What is a Concierge Signature Program?
May 08, 2024
I recently had the pleasure of appearing on Dr. Tea Nguyen's "Direct Care Way" podcast. Dr. Tea is a podiatrist and an early adopter of the direct specialty care (DSC) model.
I loved that she asked me about the differences between DSC in its current form and the concierge specialty program.
Take a listen to the episode, and follow Dr. Tea podcast. Transcript is below.
Transcript
Dr. Tea 0:52
Today, I have Dr. Regina Druz who is a cardiologist who has a virtual practice. And let's talk about how a clinician in this day and age can have a virtual practice. Why we chose to leave insurance, what kind of freedoms do we get from that? So let's just dive right in. Welcome Dr. Druz
Dr. Druz 1:11
Thank you so much for having me.
Dr. Tea 1:13
How did you get to this place where you decided to have a virtual practice?
Dr. Druz 1:19
So great question. I think I sort of gone through a couple of iterations. Early on in my practice development when I was separating from the insurance model and actually going into more of a hybrid structure where some patients have were engaged in cash paid services, or consider signature program, while other patients were just more conventional insurance based model and cardiology, I found that there was a need for increased engagement with the patient. And the virtual opportunity was certainly there. It made engagement with the patients something that I could stand up without necessarily for them coming into the office and seeing me one on one or face to face. And then of course during the Coronavirus pandemic, Virtual Engagement became the norm. And it was interesting to me because I was an early adopter. So a lot of these growing pains that doctors have gone through trying to figure out virtual encounters. I've already been there and done that. And in many ways, I think Coronavirus actually established virtual care as on par. I think with face to face care, obviously, it has limitations. And it's not necessarily transportable to all medical specialties. But I feel that it opens the opportunity for people to see it as a valuable addition to the type of services that they can get. And you know, the saying that we should meet patients where they're at is actually a great thing. And I think for cash based services, there is a huge possibility in really growing and scaling the virtual model because the virtual model brings with it a lot of other things that brick and mortar model will struggle to accomplish.
Dr. Tea 3:24
How did you decide to leave insurance? What was your life like before you had this virtual practice?
Dr. Druz 3:31
So insurance sort of left me so what happened is that I was employed in a very traditional academic cardiology and setting. running one of the sections or subdivisions of a very large cardiology department are very procedurally based, lots of cardiologists, and does medical reimbursements and procedural footprint started to become more competitive with Medicare slashing some of our rates. And you know, the commercial insurers really bugging people down and pre authorization. The whole division at that point became a department that started really pushing its doctors to the brink. So I was one of those victims of burnout, I guess, you know, back then that specific term was only beginning to circulate and the doctors circles and ended up essentially, starting solo, I was fortunate that locally where I live, my husband had a commercial property where his office was, and still is there. He's a dentist, and I sort of just landed there and said, Well, what can I do that I can do by myself that will allow me to survive, but also in the second iteration will actually allow me to practice what I was wanting to practice and what I always wanted to practice as a more precision based personalized medicine. then.
Dr. Druz 5:00
And at the time, when I separated from my academic institution, my skill set was very nascent, you know, there was really a beginner skill set, it was honestly no more than just a desire to learn it, and to apply it. And as I learned it, and as I began to apply it, and, you know, for me, I have certainly one of those personality traits where I can just learn and store it to have to go and do it. And so I literally just went out there, and I've done it. And this was an interesting experiment, and it worked. I had no plan, just the desire to make it succeed, you know, I certainly wouldn't advise anyone nowadays to go into it without a plan. But back then, doctors like these were just very, very few. And most of my colleagues, well, meaning colleagues essentially told me that I was committing career suicide, that the opposite ended up happening, I think my career flourished, and both traditional and less traditional domain. So I think it was done out of necessity. I think right now, a lot of dogs have an opportunity to do it in a more meditative way, with appropriate planning. We have, you know, people like you who are leading in this field, who could give physicians some understanding of how they can position themselves for this exit. So it doesn't necessarily need to be so abrupt. It could be structured and well planned. But I think the critical ingredient there is that one does have to be a bit of an intrapreneur. Because, and not to be afraid to fail, because failure is part of this process.
Dr. Tea 6:49
Do you think you were an entrepreneur? First? Or did you just have to become one which came first?
Dr. Druz 6:57
You know what it's hard to say? I think maybe I was entrepreneur first, because some of the stuff that I did as an academic cardiologist such as starting research projects, and sort of formulating ideas, in many ways it is part of it is in the entrepreneurial DNA, it was not necessarily conflicting with the traditional setup of medicine. But it does require some creativity, it does require being able to tolerate uncertainty, it does require sometimes going against the grain, maybe of established opinions or expert opinions, right? Anything new like this requires a little bit of lifting your entrepreneurial lift. I think what actually made me an intrapreneur or pushed me was the fact that I didn't have any other options, right? So it's sort of a sink or swim situation. And that's what broke them.
Dr. Tea 7:59
So tell me what your day to day operations look like having this kind of practice. So you had left or you left insurance based model employment essentially right? And did you immediately start up your private practice then?
