How One DPC Practice Built a Financially Sustainable Model - Without Insurance

Dr. Matthew Hitchcock of Hitchcock Medical Group in Chattanooga, TN has spent over a decade proving that direct primary care is not just better medicine, it's a smarter business. In this episode, he breaks down the layered economic model behind his DPC practice, in-house pharmacy, and cash-only imaging center.

What we cover:

• Why primary care is a loss leader in the insurance world and how DPC fixes that
• Health insurance ≠ healthcare access (and why that distinction matters)
• How a fully licensed pharmacy and cash-only imaging center ($350 CT vs. $2,000+) create financial resilience
• Why PE and VC-backed primary care keeps failing
• How DPC can actually scale — and what kills it when it tries

🎙️ March on My DPC Story: Sustainable DPC Economics Every episode this month is dedicated to what it takes to build a DPC practice that lasts. Don't miss one.

🎧 Extended, commercial-free conversations on Patreon Get the full uncut version of every March episode at Patreon.com/MyDPCStoryfan

Resources:

• CaringDirectly.com - Dr. Concepcion's physician-only DPC mapper. Add your practice today!
• Hitchcock Medical Group | Chattanooga, TN

Keywords: direct primary care, DPC economics, cash-pay medicine, physician entrepreneurship, DPC pharmacy, healthcare business model, primary care sustainability

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Transcript

1:00

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. Primary care in America had to be stripped down of the studs. What I would refuse to leave behind is the doctor patient relationship that has to be at its core. I'm Dr. Matthew Hitchcock of Hitchcock Medical Group, and this is my DPC story.

Speaker 2:44

Welcome to the podcast, Dr. Hitchcock.

Speaker 2 2:46

Thanks for having me. Thank you.

Speaker 2:48

I absolutely love that. On your LinkedIn page, you have physician operator and builder, and I think that pretty succinctly describes but doesn't fairly represent all that you're doing in Tennessee and beyond. So I'm just wondering what does each of those words mean in the context of healthcare today for what you've been building?

Speaker 2 3:07

I think, you know, it kind of frames the lens that I kind of look through things at, you know, physician obviously being at the core of this and kind of what informs kind of everything that I do for this and, you know, operator, we're doing this, you know, every day we're seeing patients and you know, kind of actually out there doing things. Uh, not just sitting in a CC C-suite somewhere, coming up with stuff. Everybody in DPC is out there blazing trails and building a whole new system that actually delivers care where it's supposed to be delivered.

Speaker 3:37

Absolutely. And I think that it's not. Like you, you could see those things on billboards from big corporations throughout the years. But like you are actually doing the operations and you're doing the building behind these things to actually make them a reality like all DPC doctors are, which is so commendable and so incredible and so needed. So one of the things I wanted to ask you about, because you know, I've, I've driven by Camp Pendleton many a time, and that's where you were at one point in your life. I just think about, I'm

Speaker 2 4:07

gonna go Camp

Speaker 4:08

Pendleton. I just think about how you're very intentional about going forward. How did military training shape the way you think about leadership and system design specifically when it comes to to the world of medicine? Because I am assuming that you. At some point in your career have felt like you're part of the, the system, especially in the military system. I don't know if you felt like you got personal attention

Speaker 2 4:35

man. So many great things in that question. Uh, the military, I think the biggest thing, first and foremost, it taught me I never want to be middle management ever again. For it. Uh, just'cause I felt like a lot of times as kind of a, oh 3, 0 4 kind of officer, you know, didn't I, was that middle management that didn't really have agency from up or down, for it. So I, I think that's the first thing, you know, but the military teaches you how to be a leader, just period. Uh, especially being an officer, even some of the enlisted ranks, you know, it teaches you how to take care of people, how to be a leader, how to, get people to kind of align to kind of what you want to do and kind of the direction you want things to go for it. I, I think that was huge, you know, being able to do that. And give me the confidence to know that, hey, I can go out and run my own business. I can do this. You know, the military kind of really instilled that confidence in me, you know, it also taught me that I can do things with less. Uh, there were a lot of operational times that we didn't have exactly what we needed, but, you know, RA Gumby, we had to kind of figure it out and, you know, accomplish the mission with what we had available. And, you know, that happens in DPC quite often for a lot of folks.

Speaker 5:40

That it does, uh, that it does. And I'm sure that people are laughing out there in terms of like, what have you been able to succeed with, in terms of not the typical stocked, cabinets of mm-hmm. You can have like 20 IUDs stacked up. Like that's definitely not a thing that we have frequently in dbc. So I love that. And I think that also it really does speak to especially those of us who are opening DPC practices and running DPC practices, like yours is a classic example of how you opened and you have grown. And I think that. When we think about systems, it definitely helps us going forward to think about systemically what we're building. And I also wonder, you have a layer of an MBA on top of your, on top of your medical degree and your, your time in the military. And I'm just wondering how that has influenced you when it comes to economic sustainability because that's what we're really focusing on, on in this month. And you, have continued to, to grow intentionally in this time of economic instability

Speaker 2 6:43

the NBA was great, you know, it was, I was about seven years into running my own DPC when I kind of finally figured out like, you know what, maybe I should actually go back and get an MBA for this. I remember when I first opened, our lender, uh, asked me for my p and l, my profit and loss statement. I'm like, my, my what, what are you talking about? What, what's a balance sheet? Um, all these things. And just like in medicine, you know, when someone starts medical school, we talk about medicine as a language and you're learning a new language and that's what makes kind of some of medical school hard at first. I think the MBA was the same thing. It kind of taught me the language of kind of business and finance. Um, so I could understand a little bit more of what was going on. I could, you know, look at our cash flow statements. I could think about capital budget planning, uh, for when I wanted to do expansion like our imaging center and kind of work through a pro forma and what that might actually look like in the future as I'm going through and I could have conversations with. CFO types or, you know, finance types and, you know, speak their language and be able to relate to them what I was wanting to do on the medical side in terms that they would understand.

