The Legal Side of DPC with Dr. Phil Eskew

In this episode of the My DPC Story Podcast, Dr. Phil Eskew, a DPC physician, lawyer, and MBA, shares invaluable insights on the legal and regulatory aspects of Direct Primary Care (DPC). Dr. Eskew emphasizes the importance of clear patient agreements, discusses HIPAA compliance and HSA, and offers expert advice on DPC contracts and physician employment terms. He also provides key considerations for telemedicine models, state-specific regulations, and integrating clinical workflows. The episode delves into the significance of understanding the legalities of DPC and encourages listeners with legal questions to engage with the podcast. The episode offers a rich resource for DPC professionals, featuring discussions on DPC's legal, clinical, and administrative aspects, making it a must-listen for DPC physicians and those interested in the field.

FREE 1 month trial - HEIDI HEALTH PRO: As Individualized As Your DPC.

FREE Alternative to Up TO Date: OPEN EVIDENCE

Transcript

0:57

Hey everyone. I'm bringing back a crucial conversation with a triple threat himself. Dr. Phil sq. MBA. J D and DL. With him being a physician and lawyer, and having been. One of the driving forces of the DPC coalition on Capitol hill. I'm excited to bring this conversation. To the top of your feed. Because with all the changes happening in healthcare right now, it's more important than ever to have a handle on where DBC and policies like HIPAA and high-tech. Intersect. So, whether you're a seasoned DPC veteran or just starting out this episode is a must. Listen.

Dr. Maryal Concepcion: 1:36

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 Concepcion, 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. Phil Eskew: 2:24

Direct primary care means that patients receive the ongoing care they need from a physician that took the time to cover every concern in comprehensive detail. It means I'm not annoyed with a door handle question or even a list of questions. It means I'm not annoyed when I look at my schedule of patients for the day, and the most common chief complaints are low back pain, migraines, or polyarthralgias. It means the physician has the time to practice broad scope primary care and to act as a zealous advocate for the patient, rather than as a mediator between two warring tribes, such as patients and insurance companies. I'm Phil Eskew of ProactiveMD, and this is my DPC story.

Dr. Maryal Concepcion: 3:06

Dr. Phil Eskew is a DPC physician and attorney. He founded DPC Frontier in 2014, prior to completing his family medicine residency in 2015. He is the VP of Clinical Development and General Counsel for ProactiveMD, an on site focused DPC company headquartered in Greenville, South Carolina. He volunteers his time as general counsel to the direct primary care coalition, where he routinely relies on his accounting and legal backgrounds to discuss federal tax policies. His research has been published in many journals, including the Journal of American Physicians and Surgeons. the journal of the American Board of Family Medicine, Family Practice Management, the journal of Legal Medicine, and the West Virginia Medical Journal. He has given over 50 CME talks about DPC, including events hosted by the AOA, the ACOFP, AAFP, and the AAPS that included well known events like the DPC Summit, DPC Nuts and Bolts, and Hint Summit. He also educates fellow attorneys at CLE venues and has spoken in New York on multiple occasions for the New York State Bar Association. Phil, you have beyond a traditional background because you hold three degrees, a DO degree, a JD degree, and an MBA. Can you share about your journey in achieving these degrees and how you came to focus on DPC?

Dr. Phil Eskew: 4:38

I grew up in a family of physicians and I would hear my parents discussing medical issues at the dinner table, and they enjoyed medicine, but they didn't like a lot of the ancillary things that went around it. And in many ways, I think they felt a little bit trapped when it came to those things, just like most physicians do today. And, you know, my mom's a pathologist. My dad's a family doc. I've got aunts and uncles in medicine as well. And they encouraged me to pursue additional training so that I maybe could be in a position to. Address some of those problems. And so one thing led to another. And when I was an undergrad, I majored in chemistry, but also in accounting and found that the accounting training was helpful, but it didn't get me where I wanted to be entirely in terms of answering these ancillary questions. It helped me with a lot of business concepts, so I pursued the MBA to sort of further cement some of those things and realized that I also needed a law degree if I was going to really address some of these problems. So, I finished undergrad in 2005, did my MBA in 2006, did the law degree in 2008. I kind of went through them as quickly as I could doing summer classes because I knew that med school was a long process and residency was a long process. And from the get go in med school, I found that my classmates were always. asking me a lot of legal and policy questions and a lot of health law related questions and health law is not covered on the bar exam. It's an elective in law school and a lot of what you do cover is traditional. But I, I learned about DPC back when I was in my, my second year of law school when a classmate of mine had been researching some DPC related issues because One of the first DUPC practices in the country was a guy named Vic Wood, who was a DO graduate of my school in Louisburg, who was practicing up in Wheeling, West Virginia, and he sort of read about that and thought that there were, in his mind, unfortunately, legal issues with the practice model, and we kind of had differences of opinions back then, so that was the first time I'd heard about this particular practice model and what the legal concerns with it might be. And so I suppose over the years, ever since my first year of med school, I always found myself, you know, spending any free time I could find kind of nerding out, if you will, on these issues and knew right as I was starting rotations, if not before, that I wanted to do primary care and wanted to be a DPC physician.

Dr. Maryal Concepcion: 6:58

And prior to finishing residency, you had created the DPC Frontier, and I'm assuming that the material that you curated for the Frontier was being amassed way before you created the website?

Dr. Phil Eskew: 7:12

Yes, that's correct. I'd been Sort of creating bookmarks and, uh, lots of word documents kind of over the years throughout my training, flagging certain things that I was trying to keep in my mind and also keep available at a quick reference. And when I was doing that visiting rotation with the Robert Graham Center, which is the research arm of AFP, I started aggregating a lot of practices for, for research purposes. And I was aggregating a lot of ideas at the same time, things that I wanted to put in this publication, and as is often the case when you're publishing something, you write a whole lot of things and then you delete most of it, because nobody wants to read your 30 page article, they want, you know, a 4 or 5 page article. And a lot of those other things, I just, I wound up saving them and collating them in a website format. And I find that that works better than trying to write a book or, or, you know, I do write papers from time to time. But the nice thing about a website is it can evolve. And that evolution is critical when you're dealing with a rapidly changing space like direct primary care, where the laws are literally being written year over year and state after state. And you need a way to sort of cleanly track all those things. And for

Dr. Maryal Concepcion: 8:20

those users of DPC Frontier who might be new or for those users who have just not visited the website for a while, how would you recommend looking at and using the Frontier?

Dr. Phil Eskew: 8:33

Well, I've got, um, tabs across the top of the site that are meant to give people kind of some pointers about where to go. Under the resources tab, there's a category called starting a practice, which is where I would start if you, if you just don't know much about this at all. And a lot of the other tabs sort of sub tabs under resources are meant to be there as a reference. There's over 100 different recordings that are linked. I don't know, probably about 50 academic and non academic articles. Maybe more if you prefer to read rather than listen to CME presentations. If you want to see some of the talks that I've given, you can go to the about tab and under about us. I've got a lot of those papers and talks linked there. Regulations that has all kinds of things from Medicare related questions to whether you should opt out, you should moonlight and HIPAA, high tech, you know, a lot of other federal things are linked there. And then the states tab has a drop down with with every state. It's too long for them to all be listed. But if you click on 1, you'll have a listing of all of them on the left. And any state specific issue that I found for your state, I try to highlight on that category.

