Dr. Kelsey Smith Talks About Building A Sustainable Practice: The Story of Pioneer Health DPC

In this episode of The My DPC Story podcast, Dr. Kelsey Smith of Pioneer Health DPC shares her transformative journey from a traditional insurance-based, fee-for-service practice to adopting the innovative Direct Primary Care (DPC) model. They discuss the challenges and rewards of this transition, including the importance of sustainability in patient care, navigating business ownership without a formal business background, and the role of community and employer relationships in growing a DPC practice. Recorded live at the Free Market Medical Association meeting in 2025, this episode provides insights into the practical and emotional aspects of shifting to a DPC model and emphasizes the individualized and personal relationship DPC fosters between doctors and patients.

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Transcript

Dr. Maryal Concepcion: 1:16

Direct Primary care is an innovative alternative path to insurance-driven healthcare. 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. I've said

Dr. Kelsey Smith: 2:05

this to, to other people, I think you expect that the internal struggle we're dealing with is evident to others. And sometimes it's not even those that are closest to you because we keep things so close to the, to the chest and, and were high performers. And so, sometimes maybe my husband just really thought I was not a nice person, and, and it really was just that strain and that that weight that you're carrying that you just don't, don't want to talk about. And so I think the, the reverse is true as well. When that weight is lifted and you feel so much better about what you're doing and about going to work each day, you anticipate that others are gonna see that, and they do, but it's not as evident to them as it is to you on, on the inside. And so what DPC has meant for me is. A sustainability of a system that was previously draining me to try to work in a system that was not made for my success or the patient's success and transferred that into something. Yes, medicine is still hard. It is still hard to be a doctor. It is hard to tell patients bad news. It is, it is hard to come up with that diagnosis that eludes you. But it is now a practice that I enjoy being a part of and I enjoy seeing my patients every day and going to work and, and engaging with my employees. So it is definitely worth it, even if from the outside looking in, it looks like they're doing the same job. I'm Dr. Kelsey Smith of Pioneer Health DPC, and this is my DPC store. Yay.

Dr. Maryal Concepcion: 3:51

we are here live at the Free Market Medical Association meeting 2025. Thank you so much, Dr. Kelsey Smith for joining us today. I'm so excited to,

Dr. Kelsey Smith: 4:01

to join you. The FMMA has been something I've been a part of for several years. Of course, I followed your podcast, been doing DPC for four years, and so to bring all of this together is pretty special.

Dr. Maryal Concepcion: 4:11

That's awesome. And it's cool that, the, the audio might sound a little bit different to the listeners out there. We're in the, we're just taking a lunch break and doing this outside of the conference itself. And I think it's really even more appropriate that we are doing this in your home state where you are a DPC doctor who is serving fellow Oklahomans. So this is, again, it's just extra special in that lens. When, when it comes to your practice, I would love if you could start us off with. What was the model that you were practicing in before you went into your DPC journey? Yeah, so I think

Dr. Kelsey Smith: 4:47

a little bit more unusual than the typical DPC practice. I was self-employed. We were a five physician group and four family medicine doctors in one pediatrician. We all had our separate LLCs, but we functioned under an umbrella as a group. And so it was eat what you kill. None of the senior partners made anything really off the junior partners other than sharing overhead and sharing call because we did everything. We all delivered babies. The family medicine doctors did, and I was OB fellowship trained. We all did operative ob, so we saw our, our moms and babies in the hospital and then any of our medicine patients or pediatric patients that were admitted, we saw those had a busy clinic schedule and things like that. And really, that wasn't something I sought after was to be an entrepreneur straight out of residency. But I was looking at all the different hospital contracts that were available to me at the time and. Really thought that was what I would do until I was approached by one of my old partners that they were looking for someone to join their clinic. And at the time he demonstrated to me that, hey, it's still economically feasible to work for yourself. And I thought, well, gosh, that's what a novel concept. So I was kinda introduced to that by my old partners to even think outside the box, it doesn't, it just seems ridiculous to think that owning your own practice is outside the box. But so in 2007 I moved to Stillwater and joined Stillwater Family Care and was self-employed as a part of that group from 2007 until 2021, whenever I launched my DPC. So

Dr. Maryal Concepcion: 6:15

I think it is unique that you had that experience because if you think about the majority of us, including myself, who are like, we don't even one, know that there's a different way, but two, that you could actually run a business even though you don't necessarily have an MBA. I, I wonder if you could tell us a little bit more about that, that discussion that you had with your history of already seeing the hospital contracts, just not finding anything that would work for you, but also hearing and translating how this could be, this idea of being self-employed, could be financially a, a, a solution to what you needed without that prior experience of, of a business ownership. There's some of us who, do realty on the side or whatnot, but for a physician to go from residency into this I would think that there's, there's, there has to be that translation for how will what you've done improved work for my life. Right.