Speaker 7:43

And I think it's just important. It's like when we're not talking specifically in medicalese to our patients and we're talking in a way that we're understandable to them it it's the same thing. And I think it's very strategic in terms of, again, systemically you are very confident and trained now in speaking the financial language as you continue to grow. So the, the, the next thing I wanted to ask you is something that you said about primary care and that it's treated typically in this country as a loss leader instead of an asset. And I'm just wondering in terms of your personal experience with also feeling like a loss leader instead of an asset. What was life like for you before you decided to go on your own?

Speaker 2 8:26

So primary care, a lot of times the value that primary care generates isn't extracted, kind of at the point that it happens. It, it's extracted later. It's the downstream referrals, the lab orders, the imaging orders, uh, the elective surgeries, all the things that happen out of primary care, kind of being the gateway to a system. And I think that larger systems understand this. This is why hospital systems and big groups wanna buy up primary care. It's not necessarily for its own intrinsic value, but it's all the downstream things that primary care can bring to that system. And I think that's where our, our system doesn't value primary care in that it values primary care for kind of what it can do downstream, not in and of itself. You know, the, the unit of care isn't the doctor patient relationship. It's, it's what value it can bring later. And those. Misalignments I, I think, have kind of really messed with our healthcare system here today. And, you know, saw that, you know, coming from the military, you know, it's still, you know, primary care. It, it's still, you know, there's still insurance, there's still things in there. It's basically one giant HMO in Tricare. Uh, and, you know, it's already, it's monopoly money, but it's still money. And I very much remember, you know, this full schedule. You know, I was, uh, there at Camp Pendleton, I was a faculty physician, uh, with the, the family medicine residency and, you know, have a completely full schedule. And we get a memo from the command basically saying that our access is horrible. They're gonna add four more appointments to our day. And I'm like. Where, you know, I'm already seeing patients from like seven 30 to four 30, like, where are you gonna fit four more appointments. And it was about that time I saw a journal article about Josh and like, huh, you know, this sounds absolutely amazing. You know, having a whole hour to actually sit down with my patients and practice good primary care, uh, the way I was trained. Um, that never actually happens in actual practice, primary care in the insurance world, but I could actually do so much good with that. And yeah, that's what landed me here all over a decade ago now, doing primary care.

Speaker 10:19

It's fantastic. And I'm just wondering if you can just give us a, a, a peek into your first year of DPC because you were going from this, this system that you're describing to going out on your own. Did you just go crazy with like innovation and excitement because you were like able to do your own thing?

Speaker 2 11:35

Oh, it was so much fun. Terrifying. Absolutely terrifying. Uh, I'll give you that, uh, for it. Especially, you know, 10 years ago nobody really knew what DPC was. You know, there were only a handful of us kind of in the whole country doing this and yeah, absolutely terrifying. It is definitely the, the way I would describe that first year for it. But it was so rewarding to be able to do it. I remember the, the first patient, ever patient number one for our DPC practice here. Um, I didn't even have a building yet. So getting my feet wet in commercial real estate and trying to find a place, which is its whole nother world of craziness for it. But I did it as a house call and I just remember spending over an hour. We were always spent about an hour and a half sitting at his, his kitchen table, kind of going over his medical history and kind of doing all this, and just thought how amazing this was and how good I felt leaving his house that afternoon. I'm like, yep, this is it. This is what I'm supposed to be doing for it.

Speaker 12:27

Incredible. And I'm sure that especially those of us who have had the time and uh, intentionally do home visits, it, that's super relatable and mm-hmm. You just feel like, wow, like I just talked with patient you don't have to feel like, because you don't have to schedule, you know mm-hmm. Five patients when you get back to the clinic, you literally can just do the home visits in a day. Mm-hmm. So, especially now in 2026 when we're recording this, you know, I think about this quote unquote big beautiful bill that has passed and there's lots of reform always going on around healthcare. Reform is such a, an interesting word to use for that. But when it comes to actually getting at the, the core issue of primary care is where most Americans are, thinking that they're gonna get access. What do you think is, is off kilter about how we're doing reforms in this country to try to get at fixing healthcare access and quality for everyday Americans?

Speaker 2 13:26

Oh, that's a great question. Yeah. One thing that I, I think I see a lot with, you know, reforms that come from above us is that they focus on trying to make health insurance. Affordable and try to like, try to somehow conflate health insurance with access and care and no, that's completely wrong. Until you talk about how we make health care affordable. You're never gonna be able to have a conversation about how we make health insurance affordable. That's is never gonna happen. And so many people conflate health insurance with access and care and it just, it doesn't work that way. When you really need to think about designing a system, it needs to kind of start with the patient and how they can access and how they can have relationships with their physician and continuity with them. Where you have the same doctor and you know them and I know my patients and, you know, can kind of take care of them. And really, until you put that at the heart of any of these reforms, it's never gonna go anywhere. You're still gonna have this downstream. Muck where a specialist trying to do primary care or patients are gonna get their care at the most expensive site where that happens, be that at the emergency room or with a specialist instead of with a primary care doctor where who could have taken care of all this way faster and cheaper. It's never gonna happen until you start talking, having conversations about how we make healthcare itself affordable.

Speaker 14:50

People, this is right here. Why I do my DC story. Amen. Dr. Hitchcock. That is what it's all about. Mm-hmm. And literally I put, I had to put myself on mute because I'm like, oh, clapping away over here in California. This is exactly why. Also, I love being around our community. I love being, I told my husband this last night, I literally love talking to rational people because it's really hard to talk to irrational people who literally think that health insurance is healthcare. So, I that I, amen. I applaud that so much and I hope that everyone listens to that because healthcare is not health insurance. Health insurance is not healthcare. And. Go ahead.

