After working as an employed physician in a major hospital system for 8 years, Dr. Jeffrey Gold began to get increasingly frustrated with the bureaucracy of insurance-based medicine that resulted in less of his time spent on caring for his patients in the way he envisioned since he was considering medicine as a career. In 2014, he opened the first independent Direct Primary Care practice in Massachusetts – Gold Direct Care PC. Based in Salem, MA he currently cares for 700 patients and has an Internal Medicine physician partner and recently added a Family NP. He has also formed a side business called the Starseed Group LLC which hopes to have DPC doctors, benefits advisers, TPAs, and self-funded employers collaborate to build employer sponsored plans that have DPC as the “seed” of the plan with direct contracting for all other services. Dr. Gold has been intimately involved in helping other MA primary doctors escape the fee for service world and MA now has approximately 15 independent DPC physicians. He is a co-founder in both the New England DPC Alliance as well as National DPC Alliance. He also is a member of the Direct Primary Coalition. Join this conversation as he shares more of his story and what his advocacy is all about.
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DPC: Planting The Seeds To Rebuild A Care System That Works For Patients And Doctors With Dr. Jeffrey Gold
Benefits With Friends
We have an exciting topic. It is something that I talk about a lot. Unfortunately, here in New York, it is something that has been growing very rapidly. That is direct primary care. To me, direct primary care is something that can help restore the American dream. I’ve been involved in benefits for the last 30-plus years. I went along with the flow and saw how managed care changed benefits from a health insurance side. Although it was there and was happening underneath everybody’s noses, managed care significantly changed the whole landscape of how healthcare is delivered in this system. Direct primary care is a victim of that change in many ways.
My guest is Dr. Jeffrey Gold, M.D. Our topic is Planting the Seeds to Rebuild a Care System that Works for the Patient and the Doctor. In 2014, after eight years working for a major hospital system, he opened up his first independent primary care practice in Massachusetts called Gold Direct Care PC. It’s located in Salem, Massachusetts. If you are in that area, look him up.
He cares for 700 or so patients as an internal medicine physician. He also started another business called Starseed Group LLC with the hopes of having DPC doctors, benefits advisors like myself, TPAs or Third Party Administrators, and self-funded employers collaborate with primary care being at the heart of their health insurance plan. I’m going to bring Dr. Gold in now. Dr. Gold, how are you?
I’m doing well. Thanks for having me. I appreciate it.
Thank you for taking the time and joining me. I did a brief introduction of you. I know there’s a lot more. I’m going to tell you don’t hold back.
I don’t think you have to worry. You’ve got a New Yorker and a Bostonian here. I don’t think there’s going to be much holding back.
This is no slight to my colleagues that are toiling in the system and trying to do the best they can, but it is almost becoming what I call a referral list where you have so little time to practice to the extent of your training. You almost want people to ask for referrals because it’s one less person that you have to see that day in a three-page note.
Fortunately, the public makes it even harder to sell direct primary care. In their minds, they’re saying, “We’re going to do another fee or charge for the wait that we had for three weeks to get seen, for a 45-minute wait in the office, and for an 8-minute visit to be referred out. We’re going to pay extra for that.” Unfortunately, the public and employers don’t even know what primary care can do if it’s allowed to operate the way that we are trained to do it.
Seeing twenty people a day in the fee-for-service model is not primary care. It’s not care. That’s why I left. What direct primary care, the best analogy I use for laypeople for the principle behind it is getting back to using health insurance the right way. It’s like what we do with our car. We don’t pay for gasoline, oil changes, and maintenance with dings and fender benders with car insurance. We search around for the best quality and best cost, and we pay for it. God forbid, if something catastrophic happens, we have a policy to protect us against financial ruin. That’s what health insurance was supposed to be for. We’ve made healthcare very expensive by insuring all of it instead of using insurance the right way.
You say don’t hold back, so I won’t hold back. I always say I’m not anti-insurance. I’m anti-insurance for dumb shit. That is how I put it. If I can get a hemoglobin A1C blood test to screen someone for diabetes or monitor their diabetes treatment for $6, who benefits from that being billed through insurance and having a claim file? We all know the answers to who it benefits. It doesn’t benefit the doctor and the patient for sure.
What we’ve decided in the direct primary care world, and I wish I could say that I was the one that came up with this concept, but I give all the credit to Erika Bliss and Garrison Bliss out in Seattle that started this whole movement back in 2009. It is like a combination of Netflix and Costco. You pay a monthly fee. We all do it differently, but pretty much all your primary care services like visits, telehealth, in-office procedures, and communication with your doctor, everything is paid for like a gym membership or a Netflix membership. We can deliver care for an average of $75 or $80 a month.