Dr. Kelsey Smith: 7:09

Well,

Dr. Maryal Concepcion: 7:10

I,

Dr. Kelsey Smith: 7:11

I couldn't have done it without the help of my partners because they already had the business structure up and running. And the 14 years that I spent in private practice taught me a lot of the just day-to-day, basic knowledge of running a business, even though I don't have a business degree or an MBA, but I just saw how things got done. We had an amazing office manager that she run, ran the clinic on the business side the entire time she was, she still is there, she's been with the clinic since it was established and continues to, to help manage that practice. And she was a, a big reason for the business success because as many of the speakers here have pointed out the ever-changing, like the resetting of the goalposts for private practice, well for any practice, but it's set to make winners and losers and private practice physicians are always strategically, made to be the losers in that argument because the bigger players are trying to monopolize the healthcare system. And so it makes it incredibly difficult for small physician groups to continue to compete. And she was amazing at, okay, well. Yes, but we can now bill for care management. So we need to hire a care management nurse. And now there are some alternative payment models out there. If we participate in that, we can save some money here and make a little extra by meeting certain metrics. Now MIPS and macro are coming along, but we can be part of an aco. And, and so she really did help keep us afloat by helping us play that game to the best of our knowledge, at the time because the rules are always changing. And so knowing all of that, I, I stayed in touch with, with her I think when I was working there more so than my other partners, to kind of understand what games she was having to play on our behalf to make sure the practice remains solvent. Whereas the other partners, I think would have more happily just stuck their head in the sand and been like, okay, we're still making money'cause I'm still bringing in so much revenue per month or whatever. They didn't really see the changing climate as intimately as I did'cause I helped with some of those. Alternative payment models, the continuous or comprehensive primary care initiative CPCI, we were one of the first practices in the first wave of that to take part in it. And, and I was naive enough when those initial initiatives came out, I was like, this is great. The powers that be are now refocusing on primary care and it's, they're finally seeing that we have worth and that we have value. And so for the first year or two of those government initiatives, it seemed like that was maybe gonna play out. But then it's after those first year or two where you come back and you're like, yes. See all these wonderful things we're doing. And then we're like, yes, but that's not enough. Now you need to do this. And so, like you say, the risk resetting of the goalpost is just incredibly frustrating to realize you're never going to reach what they consider to be quality care. And so it was when MIPS and Macro came out and I realized that this was not going to be sustainable for our private practice, the image that's burned into my mind is just. I think it's in one of the back to the future episodes where there's this burning train that like plummets off of a cliff. That scene just like replays in my mind the insurance-based model of healthcare, I feel like, is that train just headed off the cliff and maybe almost in slow motion because the people on the train don't even realize they're on it. But once I knew that, that I felt like that's what was happening, I felt like I had one of two choices. You either stay on the train and plummet with the burning wreckage or you jump off and it's scary to jump off, but it was the only solution that really made sense to me. I first con, like I said, considered DPC when MIPS and Macer came out. I think that was 2015. I might not have the years exactly right, but and I read Doug's book, Doug Fargo's book and I, I remember taking it to my partners like, Hey, I think this is what we need to do and get out of these programs. This is, one way we can continue to make it as private practitioners. And we live in a fairly small town. I mean, it's, it's a 50,000 population town with a major university in town. But they're like, no, that would never fly here. There's just not enough highway wage earners. They're kind of equating it with the classic concierge type model. And I was like, no, I don't. I think you're wrong. I think you're wrong. I think we could do this. But like I said, our office manager was really adept at finding ways we could continue to function. And so instead we signed up for an A CO and we kind of made things work for a little bit longer. And it wasn't until really Covid came along and, hospitals really, really struggled. Physicians in general struggled. It got to be ridiculous to try to go to the hospital and deliver a baby during COVID or treat any patients when you were trying to juggle them inpatient and outpatient work. And I was the youngest by a few years of my partners. And I had not come to the point that I was gonna call it quits necessarily with hospital based medicine. But, but they did. And they came, they're like, you know what? Basically like the. I'm saying we're just getting too old for this crap. And so we let the hospital know we were gonna stop seeing hospital patients. We were gonna stop doing deliveries. But I thought, well, this is my chance.'cause I, that was the one thing I didn't know how to structure for my DPC practice. I know there are definitely DPC practices out there that offer ob, but I did not know how to make that work for my specific situation because I relied on my call group. I had a lot of Medicaid deliveries and things like that. So once we decided and made that leap that we are no longer going to deliver babies, that's when the decision to do DPC was a whole lot easier for me because I was like, you know what? I, there's no reason for me not to.

Dr. Maryal Concepcion: 12:36

Totally. I, I wonder as, the, as you explain how your office manager really helped find creative ways, I also wonder if when you look at your partners, your former partners, and you think about how they weren't necessarily as engaged with learning about the business, how it is staying afloat. I'm wondering did your clinic manager mention these things as you were also asking them guys, you realize that this is not necessarily going to be working as easily as it might be today because the goalpost is consistently changing?

Dr. Kelsey Smith: 13:09

Yeah, no, for sure. I mean, she became a bit of a one-man show as far as the reporting processes go. Anybody who kind of has lived through that timeframe knows that, there are different quarterly reports that had to be reported. And if you're not using the right EMR, it may not. The boxes that you click may not, actually populate the right data points. And so you may have gotten 90% of your patients their mammograms that year, but the EMR only uploads to the federal government that it only like half of the time, did you get your mammograms. And so it really didn't matter what care you delivered, if it didn't check the right box, then it didn't get reported to the right entities. And so she was really invested in staying up there till midnight, some nights, the nights, before those reports were due to make sure all of those structured data points got into the right places, whether they were originally charted that way or not, going back and looking at raw data, making sure the right things were clicked and that we were getting credit for the work that was done. So in that way she, she was very intimately involved in that and she would tell us a lot about that and, and work by working overtime and things like that. She, she was compensated for that extra work, but I don't think anything can compensate for just the frustration that, that Yeah. Causes. And, and not to say that mother partners weren't business savvy. I mean, the senior partner in our practice was very business savvy, but. He knew that he did not have the bandwidth to deal with those things, and our office manager did such a good job that, he, he focused more on other business aspects of the practice. So I learned a lot from the entire experience. I wouldn't have it any other way. I admire people who start their DPC right out of residency. I don't think I could have it was a big enough leap for me to join a group that was doing private practice. And, and I think that now that the DPC movement is growing, that, that's probably a more feasible option for people looking to do DPC right out of practice is to find some of us that have already done it and learned the ropes from us. So,

Dr. Maryal Concepcion: 14:58

I totally agree, and I think that sometimes, because I, I know I've been there myself, even in DPC sometimes when I'm like, it is so overwhelming for, whatever it might be, like an entire, shipment from the wholesale, whatever pharmacy came in and I'm like. This is overwhelming. I cannot face inventory today. I'm going to do anything. But yeah, when it comes to business, that is a massively different type of overwhelm because especially when you know that financially it makes a difference at the end of the day for yourself, but also it makes a difference for the future of your profession. And I, I wonder as we're talking about this especially as you participate in a CO type stuff, where do you, how do you talk about direct primary care versus value-based care? Because it is a thing right now that people are saying, well, DPC is value-based care.