Speaker 2 15:30

I was just gonna say, it's so funny, we, we'll have that all the time. Patients are at DVC, like, oh, I have health insurance, so I'm gonna quit. And then, you know, a couple months later I get a phone call like, um, can I come back? It's horrible out here. I can't get in to see a doctor and I just got sent to the ER for something you would've handled and it wouldn't have cost me anything and all this stuff. And you know, people think that, oh, because I have health insurance, I don't need direct primary care or anything like that. And we are, DPC is such a good front door to the system that people don't realize that.

Speaker 15:57

That is so true also, and this reminds me so much of how we talk about how we help people navigate the system, and that's something we get paid to do these days and we didn't used to, because even though we wanted to, and we did things that helped navigate the system for people, like nobody actually cared for compensation purposes. Mm-hmm. So it definitely is much more rewarding that the time that you put in for things like that are included in DPC membership.

Speaker 2 16:24

It's so great. I think a great story about this. You know, a couple of weeks ago I had a patient, uh, one Wednesday morning, she texted me with abdominal pain. Uh, I actually called her, talked to her on the phone real quick. I was like, Hey, come on in. And so about 30 minutes later, she's in my office doing an exam. I'm actually thinking, uh, pancreatitis at this point. Uh, but here with what I have here, we were able to literally walk down the hall and get a CT scan, uh, for 250 bucks for her. And we got the CT scan. And lo and behold, it was actually, it was her gallbladder, uh, now her pancreas. And I was, you know, texting the surgeon, you know about it. And he logged in and looked at the films, was like, oh yeah, sounds good. Had her in his office that afternoon and had her scheduled in the OR the next morning for it and all because I had time and the ability to talk with the surgeon and to coordinate her care in a way that kept her out of the most expensive places she could have gotten that. And we got it all taken care of for her.

Speaker 17:15

Amazing. And I'm sure at not the same cost that it would've been had she gone through insurance. Mm-hmm. Oh my goodness. So here I wanna ask about the, the lovely thing that we seem to, quite be quite familiar with these days is VC and PE funded healthcare. And so as we talk about, these reforms from up where people are not actually practicing primary care making decisions for us, um, and our patients, you also now have from the economic standpoint, the VC and PE thrown into the mix. Especially with your MBA background, I'm wondering if you can talk to the audience about, could, could you ever have clinical integrity when it comes to the VC and PE funded models? I

Speaker 2 17:58

think that's hard with those models, really. You know, a return on investment is what they're wanting, hands down period, end of the day, you know, what matters is return on their investments for it. And that is a, you know, misalignment with I think what physicians and what healthcare really wants. So that, I think that's the first place that you get those misaligned incentives. There, the other issue, like we kind of talked about earlier, with primary care being a loss leader, they're just, especially in primary care, there just aren't the margins that you see in other places in healthcare, you know, for it, where you can extract that required return on investment that these. PE or VC companies want in the healthcare industry. And I think it goes back, a lot of'em are kind of purchasing some of these like bigger systems for those other things to control the downstream things or in, some costs, maybe the data that's associated with it. You know, the, the Syne thinks that's why a lot of these get bought up is'cause there's a lot of data generated in primary care. Uh, and that might be part of it, but I think that's what you're, why you're seeing some of these kind of get into that and then go belly up. A lot of them, uh, you know, carbon health just kind of went, uh, you know, belly up earlier this week and there's a few other things in there and it's just, I just don't think that system's gonna work in primary care.

Speaker 19:10

It brought me so much joy to stand in front of forward Health, which still has electricity in San Francisco. And I was like taking selfies and I made my husband take a picture of me.'cause I was like, this is, this is what happens when you have people who don't actually do healthcare, trying to do healthcare. And I think that like absolutely, especially being in rural America, I've said this to so many people in my community, but like we are preparing for even our local FQHC and FQHC equivalent to like go piece out on us because as a community they already, like my husband was already let go because they went to a non physician model'cause it was cheaper and that was before 2025. So, you know, what's the incentive to stay if there's bigger money? And especially as one of our, our FQHC was incorporated into a bigger system that. Informed 60% of a county in Northern California that they were no longer accepting Medi-Cal patients one month. It's like, that really is clinical integrity to me people. Absolutely. Oh my goodness.

Speaker 2 20:40

Absolutely.

Speaker 20:41

Yeah. So I, when, when we think about you opening Hitchcock Medical Group and specifically looking to do the DPC model, did you ever have any like, maybe I could go hybrid, maybe I could just take a little insurance? Did you ever have one of those moments?

Speaker 2 21:00

No. Uh, from the get-go, pretty much we said this is gonna be pure DPC, you know, as it goes. I'm not going to, you know, be a hybrid and take you know, partially bill insurance or anything like that. We're gonna jump in with both feet into the pond and just go for it. Uh, you know, in the DPC model.

Speaker 21:16

And you've, you've alluded to it, and we'll definitely dive deeper into your imaging center that you've built as well. But, you know, I, I think about here, physicians listening and they're like, I, I couldn't do DPC because, or I couldn't not take insurance because, and I'm wondering what do you see as the biggest misconceptions that physicians have when it comes to not practicing in the realm of insurance?