Dr. Maryal Concepcion: 9:33

I'd like to highlight that you also have resources for people to refer to if they're strategically choosing a place where they'd like to practice DPC. Can you touch on that, please?

Dr. Phil Eskew: 9:44

Sure. So especially if you're in residency and you're still trying to pick a location. One of the papers that I wrote a few years ago was designed around best state to practice medicine. And that was written in a more generic physician format, not necessarily DPC focused, but I think it's a, it's still useful reference in terms of other regulatory and tax considerations. And I would encourage people to sort of. When you're thinking about DPC, ask yourself, can I dispense medications here? Are there a lot of other DPC practices in this area? And do I view that as a positive or a negative? I would generally say it's a positive thing, both from a marketing and legal standpoint, because they've maybe done some of the homework for

Dr. Maryal Concepcion: 10:22

you. And on that note, I want to ask you the same question that I asked Garrison Bliss. Do you think that there's anywhere where DPC won't work?

Dr. Phil Eskew: 10:31

No, I think it works everywhere. That, you know, some states make it harder than others in New York and New Jersey. You can't dispense and you really can't get good transparent lab pricing. So, some of the value added shrinks a little bit there, but it can work anywhere, even in states where the insurance commissioners have been a little bit more aggressive. You just have to do your homework and make sure your agreements don't rub them the wrong way. People often ask this question in terms of rural versus suburban versus urban environments. And I think that DPC is a more natural fit in locations where patients are already used to asking a lot of their family physician. And in rural areas, I think it works really well because of that. Because people are already accustomed to asking the family doctor to do as much as possible because they don't want to drive an hour and a half or two hours to see a specialist on a regular basis. And I think that happens maybe in some urban areas too where The access to specialists might be not not be as great as you would suppose. And then the suburban areas that are really popular locations for physicians that have a whole lot of subspecialists and or maybe even saturated with subspecialists. And you've got patients who are really maybe well insured who are. Self referring to those subspecialists, assuming that their family physician wouldn't or couldn't or didn't, you know, didn't want to deal with a certain issue, then those places are going to require marketing not only to educate patients about what DPC is, but to educate them about what family medicine or maybe if you're an internist, what good internal medicine can be.

Dr. Maryal Concepcion: 11:59

Yeah, as you're talking about rural DPC and the value that a rural community puts on their family practice doctor, which I definitely can attest to in our community, my patients do drive an hour and a half to three hours to see specialists.

Dr. Phil Eskew: 12:13

If you want to see a specialist and they're really far away, but you know you really like this specialist who's three or four hours away, or maybe even further in California, you could probably be a 20 hour drive away, get that specialist to do a virtual consult. And there are a variety of ways to do that, more than ever, now that we We've gone through COVID. They could do it, you know, the traditional way with Doxymir, whatever platform they want, and either bill the patient privately or bill insurance. Or there's actually a set of codes now, at least under Medicare, where that specialist can review your commentary about what happened with the patient and just charge for their time to review that and to provide you advice. And that's done in a way where they're compensated. And it can go in the chart and all those kinds of things. And the patient could eventually follow up with them if necessary.

Dr. Maryal Concepcion: 13:02

Do you see any barriers created by corporate contracts that prevent doctors from working with a DPC doctor in that

Dr. Phil Eskew: 13:10

way? None that you can't overcome. So. There's two ways to go about it. One, you and the patient can decide the patient may have already hit their deductible, so maybe they want to run that stuff through their plan in the event they haven't hit their deductible and they don't want to deal with potentially being messed over with a surprise bill that they're going to have to pay all of, then that's where you can educate your patient about their high tech rights under HIPAA, where they can request a cash price in advance of the visit. And then, even if this is an Aetna or Blue Cross or Cigna patient, And even if you're talking to a specialist that is a hospital employee and thinks, I have no flexibility to give you a cash price because we've got all these contracts with these insurance companies, well, high tech trumps private contract. So, it will allow the patient to get a cash price, even from an entity that was not used to being able to do that. Now, they must do it. They could give you a bad cash price, but they probably won't. They'll probably give you a fair one. And they can do that without running a foul there. Or maybe in spite of their private contracts with those insurance companies.

Dr. Maryal Concepcion: 14:13

So how would a DPC doctor and a patient utilize that workaround in terms of using HITECH to trump a private contract?

Dr. Phil Eskew: 14:21

So, there's not a whole lot out there, at least there didn't used to be when I, when I wrote a paper about it, but if you go to DPC Frontier, under the regulations tab, there's HITECH, so it's dpcfrontier. com slash HITECH, H I T E C H. I've got a full explanation with links to the law and an example phrase. You can basically, you know, have a one paragraph phrase and go in there and sort of sign it and hand it to them. There have been other groups. I may need to update the links. I think University of Chicago had a good link that I had linked to for a while, where they had a high tech patient notification form that they incorporated into the regular HIPAA agreements. Ignorance is not an excuse to, for a hospital to not follow the law. And patients do have that right. So, you may have to educate them. The way I do it, rather than having a lot of lengthy conversations, is I, I'll, I'll link to my own article there and sort of show that and maybe send some other hospital examples. If I can find an example nearby or in their state that I know they'll trust, then I can send those via email too. But you're correct that you will have to educate them. And if your patient's going to do this kind of thing, your patient has to be ready to educate whoever they interact with. So if you had a visit where the patient was concerned about privacy and you prescribed medication and you made a referral to a specialist, then when the patient shows up at the pharmacy, they have to make sure to tell the pharmacist they're invoking their high tech rights. And when they show up at the specialist office, they have to make sure to tell them to there's no way to sort of, you know, label those visits as high tech up front. And that's something that they actually commented on in the regs that there's no great way to do that. There's not a high tech box. You can check when you electronically prescribe something to make sure the pharmacy doesn't try to run it through the plan. So the patient has to be their own quarterback for some of that stuff. Now,

Dr. Maryal Concepcion: 16:09

when you talk about states like New York, New Jersey, where you can't self dispense, there are other issues such as non competes. And I want to ask if a doctor were in fee for service because that's where they already are, or they strategically want to work in fee for service and then transition to DPC, what would you recommend they try to negotiate? in their contracts so that they can protect their right to practice DPC in the same geographical community, even with non competes on the contract.

