Transforming Healthcare, One Relationship at a Time; Direct Primary Care Doctor
In modern healthcare, revolutionary thinkers like Dr. Garrison Bliss are pioneering a paradigm shift that prioritizes patient needs over bureaucratic mandates. The essence of this groundbreaking healthcare model is illuminated in the captivating My DPC Story Podcast episode featuring Dr. Garrison Bliss, the father of Direct Primary Care (DPC). Dr. Bliss believes that DPC is the epitome of healthcare customization, allowing patients to establish a meaningful connection with their primary care physician through a low monthly membership, significantly altering the healthcare landscape.
I. The Birth of Direct Primary Care
Dr. Garrison Bliss is at the forefront of the movement that seeks to redefine healthcare delivery. His brainchild, the DPC model, eschews the dominance of insurance companies and government mandates, advocating for a patient-centric approach that revolves around the enduring bond between patients and their physicians. By focusing on relationships, DPC addresses the inherent flaws in the prevalent insurance-driven healthcare system, making healthcare more affordable, responsive, and compassionate.
II. The Economic Artistry of DPC
Economic survival is at the core of primary care sustainability, and Dr. Bliss has ingeniously interwoven this element into the fabric of the DPC model. By steering clear of the financially precarious insurance-driven model, DPC practitioners are endowed with the gift of time – time to delve deeper into patient concerns, proactively address health issues, and foster a healthcare sanctuary that embodies trust and reliability. The monthly fee model ensures that financial barriers do not impede access to quality care, mirroring the authentic ethos of healthcare that embraces all without discrimination.
III. Ethos of Patient Control and Commitment
Central to the DPC model is the prevalence of patient control, a concept championed by Dr. Bliss as a fundamental tenet of personalized patient care. Patients enjoy the autonomy to choose and retain their primary care physician, creating an environment where their health concerns are heard, valued, and addressed with unwavering dedication. Dr. Bliss has reshaped the healthcare narrative, emphasizing that genuine care and compassion form the bedrock of DPC, transcending the sheer dynamics of a business model.
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IV. Bridging the Divide: Engaging Employers and Brokers
In his discourse, Dr. Bliss spotlights the symbiotic relationship between DPC and employers, underscoring the significant impact of DPC in augmenting employee well-being while bolstering the financial health of employers. By facilitating direct engagement with self-insured employers, Dr. Bliss seeks to illuminate the virtues of DPC and its potential to catalyze transformative change in the organizational healthcare milieu. This endeavor is guided by the noble aspiration to illuminate the intrinsic benefits of DPC to a wider audience, igniting a collective shift towards a more rewarding and sustainable healthcare ecosystem.
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V. Shaping the Future: A Call to Action
Dr. Garrison Bliss articulates a compelling vision for the future of healthcare, one that champions a cultural metamorphosis, fostering a generous healthcare sandbox that accommodates everyone. His call to action resonates with an ethos of empathy and inclusion, inviting stakeholders to contribute to the evolution of DPC, for the collective betterment of healthcare.
Conclusion:
Dr. Garrison Bliss' esteemed voice in healthcare is a manifesto of hope and progress, epitomizing the enduring power of innovation and compassion in healthcare revitalization. His strides toward making DPC a ubiquitous healthcare oasis are engraved in the essence of his unwavering commitment to patient-driven care. Through his advocacy and pioneering spirit, Dr. Bliss has sown the seeds of a transformative healthcare narrative, one that prioritizes relationships, care, and accessibility, embodying the soulful essence of the DPC model.
See Dr. Bliss share more of his story here:
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TRANSCRIPT
Dr. Maryal Concepcion [00:00:01]:
As we start this new year with new hopes and ambitions, I wanted to bring an interview that can impact anyone anywhere on their direct primary care or direct care journey. Whether this is your first time hearing doctor Bliss speak or not, hearing the man who is considered by most to be the father of DPC, speak about the movement is definitely something to get inspired by. Now onto the episode. Direct primary care is an innovative alternative path to insurance driven health care. 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 fingertips.
Dr. Garrison Bliss [00:00:55]:
For me, DPC is a charmingly simple tool that changes the center of gravity in health care From the needs of governments, hospitals, nursing homes, pharmaceutical companies, medical professionals, and bankers, to the needs of patients by building a new playing field on which patients decide what their needs are and what they find valuable. For Americans, this has the additional potential benefit of being a high functioning marketplace with the expected outcomes of higher quality, lower price, easier access, consumer responsiveness, and easy adaptability to uncorrupted lower cost government subsidies for the poor and chronically ill with minimal regulations required. Think food stamps for health care. Insulating chronic care and routine health care from perhaps the worst idea in the history of health care. Health insurance as a substitute for universal health care. It also accomplishes the quintuple aim, happier patients, happier doctors, lower costs, better health outcomes and consumer driven regulation. Not bad for something so simple. For me, DPC is the antidote for a substantial portion of the disorders of the American health care system and a savior for primary and chronic health care.
Dr. Garrison Bliss [00:02:22]:
I am Garrison Bliss, and this is my DPC story.
Dr. Maryal Concepcion [00:02:33]:
Doctor Bliss attended undergrad at Harvard college where he studied both philosophy and biology. He then earned his MD from the University of Utah and and then completed his internal medicine internship year and residency at the University of Washington. After his training, he went into private practice and never looked look to back. Welcome to the podcast
Dr. Garrison Bliss [00:02:57]:
Well, thank you. It is a delight to get a chance to talk to you.
Dr. Maryal Concepcion [00:03:01]:
You've described your journey in DPC as a transformative one. Can you share more about this transformation and how it led to thoughts on fixing something that to many seems
Dr. Garrison Bliss [00:03:12]:
This is obviously stuff that I've been thinking about for a very long time, probably Over 40 years. I think that it it the the discovery that the business model might be a problem, it took a while understand. And it would even it will took a longer time still for me to see how it had affected me. We're running a a practice in Seattle with with, 3 other internists and and, you know, seeing patients and charging insurance companies. I mean, insurance was insurance for for the payment of everything was pretty new in 1980, and the idea that you would had a relationship with a bunch of insurance companies, that that would that's where your money was gonna come from. It took us a while to sort of figure out that insurance was an an interesting way of paying for things, because there seemed to be a lot of money Made available and also there was no way for them to understand what patients actually needed or wanted And they never communicated with patients to find out whether they got what they were looking for. They just pay bills. It was like a bank that you just send up a bill and they sent you a check.
