Interview with Daniel Paull - Insurance Free Orthopedics

Escape the insurance maze and take control of your orthopedic care. Discover the freedom of Insurance Free Orthopedics with Dr. Daniel Paull. Say goodbye to bureaucracy and hello to personalized, patient-centered medicine. Take the first step towards a streamlined healthcare experience today!

Tune in now to revolutionize your approach to healthcare!

Follow us and subscribe to our links below ⏬⏬⏬

Website: prp-now.com
Apple Podcast: apple.co/3Azvt3R
Spotify: spoti.fi/3oICYmh
Youtube: bit.ly/drariana

Transcript

Intro

Hey, I'm Dr. Ariana De Mers. I'm an orthopedic sports medicine surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for help. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.

Dr. Ariana

Welcome to The Business of Orthobiologics podcast. I'm your host, Dr. Ariana De Mers. And we have Dr. Daniel Paull joining us today. He's an orthopedic surgeon and founder of Easy Orthopedics and no insurance orthopedic care model. And I am so excited to bring him here today. He is a maverick and a leader in the direct care model. So if you can just go ahead and share with us what direct care is, how you got into it from the beginning, that would be great.

Dr. Daniel

Well, thanks, Dr. De Mers, for having me on. Yeah, sure. So with direct care model, the whole point is that deal with insurance companies. So you can call it a cash-pay practice, but basically, what it means, my understanding of it is, you can practice medicine how you want. You just cannot interact with insurance companies because if you do, you need all the bloat that comes along with it, which we all know is a lot. I mean, you're talking at least five staff members per doctor. And, you know, then you need an EMR, and then you need an office space to house all these, and you quickly get forced into a high volume, high overhead practice. So this kind of flips it on its head. Instead of just trying to maximize volume, we're trying to minimize overhead. And I think it allows you to basically slow the treadmill down by a lot. You get to spend a lot of time with patients and get a lot of your own time back while also still being able to be profitable once you get it up and running.

Dr. Ariana

Sure. So how did you find this model? How did you not become a cog in the orthopedics machine like all the rest of us did? How did you start from the beginning?

Dr. Daniel

Oh, my gosh. So it's probably a combination of good luck, bad luck, and desperation, I would say. So I never thought I would be doing this model. I thought I was just going to go out and practice and get a job and live happily ever after, which obviously wouldn't have been like that if that happened. But it's what I thought during residency. And I think that's what a lot of people thought. So anyways, this is my story and how I got to where I got. So I finished my residency. I started a fellowship in hand surgery. Now, I do general now, but I started a fellowship in hand surgery. You probably can guess by the way I'm talking about it, I did not finish it. So I had not a positive educational experience. So I'm halfway through and like I said, not a positive educational experience. So that's going on. And I'm also looking for a job, and I'm from the East Coast. My wife's from Colorado, specifically Colorado Springs. And, you know, I dragged her all over the country at this point for training, and we really wanted to move back. That's where her parents are and we have a young kid at that time. We've got two now. And I'm looking for jobs and man, I just cannot find one. Or if I do, I mean, Colorado is a competitive market. They're abusive at best, meaning, you know, take our entire level three call for practice 24/7. Or here's literally this I saw one time was a four-month guarantee you know, with no existing pool of patience, you know. I don't know how you build a practice in four months, but these jobs were out there. I interviewed for a job back in Connecticut, where I'm from, and it was just me talking to this embedded senior partner telling me how much money he used to make in the early 90s, and he was just so bitter. And it was just this kind of existential crisis moment where I'm like, well, I've been grinding for a while. I'm like, I just going to keep doing this? Is this sort of like forever, you know? Obviously, I like orthopedics, but at some point, you know you have this idea, which I think is false, that once you sort of get out of the training area, it's going to improve. And it was just like, hit me like a ton of bricks, this realization, and probably won't. So it was that in the fellowship, you know, not being what I wanted it to be, where I basically just-- desperation. So I quit my fellowship. I broke my lease, right? I'm halfway through. Who quits at your fellowship? I guess I do. And then I decided we're just going to move to Colorado. So I had no job or anything, and we moved into my inlaws' basement. So it's like, well, what am I going to do? And I had a friend who started a house call, cash-based practice down in South Florida, Miami. And that's where I went to medical school. And I'm like, man, this guy's happier than anybody I know. And he's doing better financially than anybody I know. And I'm like, there's got to be something here. So that was the genesis of it. No one had done it before for orthopedics that I was aware of. I looked, I couldn't find anybody. And so that was about four years ago, and I set off pioneering it. And now I'm in my own basement, so life improvements there. But it's been kind of figuring out, what does that look like? What is the value proposition for an orthopedic surgeon in the cash-pay world? Because direct primary care doctors, for those who aren't aware, they figured it out. I mean, family medicine doctors are way ahead of us on there because they hit that pain point so much earlier than we did. They were basically squeezed so hard, they had to find another alternative practice model, and they've successfully done it. And they're springing up all over the place and they're happy. So I think eventually maybe we'll hit that point. But essentially just an outlier at this point.