Dr. Phil Eskew: 16:39

So there are various things that a physician wants to watch out for when they're contracting with the hospital for a while. Um, there's a, uh, an article I've got linked under the About Us tab on DPC Frontier called Tips for Reviewing Your First Physician Employment Contract, and I'd recommend people glance at that. The things that sort of come up in these contracts the most are the non compete issue, which you've referenced, and loan repayment issues. Some states, like California, that blanket do not enforce non competes, and other states will, will do. What's, you know, what's called a blue pencil rule versus black pencil rule, which means some parts of the agreement might be enforced and other parts not. And the only way to figure out what your state considers reasonable is to look at cases that have been litigated on the matter. And some states might have plenty and other states really might not have much so it can become difficult to predict rather not the non compete will be enforced. If you are in a state where, you know, it's not enforceable, then there's no point in really negotiating it in the contract. If they put it in there, just keep in the back of your mind that they can't enforce this. Anyway, if it's broad, but maybe enforceable, then take the opportunity up front. to make sure that's not going to get in the way of you doing your DPC practice. And that might take the form of simple geography. If this hospital is wanting you to have a 20 mile non compete and you know that you want to open your DPC practice 25 miles away, then that does it. If the non compete was broader, and let's say it was 50 miles and you thought the judge would enforce it in that state, then you're going to have to rely on something else to get out of the non compete and that something else might be a specification about different practice models. And in these cases, I think judges are more likely to side with the DPC physician anyway. But it could be helpful to go ahead and write that up front in the employment agreement. So what, what am I saying there? If your non compete is really broad and it says 50 miles, any form of primary care, and you think a judge will enforce that, then that could be a problem.

Dr. Maryal Concepcion: 19:16

If a physician is Looking to sign their first physician contract, or if a physician is transitioning from fee for service to D. P. C. Do you recommend that they work with a lawyer? Usually the

Dr. Phil Eskew: 19:28

answer is going to be yes, but some people are more, um, you know, legally inclined than others. And, you know, the analogy I would give is, you know, maybe you're maybe your toilet breaks and you can fix it yourself. Or maybe you need to call a plumber. Maybe you sell your house on your own, or maybe you use a realtor. Most of the time, people are going to want to involve an attorney at some point, and what I try to do with DPC Frontier is to create a free and open access resource to save everybody a lot of legal research time and fees. And what I usually recommend is that the DPC physician. sort of take a stab at it for most legal issues, rather than throwing your hands up in the air and saying, I don't know anything about HIPAA. Just read the page a little bit and know something about HIPAA so that you're less nervous about it and try to put some of those things together using those free resources. And the same thing with your DPC patient contract, shoot me an email and I'll send you the, the sort of boilerplate draft version and you can edit it from there. And you can take these documents that you've put together yourself. And once you think you have an idea of what you're doing and you've put it on paper, then take that to a local attorney. And that local attorney, uh, hopefully has some DPC experience, but historically, often that's not the case because there weren't very many DPC practices. And you want to find one that's affordable and, uh, is, is willing to do this work. And often that might mean a small business or contracts attorney, because a lot of your issues are going to be small business issues anyway. And because a quote health lawyer often has not really had much education about DPC because most of the health law work has nothing to do with DPC practices and is oriented around lots of regulations that hospitals face and complications of third party payment.

Dr. Maryal Concepcion: 21:16

As the DPC movement is growing, I know that there's not as many DPC doctors as there are fee for service doctors. What would be the incentive for lawyers who have greater knowledge in DPC to explore the world of DPC law or healthcare law more? Because as you said, it's only an elective in law

Dr. Phil Eskew: 21:35

school. Right. Yeah. Health law is not on the bar exam. Neither is tax law, by the way. Um, all the way through there and not know much about income tax, but the, the motivation I think would take two fronts. One, you'd have to have more DPC practices so that the volumes high enough to actually sustain somebody's interest in this area of the law and two, you'd want to have more, uh, case law and sort of regulation around the issue. Not in the sense that practices need more regulations. Not what I'm saying at all. But in terms of an attorney looking at any area of the law, if they look at a place and see that there have been a variety of suits about an issue, then it's considered settled law. And it's an easier area to advise clients because you can actually reference things and, and point to safe harbors. Like, you know, as much as everybody hates Stark law, there has been a lot of litigation on Stark law. And there are certain safe harbors you can try and put yourself in if that's the kind of practice you want to run, uh, medically or legally. And I hate stark law because it's complicated and expensive and terrible, but a lot of attorneys like to do that because there's, you know, decades worth of case law and those kinds of things that you can research on the matter DPC. There's not a lot out there, and hopefully you're in a state that has some DPC defining not insurance law in the books, but a lot of them still don't, and you might be in a state where there weren't very many DPC practices, so there's nobody else for that attorney to run ideas by either. And so they feel like there's sort of not much to go on, and because they don't have a lot to go on, and they don't have experience with it, they think that their legal malpractice risk is higher in this field. That

Dr. Maryal Concepcion: 23:16

absolutely makes sense. Going back to the patient contract, are there any concerns if a DPC doctor does not use a contract for one off type service like an aesthetic procedure or an urgent care type of visit?

Dr. Phil Eskew: 23:32

There are plenty of urgent cares across the country right now, whether they're, you know, third party fee for service based or independent that really don't have much in the way of a patient contract. They might have a menu of prices and a few standard forms, HIPAA related or otherwise, that patients are given when they come in. And that's probably acceptable for what they're doing. I think it's wiser to have something in writing. In most of the states, if not all, that do have DPC defining not insurance law on the books. If you want to put yourself in that particular box. as the state has defined it, then you will need to have a written contract because pretty much all of those say that you need to have the contract in writing. The DPC practices I've heard who like to avoid having any kind of contract say, well, everything's month to month anyway, and there's no long term obligation. And that's fair enough to say, but you do have certain rules that can come into play to create some wrinkles there. You know, if the patient is suddenly decides to leave the practice or doesn't have the Money to continue paying the monthly fee, then you do still have some patient abandonment rules that could apply with certain critical medications or certain controlled substances was where there might be a withdrawal and what have you. So, they're going to be default procedures and rules that have an effect on how that patient physician relationship is terminated. And rather than risking confusion on those issues, I think it's nicer just to put everything on paper.

Dr. Maryal Concepcion: 25:02

In addition to the sample contract that you have, do you have an example of a one off, uh, visit type of contract on the frontier?

Dr. Phil Eskew: 25:10

Hmm. I, no, I don't. I could probably try to find something and link it on the example forms page, but there's not been, you know, I guess I'll emphasize the need for a, An agreement is much more important in my mind when you have a DPC membership patient than when you have a, a one visit cash pay fee for service patient. And what you do there is kind of up to you. I don't know that an example agreement there is as critical or as helpful as it is with the membership setup.

Dr. Maryal Concepcion: 25:41

Gotcha. If a DPC doctor has an existing contract with a patient and then wishes to expand their scope of medicine, how could they strategically set up their contract to address that expansion in the future? So

Dr. Phil Eskew: 25:54

you want to specify your own scope and your agreement, and you can be vague about that, and that vagary can create problems for you down the road if you're too vague, or you can be specific about it, which I think is My preferred approach is to tell them what things you are doing for that monthly fee and then the things you're not. And you might have some procedures that require expensive equipment that you do or require a whole lot of your time or that you simply hate doing and because you don't like doing them you sort of discourage people from asking you to do them by charging a fee for those things. Some DOs charge for OMT, some of them don't, some of them do more OMT than others. Uh, I know some DPC docs that do a vasectomy, and that's not included in the membership, as far as I know. Those things are sort of elective and add on, and there are a variety of DPC physicians that have cosmetic options as an add on as well. I don't know of people who routinely include that in the monthly fee, but it's your choice to add any number of things, either in or outside the fee. Uh, some people might Even have something like an EKG, which we would usually, most practices would include that in the monthly fee, but for whatever reason, they might decide that it doesn't make sense to do that because it doesn't fit their situation.

