Episode 50: Dr. Erin Kiesel and Dr. RJ Heck of St. Luke's Family Practice - Modesto, CA

Direct Primary Care Doctors

Dr. Erin Kiesel earned her BS from Santa Clara University in 1994 where she graduated Cum Laude and was part of the Alpha Omega Alpha Honor Society. She then went on to earn her medical degree from Midwestern University, Chicago College of Osteopathic Medicine in 1997. She completed her family practice residency in Modesto from 1997-2000. She went on to complete a fellowship in Faculty Development at UC San Francisco from 2011-2012. In addition to being awarded the Teacher of the Year Award by the Stanislaus Health Foundation in 2012, she continues to serve as a Clinical Professor of Family Medicine at the UC Davis School of Medicine since 2000. Her special interests include pediatrics and women’s health.

She is married to George and they have four children.

Dr. RJ Heck earned his BS from the University of Arizona in 1987 where he graduated Summa Cum Laude and was awarded the President’s Award for Excellence. He continued at the University of Arizona where he earned his medical degree in 1991. Like Dr. Kiesel, he too trained in Modesto completing his family practice residency from 1991-1994 and achieved the “Excellence in Resident Research in 1994.” He has two sons and has volunteered with Liga International where they do mission trips in Mexico.

Their non-profit practice, founded by Dr. Robert Forrester and Dr. RJ Heck, St. Luke’s Family Practice is a non-profit organization in Modesto, CA that bridges the gap of healthcare. The mission statement of the practice is "To establish a self-sustaining non-profit organization for the delivery of free outpatient health care, consistent with the Catholic tradition, to uninsured persons ineligible for government programs."

St. Luke's serves by providing primary health care to two very important groups — Benefactors and Recipients.

Benefactors are individuals and families blessed with the ability to support the work of St. Luke’s Family Practice. They receive their primary care from one of the physicians at St. Luke’s Family Practice.

Recipients are those less fortunate who do not have health insurance and do not qualify for government programs. They can also obtain primary medical care without charge from St. Luke’s Family Practice.

St. Luke's Family Practice addresses two main issues:

1. The deterioration of enduring doctor-patient relationships. Many patients today feel like their doctor is too busy for them. “Service” is a tired cliché. Choices are sharply limited by insurance. Rather than focusing on your medical concerns, doctors today spend too much time on authorizations and payment. 2. There are still millions of uninsured Americans. Worse yet, millions of Americans still have no health insurance. Despite the Affordable Care Act (“ObamaCare”) tens of thousands of Stanislaus County residents have no access to primary medical care. Most are “working poor” families. One in four Californians under age 65 is without health insurance for at least part of the year.

In today's episode, Dr Kiesel and Dr. Heck share more about the day-to-day activities at St. Luke's and how the practice was created as a nonprofit back in 2004 and how it continues to serve the people of Stanislaus County in alignment with its central mission.

A New Model of Charitable Care: The Robin Hood Practice

Here is the American Academy of Family Practice article about St. Luke's practice featuring Dr. Robert Forester.

Resources mentioned by Dr. Kiesel & Dr. Heck:

- Harrison's Textbook of Internal Medicine

- Essential Evidence Plus

- EMDs EMR

- Cirugía Sin Fronteras - a surgery center for the uninsured in Bakersfield, CA

- The Gallo Foundation

- The Foster Family Foundation

CONTACT:

website: https://www.stlukesfp.org

Dr. Kiesel: drk@stlukesfp.org

Dr. Heck: drh@stlukesfp.org

TRANSCRIPT*:

Episode 50! Dr. Erin Kiesel & Dr. RJ Heck of St. Luke's Family Practice - Modesto, CA

[00:00:00] Today's episode is the 50th episode of the podcast. When I created it, I had no idea that so many folks would be tuning in which to me is a great sign that people are wanting to learn more and more about the direct primary care movement. So in celebration of DPC and our 50th episode, I'm putting out a call to the authenticity.

[00:00:24] If you are a physician in the DPC ecosystem, and haven't gotten the chance yet to share your story on the podcast, go to speak pipe.com/my DPC story and leave us a message sharing your why. What made you think or decide to do DPC? How has it been going for those of you who have already made the jump?

[00:00:43] You might hear your story in an upcoming episode now onto today's episode.

[00:00:57] Direct primary care is an [00:01:00] innovative alternative path to insurance driven healthcare. Typically patients pay their doctor a low monthly membership and in return build a lasting relationship with their doctor and have their doctor available at their fingers.

[00:01:21] direct primary care means individual attentive care with longer appointments and better access to a provider than most people have in the community. And this should be offered in some way to all patients, no matter their ability to pay. I am Dr. Aaron Kiesel and I'm Dr. RJ, heck of St. Luke's family practice.

[00:01:39] And this is our DPC story.

[00:01:47] Dr. Erin Kiesel earned her BS from Santa Clara university in 1994, where she graduated cum Loudy and was part of the alpha omega alpha honor society. She then went on to earn her medical [00:02:00] degree from Midwestern university, Chicago college of osteopathic medicine in 1997. She completed her family practice residency in Modesto, California from 1997 to 2000.

[00:02:12] And then she went on to complete a fellowship in faculty development at UC San Francisco from 2011 to 2000. In addition to being awarded the teacher of the year award by the Stanislav health foundation in 2012, she continues to serve as a clinical professor of family medicine at the UC Davis school of medicine.

[00:02:31] Since 2000, her special interests include pediatrics and women's health. She is married to George. Four children, Dr. RJ heck earned his BS from the university of Arizona in 1987, where he graduated Summa cum laude and was awarded the president's award for excellence. He continued at the university of Arizona where he earned his medical degree in 1991.

