From Hospital Rounds to DPC: Dr. Kathryn Dreger’s Story of Empowerment

In this inspiring episode of the My DPC Story Podcast, host Dr. Maryal Concepcion talks with Dr. Kathryn Dreger, a board-certified Internal Medicine physician and founder of Prime-PLC, a Direct Primary Care (DPC) practice in Arlington, Virginia. Dr. Dreger shares her journey from fee-for-service medicine to launching her thriving DPC clinic, highlighting how DPC restores time, trust, and personalized relationships in primary care. She discusses the challenges of traditional insurance-driven healthcare, her personal experiences with bureaucracy and performance metrics, and why DPC is revolutionizing patient-centered care. Dr. Dreger explains her approach to panel size, pricing strategies, and the value of maintaining hospital connections. She also provides insightful advice for physicians considering a transition to DPC and talks about her upcoming book on the future of patient-centered medicine. Listeners gain practical knowledge about starting and sustaining a DPC practice and the importance of advocacy for primary care reform. Tune in to learn how DPC empowers both doctors and patients, leading to better healthcare outcomes and greater professional fulfillment.

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Transcript

Dr. Maryal Concepcion: 0:43

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.

Dr. Kate Dreger: 1:31

Direct Primary Care is making what we know has worked for generations start working again. But this time, with the scientific advances of the 21st century, we are harnessing and celebrating the importance of accessible, personal and personalized expert medical care that lasts for years. I'm Dr. Catherine Dreger Prime, PLC, and this is my DPC story.

Dr. Maryal Concepcion: 1:59

Dr. Kathryn Dreger is a board certified internal medicine physician and the founder of Prime, PLC, a Direct Primary Care practice in Arlington, Virginia. She completed her residency at Georgetown University where she now serves as an assistant professor of medicine. Since 2014, she has been recognized as a Washingtonian Top doc, five years in a row, and honored by Northern Virginia Magazine and Washington Consumers checkbook as a top rated primary care physician. In 2016, Dr. Dreger launched Prime PLC to reimagine how healthcare is delivered, restoring time, trust, and personalized relationships to primary care. She continues to care for patients in the hospital while running her thriving DPC practice, and she's the author of an upcoming book on the future of patient-centered medicine. Today I am so excited to welcome Dr. Kate Drager to the podcast. It has been a wonderful, set of years that I've known you since the very first summit I ever went to when I didn't even really know what Direct Primary Care was back in 2019 in San Francisco, to having conversations with you as we've, worked and advocated for policy together on Capitol Hill. And now we're able to sit down and have a longer conversation about your history as to why you chose DPC. So thank you so much for joining us today.

Dr. Kate Dreger: 3:16

Thank you so much for having me. This is a real honor and I'm very happy to be here.

Dr. Maryal Concepcion: 3:20

Awesome. So one of the things I wanna point out from the get go is Back in 2019 when I didn't even really know what direct primary care was, you would ask the audience what is primary care? And so I think about when you and I were talking about a week ago before this podcast, and you were asking, like, what, what, what about my story is helpful to the audience? I, I say to you and I say to everybody, every one of us brings a different perspective to the. The definition of what Direct primary care is because we serve our patients uniquely because our patients hire us to be their doctor. I am humbled that you and everybody who has shared on this podcast is showing that that is the truth about primary care in general, and especially direct primary care, when you can even highlight more the relationship that you can have with your patients.

Dr. Kate Dreger: 4:13

Yeah. I think it's very interesting when you think about direct primary care as a unique offering and how just messed up that is because it should be that everybody can have a doctor like this. Amen. Right. And if you have a healthcare system, if you think about it from a societal perspective, you want everybody to be able to access care and you kind of want everybody to be able to have. Their own physician. And the fact that we're to this point where it's a unique offering, I think really speaks to how much we have lost our way.

Dr. Maryal Concepcion: 4:51

Yeah, and I think it also goes back to why you and I advocate for that. This is just primary care at the end of the day, or at least what primary care should be. So, on that note, I will say if you would like to join us in advocacy, please join us. Join us at the DPC Coalition. But when it comes to your journey into direct primary care. Yeah. You've been doing this for almost 10 years now, and so I have Yeah.

Dr. Kate Dreger: 5:17

Nine. No, it's nine. Nine in October. Yeah. I started in October, 2016. So nine years. Mm-hmm. Yeah.

Dr. Maryal Concepcion: 5:24

And that. I'm sure it doesn't feel like it based on, I'm sure it doesn't feel like it, especially compared to the years prior to DPC in your medical career. Right, right. So I would love if you could bring us back to just the fact that you're an internal medicine doctor, because even though I would say a majority of the physicians who have shared their stories on my DPC story are family physicians, we absolutely have a growing number of internal medicine physicians, pediatricians, as well as specialists who are not focusing on primary care, who are doing direct primary care as a business model, or they're a primary care physician doing direct primary care as a business model.

Dr. Kate Dreger: 6:01

Yeah. I mean, I think that the differences between, in primary care, between pediatrics, internal medicine and family medicine are probably smaller than their commonalities. I think if you look, certainly listening to your podcast and remembering back to my medicine training, the the breadth of full scope. Family medicine is, is remarkable. And it involves hospital care, right? And I, people often ask me, what's the difference between internal medicine and family medicine and peds? And I think a lot of it is just age, right? I small people scare me. They get really sick really quickly and they're so precious, right? Like, I feel like you give me an 85-year-old coming to the end of life. I'm your person. I'm good with that. And I think, so internal medicine may be skews more, those complicated end stage multi-system organ failure patients than family medicine. And I certainly love those patients, but I don't think there's very much difference because I think one of the things that certainly policy makers don't think about is that patients don't actually know how sick they are. I mean, we saw that firsthand in the COVID Pandemic, where you would have a photograph of somebody who is morbidly obese and the loved one would say he's totally healthy. And what they mean is fully active, fully independent, but actually metabolically very sick. So, so I always liked adults. I've always liked the hospital. When I started in 2002, we did our practice. The, the practice that I joined was a attached to the hospital. I joined somebody who'd been in, in practice for 15 years and we admitted all our own, which was pretty convenient'cause you could walk over this little skyway and be in the hospital, in the er, and if something happened, you could run over to the hospital and run back. And then followed them up in the nursing home and saw them back in the office. And I found that to be hard. But, but so rewarding and so much easier, quite frankly, than when somebody gets admitted and then you get like typed computer generated vomit and you're trying to figure out what happened and why they did things and, and what really went down. So, so that's how, that's what I love and that's what I started doing when I, when I got out of training in 2002.