Dr. Garrison Bliss [00:04:21]:
And that began to affect health care seriously, from my point of view, probably in the early eighties. And I began to see this under our own practices We were we were just then beginning to experiment with this bizarre concept of proactivity And we're saying, well, what if we saw people every year? What if we, brought them in and we did, you know, we saw them and examined them and Did all of our medical stuff at what? Through in a chest x-ray, because you'd get paid as much for the chest x-ray as you did for the whole hour of working with them. We'll do an electrocardiogram. We don't know how useful that's gonna be, but, you know, we're just being thorough, and that all makes sense. And pretty soon, we began to act the way the entire health care system has started to act even then and has really taken to new heights, In, in the ensuing 35 years, which is incredible increases in cost while everyone is thorough And while everyone, documents their thermometers. And eventually, you discover that you're actually not working for people. You're working for an insurance company, and you're doing what they would they like you to do. They they want you to write a note of a certain kind.
Dr. Garrison Bliss [00:05:30]:
They wanna have. If if you wanna get paid more, you do a review of systems whether or not you need it or it makes any sense, and you might do a little more lab than you used to do it a little bit. You might do an EKG on everybody who feels any chest discomfort at all, and you might wanna do a chest x-ray on anybody who's a little rep, etcetera. All of these things begin to add up. And then when you get to the hospital lever level, it's crazy, because there's a lot of expensive stuff they can do. You can go that's not unusual. Go to a merchant and spend $20,000 because you have a cold and you feel a little short of breath. It seems like a a an a gigantic amount of money for that concept.
Dr. Garrison Bliss [00:06:07]:
So, you know, I I I was looking at this problem expensive care, but also not very good care, which is calling it become the hallmark of the United States of America, not to be too negative about that. I mean, if there's Enormous amounts of goodwill. Doctors are working really hard. And right now, in the COVID epidemic, they are they are taking huge risks to take care of people. But the underlying business model of health care is driving lots of behaviors that we do not need. So It it gradually became clearer and clearer that that we had to do something different as a business for two reasons. One of it was driving us to do all kinds of unnecessary stuff, And we began to realize that. But the other one was that our economic survival was actually gonna be affected.
Dr. Garrison Bliss [00:06:56]:
Because as the insurance companies discovered that that they were being basically pillaged and and stolen from by the medical community, They decided to fight back. The and the way they fought back, in part, was to pay primary care people less, because it was harder to to do it was easier to do that than it was to to tell a cardiologist they can't, put they can't put in a stent, and they would get a lot less pushback when they did stuff like that. So Primary care started to be this high turnover, rapid, frenzy like care. People running up and down the halls, seeing a patient every 10 minutes, a little bit like ENT is now, ophthalmology is now. They started to hire a bunch of people to do our work so that we could the doctor could do more, you know, challenging things. But we were the reason you needed all that was because we were busily mining insurance companies And the thing I was longing for was A place where a person, a primary care, provider, physician, nurse practitioner, Physician's assistant where where someone who's doing the work of primary care would have that enough time To do the part of it that I felt was the most important, which is to spend time with people, to get to know them, to develop a relationship with them that would be useful not only while they're well, but later when when you really have tough stuff to treat And you need somebody who you need somebody you can trust to come to. So I thought that the building of that relationship was important over time. And and I also felt that it would be extremely important to create a system which would support primary care, through good times and bad.
Dr. Garrison Bliss [00:08:51]:
And Direct Primary Care has shown its ability to do that in the toughest of times, which is the last year during COVID. This is The kind of primary care that had the least concern about survival because they work for patients directly. They were paid by patients, And the patients weren't about to drop their primary care just because, we were in a pandemic. In fact, they were just the opposite. The primary care became extremely useful because, the rest of the health care was simply disabled. And everything was was pushed into intensive care units and urgent care COVID treatment and every and all of those issues, but the underlying structure of health care was really challenged. And, yeah, and and I think has done quite well all things considered, but it certainly could have been better had we had a different business model. So anyway, as I was looking for a way to evolve a kind of health care that made better sense to me, it seemed apparent that one of the things that I needed to do was create a model that would pay you when people are sick and when they're well.
Dr. Garrison Bliss [00:09:53]:
And it would pay you roughly the same amount Because primary care is a kind of health care that is has a fixed cost. Under the underlying cost is The the what it costs to pay the physician and the support support staff and the and also the facility itself. Almost no variable costs involved in this business. And if you had a certain solid cash flow on a monthly basis, you would be able To be there when they actually needed you. And particularly, if it was a large enough cash flow so that you could have smaller panels, so that you could Extend the amount of time you spend with people when things start getting rough. You could have excess capacity that would allow you to take care of people who are in trouble, and you could get PC get people into the office early the next same or next day if they were really sick. So The only question was how to do that in the in the simplest way possible. And a monthly fee seems like a very sensible way to do it.
Dr. Garrison Bliss [00:10:59]:
Very few people don't want to practice the way a direct primary care doctor practices, with a reasonable sized panel, with enough time with every patient, With, the patient as their only driver, that they don't work for anybody else. They don't have the confusion of insurance companies. They don't have the confusion of the, you know, the Government mandated reporting systems. They don't have all of that stuff weighing upon them. So their lives are cleaner and simpler. And, also, they freed up a bucket of time and money by not doing that. So everybody wants that, But a lot of people are afraid of it, and they're afraid of what my people might say, or they are afraid that that if everybody did it, we wouldn't have enough doctors. But if if that's really true, then we don't have enough doctors because that's what it will take to have a great system.
Dr. Garrison Bliss [00:11:58]:
You can't give to someone 30 patients a day and expect them to do something miraculous or even something that they can enjoy or feel good about or, They'll have some, you know, capacity to take care of unexpected things that come up. You know, if you can do the same thing and you and you can do it in the fee for service world, fine Go for it. This is not maybe this isn't for you, but contemplating the ideal of optimizing primary care And making lots more of us as a consequence, making it a fun thing to do, something that makes you enough money so that you don't have to Figure out what other day job you're gonna take, and also to get all of that weight off of you so that you can focus on patients. That's the point. And if we can get that all across to people and why the other elements, why are we doing a monthly fee, and why is the patient paying it? Or somebody who Yeah. Who or why are we allowing other people to pay it when the patient can't afford it? You know? And how does that How does that disrupt the model and what way is that a bad thing or a good thing? You know, I come from a family where, you know, people do bizarre stuff. I just, You know, my my mother was the head of Planned Parenthood and the League of Women Voters in Salt Lake City, Utah. And my great great grandfather was an abolitionist.