Dr. Ariana

Awesome. Yeah. So many things that you said resonate. You know, you're like, who quits? Well, I quit my very busy practice but walked out at lunch with no intention of coming back. So I hear you. And it really does, I think, resonate. And I think it will resonate with a lot of people like, I want to quit, but who does that? I've worked so hard. I should be happy. Why am I not happy? And that's the fallacy, the arrival fallacy that we've all been sold is like, if I just put my head down and work really hard, when I get there, "there", I'm going to be happy somehow. And that has hit doctors and surgeons alike with this really rough realization that that's just not true. I am so happy. Yeah, I have been exposed to the direct primary care model. And you're right, these doctors are happy. You've been so vocal about the practice autonomy, and it really resonates with me. How did you gain so much confidence in this model? Was it just doing it? Because I know we talked a couple of years ago, you were like, oh, my gosh, what the heck is going on? How do I do this? And I was like, you know, I'm figuring it out too, and I'm happy as can be, but there's really not a book on this. So how did you know how to do this? Did you just you know, pull your root straps up and go, oh, heck. If, you know, small business owners can do it, I can do it, too.

Dr. Daniel

Yeah, I think that when you're powered by pure desperation, you just don't even really have thoughts about those-- I mean, I guess way in the beginning, I'm like, I think it's going to work you know, but I have no idea. I mean, it was figuring things out by trial and error. So I started mobile and I still am mobile, by the way. I still have a bag that has all my stuff in it that mostly you would need for office visits. Obviously surgeries or procedures in our surgery center or procedure room. But most of the stuff is visits. Yeah. It was trial and error. I mean, I would take my bag around and then I put on a suit, which nobody wears in Colorado, which eventually I figured out. And, you know, I'd go and meet people out in the community. And gradually, little by little, I found things that were compatible with my business, meaning that with my super low overhead, could I do it? And I've kind of just leaned into the things that worked and stopped the things that I had.  And piece by piece, I've been able to kind of put it together. I mean, the nice thing about the models is extremely durable. So the overhead is so freaking low that if you don't see anybody for a day or two, or even if you have a week, a dry spell, really, not that that happens too much anymore, you really are okay. As opposed to having a staff of, you know, ten people in a big old office and that's a big ego purchase, then you have major problems. But with this model, it's really very durable. But yeah, it was just a trial and error. I mean, I tried things that didn't work, and then they didn't work. I moved on from them, which is okay in business. You know, that's failing forward. That is okay. So there was a good amount of that.

Dr. Ariana

What business training had you had prior to this?

Dr. Daniel

None.

Dr. Ariana

Like the rest of us?

Dr. Daniel

Yeah. I mean, look, you're not going to get any in medical school or residency.

Dr. Ariana

Right.

Dr. Daniel

And we're so academically minded, a lot of docs are like, well, I need to know about business, so I'm going to go get an MBA. Which I think is-- look, an MBA can be good for some things. If it's good to make connections in a certain area, it's good to get job prospects, that sort of thing. But for small business, I would actually argue that it's counterproductive, meaning that they're going to teach you things how to work in the bowels of some large corporation, and that's not really small business. I mean, you can create all the spreadsheets in the world. That's not going to help you with small business, which I think is based on a relationship. So I found that after I started, I had a little bit of a knack for it, and it was like systems-based learning. I mean, a process. If I create a system and there's an error in it, I get to correct it immediately, which I really like. But yeah, no business training. I don't think you need to go out and take classes. I think you just need to start dabbling in the world of small business and making good relationships and learning by trial and error while not sinking yourself at the same time.