Dr. Maryal Concepcion: 8:41

That's amazing. And, it's, it is. It is so interesting. I'm sure that the listeners out there are picturing the patient who you are describing somebody who's metabolically not healthy, but they are healthy according to their, their relatives. And I think also it, especially looking back to the pandemic, I think this is where a level of fear came out about how COVID was ending up killing, people who were young people who go to the gym and it, it really, was a, whether you like to face it or not, like metabolic health matters and Right. It absolutely impacts your ability to have an immune system that is robust and is able to adjust whether you're vaccinated or not, so. Right, right. I, yeah. And then there's just

Dr. Kate Dreger: 9:32

random. Randomness of illness, right? Yeah, absolutely. That we know well as physicians, that you don't have to have done anything wrong to just have something horrible.

Dr. Maryal Concepcion: 9:43

Right? Totally, totally. Yeah. When you made the decision to become an internal medicine physician and you joined this practice, I'm wondering what were the opportunities at the time that you decided to join this practice? Because I think about how nowadays, the stats in California that 80 to 90% of family medicine residents choose a role that is employed under a corporation. And I'm wondering what the options were for you when you were graduating residency.

Dr. Kate Dreger: 10:11

Yeah. So when I finished residency, we didn't really have hospitalists. And really there were hardly any employed physicians. So everybody went into private practice. I work at a community hospital. We had 200 people on staff who were family medicine and internal medicine who were all admitting their own patients. So I sort of did what everybody else was doing. And I liked it actually because my business partner had a computerized record, which now I'm really dating myself. When you got to work past the pterodactyls and the dinosaurs. Life was in black and white. 2002. The your sound is off.

Dr. Maryal Concepcion: 10:58

It's, it's so I don't cackle over your, your amazing jokes. It's great. Okay,

Dr. Kate Dreger: 11:06

that's fine. I just nobody was using a computer, right? So everybody was using like the paper charts, which has its own level of pain that I really think we all need to remember when we get com annoyed with computers that you are like, where is their physical chart? Like where is the piece of paper I need to write on? And now you can do it kind of remotely. You can be downstairs, you can put the order in without having to run up and put orders in manually and then wait for the secretary to take it off. So, there are huge advantages to computers and he had a computerized. Healthcare record. So, and he'd been using it for two or three years. So I thought this was great because I could, as a new physician, enter all my data. And he also did something that was very, very interesting is he was involved in PPR net, which is a research organization. And they were using the data and actually studying how doctors deliver better care. Like how can you train physicians to kind of finagle their office to get better population health, right? And what are the barriers and that kind of thing. And they did some wonderful research and from probably late nineties to early 2010s and we participated with that. And part of what we did was we would actually get our patient metrics and those would be pulled every quarter and we learn how to read them and then how to use those lists and. Call our patients up who weren't due. And so I, I was actually really into taking good care of not only my individual patients, both in the hospital and in the office and in the nursing home, and also just'cause they were just ordinary functional people who came in once or twice a year. And benign stuff and and severe stuff. But also learning how to use, it's gonna leverage the computer to actually deliver better care from a population perspective. Right. So like I was super excited about that and the person I was who hired me, who lately we, I became a partner in the practice. It was super clever. It was really nerdy. It was a good time. Yeah. Initially.

Dr. Maryal Concepcion: 14:39

Yeah. I think it's awesome'cause it definitely sets the groundwork for somebody who is passionate about what primary care really is and not what codes define primary, primary care.'Cause even though you're talking about research, you're talking about. Meaningful versus meaningless data. Right. So tell us a little bit about your, when you think about meaningless use versus meaningful use, what are the things that that you think about, especially as the like? Oh, absolutely. Let me tell you my examples of meaningless use that I experienced in fee for service. So