Dr. Garrison Bliss [00:13:14]:
So we have permission in my family to actually try to solve problems that are not soluble. So it was it it it's fun to To realize that people have been fighting for, justice. We we didn't invent the concept, and we didn't invent even the words, And, and he's one of the, you know, he wrote a he wrote a newspaper in Boston for 40 years called The Liberator. And, you know, he was almost lynched On multiple occasions that they actually had to lock him in jail to protect him from crowds. So he was doing harder stuff than I ever tried to do. But it it's, You know, there have been people who are crazy enough to look as if, they're up to that job of fixing something that's Simply unfixable, which is human nature and and, awfulness, of human behavior. But also, there's also the other side, which is Delightful to see and and and if you can draw on that, that's really the antidote for the disease. And also being cognizant of the gradual Failure of primary care as a business.
Dr. Garrison Bliss [00:14:22]:
Those are you know, the the the there were lot there are lots of forces at play for me.
Dr. Maryal Concepcion [00:14:27]:
After being on call for your patients for 40 years, you decided to retire from clinical practice. What drove this decision, and how have you felt about retirement?
Dr. Garrison Bliss [00:14:37]:
I didn't think I would be doing as good a job of it as I got older and older at this point. So I'm I'm happy to spend some time with my wife and to control my life a little bit more, But I I am not I am not disengaged. You just get you get to have what you get to have, and you get to do what you get to do. And sometimes you feel like a success, and sometimes you feel like a failure. But it's much nicer to know what road you're on than it is to have no idea or to be just unhappy About the fact that things aren't the way they're supposed to be in some in some ideal universe that you don't belong to. So I I much prefer to to look at What there is to do and then to say, well, I'll just start, and then we'll see what happened. And a lot happened on this start. So I was I was delighted, and part of it is not being willing to quit.
Dr. Maryal Concepcion [00:15:26]:
Prior to today's interview, you had wanted to share 7 points about DPC. Our eager minds are open and waiting
Dr. Garrison Bliss [00:15:34]:
Number 1, this is a movement about a culture of care and service Much more than about being a business model. That is to say that the business model is not what is important here. It is the kind of care that's delivered, the kind of service that is accessible because of the business model. The kind of that kind of of care and service, which is largely destroyed by our current business model, which is driving people to see 30 people a day To break even and pay their staff and make it all work. The point of the business model is not that this is the best business model. This is a very simple market design Really, that's really all it is that has the advantages of markets in it it which is that you have a customer Right? When it comes to business models for primary care, there's probably a lot of different ways to do this, and they're all happening right now. I mean, all the ones anybody's thought of are probably are already happening, probably. I don't know all of them.
Dr. Garrison Bliss [00:16:34]:
But every time I meet somebody, they've got a different variation. And that's evidence That that the point of this, which was not to create a business model that everyone had to do or they weren't real, The point of this was to say, understand the philosophy. Understand the point. Understand what we're trying to accomplish here And understand what we're not trying to accomplish. And once you understand that, then go build something that works and works in your neighborhood for the patients you take care of and for you and for your staff and do the right thing and know what you mean by that. Number 2, The success of the model requires that patients control the hiring and firing of their of their primary care No matter who pays for that care in the 1st place. So it became clear early on that only a small percentage of people have extra income to play with, in terms of hiring a monthly fee primary care doctor if they're paying for massively expensive insurance in the 1st place. So, we had to look at at at figuring out a way to involve the current payers, for health care, which are maybe insurance can insurance pay, government, but also our our employers.
Dr. Garrison Bliss [00:17:53]:
And, to a way to engage employers so that they can support primary care on behalf of the of their employees. There may be some imperfection to that, that there there's debates within our movement about that issue. But If you want to engage a 100% of America or even more than 10% of America with this business model, you have to have a way to to devise enough, resources so that primary care is well supported and independent. So the doctors don't need to know that they work specifically for the patient. But if the patient can't fire them on the at the drop of a hat, then there's no accountability. And I think that that's important. We need to be to work at the At the pleasure of our patients. And that's a one aspect of market systems that would drive a lot of The care that we want and the access that we want and because these are things that patients want.
Dr. Garrison Bliss [00:18:50]:
These are not things that insurance pay insurance companies care about. So number 3 is the point of the monthly fee is that it provides a consistent cash flow and allows us to do the thing that is important, which is to be available all the time. That is not not me individually, but my group so that you can call at any time of the day or night, 365 days a year. So that that's why the But The The The is useful because we don't have to be have a bunch of sick people to make this work, And we don't have to make them sick or pretend that that that the important thing is to maximize the number of diagnoses so that we can maximize our income. I I want no kind of extra incentives to create the The medical mess that is part of America right now. I I so this this system with a with a a reasonable solid monthly fee, creates smaller panels, and, and stops rewarding overtreatment, overdiagnosis, over evaluation, and overpricing. Number 4, the importance of avoiding fee for service incentives is to obliterate the idea that PCPs can make more money by doing or not doing something to patients if you add fee for service to that if you which is part of the concierge movement of the united states Then you have left the fee for service incentives intact, and that will definitely tank what you do and how much you do And how many gadgets you have in your office and how much extra money you make, is another cash flow source. And it separates you From your patients, and it makes it affects their ability to trust you in terms of what motivates you.
Dr. Garrison Bliss [00:20:35]:
My my background in college with philosophy For the 1st 2 years before I went to biology so I could be pre med. And so for me, the Ethical infrastructure is the is the only thing that you shouldn't can't compromise. And if you do compromise it, you should Compromise it as minimally as possible because anybody who knows anything real about about, ethics knows that there there aren't just one set of rights and wrongs, and it is an order of it that everybody knows and understands and agrees with When it comes to what you know, what's right? Well, is it take good right that I make enough money to take care of my family? You bet Is it right that I take that I I have a price that people can afford so they can see me? Yeah. And, you know, there may be a limit in terms of of how your business has to function so that you can actually be there for people. So you can't just charge 0. It doesn't work. And if active you if you judge and that when you take insurance, you're taking somebody else's money. And that has that that makes it easier in some respects for people to get access to you, but it doesn't because you have to see so many people because of the way insurance pays you that you actually compromise your care every day.