Dr. Maryal Concepcion: 27:04

How can a DPC doctor strategically expand their scope of practice or include services without going above the 150 price per member per month. So

Dr. Phil Eskew: 27:15

the 150 thing comes up a lot when people talk about the primary care enhancement act and the HSA discussion. And as I've said many times before, I think that putting any kind of number on it is silly and, uh, it doesn't make sense for a variety of reasons. It doesn't restrict a scope the way they think it does. Because what you can do is, you know, if you were charging 200 a month and you were a cardiologist and you used to include echocardiograms and EKGs and ZioPatches in the monthly fee, then you can simply carve those out and start charging on a cash pay fee for service basis for those other things. And your monthly fee might fall from 200 to 100 a month. And now you charge 300 400 for the echo and 100 for an EKG and you can get to the same net amount at the end of the year and it becomes kind of a sillier setup that you're going to have to do to get around a regulatory issue.

Dr. Maryal Concepcion: 28:10

I always think about how we can incorporate specialists into the movement as well. And strategically, could a specialist use that? way of charging a patient so that they could do fee for service procedures as well as charge a monthly membership rate?

Dr. Phil Eskew: 28:28

Oh sure, yeah, there are already specialists doing this. I'm aware of some cardiologists that do it, some gastroenterologists. You know, they'll be pulled to expand their scope towards the primary care setting some. My general response when I get a specialist asking about can I do a DPC practice, I say well, If you're treating a lot of patients for chronic ongoing conditions where they need to see you on a routine basis, then this works well. If all of your patients come in and see you once or twice and then you never see them again, then it doesn't make as much sense.

Dr. Maryal Concepcion: 29:01

Dr. Joshi, who is a neurologist in California, uh, discussed this and how he had difficulty getting patients to pay a monthly rate for neurologic conditions because they were typically one off conditions rather than chronic management conditions.

Dr. Phil Eskew: 29:16

So I imagine a neurologist would probably have plenty of patients with maybe multiple sclerosis or very severe chronic refractory migraines who might be more interested in this than some of the others who are coming in and out for nerve conduction studies for carpal tunnel and what have you. Definitely.

Dr. Maryal Concepcion: 29:31

Now you did mention HSA. So like we all know what people all have their opinions about HSA, but How do you foresee HSA in the DPC space as of March of 2021?

Dr. Phil Eskew: 29:43

For the rest of this calendar year, if you were to design your practice to fit in the CARES exception where you charged a monthly fee only for remote services, then this would have probably Appease the employers who were worried about the HSA issue when it comes to individual patients that might be tax savvy and asking you this question, then you can refer them to the tax page of the frontier if they really want to nerd out on it. But generally speaking, I don't. Vice physicians to give out tax advice, I would stick to medical advice and whatever the patient decides, it's not your job to police it. So the patient's going to talk to their accountant about it and their accountants probably going to tell him it's fine. And ultimately, the I. R. S. Hasn't really tried to litigate it anywhere yet. If they do, it will probably be with a larger employer that's made this decision not for one person, but for hundreds or thousands of people at once. And those are the groups that are more cautious about it. So, for those groups, you're either using the CARES exception or you're going to do some sort of modified fee for service arrangement that is hopefully not too intrusive to your practice cash pay fee for service, but is close enough that it approximates your monthly membership fees. But to do the CARES exception is the simplest way, and so your monthly fee is just for remote services, which is arguably most of what you're doing, especially during COVID, and then you're charging some sort of small fee for in person visits. And

Dr. Maryal Concepcion: 31:06

do you have any predictions on what HSA usage will look like beyond 2021?

Dr. Phil Eskew: 31:11

I'm not the best weatherman. Um, you know, there is bipartisan support for the Primary Care Enhancement Act this year, so we'll see what happens this time around. I wouldn't be surprised if that CARES exception gets extended. The government has a habit of extending all kinds of things that were sometimes written for emergencies, so we could keep using that in the interim if the Primary Care Enhancement Act doesn't go through this year. Well, at

Dr. Maryal Concepcion: 31:33

least it's bipartisan. That's a good thing. Another hot topic is HIPAA. Do DPC doctors need to comply with HIPAA? Generally, my

Dr. Phil Eskew: 31:42

answer is yes. They can put themselves in a position to argue that they're not a covered entity, but it can be a very challenging argument to make, and it's not, this is another area where you're Where most attorneys are not going to want to even touch this idea because the country doctor exception is not one that's been litigated much, if at all, the concept is that until you electronically transmit health information in connection with one or more standard transactions. then you don't trigger covered entity status. And the way most traditional practices trigger that status is they're sharing information with insurance companies in an electronic fashion related to payment. And since we're not doing that, you could start to try and build this argument that you weren't a covered entity, but it's easy to mess up and you only have to mess up once and then all of a sudden you're a covered entity. So you might share it related to a worker's comp case. There are some arguments in there about how you share information with pharmacies could trigger it. And there are also State laws state privacy laws that are often modeled after HIPAA and those things typically apply even if you're not doing any third party payment. So my general advice is to go ahead and comply. It's actually not as hard as you think it is. I've got 1 page for it on DPC frontier about what you need to do. And and then if you want to go ahead and build some sort of Argument that you're not a covered entity, you can have that sort of as a backup, but your first thought should be, Hey, I complied with this anyway. And if you find yourself one day threatened, um, with some sort of litigation surrounding HIPAA, you can not only are you complied with it, but you can also argue. I'm not really a covered entity anyway, so you can try and take two approaches at

Dr. Maryal Concepcion: 33:17

once. Now, when it comes to HITECH and the OpenChart movement, do you have any advice for DPC doctors so that they are compliant? Yes, so

Dr. Phil Eskew: 33:27

HITECH was a modification to HIPAA, and HITECH is what your patients are going to use, mostly outside of your practice, to push for price transparency from groups that are not inclined to provide a cash price. The other part of your question, you know, the open, open notes, what does that really mean? Well, the open note concept is kind of what it sounds like that more and more EMRs basically have a login for the patient and they can see pretty much everything you've typed. That makes a lot of physicians nervous, but my advice is to always write your notes in a way that you expect one day the patient might read it and that another physician would read it as well. If there's some sort of litigation, uh, then those things are probably going to be read in the courtroom. So you might as well write them correctly the first time and not do anything, uh, embarrassing or lazy or what have you. You know, even if you think a patient's being disingenuous with their symptoms, you're not going to see me put the word malingering in a chart. Because that's almost always an assumption that you're making and not something that you could necessarily prove. So there are better ways to go about those kinds of things. And what you write in there, you need to plan for them to read one day.