Dr. Kate Dreger: 15:15

there are so many, and I'm sure many people have are listening to this and thinking, oh yeah, let me get out my pen. I, I think, I think my favorite story it's called this person Isabelle, which is not her name. So Isabelle was lovely lady who had absolutely terrible diabetes. Like, terrible, like hemoglobin A1C on a good day was 13.5 like. So what she liked to do was she really liked sodas, particularly Cokes. So she would drink six to 10 cans of soda a day, right? Her BMI was 45 and she just loved that fizz of the coke and I tried everything. She did not like the idea of giving herself injections. She didn't wanna do this, that, or the other, right? So eventually we worked on a lot of things. We bought the mini cokes, we like finagled. If she would do the shot after a shower, she would take like one of those once daily long acting insulins. And I got her hemoglobin A1C routinely down to nine. Which like for me was like, I mean, yes, I am like, I am so cool. I am so proud of myself. And then. Then I did the meaningless abuse. Right. And, and I had to put in the data. So you had to have enough patients to make the metric, right? Like you had to have something like 30 people. But there, there was some reason why it worked in primary care where you had to have a, a, a common disease because you have so many patients, we don't actually have a lot of patients with any one condition. And then you had to whittle it down so that 10 of those patients were actually Medicare patients who during the year that was being studied, were between 65 and 74 years old. Right? So you had, so I had to find something that had 10 of those people. So it was diabetes. And when I looked at my whole population in the office, like my average hemoglobin A1C, and all my diabetics was 6.4. Which I was like, nerdy. Yay. Right? Yay. Okay. As an internist, I'm feeling super nerdy, super successful. And then I put the data in and the only data that counted were the 10 between 65, age 65 and 74. And I remember putting it in, and I, I knew, I knew the six people of the 32 who were just like Isabelle, like, ah God, I tried, right? I tried, can you do one donut, not two donuts, that kind of stuff. All six of them were in that 10. And so from CMS and Medicare's perspective, I was a terrible doctor and I should be punished for my lack of medical care by reducing my fee schedule by whatever percentage and. Even thinking about it now, I get kind of furious. It just the way we were doing performance metrics was thinking about them critically. Did you make a difference in this person's life? Did you help them? Can you help them? I always joke that sometimes patient care is, you know, you lead the horse to water. You ha hang onto the bridle, you put the horse underneath the water and still they will not drink. And eventually you're like, dude, if you're thirsty, there's like a great big pond over there. Help yourself have some water, right? And so when we were reading our metrics, we could divide those patients into the people. We were like, okay, we're doing the best. Can you see them? Can you get anywhere? And the people where you would be like, why did they not? Why did they not come back? That's not like them. And it turns out like, the dog died or something happened or they switched jobs and they'd come back in, but you didn't know to call them. And these lists can help you do sort of things that are u useful. Right. But being punished when I'd actually made a big difference was really maddening there. That's polite.

Dr. Maryal Concepcion: 19:58

I, I would agree. That's polite. But yes, it's maddening is also polite to, to to describe the ridiculousness of, the, the current fee for service system and the insurance driven way of life. And it is, it has led to data denying people care without even having the physician's opinion included in that decision making. Right. So, so from here, you were still. Doing hospital medicine, you're still doing outpatient medicine. You're still, you're still doing your thing and then you weren't, you decided to open Prime PLC. And I'm wondering, because back in 2016 there were not as many DPCs as there are now. Mm-hmm. Definitely not as many DPCs in your area as there are now. And I'm just wondering, what was it that inspired you to change? Because you had been in practice for a good number of years, you had an established practice. Yeah. And you had you had, a panel who was, was equaling, whether it's fair or not, some kind of income that you became used to before changing over. So I think I, I

Dr. Kate Dreger: 21:10

think it's a little bit like a death of a thousand cuts, right. I think that I'm a very nerdy person. So when, pay for performance came out, I was like, I don't understand. Like I must be missing something. I'm always the person who's like, what am I missing? Like, did I, did I not get the memo that this works? Like, so I started reading it and I live basically inside the beltway. I want you to know there are nice people inside the beltway for people who hate people inside the Beltway. We actually have a functional society. We're all very nice and very normal, okay? And it's not a swamp. It's got roads and everything. Anyway, so I happened to, I happened to know people who worked on the pay for performance stuff, and I got to talk to'em. I went out and had a beer. I was like, this is like not working. And I remember talking to one policymaker. One of the things he said that he's like, listen, I, I know all about healthcare reform. I live it every day. I am completely in tune. I mean, in terms of the day-to-day running of a medical practice. I don't really know anything about that. But, but that's not important to what I do. And, and it was comments like that. You're like, well, how can you reform a healthcare system when you don't understand what, how the bricks work, right? Like, if you don't understand how the little pieces work, the little pieces, like how can you possibly fix it, right? So that I could see happening, so I could hear it kind of going through. And I read a lot about. Our poor healthcare outcomes as a nation. And I don't know if you've ever read this, if anybody's really in the mood to really something. Yeah. There is a report from the National AC Academy of Sciences, which was the Institute of Medicine, which I think is called now the National Academies of Medicine. But the Institute of Medicine, as it was called at the time, issued a report on shorter lives, poorer health, and why do we have poor health outcomes? And one of the biggest reasons is we don't have primary care physicians. So I'm watching my practice get like hammered and I'm hearing people making decisions like actually speaking to them and they don't understand how the system works. And I'm reading the science that says what they're doing is wrong and. I'm trying to make it work and we are trying to use the computer and bill for the things we need to bill. And because I was also working in the hospital, I'm having to do all the things in the hospital to make the billing and coding work in the hospital. I'm learning all of that and all of that bureaucracy and all of those things that aren't actually patient care, but like the patient has to stay in an extra night, otherwise they don't qualify for this and, and if you don't add this IV in the right time, then they can't get rehab and all of those bureaucratic, silly, ridiculous things that actually impact care. And that was hard. But then I started realizing that I was working so quickly, like we, I think we added. We basically went from seeing 15 people a day to seeing 22 to 24 internal medicine patients a day. And I will say, I don't know how family medicine people do it in internal medicine, we have all these like long nerdy list and people have like 10 medical problems and you're going through all of them and it's hard to do that in 15 minutes. It really, really is. And so, I had a lady come in who was like, I said, how are you doing? She's like, well, the move went okay. And I was like, what move? She's like, well, I moved apartments. I'm like, I don't remember you telling me you moved apartments. Like I would've remembered that. She's like, no, I told you. I said, well, why did you move? She's like, well,'cause my back was so painful I couldn't live there anymore. And I was, I was like, what? What? Back pain? I went back to my note, there was nothing in there about back pain, and she just put her hand on my, on my hand and was like, Dr. Drager, it's okay. You looked really, really busy and you were typing a lot that day. And I thought, oh my God. Like I can, I, I know how to treat back pain for God's sakes. Like I am now treating the computer and I'm not treating the patient. And, and you can probably hear in my voice like these things, like on all fields, you look at it and you're like, this is actually not, there's no sense to this. And I sort of wanna state for the record, it's not'cause I'm a wuss, right? It's not'cause any of us are wusses, right? We all were, we're all the kind of weirdly wired people who, when you said you're told like, I would like you to stay up and work continuously for 30 hours. We're like, great. And can you please give me a good grade? Please click. Who does that? Nobody does that. Okay. So then my business partner. Decided to retire. And he retired way earlier than I ever thought he would. And that was in like right at New Years of 2015. And then I actually had a decision to make, right? Like this is like, you, you get pushed into a decision, you're unhappy, but, but now you have to choose. And so that's when I started looking at my options and, and do I become a hospitalist? Do I join a bigger practice? Do I try and go solo, maybe go into academics? But for a long time I had been looking at direct primary care and kind of thinking about it and comparing this model of care to the reform that people were doing and thinking, no, no, no, this is actually. This is actually way more elegant because what Direct Primary Care does is it, it empowers critical thinking and it empowers expertise at the level of patient care. And it is a free market solution, which Americans love free market, right? So if your patient doesn't like you and you don't do a good job, they can fire you and go somewhere else. So then you are now working for your patient, right? And then a colleague died and my favorite aunt died just like two months after that and three months after that. And then I decided. Life is short. And if I, if I don't do, if this, if I do this and it doesn't work then I'll just do something else with my life.'cause I can't work like this anymore. I can't worry that I'm gonna hurt somebody because I couldn't hear them'cause I was doing so many other things at the same time.