Pricing varies around the country, depending on the cost of living. I do age-based pricing because we expect that the older patients are going to need more touchpoints. They’re a little more expensive than the kids under 21. Pretty much, it’s there. There’s no barrier to access. I always say insurance often creates more barriers than needed. We are insurance blind. We don’t build third parties, but I have people that are on Medicare. I have people with no insurance. I have people on Cadillac health plans still that want better access, better care, and better relationship. I have people on huge deductibles that are tired of going in for one visit and getting billed $400. That’s almost half a year of care to me.Insurance often creates more barriers than needed. With direct primary care, there is no barrier to access. Click To Tweet
We’re like Costco in the sense that by being a member here, we give people access to what things cost. We try to break through these walls of opacity and cause transparency. People think that the A1C test is $105 because that’s what the hospital bills insurance says when it’s $6. We pass those savings onto our patients so that when they come in, need a visit, and need labs, or an EKG, we can do all that for under $40. That is on top of the membership with the EKG included. I’m talking about lab work. We can get them care before something major happens where they’re sitting at home and worried about what this is going to cost. It’s that simple.
For the audience, what they need to understand is that this is a direct primary care doctor that doesn’t take insurance. You’re paying a flat monthly membership fee. That will vary. My daughter who works for me has the only direct primary care. It’s brick and mortar that’s, available here on Long Island. She’s a patient for it. I got sick of 10 years or more of 4 to 10-minute appointments.
I look at it this way. I love doctors. It’s the system that we’re in that makes doctors not be able to practice medicine the way that they’ve been taught and where their passion is. If this was a sport, doctors would have to have their names on their backs because you’re looking at their backs half the time. The other administrative burden on so many doctors is that they have to put in notes, records, and things like that.
If they waited until the end of the day, they would have to work another three hours. Half the time, they have their back to you. They’re typing the notes while you’re there. You got to wonder, “Are they even listening or are they just putting the dots and crossing the Ts to get to the next patient because of that fee for service-managed care?”
When you think about primary care doctors, over the years, the health insurance systems or the health insurance companies have tried a lot of different ways of reimbursing primary care doctors. It’s not for the advantage of the primary care doctor but for capitation and referrals. There were no referrals, and then all the insurance companies changed their licenses and put them back on indemnity paperwork. They sold EPO plans and PPO plans. All of that was to benefit the insurance company and eliminate the barriers. Maybe at one time, they didn’t want people to get as much treatment. They wanted to cause a situation where there was a speed bump.
It’s interesting. It was 2009. You credit Dr. Bliss for starting this type of transition before the Affordable Care Act. That changed the math. In the Affordable Care Act, there is something called the medical loss ratio, which means insurance companies profit by paying more claims. They eliminated the barriers, but they still bombarded the primary care system of healthcare and made it to make a living. You correct me if I’m wrong because I’m not a doctor. To make a living, you have to see a lot of patients under the fee-for-service system. Doctors, especially at the primary care level, are not ridiculously compensated for their work.
Probably a lot of people wouldn’t understand that. They think doctors are making so much money. The majority of the cost of healthcare and where it has changed over the last 30 years since I got involved when managed care came in is going to administrative costs and private equity. I think $0.70 on every dollar goes to administration, and $0.30 goes to care. That is a pretty ridiculous number. When you’re talking about direct primary care, that monthly fee that you’re paying to access that doctor 100% goes to that doctor. The doctor has a lot of expenses.
It could be a lot less. That’s the thing. We could probably do five shows because I can go on for hours here. That’s the biggest thing too. What people don’t understand is that when you look at a hospital-owned primary care clinic, which is where I worked, those clinics operate at a loss on a good day. They’re operating at 65% overhead because the administrative staff needs to be there to support one doctor or a nurse practitioner. What people don’t realize is the reason the system doesn’t care about that loss is that for every employed doctor or nurse practitioner they have, that person generates about $2.3 million a year downstream in referrals, testing, and where they send people. They’re fine with it.
What we do is because we don’t have to deal with the third parties and the rule makers that do nothing as far as providing value, and they just accept money, we’re able to operate at about 45% overhead. I have an office with one office person, a medical assistant, and a part-time nurse practitioner that I was able to hire. Everything is streamlined. We don’t need twenty people pushing paper around and dealing with administrative waste that the rule makers impart.
Getting back to what you were saying about the value, there are two points I want to make. Number one, primary care is very different than specialty care in most cases. I’ll give you an example. What we do should be based on a relationship. With primary care, there’s nothing sexy about it. We’re not doing high-tech procedures. It’s about establishing a relationship and a trust that you trust me as your physician to tell you what I know and also admit what I don’t know. If I don’t know something, I’ll get you to the right person who does.
When you go to get that knee replaced, it’s a transaction. It is great if your surgeon has a great bedside manner and is touchy-feely. The reality is you want your knee fixed. You want to get off the table in one piece, and you hope you never see them again. That’s the reality. That’s an insurable event. Insuring a relationship with an I instead of an E is where we’ve gone wrong.
I’ll give credit to one of my DPC colleagues in Lawrence, Kansas, Ryan Neuhofel. He came up from NeuCare. He came up with this great thought experiment that he posted on Facebook that I use all the time. He did this a couple of years ago. I’ve asked many people this. If I gave you $100 and said, “I want you to divvy it up into two pools. One for primary care and mental health and one for specialty in hospital care. How would you divvy it up?” There’s no right or wrong answer. It all depends on your family history, chronic conditions, or whatever. The reality is I have never had one patient or person that I’ve asked that question who put less than $20 towards primary care and mental health. Even if they’re going through cancer treatment, they still would at least give $20 this way.
