collar jobs have done, which is start a small mom and pop business and get to work doing what you love and what you care to do. And I'll tell you, there are so many opportunities, so many needs in your community right now that if you just. are faithful and meet the needs and are listening to what your community needs, you will be successful. And that for me, I didn't, I didn't plan on being an allergist, but that was a need that my community had. I did not plan on using my ultrasound to every other patient because my patients are constantly injuring themselves in my community, which is a high sports, high outdoor. You know, arena for all the crazy things, but that's what my community needed. That's why I started doing PRP injections because every other patient it's like, yeah, you blew out your shoulder. You blew out your knee and I hate injecting steroids. So guess what? I'm going to start learning how to do PRP injections. And that's a huge part of my practice now, but it's about being able to see a community need and filling that need. And even if that skill set for you right now is just providing a relationship that provides care, there are so many people in your community that need that right now. And if you keep your ear to the ground and you're there to provide what they need, I will tell you your chances of success are phenomenal. It's going to be hard. It's going to be, there's going to be ups, there's going to be downs. It's a leap of faith, but find the people that you trust, find the people who can give you good counsel and you can do it. Now is a great time.

Dr. Maryal Concepcion: 1:16:45

Thank you so much, Dr. Douglas for joining us today and sharing your story.

Dr. Neal Douglas: 1:16:49

my pleasure.

Dr. Maryal Concepcion: 1:16:50

We're going to continue the conversation over on our Patreon community and really focus on what full scope family medicine looks like and how Dr. Neal Douglas is delivering what his community needs and having an amazing time doing it and growing his DPC. So be sure to join us on the Patreon community for more of the conversation. 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 Mariel Concepcion.