[00:02:55] And like Dr. Kiesel, he too trained in Modesto, California completing [00:03:00] his family practice residency from 1991 to 1994 and achieve the excellence in resident research. In 1994, he has two sons and his volunteered with Liga Internacional, where they do mission trips to Mexico together. They are part of the team at St.

[00:03:18] Luke's family practice and Modesto. Califia. Dr. Robert Forrester, who has recently retired and Dr. Heck opened St. Luke's in 2004.

[00:03:30] Welcome to the podcast, Dr. Kiessling. Dr. Heck, thanks for having us. I want to start by reading the mission of St Luke's and that mission. To establish a self-sustaining nonprofit organization for the delivery of free outpatient health care, consistent with the Catholic tradition to uninsured persons ineligible for government programs.

[00:03:52] Now that, with that statement, what does this mean? Or tell us about your practice. Yes. I will take [00:04:00] that one because I was around at the very beginning of it, but it's when Dr. Forester got this idea, it was really a gift of the holy spirit. And it was to take care of a small number of people who would be donors to a practice that then would allow us the time because it was just a small number of patients.

[00:04:19] It would allow us the time to take care of uninsured people. For free. And this was before the affordable care act. And so there were lots of people who were in that notch group who didn't have their own insurance. Didn't qualify for Medi-Cal. That number has dropped quite a bit with the affordable care act, but there's still a huge number, particularly in the central valley of people of human beings.

[00:04:44] Be they American citizens or not, who don't have access to healthcare. And so our goal has always been to reach them. And at the same time, take great care of a small number of people. We call them the goose that lays the golden [00:05:00] egg, the benefactors who contribute to the practice each year and keep us running.

[00:05:04] Thank you for explaining that. And on that note, can you give us a little bit of a breakdown with regards to your demographics? For the most part on our recipient side? I think we're probably in the range of about. Two thirds, Latino, maybe even closer to 70%. And of those, I would say. About a good two thirds of them are Spanish speaking only, or at least primarily on our benefactor side.

[00:05:33] Mostly people who are more affluent and older. So our uninsured side can be all ages, rarely kids, because most times kids, whether or not they have papers are eligible for some form of medication. But on the adult side of those uninsured patients, that was the demographic I was talking about with our [00:06:00] uninsured folks and for the benefactors, I would say people who are affluent and for the most part, my practice has matured more.

[00:06:09] And so all of them I think, are now. At least over the age of 40 and have kids. And I would say a huge number better than 50% of them are Medicare age and older. Can you explain to the listeners. What is a benefactor and what, is there a certain you want to do that or? Sure. So I would say a benefactor is a patient that comes to us and has the ability to pay for their care.

[00:06:36] We have an annual fee that they pay it's based on age to a certain extent it's based on how much care they need, patients that are older and that require care at home or care in a nursing facility or, or home care are going to be a little bit more expensive. But in any case, they pay an annual fee with the money that.

[00:06:54] Is leftover of what they're putting into their care. We are able to take [00:07:00] care of another subset of patients that are called recipients that are completely uninsured and are not able to pay. And for the annual fee, do the benefactors determine how much they donate to the practice as an annual fee, or there is a set fee and it's based on age.

[00:07:20] So I don't have the breakdown in front of me, but it is a set fee. So they know in advance how much they're going to pay. And as we take care of them through the year, we do keep an accounting of their visits and the time spent. And then at the end of the year, Those amounts, which are assigned a value, like an RBU value, if you will just like, as if we were billing insurance, but we don't bill insurance, that amount is subtracted off and whatever's left.

[00:07:47] The benefactor is able to write off their taxes as a donation because we are a nonprofit it's very unique in terms of how to approach it. Providing care for all in the DPC [00:08:00] umbrella, because St. Luke's has both benefactors and recipients. How do you guys get the word out in the community that you do have care for anybody who might need care?

[00:08:10] We have some different approaches for that for the recipient side. Of course. Word of mouth is, has always been on our side. Local churches know about us emergency rooms. Urgent care centers, the Medi-Cal offices where patients sign up for Medi-Cal has our information as well. We're also starting a social media campaign, which of course social media is available to anyone.

[00:08:33] And some of the local county clinics also know about us. And so when patients come in and they have they're completely uninsured, they send the patients our way. I want to go into more detail with regards to when a patient, whether they're a benefactor or a recipient. Can you walk us through how it looks in your practice when they wish to join uninsured patients?

[00:08:59] When they hear [00:09:00] about us, it used to be, we'd have them come in and see us and we'd see them the first time, no matter what their payer status. Now with COVID, we're requiring everybody to call and make an appointment, but we will see them the first time and figure out what their payer status is ahead of time.

[00:09:24] What happens? The front desk nurse asks them, do you have insurance? And if they already have Medicare or Medi-Cal. And they want to become a benefactor. We will offer them that many people to choose to do that. Others don't. If a person wants to be a benefactor, we've found that our greatest source of referrals in the past has been other benefactors.

[00:09:57] We hope or anticipate that will [00:10:00] change with our social media campaign that will reach a newer, younger demographic. Up till now, if a person expressed interest, we invited them in and scheduled them for a meet and greet appointment where they just got to sit down with the doctor and talk about the philosophy of the practice and what would be done, what could not be done and all of the details a half an hour out of our day.

[00:10:28] Is it easy in terms of selling? It's an easy payoff because most of the time, when a person can sit. Face-to-face with a doc for half an hour and get details about a practice. They love the place. That's how we approach those two. And as Dr Keezel said, marketing. We had not expended a whole lot of effort into that in the past, because our greatest source of referrals for benefactors was word of mouth.

[00:10:55] But as we were trying to ramp up as Dr. Keezel joined our practice [00:11:00] and we had a third doctor, we discovered social media is a huge untapped area that we needed to get into more. And so just toward the end of 2020, we were starting. Actually the middle, we were starting to get into tapping into that resource.