Speaker 2 21:43

I think one big thing is they're gonna worry about how they're gonna get patients because in the traditional insurance model, a lot of the patients are just driven to them because they have their insurance and you're in network of their insurance and you don't have to do as much active marketing, especially in the primary care side of things. And I think a lot of physicians worry that they're not gonna get those patients. And having to market yourself is a huge jump for a lot of physicians that we're just usually not comfortable with. Um, you know, physicians aren't comfortable marketing themselves or talking about themselves or, you know, striking'em up. That, working in that conversation when you're checking out a target that, oh hey, I'm buying this because I'm opening a new practice and doing this, and how you work those things into those everyday con conversations. I think that's one big thing that I see with patients, uh, or with physicians who are worried about leaving insurance. Uh, for it. And it's the system they've known forever. And, you know, DPC is something new and possibly terrifying for'em. And, you know, there's no guaranteed salary as they go through stuff. And I think that's a, a terrifying thought for them too. For it. And then they're also worried about how am I going to order things for my patients? How am I gonna order labs? How am I gonna order imaging? How am I gonna refer to specialist if I'm not in network or anything like this? And for the most part, it really doesn't matter. The patients can still use their insurance for those things that they want. Unless you live in like a weird HMO kind of area where HMOs are popular. Uh, that could be an issue. But for the most part, you know, I order labs and patients, um, use their, their, their insurance for labs, even though it usually costs them a whole lot more than doing my direct pricing for it, or, you know, see a specialist or whatever. It still works just fine.

Speaker 23:12

I definitely would say if you're listening and you are wondering like, how, how would I do that in my area? Talk to DPC in your state.'cause there's DPC in all 50 states, so mm-hmm. Uh, it's definitely something that that's a, that's an a very, um, understandable thing to be thinking about and there's also a very reasonable solution in every state. So I wanna ask here, because you intentionally went away from insurance talk to us about what were the incentives that you experienced immediately and over time when it comes to being direct and transparent with your patients, with their care as well as their billing.

Speaker 2 23:52

I mean, the first thing you notice in DPC is having time to sit down with patients. You know, it's not the seven and a half minute or double book fifteens or whatever you had before you actually get, uh, time. In our case, usually it's about an hour to actually sit down and know your patients. You know, it's not, um, I'm worried about the other two other patients that have roomed and I'm waiting for this as we go through. And, you know, that shows up in little things when we're working with an architect to kind of do our new clinic here. He's like, oh yeah, every physician needs like three exam rooms. Like, no, actually you just need one. Sorry. You know, for that, because I don't have to have three other patients waiting as I'm kind of going room to room to room and worry about efficiency, for that. And that's probably the first thing you really notice is time and having the time to actually practice good medicine and to know your patients.

Speaker 24:37

It, it makes me think about the lines in the women's restroom versus like, there's never a line in the men's restroom. Yep. Like if there was more architectural input from people who actually use the restrooms, I think that we'd have more of like a different, different, uh, arena when it comes to restrooms. So yes, I totally appreciate that, and I think it's so relatable on so many levels when it comes to you being a person to think about systems and you're going outside of the insurance world. You have intentionally gone into opening your own imaging center as well as integrating a pharmacy where patients can get direct access to wholesale medicines. So versus staying a lean DPC quote unquote, in, in terms of not having those options, what, what made you go down the pathway or what inspired you to go down the pathway of integrating imaging and pharmacy into your DPC?

Speaker 2 25:31

A lot of these things were, as I'm practicing DPC and I start running into friction points or pain points like, Hmm, how do I solve this? How would I do it? You know, pharmacy, you know, just like most DPCs we started off from day one dispensing for our own patients, for it. And it was pretty easy when it was just me, you know, we still kind of took time to kind of get everything, but as I brought on more physicians, you know, two, three physicians in dispensing was almost turning into a full-time job for one of my nurses, uh, to get the refill requests in every week, uh, to get the order in, to make sure we got it on time to get the meds entered in to EMR, to get the labels printed, to kind of fill everything and do everything. It was almost a full FTE for one of my nurses. And actually, uh, my wife Kathleen is kind of the, she's the. Operations officer, you know, kind of the, I real queen of everything is what I actually call her for this. But, you know, she and I were talking one day, it's like, are we gonna have to hire a pharmacy tech to kind of do this? You know, how, how do we do this? And, uh, I got a cold email from a, a pharmacist who was, uh, unhappy with his job and, and retail pharmacy and like, Hey, I see what you're doing. Is there a way we could work together? And we actually brought him on as a 10 99 to kind of come in one day a week. And he was just so much more efficient at it than we were because that's what he does for a living. And we were able to kind of do that and we're like watching it happen. And we have patients who would get a prescription from. Specialist or you know, something like that, or, you know, knowing was a pain point for us. I'm like, you know what, you know, have a pharmacist here. Why don't we expand this? So we got it fully licensed, uh, which actually wasn't a, a horrible, thing. Uh, got it fully licensed and you know, now the, our pharmacy part, Hitchcock Family Pharmacy is a fully licensed pharmacy opening the outside world. So we have non DPC patients who are getting the prescriptions through us for it. And we have other DPCs in town who are like, you know what, you know, I never dispense'cause it was such a pain. I was worried about keeping inventory in stock and, you know, going through stuff. And so now they just use our pharmacy, they send the scripts in just like they do any other retail pharmacy. We fill it and take care of it for'em. And then imaging was kind of a similar thing. It was so hard sometimes to get. Yeah, the patient's in imaging slot, either they couldn't afford it or, you know, had to wait days with the prior authorization or all of these things. And a friend of mine, uh, from medical school is a radiologist in town. He and I got the crazy idea to open a cash only imaging center. And, you know, here we are doing it, CT X-ray ultrasounds for it all for cash, no insurance, no prior authorizations. And, but that was a learning experience, jumping through all of the hoops with the state between certificate in need and the licensure for it. Uh, trying to kind of navigate all of those regulatory things, uh, to do it. But it has been absolutely fantastic. Um, not only from the, the standpoint of here with the DPC, being able to walk down the hall and get a CT scan or ultrasound or whatever and literally having all the capabilities that a lot of these freestanding ERs have here in my office. Uh, but then just for the outside world, so many outside patients come in, like, you know, we had one the other day, you know, at a local imaging center. They quote her like, over$2,000 for a ct. I'm like, yeah, that's 350 bucks, through us and we can do it today. Not in, you know, a week from now when we have time or when, you know, kind of goes through everything. And it's just been so good for patients to have that transparency in healthcare and to know what imaging actually costs and to get affordable imaging.