Dr. Druz 8:13
So I left the employed model when I first started as a private practitioner, because remember that prior to that, I was never in private practice. So I had no idea how private practice even runs, traditional or non traditional, it was always an employed physician. So my first foray was that brick and mortar practice, which was 100% insurance based and as my skill set progressed in what I liked, which is this precision medicine, integrative medicine, functional medicine, I decided to bring some of its components into practice. And that was the first sort of opening, the opportunity opened. And I created a hybrid practice structure, which I think for a lot of specialists is a great option, especially specialists like cardiologist or gastroenterologist or pulmonologist where there is a big procedural component, because procedure continues to be a significant revenue driver and procedure continues to be very much needed by our patients. And so building on that, that, of course, allowed me to bring in some digital therapeutics and a virtual interaction. So the hybrid model became more dynamic because as it grew, I would progressively phase out insurance until it wasn't really needed anymore. And actually, eventually, I sold the brick and mortar, part of it to a local healthcare system. And I brought this entire cash based services suite into the health care system. And after leaving the health care assist them. I iterated on this model. And I realized, you know, because of the Coronavirus pandemic and how the mindset shifted in both patients and practitioners was acceptance of virtual care, and actually expansion of virtual care capabilities. In many ways, not only digital biomarkers in digital therapeutics, but direct to consumer testing. So there are a lot of verticals that I think in a brick and mortar practice are, you know, they're not necessarily coalescing in a brick and mortar environment, they're much easier done in that virtual space.
Dr. Druz 10:35
So this I'm going to say is my third iteration on the concept of precision cardiology, which right now is the virtual platform. And honestly, if I use what my day to day is like, it's very flexible. At this point, I make my full time salary, which is average cardiology, full time salary, it's not, you know, at at the lowest percentile, but certainly not at the highest, we're going to say it's somewhere in the middle of what the MGMA considers a cardiologist, you know, should be making. So I actually make it working approximately 20 hours per week, most of that time is not face to face time, I certainly have face to face virtual time as patients, I also have two locations and a couple of areas where I see my established patients, sometimes once a month, sometimes once per quarter, because you know, cardiology is still a specialty or physical exam is important. Although I could, you know, I certainly have a lot of biometric monitoring, and a lot of other things patients do appreciate being able to see you in person once or twice a year, which also allows me to establish care for some patients who may be out of state. So I think what ended up happening is that I essentially flipped this brick and mortar plus a little bit of telemedicine model the other way, so it became primarily a telemedicine model that was a little bit of brick and mortar. So I have a lot of flexibility there and obviously spend some time lecturing and writing and business development and working with other Doc's. And I feel like this is the best combination for me right now. And giving me the freedom that I was looking to have, you know this later on in my career and my more mature career stage. And I think it's a tremendous option for a lot of doctors out there.
Dr. Tea 12:38
You said that you make a regular salary, with just 20 hours a week. And you sound really happy, like this sounds like. And this is really hard to come by, you know, I intersect with a lot of specialists, cardiologists, vascular doctors, and so on. Not a lot of doctors are happy, or they are just tolerating. And so to be able to hear somebody like you who just created something out of scratch, and you're making a regular salary, and you're happy with less time in the clinic, I mean, how could this be real? How are you making this real? What is working tell us?
Dr. Druz 13:23
Yes. So I'll tell you the secret. It's a wide open secret, because since you know you and I think we interacted in a couple of social media portals, you have probably heard me say it a number of times. I think the specialist who is aiming to work in this model needs to develop what I would call a consumer signature program. Right. So the standard direct or the typical direct pay practice, whether it's in primary care, specialty care, usually relies on a membership model. And the membership model is some time, some type of a recurring monthly revenue. Sometimes more, sometimes a little bit less, potentially some other services that are either chain of membership or just additional revenue generators or value added services.
Dr. Druz 14:19
The problem was this model, I think, for specialists is that number one, hope procedural specialists, again, cardiology, gi pulmonary, probably a few others. It makes it challenging to serve patients who do need procedures because if you are out of network with major insurance carriers, well what do you do when a patient's need procedure, then you have to refer them out. So that sort of dilutes the value of the membership for this patient right now. Yes. Patients, a lot of patients as we go along, have high deductible insurance plans, right or health plans HDHPs. They may use their HSA accounts. So for many who have them there is almost no difference, they actually will benefit more in a membership model because their HSA payments potentially could be less. But what about the Medicare patients? And you know, again, I'm in a specialty where Medicare patients are very prevalent, right? You know, this and sort of these older adults, more mature adults are the ones who are bearing a lot of burden for cardiovascular disease. So I find that, you know, the one of the steps that doctors may want to consider is to really create this kind of car signature program. And I worked with a number of physicians to help them do that. And my experience, essentially, this is what gave the legs to my exit, was the fact that I developed such a program so patients can very clearly identify what is it that I can do for them, it has a name, it has a structure. And because of that, it has a certain other things attached to it, you know, things which have to do with digital marketing and creating appropriate patient journeys and understanding the revenue and, you know, the income generation opportunities and how the ancillary services fall into place. And it fills a specific need that a lot of patients actually have. So I think that's where the spectrum may find the sweet spot. Right. It's not that the membership model is not going to get them there, it will get them there eventually, probably not going to get them the degrees of freedom that I think I'm experiencing, having launched, refined and scaled this currency or signature program.