Dr. Maryal Concepcion: 34:32

Now, what about Medicare in terms of opting in or opting out strategically? What do you recommend for doctors who are thinking about doing DPC and wondering about what to do about Medicare? Most of

Dr. Phil Eskew: 34:46

the time when people first start a DPC practice, they still want to do some work outside the practice and there are limited. So, correctional medicine or occupational medicine, especially workers comp, and depending on the response you get from your local VA. are probably the most likely places you could potentially work even when you've opted out. Assuming you're not going to work in one of those settings, then you're probably going to begin by not opting out of Medicare and thus not privately contracting with Medicare patients for covered services. And instead what you would do is you build a wait list of Medicare patients who want to join your practice. And as that wait list increases and as the size of your practice increases, your interest in time and ability to moonlight will decrease. And at some point you'll reach a point where this decision that used to be hard is now obvious and you'll say of course I'll opt out now because I barely have time to moonlight anymore and I have 30 or 40 patients on this waitlist who want to join the moment I do it. The only reason you want to opt out of medicare is because you number one want to see a medicare patient, number two under a private contract, number three for covered services. So all three of those things need to be true or opting out is not really a rational decision for you. For number one, so seeing a Medicare patient, you're very rarely going to see any pediatricians opt out of Medicare. It's just not necessary because the only Medicare patients they see are the rare child with end stage renal disease. And for concierge physicians, they don't opt out because number three is not true. Their private agreement is for non covered services and D. P. C. We do a whole lot of covered services and we can't really take advantage of that exception as easily because if you try to take that approach, then it carries with it the burden. To continue billing on a fee for service basis for covered services, which is something we don't want to do

Dr. Maryal Concepcion: 36:41

with you mentioning correctional medicine as an option for those who are opted out of Medicare. You are currently physically still in Wyoming. You haven't moved to South Carolina yet. And you've been practicing correctional medicine. How did you come to enter your practice? And what has it been

Dr. Phil Eskew: 37:00

like? I found it because it was a moonlighting option for people who had opted out. And I knew that I wanted to do that and to be able to see any patient in a DPC setting. I was finishing residency in Pennsylvania and sort of looking at various places in Wyoming, and there were a few, um, prisons that were nearby in Wyoming standards to Cheyenne, which is what I was looking at closely at the time. And I found that the correctional medicine work was clinically rewarding because you had a lot of patients who had not had a lot of good primary care over the years. You know, they, they'd had other priorities in their lives beyond their healthcare prior to their incarceration. So, they often had a whole lot of chronic conditions that needed taking care of, often complicated cases, and they were usually grateful for the care they received. We didn't do any coding, at least initially, now there is some of that. Since there was no coding and there were no co pays for the patient, in some ways it was, it had many of the advantages that a DPC practice has. Obviously, you have a little bit of the arranged marriage problem that any capitated model can have, and that the patient doesn't have a wide array of physicians to choose among. There's just a few people that go on site, and that's that. So, some of those issues were at play, just like they can be at play for, in the on site, uh, Space with, with any employer, whether you'd be a small DPC practice or a larger group, anytime you work with an employer, you have some of those, um, on site assignment issues that you have to overcome as well.

Dr. Maryal Concepcion: 38:34

How has your practice been with COVID?

Dr. Phil Eskew: 38:37

Oh boy, we've kept the volume up. Um, and we've done more and more telemedicine, just like everybody else. We've been fortunate, I guess on the on the correctional side, at least at the sites that I cover, we've not had a massive outbreak. We've had a few smaller ones, but the facilities in Wyoming that had the larger outbreaks were not ones that I have covered. So we've been fortunate

Dr. Maryal Concepcion: 39:01

there. Thankfully, now, soon in a week, you're physically leaving Wyoming to move to South Carolina and you're transitioning from a remote legal role to an on site full time clinical and legal role with ProactiveMD. Could you share with us what made you decide this and what is your role going to look like at ProactiveMD?

Dr. Phil Eskew: 39:24

So it's, it's something that I've been been looking at for a long time. I met John Collier, the CEO, oh, um, probably 20, 2014, 2015, somewhere around there. And we've, uh. I've shared a lot of ideas for a long time and worked together remotely and, um, and I traveled, I used to, you know, pre COVID back when everybody was traveling a lot, I would often travel to South Carolina and I've done remote work over the past year, mainly in, in, in legal capacities, but the, the timing was right for me to go ahead and move there for a variety of reasons from the, from the size of our organization now to clinical opportunities that were very close to my family. I've got a sister who's. Settled in Charlotte and I got parents that are south of Asheville in North Carolina. So it worked out for a variety of personal and professional reasons. And it's, it's exciting to me now to kind of focus on third party free kind of clinical workflows within proactive MD. And, uh, hopefully share some of those with the DPC community. Right now, everybody sort of is used to me just talking about legal things, but I think there's plenty of clinical ideas I have too that I'd like to be able to share at some point.

Dr. Maryal Concepcion: 40:39

I, for one, can say that I'm very much looking forward to learning about those clinical developments.

Dr. Phil Eskew: 40:45

Some of those things have to do with, with just regular CME, I guess you would categorize it. But. Other things have to do with efficiency about the office and ways to actually track quality that aren't related to coding and all those third party things that we know get in the way. Do you

Dr. Maryal Concepcion: 41:01

envision creating something where, similar to the Frontier, you have Guidance on updated guidelines like community acquired pneumonia, updated guidelines for the DPC position strategies there or what, when you mentioned CME, can you describe in more detail what you're envisioning?

Dr. Phil Eskew: 41:21

One of my colleagues at ProactiveMD, Patel, he Already he's a physician and, um, he already kind of manages our own internal CME. So we have some things that we do on kind of a quarterly basis where we'll have a few lectures back to back. And then most weeks, uh, one day a week, usually Wednesdays around lunchtime, we have some sort of group discussion on a topic. And I think it'd be, it might be some sort of build out from what we're already doing. I'm nowhere near qualified enough to write, you know, new guidelines for COPD management or congestive heart failure management. That's not really what I mean so much as having a lot of information that is important to us and to the patient in your hands at that particular moment. So you might be able, for example, you could pull up an AAFP summary about hepatitis C management maybe, or, or lupus or any, any number of those things. And They're often really helpful summaries that will sort of give you a crash course on that topic and remind you about certain things, certain questions you should ask in the history, certain exam findings, labs, but those things don't necessarily consider how much work you might be able to do if you had more time. So, they might assume you need to refer before you really have to refer if you have the time to sort of do the lab work up on your own or. They might not discuss lab pricing to the extent you need or medication pricing to the extent you need. And I wanted to have our own internal workflows, incorporate those things more and more and more so that you can quickly pull up your own kind of guides that you've built. From those things that also have the pricing integrated in, you can quickly review that with the patient and sort of hit it all at once, rather than it being a 20 step process with I'll get back to you later, you can sort of do all those things right away in a clean and quick manner.