[00:11:17] And so we'll explore that further and anticipate further growth in the future. When you mentioned social media, what avenues of social media have you guys targeted so far? We've mainly just started getting a Facebook page together and Instagram have been our two, our two main platforms. We've had a little Rocky start with that and we're going to get a little help getting that going, but, but that's where we're starting basically.

[00:11:42] And when you mentioned a little help, are you guys looking to hire a person in marketing or are you guys going to organize the social media campaigns? Well, we have a, we have a consultant right now. That's helping us with that, but I think they're going to help us just launch it. But then we [00:12:00] are myself and our physician assistant is pretty good at social media type stuff.

[00:12:06] And so I think the two of us are going to try it. Do it on our own or possibly use perhaps like a college student that's interested in marketing that might just help us with just putting content up frequently to keep up with it. If we get too busy. Absolutely. And that's actually at an untapped resource that a lot of, a lot of docs don't necessarily think about if you have a community college or university or something where you can reach out to a member in the community who might be interested in.

[00:12:33] Um, having your clinic or your DPC as their quote unquote project to work on, I've seen, yeah. I've seen doctors use that successfully to develop a marketing campaign that they may or may not continue on their own after it's fully developed. That's wonderful that you guys are, are building that from the ground up and it will be interesting to see, like you're talking about the targeting, the younger population.

[00:12:57] It'll be interesting to see how [00:13:00] that impacts your guys's demo. Because with the pandemic, it's, you know, it's our way of communicating even more so than it was exactly. It's become everybody's way of communicating. Even my, my 80 year old mother now is become an expert at FaceTime and zoom. The opposite ends.

[00:13:20] I have a three-year-old who knows what FaceTime is compared to zoom. So. I, I definitely, I definitely hear you there. Is there any other way that you guys have been affected by the pandemic because you were mentioning how the way patients are scheduled is different and that's absolutely seen in a lot of clinics where you have to call rather than sit in the waiting room or you have to be screened before entering the clinic.

[00:13:47] I think that we're lucky because we enter DPC when change needs to be made. We can. Do it quickly. It's not like we have to get permission or go through a lot of rigmarole to make [00:14:00] changes. And so we were in a really good position actually to offer. We never had to close. Really. We were, we continued to offer our patients service.

[00:14:08] We've continued to through this whole pandemic and we were able to make safety changes and get our PPE. Change the way we scheduled and the flow of the clinic actually really smoothly and easily to keep the patients safe, but to be able to continue to see them, we offer testing we're out in the parking lot.

[00:14:27] Every day, swabbing people we're helping to screen. We initially we helped quite a few of the recipient patients who really didn't know what to do. A lot of them, the migrant farm workers. Yeah. And people that were coming down with COVID didn't know how to access disability benefits, and they didn't know how to get back to work and with notes.

[00:14:45] And so we were really able to help them navigate things right from the get-go. So I feel pretty lucky that because of our DPC status, we really were able to just do it the way we want it to. For those who might be early [00:15:00] on in their DPC journey in medical school or residency or exploring the world of DPC.

[00:15:06] I hope that they take that to heart, right? Because not only are your patients, I'm sure, so grateful and they are absolutely blessed to have you. In existence and to have you guys, as their doctors, but also the fact that you were able to help them navigate through things that you would never get help with in a fee for service clinic, the doctors don't have time because there's no code for, I helped a patient understand or get to a particular page to download an application.

[00:15:34] Right. So I that's incredible. And like, Everybody in this country, no matter who they are should have. I think the other advantage of a democracy is the same day scheduling module, where people are not scheduled way ahead of time. Interestingly, the pandemic has that's. Something that has changed for us is that our uninsured patients are now scheduling in advance.

[00:15:58] But previously it was [00:16:00] same day. Scheduling benefactors would rarely be scheduled out a few months, but most of the time they make an appointment for two tomorrow, today. And so we didn't, as that Kiva said, we didn't have to close, but even if we had been faced with that, we wouldn't have had to call six weeks worth of scheduled patients to, to let them know everything was delayed so that the DPC.

[00:16:24] Scheduling kind of thing is just incredibly advantageous, which is the reason I wanted to go into it in the first place was you're your own boss and it's so much easier, so much more time with each other. And so much easier in terms of the administration part. Yeah. I think a couple other things that I thought were awesome that we, we were able to get FaceTime.

[00:16:46] We have, of course we have that on our phones, but we were able to set up a station with, with Skype. To offer that to anybody recipient or benefactor that wanted to do a virtual visit. If they, or over the phone visit, they didn't want to come to [00:17:00] clinics. We were able to mobilize that we already were doing that a lot actually as well.

[00:17:04] So it wasn't hard to get that going. And I think the other nice thing has been is that both Dr. Heck and I have quite a number of patients that either are homebound or in some kind of a facility. And we have the, have the unique opportunity to be able to go in at the beginning. We were actually testing some of those patients because some of the places didn't even have testing supplies yet.

[00:17:27] But I think also just some of these people are so isolated. They haven't been able to see their families, the places around locked down and to be able to go in and see a patient and call the family and say, Hey, I saw your mom and she's okay. I saw her and I examined her and she's fine. It was really, I think that the families really appreciate it.

[00:17:46] And when in, in a regular fee for service model, if a patient is being seen in a nursing home or in a facility, they, in most cases don't know their doctor. Like you guys know your patients [00:18:00] right. With the way that your practice has pivoted with the pandemic. Do you guys maintain a limit of how many patients you take and has that changed because of that idea that we're limited in terms.

[00:18:14] The number of patients, we limit the number of benefactor patients. And primarily because they require that individual attention, they tend to be people who need more time than, than people out in the community who aren't necessarily mean somebody who's paying that kind of money to be able to have better access, wants more time with their physician.