Dr. Tea 16:44
That is what makes sense. That totally makes sense, because I think we have struggled as a specialty entity to try to mirror what DPC is doing. And I find that to be incredibly challenging because then we're just copying and pasting and like you said, diluting our value. Because DPC do, they do more procedures. And so where is the opportunity for us to grow if they're doing similar things in a different model? So we definitely have to do something uniquely different. And I completely agree with that. I just didn't put my finger on it, that you're calling it a concert signature program, which could be they could look like a membership. It sounds like it could look like a high ticket item. What does it look like for your practice?
Dr. Druz 17:32
So that's to your spot. So for my practice, it actually starts with packages. So we have by happened upon a type of structure that initially allowed me to transition from insurance into a cash based model, where patients initially would come in for a short visit. And I call it an exploratory visit. And initially, when I started, it was entirely insurance based. So when patients said, Oh, I wanted to see you, you're an integrative cardiologist who is different from my cardiologist. One of the challenges for me, because I, at the time, practice in a very saturated area, literally surrounded by nega cardiology institutions with huge academic pedigrees, I really didn't want to sour my relationship with my colleagues, you know, we all knew each other. And so my resolution to it was to say, okay, you can come for a typical, you know, typical duration visit covered under your insurance, I'm not going to repeat or do things that your cardiologists have already done or is planning to do, I'm simply going to tell you, what I can contribute to your care. And if you decide that this is something that makes sense to you, I will become part of your care team. But my services from that point forward will be cash based. So you will continue to see your cardiologist, they will continue to do all the standard cardiology things. And I will be that sort of cardiology sub specialist that will fill the void in integrative cardiology space, or signature program space, lifestyle space, or whatever space a doctor chooses to be. Right? You know, it could be a complex patient, let's say a patient who needs certain specific procedures and has not really done well with them. You know, there could be various types of patient populations or scenarios where there is a demand and there is a gap. And by positioning the services and what is known as a value proposition canvas, where we look for patients' jobs, understand their pains, and amplify their gains, we could actually tap into that patient demographic. So that was very helpful.
Dr. Druz 19:45
And eventually as I got traction, I said, Well, I really don't need to bother with this initial exploratory step being insurance covered because we could simply take a fairly small fee. It's not a free call, you know, free call is something very patient, as my patient coordinator who is non physician, non medical, just to go over the entire logistics of it, that in that kind of simple 30 minute encounter at fairly low fee, I'm able to give patient and understanding what is it how we can add to their care, and are we actually aligned in what we're trying to accomplish. So it's not standard care anymore, I'll do it very often, I actually find significant gaps in standard care that patients have not received, you know, and I do ask them to go back to their cardiologist or primary care physician to fill those gaps. And then, you know, usually following this encounter, I will make a recommendation, you know, the proprietary program is called Fit New Jeans. And we usually run it for three, six or 12 months, it has a set of services, visits, testing, of course, biometrics, it's all laid out and packaged for a patient to understand that well, and depending on their degree of complexity and what actually needs to be done, I will make a recommendation for duration in that program. Most patients that come our way and up in either 6 or 12 months, engagements, so 6 to 12 months packages. And once they finish the package, because we already have a relationship, and we'll already learn a lot about them. And these packages are built to actually intensify their care. So a lot gets accomplished in that period of time. Most of them actually then graduate onto the membership. So we have a very low churn rate of people not actually graduating from these packages into memberships. Honestly, I'm going to say it's less than 5%. Although I, you know, haven't run my numbers recently, it's almost never that our patients opt out of continuing with us as members, or interrupt their membership. It's literally a few individuals that I can recall. And they're almost always a serious extenuating circumstance to that. So I think it's a very durable and scalable model for a specialist who is aiming to divest their practice from insurance.
Dr. Tea 22:24
What kind of patient comes to you, compared to what kind of patient wants to use their insurance? Do you see a difference in demographics, income personality type? Who's a good fit for your practice?
Dr. Druz 22:39
It's a great question. I think demographically, I'm actually not seeing a huge divergence. For my standard cardiovascular patients, you know, most patients are between the ages of 40 to 65. They do not necessarily have college education, they sort of, you know, a third, a third and a third, you know, I'd hit against degrees, college education and what not. There, for the most part, somewhere in the middle class, this Ignatian, if you're just looking at the US defined categories as to what constitutes middle class, and they have very typical cardiovascular diagnosis and issues. What I think distinguishes those patients is that they want ownership of their health. And this is the defining criteria. So they want to own their house, they want to be able to understand what they can do, in addition to what they've been told to do, which they know is, for the most part, not really a personalized advice, that could be solid advice. And they have this desire to optimize their health. For some of them, it optimizes their health and longevity. And with so many resources available to us on the internet and podcasts such as these podcasts and books and sort of various examples from friends and family, These are the patients who are seeking optimization and are willing to take action.
Dr. Druz 24:20
So if you're familiar, for example, was diffusion of innovation curve, which is a fascinating curve because it was described by a psychologist Everett Rogers and think 1960s And it was meant to explain to the scientific community how people adapt to new things. He studied physicians and their responses to the introduction of a new antibiotic, which at that time was tetracycline. And so, you know, diffusion of innovation is actually what lots of startup companies are always quoting and, you know, startup gurus writing about the chasm and how to cross the chasm. So if we position it in those terms, most of these patients in Initially, when this practice was obviously launching, a lot of these patients were so-called early adopters, right? They were people who already had a lot of interest in alternative therapies, let's call them that I'll go. I don't like the name, but complementary alternative therapies for coronary disease, vascular disease. And they may have tried numerous things, and they did not necessarily reach their goal. But then over time, there was growth and crossing of the chasm. T came in early majority, and the early majority are pragmatic users. They are the type of patients who not only do they want to own their house, but they want to see evidence that it works. And I think when one has a focused program, and by the way, a focus program doesn't mean that you don't do anything else. But if you could sort of stretch it, depending on what your practice needs are. But when one has a focused program, you're able to show results, and it very much appeals to those pragmatic users.