I then ask, “If you look at the public and private payers in the US, how do they do it? How do they divide it?” It’s $0.70 on the dollar goes over here, and then we sit and wonder why we have so many problems. We put a city of all this ornate beautiful stuff on a pair of stilts and say, “Let’s see what happens,” and then wonder why the cost continues to go up. The key is you can’t build plans, in my opinion, and have a functioning system that works to protect everybody in the right way without a foundation that works and is solidified. We have the total opposite.
It’s the foundation of health. Where does that come from? The misaligned incentive is a big word these days with benefits. We’re eliminating any misaligned incentives. We’re making sure that the doctor is compensated fairly for their time. Not only that, it’s the amount of time you have. I would assume that this is at the state insurance department level maybe. That dictates the number of patients a direct primary care doctor can have versus what a typical primary care doctor might have.
My first experience is with my daughter when we signed up for Dr. Blyskal in Sayville, New York. She is a wonderful doctor. We reached out to her a couple of times. She’s pretty busy because there’s limited access. This is still not a tremendous amount of awareness. I went with my daughter for the first appointment. It was an hour appointment. We got there and walked into the office. There was nobody there. It was a closed door.
She was friendly. She came out, signed my daughter, and showed us around. She said, “This is the waiting room, but it shouldn’t be called that because no one waits. We run on time. You have 30-minute, 45-minute, or 1-hour appointments.” She brought us in. It was beautiful. I’ve never met a doctor that was under less stress than her. She spent an entire hour with my daughter and me. As part of the visit, I was there. I was witnessing it both as a dad who was so happy with the decision that we made, and then also as a benefits advisor. I’m seeing it up close and thinking, “This is what healthcare should have been.”
I’m a twin from Brooklyn, New York. Dr. Zimmerman was our doctor. He took care of the entire neighborhood. Many years ago, he was walking around Brooklyn, New York with his leather briefcase for house calls. He knocked knock on the door, “How are you doing?” It was not because he was looking. He truly cared. He knew about every single one of his patient’s health conditions.
It is part of the community. That’s where primary care belongs. We need tertiary centers to treat the bad stuff and the rare stuff. Health starts in your community. That’s what we want to try to get back to with direct primary care. We look at it like we’re taking the oldest parts of medicine that do work and that have always worked. We’re taking the technology that we have now to enhance it and make it better.Health starts in the community. That’s where primary care belongs. Click To Tweet
I don’t want to talk to some random person on Teledoc about my herpes. I have a doctor that I have a relationship with. He’s not DPC but if he went DPC, I would follow him because I trust him and feel comfortable with him. That’s what everybody should have. We want to get back to that old-school relationship-based primary care where the reality is everybody talks about population health and value-based. Who’s determining the value and who should determine the value? My personality and style may not be good for everybody, and it is not. That’s okay.
For me, it’s informing what I call the American healthcare consumer. Its employers are consumers of health insurance. When you’re buying an employer-sponsored health insurance plan, whether it’s fully insured or self-insured, you’re buying access to healthcare for your employees in theory. They wrap it in a box. They put a bow on it. They call it insurance so it’s a lot easier to think about insurance.
If you go back 30 years ago before managed care, most plans sold in this country were indemnity plans. There were no networks. There weren’t books to thumb through. Doctors were mostly independent. There were practices, partnerships, and things like that, but they weren’t part of the healthcare systems or the hospital systems. That started much more recently.
To quickly go through it in my mind as a benefits broker, and I never thought about this as it was happening. You would think, “This is awesome. Northwell and NYU, these systems are growing. They’re going to use that growth and size to the benefit of their patients.” That’s what you would think. As insurance companies are growing, you think they’re using their leverage and their patient base or their member base to get the best prices. That’s not the case.
Hospitals needed to come together because the insurance company’s discounts, which at the time were actual, were beating the hospitals up. They were accepting $0.60 on the dollar. Their investors weren’t happy. They got together and said, “We need to do something about this. These managed care companies are killing us. Let’s join together so it will be a little bit harder for them to negotiate. We’ll have some leverage.” They did that and they were successful. The largest hospital system in the country has 140 hospitals under one umbrella, but they didn’t stop there. They started merging vertically into the facilities, specialties, radiologists, labs, and urgent cares, all the way down to the primary care doctors, which were hurting.
I had a doctor. He has since retired, but he was a specialist. He wasn’t a primary care doctor, but probably the best doctor that I’ve ever been to personally under the managed care system. He would spend 45 minutes talking to you. He was a specialist. He was a gastroenterologist, but he would talk to me about my weight at the time and dieting. He was passionate about the people.
I wanted to have him on the show but COVID happened and I didn’t see him for a year or two. I went back to see him and he said, “The hospital system is in his building.” I was disappointed. I was like, “They got to him too.” I asked him about it. He said, “I hadn’t gotten a nickel more out of insurance in the past ten years. In order to make more money, I had to sign with the hospital system.” Having that logo on his building immediately got him higher fees. It shouldn’t. It should be the quality of the care. It should be that people are going to see him and he’s being compensated because he’s such a great doctor who cares about people.