Dr. Kelsey Smith: 15:48

It's so different. I heard, I heard you say that in one of your previous podcasts here recently. And from an insider's view, like they are totally non equivalents, like they're in different ball fields. I don't, I don't see where, because even though value-based care, it sounds like what we do at DPC, we provide valuable care, but the value-based care in. As it's defined in the system, I think just generates this sense of anxiety in my inner being because it means, you're considered a good or a bad doctor based on what metrics you met. And if there is that 90-year-old lady that you've decided they really don't need to have their A1C, strictly controlled, well now you're a bad doctor'cause that brought up your average A1C score or whatever it may be. So, I, I talk to my patients about this a lot when we're talking about guidelines for maybe, whether it be, whether they're due for their pap smear or their mammogram and the, maybe whether they're choosing to do that that year or not. And just the different intervals that things are recommended at and why is that the case? And, and that's what I'll tell them is that, population based recommendations are very different than when you're sitting face to face and talking with an individual. And so, yes, population based recommendations can be very valid. But they may be completely invalid when you're talking to that specific individual. And so trying to, to take those recommendations with a little bit of a grain of salt, because I think value-based care takes those recommendations and blanketly just applies them to every individual. And I don't, I don't think that that's DPC at all. I think it allows the physician and patient to have an individualized personal relationship and decide, what is most valuable for that patient's health. And it may not be, getting a mammogram every year. I, I typically recommend a mammogram manually rather than every two to three years. But for, certain situations, I can't even think of what one might be right now, but, it may not be, we may be prioritizing something else that year that is, you know, because of limited funds or whatever. So, so there's, it's DPC is individualized, whereas I feel like value-based care is. Definitely focused on the population health measures that don't always directly apply to the individual.

Dr. Maryal Concepcion: 20:26

Thank you for that. And I think especially as you mentioned earlier, how you might have done 90% pap smears Yeah. According to the, the USP ftf Sure. Requirements. But whether they got reported Yeah. Say, and that is, that is, it's so devastating when like you're working your butt off to do what's best and to keep the relationship personal. And then you have an hour and a half of patients waiting in the waiting room. Right. It's so tough.

Dr. Kelsey Smith: 20:53

Well, yeah, because you, you start to realize with all the reporting measures that are out there, you're like, wait, I did all of these, let's say pap smears, like you said, or I ordered all of these mammograms or colonoscopies or things that were being judged on how we performed. The payer paid for them. So the payer already knows that they were performed because they wrote the check. But yet I have to prove to them that I did them by reporting on what they already know happened. And so then you start realizing that it really is a game like Dr. Norman IMEs was talking about, that you cannot win. It's not designed for you to win. There it's almost well, sometimes when you, it's tax time. And so, I've seen the meme out there where it's like the IRS says, we know how much money you made and we know how much you owe us. And you're like, oh, great. What is that number? We're not gonna tell you. Okay, well you're gonna have to guess and if you're wrong, you go to jail. It's yeah. But it feels the same way with some of the value-based care incentives and primary care. It's like you already know, which ones I ordered and what you paid for which is different now in my practice, I, I always kind of chuckle to myself just a little bit when I get some of those faxes from payers now because they're like, oh, it looks like your patient's not taking their statin or their ace inhibitor. I'm like, yes, they are. They're just getting it straight from me and you don't see that transaction. So those go straight in the trash can. But to be shredded. Of course there's patient specific information in there, but but yeah, it's just they hold all that information. And I do try to sometimes tell patients when I get those things back, they're like, Hey, big Brother just sent this for you. Checking in on how you're doing according to national guidelines. And patients do start to, ask those questions then well how did, how did they know that? Yeah. Why is it their business whether I'm taking this or that medicine? And so it, that personalization of care is not just, the feel good type of medicine. It really does take to some degree Big Brother out of the picture a little bit. Yeah.

Dr. Maryal Concepcion: 22:45

So let's get into your DPC transition. Yeah. Now, because you went from this private practice where you were working with your partners to now, as I was commenting before we even started recording a flip, an amazing, beautiful building. Oh, thanks. And it is. It is this journey that I'm sure your, 10 years ago self would've been like, no, no, we we're, that's not even possible. No, exactly. I'm just a Exactly