Dr. Maryal Concepcion: 43:07

And with you being an advisor for Bagel MD, as Colin is continuing to work on Bagel, do you foresee Those types of workflows being built into bagel as an

Dr. Phil Eskew: 43:20

EMR. I certainly hope that's the, that's the case. I mean, Colin and I have had a variety of projects over the years. He's done a lot of excellent work on DPC frontier, especially with the mapper. And we had my, my first idea with him, which I still think is a good one, but a lot of other DPC physicians, I guess we're not as excited about it, but was called DPC lytics, which was meant to be kind of a, you know, whether you view it as in front or behind, it was not an EMR displacement so much as a way to track things that were meaningful to the DPC physician community, you know, to give you some clinical examples there, like for my hypertensive patients, I track their systolic and diastolic pressures. But I also routinely track their creatinine, their total cholesterol, their LDL, their triglycerides for my own reasons that I think are clinically meaningful. And using Linux or using your own EMR, whatever you want to use, find a way to do those things quickly and cleanly. And I, I think part of the problem with what people do out of habit in the regular system, which is most of, you know, where most of the EMR has come from is they might order a set of labs and then they click a button and they just dump everything from the CBC and CMP or whatever panel the order gets dumped into their note. And that doesn't tell you or the patient at a glance down the road, what things you actually valued and what things you were really trending. Because, you know, if I'm not in the ICU, I don't really need to trend a bunch of normal by cards, but that's what winds up happening when you sort of lump all this information in there. So, the concept that I try to express to people is you want to track what's meaningful. And the only way to know what's meaningful is to see what I think I should track and what fellow physicians think should be tracked. And you want to have a, whatever you're using, whether it's something in front of an EMR or whether it's an EMR. You want to have a process in place that makes that so easy to do that it's actually done and that it doesn't get in the way because if it gets in the way of patient care or efficiency, then it won't happen. And if you try and track everything and then you're tracking nothing

Dr. Maryal Concepcion: 45:22

in the EMR that I'm currently using that type of curating the data, that ability to pull exactly what you want to build your story as to why you saw that patient and what led you. to make the decision that you made at the end of the visit, I think is very useful. And I hear you with regards to having too much, because that is something that physicians think about when they're choosing the tech products out there. Some see it as an advantage to have everything. And some people want just what they need to again, tell their story or put the pertinent things in a note so that they can track those specific things as the patient continues with them. But this idea of DPC lytics, is that potentially something that can be rolled into

Dr. Phil Eskew: 46:05

bagel? Yeah, I think so. Colin and I have talked about that. Um, he's got a lot of sort of projects that he's Going back and forth on and, you know, one of the other ones that people heard about recently was air PCP or he's kind of renamed it brick health because their PCP was admittedly confusing to some people, but, you know, he, he goes back and forth and we share a lot of ideas. So we'll see. We'll see which thing kind of gets the most attention over the coming months. But the, um. The BrickHealth concept was one that was focused on the recent rise of telemedicine across the country, where you have more and more physicians, be it traditional telemedicine or be it DPC focused telemedicine that don't want to limit their scope to the extent you have to, if you're doing purely telemedicine. So, most DPC physicians could easily pivot there and keep doing most of their work because they've already seen their patients a time or two in person, and they can still appropriately self triage people from their area to see them in person. But you might have some DPC physicians or, uh, or even just traditional telemedicine physicians who have patients in states where they don't have an office, or in a place that's so far from their office that they're not routinely coming to their office. And the, the idea is. Rather than saying, I can't do these things for you because certain visits need to take place, you can rely on this software to expand your scope in that telemedicine format. So, the obvious examples are tasks that are nursing related and don't require the involvement of another physician, but if you were to try and do that within the regular system, it would sort of force a visit when you didn't want one. So, in other words, You live in California but you also have a license in Texas because you used to work in Texas and you've got a few patients who want to follow with you from Texas, most of the care being remote. But one of these patients says, yeah, I had a heart attack two years ago and I'm on aspirin and lisinopril and carvedilol and I need you to renew these meds for me. So you can ask the patient to do home blood pressure monitoring and depending on which device they purchase that may or may not be accurate. And you can ask them, depending on what app they have on their phone, to try and do maybe a one lead EKG, or even some things advertise these six leads, but by the time you're doing that, you're buying and mailing a lot of equipment, and the results are still probably not reliable to the extent you would prefer. And if you try to send that patient to a nearby urgent care with instructions to just do an EKG and not have a doctor's visit, they're going to laugh at the patient and you, and then they're going to do the EKG and charge them 200 for a visit just to get it. So the idea behind BrickHealth was you could send them to a nearby DPC practice. Who wouldn't really engage the patient and at the physician level so much as see the order that you had requested and fill that order and provide them with the EKG or the spirometry or what, or maybe some labs that you've requested on a, on a reasonable cash basis, rather than the price that the hospital system would give you.

Dr. Maryal Concepcion: 49:06

Say a doctor in Florida is taking care of a patient coming from California because the patient is now being seen in a different state. Are they then potentially going to sign a one off contract with the DPC doctor in Florida under the model of Brick Health? There is

Dr. Phil Eskew: 49:25

a one page contract that the patient would sign when they showed up at that local practice that basically explains. They're there exclusively for those tests that were ordered by another physician and that those results will be relayed to that other physician. In terms of their virtual physician who placed the orders, that virtual physician either needs to have established a treatment relationship with that patient in a state where they were licensed or if the relationship was established outside DPC practice is. then that virtual physician has to have a license in this additional state as well. So, in your hypothetical, if the patient was also from Florida but living in California for three months during the pandemic and the relationship were already established with the virtual physician in Florida, then that Florida physician does not need to have a California license for the patient to proceed with those orders in California at that other PPC practice. But if the relationship were started with the Florida physician when the patient resided in California, then that Florida physician also needs to have a California license.

Dr. Maryal Concepcion: 50:31

Would a physician who's participating in BrickHealth need to adjust their malpractice in any way in addition to addressing licensure in different states?

Dr. Phil Eskew: 50:39

Malpractice agreements are written broadly to cover things unless they're not covered, and this is all fairly new. So, both physicians would have malpractice in place, and both of those malpractice policies would cover their respective Involvement in the transaction, the, the brick and mortar DPC physicians involvement is very minimal. And, uh, their risk is therefore minimal. The virtual physician is the main physician delivering all of the ongoing chronic care, which is what the arrangement is about. So they're the ones that bear that respective malpractice risk, just like they always would have borne that risk. My own biased, obviously, opinion is that by doing these things that virtual physicians always sort of wish they could have done, they should be both broadening their scope and reducing their malpractice liability, because without doing these tests, without having these objective measures, they are relying more and more on self reported things from patients. who might be using equipment at home that is isn't reliable or might just not be using it at all. And they might be doing refills on medications that are sort of at the edge of what they view as comfortable. And all of us have been pushed, I'm sure, because of the COVID pandemic in various ways on that regard, things that we would maybe like to have in person are less likely to happen in person. Anyway, I guess the long winded answer is, I think it reduces the malpractice risk on the virtual physician side and any additional risk on the brick and mortar side for the DPC physician who's simply filling out an order request for another physician is minimal.