Dr. Maryal Concepcion: 28:37

it's so relatable that it's so heartbreaking because I, I totally, I can picture you at the computer. I can picture your patient holding your hand and saying, it, it's okay. And and the, the passivity as well as the entitlement that we get from our patients because they don't necessarily have a relationship with us in fee for service and as much as they do in DPC. And they you can see like the Jekyll and Hyde in our patients because it's like they're really, really. Desperate for help. And then some of them are so just like resigned to, I know I'm not gonna get help here. It reminds me of a time to kill when Matthew McConaughey, sorry for being a spoiler is talking about a very, terrible case that was involving a black child and said to the all white jury, now imagine if that child was white. And it makes me think about when we put ourselves in our patient's shoes and when we think about would we like to be on the receiving end of that type of care? It it is it, it makes me at least stop and think about the shame I have for some visits that were just like that for myself in clinic. And I'm sure the listeners out there can think about times when they were going too fast or, wanting to walk out of the room because they were behind and they didn't wanna miss their kids' soccer game or whatever. These are things that that make it so frustrating to be in a fee for service, corporate driven, insurance driven. Somebody who's not the doctor is determining how you deliver care model.

Dr. Kate Dreger: 30:14

Yeah, and I think, listening to what you're saying, I mean, that is actually the heartbreaking thing. Like I went into medicine because I think this is such an honor and such a privilege to try and help people. And I would never, ever, ever intentionally not listen. Right. It was just, it's just you see, 12 people by noon, right? And then you're running out the phone's, ringing somebody in the hospital needs fluids like you're running over back and forth and it's, it's just very difficult to do all of that work. Yeah. And I think that's, that shame is part of that moral injury where the only way the game is played is fee for service and you're supposed to just get on with it and you're supposed to do it perfectly. But when I look at. Kind of the way we've created the current fee for service. It's not by design. There's a joke from a lot of policy makers here that actually is very common that nobody talks about, which is reforming healthcare is like putting, laying down track in front of a moving train. That's not actually reform, that's just panic. There's no, there's no, that's not how you sail a ship. You don't just go like, oh, let's go this way. Oh, look, oh look, there's an island. Ha ha. No, you have a plan. Like what do you want this to look like? You don't have a reactionary system, but we have a very reactionary system. And so, yeah, so I decided, forget it. I'm gonna do something different.

Dr. Maryal Concepcion: 31:56

And I also just wanna call out that it's wonderful that, you even had the discussion of, if it doesn't work out, like I'm still me, I can do other things. I think that that's very important to remember because it is not everybody, everybody who can go to medical school and become a physician in the first place. And so, if you're having the only thoughts of like, I can't do it'cause what if it fails and you're not thinking the, I'm so valuable that there's other things that I could achieve in life and do in life. That, that's a challenge there. Right, right. I also have a funny story about

Dr. Kate Dreger: 32:28

this. So, when I started the DPC practice, you, you do the, the math, how much money do you need to bring in, how many patients to get to that money? What's your overhead? Blah, blah, blah. And I figured like I, we could make, we could swing it for 18 months. And so I had to opt out of Medicare from the get go.'cause most of my patients are Medicare patients which was terrifying. And you can't opt back in for two years at the time. Right. So I knew that if it was a bust and like nobody signed up and it was no good, there would be at least a six month window where I had no income. Right. It turns out just for anybody out there, you can actually work in a prison without Medicare numbers. So there you are, it's an option. You get paid, it will be excellent medicine. People need you. So that was my, that was my fail safe. Yeah. I had many fail safes.

Dr. Maryal Concepcion: 33:27

Amen. So timely that you mention, funding going into your DPC because coming up in the coming up in the third week of October, completely virtual is a summit that I am collaborating on with two, two physicians ob gyn and an orthopod. And the conference is called Rise Up, but we're going to do empowerment through teaching physicians, including DPC physicians, about side gigs, about locums and direct contracting and how to do things when you're opted out of Medicare. So I think this is so appropriate that you mentioned that, right? Because there's lots of, lots of options. Lots of options. Yeah. I,

Dr. Kate Dreger: 34:05

I didn't know about that at the time, so I was like. Looking how far away the prisons were from my house and how the commute would work.