Dr. Tea 26:03
That is so awesome. I thank you for sharing that. So there is kind of (welcome) You have really defined what makes direct care practice. Really, in such a short period of time, a lot of it, I think, comes down to the reason why we became doctors, we wanted to make a difference, not just break the bone and put it back together, we actually want them to have quality of life. And it's really hard to do that with insurance when we're allocated minutes just to see a patient. Whereas I think a lot of us are deeply desiring to help patients not just get better from their physical issues, but their mental well being and so much of that is tied together. But somewhere along the line in our medical education, it got segmented, where somebody is only good at this one thing, and then you have to go to somebody else for that other body part. And then you want to talk about the decline of mental health in our country right now. That's a whole nother segment, you know, and there's just problems amongst problems that just gets magnified, the more we separate our physical issues from our entire well being. So I really appreciate what you do in your practice and you sharing your, how it's working for you and your signature programs, I'm very fascinated with the idea of just giving patients our entire attention, giving them things that they can measure. So it's not just hocus focus medicine, it's validated, precise, and giving them tools where they can feel empowered, that they can make appropriate changes for their health, and for their well being. And with that, when you give patients those outcomes, it just sounds like they're bound to tell all of their friends that this is the place to go.
Dr. Druz 27:54
Yeah, it's very evident. You're absolutely right. It's very gratifying. And I think one of the eye openers for me is the fact that it wasn't necessarily my credentials, or my competency that was so appealing to patients, obviously, it is very appealing. You know, we can't just leave it by the wayside and say, Oh, who cares about your credentials or competency. But it was the fact that they were heard. They're just as you mentioned, the fact that we outsource so many things, and everything is so siloed it's very frustrating to individuals, especially as medical information and medical decision making becomes much more complex. You know, we have seen such an increase in patient complexity in the past two decades. It's absolutely astronomical. And one of the things that I find that patients consistently remark on is that they're being listened to, they're being heard. And, there is communication, there is collaboration. And so this is what I think the do rec model actually brings back into medicine, just as you said, we are truly collaborators for these patients. We're not just transactional physicians that they see today and whip out their insurance cards on mobile. And, you know, we are partners in their health journey.
Dr. Tea 29:16
I heard a doctor say they felt like they were just the referral widget. Like they were no longer practicing medicine. They were just outsourcing and I couldn't agree more. And I think it's quite terrible what's happening. So do you think and agree that we will be changing the face of medicine through direct care. And the challenge is, how is it going to look for each specialty because you're doing it for cardiology. I'm still trying to figure it out for podiatry. We have an abundance of specialists listening to the podcast and everyone out here is just trying to solve the puzzle for their niche area. What are some key things that you would advise the doctor who is just contemplating leaving insurance
Dr. Druz 29:58
Number One, Have a plan. Number two, understand why your plan may or may not work. It is a painful exercise, because obviously everyone thinks that their idea is great. And you know, it's going to apply. But we do need to be realistic. And number three, run a little observation trial, even in the occurred practice, whether it's employed practice or private group practice, but maybe it's not cash based, or even if it is cash based, what is it that is bringing patients your way? What is it that they're looking for? Have a conversation with them to identify what their pain points are, and where you can truly improve their life by alleviating those pain points. Do not come into it with preconceived notions. I don't know if you have observed this. But initially when I started in this journey, a lot of my colleagues felt that most of my patients will be very sort of high net worth individuals, very entitled individuals that are able to come and pay cash for medical services. And I can tell you, it is 100% not true. Do I have some people who meet that definition? I do have a little bit. But the majority, surprisingly, are the exact same patients at least phenotypically that one sees in standard cardiology practices. They just think of themselves differently. And they want to find somebody who can help them to make the thinking that quest a reality. So don't despair, but analyze your situation and have a plan.
Dr. Tea 31:40
Good advice for you. How long did it take for you to feel steady and safe? Building this practice,
Dr. Druz 31:48
I'm going to say that for approximately five years in all honesty, I didn't have a very straightforward sort of straight line, because I was still very much involved at some points in the more traditional cardiology practice leadership roles. So I think if I was 100%, just focused on this practice that may have been a little shorter. But I think, you know, at a five year mark, is where I finally felt that I know what I'm doing. And, you know, and I can present it to the world with that feeling that people will just like, you know, throw stones at you and scream that you violated all the cardiology rules of engagement, like fetching, like recommending supplements, and you know, telling people that they could get away with lower dose of statin drugs and things like that said that, that takes time.
Dr. Tea 32:42
It's so funny the arguments against supplements, I just, I know where you're coming from when you're talking about functional medicine and just holistic care, wholesome care. But if we don't change, you're gonna be stuck, and you're gonna be sad, and you're gonna burn out. I think that's the lesson we'd get through this (100%) which is not what we want, we all aim to create a practice of our own. And Dr. Druz here has demonstrated that she is able to do it for cardiology. So I really appreciate your time. Thank you so much for sharing your wisdom and I look forward to talking to you again sometime in the future.