Dr. Maryal Concepcion: 52:16

Definitely makes sense. Um, when you mention remote monitoring, I want to ask specifically about all of these pieces of tech that are coming out, wearable devices to track your sugars, to track your heart rate, to track your sleep cycle. You name it, things are being developed for different aspects of the human body. Do you see any potential legality issues with wearable devices as we find more of them in the market? Well,

Dr. Phil Eskew: 52:46

the short answer is yes. Um, I mean, the who's vetting those and whether or not you trust them can be kind of complicated. I'm not, I'm not an expert on wearables by any stretch. I don't use very many myself. You know, a lot of the smartphone apps, I'm not, I'm not one who sees a whole lot of value in some of those. I think sometimes the quantified self can lead to some paranoia. A lot of the devices that were meant to monitor your sleep quality, uh, beyond the basic pulse oximeter screening for obstructive sleep apnea, I think. Often they make a patient so paranoid about their sleep that they make it worse. But with certain things, whether it's a home blood pressure cuff or a home pulse oximeter, those things need to have been externally validated somewhere. And there are a variety of entities that do those kinds of things. And I would look to those validations when deciding whether or not I believed self reported numbers and wanted to rely on that. I'm not aware of a whole lot of malpractice litigation based on failure to appropriately vet a home monitoring equipment of some kind, but I'm sure those things are possible down the road. I think that the area that bothers me the most is maybe on the cardiology side, where you have more and more groups kind of doing things, uh, without a 12 lead EKG, where you're using, you know, either one lead, um, which may not be accurate. Or, or some of the six lead things, I'm not, I'm not convinced that really replaces the, the value of 12 lead EKG. If I have somebody who I know has a history of cardiovascular disease, and they may or may not have had a silent heart attack two years ago, then having that baseline, uh, well done 12 lead is important because I need to have something to compare it to down the road in the event they do start to have

Dr. Maryal Concepcion: 54:24

chest pain. Definitely understandable. I wanted to jump back to ProactiveMD because you shared about the CME and potential ways to, to measure data and performance quality for DPC practices. Can you tell us more about ProactiveMD? Because like we know if you've seen one DPC, you've seen one DPC. How is ProactiveMD doing DPC? ProactiveMD

Dr. Phil Eskew: 54:52

is an, it's an on site and near site DPC company. We're headquartered in Greenville, South Carolina, and we have clinics across multiple states. Most of them Uh, serve the needs of one employer. And this often will include family members of those employees. Uh, some of the clinics like the one I'll be spending most of my time at in Malden, South Carolina are open to members of the community to sign up as well. We track a focus set of clinical outcomes that allow our physicians to practice in an unencumbered manner while demonstrating the value of what we do. And our software brings information to physicians so that they can spot clinical outliers quickly and have price transparent discussions with patients without, you know, a whole lot of delay. We practice in a collegial environment and share challenging cases with each other. And, uh, we, we have our own internal CME events on a regular basis and it's a fun and intellectual, intellectually stimulating place to work. When you

Dr. Maryal Concepcion: 55:41

transfer to the clinic in Malden, how much time will you be spending doing patient care?

Dr. Phil Eskew: 55:46

That's going to vary, um, a little bit over time. I, I suspect about 50 percent of my time is going to be patient care. The other half will be kind of legal and administrative and, you know, some software design stuff. So. And

Dr. Maryal Concepcion: 55:58

with you mentioning that Proactiv has clinics in multiple states, are they actively looking for physicians to join? Oh

Dr. Phil Eskew: 56:06

yeah, as we have employer contracts in different areas, then we advertise for those. We've got some clinics we're planning to launch in New Mexico and around Austin, Texas and Illinois. We've got some new things starting in Pennsylvania. So yeah, growing in several different areas.

Dr. Maryal Concepcion: 56:23

And does ProactiveMD have a particular classifieds board or somewhere that people can go to if they're interested? Yes,

Dr. Phil Eskew: 56:32

so the website's proactive. md and then we have a careers page there. Gotcha.

Dr. Maryal Concepcion: 56:38

Now that you are transitioning, I want to ask a question that is very much related to the patient care space. If there is a patient who sees a DPC physician and leaves a poor review on a platform such as Yelp. How do you recommend that a doctor address that poor review?

Dr. Phil Eskew: 56:58

Well, people used to take the approach of trying to contact Yelp or whatever the platform was and saying, Hey, this doesn't fit. This person isn't even patient. And I can tell because of X, Y, Z. That's a futile effort. They usually don't want to remove anything like that and they don't want to get in the business of trying to police the accuracy of those kinds of things. One thing I will say right off the top is that there have been HIPAA breaches based on patient complaints and The ones I've read haven't been the physician so much as office staff. There was office staff in a dental practice, actually, that had this happened within the past year or two, where a patient used some type of Yelp or social media platform to complain about something and gave away a little bit of detail about their case in the process and the practice and trying to defend itself. Also, you know, discuss some details of the case, which, you know, is a mistake they shouldn't have made because you can't, you can't discuss those details in those kinds of open forums, which is why you're probably used to seeing any number of times where a patient might be complaining in the news about a given hospital, and then they go to interview the person at the hospital and hospital says, well, we can't comment on the details and it's because To get into the details to defend yourself, you have to dig into clinical details that you're not allowed to, you know, discuss due to HIPAA privacy rules. So the first thing to remember is don't get into detail with those kinds of things. If you look at a practice that's doing this well, they might have a chance to reply to that comment within the forum. To do it is you, you say something like, you know, uh, sorry, you were disappointed with our practice. Call us to discuss how we can make things better for you. Something like that. And then invite your own patients who are happy with you and are probably not in a hurry to go online and leave your review because they're happy. Invite them to review you wherever they want. Or maybe point them to the site that you think gets the most traffic and what you do is you bury the one out of five star review with 99 five out of

Dr. Maryal Concepcion: 58:56

fives. Very helpful advice there. One of the pieces of advice that you had mentioned previously at a summit meeting was this idea of kicking back a prior auth. And so I'm wondering if you can share with us your technique that. Um, you use to address prior authorizations.

Dr. Phil Eskew: 59:15

So the, the physician who started, who started this, there were two actually, the first one to do it was a physician named Gary Gibson, who's an MD. And he got kind of irritated with a, with the insurance company for wasting his time. And he was able to make an argument in the small claims court that this had nothing to do with patient care. This was just paperwork for the insurance company and that the insurance company and. You know, forcing him to do their paperwork was not okay, and he should thus be compensated for that. And the insurance company really, uh, didn't really even show up for this kind of thing. But nonetheless, he got a little bit of a small case kind of on the books about it. And Greg Zydiak gave an excellent talk at a AAPS meeting probably back in, uh, maybe 2015 or so. I can't remember the year, but he went into detail about this. So what he does is he takes that old case from, from Dr. Gibson. That legal case. And when he gets a prior auth request, he sends them back a request. The insurance company and says, Hey, if you want me to do your work for you, I'll do it. And this is what you need to pay me to do your work for you. And you'll have a bunch of fax wars with him and he'll attach that legal case. And then usually they just start approving what he does. Because they get tired of their own, you know, paper war that they created, because the idea of doing a prior auth for satirizine is ridiculous. So, eventually they, they seem to give up and Dr. Zydiac's point was, hey, he gave, you know, in this 10 minute talk, which you should all take a listen to, you know, he says, if we would all do this, we could end this problem in a week or two, nevermind, you know, this is obviously important for DPC physicians, but regular physicians could do this even in the, even in the system as it were. And.