Speaker 28:44

Absolutely. I, I know I've mentioned this on the podcast, but it's been a while. When I went to the Dominican Republic Medical School, we stopped by a, an imaging center where the radiologist owned their own facility. They sat the patient, they did the imaging, they did the report, they printed the report and the images on a cd and the person would fly back to Miami and take it to their US doctor.'cause for$350 plus the price of a plane ticket, it was way cheaper to do that. Crazy. And so, you know, it's, it's so crazy how. It's, it's it's, it's sad that it's mind blowing for patients to be like, wait a minute. It, it costs what? Like it's, it's so empowering to be able to do that. Especially I can imagine when it's your own facility, because I remember in superior Nebraska, I'd be like, Hey could you meet me down the hall in the ER and walk through the other door so that I can do my MRI that I need on you now because I can't order it from this clinic.'cause I'm in the wrong hallway. And it's like the stupidest thing ever because you as a clinician, you as a physician are like, I, I actually know what I need, but it's the access part that is really hard for me to get it. You know, same with specialists when it comes to like, oh yeah, you're having heart issues, angina. Six months maybe to wait. Yeah, that sounds good. Much so. I can imagine the relief for our patients when they, they get this upfront care.

Speaker 2 30:07

It's so nice. The story I love to tell, like before we had ours up and going, I had a patient with a kidney stone and you know, I send the order over to a local imaging center to like, Hey, let's grab a CT and kinda see where it is, how big is it, can he pass it on his own? And, uh, the imaging engineer calls me back and like, Hey, can you send clinicals over? We'll try this. I'm like, oh, well Blue Cross Blue Shield needs you to call him. And so I call him and talk to the lady on the phone and she's like, okay, sounds good, but it's gonna take us seven to 10 days to determine if he needs this. I'm like, he's riding in agony on the, my exam table and I have to walk in there and tell him it's gonna be seven to 10 days, uh, before he can get the CT scan. And her exact words were, well, if it's that urgent, just send him to the er. And I'm like. Where is the cost savings in any of this? You're more than happy to pay for an ER visit or make him pay for an ER visit rather than this, you know, low cost CT scan out there. And just, it's that access and all the bureaucratic things that hinder that are just absolutely insane.

Speaker 30:59

And if your ER still remains after this year,'cause in rural America, I don't know if that's guaranteed that's gonna be happening way more. Mm-hmm. And so, you know, it's, it's uh, it absolutely, again, it's like who is pulling the strings of this puppet that we call healthcare? When you're in insurance driven world, the insurance driven world, it's a very different it's a different set of puppeteers. Mm-hmm. Oh man.

Speaker 2 31:22

Absolutely.

Speaker 31:24

When it comes to the sustainability of your dbc mm-hmm. You know, you, you have these layers of pharmacy and imaging that are accessible to your patients as well as your community. How has that impacted your long, your long-term stability and economic stability, parti in particular for your practice?

Speaker 2 31:44

Been doing this for 10 years, so, you know, growing kind of organically as, as everything's kind of grown up for it. But, you know, having, being able to have all those pieces in the DPC really, I think positions us as a great augmentation to someone with insurance for it. Because again, insurance does not equal access and does not equal healthcare for it. And, you know. Positions us that patients be like, okay, I, I need this, for it because I can get the, the lower cost imaging, I can get the access when I need it and not the, the middle of the night and just get sent to the ER or anything like that for it. And they have access for that. And then now, especially this year, oh, many people in the past few months have been reaching out to us basically saying, I can't afford health insurance this year. It just, it's not gonna happen. I'm gonna go without health insurance and I'm gonna have you because you can handle 99% of what ha is gonna happen to me in a year, and I'm just gonna have take you and I'm gonna roll the dice. Uh, that nothing bad is gonna happen to'em. And I think that has, this year especially, has really kind of positioned us in a unique place, uh, for that.

Speaker 32:44

When it comes to the autonomy that we have in DPC, one of the things that we, are able to do is choose our own tech stack and our, our platforms that we use. And you've been doing this, like you said, for, it's, it's now over 10 years because it's already 2026, you're going towards year 11.

Speaker 2 33:02

Mm-hmm.

Speaker 33:02

What do you love about and what do you hesitate about incorporating technology in different tech pieces, in different pieces of the tech stack into your practice?

Speaker 2 33:12

I think the use of technology in medicine always needs to be intentional. You know, my background, I was a chief medical informatics officer before kind of DBC, uh, for it. So yeah, I've always kinda lived in the tech world for things. Uh, my wife likes to call me a technopath, uh, technology just behaves around me for it and, always, you know, anytime I look at technology and healthcare, I look at it through the lens of how does this either, you know, support or detract from the doctor patient relationship. And that's really where all technology and healthcare needs to live. And, and we need to think about it and that it should support that. Um, you know, great example, you know, when I was the chief Medical Max officer in the military, I would, whenever I would walk in a room and someone was typing at the computer with the patient like behind them and they're paying more attention to the computer over here, rather than the patient like, Nope, nope. This is not what technology needs to be. It needs to be invisible or preferable and support the doctor patient relationship. And so really when we're looking at technology for the practice here, we look at ways we can do that. You know, how can we. You know, support that, uh, from ambient documentation, uh, which I think is fantastic because it gets to sit there and you catch everything and let me be present and talk to the patients and not have to worry about remembering everything to document to kind of some, you know, AI kind of scheduling and kind of help'em with some email responses for patients from our nurses to kind of, you know, help them kind of think through some stuff and kind of keep the tone consistent as they go through stuff. And just ways that we can use technology to support that human relationship that happens. And really what is at the core of healthcare and DPC.