When you go to see a doctor like that, you know you’re being taken care of. You’re not just there to make the doctor money. Doctors should be able to perform and be compensated for the quality of their work, not the quantity of their work. If you had to see 100 patients a day, there is no way that the quality of your work could be at the same standards that you perform today.Doctors should be able to perform and be compensated by the quality of their work, not the quantity of their work. Click To Tweet
You were in non-traditional primary care for eight years. How did you make that transition? That’s a hard transition for a doctor to make. I wanted to talk about the barrier to entry for doctors. You didn’t wake up one day and say, “I want to be a direct primary care doctor,” because that cashflow or the claims flow stops. Now it’s just “I have to have a body of patients.” How were you able to do that? How difficult was that?
It was brutal. I was on divorce and a whole bunch of stuff. People think that a lot of doctors are riding high on the hog here and golfing every Wednesday. Maybe that was the vision when I was a kid growing up, but the reality is you’re graduating with a lot of debt. We’re giving up pretty much most of our twenties to pay to go to school, train, and work to try to do the right thing. You have this idealistic vision of what you want to do. It’s a topic for another day. The way you’re educated is part and parcel of the problem. It took me a while to figure that out.
I had people that knew that I was miserable. They knew I was unhappy and depressed. They were like, “Why don’t you do concierge?” I don’t begrudge anybody doing it but you’re still billing third parties. You’re charging people a minimum of $1,500 a year that not everybody can afford. It didn’t fit with what I wanted. I knew nothing about DPC or Direct Primary Care.
In my ADD-rattled brain, for years, I was trying to figure out, “What is the way that we fixed this?” I couldn’t do it. When I heard about DPC, it was like a light bulb went off. I was like, “This is it. This is what people are already doing. This makes sense.” Someone has already formulated what my brain wasn’t capable of doing. The minute I read about it, I was like, “This is it. I got to do this.”
I traveled to Atlas MD in Wichita, Kansas, and shadowed them for a few days. I started reading more about the ACA and health policy in general. I put together a presentation to my old hospital employer to see if they wanted to pilot it with me there. They could give me 400 or 500 patients and do a study, look at outcomes, or do whatever they wanted to do. I knew it would go nowhere, but I thought it was the right thing to do. They said to me, “If we can’t do this with you, are you still planning on staying in the area as part of the system?” I said,” Yeah.” The specialist relationships I have and the hospital, I don’t want to lose any of that. It was nothing personal. I just couldn’t practice in that model anymore.
My ex-wife and I had applied to get a loan from a bank. I was going to go hang a little shingle somewhere with a small little private office and do my thing. There’s no non-compete here in Mass, but I couldn’t market to the patients I had because the message alert to patients was, “You are not the property of the doctor. You are the property of the hospital that owns the doctor.” I had to be very careful of how I did things.
One of my patients who I’ve been with for a while uses a concierge doc down in Naples, Florida when he is down there for the winter. He is then seeing me when he is back up here for the summer. He did very well in the stop-loss world. He understood how the system works and doesn’t. He said, “Why don’t you do concierge?” I said, “It’s not my thing. Have you heard of DPC?” He said, “No.” He was going to Florida. He said, “Send me a bunch of stuff to read. Don’t sign a bank loan until you talk to me first.”
He came back. That was April 14th. He sat down with my ex-wife and me. He said, “Do you guys want a line of credit with simple interest? Pay me 75% of the annual profit until you pay me back. Build my salary into the loan.” I was like, “How can I not?” I had my old family attorney look at it. I’ll never forget it. He looked at the one-page loan note and said, “If I try to get this for a client, they would laugh at me. This is the closest thing you’re going to get to a gift. This guy has faith in you. He believes in what you’re trying to do and wants to help you. Do it.”
We probably spent more money to start up than we really had to. He wanted brand-new equipment and top-of-the-line stuff. He’s like, “If you’re going to do this, you’re going to do it the right way.” I don’t regret doing that. I’m still in debt. I’m very open about my situation because I know that not everyone is going to have an Angel investor that they can go to and have a situation where they don’t have to worry about keeping their lights on if they have a month and only two people are sitting up.
Getting back to the question, I fooled myself. I was everybody’s favorite doctor until I didn’t take their insurance. I’ve written about this in blog posts and stuff. I’ve framed it in the addiction model. The worst we have in this country is health insurance as a form of payment for everything. I thought I would have lines down the street given how bad the system is of people wanting to sign up. It didn’t work that way. Out of the 3,000 patients I had, which is pretty typical for an insurance-based primary care doctor, right off the bat after 12 years, only 110 came with me. More came as time went on, and it was good. I got new patients and new blood in there.
It’s not for the faint of heart. It’s very regional. It depends on where you are. Certain state laws make certain things complicated. New York is a state that is similar to Massachusetts. It is not easy to do things innovative in healthcare without over-regulation. In places like Kansas that didn’t expand Medicaid, DPC was like a saving safety net for a lot of people that made too much money to qualify for subsidies but ran their own businesses. They didn’t make enough that they could spend $600 a month on a $3,000 deductible health plan. Massachusetts is different. It took a lot still to this day.