Today, I have Dr. Regina Druz who is a cardiologist who has a virtual practice. And let's talk about how a clinician in this day and age can have a virtual practice. Why we chose to leave insurance, what kind of freedoms do we get from that? So let's just dive right in. Welcome Dr. Druz
Dr. Druz 1:11
Thank you so much for having me.
Dr. Tea 1:13
How did you get to this place where you decided to have a virtual practice?
Dr. Druz 1:19
So great question. I think I sort of gone through a couple of iterations. Early on in my practice development when I was separating from the insurance model and actually going into more of a hybrid structure where some patients have were engaged in cash paid services, or consider signature program, while other patients were just more conventional insurance based model and cardiology, I found that there was a need for increased engagement with the patient. And the virtual opportunity was certainly there. It made engagement with the patients something that I could stand up without necessarily for them coming into the office and seeing me one on one or face to face. And then of course during the Coronavirus pandemic, Virtual Engagement became the norm. And it was interesting to me because I was an early adopter. So a lot of these growing pains that doctors have gone through trying to figure out virtual encounters. I've already been there and done that. And in many ways, I think Coronavirus actually established virtual care as on par. I think with face to face care, obviously, it has limitations. And it's not necessarily transportable to all medical specialties. But I feel that it opens the opportunity for people to see it as a valuable addition to the type of services that they can get. And you know, the saying that we should meet patients where they're at is actually a great thing. And I think for cash based services, there is a huge possibility in really growing and scaling the virtual model because the virtual model brings with it a lot of other things that brick and mortar model will struggle to accomplish.
Dr. Tea 3:24
How did you decide to leave insurance? What was your life like before you had this virtual practice?
Dr. Druz 3:31
So insurance sort of left me so what happened is that I was employed in a very traditional academic cardiology and setting. running one of the sections or subdivisions of a very large cardiology department are very procedurally based, lots of cardiologists, and does medical reimbursements and procedural footprint started to become more competitive with Medicare slashing some of our rates. And you know, the commercial insurers really bugging people down and pre authorization. The whole division at that point became a department that started really pushing its doctors to the brink. So I was one of those victims of burnout, I guess, you know, back then that specific term was only beginning to circulate and the doctors circles and ended up essentially, starting solo, I was fortunate that locally where I live, my husband had a commercial property where his office was, and still is there. He's a dentist, and I sort of just landed there and said, Well, what can I do that I can do by myself that will allow me to survive, but also in the second iteration will actually allow me to practice what I was wanting to practice and what I always wanted to practice as a more precision based personalized medicine. then.
Dr. Druz 5:00
And at the time, when I separated from my academic institution, my skill set was very nascent, you know, there was really a beginner skill set, it was honestly no more than just a desire to learn it, and to apply it. And as I learned it, and as I began to apply it, and, you know, for me, I have certainly one of those personality traits where I can just learn and store it to have to go and do it. And so I literally just went out there, and I've done it. And this was an interesting experiment, and it worked. I had no plan, just the desire to make it succeed, you know, I certainly wouldn't advise anyone nowadays to go into it without a plan. But back then, doctors like these were just very, very few. And most of my colleagues, well, meaning colleagues essentially told me that I was committing career suicide, that the opposite ended up happening, I think my career flourished, and both traditional and less traditional domain. So I think it was done out of necessity. I think right now, a lot of dogs have an opportunity to do it in a more meditative way, with appropriate planning. We have, you know, people like you who are leading in this field, who could give physicians some understanding of how they can position themselves for this exit. So it doesn't necessarily need to be so abrupt. It could be structured and well planned. But I think the critical ingredient there is that one does have to be a bit of an intrapreneur. Because, and not to be afraid to fail, because failure is part of this process.
Dr. Tea 6:49
Do you think you were an entrepreneur? First? Or did you just have to become one which came first?
Dr. Druz 6:57
You know what it's hard to say? I think maybe I was entrepreneur first, because some of the stuff that I did as an academic cardiologist such as starting research projects, and sort of formulating ideas, in many ways it is part of it is in the entrepreneurial DNA, it was not necessarily conflicting with the traditional setup of medicine. But it does require some creativity, it does require being able to tolerate uncertainty, it does require sometimes going against the grain, maybe of established opinions or expert opinions, right? Anything new like this requires a little bit of lifting your entrepreneurial lift. I think what actually made me an intrapreneur or pushed me was the fact that I didn't have any other options, right? So it's sort of a sink or swim situation. And that's what broke them.
Dr. Tea 7:59
So tell me what your day to day operations look like having this kind of practice. So you had left or you left insurance based model employment essentially right? And did you immediately start up your private practice then?