Dr. Maryal Concepcion: 1:00:51

So the listeners are aware that link to Dr. ZDX's video will be posted on your accompanying blog as well on the My DPC Story website. Off the top of your head, you could think of three legal tips for the average DPC doctor to know. What would those three tips

Dr. Phil Eskew: 1:01:11

be? The first one that comes to mind is one that's changed during the pandemic. So people often ask me about opting out and, uh, wrinkles around that. Typically when you opt out of Medicare, you have this at the very beginning, you have 90 days to sort of say, oops, I made a mistake. I didn't want to do that. And you can reverse it outside of that window. You have a rolling two year window when you can decide that you want to come back in, if you should change your mind for some reason, and that, uh, understandably gives some people pause when they're deciding to do this for the first time. What I would point out is that for as long as the pandemic lasts, according to the federal government, um, and I don't, and I don't know when that'll be, when they might declare it over with, but for as long as the, it's, it's considered an emergency, you are allowed to, um, Opt back in at any time without waiting on that two year window. So, some people might find that flexibility helpful, uh, at least in the short term. That'd be number one. Number two, if you're looking at, uh, different states where you're contemplating practicing and, and you're looking at states that don't allow you to dispense and considering that a major hurdle, I would point out that not only does, um, Texas have a lawsuit for physicians to obtain the right to dispense medications with the Institute for Justice, the Institute for Justice has also helped me. Uh, Montana physicians as well. So there are two, um, sources of litigation that are pending on that and those are worth following and, and hopefully there'll be good models that could be used, um, in New York and New Jersey eventually too, to make state constitutional law arguments. Uh, number three, I've had it on my, uh, bookshelf for a while. I got a bad habit of, of starting books and then, Not necessarily finishing them right away and sometimes coming back months or years later and finishing and um, one of them I've had had for a while by a Ph. D. named Norman Gevitz who wrote this, the D. O.'s Osteopathic Medicine in America and it's this history of osteopathic medicine and I came across for anybody who happens to have this Second edition that I have, if you want to look it up and verify it's on page 30 or 43, excuse me, of this book. They're talking about this history of, of D. O. S. beginning to practice. And this was late 18 hundreds. He says patients were generally told that quick cures were the exception rather than the rule. And most deals agreed with Dr Evans who observed and then he gives this long quote talking about how this ongoing relationship was important and that you had to. It took time to make a diagnosis and to treat a condition, and then it says to encourage this type of thinking, DOs generally bill their patients by the month, charging the standard fee for four weeks of treatment of 25. So when people ask me, when did DPC start, and there's always this debate about some of the more recent physicians who do things, I like to tell people it's actually started in the late 1800s as far as I know. That's

Dr. Maryal Concepcion: 1:04:03

pretty incredible. And I will make sure that that is linked to your blog as well. Phil, are there any other books that you recommend to others?

Dr. Phil Eskew: 1:04:11

Oh, boy. Um, there are, I don't, I don't want to name a bunch of DPC specific books because I'm going to inevitably leave somebody out and offend people, but there are a lot of, uh, DPC colleagues of ours who've written, you know, great texts and some of which are even entertaining, um, beyond just educational on the topic. And I think people would be wise to sort of pick those up and review them. They didn't exist until recently, and it's nice to have those resources available. There's one called play bigger. That's pretty good. How pirate streamers and innovators create and dominate markets. There are some that, um, that I look at sort of on the clinical side of one of my favorite ones is a really readable rheumatology text by a physician named Rudy Green. G. R. E. E. N. E. Um, it's Rudy's rheumatology. I think there are certain areas of medicine that are overlooked more by traditional primary care physicians and and we can really make a difference if we if we get good at rheumatology and occupational medicine and in some in some ortho issues. I think we can really stand out. Thank

Dr. Maryal Concepcion: 1:05:13

you so much for sharing those resources. I'll again, make sure that those are linked to your accompanying blog. I have one final question, which comes from the previous interview that was released on my DPC story. During that interview of the team at Meridian Springs, Sunil Vasisht asked. What, if anything, would break DPC? And what is your answer to that particular question, Phil, in terms of where we are as a country with regards to current DPC laws and the fear that A D. P. C. Physician might have if we go towards Medicare for all or a different type of health care system. Could we lose the ability to practice D. P. C. Safely and legally in this

Dr. Phil Eskew: 1:05:55

country? I think it's very unlikely that we would lose the ability to to be DPC physicians, you would have to have the government take pretty drastic steps. Medicare for all can mean a whole lot of different things. It could mean everything from the government totally taking over everything and outlawing any kind of private medicine, which would be one way to kill DPC and kill a lot of other things too. Uh, kill innovation and, uh, probably get rid of most people wanting to practice medicine. But apart from that very, very drastic and unlikely scenario, I think DPC has a future. You know, if, if you were going to try to kill DPC without doing that, then you would need to give away primary care. And at the same time tax private primary care so heavily that DPC became unaffordable, which I think would be a challenge and is also unlikely for the government to do if they had some sort of Medicare for all, uh, safety net, which promised primary care, but didn't really deliver it even then, even if it's quote free, I think there's still there's still room for DPC. You'll have people, uh, You know, people give away food in a variety of settings, but we still have grocery stores. We still have restaurants. So I think D. P. C. is going to have a future and 99. 9 percent of possible scenarios

Dr. Maryal Concepcion: 1:07:12

with this past year, having proven how vital and valuable primary care is. I hope that you have reassured a lot of people who might still be on the fence about D. P. C. Because of that particular question,

Dr. Phil Eskew: 1:07:26

Yeah, and I hope I hope policymakers sort of realize that too. I think one of the biggest secrets that DPC exposes is that primary care is in fact affordable. And if enough policymakers realize it's affordable, then they won't feel the need to tinker with it as much. You know, if they want to get involved for patients who still can't afford something that's affordable, then we already do that in certain circumstances with food stamps. And there's no reason we couldn't do that with something similar in medicine. But where I think policymakers are much more likely to get their hands on things or things that are not affordable that they want to increase the access on. So those are your high price procedures and hospital issues more so than DPC clinic issues.

Dr. Maryal Concepcion: 1:08:07

What is the best way for others to reach out to you after this podcast?

Dr. Phil Eskew: 1:08:11

I follow email better than anything else. I probably check my, you know, Facebook between once a month and once a week. So I don't that's not the best way to get me. It's it's my email, which is. Phil at DPC frontier. com. Perfect.

Dr. Maryal Concepcion: 1:08:25

Thank you so much for joining us today, Dr. Eskew. It's been a

Dr. Phil Eskew: 1:08:28

pleasure.

Dr. Maryal Concepcion: 1:08:31

I hope you enjoyed today's episode and that it helped you understand more about the legalities of DPC. As I mentioned in the beginning, if you have a legal question pertaining to your DPC practice, even if you're in the preparation phase, call in with your question. You'll mydpcstory. com or check out the link in the show notes and be here next Sunday as we play another one of our most popular episodes to date. And if you're looking for more about DPC in the meantime, check out dpcnews. com. Until next week, this is Marielle Conception.