Dr. Kelsey Smith: 23:10

right. Yeah, it, it was interesting'cause when I started to consider DPCI still thought of our group as, kind of a collective entity. And, and I considered myself, I was going to maybe be the Guinea pig, but I really still can thought that we would stay together as a group and everyone would transition to DPC.'cause I just, I had it in my brain that there just really wasn't any other logical conclusion. And obviously people have different opinions on everything, so that's not necessarily the case. But in 2020 when we, I started thinking, okay, the timing is basically ni there were no in-person meetings. I did the Hint summit virtually that year and the DPC Alliance was hosting masterminds. Because trying to keep, large gatherings to a minimum, these more intimate, smaller gatherings were a solution that they found in the Covid era. And so I remember going out to Amy Walsh's practice in Raleigh and meeting her and Dr. Tom White and who else was there? Gonna have to help me spark stop fires. Julie Gunther was there. So many of us that are like now, like common names, like superstars in the DPC just era or were there at that mastermind largely because Doug was getting ready to retire. And so my timing was impeccable. Like I got to meet tons of people who were already doing this well. We're leaders in the space and meet them face to face. Kissy, kissy Blackwell was there. And I didn't even know at the time, but I, I at least had read Doug's book at the time and was, once I got introduced and didn't realize who I was talking to, I was like, oh my gosh, I've read his book. And so it was really cool to then have those people as mentors. Yeah. And I remember I credit Amy Walsh with part of this'cause I kept saying, I'm really, I'm the basically the investigative reporter for my group. I'm coming to learn about this so I can take it back and tell the group and we're all gonna do this together type of thing. And I remember over lunch one day during that mastermind conference, Amy Walsh sat down and she said, yes, but what if they don't decide to do it? She's are you going to do it? And I was like, well, I don't, I mean, we kind of make a collective. We, we make decisions together, right? It was, and she's no put them aside. Is this what you want to do? And I was like, well, yeah, it's what I want to do, but why would they not do it? And then come home and kind of. Sales pitch, everything that I was so enthusiastic about and to kind of get a eh, ho hum response. I don't know. It's, it's kinda like you think, I don't know. We're sitting in Oklahoma, kind of wild west. My, my DP C'S called Pioneer Health. And I, I think in pictures a lot of times, so kinda think about that, like pony, express, pony, like you just, you whip that horse until it collapses underneath you. And so, but it's the devil, you know? right. So I feel like that's kind of where my old partners at. They see the flaws in the system, but they're like, the horse is still running. We know it might collapse, but we're just gonna keep whipping it until, it comes to a screeching halt. Yeah. And I, and like I said with the, the burning train analogy, I was gonna jump off. I was just like, there's, I can't, I can't follow this to its eventual end. So when I realized that, hey, they're willing to. I guess tolerate me, maybe not support me, but they were okay with me doing it, but they, they had no interest in at least transitioning their practice at the same time I did there. It was still, it was not a hard no at that point. But they were just like, eh, we'll see, kinda see how it goes for you. And so that's what I asked'em, you know, we, we owned our own building that we practiced in and I said, you know, if, if I transition to this different business model, is it okay if, I stay here? They really, I guess could have said no, but not necessarily.'cause I was part owner in the building, so how do you kick an owner out? But so I stay kept my, I, I had three exam rooms. I transitioned down to two, kept my ma she was on my personal expenses anyway. And then we had to just re divvy up the expenses.'cause I was like, well I'm not paying for our biller. I'm not gonna pay for the front desk staff.'Cause we're gonna take our own phone calls. And it, it gets a little sticky because you know the very. Granular things that you come up with. When people come in the door and they come to the front desk and they say, I'm here to see Dr. Smith. Well, my partners were like, that's taking time from our staff. We don't want to them to have to tell you you have a patient here, or you'll, or you'll need to pay a portion of their time. Okay, that makes sense. So, figure out creative work around. So it's you know what, we'll just tell all our patients in the text they receive, when it's time to make an appointment, there's a doorbell in the front lobby, go straight to the doorbell and ring it and it rings a doorbell in my office and lets us know that you're here. And that way, no, I'm not paying the salary of the employees that work for the overall practice, so they're no longer my employees. So we came up with things like that to kind of help delineate whose expenses were whose and, and it worked quite well because I was delivering babies. I didn't have an abrupt transition. I didn't want to kick any of my pregnant women outta the practice. So as I was opening up my DPC, I still had women who were expecting. So I had a six month timeframe there where I launched my DPC in January of 2021. Started taking enrollments, but I was still practicing in my old model as well and billing insurance companies with the other LLC up through my last delivery at the end of July 1st of July in 2021. And so we had two completely separate EMRs, two completely separate schedules. And so if a patient was booked on one schedule, you had to block that time out on the other schedule to make sure you didn't end up double booked. Of course, that doesn't always work perfectly. But that gave me the perfect opportunity for my busy family practice base of patients to let them know, Hey, you've got plenty of time to check this out. And I could talk very openly about what I was doing, why I was doing it. I started a Facebook page and put together a few little basic videos of, I'm really not doing this as a money grab. This is just how I feel like I can sustain my practice and take better care of my patients. And, I really, really thought,'cause you hear it all the different things. When somebody's looking at transitioning a practice, they're like, oh, you'll expect 10 to 15% of your patients to follow you. I was like, no, I have taken such great care of my patients. I, I really just dunno how this is gonna work. I'm gonna have so many patients, I'm gonna have to start turning people away because I'm gonna be full. At the very beginning, I just had this somewhat grandiose view of the relationship I had with my patients and certainly many of them followed me, but it was about 10 to 15%. Yeah. And, and then you do, it is somewhat freeing then to realize had some people say, it's like you've been just living and dying on, taking care of some of these people who wouldn't cross the street to help you. And Yeah. And, and maybe that's not the case. Sometimes they just don't understand the model. They're like, I even had some patients tell me. Dr. Smith, were really worried that you could go to jail over this. And I'm like, I promise it is not illegal to pay your doctor. You don't have to always use insurance. So, so there's that as well. But it, but it, it is freeing to realize that the people who followed me, they, they invested in the relationship that we had already developed and, and other people were willing to let that go. And so I had to be willing to let that go as well. And so it did let me focus on what's more important to me and as a, person and a wife and a mother and all of that rather than just living and breathing by what happened at the office,

Dr. Maryal Concepcion: 33:05

I just, I have this, as you're describing the burning train, I'm like, you also being this like fugitive on the burning train when your patients are saying this. So I'm like, that's so perfect because right along lots up burning train.

Dr. Kelsey Smith: 33:17

Yeah.

Dr. Maryal Concepcion: 33:18

Gives a whole new meaning

Dr. Kelsey Smith: 33:19

to Stockholm

Dr. Maryal Concepcion: 33:19

syndrome. Oh God, that's awesome. I wanna ask here, because as you are seeing patients, even if it was a 10 to 15% Yeah, those 10 to 15% financially, it's what the heck what was I doing the, for the years prior? Because I, I, I don't know if you had this reaction where you're like, wow, like it literally is this many number of patients at this rate per month equals, and I didn't have to code for any of that,

Dr. Kelsey Smith: 33:48

right? Well have to say we played the game very well, and so the system financially rewarded me quite well for all the work that we did. But as a self-employed physician for most all of my career since training, I like to, to just point out, like you can be self-employed and still hate your boss. And so for those 14 years I was a slave to the grindstone. I mean, I would feel some sort of. F validation just from the fact that when, and my husband's an airline pilot, so when he's gone, I'm a single parent. When he's home, I have a stay at home dad. So it's all or nothing. But when my kids were little and I was delivering babies, there might be a time where I had to drag them up to the hospital and they sat in the physician call room because I had to manage a delivery and take care of the newborn. And then that was in the middle of the night, and then now it's time for you guys to get to school. And I would, somehow get them from the call room to school in time and then maybe change clothes, probably not go straight to clinic and start my clinic day. And then, maybe I had somebody else in late. You know, There were days where I remember just vividly so much happened that it seemed like not humanly possible to get it all done. And then you like pat yourself on the back for that. You're like, look at all that I accomplished. And you're like, why? Why? Why do we pride ourselves in that? Yeah. That we are just running ourselves and our family to death. Mm-hmm. Wow. But, but it's what I did for 14 years, my kids, and that's, I, I kind of laugh to some degree. I don't think my kids would ever have considered a career in medicine just because of what they saw growing up. My son has watched my DPC journey and, and he actually is thinking maybe medicine wouldn't be a bad idea. He's, he's super funny though because he's like, is there a part of medicine where you don't have to see patients? And I was like, actually, pathology, that's what he wants to do. So yes, now he's thinking about pathology, truthfully. But oh my God, he's like, he's I could cure cancer. I could do all these things as a patho Anyway, so he's, he's yeah, he's reinventing what his, perfect scenario of a career looks like, but who knows what he'll end up doing. He also likes automotive and is at the vo-tech program with that. So, but it's just interesting to, to think through the different, different ways people can. Can serve patients