Dr. Druz 8:13
So I left the employed model when I first started as a private practitioner, because remember that prior to that, I was never in private practice. So I had no idea how private practice even runs, traditional or non traditional, it was always an employed physician. So my first foray was that brick and mortar practice, which was 100% insurance based and as my skill set progressed in what I liked, which is this precision medicine, integrative medicine, functional medicine, I decided to bring some of its components into practice. And that was the first sort of opening, the opportunity opened. And I created a hybrid practice structure, which I think for a lot of specialists is a great option, especially specialists like cardiologist or gastroenterologist or pulmonologist where there is a big procedural component, because procedure continues to be a significant revenue driver and procedure continues to be very much needed by our patients. And so building on that, that, of course, allowed me to bring in some digital therapeutics and a virtual interaction. So the hybrid model became more dynamic because as it grew, I would progressively phase out insurance until it wasn't really needed anymore. And actually, eventually, I sold the brick and mortar, part of it to a local healthcare system. And I brought this entire cash based services suite into the health care system. And after leaving the health care assist them. I iterated on this model. And I realized, you know, because of the Coronavirus pandemic and how the mindset shifted in both patients and practitioners was acceptance of virtual care, and actually expansion of virtual care capabilities. In many ways, not only digital biomarkers in digital therapeutics, but direct to consumer testing. So there are a lot of verticals that I think in a brick and mortar practice are, you know, they're not necessarily coalescing in a brick and mortar environment, they're much easier done in that virtual space.
Dr. Druz 10:35
So this I'm going to say is my third iteration on the concept of precision cardiology, which right now is the virtual platform. And honestly, if I use what my day to day is like, it's very flexible. At this point, I make my full time salary, which is average cardiology, full time salary, it's not, you know, at at the lowest percentile, but certainly not at the highest, we're going to say it's somewhere in the middle of what the MGMA considers a cardiologist, you know, should be making. So I actually make it working approximately 20 hours per week, most of that time is not face to face time, I certainly have face to face virtual time as patients, I also have two locations and a couple of areas where I see my established patients, sometimes once a month, sometimes once per quarter, because you know, cardiology is still a specialty or physical exam is important. Although I could, you know, I certainly have a lot of biometric monitoring, and a lot of other things patients do appreciate being able to see you in person once or twice a year, which also allows me to establish care for some patients who may be out of state. So I think what ended up happening is that I essentially flipped this brick and mortar plus a little bit of telemedicine model the other way, so it became primarily a telemedicine model that was a little bit of brick and mortar. So I have a lot of flexibility there and obviously spend some time lecturing and writing and business development and working with other Doc's. And I feel like this is the best combination for me right now. And giving me the freedom that I was looking to have, you know this later on in my career and my more mature career stage. And I think it's a tremendous option for a lot of doctors out there.
Dr. Tea 12:38
You said that you make a regular salary, with just 20 hours a week. And you sound really happy, like this sounds like. And this is really hard to come by, you know, I intersect with a lot of specialists, cardiologists, vascular doctors, and so on. Not a lot of doctors are happy, or they are just tolerating. And so to be able to hear somebody like you who just created something out of scratch, and you're making a regular salary, and you're happy with less time in the clinic, I mean, how could this be real? How are you making this real? What is working tell us?
Dr. Druz 13:23
Yes. So I'll tell you the secret. It's a wide open secret, because since you know you and I think we interacted in a couple of social media portals, you have probably heard me say it a number of times. I think the specialist who is aiming to work in this model needs to develop what I would call a consumer signature program. Right. So the standard direct or the typical direct pay practice, whether it's in primary care, specialty care, usually relies on a membership model. And the membership model is some time, some type of a recurring monthly revenue. Sometimes more, sometimes a little bit less, potentially some other services that are either chain of membership or just additional revenue generators or value added services.
Dr. Druz 14:19
The problem was this model, I think, for specialists is that number one, hope procedural specialists, again, cardiology, gi pulmonary, probably a few others. It makes it challenging to serve patients who do need procedures because if you are out of network with major insurance carriers, well what do you do when a patient's need procedure, then you have to refer them out. So that sort of dilutes the value of the membership for this patient right now. Yes. Patients, a lot of patients as we go along, have high deductible insurance plans, right or health plans HDHPs. They may use their HSA accounts. So for many who have them there is almost no difference, they actually will benefit more in a membership model because their HSA payments potentially could be less. But what about the Medicare patients? And you know, again, I'm in a specialty where Medicare patients are very prevalent, right? You know, this and sort of these older adults, more mature adults are the ones who are bearing a lot of burden for cardiovascular disease. So I find that, you know, the one of the steps that doctors may want to consider is to really create this kind of car signature program. And I worked with a number of physicians to help them do that. And my experience, essentially, this is what gave the legs to my exit, was the fact that I developed such a program so patients can very clearly identify what is it that I can do for them, it has a name, it has a structure. And because of that, it has a certain other things attached to it, you know, things which have to do with digital marketing and creating appropriate patient journeys and understanding the revenue and, you know, the income generation opportunities and how the ancillary services fall into place. And it fills a specific need that a lot of patients actually have. So I think that's where the spectrum may find the sweet spot. Right. It's not that the membership model is not going to get them there, it will get them there eventually, probably not going to get them the degrees of freedom that I think I'm experiencing, having launched, refined and scaled this currency or signature program.
Dr. Tea 16:44
That is what makes sense. That totally makes sense, because I think we have struggled as a specialty entity to try to mirror what DPC is doing. And I find that to be incredibly challenging because then we're just copying and pasting and like you said, diluting our value. Because DPC do, they do more procedures. And so where is the opportunity for us to grow if they're doing similar things in a different model? So we definitely have to do something uniquely different. And I completely agree with that. I just didn't put my finger on it, that you're calling it a concert signature program, which could be they could look like a membership. It sounds like it could look like a high ticket item. What does it look like for your practice?