Dr. Maryal Concepcion: 34:14

Oh my goodness. But I'm, I'm, I, I think it, it, even like, I, I just think about the, the time in which you opened in 2016 to opt out of Medicare was very different than like when I opted out of Medicare. And it was during the pandemic when they're like, oh, you can change back tomorrow if you want. Right. Like two years of a commitment is very, it, it's significant.

Dr. Kate Dreger: 34:34

Right. Right,

Dr. Maryal Concepcion: 34:35

right,

Dr. Kate Dreger: 34:36

right.

Dr. Maryal Concepcion: 34:37

So when we talk about, what, what you were noticing the, all of these different paper cuts and then you decided to open up your own practice because you truly saw it as a way to actively build a practice. That was the type of practice that you wanted to be a part of. Mm-hmm. You opened Prime PLC and you had quite a bit of patients who were with you when you opened, so you didn't Yeah. You didn't have, thankfully that nobody's going to join me in two years. What else will I do? Situation. when we, and when we look at the number of practices who've been on the podcast who have transitioned their private practices fee for service over to DPC, we see a five to 10% buy-in from patients. And so I'm wondering if you could tell us about the fact that your partner was retiring, you had this practice, people have known you for over a decade, and they mm-hmm. Were forced with the decision of you can be with Dr. Dragger or you can be with the insurance group. How did, how did your patients react when you transition to DPC? So,

Dr. Kate Dreger: 35:40

we had a 15%. I had 15%.

Dr. Maryal Concepcion: 35:43

That's amazing.

Dr. Kate Dreger: 35:44

So, so, okay. So I decided to do DPC around about February, March. Think it was March. And between March and Memorial Day, I got a new logo, created a website created a pamphlet and a mailer. Created new patient contracts and Signed up with an automated billing service and, and then between kind of Memorial Day that year and then we opened on October 1st, really spent a lot of time talking to the patients and responding to phone calls and trying to get people to come over. And I think the biggest thing, certainly for listeners who are considering this, it is, it is a very important thing to keep in mind when you're doing this and that is that nobody cares about us. It is nothing to do with them. And if you just save your breath for how much you need it and how much you're suffering, and how much happier you think you're gonna be, that is not the sales pitch. Nobody wants to give you a monthly membership so that you can go get your nails done. Like no, no, no, no. So I think that a lot of what we, what I did was just talk to them about how much more time we'd have together. I could see them on the same day. I really wanted to have more time to focus on them and listen to them properly. And I was frustrated that I couldn't listen to my patients. And I, I think patients deserve better. Right? And then the other thing I did was I said to people like, if you can't afford it, let me know and I will cut the rate.'cause I was not doing this for the money, I was just doing this, so I didn't quit medicine completely. So, that actually allowed us to open the doors on October 1st with 450 people. Which I didn't know until years later was actually pretty good. And it was a conversion rate, I think, and I just did the math. I think it was like a 15% conversion rate. I think it was about 20% from my practice and 10% from,'cause of the average. And and it's been pretty steady since actually I got to a max of 610. 620. And then it, it was too much. Mm-hmm. It was too much to go over and see the hospital patients and do 610.'cause the thing I, I have noticed is that the people who sign up for my practice tend to be much, much sicker. So they tend to want to pay for it because they know, they have so many specialists and so much going on that they need somebody to really sit with them and go through it. So they're pretty intensive care. Not ICU Care, but I'm caring intensively. And and so I, I closed the practice off and then just slowly drifted down. And now and now I'm about 5 20, 5 15, 5 20.

Dr. Maryal Concepcion: 39:03

That was really hard for me to like, not. Vocally expressed by Mary Catherine Gallagher. Level of excitement that you just said what you did, because so many people think that DPC is a way to cherry pick the well patients so we don't have to take care of the sick patients. Oh, no, no. And the fact that you said, yeah, the fact that you said that the people who are sick are value healthcare access even more, it is fricking true. And also, just like if you can't see that, I don't know if you're also doing healthcare reform by laying those tracks down while the train is, is chugging along. Because you see, especially our adult patients or the kids who are with chronic illnesses, it's like those are the people who are so grateful. When you just call to check on them, like, I have two I have two adults who one's older than 90. One's older than 80. And we had a fire, recently and it was in their neighborhood and I didn't know if they had, because they don't use cell phones like I do. And so I called them to make sure they knew that like they needed to be aware of evacuation orders. And they were like, oh my God, you're, oh, you're calling me. Oh, this isn't about an appointment. You're just checking on me. And I'm like, yeah, yeah, because that's what we get to do. We just get to take care of you guys.

Dr. Kate Dreger: 40:20

Yeah. And I think those phone calls where you called to check on someone, like you're just thinking about them and and we were doing it before in fee for service. You just couldn't get there. You just couldn't get to actually make that phone call. And I think. I think that kind of care makes a huge difference. I also think the concept that direct primary care doctors cherry pick their patients is actually very harmful to the movement. I don't think it's true. I think that for many people who are struggling to build their practice, any patient is a patient. Right? And, and I mean, that's why we went into medicine, right? If you wanted to have an easy job, you, you went to the wrong school, right?'cause it's long, long, long road to get an easy job. You get an easy job some in an easier way. Right? And I think that's something else that I, I, I, I did wanna mention think one of the things that has been very harmful to the healthcare system. Has been a sort of dumbing down of primary care that primary care is so easy that all we do is cold and we titrate high blood pressure meds. And then we like, occasionally, occasionally give you a diuretic for your swollen ankles. And that's about it. Right. And I think if we were to say to the average person, like family medicine, do you think it would be useful to have one person who could see you when you're pregnant, deliver you and take care of your infant and your children and your mom as she's dying of cancer? And have one person have all that knowledge, would that be useful? I think everybody would say, oh my God, that's amazing. And in fact, I think many Americans would say That's not possible. Right? And yet that's what family medicine does. And if you had like somebody say, okay, could you take care of somebody in the office and then somebody in the intensive care unit and somebody at the re has enough knowledge to do all of those things, I feel much LaMer right now than a family medicine doc. Just wanna say, if you were just taking care of really old, decrepit people with lots of medical problems all the time, would that be useful? Yes. Yes, it would be useful. And we don't pay for that, right? We don't actually value that. We've actually said like, yeah, that's so easy. You don't need a medical degree. And I think that that really undermines the power of what. Medical care is and, and what a physician degree is. So I think that direct primary care allows you to use that knowledge properly. Right. To say to your patient, I don't know, let me go home and like read the latest study on that. Like even while you're changing, I'm gonna go, there was an article that came out. I, hold on, hold on. Come back.