Dr. Garrison Bliss [00:21:46]:
So the this is this is the, you know, where the rubber meets the road of of medical care. Absolutely. When we decided to pay cardiologists 3 times what we pay primary care doctors. That was a good thing for cardiology, but it may not have been a good thing for patients because primary care has a very, very important role to play in health care. It's not as sexy and cool, but it actually probably saves more lives and it prevents more need for cardiologists. What we've done by by making this a commodity is to artificially affect what prime what care looks like, Because we're not all on the same project. Specialists are on their special project with their special patients. The primary care people are on their primary care project with their primary care patients.
Dr. Garrison Bliss [00:22:33]:
But the overarching point of all of this is not for us to practice medicine in in the way it says to do it in the in the textbook. We're supposed to be producing healthier people. Mhmm. We're supposed to be producing people who are autonomous, who can take care of themselves to a large extent. We are trying to not indoctrinate people in such a way that we make more money. So it is because it it's very when when this is this is where the discussion of incentives is so important. You can say that you don't pay attention to the incentives, But you do. It it completely shapes your life, and it shapes your relationship with your patients in a real way, which is what people discover when they go on direct primary care for real.
Dr. Maryal Concepcion [00:23:17]:
No. I I remember Neil Douglas once said to me, he he I was so good at coding. I was so good at it. And then I I sat there thinking about how I was trying to listen to my patient, but in the back of my head, I was no. That's definitely a 99214. If I talk to them a little bit longer, I can go up to 99215 and how he hated that dichotomy seems to be. Yeah.
Dr. Garrison Bliss [00:23:37]:
Oh, I should do a review of systems here. I can increase my money. And and in my time, before we always all that subtlety about it, It was maybe we should do a chest X-ray with every physical exam. We would just be more thorough, and we get paid twice as much.
Dr. Maryal Concepcion [00:23:50]:
And that strategy of Slowly incentivizing medicine in the wrong way is really ingrained in patients' minds still to this day. But aren't you going to check my UA and my chest X-ray for my annual physical?
Dr. Garrison Bliss [00:24:05]:
Because there's no reason why There's a reason not to do it. That's the and and the question is, do we even know that? What do we know and what are we making up? Because it's when you know what you're gonna do, what your business looks like, It's easier to say this is all necessary. And I I was very much a part of this evolution because when I when I started as a resident. When I finished medical school, proactivity was an idea. We all sort of thought that being proactive was a good idea. We really should investigate that. But we were still just treating diseases. That's all we were doing.
Dr. Garrison Bliss [00:24:41]:
And when when proactivity started to be a thing, We all assumed that all that stuff we've been doing, we we should just do it for everybody and then that would be proactive. And, You know, and we and, you know, we should do the labs every time we see a person for their annual exam, which we invented, essentially, at that point. And they wait. Look. Maybe that's just a trick, Tracy. Because every once in a while, it shows something shows up, and it makes us look good, And it gives them a new problem to go on their problem list, and then we've we've we've prevented something. Well, no. Maybe we created another problem, And now we know how much of a problem we created, and there's plenty of examples of that now.
Dr. Garrison Bliss [00:25:20]:
Number 5, primary care must be independent. So this is the hard one for a lot of people, to avoid being pulled back into the fee for service game by being owned and controlled by insurers, specialty clinics and hospitals, which all benefit from overutilization, overreferral, etcetera. So That primary care was, 10, 15 years ago, almost entirely independent, And now it is more than half of it is is owned by hospitals, specialty clinics, and other entities that make their money by having us refer within the system.
Dr. Maryal Concepcion [00:26:00]:
How does this model allow people to leave fee for service?
Dr. Garrison Bliss [00:26:03]:
There are many variations. This is you know, we're starting this process. We are inventing their this, and there there may be better ideas that come along or for different circumstances. You may wanna do something different. There are people who are doing practices which Start in half you know, in mostly fee for service, and then they start adding a group of people who are paying for it by the month. And they gradually increase the monthly fee people, and then they'll eventually, as they get a big enough practice, they will cut back on On certain insurance companies until they're down to an all pry an all DPC practice. That's a way to do this with less risk. So that's the way they did in Colorado With NextEra.
Dr. Garrison Bliss [00:26:44]:
When I talked to Clint this is a long time ago now. Like, I don't know, 8, 10 years ago. I I met with him and, In Denver, we I I was I was talking at a conference there and, and that's where he was based. So he took me out to dinner, and we talked about all this stuff, and he said he was gonna you know, he'd been doing fee for service, but he really, really wanted to, like, make his way over to direct primary care. But he was un he was uncomfortable with the idea of just, you know, dropping a bunch of people so he could do it. And I said, fine. You know? Do do what you wanna do. Do what feels right to you and and and also but make sure you get where you're going, eventually.
Dr. Garrison Bliss [00:27:22]:
Make sure you've designed a practice that That, you know, you can take care of lots of people and do it the way it ought to be done. And he's done that. Number 6, by competing for a patient allegiance, We can use market forces to increase access, patient experience, patient, physician satisfaction and continuous innovation. That's, I think, really important. So once the patient can hire and fire you, then we are competing as independent physicians for their business. And what that means is for things that they want and need, and it also means, it also means that, that we are have the possibility of doing something really beneficial for people, which is what most of us want in the 1st place That's what we get set. That's what satisfies us and our inability to do that is what makes us extremely unhappy, which causes what we call burnout, but which is really an enormous anger at ourselves for being willing to play in that in that system Number 7, when the above design is brought to fruition, the net effect has always been happy patients, happy doctors, Stable, sustainable income, modestly increased PCP income, dramatic increases in innovation, markedly decreased overall cost of care, overdiagnosis, and overtreatment. This automatically begins the process of rebalancing the medical ecosystem to improve outcomes, control or utilization, and improve the lives of everyone in the ecosystem.
Dr. Garrison Bliss [00:28:56]:
So that's the other thing about this system is that one of the things that that primary care doctors get in the middle of with this system is managing the rest of health care, of getting their patients to to doctors who provide great care, specialists, hospitals, To places where they won't well, won't get fleeced, places that aren't insurance mills, and also by by Acting as their advocate within those systems.
Dr. Maryal Concepcion [00:29:26]:
I have become a huge fan of podcasts. Ever since Sarah Koenig hosted the 1st season of Serial, I was hooked. Now creating this podcast has become part of my daily life. While it is an exciting new hobby, I also see it as a privilege that I get to interview so many DPC and direct care doctors. If you're interested in starting a podcast, Let me tell you a little bit about Anchor. First of all, it's free. There are creation tools that allow you to record and edit your podcast right from your phone or computer. Anchor will distribute your podcast for you so it can be heard on Spotify, Apple Podcasts, and many more.