Dr. Maryal Concepcion: 36:07

well. Yeah, totally. I, I will say though, for the listeners, especially like we all know those people in our medical school classes who went into pathology and that it was like the best fit for them, right? Yeah. And they wanted that for those reasons. I love it. Exactly. I love it. That's awesome. So when, when you were going from this place of you have some moms who were still about to deliver, you gave this six month, sort of runway Yeah. Between DPC and you're on two EMRs. What was it like when you were, fully into DPC, especially as you had, like you had access to your old records. Mm-hmm. You, you had your MA come with you. Yeah. Do you have any tips for other people who are transitioning their own patients from fee for service into direct primary care?

Dr. Kelsey Smith: 36:53

If you can educate your patients, do so. I mean, I know that that is restricted in so many, scenarios where maybe you're not even supposed to tell them you're leaving until your last day or whatever, but if you can educate, educate, whether that's in person or through social media or a, some sort of email that you send out to people as a newsletter. Just letting them think that over. Because I think there are very few people who are going to say yes the first time they hear it. There are a few of my patients who I told them what I was doing. They're like, yeah, none of that made sense, but I don't wanna lose you as a doctor, so where do I sign? But the majority of folks were like, huh, okay, let me think about this. And so the earlier, as you're transitioning your practice, you can introduce the model to patients, because at least in this part of the country, it is still unusual that we have somebody calling that really understands what direct primary care is. My. Yeah, well, I say she's my front office staff, but everybody's kind of multi trained to do everything in my practice. But she took a phone call the other day and I could hear her talking to this individual and it's typical that we, how did you find us? Do you know what our practice is? Based on what our business model is. And, and she was starting to explain, and you could just tell the person on the other end cut her short. And she was like, no, I understand. You know what DPC is. And she's oh, okay, so you're moving here and you had DPC in your old hometown. She's okay, so you get it? And she's like, yeah, I basically cut her short. And it's like, you don't have to sell it. Yes, I know what I want. So that, but that's unusual. It doesn't. You, I think one of the other presenters here said it, if you build it, they won't necessarily come. You do have to do some marketing that is not a, a four letter word, but you don't have to do. Massive amounts of marketing the way that people think of it. You don't have to go hire an ad firm and spend, tens of thousands of dollars on marketing, depending on where you're at. Usually that's more grassroots. Join your Chamber of Commerce and let them know what you're doing. And if you are transitioning a practice, they may already know who you are. And then they're more interested in like, well, why aren't you doing what you've been doing the past five, 10 years? And so they have a genuine curiosity. Everybody likes a good story. And, not that you want people necessarily gossiping about you, but it's not necessarily a bad thing to be on the mom's forums in your, your community on social media. Or as you start to transition some patients at, it's been said before, but it's true. Your patients are your best marketers. Mm-hmm. And so I love it when I look at our community Facebook page for our small town, and it's not uncommon. People ask who, who's the best doctor in town? Blah, blah. Who should I go see as my primary care? And then to see my patients really go to bat for me.'cause I don't ever post it. Hey, you should come see me. But they will, they'll be like, Hey, my doctor's the best. She, takes cash pricing, you should go see her. And of course I see people recommending my old partners and things too, which is great. They're wonderful physicians, but your, your patients, once they figure it out and have kind of seen the light for themselves will do the marketing for you. Yeah, absolutely.

Dr. Maryal Concepcion: 41:58

And I wonder, as you were getting people really understanding what you do, because you were just being a doctor and you were free of these coding requirements. Mm-hmm. How did you either change or further, optimize the way that you're practicing or how you were talking to people based on what you were hearing from your patients in the, in that first year?

Dr. Kelsey Smith: 42:19

Yeah. So your elevator pitch is not a static thing. Right. Because you do need to become more perceptive as to what the individual you're talking to, what their needs are. And so for one person it may be that, hey, you don't have to have insurance if you know you're not covered by any program. We're accessible to you at a cash based price. And other people are like, you know what? I don't care about that part of it. The next, some people are like, well, do you take my insurance? And then you have to kind of pivot that and be like, we see patients of all different kinds of insurances, but we don't necessarily, well we don't, we don't get paid by them. And that's to your advantage because we help you to negotiate how to best use your insurance. Mm-hmm.'Cause I'm not paid by them. I work for you to help you decide is that MRI best to be paid for by insurance and jump through their hoops to get it? Or is it better to use your HSA money and just go pay for it? And so you have to kind of know the patient. And so I would say with an elevator pitch, you, you develop a lot of different trains of thought in your brain. But I think it's smart to always ask. Whoever you're wanting to pitch to. A few questions to begin with, to find out where, where they're coming from. Are they an employer? Are they looking to bring five or 10 lives to your practice? Are they a mom? Are they in a healthcare crisis right now, what are the things that are gonna speak to them that they need? Because they can tell you what's broken in the US healthcare system for them. There's so many points where there's pain points for people, but they're not the same for each individual. Totally. So if you can tailor what your spiel is to what their experience has been, you're gonna be much more successful then if you just always spout the same information and it may hit the target or not.

Dr. Maryal Concepcion: 44:05

Totally. I love that. And I completely agree. One of our most helpful questions that we have on our applying to be a member at our practice form is what are you looking for in primary care? Yeah. And it's a very open-ended question, and we will get, just like you're saying, the answer of what type of personal medicine they're looking for. Mm-hmm. In their own words. And so it really cuts down on length of time you need to spend on a meet and greet. But also you have, this is what I love about DBC, is that like every time you have a conversation about your own practice, you hear a different way people are translating it. Yeah. So as you have more, more conversations, you can bring up these examples for people who are similar to your existing patients, which I think is so just reinforcing that personability of our model. Yep. Yeah. in terms of Oklahoma in particular, I mean we, we've talked a little bit about how it is unique. One of those things that you mentioned is that it's not maybe as well known DPC is not maybe as well known as somewhere like Texas, like Houston, where there's a gazillion what else about Oklahoma do you find is unique about practicing as a DPC physician?