Dr. Maryal Concepcion: 43:16

Amen. And, especially for new listeners out there and for listeners who have been listening for a while, I will proudly remind people that my husband was let go relieved of his position as a fullscope family medicine doctor. The last insurance accepting doctor who you could see if you were pregnant, needed a procedure, et cetera, in our entire county because the company that we worked for went to a non-physician model. So I absolutely, this is not to say about nurse practitioners or non-physician providers, but to say that the medical degree does matter, that knowing, thousands of hours, I think when, when before, when, before we jumped on this call, we were looking up, 12 to 16,000 hours of training is what we go through minimally in primary care to know what's normal and to know, like what you can handle and to

Dr. Kate Dreger: 44:03

know when, when to move, right. When to move quickly and, and what to do about that. And I think that. A lot of the cost savings we see in Direct Primary Care come about because we know what the hospital would do and how long it will take. So, you could do something in the office. Like my favorite story, if And a patient come in on Monday afternoon and she said, I've been having like, I think I had Melan this weekend. I'm like, sorry, what? And so she very clearly describes the GI Bleed over the weekend, right? Started on Saturday afternoon and last bowel movement was Sunday evening, right? So now it's 24 hours later. Well, if you haven't been bleeding for 24 hours later in the hospital, you get sent home. That's just how that goes, right? So I know that she would be sent home, she's hemodynamically stable. She looks good, but she needs a scope, right? So I leave the room, I call my colleague the gastroenterologist. I'm like, oh my God. Like she's, I do stat labs, right? Her labs are fine, her blood counts are fine. She's, she's, she's dropped a little, but not a lot. So she's medically safe, right? He's like, I can scope her tomorrow at seven 15. And there's no way in the fee for service model that that works, right? It just doesn't work. But that saved her an entire hospitalization. She had a non bleeding ulcer. He like checked it, we put her on meds, she didn't bleed again. And, and like I said to her, I was like, listen, if it happens again, go to the er.'cause you know what, it's always open. And that's what it's there for. It's for actual emergencies, right? So. I think we've lost sight of the fact that direct primary care and old primary care saves money because we are able to do very clever things. Right. And I think that's valuable.

Dr. Maryal Concepcion: 46:04

Totally. And layer on top of that transparent access to, what does A CBC actually cost, under$6? Oh my God. Like what does a, what does a mammogram cost? I will say my story here most recently I had a recall for my mammo, and that's not covered. So the, when the lady was like that'll be$330 copay. And I'm like, Hmm, thank you. I would actually like to switch to the cash price because I send my patients to this imaging center and I'm like, I know that what I will spend in cash is less than what my insurance is charging with the copay. So I saved money because I was advocating for myself knowing the prices, like a restaurant charges. So, oh my God. Yeah, it was amazing. And they, and they let you do it? Oh, absolutely. Yeah. And it's not common that they, how, how much was it? How much this, so I paid, I think I paid maybe 290 and it was gonna be 330. So it wasn't a huge, huge difference. Right. But at the same time, like I knew the math, like I, I could actually calculate it as she was telling me like, that's more than I am gonna pay if I just go to the cash price.

Dr. Kate Dreger: 47:12

That's ridiculous. Yeah. How did we get here? How did we get here? Yeah,

Dr. Maryal Concepcion: 47:15

it's

Dr. Kate Dreger: 47:15

nuts. How did we get here? Yeah. Yeah.

Dr. Maryal Concepcion: 47:17

So I wanna ask about the idea that you went above 600 patients, 610, 620, and then you went back down into the five hundreds. Because I think that's something that more people are facing right now. Like, how big is too big? When am I comfortable with my size, with my panel size? Mm-hmm. And because you still do hospital care, you still look after your patients in the hospital as well as your outpatient practice. I, I'd love if you could talk to us about your thoughts when it comes to, how do you, how do you navigate what is a full patient panel quote unquote, for yourself? Yeah. Especially if you want to do, different levels of care like hospital medicine.

Dr. Kate Dreger: 47:59

Right. So I should make clear that I, I do. Have hospitalists taking care of my patients. I go and see them and I write notes and I talk to the hospitalists, but I'm not doing the admissions largely because I'm solo low. And I think that I would not see my family and that would just be bad. So I'm, I'm very fortunate. I mean, all the internists are lovely, they're very patient with me, but it's just coming along and saying, okay, we did this last month. This is actually what happened. Okay, I'll see them on Tuesday. Do you want me to do this part? And, and I think I, I think it's, they tell me it's helpful to them and, and it's certainly incredibly helpful to me and very rewarding to me. So, so that's how I work in the hospital medicine. I, I think, for me, when I go above like 55, 60 hours a week. That's when I start saying like, okay, this is too much. The staff were like, you need to stop accepting new patients. Like you need to just stop.'cause of course, when you accept a new patient, it's about four hours of work. Just to get their chart organized and all of their echos and scans and cts and consultations and get all of that done. And then you've got the first visit, right? So, so every time you're seeing new patients, every time they sign up, it's like an extra five hours of work each time. So I, I think that's a personal judgment. My sense is if I had a population that maybe wasn't as sick, I could probably see more people. But you know, you get to like 400 Medicare, over 65 patients with 15 medical problems a piece, and it starts getting a little tricky. I mean, I think everybody makes their own decision, I guess is what I would say. Yep,