[00:18:39] So that's the number that we seen. But on our uninsured side, we'll see as many people as we possibly can. We, for a while, actually, I remember in 2012, that right, 2012 or 13, right before affordable care started, we did 5,000 free visits that year of uninsured [00:19:00] patients. And we had two full-time doctors and.

[00:19:03] One full-time PA and another PA coming in part-time so we don't limit that except for availability. If there's a lot of benefactors scheduled on a given day, we may not have as much access for uninsured patients. But we don't necessarily limit that number. It's just, we see as many as we possibly can.

[00:19:25] When you talk about your schedule, I'm assuming that there are time slots that benefactors have to choose from how does that work for the recipients in terms of scheduling and how long are their appointments set for benefactors do have access to our portal, which allows them to schedule their own appointments.

[00:19:44] And they. Can schedule as long of an appointment as they want. Honestly, most people don't schedule. They schedule somewhere between 15 minutes and an hour, depending on what they want to come in for. Sometimes we will choose the time if they, for example, call or text and they [00:20:00] tell us what it is we guess how long they're going to need.

[00:20:02] And so most of our schedule is open for that. The recipients, we try to put them into our schedules same day, if possible, wherever there are openings. It's a similar idea. The appointments are probably 15 minutes to a half an hour, depending on what they're coming in for. And we just decide that based on what they tell us they need.

[00:20:24] Gotcha. You guys mentioned that you're using FaceTime and Skype. Do you have that running through your EMR and what are you doing, which is out of Austin, Texas, and the, we have to document in the actual electronic record. Whatever the results of an interaction with a patient are whether that's in person or a FaceTime.

[00:20:47] And of course, there's the additive. I think it's dash 95 for if you have a 9 9 2, 1 3, there's a dash 95 for tele-health, but we have to actually do the documentation in the [00:21:00] electronic one. It does the face-to-face program doesn't run through the electronic record, per se. When you mentioned the codes, is that because some patients will turn those codes into their insurances rather than you guys doing it?

[00:21:15] Or how do you use the codes? Patients codes to insurance? To get something off of their deductible, but we haven't had that in more than 10 years. I think that option was removed, but I'm not entirely sure not being well versed in insurance, but we haven't had to do that in quite a long time. So for the most part, it's only to document the number of visits and their acuity on our uninsured side to make sure that we are doing our 50%.

[00:21:48] Visits the number of benefactor visits we want to equal or exceed that on our uninsured side. And is that a goal that you guys set forth or is that a [00:22:00] goal that's helping you maintain the nonprofit rise for nonprofit status in 2003. And it's been an edict ever since we've never been audited. And now that I said that on the air, we probably will be, but nobody's ever checked into that, but we've exceeded 50%.

[00:22:18] We just, that was something from the very beginning we wanted it to be 50 50. And so we've been somewhere in the vicinity of 55, 45 for recipients, uninsured folks, since the very beginning, going back to the beginning, how did you guys become a nonprofit? I hear the, the goals and the fact that you're reaching those goals with what you put forth to become a nonprofit, but how was the process of becoming a nonprofit for you when you guys started?

[00:22:43] The IRS had never seen a mall. Like St. Luke's family practice that combined DPC concierge care as it was referred to in the early two thousands with a beneficence model so that we could consider ourselves a 5 0 [00:23:00] 1, 3 C nonprofit. And so we applied in 2003, open in 2004, and people continue to make donations with an uncertain nonprofit status.

[00:23:11] And it wasn't until the summer of 2005. When Dr. Forester and two of our early board members flew to Washington, D C sat down an IRS offices to prove to them that we were on the up and up. And there was also a Washington DC tax attorney involved in this that made that happen for us. And it was retroactive to the very beginning, but it turned out to be a pretty tough process.

[00:23:39] And then, oh, six, seven years ago, we discovered. The way we were set up in the state of California, you could not be a corporation and practice medicine, which is unique to the state of California. So we had to reorganize we're now a, I think it's a five, 10 social purpose corporation. So we still [00:24:00] have.

[00:24:00] Federal non-profit status and state non-profit status as well, but under a different guise, it's just incredible. When people used to pay their doctor with whatever they had, whether it be chickens or money or whatever. And the idea that like Amy plastic once said, California is its own nation. State is it's pretty incredible.

[00:24:23] What exists out there for DPC? The doing it yourself and billing your insurance yourself, and that kind of thing. The music part at St. Luke's is that on the uninsured side, people feel so grateful that all the time we get. Fruit and nuts and people bring in boxes of candy. We'll have our migrant workers are picking cherries and we'll have a whole box of Terry's sitting in our staff room.

[00:24:55] Everybody take a bag of cherries home by golly, because can't let those just ride. [00:25:00] Absolutely. Yeah. We have a couple of wonderful women that cook us food and bring in food all the time. Yeah, absolutely. It's the community. Yeah, that's, it's just beautiful. And when you feel a community spirit like that, I'm sure that that leads to patients being more forthcoming with you and more willing to see you for something that they might've pushed off.

[00:25:26] If it was a different yeah. The clinic setting. Yeah. I'm sometimes amazed at the distance people, people, we talked about the word of mouth thing. Coming from as far as Bakersfield, I've had a patient come from the Napa area, people hear about us and they come from a long ways to get help with that said, given that I trained in part under Dr.

[00:25:46] Castle for residency and are familiar with that population because people are coming from that distance because you offer care to anybody and everybody. Do you guys see people coming with [00:26:00] significant pathology, pathology? It's not so much the kind of stuff that, that we all saw at county, but we still see people who have ignored for a long time because they couldn't get access.

[00:26:16] And the destructive results of. Ordinary things that could be cared for that, that get neglected because of a lack of care. Long-term side effects of diabetes and high blood pressure. But occasionally you'll get one of those fascinomas walk in of somebody who got something really strange. Like I saw a woman a few weeks ago.