Dr. Kelsey Smith: 45:08

So, I think Oklahoma is, as far as like the regulatory climate, the political climate is very open to DPC. There. It is a long history in Oklahoma of just being a self-made person. A self-made man. And so I think people, once they figure out what DPC is, they're very supportive of that. And I think the political climate is very supportive of that. But those people who have that idea of, you can make it on your own, I think will invest more because they have kind of an inherent distrust for systems. They don't feel like the man has their best interest at heart. And truthfully, that's, there's a lot of truth in that. But because of that, I think people who even have great insurance, whatever that is, and once you get their attention, are more likely to support DPC just because of kind of the climate that's here. Yeah.

Dr. Maryal Concepcion: 45:55

And given that we're at the Free Market Medical Association conference, this is definitely a space where people who are not necessarily physicians, but people who are building self-funded plans, they're looking at community owned health benefits. Yeah. They're all, talking amongst people like yourself and myself who are the physicians giving the care. When you think about direct member care and where it intersects with medicine provided to an employee by their employer. How has employer sponsored DPC come into your practice at Pioneer?

Dr. Kelsey Smith: 46:25

Yeah, so, I mean, more to the specific nature of Oklahoma based DPC, I mean, we are so fortunate to be the birthplace of the Free Market Medical Association with Dr. Keith Smith and Dr. Steve Lanier, who co-founded the surgery Center of Oklahoma, Jay Kempton, who then helped co-found the FMMA with Dr. Keith Smith. So we've got such a heritage here of kind of. Being a warehouse of just innovation and ideas that has spread nationwide. So that is super cool and have been able to make those connections early in my career has been incredibly valuable. And then the scalability of DPC is strangely controversial amongst DPCs. I mean, some people really don't feel like it should be scaled. Other people see the opportunity to just scale beyond our wild, wildest dreams. And so I've tried to hit a kind of a happy medium there, kind of Goldilocks wise. But know Dr. Kyle Richner is here from Oklahoma. He's made a great brand with primary health partners and has saved so many physicians from the systems in this area who wanted to practice DPC, but did not necessarily wanna be practice owners. And I think that is. A huge accomplishment and I love that. But he has also been super respectful both he and Chris Eth, who is the owner of Remedy Health who has also kind of scaled DPC in the Tulsa area. I was, I had discussions with both of them early on as far as when I was getting ready to open my practice and, even though they've scaled their practices and obviously could have just said, well, you can work for us, but we're not gonna share with you, the secret sauce. Neither one of them were that way at all. They're like, I can see that you kind of wanna do this on your own, and that's perfectly fine, but if you decide you wanna be a part of Remedy Health or part of PHP, we're always here If you, you want to be an employee. And, and I didn't, but, but that was great. I mean, we are close friends to this day on both sides of that divide. But. With, with PHP, they have been successful in talking with employers. And the very first employer group that Dr. Ner was able to recruit is a local, well, and several other people in other areas of the country probably have heard of it too. But Life Church is based out of Oklahoma City and it's a televised church broadcast. And you have your local church staff, but then the main sermon is televised from the main campus here in Oklahoma City. And so Dr. Richner attends that local church here. And he was telling the staff, you know, I really think that this would be something great that we could offer to the church employees. And they're like, yeah, that's great, but we have 26 campuses. We can't offer something to the main campus that we can't offer Nationwide. And, and he put together a grassroots roots network of DPCs in each of those locations to say, no, here, you need to offer this to your employees. And I've already got the doctors in place to be able to do that. And, and we were connected through Hint, so. That has been, I have the hint what is it where you can get employers through Hint, hint Connect. Yeah. Hint connect. Mm-hmm. But then I also have through PHP as an affiliate, I have kind of a second stream through Hint for that. But, but as a primary Health Partners affiliate, not an employee if they have an employer that has overflow into my area, they know that they're gonna be taken care of. So I started off with those Life Church employees, but now I have probably I think probably 10 different employers as a PHP affiliate that I help take care of the people in my area. The University of Central Oklahoma has direct primary care benefits, and they're a fairly large university here in the Oklahoma City area, Edmond. But yet some of their professors drive from my town in Stillwater to work in Edmond. So I take care of the ones that live in Stillwater, if they choose to take care, take advantage of those benefits. And so that's one way I've gotten a lot of employer access. The other is just. By talking with patients and local businesses that have signed up with me directly. And that has typically been smaller businesses not the people that have multi-site locations and things like that, but just your mom and pop, like plumbing office or construction. We have one that's an oil well service that are all signed up with us directly for our DPC services. But you know, when you get their attention, and there's one company that I take care of, he just really wanted to invest in his employees. He was like, I can't offer them full benefits. He's but I want, I want them to be taken care of and I can afford this. And I think it's more valuable to them and to me as a business owner. So, you, I give that gift to your employees, which gives back to the employer because they're able to be at work more, but yet they're healthier and, you get more bang for your buck. So it, it does make sense. But I know there's people out there that just. Feel like an employer is the same as a third party. And there's probably some some benefit to that argument, some, some truth to that argument as well. There's occasionally times people don't see the benefit of their membership because someone else is paying for it. Maybe they don't value it as much personally but people just kind of expect in today's climate that their healthcare is covered by their employer. Mm-hmm. So, so I, I don't know. I have, like I said, tried to strike a happy medium between, you know what I, I really like it when people find me as an individual, but I wanna be able to work with employers to to, to help them feel like they're not stuck in the same burning train that yeah,

Dr. Maryal Concepcion: 51:47

that doctors work. And I think that what's unique about it when we zoom out on any DBC who works with an employer is that you are the DBC doctor at the table helping them understand as employers, but also you're the one delivering the care. Versus in the fee for service system, we just signed our names to contracts. Yeah. Not in your case necessarily because you were a private practice, but like in the typical fee for service journey, you don't know who the heck talking. Yeah. You still have no negotiating

Dr. Kelsey Smith: 52:11

power though. Yeah. I mean, they just bring it to you and say, we're cutting your reimbursement. Yeah. And you have no, have no recourse to that. Yeah. So yeah, it is, it is interesting'cause there'll be some employers who maybe decide that's not the way they want to go. Mm-hmm. But but you can, you can set the tone and negotiate what might work best for you and, and for them. So.