Dr. Maryal Concepcion [00:30:03]:
You can make money from your podcast well with no minimum listenership. It's basically everything you need to make a podcast all in one place. Download the free Anchor app or go to anchor.fm to get started. Can you touch on the idea that a rising tide floats all boats and how we can come together as a community to promote those 7 points going into the future.
Dr. Garrison Bliss [00:30:29]:
Well, what we're trying to do is really to correct and imbalance in health care that was created by a fee for service system, which massively over would massively valued specialty care hospital care surgical care invasive care expensive treatments and drugs and way undervalued the less expensive and more patient centric and more long term care. And we have to fix that Imbalance. And that will be a painful process. But one of the thing but all you have to do is to create excellent primary care And that begins to offload the rest of the healthcare system magically. And I've certainly seen that, both in my own practice, but also in the the scalable versions of direct private care that I've tried to put up in the over the years Where where we could demonstrate, 20 to 40% reductions in the cost of health care, Massive reductions in the number of surgeries required without any apparent loss to the patient and With reduced lab costs, reduced x-ray costs, with, less imaging. So better results, Happier patients, much happier primary care people, and and a stable ecosystem of health care. So we know this can happen, and it and and the the the scaled versions of primary of direct primary care are all doing the same thing and producing very similar kinds of data that our our system our American health care system is Out of balance. And and so I'm trying to rebalance it, but to rebalance it not by making primary care doctors slaves and and and, and handcuffing them to an or in the in this in the in the slave ship.
Dr. Garrison Bliss [00:32:29]:
I'm trying to create a system which we more people will wanna do primary care. They will have an adequate, although no not exorbitant income, hopefully. They will they will be able to take care of their families and their kids get to go to college, and they will have plenty of time with patients so that they will have a rewarding life. And if you do that, then we can get up to the magic 50% primary care number, which is a number that was arrived at a long time ago by some wonderful research. But it's around the 5050 kind of balance. And once that's done, then The specialty care people, you know, so you so you don't have a big specialty clinic that's got primary care people seeing 30, 40 people a day And everybody with a cough sees a pulmonary doctor, and everybody with any kind of chest discomfort sees the cardiologist, and gets a cath and, you know, all of that stuff, which is emblematic of the American health care system. And at the same time, the cost of everything goes down and we start to have the right number of primary care people, the right number specialty care people. And we then get to start to the thought thinking about the concept of how can we marry this whole thing together In a in a high functioning health care system, which met that which does the right thing As as close to all the time as possible.
Dr. Garrison Bliss [00:33:48]:
John, I'm very excited about DPC as being the initial icebreaker To get us to moving toward that that goal.
Dr. Maryal Concepcion [00:33:57]:
When you mention that goal of 50% or more primary care, do you have any thoughts on how we can affect the pipeline of medical students and residents to join the movement and to promote primary care as a specialty.
Dr. Garrison Bliss [00:34:13]:
Well, I mean, there there there are so many things that that we should be doing, but, I I think if you the way to engage medical students in primary care is, first of all, to have primary care practices that are ongoing that they go and visit and say, boy, these are happy people. Everybody's happy. The patients love it. The doctors love it. I wanna do that. That's first. The second thing is that you you can't have a system in which you can earn 5 times as much money, doing doing specialty work or 3 times as much money doing specialty work, and then and then Try to talk people in doing primary care because it's it's valuable to patients, but, but they're turning down A lot of money. So incentives matter.
Dr. Garrison Bliss [00:35:05]:
And and, and if you get to do something cool and sexy, and, oh, and massively overpriced, then that You can be you can you know, you can feel bad about the fact you're not doing primary care even though you love to kinda be in a room with patients. But at the same time, it's a practical matter. You got a family and and you want your you you wanna be able to send your kids to to a good schools and whatever that is. Oh, you wanna have a better house. Those forces are at play all the time right now in the selection of specialty. And, also, there aren't there aren't as many programs in primary care as there as there ought to be because there's not that much interest and because people, You know? And, also, if you wanna go on to primary care, there's somebody in your training program who's gonna say to you, oh, come on. You could do something better. You could do more than that.
Dr. Garrison Bliss [00:36:00]:
You're really one of our top students. What what you you could be you could be an invasive cardiologist. You could do that. And the answer is, yeah, I could, but why would I? I can do something that's more meaningful that I really enjoy and that may have much greater impact on on whether pay whether The citizens of this country are healthy or sick. So catching it after the fact is not an accomplishment. These are important issues and it's not to say that, I mean, we need all of it, but we need to have some kind of way of of normalizing this in such a way that we actually optimize the the care. And and we should be able to prove it when we do it. And that's what DPC has been, you know, slaving away to do even even in its kind of underfunded phase.
Dr. Garrison Bliss [00:36:47]:
You know, we've been collecting data to demonstrate what difference it makes, and it does. It it is there's very little question, I think, about that
Dr. Maryal Concepcion [00:36:56]:
do you think that there are any communities where DPC won't work?
Dr. Garrison Bliss [00:37:00]:
No. I I the answer to your question is no. Right now, the the limiting factor is who can afford to pay for it. That's the that's the whole point. So so right now, It it was like when automobiles were invented. The 1st people who bought the automobiles, were wealthy people. And automobiles were expensive. But over time, you know, the Model T Ford was invented, and we we and Ford is still alive and well, Last time I checked.
Dr. Garrison Bliss [00:37:29]:
And that's the conundrum is how do we take care of everybody? So in my practice, one of the things that we did At the beginning, when we started the first what I think of as the first EPC practice in America, we knew there were gonna be patients who couldn't afford it, who had insurance or they were in Medicare or Medicaid or something, but but and might not be able to afford it. So we put we had 10% of our practices for free. Free and discounted care. So and we had as enough of it so that We could make minor adjustments in the overall pricing for the rest of the people and it would just work. So this one simple business model, Monthly fee patient pays. I work for them. That simple business model is a way of providing the kind of care I have in mind, But it is by no means the only way of doing it. And direct primary care has already demonstrated spectacular ability to, develop newer, more stay more, customized versions of direct primary care.