Dr. Ariana

Yeah, absolutely. I hear you. When I opened my business for the first time, I'm on my fourth reiteration of business. And when I opened my first business, I literally read like "Business for Dummies" book because I had no idea. My accountant was talking to me about a P&L sheet. I was like, what in the world is this thing? It's called a profit and loss sheet. Turns out. I did not know that at the start. But I think you're right. You just fail forward, continue to have the autonomy to change things that aren't working right away. And it continues to be a reiteration. And you're like, wow, this is actually working. I'm actually serving patients. I'm having fun, honestly. And you're right, because the overhead is so low, it's not risky. It kind of takes that risk out of it. So can you kind of walk me through your day, your office setup? How do you get coverage? How do you book surgeries? Like of all of those things.

Dr. Daniel

Sure. So you got to understand with a direct care model that the image of orthopedic surgery and how we practice it. I'm not talking standards of care medicine. I'm just talking about the model of how you practice it. Now we have in our heads, it looks a lot different than that in the direct care world. I think for positive. So I'm mobile, I can see people in their houses, and over time, I found offices that I can use as well. And those were basically people in the community who would say, well, this guy's got a shoulder problem. Can you come to my office and see him? I go, yeah, sure. And then I pop in. I'm self-contained. I have all my own documents and everything I need. I don't use their staff. I'm just using their room. And over time, I found a handful of places that I go. I don't pay for these places. I get them for free. Well, I mean, yes and no. I'm value-added when I'm there. To have an orthopedic surgeon pop into your office and pop out, you can do injections. That's a value add. So you got to remember that. And so I found people that appreciate that and let me use their space when they're not using it, maybe lunchtime or whenever. Or like if they have a slow Thursday, then I can use it on Thursday. But you're not talking a tremendous amount of patience. I mean, you're talking handfuls at a time. I mean, I do other things like medical-legal work, which I really like as well, which I would recommend if someone has a stomach for it. So you're only talking handfuls of patients. I book them for an hour. In the travel time, sometimes I can book them back to back at the same place. We go over all problems. So if they have seven, eight problems, I go over all of them. I can give injections or ultra-side guided injections on-site. Try to keep people away from surgery, which is kind of in the cash world, it's what they want. And then if they do need it, I've been moving more towards a procedure room, which I found is just so much freaking easier than trying to do at a surgery center. The price is much lower. I've been trying to do more things under local lately. It's more profitable. Let's say, who's ever listening probably is curious about the numbers here. So let's say a carpal tunnel release I recently did, right, which every orthopedic surgeon certainly can do, even if they haven't done it for a while. So I paid the facility $1,000 to use it, which is basically sterile instrumentation, you know, sterile draping in a nurse. We use local anesthesia for the preoperative visit, the carpal tunnel, and the post-op visit, which is-- so total-- I charge $3,000, I pay $1,000, which means I get to keep two of it. Now, if you have to look at that compared to what a joint replacement doc would get, I mean, it's more in some instances with a lot less work. So the numbers work. And the way this carpal tunnel surgery got paid for was by a business. The business says, hey, it's much cheaper with me with easy orthopedics than sending them out somewhere else. So for them, they paid a lot less money, and I made a lot more money. The only people who didn't make money are all the insurance middlemen parasites. So by removing them, it's honestly crazy, you know, how well you can do with a little amount of work. I mean, I think if orthopedic surgeons actually got paid for the value they were providing, it would be really going to be obscene sort of payments, which maybe they were in the 80s and 90s, I don't know. But the United States is the wealthiest country in the history of the world, and 20% of the GDP is health care expenditure. So we're sort of getting squeezed out of that because they can, right? If you do joints and if you do knees and hips and that's what you do, and then they tell you they're lowering how much they pay for a knee or a hip by 300 bucks, what are you going to do? Nothing. You have no [inaudible] 