It is constantly working on getting people sober. The hard part is when you look at anybody who struggles with addiction as we do every day, doing what we do, they want to get better. People who smoke cigarettes know it’s not good for them. They’re not dummies. They know that. The question is do they want to go through the pain of change? It’s hard for doctors, patients, and employers. It’s hard for everybody because this is the way things have been done for so long. We have people that think they’re doing something illegal almost. It’s not illegal to pay a doctor directly nor should it be.
It’s that “set it and forget it” mentality. When you make the assumptions that most people do about your insurance companies and the healthcare system, it’s easy to think you’re in good hands. You’re like, “I’m getting the best prices. How could you get better prices than this?” I tell people all the time that I couldn’t get better prices if that was their intention. Their intention is not to drive down costs. The intention of hospital systems is to not provide the best care at an affordable rate. They answer to Wall Street. They answer to investors or the board of directors.
The real tough decisions and the masterminds that are continuously changing the rules of the game are in boardrooms and no one knows who they are. Those are the decisions. It’s, “How much money can we suck out of the American healthcare system?” They don’t care who the casualties are. They don’t care that the primary care doctors are struggling. I posted something. The top four insurers in the country had $11 billion in profit in the third quarter of 2022.
It was right after a pandemic.
Do you think anybody’s premiums went down? No. They invented medical trends. We’ll talk about insurance a little bit here for a second, but the medical trend is a word. It’s on your renewal. No one knows what it is. People think that the medical trend is that the cost of healthcare goes up by 10% every year. That’s because doctors’ prices are increasing. When they think of healthcare, they think of the practitioner. It’s not. The insurance companies are happily paying 10% more potentially, but it’s not going to the practitioner. It’s going to the facilities. It’s going to those silent partners.
Healthcare and health insurance both want your cost to go up. They don’t want the individual providers to get richer. They want their systems to get richer. They want their investors to get richer. When the indemnity plans were starting to be replaced by managed care, our average deductible at the time was about $250. They had introduced co-insurance.Insurance companies don't want the individual providers to get richer. They want their systems to get richer. Click To Tweet
There was a time when we had 100% coverage. The single rate was $54 for a 30-year-old male here in New York. How is that possible? They didn’t go to the doctor. They weren’t steering people into the system to get the highest price. That’s one of the other things. You alluded to it before. Hospital systems that employ doctors will happily lose money on running that practice, but they’re making up for it ten times as a result of the steers.
That doctor doesn’t have their say. They have to meet their quotas. It’s like the 31st of the month when the police are out there. They got blasted because they didn’t write enough tickets that month. Guess what? You’re getting a ticket even if you were going 2 miles an hour. They have to write those tickets.
As a doctor, you have to see X number of patients a day. You have fifteen minutes for lunch. You’re responsible for doing the notes. Figure out how you’re going to do that. I’m going to make an assumption here. I don’t know if it’s a percentage. Would you say that the referrals for things like MRIs, CAT scans, and Sonos are based on a quota they have to meet, or if someone needs it, make sure you refer them to our facilities that are affiliated with the hospital systems where it’s going to be billed at $5,000 and paid at $2,500? Are they sending people for tests that they know aren’t necessary simply because they know the insurance company will approve it if they put a certain diagnosis down?
Yeah. It’s multifactorial. That’s part of it. The other part of it is you’re covering your own back. When you’re seeing twenty people a day, you don’t want to miss anything. You’re much more likely to err on the side of caution, especially when you’re in a model where you have no concept of what things cost and don’t cost or what they cost where. You’re more likely to just reflexively order it.
You never get a document saying, “This is what you have to do.” In hockey, there is the informal rule book. There are rules. You don’t keep beating a guy when his head is down on the ice. There are informal rules where you know that you’re not referring out to a different hospital system to see that specialist or MRI. You probably will, if you frequently do it and hear about it.
If people only knew, there are so many horror stories that I am sitting on up here of what meetings we were told to do as far as coding, and messing with medical records, or vital signs to get your pay for performance contracts met as a group. We are then going to give you a bonus, which is a withholding return. It is money you should have been paid anyway. It’s sad. What I tell people is the key question you have to ask yourself is who do you want your doctor working for?
You want them working for the patient. To connect this with insurance, why would someone want to pay $75 for a primary care doctor when they’re already paying too much for insurance? If you’re a CEO, CFO, or HR director out there, we’re suggesting potentially. This can go in many different directions, but let’s assume you’re fully insured today.
Many employers now are holding onto gold plans. They’re paying a lot of money for gold plans because they’re thinking about the insurance. They’re thinking about potentially the out-of-pocket cost. They’re making the cost of the program to the employer and the members very expensive. You take that gold plan and switch it to a silver or a bronze plan.
You then offer direct primary care as an option where the employer could pay for it for their employees with no cost for the direct primary care doctor whatsoever. You’ve eliminated any barriers to care for that doctor. The other thing about the healthcare system is you can’t do it there. You can’t do an X-ray in your office if you’re a part of XYZ managed care company. Depending on your state, equipment, and facility, could primary care doctors take care of 80% of why people even go to the doctor? Is it more than that?