Dr. Maryal Concepcion: 52:28

And have you ever put on your intake forms? Do you own a small business person applying to my practice as an independent patient? Yeah.

Dr. Kelsey Smith: 52:36

my intake forms are pretty standardized. I don't have the opportunity to add anything to that, but but when they come in for their first visit, of course that's something that, we kind of talk about and how did you find us and what do you do and, and all of that. So sometimes that will. Kind of naturally evolve into those kinds of

Dr. Maryal Concepcion: 52:51

discussions. Yeah. And for those people who are like the, the the oil company that you mentioned mm-hmm. And these smaller employers that do buy their, buy their healthcare through you as a private physician. Yeah. How did those conversations go? Do you have any tips for people who are like, I, there is a mechanic off mechanic shop literally down the street. I don't even know how to, to approach that mechanic shop.

Dr. Kelsey Smith: 53:15

Truthfully, I, I was busy enough. I did not put boots to the ground to like just go out and, knock on their door and, and ask for a conversation. Mm-hmm. Most of those conversations came to me and typically either through someone that worked there, that was a patient who went back and told their boss, this is amazing and you guys should cover it for us because it has been such a great deal for me. Or the, the boss themselves. Chose to, be a member of the practice and then was like, huh, so we can, we can offer this as a benefit. And, and they, so truthfully, I didn't sell it all that much. My, my growth was, was rapid enough and, and praise God for that. But it, I didn't really have to do a lot of knocking on doors to go find people. Which is, is why, I always kind of chuckle because, I think when you first start your DPC, you're like, okay, what's my ideal number mm-hmm. Of patients and, when can I be full? When will I break even? What's my ideal, patient volume all of that type of thing. And I, I didn't know, I mean, I was like, knowing that I was currently taking care of like 2,500 to 3000 patients in the system, I was like, well, I should be able to take care of a thousand patients. Easy. I mean, that's like less than half of the work. But then you start to realize, oh no, there's a lot more that goes on when you're doing all the things and you wear all the hats, and it makes it a whole lot harder to take care of those folks. But we grew with myself and my ma between 2021 and 2023, we had grown to 600 patients. And I remember my ma telling me, she was like, we have to start a wait list. Mm-hmm. Or I'm leaving you. And so we started a wait list. But then I was able to thankfully get more help. I had a second employee that joined the practice. She came to me saying she had worked in the healthcare system in the local hospital too long. And she said, I just, I can't do it anymore. But I see what you're doing and I want to be a part of it. Can I come work for you? And I was like, you have all this experience. She was a scheduler with the system. She'd worked in the ER in the system, she'd done all, she'd worn a ton of different hats for the system as well. And I was like, I can't afford you. She's I will take a pay cut to come work for you. She's I believe in what you're doing. I see it from a distance and I want to be a part of it. And now, a year and a half later, she's an integral part of the practice as well. Kind of functions somewhat as the administration or front desk staff. While Joanie, my ma she has been with me for 18 years now. And so she's my right hand person that really is my closest clinical assistant. Although Angie can do all of the clinical things really too. They can both draw blood, they can all know the referral techniques and the referral sources and things and ways to do everything. So I, I couldn't have grown like I did with, without that help. Mm-hmm. And so with that, our. Wait list didn't stay closed very long. Joan didn't quit and she didn't quit. So yeah, we continued to grow up to 800 patients and now thankfully I have a second doctor coming on who can be a pressure relief valve of sorts to me, and she can start building her practice because I, that's the other thing, Joanie knowing me as long as she has, we, we joke a little bit because, our working relationship has lasted longer than a lot of marriages. And she's like, you don't wanna recreate the beast. You're, you're doing it again, kind of thing. You might tell your husband or wife and I'm like, I know, but there's people that need taken care of and I could do it. And she's yeah, yeah, you could. But anyway, so, so I ha have to listen to those people in your life that know you well to make sure you're not falling into the rut of that same old habits that you know, you, where you've become a workaholic and work yourself to death. But,

Dr. Maryal Concepcion: 57:08

yeah. And be proud of it. Like you said before, like you would kill yourself over all of these things, taking your kids to the hospital mm-hmm. To put them in the physician lunch so that you could survive. And you're like, and I did this like it's a pride thing. Like it's, I, I think it's, it's a habit almost that we, we can fall back into. When it comes to the, the entrepreneurial, the physician entrepreneurial journey, you and I don't have MBAs like we've said during this interview already, but when you think about maybe like the top three emotions or experiences that evoke emotions that you went through, that you've been through so far in your DPC journey, what are like the top three most surprising things that you would never have known? Because you, you don't know until you do it. Yeah.