Dr. Druz 17:32
So that's to your spot. So for my practice, it actually starts with packages. So we have by happened upon a type of structure that initially allowed me to transition from insurance into a cash based model, where patients initially would come in for a short visit. And I call it an exploratory visit. And initially, when I started, it was entirely insurance based. So when patients said, Oh, I wanted to see you, you're an integrative cardiologist who is different from my cardiologist. One of the challenges for me, because I, at the time, practice in a very saturated area, literally surrounded by nega cardiology institutions with huge academic pedigrees, I really didn't want to sour my relationship with my colleagues, you know, we all knew each other. And so my resolution to it was to say, okay, you can come for a typical, you know, typical duration visit covered under your insurance, I'm not going to repeat or do things that your cardiologists have already done or is planning to do, I'm simply going to tell you, what I can contribute to your care. And if you decide that this is something that makes sense to you, I will become part of your care team. But my services from that point forward will be cash based. So you will continue to see your cardiologist, they will continue to do all the standard cardiology things. And I will be that sort of cardiology sub specialist that will fill the void in integrative cardiology space, or signature program space, lifestyle space, or whatever space a doctor chooses to be. Right? You know, it could be a complex patient, let's say a patient who needs certain specific procedures and has not really done well with them. You know, there could be various types of patient populations or scenarios where there is a demand and there is a gap. And by positioning the services and what is known as a value proposition canvas, where we look for patients' jobs, understand their pains, and amplify their gains, we could actually tap into that patient demographic. So that was very helpful.
Dr. Druz 19:45
And eventually as I got traction, I said, Well, I really don't need to bother with this initial exploratory step being insurance covered because we could simply take a fairly small fee. It's not a free call, you know, free call is something very patient, as my patient coordinator who is non physician, non medical, just to go over the entire logistics of it, that in that kind of simple 30 minute encounter at fairly low fee, I'm able to give patient and understanding what is it how we can add to their care, and are we actually aligned in what we're trying to accomplish. So it's not standard care anymore, I'll do it very often, I actually find significant gaps in standard care that patients have not received, you know, and I do ask them to go back to their cardiologist or primary care physician to fill those gaps. And then, you know, usually following this encounter, I will make a recommendation, you know, the proprietary program is called Fit New Jeans. And we usually run it for three, six or 12 months, it has a set of services, visits, testing, of course, biometrics, it's all laid out and packaged for a patient to understand that well, and depending on their degree of complexity and what actually needs to be done, I will make a recommendation for duration in that program. Most patients that come our way and up in either 6 or 12 months, engagements, so 6 to 12 months packages. And once they finish the package, because we already have a relationship, and we'll already learn a lot about them. And these packages are built to actually intensify their care. So a lot gets accomplished in that period of time. Most of them actually then graduate onto the membership. So we have a very low churn rate of people not actually graduating from these packages into memberships. Honestly, I'm going to say it's less than 5%. Although I, you know, haven't run my numbers recently, it's almost never that our patients opt out of continuing with us as members, or interrupt their membership. It's literally a few individuals that I can recall. And they're almost always a serious extenuating circumstance to that. So I think it's a very durable and scalable model for a specialist who is aiming to divest their practice from insurance.
Dr. Tea 22:24
What kind of patient comes to you, compared to what kind of patient wants to use their insurance? Do you see a difference in demographics, income personality type? Who's a good fit for your practice?
Dr. Druz 22:39
It's a great question. I think demographically, I'm actually not seeing a huge divergence. For my standard cardiovascular patients, you know, most patients are between the ages of 40 to 65. They do not necessarily have college education, they sort of, you know, a third, a third and a third, you know, I'd hit against degrees, college education and what not. There, for the most part, somewhere in the middle class, this Ignatian, if you're just looking at the US defined categories as to what constitutes middle class, and they have very typical cardiovascular diagnosis and issues. What I think distinguishes those patients is that they want ownership of their health. And this is the defining criteria. So they want to own their house, they want to be able to understand what they can do, in addition to what they've been told to do, which they know is, for the most part, not really a personalized advice, that could be solid advice. And they have this desire to optimize their health. For some of them, it optimizes their health and longevity. And with so many resources available to us on the internet and podcasts such as these podcasts and books and sort of various examples from friends and family, These are the patients who are seeking optimization and are willing to take action.
Dr. Druz 24:20
So if you're familiar, for example, was diffusion of innovation curve, which is a fascinating curve because it was described by a psychologist Everett Rogers and think 1960s And it was meant to explain to the scientific community how people adapt to new things. He studied physicians and their responses to the introduction of a new antibiotic, which at that time was tetracycline. And so, you know, diffusion of innovation is actually what lots of startup companies are always quoting and, you know, startup gurus writing about the chasm and how to cross the chasm. So if we position it in those terms, most of these patients in Initially, when this practice was obviously launching, a lot of these patients were so-called early adopters, right? They were people who already had a lot of interest in alternative therapies, let's call them that I'll go. I don't like the name, but complementary alternative therapies for coronary disease, vascular disease. And they may have tried numerous things, and they did not necessarily reach their goal. But then over time, there was growth and crossing of the chasm. T came in early majority, and the early majority are pragmatic users. They are the type of patients who not only do they want to own their house, but they want to see evidence that it works. And I think when one has a focused program, and by the way, a focus program doesn't mean that you don't do anything else. But if you could sort of stretch it, depending on what your practice needs are. But when one has a focused program, you're able to show results, and it very much appeals to those pragmatic users.