Dr. Garrison Bliss [00:38:32]:
So if you happen to have a substantial block of very poor people you take care of, and then you have a lot a group of of more well-to-do people who people who are also who are patients, that you you adjust your price so that you can take care of these other people well, or for free and make that decision. But the practical question is is, you know, when are we gonna get to a point where the where the government is willing to pay the monthly fee Without a without handing us all the red tape and all the and all the documentation requirements and all of the stock that we're trying to eliminate, the fee for service incentive designs that we're trying to dodge right now. So are they willing to be To to start prying for primary care. We've well, I've had discussions with a number of people on in Washington, DC about about finally getting over this hurdle so that the federal government, state, or state governments can get involved With with, paying some or all of the the the monthly fee for the poor. Then you can you can it this is like food stamp. So We have grocery stores and lots of lots of us support grocery stores to, we all and we pay for our own groceries. But if the government wants to get engaged and help the poor, They provide food stamps or they give them a credit card that they can use at grocery stores, and that allows them to make use of the the The, service and the access and the wide range of of of availability that markets provide And and to but to engage the poor in such a way that it's not an embarrassment for them. They just hand they just use a different credit card.
Dr. Garrison Bliss [00:40:12]:
So it's a way of of bringing the benefits of a well designed market based system And make it available for everyone. So when you say, are there groups of people who who this has worked for? And the answer is no. Who doesn't need A working relationship with their doctor. Who doesn't need enough time? Who doesn't need access when they're sick? Who, you know, who doesn't need that stuff? Everybody wants it. Everybody needs it. And what we've done is we said, we are offering that, and we're doing it at a price that, you know, let's say, 70, 80% of America can afford. And if we're doing that then that's the opportunity for, charitable institutions and for Governments To kind of weigh in and help and help the people who can't get over that hump without making this into a government run fee for service, system with all of all of the fee for service incentives and the kind of weird pricing decisions and all the other stuff that's just part of our government run system right now.
Dr. Maryal Concepcion [00:41:14]:
Do you see in addition to HSA's government paying in a different form for the type of quality that DPC offers patients.
Dr. Garrison Bliss [00:41:24]:
Oh, yeah. I can see that. Now there there's some people in the movement who will scream if I start talking about this, but That's fine. What I'm saying is that if if direct primary care can only take care of wealthy people That is not what I envisioned And it's not what we want. It's not what the cover it's not what our country needs. We wealthy people have always been well cared for. What we want is a system that can take care of everybody. We have to figure out how to get past the the the roadblocks.
Dr. Garrison Bliss [00:41:52]:
But, yeah, I I have I've talked with a number of people in Washington, DC about this issue. I'm saying, Why isn't Medicare paying a monthly fee for prime for independent primary care? It's not tied to Big clinics and hospitals and fee for service mills. Pull us out of that cauldron where we're basically Making our ability to refer our value. Now we're we're handing them 2 to $5,000,000 a year per doctor so that they can they can speed all of their expensive systems and overdo everything. We should be out of that business. We should not be compelled To support the highest priced and most invasive health care in the world. We should be here to to support the needs of patients And that will interface with that. We'll be needing some of those exotic and great things, but we're gonna need them.
Dr. Garrison Bliss [00:42:44]:
We need to send people there because they need that, Not because the system needs that, and and that's what they're why they're paying us to work for them.
Dr. Maryal Concepcion [00:42:51]:
In terms of your practice, how did you go about identifying the people who were in that 10% who could benefit from care without having the financial burden of paying for their care while they were in your panel.
Dr. Garrison Bliss [00:43:05]:
Oh, that was easy. When we did the conversion, we wrote a letter to people and we said, this is about the care. This is about it's about having a survivable business model, but it's a very simple model. It's not expensive. At that time, it was 40 to $60 per member per month. That's what it was depending on age. And if you can't afford that, tell us And we will see if there's a way to get you on board. So, if you wanna join and you want this kind of care, then we will do our best to make it fit for you based upon what you can afford and We'll let you decide what that is.
Dr. Garrison Bliss [00:43:37]:
So it's we're not gonna wanna look at your at at your last 4 years of tax returns and decide, you know, what our Thresholds are. Because what people can afford is more of a of a personal decision than it is a numbers based thing. It has to do with what's what you require for financial security. So, yeah, we just made it easy. We said, you know, if if you can honestly say to us that you can't pay $60 a month for this, But you wanna pay 50? Fine. 50 is your price. If you can't afford anything, you are almost living on the street, great. Perfect.
Dr. Garrison Bliss [00:44:07]:
We'll take care of you for free, and we'll just get an extra patient. So we allotted ourselves about a 10% free or discounted patients to start with, and and then we'd take a look. But that's a luxury, You know, you have to have people who can afford your your fee in the 1st place. So don't come up with a fee that no one in your neighborhood can afford because you will have a very small practice.
Dr. Maryal Concepcion [00:44:24]:
When you mentioned that you sent out a letter, how was the response amongst your patients in your previous practice?
Dr. Garrison Bliss [00:44:30]:
This is the first time anybody had ever done this that know that that I knew of. And when we first did it, we wrote a letter about 3 months before we were gonna transition the practice. We we'd actually had sold our practice to a hospital thinking That they were the business geniuses, and they would, somehow make us magically, solvent. And the hospital discovered quite quite rapidly that this was not gonna work, for them. And so they immediately dropped us off to another clinic that was Doing mostly government work. And they they said, oh, your problem is you have too many expensive employees, so we'll take care of that. So they basically cut the salary. Of all of our employees and and half of them left, and they didn't fix things that broke.
Dr. Garrison Bliss [00:45:12]:
And it was a terrible arrangement. So when we left that arrangement, we just said, let's figure out what it's gonna cost us to run this clinic ourselves. Let's come up with a a patient panel size that will support that at the price point that we think people can afford, and we we did the math. And if anybody's thinking about how to do that math, I'm happy to talk with them. But it's pretty simple because it's a fixed cost business. Know what your costs are and know how many patients you think is an optimal panel. So for I I was thinking at some point, something between 408 100 patients in those days, but we ended up thinking more about 800 because we were afraid To have a higher price at that point to make that work at lower patient numbers. But, you know, right now, you just have to take a look at what the market is in in your neighborhood, and And you can help figure out what that price is.
Dr. Garrison Bliss [00:45:58]:
Then you know how big a panel, but I would say I would say aim between 406 100 patients if you're gonna do this, If you're if you're gonna have a complex practice, if you're gonna if you have a mostly young, group of patients, then you can go first for lower pricing and have more patients. But don't put yourself in the position of just running your own slave ship, where you're enslaved by your choice of pricing. So make sure that you're charging enough so that this whole thing will work and also so you can have a a little extra padding. So if you can take you can take care of some of the postsynany patients you have and don't feel like you're excluding them. So there are certainly ways to to do that.