Dr. Kelsey Smith: 57:56

No, I. And I think that's just, it is, I think that's what hinders a lot of people from making that jump is they're like, well, I don't know enough. I don't know how to do this. And I, I'm, I think back to all of us tend to have silly things we worry about, but I have this vivid memory of being like a, I don't know, sixth or seventh grader. I think, and my mom might not even remember this, but I remember I was in bed one night and I was like crying myself to sleep. And I was just like sitting there anxious and worried. And my mom comes in and she's what is the matter? What is going on? And I was like, I just don't know how I'm gonna pay taxes when I grow up and I don't know how that works and I'm gonna end up in jail because I don't know how to do tax. I don't know if I'd heard my parents talking about it being tax time or what, I have no idea. But I was literally obsessing over something that I didn't have to worry about for 10, 15 years. Yeah. Down the road. And I think that's what people do when they start anticipating being an entrepreneur. They're like, yeah, but I don't know about how to do unemployment. And I don't know how to do this and I don't know how to do that. And what about retirement and how am I gonna manage all these things? And it's you know what? You figure it out. Everything is figureoutable. And so, I don't know how a lot of people would do it without a background in faith. And as a Christian physician, I felt like my calling is to take care of people. But I also felt like the plan set before me is higher than, than my individual aspirations. And so having just that faith that, you know what, I really feel like I'm called to do this and to make this leap and it's gonna be okay. And, and relying on that faith that yes, there are gonna be problems, but I have a God that is, wiser than I am. And, and there's gonna be a way to, to figure it out. What is in the sound of music? Sister Maria says, every time God open closes the door, he opens a window. Yep. And so. Kind of feel like that feeling of, I don't, I really know how we're gonna cross that bridge when we come to it, but we'll figure it out. We'll build the bridge if we need to. So I feel like from that standpoint of just having faith that we can, we can find the resources, we can, I don't really take care of my own payroll. I have an accounting firm that does that. I know there's definitely doctors out there who they really pride themselves on doing their own Quicken account and all that kinda stuff. No, I don't do that. I pay for that to be done. So, you figure out what you want to focus your time and efforts on and what you want to, to kind of source out. So that, that aspect of, just kind of the faith that this is the direction I needed to go was was huge. There's definitely days where I show up to work and I'm like, what have I done? There's, several things blooming to get taken care of and you're like, oh my gosh, I can't, so there's still days you feel overwhelmed. But those are so far between compared to where they used to be. I think. We were talking earlier before the podcast that I stopped by the office before I drove back down here to Oklahoma City this morning, and Joani and Angie were saying, I didn't think you were even supposed to be here. I was like, yeah, I know, but I needed to sign a check for you guys to leave for somebody anyway, just had some, little administrative things to do. And I said, but this is my happy place. I don't wanna leave you guys. And they're like, go to your conference. And so, I think back to, you know, you find yourself in, I think, not just medicine, but in a lot of work situations. You work for the weekend or you're always working for that next vacation because you can't, can't wait to get out of the day to day the grind. And when you find your ideal working situation, I mean, it's still hard work, but I love to go to work. Was it one of the, the endocrinologists that you spoke with on your panel. She said, the one of the girls that she hired says, I don't get the Sunday scaries anymore. And so to not dread going back to that place that drains the soul and life out of you while you're trying to breathe life into others mm-hmm. Just doesn't work. It's not compatible with a long term survivability. And so, yeah. I mean, just,

Dr. Maryal Concepcion: 1:01:51

yeah. Yeah. It's, I'm sure there are people who are just, taking what you just said and emotionally experiencing it. Yeah. Because there have been more than one, and this is terrible, but this is the reality. There have been more than one physician, there have been multiple physicians on this podcast who have shared that they, that the Sunday scaries to them was crying before going into work. Yeah. Dr. NamUs Bradley said at the beginning of the season people who would just like, Dr. Liz Ortiz said she had gut issues that were like mm-hmm. Totally gone. Once she transitioned out of the fee for service world. So those, those Sunday scaries, it absolutely is unique for everybody, but that's real, and that is definitely something to pay attention to as you might not know what the alternative is going to look like. Exactly. And that is uncomfortable for us who are like, if this, if, if this, if step says a yes, you go to yes or no, and we follow the algorithms, but that's not how life is. Mm-hmm. And I, I do agree that there is, there is a portion of it is what it is, and you don't have power over every single thing. You can't control every single thing. Yeah. When it comes to you talking to people who are coming up, like there's a, a, a wonderful doctor from Minnesota who's here learning about DPC. Mm-hmm. Right on the cusp of opening. What are some of the things that you love telling other people who are in this space of almost there. Not there yet. To empower them, but also to help them have something that they root in, that they, that they're rooted in, that I, that they identify with and only they can identify with as they go forward in their DPC journey. Yeah.

Dr. Kelsey Smith: 1:03:33

Well, I think it's, it's interesting, I've been asked the kind of open-ended question of zero to 10, how much would you recommend DPC to other physicians? And, you would think if you're a happy DPC physician, maybe you would always say 10, but I, I wouldn't, I mean, I don't think DPC is for everybody. Yeah. And so I, I've, I've rated that a seven, if you're looking at physicians as a whole, but when you're talking to individuals and you can kind of see where they are struggling and truthfully, I mean, I know it happens to male physicians as well, but I really feel like the system preys upon female physicians more so than, than men just in our unique practice styles as. Female physicians, and I know I'm generalizing with that as well, but there are so many more female physicians who I think are feeling that crunch more so than our male colleagues. And so trying to speak to them that, you are more than just a cog in the wheel. You have value, and you, it is not a sin to talk to your patients about that value, even in monetary terms. Because I think we become so humble to the point of it being a a hindrance to our, we, we think we have no value and that everything we do is, is a service. And oh, thank you, dear hospital system for my paycheck every two weeks because I know what I do has no value. No you have value. And I think once you start to realize your value, you start to realize really how, you know you can't pour from an empty cup, right? Mm-hmm. And so once you realize your own value, and that may not mean. Okay. Self care and kind of the modern way we think about it. Oh, get, go, get a pedicure. Go take a vacation. No, you can still be at work and getting your cup filled. It does, work should not always drain your life out of you. And I think once you can show that to others, and like I said, there's, there's just, I don't know, a different field. And whenever you get direct primary care physicians together in a room that someone who is considering it, it's just a entirely different experience. They're like, what is different about you guys? Yes. And so I think once they've experienced that and felt it that you guys are happy, you, you feel like there's value in what you do and that you're doing good for your patients and for yourself, they're like, tell me more. Yeah. So I think once you've felt that in your soul, like there's no going back,

Dr. Maryal Concepcion: 1:05:58

it's amazing. Well, thank you so much for sharing about Pioneer and your journey as a physician who went from residency to being a private physician to being a private DPC physician. And I am so excited for other people to take your words and put it on, put, put your advice to their own lives. So thank you so much. That's Thank you for listening to another episode of my DBC story. If you enjoyed it, please leave a five star review on your favorite podcast platform. It helps others find the show, have a question about direct primary care. Leave me a voicemail. You might hear it answered in a future episode. Follow us on socials at the handle at my D DPC story and join DPC didactics our monthly deep dive into your questions and challenges. Links are@mydpcstory.com for exclusive content you won't hear anywhere else. Join our Patreon. Find the link in the show notes or search for my DPC story on patreon.com for DPC news on the daily. Check out DPC news.com. Until next week, this is Marielle conception.