You’re not paying for that more expensive specialty care. You offer a plan. You take the premium savings between the gold and the silver or the gold and the bronze. Make it an option for employees. If you have a 200-person company, you say, “Here’s plan one,” because not everybody’s ready to take that jump. You have people that don’t even go to the doctor.
At this point, when you look at statistics, about 50% of people have no relationship with a primary care doctor. They’re using doc in the boxes. That is what I call them. Most of them, if they do have a primary care doctor, don’t even know what that doctor looks like, and vice versa.
You can’t get to the doctor when you need them. That’s the other problem. You have this direct primary care option. We’re not talking about eliminating a health insurance plan. You need something there for catastrophic situations. Most people would say, “The last time I was in the hospital was the day I was born.” Some people go three times a year. It does happen. You have this underlying health insurance plan. You have much more comprehensive primary care, which is going to help the employer eliminate a lot of the unnecessary claim spending, upcoding, all of these coding errors, and manipulations.
There are so many things that happen when you’re dealing with insurance companies because it’s business. There are a lot of inappropriate billings or incorrect billings. It’s very complex. You’re not sending a bill to the insurance company. You have your doors open. I’m assuming that maybe your practice works this way, but there can also be options for it to be virtual, email, or a quick phone call. It’s not like someone has to come. It’s unbelievable that they can come if you have a brick-and-mortar facility. You are there to take care of the people and meet them. Maybe they don’t have to miss a day’s work or wait three weeks. They have pneumonia when it was maybe a bad cold when it started. There are so many different things.
Under a fully insured model, it can help. There are so many people that are walking around with high deductible health plans and HSA plans that avoid care completely. I have a stat here. It’s 38% of employees with insurance admit to avoiding or delaying care because of their out-of-pocket cost. That’s unacceptable. More than 1 out of every 3 people with insurance isn’t getting the care. What service is your insurance providing you? That’s the barrier. It’s the insurance. It’s that upfront out-of-pocket cost. There is this other program that you’ve started, which is hoping to bring direct primary care, TPAs, stop-loss companies, advisors, and employers together. If you could talk about what that vision is that you have there.
My vision is what you touched on with this vertical integration, which we know doesn’t work. You look at the independent docs that remain left, whether a specialist or primary care that tried to do a horizontal integration. They form these independent physician groups to try to negotiate a better price, which didn’t work either because they didn’t have the clout and the power to negotiate for better reimbursements. That’s how doctors get paid. It’s getting reimbursed.
One night, I had this vision and I woke up in the middle of the night. I was like, “Shouldn’t healthcare be a wheel?” I’ve never done this. I wrote it down on a little piece of paper or a napkin or something. At the time, I had thirteen-year-old twins, a boy and a girl, and my daughter was probably nine at the time. She helped me put it into a graphic on the computer because I’m useless with that stuff.Shouldn't healthcare be a wheel? You have to have primary care at the hub, and then everything else is a spoke. Click To Tweet
You wouldn’t write laws without lawyers. Yet, here we are writing health plans without doctors. I’m not an insurance guy. I don’t want to be an insurance guy, but I want to collaborate with it. I don’t want to work for an insurance company, but I’d work with them because insurance is a key component of protecting people in healthcare. Yet, how do you design a plan this way or this way and expect it to work?
You got to have primary care. I include mental health at the hub, and then everything else is a spoke and an extension. You have your stop-loss around it. I have the diagram. I won’t show it, but for people who are interested in sitting down and working together, that’s what my hope is. We can take that diagram and customize it with all those key pieces, the TPA, PBM, and stop-loss. It is all the things that are crucial to making that wheel and that ecosystem works the right way for the client that you’re dealing with. How you work with a group of construction guys is going to be different than what you need for yoga studios. They have different needs, and that’s okay.
To me, it’s got to be DPC in the middle. I admit I’m biased. It’s what I do. I wrote an article that I got a lot of flak for from colleagues. You can go read it. It’s called Aiding and Abetting. I posted it on LinkedIn. You got to have that independent direct pay where you’re investing in that relationship and that downstream ROI, and then direct contracting on imaging. You’re using things like green imaging and medmo. There are all these other people out there, even surgeries, that are finding the best quality at the lowest cost. Cash is king. It always will be.
As Carl Schuessler always says, “Get rid of the middle.” I’ve learned so much from going to these conferences. If you asked me fifteen years ago if I’d be going to health insurance conferences, I’d laugh at you. The reality is it’s long overdue. We have to start working together because if we don’t fix this mess that we’ve all been part of creating in some way, it’s going to be pretty bad.
It’s already so bad. All indications are it’s going to get worse. I always use in my mind the visual of this net. The healthcare system is casting a net. They’re using their primary care doctors that work for the health systems to make sure that as little escapes the net as possible. Everything is being upsold into our healthcare system. The healthcare system might own an independent radiology facility, but they want you to go to the one here that’s affiliated with the hospital because they can charge or get paid. The charge is irrelevant, but they’re going to get paid four times more here.