Speaker 34:44

Here's a question because recently, last summer we had our battle of the EHRs come out and we had people, you know, saying why they love, why they left, whatever, all these different things about their electronic health records in particular. And this summer we're going to be doing the support technology that goes in addition to those electronic health records. But I think about, in this world of healthcare and PE and vc, we also see that when it comes to technology solutions in particular EHRs are coming up quickly and then, these are people who have had multiple startups in the past. There's there's, you know, talk about acquisition of certain EHRs. Certain DPC EHRs have been already you know, combining forces and saying it's a good thing. So I'm just wondering in terms of your outlook on sustainability of a, of a practice, if your tech stack. Just like completely goes, out, out the window in terms of accessibility, in terms of, your, uh, ability to talk with the company to say like, Hey, I would love this change. You used to get that. Once it goes VC or pe you can't talk to anybody anymore. What's your, what's your take on sustainability if you have to ride the wave of tech stack changes?

Speaker 2 35:58

That's a great question, uh, because your EMR is so fundamental to kind of what you do day to day and kind of everything that you do, and when that gets disrupted, you know, even if it's just, you know, temporary for an outage or something like that, just, you know, the, the, the wheels come off a lot of times and, that support aspect that you just mentioned, being able to call and actually talk to a human there, preferably the same human every time. You know, especially a VC buys, buys out something that might get, eliminated pretty quickly as a superfluous, uh, expense for'em. You know, that's huge. You know, good support is always something that I rank, um, you know, a software solution on, or, really any tech solution on, you know, if something breaks or, you know, it's not exactly kind of what I like and I talk to a person about kind of fixing that. So that is huge for it. And there's such a lock in factor a lot of times with EHRs that it's, it's. And a lot of'em intentionally, kinda make it hard to switch, uh, just so that there's some friction. So you don't, you don't wanna just jump around like, oh, hey, this year I'm gonna try this. EMR. Or there's definitely an intentional friction there, uh, from a lot of vendors for it that it can be hard and it can really be challenging for a clinician if they don't love their EMR. Maybe they pick the wrong one from the get go to be able to like, huh, I don't know how, how I'm gonna love this. That can be a really challenging problem for that clinician and why a lot of them, you know, I talk to'em. It can be, you know, need to be intentional kind of on the front end. Uh, when you're evaluating the EMRs, really kind of think about what you want out of your system for talk to other people, kind of what they like.'Cause obviously when you're first starting off DPC, you may not. Fully understand exactly what you need out of a product. And so you're a year or two in like, huh, you know, I wish it handled my communication, or I wish it kind of did this, uh, for it. And that can be, hard years in for it just to make sure that on the front end you're picking the right product for what you need for it. And, you know, try not to get locked into to some of these things and you know, hopefully. They will, even if they get bought out vc, kinda keep that customer support part, you know, even though you're kind of starting to see a lot of that farmed out to AI and things like that now too. But, you know, I, in general, I love competition. You know, I, I think seeing more competition in the ER space is good. It's gonna kind of pro like, prompt some of the, the legacy folks to kind of add new features. You're kind of exploring new things as you're getting other, competitors in there for it. Um, though a lot of the competitors are just kind of jumping in'cause they're, maybe they're entrepreneurs and they see a problem or they see some money and they kind of might be able to fix this without having someone who actually practices medicine say, yeah, you may want to think about, you know, having your EMR do this or do that for'em. And, you know, hopefully we'll see some improvement in functionality and kind of software across the board just as there's more competition in the market.

Speaker 38:31

Another economics question when it comes to the economics of one's time, a lot of, uh, a lot of startups are, oh, we love your feedback. Thanks for your feedback. What do you think about company balancing feedback to learn from physicians and physicians not getting compensated for that time?

Speaker 2 38:50

Well, obviously if you're the em r company, you're wanting to do that as cheaply as possible for it. Uh, so that's kind of what you see. If they can entice you some, you know, non-monetary things, and especially some of these startups may be kinda lean, you know, on their startups, so they may not have like cash resources to like pay the physicians kind of for their time as it goes through. So yeah, that can, uncompensated expertise and time from physicians is I think a huge problem across the board for it. Yeah.

Speaker 39:14

I appreciate that.'cause it, it is important to acknowledge that mm-hmm. That, you know, we're, we need technology, but also we are experts in being

Speaker 2 39:23

mm-hmm.

Speaker 39:23

DPC physicians, you know, or future DPC physicians because we already have experience in fee for service or residency. Changing lanes a little bit when it comes to this idea that, I mean, we could have like a national debate about this. I, I feel, um, especially on the Facebook groups. Some people argue that DPC can scale easily and some people think that DPC is not necessarily something that should scale. So in terms of your thoughts with systems and with the intentionality of your practice and the way that your community is getting access, like it didn't, before you opened, what is your opinion on D can DPC scale?

Speaker 2 40:03

It's a great question and a question that does get hashed out on social media quite often for it. And, you know, I think it can scale to a degree. And you're seeing some people try the big kind of corporate national DBCs, for it. And for the most part they're not making it. You know, one thing I noticed with the, you know, uh, one medical that as I was kind of in my MBA kind of watching their financial statements.'cause in my accounting class we had to pick a company and kind of look through their, you know, as we're kinda learning, you know, financial statements. And I picked one medical because they were kind of doing the closest, public trade company and kind of what I was doing. And what I noticed were, as they grew in scale, their, they didn't publish this me metric, but you could see their loss and you could see their total patient numbers. You could do the math and divide. Their loss per patient increased as they scaled So very clearly, it wasn't a scale problem, it wasn't a, Hey, let's just grow and try to outgrow this problem. So that wasn't, obviously wasn't the issue. And because as you scale anything like that, you're gonna have to just by necessity, add extra layers of coordination and, you know, extra cost and people in the mix to kind of manage that as it grows. And that's going to by default increase your cost as it scales. And I think that's one reason why these big nationwide things, aren't, growing or won't scale very well. As much as if we could just get individual docs out there, one doc, two doc groups and have those everywhere and convince, you know, primary care docs that you either don't have to leave medicine probably being the big thing because you're a burnout primary care doc. You don't have to go take a nonclinical role or, or just resign yourself to working for a hospital system. You can go open your own DPC as a solo doc and maybe have support systems for that one solo doc. Whether it's, you know, the imaging, it's lab, it's pharmacy, it's you know, some administrative things to kind of support them so that it's ready and easy for them to do. I think that is really how you scale DPC'cause there's definitely something magic about a one two doc DPC practice, you know, that you lose when you go this kind of big corporate, you know, nationwide con kilometer of DPC practices, for it. And I think truly that's how DPC scales is by one to twos, like having these 1, 2, 3 small groups doing DPC out there at the small level.