Dr. Maryal Concepcion [00:46:35]:
Did you ever increase your pricing throughout your DPC sis.
Dr. Garrison Bliss [00:46:40]:
Look, I I I'm a tinkerer by birth, I think. I I wanted to see what worked better and also I understand what our pricing was doing or not doing for us. But over the years, as our costs went up, we needed to increase our pricing Because the price of everything medical, you know, everything that you buy that for medical office has been going up way faster than inflation And so we made sure that we kept up with that and also that that we made sure that our income kept up with inflation for us. So every 2 or 3 years, we would have small increases in in our pricing, and we'd explain that to people, why we were doing it. And we weren't doing it to make ourselves massively wealthy, But just to kinda keep us where we were, and I've made pricing decisions since then when I when I moved to do a start up in direct primary care. We went for a lower pricing for that system, and then the patients who stayed with me paid higher, pricing for that so I could have smaller panels. And then the ones who didn't wanna pay that were were moved over to this, direct primary care startup so they could get half price care, basically. And, And but also I still have access not only to me, but to this philosophy of care and this kind of care.
Dr. Garrison Bliss [00:47:53]:
So, yeah, the price is not a fixed number. It's Scary for doctors to think about pricing. And when you own a business, it's it's always you know, there's some things about it that make you uncomfortable. But if you don't think about price and you don't think about what patients are comfortable paying or how much value they're getting for their dollar, then you will be a victim of your Lack of understanding of what they want and need and what what they think is a reasonable thing price to pay for it. So you have to engage yourself in Not and patients, not only in terms of their medical needs, but also their financial requirements. That's what market systems make you do. It's what keeps you from Doubling your price every year until the insurance companies won't pay you anymore, which is the way the rest of the health care system has worked.
Dr. Maryal Concepcion [00:48:35]:
On a different note, Throughout your time practicing DPC, did you work with health brokers, and how was that experience
Dr. Garrison Bliss [00:48:43]:
for you? We had no contact with brokers From the moment we switched our primary care practices, which we call Seattle Medical Associates, we swift flipped that to a monthly fee practice in 1997. And we actually had a number of discussions with insurance companies at that point because we didn't want their money, because we understood that We wanted to work directly for patients. That was part of the concept at that time. So we didn't want to get to engage with insurance. And with the time when I started to have contact with brokers again was when we started Q Alliance, which was the scaled version of direct primary care because we realize that you can't grow anything in a bigger way unless you have some interface with both insurers and with brokers and with, the people who decide the pricing and the people decide what the premium costs are gonna be and so so we found ourselves in that pool talking with those people. But at that time, brokers mostly saw us as dangerous Because they already knew that we were capable of reducing the cost of health care. So if we reduce the cost of health care, that would reduce the cash flow going through the insurance company, which would Which would, in the end, reduce the premium because insurance companies are constrained in terms of how big a profit margin they're allowed. So if there's less money going under the bridge, they have to lower their premiums.
Dr. Garrison Bliss [00:50:04]:
And if they lower their premiums, they are low they're really lowering their profit. And so the brokers mostly didn't wanna have much to do with this. In fact, they were busily telling people that we just wanted to take care of wealthy, healthy people, And that that that all that stuff about better care, well, that was just us, you know, making that stuff up. Well, we've entered a new era now To a large part, thanks to Dave Chase who, has been a guy trying to evolve health care From a nonmedical viewpoint for almost as long as I've been trying to evolve health care. He in fact, he and I met right after starting Q Alliance, and he had wrote an article about direct farm may care It's a multi $1,000,000,000 bunker buster article that he wrote for Forbes magazine. And he talked about, you know, what this could do. Well, he's now formed another organization that I think is growing pretty rapidly, Called Health Rosetta. And the purpose of that is to take the lessons we've learned in the last 20 years about how to make healthcare better, Cheaper, more accessible, more effective, and teach that to employers Because they handle a very substantial portion of the health care budget and because many of them are self insured.
Dr. Garrison Bliss [00:51:19]:
So if they money, they would be putting money on their bottom line and they'd also be able to pay their employees more if they reduce their healthcare costs. So that's the 1 group of people who have a big effect on the on the marketplace who, actually will benefit From the stuff that Direct Primary Care does in an obvious way. So he has been training brokers, and there now is, Health Rosetta qualified and certified brokers Who know not only about Direct Department of Care as the basic foundation of any kind of care system that actually accomplishes the The happy patient, happy doctor, lower cost, better outcome universe. So they are, peak training brokers To walk away from their adverse incentive systems, which involve getting, paid for delivering employers To the insurance company, but not delivering any savings to the self insured employer. That is the world they live in. So they They are literally paid by insurance companies for selling their product. And so, that's an incentive that's massively adverse. And so, they've gotten brokers to Walk away from that, which is a very scary thing for them.
Dr. Garrison Bliss [00:52:31]:
If you think it's scary for you to leave insurance just to think about that that's been their source of their livelihood for years, But to start working with a different set of incentives. Same idea, but now applied to another segment of the health care system in a very important And, and also that to leading to newer ideas in insurance itself that is more directed toward what patients wanna need, What individuals want, need, and can afford rather than, how to maximize cash flow for an insurance company.
Dr. Maryal Concepcion [00:53:01]:
Thank you for for sharing net. Some people don't know what the health Rosetta is, or they hear broker and they get a little gun shy.
Dr. Garrison Bliss [00:53:09]:
Well, this is a way of expanding the direct direct primary care universe by engaging employers who are likewise motivated to have their employees healthier, Have better access to the health care system and, missing fewer days at work. And at the same time, the employer could pay less money to get more services for everybody. That's a win win win win win win solution. And this kind of a solution is the long term answer to the health care system in America. And I'm hoping that, self insured employer marketplace is gonna be one of the earliest adopters.