Dr. Ariana

Yeah. I've had that experience as well, both the getting squeezed part as well as being outside. So I am outside of commercial insurance. I don't take any commercial insurance. I made that decision when I went to my new office in 2019. I do take Medicare and it's partly because I'm scared, partly because I don't know what to do about this social program, partly because where I live is 65% Medicare. So ultimately, I'm still taking it. And so I get both experiences where I get what the Medicare takes, decides to pay me. And then for the rest of my practice, it basically keeps everything else afloat because if you take Medicare only and you're not doing a volume solution, you're going to go under and you cannot-- it's not sustainable. And so I'm using all the rest of my cash pay practice to basically float my Medicare experience, which is basically giving it away for free. But, you know, this is a charity. That's my charity part, I suspect. So I'd love you to share maybe a little bit about your documents and how you set that up and what do you use. Because I have a lot of questions from doctors, like, how do I set it up? What EMR do I use? Do I use an EMR? I'm like, well, you don't have to, but can you kind of share that part, the nuts, and bolts part of how you set up and how you do those things?

Dr. Daniel

Sure. Yeah. So legally, I don't think you have to. You can use paper records as long as you work within certain parameters. And I talked to a recent older doc who's doing this now, and that's what he's doing, or some variation of that. So what I use, I really like this solution, I use a HIPAA-compliant. Right? I want to be clear about this. It's HIPAA-compliant Google Workspace, right? So Google has Workspace, which includes these things that you're used to using, like Gmail and Drive, and Calendar. You pay for it, it's $18 per user per month. So I have two users, so I pay $36 per month. And basically, what I have, once you sign the business agreement with them, it makes all of their products HIPAA-compliant, meaning that if you edit documents, it keeps track of all that, gives you metadata if someone were, you know, to want it. And I use templated Word documents. So I see a patient, iPad, bring it around. It has basically PDFs where they can kind of sign certain parts, which is a consent form, basic demographic information, HIPAA release, privacy practices. How many pages is that? It's maybe eight pages. And then various other things they can sign surgical consent. So I carry that around on iPad, get home, make a folder for them, right, a chart, which is literally just a folder in this drive. And I upload the documents and then I create a new document and it's just a bunch of templates of Word documents for new patients or orders or whatever. Then I get out. It's usually a page right, because I'm not billing insurance. Sometimes it goes nowhere and then I save it back up as a PDF. And then I have a PDF, which is like one to two pages of what I did. And if I need to send an order out to, let's say, an imaging facility, it's the same thing. I generated a PDF of an imaging order and I email it to them. I don't use Fax at all. I don't believe in it. I mean, you know, I refuse to use it.

Dr. Ariana

It's amazing.

Dr. Daniel

If someone wants to Fax me something, I tell them they can email it to me. If they can't do that, they can snail mail it to me, which some people do. Or if they can't do that, it must not be important. We literally don't have a fax number. That's kind of the nuts and bolts. I mean, I created all these documents on how to write you know, it's pretty efficient. You can use dot phrases as well. If you want to put in the injection, you can do it however you want. I mean, there are no click boxes, so it's not expensive. I mean, EMRs are expensive because they have to license all these CPT codes from the AMA, which that's how the AMA makes a lot of their money. Then it's a billing machine. It's a freaking billing machine. You're paying for a billing machine, you're using a billing machine. When you're not doing that, it actually simplifies the whole note-taking aspect of it. So that's my recommendation of what to use. And it's not like you're just keeping them on your computer. They're backed up on a cloud. If you want, you can even get something called the Vault, which I do as well, where it's super backed up. Or even if someone were to hack it, the files are still untouchable in a certain area. So, I mean, it's Google, the business products are very good.

Dr. Ariana

Sure. Awesome. Yeah, that is one of the options that I share with my listeners is that the Google Workspace is very viable, and that is what I recommend. If you're going to start out with a low volume, low overhead practice, by all means, that's a really straightforward, easy way, and it is HIPAA-compliant. What happens if you go out of town? What happens if you need coverage or you're gone in the Himalayas for three weeks? How do you work that?