Speaker 42:25

And definitely if you're a DPC practice and you haven't yet added yourself, there's a physician only DPC Mapper that I've created specifically for patients called caring. It's at caring directly.com, but you can register yourself and basically if you're not a physician led clinic, you get removed on the backend. So I know that that is a, a thing that patients are looking for and I definitely would, would encourage everybody to just visit caring directly.com and add yourself on the mapper today. And it'll be. Publicized when I'm releasing patient stories later this year. So it's exciting. And here, you know, I think about one medical, and I think that's awesome that you picked one medical, super, super smart. Just thinking about like any, all, all of the, all of the companies that exist in the world. I think that was a very, very smart choice. And it was, it's so interesting to hear what you saw, you know, financially as they grew bigger. But I'm wondering, could you envision Hitchcock Medical Group as a prototype for scaling in terms of the way that your culture exists and the way that you're hiring and the way that you're training people and the way that you're interacting with patients because you did open, uh, you know, as a smaller group compared to what you are today and then yet you still are delivering what you opened to what you intentionally wanted to in the beginning.

Speaker 2 43:45

I think you can, uh, I think you have to be intentional about as you're hiring clinicians and um, you know, and bringing them in and making sure, you know, culture and you know, what we want, uh, the patient experience to be is front and center as it's going through stuff. I, I think you can, and here with the, the whole medical group, uh, the imaging center, the DPC and the pharmacy together, there's just something magical about having all of that under one roof. And, you know, for here that I think is harder to re reproduce when you're just a DPC here in a imaging center down the road and the pharmacy kind and down the road for that you know, at love. And where I knew that, that we had something magical right after we kind of moved this new building. And, you know, we're still in the process of opening the imaging center, but we had the, the plane x-ray up. Um, I saw a, a kid with a pneumonia. And brought'em in and, you know, saw them, you know, evaluated'em in the exam room. We walked down the hall, grabbed the x-ray, and then they walked back and I put in the antibiotics, and Robbie, the pharmacist, walked down and he was sitting on my couch in my exam room with the mom and the kid had the, the bottle of antibiotics in his hand and was going over that with the mom sitting on our couch there. And I'm like, yeah, th there's something special about this. I made the right decision. This is what we're supposed to be doing for here. And really being able to bundle all of that together under one roof, for these patients is just magical. And that being said, it's still great for the other DPCs in town. You know, they, they use the, my Imaging Center, they send patients here, we get the resorts back to'em fast. They use our pharmacy for it. But having it all under one roof, there's just something magical about that.

Speaker 45:13

And in terms of the. The the collaboration you had with the radiologist who you opened the imaging center with, I'm wondering, you know, you mentioned that you had to jump through certain hoops to get it off the ground. Um, damn those certificate of needs man, I swear. But when it comes to like choosing equipment, did you mm-hmm. Get new things? Did you get older things? Did you, uh, get things from facilities that have closed

Speaker 2 45:40

Um, the ultrasound was new for it, but the, the x-ray, uh, and the CT were both refurbished for it. So those weren't brand new. Uh, the only thing for the ct, you know, I had to set at least a 64 slice so I could do cardiac calcium scores for it. And that was kind of what we thought was kinda the bare minimum, uh, for what I needed to accomplish for it. And but yeah, it was almost a two year process between the certificate of need and the licensure with the state to go from before we could open to the outside world for it, it was, um, an ordeal and an adventure kind of learning of the in and outs of all the bureaucratic hoops that I, I think prevent the competition, the imaging center space, and, you know, learn that a lot of the imaging centers here in Chattanooga actually aren't even licensed and don't even have certificate of need for it. They're just kind of rolling the dice. The state's not gonna do anything to'em, which I thought was kinda interesting for when we're talking about the attorney. He's like, uh, you could, but I wouldn't, wouldn't recommend doing it that way. Uh, but it was a process.

Speaker 46:34

I love that word. It's like, that's like your, uh, your three words. Uh, if physician operator, builder process is a good way to, to describe your mm-hmm. Your, the, the, uh, the hoops that you went through. Oh man. So, I wanna bring us back to the beginning when it, when we talked about, this idea that primary care in this country is really treated as a loss leader instead of an asset. I'm wondering in general, if we stripped down primary care to the studs, what would we keep from your perspective? No matter where a physician is practicing.

Speaker 2 47:08

I think the biggest thing is you need to keep the doctor patient relationship at the core. You know, that is really the core of primary care, but healthcare in general, and then you build it out from around there for, and you value primary care. Uh, if you look at a lot of other countries that have, you know, way lower cost and way better outcomes than we do, they value primary care. They focus on primary care. Uh, here in the US more than half the doctors are specialists and, you know, because we don't value primary care and we don't pay for primary care. But that's what I would do if we were really gonna think about redoing the healthcare system in the us. Strip it down, start with the doctor patient relationship, and build everything up to kind of support that relationship.