[00:26:39] With the third types, you come in with some lesion on her abdomen that at one point last year, we biopsied and had gotten a benign result, but it continued to grow. And we sent her down to a place in Bakersfield called . That does surgeries for cash for cheap. And she had a [00:27:00] spindle cell carcinoma. And one of those things that, yeah, I've seen maybe three of in a 30 year career comes walking in somebody who's here working and afraid doesn't want to go back to Mexico to have surgery because she knows she's not going to be able to get back across.

[00:27:13] And we were able to provide. Um, get her to somebody who could make a diagnosis and get her treated. Yeah, I would agree with that. I've seen quite a bit of pathology since I've been at St. Luke's. I think we get a lot of follow-up out of different ERs things that are maybe halfway diagnosed at an ER that we finish up, or even just things that walk in a lot of what Dr.

[00:27:33] Heck is saying that have been ignored for a long time, but also just some really interesting infections and things that you wouldn't expect. It's for sure. Contact with somebody who has leprosy was at St. Luke's. I know I had a case of scruffy, which I had never seen. Okay. I take it back. We sit great for though you guys have, uh, Googling like Madden shirt right now because of the [00:28:00] patient population in your clinic, especially those who are without insurance.

[00:28:04] How did you guys set it up? Follow up for those patients. You mentioned the surgery center down in Bakersfield, but locally, like for imaging, for labs, how do you guys get your uninsured patients care? Do you, do you have the money that is from the benefactors also paying for those types of things? Not exactly.

[00:28:26] We do have some agreements. Quest diagnostics has been extremely generous in an agreement that we have with them for very low cost labs for patients. So labs are almost never an issue that includes pap smears and biopsies like skin biopsies or endometrial biopsies that we do in the office that can be done very.

[00:28:47] Offensively for these patients. And then as far as radiology, often, our patients qualify for a charity care program through the Sutter system where they can get extremely low cost x-rays, cat scans, all that kind of thing. [00:29:00] But some of the other races offices also offer cash prices that are pretty competitive and doable.

[00:29:06] And sometimes they offer payment plans sometimes for the patients, same as some of the local specialists, we'll do a cash price for different the consultation. Certain procedures or services, I'll try to work with the patients to take care of them locally. You guys have been open for quite some time compared to some DPCs, but in Dr.

[00:29:26] Heck in 2004, when you guys opened up until now, how do you guys find those? Specialists over time that specialists profile has changed as people have moved on through retirement or moved out of the area or they become restricted because of their affiliation with a different network. Yeah. It basically what's your prior referral pattern established was try that first.

[00:29:56] And if that person's not available, then start beating [00:30:00] the bushes and see what you can find. For instance, gastroenterology for awhile, we had somebody here who was doing inexpensive colonoscopies for patients, that person stopped practicing in Modesto. And we ended up, I think it took us five or six months to find.

[00:30:16] He local practitioner who could do it for a price that was moderately affordable for our uninsured folks. So it varies in terms of other ancillary services. There was one place that we use for three or four years. That they gave us great cash prices. And then they were bought by a bigger hospital network and we couldn't use them at all for awhile.

[00:30:42] And then that hospital network established a charity arm that people can apply for qualify for, and then they get free imaging for a year. And suddenly we're back to referring to that sentence. [00:31:00] Because if we can get somebody on for a year, heck we can do the x-ray of their arm. And at the same time, do that ultrasound of their abdomen to look for the golf.

[00:31:09] It's all free. It varies with time and it depends what the local scenario looks like at the given time. I want to digress because you had previously mentioned a board of directors. Can you tell us more? So we have, since the very beginning sought people with business experience in the community, and we've always tried to have several different disciplines on the board, legal representation, accounting, or numbers, representation, somebody who's experienced with insurance.

[00:31:43] And people who have business experience and often people who've been on other non-profit boards. And so they can bring that experience to us. So I think we're in our fifth generation now [00:32:00] of a particular board members, and we've got a couple on our current board. Who've been there. Four to six years and a couple who are relatively new, but our board consists of usually five or six community people.

[00:32:16] And then Dr. Keezel is on the board. And Dr. Forester has been on the board and will continue as such under a reorganization. I'm no longer on the board. I'm the shareholder of a medical group that contracts with the board to provide care. For patients. This was part of the reorganization stuff that anyway, the, the board of directors, our community, people with business experience that have a fiduciary responsibility and make the numbers decisions, the, those determined the benefactor charges for a given year, and they'll determine the compensation for each of the employees.

[00:32:56] And they also give us advice about how to. [00:33:00] Run from a business perspective, but all of the medical decisions at St Luke's and equipment purchases are at least suggested by us. And we have permission to make purchases on our own if necessary up to a certain level. And then it has to be approved by the board for larger purchases.

[00:33:20] So that's basically the function of the board of directors. For your board members separate from Dr. Forester and Dr. Kiesel, how did you find them? There's no set was created by Dr. Forester and myself, as we were organizing and creating St. Luke's that of course was in existence before we opened our doors.

[00:33:42] It was a nonprofit and it was an existence for a full year before. The doors opened and they were just people. We talked to them about the mission to them. After that it was, uh, suggestions by board members about other board members who would be good possibilities. We'd invite them in, [00:34:00] let them experience the board meeting and see if they were interested and then seat them if.

[00:34:06] If they were interested and that's the way we've done this now the whole time, when you mentioned medical equipment, how do you guys go about getting medical equipment and supplies for your practice? A lot of our equipment initially early on was donated by some really generous community members. Now the ongoing equipment, generally we get because of donations that we receive and from generous.