Dr. Daniel

I mean, we're closed on the weekends, so what I do is I give all my patients my phone number, my personal number, and they can call or text with anything they have. So honestly, most patients don't use it. Occasionally, I'll get somebody who has something where they do, and it's very reasonable. But honestly, I'm not working at a hospital. I'm not on-call like that. I'm available if somebody really needs me, but most of the time they don't. So if I'm out of town or whatever, they can always call me and I'll call them back. And for most reasonable human beings, or mostly everybody, that works fine. You know, if there's an emergency, they break their ankle, I'm not the guy who's going to fix it anyways. So I'm not there for that. I'm not an emergency service. But yeah, if you have a post-op or something and I'm going out of town, they certainly have my phone number and they have problems, I encourage them to call me anyways.

Dr. Ariana

Yeah. I think that for me, I give every single one of my orthobiologic patients my cell phone number and I tell them you know, text me, call me because honestly, the on-call doctor is not going to know what to do. They're not going to know if it's normal. They're not going to know how to guide you. So I want to hear from you. If you are worried or something's going on, please call or text or something. And my experience has been exactly yours. They rarely call. And it's not this ridiculous high volume experience, what you experienced during residency where you're getting killed and everybody and their dog is calling you and paging and doing all these things. It's just not. I did an experiment where I tracked who was calling me at night for a month. I got zero calls. I pay a call service to cover me and I got zero calls. It's like, holy cow, what am I doing here? But it's really interesting to talk and see how people solve these problems differently. I have a question. So what do you think has been the biggest challenge in your business, either business or personally in this model? What do you think that has been the biggest hurdle? Has it been mindset? Has it been getting out of your own way? I know when we talked a couple of years ago, you were really struggling with these ridiculous requirements from hospitals and operating rooms.

Dr. Daniel

Oh, yeah. For me personally, I think the biggest, the hardest nut to crack was essentially the surgical part of it. So with this practice, you can essentially make it perfectly viable without doing any surgery. But obviously, we're surgeons, we do surgery. I mean, at least a lot of us do. I really don't need to do it to be very profitable, but I want to do it. So it's always been something I dragged along. So this is the process for me. Hopefully, someone can listen from it and save themselves some time. So I moved to a new area, right? I didn't work in the area previously. I'd go to surgery centers, you know, which is that's where I was used to operating. I'd say, I'd like to bring patients here, cash pay patients. And they'd say, okay, literally, "We'd love to have you here". Perfect. Just go get a credential at the massive hospital system. And where I am is every other place in the United States, you have these massive nonprofit hospital systems that own everything in the world. So I quickly found out that credentialing with them was A, I didn't want to do it and I want to be pulled on the call schedule. I've opted to have Medicare. I don't have a physical office. It's not a good fit for me. B, I don't want to support them. You know, I'm kind of anti-hospital system, which a lot of docs are. I'm not anti-hospital. I'm anti-hospital system. I learned also that if you're in a competitive market and you want to get a credential at one of these hospitals, they're going to find ways for you not to be able to do that. So I quickly realized that was not an option. And then I was able to find a surgery center, which was essentially not-- it didn't have that requirement because it did not participate in Medicare. So that's a Medicare requirement, which I was told that it was repealed a while ago, but it's still in the bylaws of a surgery center that you basically need to have hospital privileges in case something goes wrong during the surgery, which on the surface sounds fine, but if something goes wrong, the patient can always go to the hospital. And every hospital, they should have qualified people who can do exactly what you do to take care of them. I mean, I'm not so narcissistic to think that I'm the only one that could take care of the surgical complication, you know. But that's what they say. And so I found this place, I put a lot of my own equipment in it, and it was kind of a pain in the butt. Every time I would get a quote, the price was to be different. It'd be like a $3,500 facility fee for a distal radius, which is somewhat reasonable, and 4,000 for a trigger, which wasn't. So I got frustrated. And then luckily, I was able to find this procedure room, and that's basically been the best solution that I found so far and basically, move towards doing things just under local. And that I think has been wonderful because it costs much less. People are actually like that. It's under local, they don't have to go out. If it's just local, you know, you need less medical clearance. And for me, you know I put some equipment in there. And there's a lot more technology that's been coming out that allows you to do things under local, like the Nanoscope, which I don't have, but I messed around with a little bit. So that's probably been the biggest challenge. But I think really, if you would start with a procedure room, you could probably skip a lot of that junk. And, you know, even if you're not doing all the big surgery you used to do, you're still doing surgeries and they're still helping people and it's still profitable. So that's been where my head space is kind of building my practice more. What can I do in the procedure room safely and what can't I do?