Dr. Tea 26:03
That is so awesome. I thank you for sharing that. So there is kind of (welcome) You have really defined what makes direct care practice. Really, in such a short period of time, a lot of it, I think, comes down to the reason why we became doctors, we wanted to make a difference, not just break the bone and put it back together, we actually want them to have quality of life. And it's really hard to do that with insurance when we're allocated minutes just to see a patient. Whereas I think a lot of us are deeply desiring to help patients not just get better from their physical issues, but their mental well being and so much of that is tied together. But somewhere along the line in our medical education, it got segmented, where somebody is only good at this one thing, and then you have to go to somebody else for that other body part. And then you want to talk about the decline of mental health in our country right now. That's a whole nother segment, you know, and there's just problems amongst problems that just gets magnified, the more we separate our physical issues from our entire well being. So I really appreciate what you do in your practice and you sharing your, how it's working for you and your signature programs, I'm very fascinated with the idea of just giving patients our entire attention, giving them things that they can measure. So it's not just hocus focus medicine, it's validated, precise, and giving them tools where they can feel empowered, that they can make appropriate changes for their health, and for their well being. And with that, when you give patients those outcomes, it just sounds like they're bound to tell all of their friends that this is the place to go.
Dr. Druz 27:54
Yeah, it's very evident. You're absolutely right. It's very gratifying. And I think one of the eye openers for me is the fact that it wasn't necessarily my credentials, or my competency that was so appealing to patients, obviously, it is very appealing. You know, we can't just leave it by the wayside and say, Oh, who cares about your credentials or competency. But it was the fact that they were heard. They're just as you mentioned, the fact that we outsource so many things, and everything is so siloed it's very frustrating to individuals, especially as medical information and medical decision making becomes much more complex. You know, we have seen such an increase in patient complexity in the past two decades. It's absolutely astronomical. And one of the things that I find that patients consistently remark on is that they're being listened to, they're being heard. And, there is communication, there is collaboration. And so this is what I think the do rec model actually brings back into medicine, just as you said, we are truly collaborators for these patients. We're not just transactional physicians that they see today and whip out their insurance cards on mobile. And, you know, we are partners in their health journey.
Dr. Tea 29:16
I heard a doctor say they felt like they were just the referral widget. Like they were no longer practicing medicine. They were just outsourcing and I couldn't agree more. And I think it's quite terrible what's happening. So do you think and agree that we will be changing the face of medicine through direct care. And the challenge is, how is it going to look for each specialty because you're doing it for cardiology. I'm still trying to figure it out for podiatry. We have an abundance of specialists listening to the podcast and everyone out here is just trying to solve the puzzle for their niche area. What are some key things that you would advise the doctor who is just contemplating leaving insurance
Dr. Druz 29:58
Number One, Have a plan. Number two, understand why your plan may or may not work. It is a painful exercise, because obviously everyone thinks that their idea is great. And you know, it's going to apply. But we do need to be realistic. And number three, run a little observation trial, even in the occurred practice, whether it's employed practice or private group practice, but maybe it's not cash based, or even if it is cash based, what is it that is bringing patients your way? What is it that they're looking for? Have a conversation with them to identify what their pain points are, and where you can truly improve their life by alleviating those pain points. Do not come into it with preconceived notions. I don't know if you have observed this. But initially when I started in this journey, a lot of my colleagues felt that most of my patients will be very sort of high net worth individuals, very entitled individuals that are able to come and pay cash for medical services. And I can tell you, it is 100% not true. Do I have some people who meet that definition? I do have a little bit. But the majority, surprisingly, are the exact same patients at least phenotypically that one sees in standard cardiology practices. They just think of themselves differently. And they want to find somebody who can help them to make the thinking that quest a reality. So don't despair, but analyze your situation and have a plan.
Dr. Tea 31:40
Good advice for you. How long did it take for you to feel steady and safe? Building this practice,
Dr. Druz 31:48
I'm going to say that for approximately five years in all honesty, I didn't have a very straightforward sort of straight line, because I was still very much involved at some points in the more traditional cardiology practice leadership roles. So I think if I was 100%, just focused on this practice that may have been a little shorter. But I think, you know, at a five year mark, is where I finally felt that I know what I'm doing. And, you know, and I can present it to the world with that feeling that people will just like, you know, throw stones at you and scream that you violated all the cardiology rules of engagement, like fetching, like recommending supplements, and you know, telling people that they could get away with lower dose of statin drugs and things like that said that, that takes time.
Dr. Tea 32:42
It's so funny the arguments against supplements, I just, I know where you're coming from when you're talking about functional medicine and just holistic care, wholesome care. But if we don't change, you're gonna be stuck, and you're gonna be sad, and you're gonna burn out. I think that's the lesson we'd get through this (100%) which is not what we want, we all aim to create a practice of our own. And Dr. Druz here has demonstrated that she is able to do it for cardiology. So I really appreciate your time. Thank you so much for sharing your wisdom and I look forward to talking to you again sometime in the future.