[00:34:32] Either benefactors or families that are just making donations, not necessarily as patients just making a straight donation since we are a nonprofit. But in addition, we get lots of donations from patients and families of all sorts of supplies. Dr. Huck was talking about, he just had a patient come in and dropped off all sorts of.

[00:34:52] Supplies that a family member didn't need gauze and, and wound care supplies. And sometimes we'll get medications, samples, or unused [00:35:00] medications donated, or just other pieces of equipment that someone might call and say, Hey, we have an office closing. We need to get rid of all this stuff. Do you need any of these things?

[00:35:09] Do you want to come look and see what we've got? And they've been generous in that way and donating again, community, right? The generosity of this community, not just our benefactors, but. Uh, our benefactors make up about 92% of our yearly collections, but also local foundations of business. Squeezably generous over the years, the Gallo foundation and the foster family foundation and some smaller local nonprofits like Mary Stuart Rogers.

[00:35:41] The enviro tech, all kinds of people who just feel compelled to give to what they feel like is a good mission. So those monetary donations help with equipment purchases. Each year, we send out four or five letters to local boards of directors, of other nonprofits that are out [00:36:00] giving they're basically foundations, giving out money and saying.

[00:36:04] Here's some equipment we'd like to buy. And would you be willing this year? Guess what was in that a machine to test for COVID and influenza. We've also had some generosity. Some philanthropic groups in the community Soroptimists and another group called omega Nu always donate. And sometimes it's very specific for women's health.

[00:36:23] So we, there are programs in California to get women mammograms, but some people don't qualify and we always want to be able to take care of our women and get them their mammograms and their breast care and their pap smears. And so we do have a fund of money that if we can't get someone qualified on a program or they can't pay that, we never turn them away for those services.

[00:36:43] Thanks to those groups. And do you guys approach groups like Soroptimists and alpha Nu with us also sometimes we'll go speak, Dr. Keezel spoke to Soroptimists last year. Sure. And Dr. Chiesa when you spoke with sir optimist, can you give us a [00:37:00] flavor for how that went? Because if someone is listening and they are considering speaking to a community group, this might help.

[00:37:07] Yeah, they asked me to come and just tell a little bit about St Luke's. So I had the opportunity to make a little PowerPoint presentation and to give them a history of the practice and explain to them what kind of patients we serve, what our mission is, how we do it. I tried not to make the presentation too long, as inclusive as I could, but I wanted to leave a lot of time for questions because actually there were a lot of questions.

[00:37:32] About it, which allowed us to put the word out in the community about the services we do offer for the recipients, for anybody that is uninsured. But also it seems like there's a good part of our community that doesn't even know that St Luke's exists as a practice for anybody that could join as a benefactor as well.

[00:37:51] So it was an opportunity to put the DPC model out there for people. That didn't know what it was. And I like to add in kind of the DPC [00:38:00] flavor and kind of explain how it's, it's a thing that AFP recognizes it and it's growing. And it used to be called concierge or boutique practice. And I don't really like that because I think it sounds a little bougie, a little exclusive, which it's not really, it's not at all.

[00:38:15] And when I explain our model and show people what the cost is, they realize that it actually is. Something that is just for super wealthy people. Many people can, can join our practice and afford it and make it work for them. And I enjoy educating groups about this model of care, as well as letting them know that we do provide this service for the uninsured and the community.

[00:38:36] And Dr. Kiesel, what types of questions specifically were you getting from the Soroptimist group? For example? Many it is interesting for as long as the practice has been in this community, a lot of people still don't know about it. So a lot of the questions are, wow, I've never heard of this before. I can't believe you've been here this long, and I've never heard of you, but a lot of the questions have to do, can I use my insurance?

[00:39:00] [00:39:00] Do I have to have insurance? How does that all work? That's a lot of it. Is that about how the insurance situation works. People want to know about how much time can we spend with them? How do I make appointment? How can I communicate with you compared to at a big organization, which a lot of people are used to a big Sutter or Kaiser managed care organization.

[00:39:22] They want to know how it's going to be different than that. I'd say that's mostly what they have. Have you guys, as part of your, your social media marketing campaign, have you guys also thought about doing like a general video to explain those things? Yes. Videos are something that we definitely. Start doing to explain, explain the model a little bit more.

[00:39:40] You mentioned education of the community to make the community aware that you guys exist is huge, but also education of people who are potential doctors to join the movement. So with the residency being in Modesto, I want to ask how do you guys interact with the [00:40:00] residents? And do you have medical students who get exposure to St Luke's as well?

[00:40:03] Yes. So we are actually part of that. Practice management curriculum for the family medicine residency programs. So they regularly send a resident as part of the practice management rotation. To come spend some time with us, not seem not to work for us, but to just learn about the practice and the practice model.

[00:40:24] So that's where they get their first exposure of us. And then we always invite them to come spend elective time if they want to seen patients. And we've had some residents come and spend time with us. And we also do teach it in the family medicine clinic, which kind of reminds them about us when they see us and reminds them to ask about St.

[00:40:43] Luke's and then we definitely have medical students. That come from all over that rotate with us usually a month at a time. And interestingly, to get into medical school, it seems like many schools are requiring observation hours prior [00:41:00] to applicants submitting their applications. And so we've had quite a number of students reach out to us because it's difficult now to find a spot, to do that with the HIPAA laws and restrictions, a lot of offices won't take.

[00:41:13] Any kind of student that's not already in a medical school or in a residency program. So we've been able to help some undergrads and get some exposure as well. There are doctors retiring or clinics needing to expand and patients wanting and deserving this quality of care that you guys are describing.

[00:41:33] So, uh, effecting the pipeline is a huge component of making sure that the movement grows that said because you guys are interacting with undergrads, medical, students, and residents amongst others. Do you guys have any suggestions as to how the pipeline can be affected for the future of the model? I think inviting people in and giving them a positive experience.