Dr. Ariana

Yeah, absolutely. That has, for me, local anesthetic and regional blocks has been a game-changer for my orthobiologics practice because if I'm doing orthobiologics in a surgery center setting, a lot of times the insurance companies won't pay for something that is a non-covered service for them. And so then they're stuck with the bill of the anesthetic and it's not covered by insurance. And so it really starts to become a problem. And I talk to my patients all the time that their insurance company, you can get a quote from them, but it's not going to cover it. And so we can get a cash pay price for an anesthesia, but ultimately that is not going to be covered. So I think I've educated myself on regional anesthetic, which has been amazing and a huge game-changer. Have you had that same experience using regional anesthetic?

Dr. Daniel

It's probably something I'll do in the future since I use ultrasound and everything. But right now it's been just small local that I've been able to get away with local. But, you know, I think we need to look towards plastic surgeons, really, you know, because in this procedure room, there's a plastic surgeon who will do like five or six, seven-hour cases. So, I mean, they've figured out how to do all that stuff in these procedure rooms and do it safely and effectively. At least, you know, a lot of them have. So I think there's something to be learned from that as well. Maybe we don't need this giant surgery center. Can we do this safely in a smaller setting, you know which a lot of people like better? I think we can.

Dr. Ariana

Right.

Dr. Daniel

We need to figure out how exactly to do that. But I think you're right, regional blocks, local blocks. You know, avoiding any major anesthetic is the way to kind of start seeing, well, what can we do?

Dr. Ariana

Absolutely. So what information do you wish you had about any of this at the outset that would have maybe made your life a little less of a struggle or setting up your business a little bit easier or more enjoyable? What have you learned or gleaned out of your experience that has been helpful?

Dr. Daniel

Got you. So I mean, the practice is pretty minimal. It's pretty easy to set up, I mean. But I think the main thing that keeps it running, right, the gas for the engine is referrals. So figuring out who actually does give good referrals to my sort of practice. And over time, I've made a list of what types of docs give good referrals, what types don't, and who specifically does or doesn't. And before I would spend time on the people that really didn't, hoping that they would. But what I realized is that's not really worth where you should spend your time. You should spend your time with the people you already have good relationships with, who are already sending you and enlarging those relationships to you. They might send to you more. So that I kind of have a profile now on what type of providers prefer and what-- I mean, that would have saved me a lot of time in the beginning. There was just no way to get that information until I did it.

Dr. Ariana

How much interaction do you have with direct primary care providers? Direct primary care docs, has that been a big refer as a source for you, or has that been helpful in any way?

Dr. Daniel

So this is an interesting topic that you raise here. So let me talk about it. So when I first went out and met all the direct primary care docs, and out of all of them, I know five or six. There's one of them who has a business contract, who basically refers me to all of her orthos, all the injections, all small surgeries, and everything. So she refers a lot, and that's been really good. But basically, I bill her, she bills the business and then that's how we all get paid. She doesn't bill on top of me. So in that experience, it's been really excellent. And she's a PA who runs her own practice. But I found as far as all the MDs, DOs, DPC docs, while I personally belong to one and I strongly believe in that medicine, I think it's the best that you can get for primary care, they do not refer a lot. I don't know what your experience has been. They really don't. And it's kind of a funny thing to find out where basically in the system, it exists where they'll refer out the drop of the hat, [inaudible], I don't want to deal with it, go out. You flip to direct primary care and it's the other way around where they won't refer out even when they probably should. And so it's one in the other direction. So ironically, even though I'm a huge supporter of direct primary care, they really do not refer out. Some never. And I think it's a product of, I don't know, maybe when you're taking care of people with heart attacks and diabetes and medical problems that can kill somebody when someone comes in with shoulder pain, maybe it's kind of brushed to the side or I don't know. But they're obviously not trained as well as we are because that's all we do is MSK. So that has been somewhat of a struggle. And I've actually found that I get much more referrals and better referrals from chiropractors who seem to actually really get it, right, because they're cash-paying the MSK world. And they know a good one, right? They know where their bounds are. They'll bounce things out much faster than a DPC doc will who you know-- I've known one DPC doc for four years. I think I've gotten one referral ever. So, I mean, I don't know if that's just what I'm dealing with. I would love to hear if other people in our position have that similar experiences.