Dr. Maryal Concepcion: 49:55

yep, yep. It's good. And so here I'd like to ask about pricing because just going back to again, the, the DPC ecosystem was much smaller in 2016. Yeah. And you had pricing, that is still very reasonable. I mean, your website also says, we're not accepting patients at this time. But in general, how did you think about your pricing knowing that, you've mentioned, I need this amount of money to like you, you mentioned overhead, you mentioned the, the, the math of DPC, but how did you calculate your pricing when you opened and has it changed over the years? So I. I

Dr. Kate Dreger: 50:32

sort of did a tiered pricing. I feel like somebody who's 2018 to 29 is generally not that complicated to take care of, and somebody who is 95 is right. And so I just have an age-based pricing. Kind of goes up a little bit as, as you get older. And it's once you get to 60, it's flat, so I don't go up past 60.

Dr. Maryal Concepcion: 50:59

Has

Dr. Kate Dreger: 50:59

it

Dr. Maryal Concepcion: 50:59

changed over time?

Dr. Kate Dreger: 51:01

Oh, no. And I probably should'cause it's nine years and I haven't increased my rates. And my, my brother actually has an MBA and he's just like despairs of me. It's like, what are you doing? I'm like, yeah, it's, it's like the, the money isn't quite the same as it was. He's like, you're such an idiot. So I do, I do probably need to increase it, but I always feel bad. But I probably should increase it. It's been nine years.

Dr. Maryal Concepcion: 51:27

It's

Dr. Kate Dreger: 51:27

bad when your patients come in. They're like, Dr. Drag.

Dr. Maryal Concepcion: 51:34

Oh my goodness. I, I have, I have a, I have a, I, I think I mentioned this on the podcast before, but I have a person who's a 94 and she said to me, Dr. C, I'm gonna live to a hundred because then my care will be a dollar a month, which is like 67 cents after stripe fees. And I was like, amen. Let's do it. Let's, let's do it. So I, I our, our care pricing goes down after 99 and 364 days, but yeah, it's it's, oh, that's delightful. I love it. I love that. I love it. And I'm like, dude, if that gets you motivated to like, still like live a quality life, amen. Like that the, that you can claim that your healthcare is a dollar a month. I'm like, let's do it. I may have to do that. That's so great. Yeah. Okay. Well, I wonder what your brother will say about that, though. I know he's a super guy. He'll be fine, but he's just, yeah. Oh my gosh. So one thing I wanna ask about also is that you have a signup fee. And I do think that, you, you called out very, very relevantly that when you onboard a new patient, it can take multiple hours to onboard that patient because the conversation is part of the, the, the welcome to the practice. But it's also, making sure that insurance cards are there. And even though we don't bill insurance, we still need the insurance card information if we're gonna, use their insurance for ordering labs or mammograms or sending referrals, et cetera. And so, just the, the nuances of, or the details of getting a person onboarded, getting records, there's definitely tools that are out there to help us go faster when it comes to getting records. But going through those records, putting a story together, it's a little bit different for you because you had. You knew your patients, at least most of them before you opened. Yeah. But I'm wondering if you could tell us about how you use the$75 signup fee as part of the the way that members signed up at your practice.

Dr. Kate Dreger: 53:31

I mean, I think part of it was, was also meant, it's meant to cover that initial signup cost and moving, requisite over and doing all of that. And then also when we first started, you could only bill at the end of the month. And so, you, you ended up with sort of no money until the end of the month. Even though you were gonna be doing a whole lot of work to get everything sorted out and get people plugged in. And and so it was a way to sort of offset that upfront cost at, at, not in exorbitant levels, so it's, it's, it's the same fee for everybody, but my older patients, it's 1 25 a month, so it's not even a month's fee. So that's kind of how, that's why I did it. And I've kept it that way because, like, I just had a lady join at her first visit was two days ago. And I, I did actually spend about four or five hours going through all her records, right. And her allergies that were in fact, really severely persistent asthma. And she'd been. So many places with her, quote, allergies that were well controlled, but this weird cough and, and you're like, wait. And so you go back and back and back and there was a pulmonologist way back who'd done PFT and diagnosed asthma, but it had just gotten lost. It, it had just gotten lost.

Dr. Maryal Concepcion: 54:57

Yeah. And I, I will say that it's something to think about. On the Facebook groups you may see people poo-pooing a signup fee. But I do think that it, it is a way to help cover your fees of your practice, especially if you are newer and your opening and you have membership fees, but you also have an onboarding fee or a signup fee. It does help with the, the cost of having a practice. And so, I, I think it's, it is definitely something to think about and not just poo poo because somebody says it's not a cool thing to do.

Dr. Kate Dreger: 55:30

I think the other thing it does actually is separates whether or not people are kind of interested. I mean, that's not a perfect example because if you don't have the money, you don't have the money and it can be prohibitive. So I, I think that's a double-edged sword, but I do think it's very easy to sign up for something if you don't actually have to pay anything for, a month or two. Right. So it kind of, this is a, this is a contract, right? This is a, do you want me to take care of you? Yes, I do. It's a, it's a commitment on both sides. So. I mean, and I think that's why it's a, it's, it's a free country. You can charge a fee or not charge a fee, whatever works for you. Right.