[00:41:57] And so many people when I first got into [00:42:00] medicine were. Grousing about how medicine was changing. And here's a method that medicine is changing for the better and making sure that residents and medical students, and frankly we've even had high school students coming in, that they understand what the difference is between our practice and a regular practice and understand the advantages I advertised as DPC for the future, because it's a growing movement.

[00:42:30] It's something that. That will continue to grow in, in popularity and in abundance in the United States. Yeah, just to tag onto that, I think just us role modeling, not only the practice model, but just the lifestyle. Can be with this model where Dr. Huck and I are two pretty happy people. It's a nice lifestyle.

[00:42:50] We don't make the most money of anyone around here in this community, but, but we're happy and there's kind of a, there's just a great audience in our office. There's a [00:43:00] great spirit. There's a lot. Stir a lot of joy. There's a lot of birthday. There is. There's a lot of foods there's yes. And I just think role modeling.

[00:43:10] Good, good work-life balance for these students is another way to make the DPC movement attractive. And, um, something that their interest, you mentioned that St Luke's has become part of the family practice management curriculum. How did that happen? Because when I was in residency, we did not have that opportunity.

[00:43:30] So how did rotating in your clinic become part of the curriculum for the residents? Yeah, I think that it, a number of different practices are involved in that curriculum around the community, but now private practice has narrowed down. There's only a handful of private practices left in Modesto, I think.

[00:43:49] And I think that St Luke's was on it for a while. And then for some reason it went away. That had to do with, I think it may have had to do, do more with [00:44:00] the program and that when the numbers of residents shrunk down for a while, they were being pulled to different services so much, they just weren't getting sent over to our office.

[00:44:10] But now I think it's, we've just got it right. Set up and looped in. And Dr. Kerns, the residency director knows about us. And so she's just making sure it's on the schedule basically and making sure they come over. Dr. Ha, when you guys were starting out, did you speak to Dr. Broderick who was at the residency director prior to Dr.

[00:44:31] Kerns? Or how did you guys develop that relationship? We were both graduates of that program and of course, Peter Broderick was too. And we initially didn't have much room. We were in a, an 850 square foot office. So w we had an occasional observer, but we didn't have the room that we have now in an office that with our Mo our recent expansion, we're close to 4,000 square feet, but we were at about 2,400 [00:45:00] when we first moved into that building.

[00:45:02] And. Two extra rooms, one of which full-time PA occupied that the other was just an observational room. So we could have residents and let them observe what we do, and then let them start seeing patients. And that's why it became popular for awhile. We were not just doing family practice management rotation.

[00:45:20] Where they come in for a single day and learn about our practice. But we had a couple of times people come in and do a two week rotation through, I think even one came for four weeks. About two half days a week. Our office basically supplemented what they were doing in the family practice clinic.

[00:45:40] Because of our, just our previous relationship with that residency program. I think that's how it happened. And as Dr Keezel said, it dropped off as relationships change and leadership changed. Interestingly, I think it picked back up when Dr. Kiza was the associate director. She was the deputy director of the family practice [00:46:00] residency program for awhile.

[00:46:01] Yes. Having that connection I think has definitely helped get it going again. Let's put it that way. Yeah. I asked that because if a DPC were close by to a residency, which there are a number of DPCs that fit that category. I just, I wonder if there's any advice that you guys could give as to how to approach residency, right?

[00:46:23] Because just like how you guys have it set up, there are a number of residencies that are incorporating DPC options into their curriculum that I've learned about. Which is awesome. But for those who are just like starting a DPC from the ground up, starting a relationship with a residency, do you guys have any advice as to how a practice could develop that type of work?

[00:46:47] Well, I would say, definitely reach out to the program director or associate program director, or if there's someone that coordinates the clinical rotations. For the residency to put your name in the [00:47:00] hat type of thing, let them know about you. Let them know about your practice. Most residencies have some day or certain times where didactics are happening.

[00:47:10] And you may, they may want to request a slot to give a lecture about their DPC practice, to come over and give a lecture to the residents. And then at that time say, Hey, I'd love to have people rotate with me. Give me a call. I think practice management is part of the curriculum of all family medicine rotations.

[00:47:26] So they have to be doing some kind of practice management. And so to offer it that way, Hey, I'd like to be. Practice management, whatever experience you're offering your residents. We'd like to be part of that and just put yourself out there, contacting chief residents to get the word spread around, especially if you're willing to have residents come rotate at your practice.

[00:47:45] Going to the residents themselves is always really good. I think most places it would be really open to and would love it. If a practice was open to having the residents come and learn, and I think it's a much easier sell now. DPC [00:48:00] is a, again, a growing part of a family practice of family medicine in general, and particularly AFP is much more strongly emphasizing DPC and the DPC type of practice for us as family doctors.

[00:48:16] The value that we bring when we finish training is incredible and patients are not really aware in a lot of cases. What we offer, like you guys are saying the community is aware of your practice. Patients don't realize that we can, as well-trained family physicians take care of a lot of things, 85 to 90% of medical issues that are not life-threatening, we can manage in an outpatient clinic.

[00:48:45] Absolutely. Amen to our residency, because I felt absolutely prepared to practice in a rural environment. So thank you to our residency and thank you to you directly for that, for sure. Dr. Heck, you mentioned [00:49:00] your space and how it's developed over time and recently you guys had an expansion. So can you tell us about.

[00:49:07] Your space, how you came to be in your current space and a little bit about your role. We started in this much smaller space, but one of our board members in 2009 said, you've outgrown this place because every day we had people streaming out the door into. The lobby of this building, where there were multiple medical offices and he looked for a space that we could have the originally we thought maybe freestanding, the space we're in now is, has been a pediatrician's office.