It doesn’t matter if the patient has an insurance plan with a $10,000 family deductible. There’s no one there to help say, “Did you know you can go to this one? If you pay cash, you can get it for $500. I can get you in today. I have a relationship with this facility.” The doctor can’t do that. You have all these gag orders, which have been eliminated. That net is what’s driving up so much of the claim cost.
You have the health insurance companies that are casting a net. They want as many members as possible. They want to get all the members. They’re becoming the providers. UnitedHealthcare is the number one employer of doctors in the country. They’re the insurance. They’re also the provider. They build plans that incentivize members by lowering the upfront out-of-pocket costs to go to those insurance carrier-owned facilities. They then pay themselves not less, but more. They’re not doing it for the sake of, “Let’s drive down healthcare costs.” Everything is about. “Let’s drive up premiums. Let’s drive up claims. Let’s drive up profits.”
It’s a cost share between employees and employers. Once they understand that it’s a very ugly business but it is business, “Why don’t I throw a net out? I could get all of these claims. 80% of my claims could have been cared for at a primary care doctor setting where there’s no misalignment and no reason for that provider to upsell anything. I can even provide through the TPA.”
Let’s talk about self-insurance for a second. If you’re self-insuring and you have that direct primary care model at the hub, you know this is a fixed cost. This is a predictable cost. I’m paying $50, $75, $80, $100, or whatever it is per month per member. I know what that cost is. I’m now going to eliminate not only the other additional unnecessary specialty care and things like that.
Think about all of the medications that are prescribed by providers that also have misaligned incentives like injectable medications or specialty medications, which are big problems already. There’s more every year that are going to be entering the market. These are medications that are $10,000, $20,000, or $30,000 per month that might be 10% effective in some cases. Wouldn’t you want a doctor that knows you, knows your insurance, and says, “Maybe we could try this?” They have that relationship. They look at that patient as a whole person and understand the stress that unnecessary and costly healthcare could have on their family.
It’s insane what’s happening. Employers need to start looking at their insurance and understand that this is a huge business decision. If we don’t get off of this mouse wheel we’re on, it’s never going to stop. You can’t control the cost of your insurance when your main focus is insurance. We’re telling people all the time, “My job is to take the focus off of insurance and put it on the cost and quality of healthcare. How is your plan serving the needs of your employees and their families?” When you do that, I haven’t found a situation where you don’t end up saving money. It’s not the goal to save money. The goal is to provide the best care for your employees.
I’m very passionate about primary care. When I found out about direct primary care the first time, I went right on that DPC Mapper, Frontier, or whatever. I was like, “There aren’t any here.” I’m on the Forbes Business Council. I was on a call a few months ago. I’m in this finance group. I’m in insurance. It’s like finance, so they threw me into this group. I’m on a call. Everybody is introducing themselves and what they do. Everybody is in banking, finance, investments, and all these things.
I’m like, “This is going to be embarrassing.” I’m a health insurance advisor. People call me BOO because I’m the Benefit Optimization Officer. I stopped the meeting in its tracks. What I wasn’t expecting is they all wanted to know. They asked me, “Can you tell us what direct primary care is?” It is because they see such a shift in private equity money going into that arena. If you follow the money, you’re going to know what healthcare is going to look like in 5 to 10 years. I thought about that. I’m like, “I don’t know. Do I want private equity to be involved in that relationship again?”If you follow the money, you’re going to know what healthcare is going to look like in five to 10 years. Click To Tweet
I don’t blame them. I don’t blame urgent care for popping up all over the place. It’s a great business model for a fractured system that doesn’t work. Why wouldn’t you take an opportunity? I’m not going to sit here and say that I hope someday, I can get my investor paid off and make money too. I’m a capitalist through and through. The question is what would I do with that money? Do I need a yacht? No. Do I want a yacht? No. Do I hope that I can maybe have enough money someday to open up a DPC clinic like this that serves people that truly can’t afford it? Yes. Profit is not a bad thing. It’s what you do with it.
Even in DPC, there are bad seeds too, just like with anything. People are getting pretty quick at sniffing them out. My answer to that is no. If you look up what a Starseed is, you’ll see it’s out there. I’m a little out there too. I probably got hit in the head too many times. It’s planting seeds and nurturing this organically so that it has a root foothold in how we fix this. Bringing in more money people is not going to fix this. Everybody wants to build the new best tech platform, ChatGPT, and all that stuff. It’s not that that stuff can’t help, but no one has invested in what the real way to fix healthcare is, which is the patient-physician relationship.
When my children were going to school, we found out about these programs for STEM programs here in New York. I’m sure it’s not the only state that does this, but in New York State, if you go to a state university for science, technology, engineering, or math, and you graduate, they will pay your student loans as long as you agree to stay in the state for five years. Does something like that exist for providers? I’m thinking if you go into direct primary care and come out of medical school, as a pathway to do this, and I’m trying to find ways where this can happen, help that provider pay off those huge loans.
Science, technology, engineering, and math are great. My son is an aerospace engineer. He works for Blue Origin. Shout out to Andrew in Washington State. Can’t you find a pathway to help doctors with that financial barrier? This should not be a huge financial barrier for medical providers to get into something that’s going to be so impactful to the communities they serve.