Dr. Maryal Concepcion: 56:10

Yeah. And I will say, like you said earlier, when you asked your patients, if you can't pay, let me know. It's your business. You get to decide like if you need to waive a fee or if you need to do whatever you have to, but it's your business. And so, but I, I do like that in terms of you're putting skin in the game. So when it comes to and, and also I just wanna mention here, thank you for clarifying in terms of that you do work with hospitalists, but like, I think about just with that, the hospital visits that you do, do, I, I just think about how even as a resident there would be, my co-residents taking care of my patients in the hospital, but when I would talk with them about, Hey, this person lives alone at home, like, discharge is da, da, da, it's gonna be difficult to da da, or like, I know the, the sun, the son to contact or whatever. I think that the primary care involvement at any level even if you're not the primary admitter and taking care of person in the hospital, it still makes a huge difference to paint that person as a person and not just a number.

Dr. Kate Dreger: 57:12

Yeah, and I think also the science is helpful because sometimes people are like, oh, I don't know why they're on that. And you're like, oh, well this happened and that happened, the other happened and this is how we ended up here. Oh, I didn't know that. Or you come in and, and somebody didn't actually realize that they had had cancer the year before.'cause it wasn't, they were in a different computer system so it doesn't port over. And the whole, different major corporate medical systems with their own electronic medical systems can make it very, very hard to get that data. So I think some of it is social and some of it is science as well. I mean in the science and art of medicine right there all the time.

Dr. Maryal Concepcion: 57:53

Absolutely. So. In closing for our main interview, I wanna ask about the, the idea that you mentioned you can lead a horse to water, but you cannot make them drink. And you were, presented with the water that is the DPC Kool-Aid and you decided to jump in. And so I'm wondering if you could tell us what you would say to those physicians who are aware that there is a pool of water and that they can drink, but they're on the fence about it.

Dr. Kate Dreger: 58:23

I'm gonna answer this question by going just slightly sideways. Part of our job. Is to take care of people at the end of their days. Right? And we see people of all ages come to their end and sometimes it's sad and sometimes it's cruel and sometimes it's a relief, right? But we know we're mortal and yet sometimes I think we forget we're mortal. Like we're so busy taking care of the people that we forget that we just have one life and we can do with it whatever we want. I think imagining what it is you really want out of life is, is not easy to do because you actually have to be honest with who you are and what you're really up for, right? I teach medical students still too. And. One of the things I say to them is, the problem with picking your specialty is you actually have to know who you are. Not who you think you'd like to be, not who you like, envision yourself being, but actually who you are and what you actually like. So if you're on the fence of deciding to do direct primary care, I think it's really important to think about what the costs are to you, like the real costs, what failure will look like, and what it will look like after you fail. So if you fall on your face, scrape your nose up, blood all over your jeans, you've torn them, they were your favorite pair, then what? Like then, then what will you do? And if you can envision what will happen after you've, if you fail, like, okay, I'm gonna work in a prison. I was like, all right. Okay. Okay, I have a solution. That is what, and I picked out where the prisons are and how long the drive is. There are like four of them. I was like, okay, I think I can get a job there. Okay. I have a plan just envisioning what happens. And on, on a personal note, I would say I immigrated here when I was a teen and so I left my whole country and came to a different country. And it's okay, right? I've made a different life. I love it here. I love this country. And I think knowing that you can do that, it just makes you feel like, okay, it will be okay. Right? Even if you, even if you go and you fail and it didn't work and you have to go back, you're, no, you're actually not worse off for trying. And the joy. I have now in medicine just to be able to really listen to people and really think about what they're saying and what they're not saying and what they meant. And is that really how that happened? Because actually you just said two completely different things. Can you say that again? Like really going through their history so you can figure out what the problem really is. Then treating them becomes much more straightforward and you have a higher success rate. And, and that's, that's what we, that's what we did this for, is to help people. And so think about why you went into medicine, what you wanted to do, whether or not this helps you get there. And if you do it and fail, what's the worst thing that can happen? And I think going through that in your own life and talking to the people that love you and are, and will call you out on stuff and support you. I think that's what I would suggest.

Dr. Maryal Concepcion: 1:02:01

I love it. And with your wicked sense of humor, I also want to mention that you are coming out with your own book and I think about when you told me that you were going to write your book, I just think that it's so important especially as we see media being so quickly used and, and discarded. I, I do see the value in writing down one story. I mean, we celebrate stories all the time on this podcast, but I'm wondering if you could tell us about your book and where can people find it?

Dr. Kate Dreger: 1:02:31

I have been writing this book for a long time. Very, very, very slowly. I'm nearly done. Full disclosure, I don't have a publisher yet. I I need to get one. But my goal with the book is to actually, in many, in many ways tell the story of how I got to direct primary care, but use that as a platform to explain to the average person who isn't in medicine, how the healthcare system works. I think in this country we have a huge majority of people who are unhappy with the care they're receiving, and I think very few of them understand how unhappy the doctors are. I think explaining that how we got here, what's happening, why it's happening, and what we can possibly do to fix it. I'm hopeful that would be helpful. It's not a book. I mean certainly physicians can read it but it's really supposed to be for people who aren't in medicine but want better care. And I think if we all actually understand how the system works, we're much more likely to design something that will fix it moving forward. I mean, if the bureaucrat or the policymaker actually understands how the doctors visit doctors practice works, then maybe their solution will actually help the doctor's practice. Thrive. Right. So, and if you're interested, you can go to my website, which is prime plc.com and there's a little button and you can put in your email address and let me, I will let you know when the book comes out.

Dr. Maryal Concepcion: 1:04:07

Amazing. And I do encourage people to go to Dr. D Drer's website especially because just hearing her speak, during this interview, it's like, can you imagine the impact her words have on people who are our patients or future patients, or who are another DPC doctor's, future patients? And it's something that patients can share amongst themselves to help themselves feel more empowered when they look for a DPC doctor like you.

Dr. Kate Dreger: 1:04:34

Thank you. Thank you.

Dr. Maryal Concepcion: 1:04:39

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.