[00:49:41] I think the buildings. There for 60 years, but we were very well blessed in that the owners of that building, let us move in and have a low-cost rent and it has increased only slightly over time. They also, interestingly that family became patients of ours [00:50:00] and we occupied with the idea that initially we'd have just those four rooms.

[00:50:06] We talked about one for Dr. Forest or NY, a PA, and then a room for residents or observers, but it became clear that we wanted to grow it and add a third doctor and Dr. Forrester and I had long sought after the services of Dr. Keyes. Who's been a talent, grew up in this community and 20 years out of residency and just a smart cookie.

[00:50:33] So anyway, we finally were able to convince her in the early part of 2018 to, to join us. And after she joined us, she occupied that fourth room. We knew immediately. We had to proceed with plans to expand. Those had actually been started in 2014. Put it on hold because at the time it was maybe a little earlier than that, [00:51:00] because the bids we got, we had collected some money and that it turned out.

[00:51:05] We couldn't proceed for a couple of reasons. By the time we were ready to proceed, the bids were. Way under, or what we had in the bank was way under what the bids turned to. And we waited a bit and sought some more community funding, but we were finally able to proceed with that starting, I think, in early 20, 19.

[00:51:29] And gosh, when did we finish that? Aaron Christmas. 2019. Yeah. So it's been through the planning of earlier board members and then the generosity of local foundation. That we were able to get the expansion part done. And then the fact that we've got the generosity of benefactors and foundations to continue, it didn't increase our rent at all our rent at the time included this floor space.

[00:51:57] And so our rent wasn't increased. [00:52:00] It just was the cost of actually doing the build out. And one of our current board members is owner and chief operating officer of a. A local construction company. They were gracious enough to help us out. So again, more generosity, usually they, this company doesn't do any builds.

[00:52:17] I think he said we re we usually don't shoot after anything under $2 million. And we were weighing under that generosity from multiple sources here in the community, made it happen. I want to turn the conversation to collaborations. Now, you guys have helped different clinics open over the years, specifically, our lady of hope in Madison, Wisconsin, and St.

[00:52:37] Joseph's primary care in Raleigh, North Carolina. I wanted to ask how did those collaborations happen? And can you give us some details as to what type of collaboration you had with them? Would those be sought information from us, primarily Dr. Forests or who had gone to. AFP and given lectures, Catholic medical association, [00:53:00] and talked about the, at the time, it was known as the Robin hood model.

[00:53:04] And then those people sought information from us about our particular type of model of KM, combining DPC with a nonprofit beneficence side. And so. Didn't charge anything, just sent them all of our paperwork and gave them all the details about how to set up with the IRS and both of those places in Madison and in Rome.

[00:53:30] Had really no trouble getting IRS approval. Do you guys have any tech or tools that you use in love that you can't go without in your car? We love our electronic medical record, the EMD system, just in general. And then we use some, I think ones that everybody uses up to date. some of the different calculators we used to buy.

[00:53:52] Harrison's the updated issue of Harrison's every three or four years. And now it's all on us. Dr. Kiesel you are [00:54:00] using essential evidence. Are you still using that? Not using it quite as much as I used to. I still have it. It's so nice because it's so inexpensive and it's also just a quick, it's like up to date, like slimmed way down and con, and I don't know.

[00:54:16] In a concise form of whatever your clinical question is. So I'm not using it as much just because I think I'm not teaching evidence-based medicine as much anymore. I should use it more. Actually. It is. It's nice. But I still love it. Good to hear because yeah, I had not known about resource prior to training with you.

[00:54:33] What advice can you guys give to people entering the DPC space? I've had students from high school on up to residency ask. Do you feel like you made the right choice? Yeah. I can't ever remember a time when I didn't want to do this. So I've been very well blessed to be able to get into family medicine, but I think DPC has been the ultimate [00:55:00] practice of family medicine.

[00:55:01] Much more time. With each patient, getting to know multiple generations of the same family, viewing all kinds of incredible pathology and feeling adequately trained to treat that it to me, DPC is the best combination of family matters. Yeah, I would totally agree with that. It allows you to practice full scope, family medicine, and to use whatever special skills or interests that you have.

[00:55:27] I think each of us in the practice has some certain things that we're particularly interested in. Dr. Heck has a bunch of things he's really good at Dr. Forrester was our derm. And I like women's health and, and we can all do that as well as everything else. And we learn from one another. I think so advice wise, I would say stay true to the profession.

[00:55:47] If that's what you're looking for is to practice full scope, family medicine. This is a great way to do it. Definitely. If you can get with some other like-minded people. That you enjoy being with all the [00:56:00] time and that you can learn from each other and work well together prepare to probably make less money.

[00:56:06] But I know that's difficult in this day and age when medical school is so expensive and there's a lot of loans afterwards, but I think if it's what you want and it's what you're passionate about, you can make it happen. So just stay true to that because I think the trade off of a happy life, it makes everything worth it.

[00:56:23] What is the best way for others to reach out to you? I would say by email addresses at St. Luke's fp.org and Dr. as Dr. K and any of those emails, we will be able to get back to you within three or four days. And that's assuming you read on a Friday and we don't see it till Monday. Otherwise it will be next day.

[00:56:49] Yeah. Thank you so much, Dr. Kiesel and Dr. Heck for joining us today. Thank you so much for having us appreciate the opportunity to talk about this

[00:57:02] [00:57:00] next week. Look forward to hearing from Dr. Jake much Dr. Christina, much Dr. Lauren Hughes and Dr. Dipti non-core as they share their stories. One year later, if you like what you heard today, please leave a review and subscribe wherever you listen to your podcasts. To for more information on this episode and much more, please visit my DPC story.com also for the latest in DBC news.

[00:57:26] Check out DPC news.com until next week. This is Mary .

*Transcript generated by AI so please excuse errors.