Dr. Maryal Concepcion [00:53:44]:
If someone were not yet working with a broker and interested in talking to employers, whether they be a large scale employer or a small scale employer. Do you have any suggestions as how a person can start that conversation employer group, especially if they're on a micro Well,
Dr. Garrison Bliss [00:54:01]:
there there are a number of ways that you could I mean, there's some other parts of this ecosystem that have been growing around Direct primary care. One company that has been here a long time and has really come into its own is Hint Health. Initially, as to Developing billing software for Direct Primary Care, specifically, monthly fee billing, which is a a specialty unto itself. They have a great affection for this movement. And, obviously, they've put all of their personal capital and, and hopes into this movement. And so they've done everything they can to support it, and part of that is to start giving courses in how to do the business part of the business, how to engage with employers, How to set pricing so that it makes sense for you and your community. And there are other a number of other organizations that I've had the pleasure to meet with Who are now trying to engage with this question of how do we put together direct primary care people with employees of companies And create a system where direct primary care people who wanna try direct primary care. They they're afraid of letting go of their their fee for service, But they might be willing to take 10 direct primary care patients to see what that feels like.
Dr. Garrison Bliss [00:55:13]:
And patients who wanna shop around for the best primary care doctor they can find at a price point that makes sense for them, knowing what their employer is willing to pay, what portion of that their employer is willing to pay. So They they have a choice whether to get a more expensive direct primary care doctor or a less expensive one and deciding how much of that difference they're willing to pay. So does this maintains the structure of it as a marketplace. It also means that it, it puts a little pressure On direct primary care, people who are starting out to start out at a lower price and gradually make their make their way up depending on How big a following they get, how much their patients like the work they're doing, and what the actual valuation is of their practice as a matter of public knowledge. So there there are now systems that are being developed at Hint Health and other companies are doing this So that those of us who are a little scared of this concept, which is most any sensible primary care doctor, you know, this all sounds kind of Scary not having they just fill out a bunch of diagnoses and wait to find out what the what you're gonna get paid for 3 months from now by an insurance company. That's somehow that seems less risky, but I I will assure you it's not. But there's a lot that's known about this, and there's a lot about marketing That now is much more plausible than it than it was even 5 years ago. And also, go to a hit summit sometime.
Dr. Garrison Bliss [00:56:34]:
It's once a year, usually, And they bring a bunch of people to give talks from all kind of early to people who've never done it but are thinking about it, And they have courses available for people at all stages.
Dr. Maryal Concepcion [00:56:47]:
I love that they have their past conferences available for people who are learning about, or who have missed the conferences
Dr. Garrison Bliss [00:56:54]:
Yeah.
Dr. Maryal Concepcion [00:56:54]:
So they can still get that information.
Dr. Garrison Bliss [00:56:56]:
It is such a different experience From any conference that, I have been to because this engages doctors with the reason that they started in medicine in the 1st place, Which is actually great care, but great care as as determined by what patients want and need, not as determined by what your textbook says. Although, you need to know all of that too. But the idea that that that we're actually trying to fashion great care And to do it on a reasonable budget and do it in such a way that, that we improve the rest of the health care ecosystem. That is A wonderful space to just be in for a few hours.
Dr. Maryal Concepcion [00:57:38]:
I find it's a very well rounded conference, and to hear the ecosystem, as you put it, of direct primary care involves so many professions and to make sure that this movement continues. I think, hint definitely pays attention to that and that's why they feature the speakers that they do.
Dr. Garrison Bliss [00:57:56]:
The other thing that that allows you to see, Which most doctors do not see because most doctors are in a healthcare system in which they think it's about them, and, you know, what they need and What what they want for their patients and what they think should happen without really seeing the entire ecosystem. And The thing that this particular kind of care has seen from the beginning is we need all the help we can get, You know, that we have had no no significant support from insurance. We've had very very little from national government. We've got passed laws in 30 states, approximately 30 now, to make this legal to do, and we've realized How many different kinds of people and different who are a part of the current health care system who want to do better work and want to get better results? How many of those people can come across to this to this sort of monumental opportunity to fix health care itself? It's fun. Do you mean we aren't doing this ourselves, you know? If the if the insurance companies are aren't aren't on board, then, You know, 90% of America. If we if the government's not involved, we've got a very large proportion of people who who are not gonna be able to participate because they don't understand what we're doing. They think it's just a business model. So we we need to show them that.
Dr. Garrison Bliss [00:59:18]:
We need to engage with those people. They need to under see it and understand it. That's what's gonna move this movement forward. It's not just what doctors do. Our responsibility in this whole thing is, first of all, to be great doctors and to make use of the time and space, and access that we have to show people what's possible and to create what's going to be possible when we innovate around what we do. So This is a place for us all to play. This is ours this is a sandbox. I mean, I was the 1st guy to play in the sandbox, but I believe me, I want the sandbox to be all across the united states And I want everybody in this country to have access to it, you know, I love seeing people who have who are doing something with this and who are doing the next round of innovation who are Creating the next group of people who will who will take this thing on on and carry this flag.
Dr. Garrison Bliss [01:00:13]:
It's it's, you know, the thing I didn't know when I started was How we would find the patients, how we would find the physicians. And what I've tried to do is to create a sturdy enough culture That I'd be public about it enough so that people will have some kind of touchstone as things get messier. It's like democracy. Right? So we've had our democracy tested, and it survived. Yeah. And it that's good. But we also realized we need to do a little bit of, you know you know, cinching up this and fixing that too because it's not done yet. It's not cooked, and this isn't cooked either.
Dr. Garrison Bliss [01:00:54]:
We it's not cooked until, you know, until we have remade the culture of health care.
Dr. Maryal Concepcion [01:00:59]:
Doctor Bliss, you continue to be an inspiration. Thank you so much for being on the podcast today. If someone wanted to spend some more time discussing DPC with you. What is the best way to connect?
Dr. Garrison Bliss [01:01:11]:
Give them my email address if they wanna engage, and, which is garrisonbliss@gmail.com. And then, you know, we'll decide whether to, you know, where to where to go with it. I wanna help this movement. I have gained an enormous amount of well-being, and purpose from this movement, And I have had a the delightful experience of working with other people to help them get the same thing. So to the extent that we can I there are people who wanna play, and they they wanna, you know, talk to somebody to give them a little extra gumption? I'm happy to do that. And if there are people who are involved in a big project, or they need a board member or something like that, then, I'm happy to talk with people about that too. I I I can I'm good at limiting my exposure at this point, and I've I've never felt that talking with like minded people was a was a difficult or or daunting problem.
Dr. Maryal Concepcion [01:02:18]:
Next week, look forward to hearing from doctor Althea Tindall Smith of Gainesville Direct Primary Care Physicians. If you like what you heard today. Please leave a review and subscribe wherever you listen to your podcast. Tell your friends too. For more information on this episode and much more. Please visit my dpcstory.com. Until next week. This is Mariel Concepcion.
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