I went to UMass Med School, which was built in the late ‘60s and early ‘70s to bring more primary care docs to Mass. One of the things they had at the time, or I think they still have, is the learning contract. It is where if you end up doing a primary care residency in the state or you go out of state for residency but come back and do five years of work in the primary care field in Massachusetts, the 2/3 of tuition that was deferred when you were there, you don’t have to pay back. There are programs out there that exist. The reality is you still have to make it appealing to do that career. Who the heck would want to do insurance-based primary care? That’s the reality.
We do have a chicken or egg problem. This is where I lean on people like you in your industry. When we come out of residency, we have no business training. You sign those employment contracts and those insurance contracts and you’re guaranteed. That is because in this addiction we have, you’re guaranteed patients. You will get paid and get busy very quickly. There are colleagues of mine and friends of mine that have done it right out of residency that have way bigger cojones than I do because I don’t know if I would’ve done it right out of residency. They’ve done it and they’ve done it well. They’ve been successful.
The best way that I can help my colleagues, and this is what the hope of a Starseed-type plan is, is to bring employer groups that want this. I can go to my colleagues and say, “Do you know that barrier that you have about your mortgage and your loans? I’ve got 400 lives waiting for you to take care of.” It’s scaling left and right. It’s growing every day, if you ever read anything by Malcolm Gladwell, to get to that tipping point where you are finally like, “This is the norm,” which is what we want. I want every American to have this. It’s that plain and simple.
I can target that point where I can go to a colleague or a resident and say, “I can guarantee you a $250,000 salary in benefits right off the bat. I can let you take care of these people and do the job that you are trained to do. I’m here to support you.” It’s going to be that organic grind, which isn’t a bad thing, but that’s where employers will say, “There’s not enough of you.” There’s the problem. How do we get enough of us? Give me a life to take care of. We have employees all over. You can drive from Maine to Alaska and have a DPC doc in almost every state. There may be some areas that are DPC-barren, but maybe we do a telehealth option. There are ways around this. Pick your heart is what it boils down to.
It comes down to awareness. I’m connecting you with him. I won’t mention his name, but one of my clients who has eight locations in Brooklyn has about 100 employees working for him. He was only vaguely familiar with what direct primary care is. He’s a pretty successful primary care quasi-specialty provider. After we get off this call, I will try to reignite that connection. I want to thank you. This is great. Is there anything else you wanted to add before we come to an end?
If you’re a benefits advisor, an employer, a doctor, or a patient, I’m always happy to talk. Reach out. The reality is this affects all of us. If it hasn’t affected you yet, it will someday. We’re all patients. We’re all humans. It’s going to take a village. It’s not going to take one Lou and one Jeff to do this. It’s going to take a village of people. Making money is not a bad thing. It is how you go about doing it and what the value you’re providing is that matters, and what you’re going to do with that money. This is our future. It’s that plain and simple.Making money is not a bad thing. How you go about doing it and what the value you're providing is what matters. Click To Tweet
You can find him on LinkedIn. We met at those conferences, so I know your passion is there. It’s a tough fight, but keep fighting it. We’re doing it on our end. I’m as blown away as you are that we’re even on this call together. Many years ago, I’m selling insurance but I didn’t think about what was happening on the healthcare side of it and how those products we were selling may or may not have been serving the people. Thank you so much. I appreciate your time. You are relaxed for a doctor.
Thanks for having me on. I can honestly say too that the other benefit of doing this type of stuff is you do get to meet people outside of your own little circle that you become friends with. You realize you are on the same mission. You’re just coming at it in different ways. I’ve met some amazing people that if I stayed at my old job, I never would’ve met. Thanks for having me on. I appreciate it.
We’re tackling it from different angles. That’s the best way to solve a problem. Thank you so much. I will talk to you soon. I appreciate you being on the show.
About Dr. Jeffrey Gold
After working as an employed physician in a major hospital system for 8 years, Dr. Gold began to get increasingly frustrated with the bureaucracy of insurance-based medicine that resulted in less of his time spent on caring for his patients in the way he envisioned since he was considering medicine as a career. In 2014, Dr. Gold opened the first independent Direct Primary Care practice in Massachusetts- Gold Direct Care PC. Based in Salem, MA he currently cares for 700 patients and has an Internal Medicine physician partner and recently added a Family NP.
He has also formed a side business called the Starseed Group LLC which hopes to have DPC doctors, benefits advisers, TPAs, and self-funded employers collaborate to build employer sponsored plans that have DPC as the “seed” of the plan with direct contracting for all other services. By doing so, more doctors can leave the system with less risk and actually practice medicine the right way all while patients and employers get the care, system navigation, cost savings, and advocacy they deserve.
In addition to growing his own practice and the DPC model, Dr. Gold has been intimately involved in helping other MA primary doctors escape the fee for service world and MA now has approximately 15 independent DPC physicians. He is a co-founder in both the New England DPC Alliance as well as National DPC Alliance. He also is a member of the Direct Primary Coalition.