47:50

If you've listened to Julia Louis Dreyfuss very first interview in her podcast with Jane Fonda. She had a power outage, and that's exactly what happened with Dr. Hitchcock and myself. Um, I'm actually, uh, down in Sacramento now recording this because we still have a ton of snow from the snowstorm up in Arnold. So if, uh, I have different glasses and the voice sounds a little bit different, just bear with us. So, picking up where we left off. Mm-hmm. Uh, you know, I think about that that saying kiss, keep it simple, but I'm gonna say keep it simple. Smart doctors who are choosing to do d pc, uh, because we are definitely not stupid. We are definitely seeing the, the storm as it's coming or as it's here when it comes to financial structures, in particularly that need to change for pri, for primary care to be treated as an asset. What do you see, especially with your financial and economic background as things that would be, you know, low hanging fruit for us to change in this country, for us to value primary care? I think, you know, obviously, you know, primary care physicians need to be, you know, paid better and, you know, drive an incentive to, for, have physicians to do primary care as opposed to, I'm gonna go become a neurosurgeon because, you know, the, the pain and the lifestyle and, and those kind of things. And really make that incentive to be, become a primary care physician for it. And along with the, the, the lifestyle considerations, you know, with that as well, which is what I love about DPC is, you know, I can have a great lifestyle and make. Good paycheck and enjoy what I'm doing for it and hopefully encourage, you know, medical students that, you know, primary care can be a, a great opportunity for them. So I think that's one thing, uh, that needs to happen for it. Uh, I think kind of talking about models, I, I think, uh, a capitated model, which is exactly what DPC is really. Is the way to go for it. Just because if you turn primary care into that kind of transactional, I'm, I'm just gonna get paid per visit, I'm gonna get paid per, you know, metric that I can prove, then you get right back to kind of where you were and you're, you're not getting, you know, quality out of that. Whereas a cap data model, you get quality, you know, my patients don't have to worry about how many, you know, paying to come in and see me every single time so they can actually get the care that they need for it. And there's no roadblocks for that. And I can, you know, my incentive all of a sudden becomes to keep them healthy and to keep them away from me. So if you know I'm getting paid, whether you see me or not, my goal is to have you not seen me. So I want to keep your diabetes under control so that I'm not having to see you every couple of months for, you know, your. Diabetes Beyond Control or your neuropathy or your, all of these things that I am really working on your lifestyle and you know, what you're eating and what you're doing and your exercise and all of these things so that you're, you know, not an outta control diabetic and you don't have uncontrolled hypertension and I, I'm taking care of those things. So I think more of that CAPA data model, like direct primary care is how one way you can, you know, really kind of get some value in primary care and make it attractive, uh, for everyone. It's almost like when you listen to what you're saying, this is why you can. Throw an opposition to every criticism about DPC that there is, because literally we're doing things sustainably. We're doing things profitably. We're doing things with the patient physician relationship at the center. So it, it's like. You can't really argue with what you're saying in terms of the, the focus that we have at the, at the heart of all of our practices. And, you know, I think about Qian in terms of like, they, you know, did have a capitated model. They were for, for those of you who are not familiar with Qian and the history there, um, definitely the very first, you know, very, very big direct primary care model. Founded by, uh, Dr. Garrison Bliss and Dr. Erica Bliss. Mm-hmm. Uh, definitely. Look up Bliss, B-L-I-S-S, my DPC story and you can find their episodes. But I think that. Here there's, there's always that proceed with caution if it's not physician led and physician managed. So what would you say in terms of growing sustainably like you have, working with physician partners, growing into doing pharmacy and and radiology options for your community as well as your DPC members? What would you say needs to be maintained by physicians as we go forward building, you know, more systemic access to DPC? I think physicians need seats at the table for every part of that, and I think that's probably the biggest, uh. Concern with all of that is ha keeping physicians a seat at the table. Because when you start letting unfortunately kind of the, the bean counters and all those people start running it, you know, physicians become metrics and they become cogs and, you know, you lose a lot of autonomy and you know, just the organic, wonderful growth as it goes. And so having, having physicians a seat at the table across the board is key for it. And I think the other thing too, and kind of what we're learning here with my practice, having. The ancillary services. And so the, the radiology and the pharmacy and where primary care is, you know, not having to stand alone as the primary economic driver of everything has, has really worked out well. Uh, you know, in the, the beginning of the primary care was say to subsidize damaging center of the pharmacy. And now, you know, the, those are really kind of taken over for, it has allowed us to kind of grow without. Pressure of, you know, primary care, you know, being a profit engine, uh, which is I think what I have seen just kind of watching, you know, other, you know, larger tries at DPC, you know, they've tried to extract value and have the primary care be the profit engine, and that just doesn't work. Just you try to scale that up. It just, it, it never, you know, works out well. I think one notable thing, like with One Medical, when I was looking at their financial statements, uh, before Amazon, you know, kind of bought them as they grew, their loss per patient increased. So that tells you it wasn't a scaling problem that, you know, it's a, you know. Core business model kind of problem in that, and it's something you kind of really need to watch as primary care grows. And I just think you were kind of talking about it earlier. I, I think there's something magical about that one, two, you know, couple of physicians small DPC practice that you lose when it kind of grows and becomes this kind of big corporate monstrosity. And you get all these and you start getting all these extra layers in there that have to be, you know, fed. And I think that what is, what drives a lot of these big groups, uh, that have struggled, this have gotten bigger. Like, as you're talking, I'm like, who in the audience has been bought out or experienced a buyout by Optum? Like who? Mm-hmm. Because I think that that's gonna be a lot of people raising their hands in their car or, you know, as they're mowing their lawn, listening to this podcast. So, absolutely. Um, I think that this is great food for thought. Well, thank you so much Dr. Hitchcock for joining us today. Absolutely. Thanks for having me. Thanks for being here for this episode of my DPC story. 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There's a free tier and a paid tier, and both help keep the show going. Follow us on socials at my DPC story and find everything episodes free resources, the DPC Toolkit Magazine, and more@mydpcstory.com. Until next time, this is Marielle conception. I.