Dr. Ariana

Yeah, interesting. My experience, I don't have any DPC docs in my area. Actually, that's not true. I have one. And coming up on two. And I will say that they as a whole, I think DPC doctoring is built on that premise that they are providing globally all of the things for their patient. And so I see where that rub, where they're not referring out for MSK is maybe common. But yeah, absolutely. I think that referral patterns are the most important thing. And sometimes super frustrating, you're like, what's going on here? I'm taking really good care of your patients. Even when you're not sending them to me, they're finding me anyways.

Dr. Daniel

Yeah, I know. It's funny you say that real quick. There's a giant DPC company where I am, and I started to get referrals from them and it was really good. I met with the CMO. We had a great conversation. He's like, I'm going to introduce you to all my docs. They have ten, 12 docs. This is good, right? Very good.

Dr. Ariana

Yeah.

Dr. Daniel

And their CEO found out about it. It was also a doc and he just squashed it, you know. So I stopped getting any referrals from them. And I actually met him when I first started. And he basically like, well, the point of view is just to do surgery. We'll take care of everything medically, everything until they need surgery and we'll send it to you. It's like, well, how do you even know when they do need surgery or they don't? Are you injecting the right spot? Are you treating the right spot? I mean, there are a lot of nuances to this. That only go appreciated, go often underappreciated. I forgot about that. But yeah, that's been my experience as well. So I think you're right. You know, they don't see the value in sort of what we do unless it's only with a knife or a scalpel. So that's something that I've been working on. I mean, it's an interesting nut that I found to crack, and I haven't really cracked it, but you wouldn't think that it would be like that. But that's my experience.

Dr. Ariana

Sure. What advice would you offer to a physician who is either contemplating cash pay or adding orthobiologics or any uncovered service to their practice where they're not going to be dealing with insurance because it's outside the insurance purview, what kind of advice would you offer them? Should they do it?

Dr. Daniel

Yeah, absolutely. I mean, look, do it if you want to be happy and want autonomy, which we all want. So I would say that if you're doing a hybrid practice, you need to create an autonomous business unit with probably if you have a lot of staff, maybe a dedicated staff member who doesn't have the mentality of insurance billing, there's nothing worse than a cash pay patient being funneled through insurance billing practices. It's bad for everybody. So autonomous business units can be successful because otherwise if it's in your main business, it's going to be hard to get people to work in those two sorts of systems. So that's one. And also, two, a cash basis will give you stability and autonomy, right? You control your cost, you can control your overhead. You cannot do that with insurance-based billing. So the further you get into that, the better off and more stable you'll be. I mean, it's paradoxical that my practice is very stable. You wouldn't think it is, but with all these mergers and conglomerations and large practices breaking up and reforming, I'm a very stable practice, which is insane. So there's that. I would also say that if you really go deep into it, you really-- you know, a fully cash-based practice, you're not going to make money for a while and you'll be poor for a while. Right? I don't know a better way of saying it. So if you've saddled yourself with golden handcuffs, meaning that you have multiple luxury cars, multiple really nice houses, kids in private schools are really expensive, you're not going to be able to leave. You need to figure that out. You need to, you know, start tamping that down.

Dr. Ariana

Awesome. Well, this has been Dr. Daniel Paull. Thank you so much for sharing all of those things. We'll have to have you back on the podcast again. This is just amazing. And I really appreciate your time. This has been the Business of Orthobiologics podcast with your host, Dr. Ariana De Mers, and thanks for listening. It's been a pleasure. Have a great day and we'll talk to you soon.

Outro

This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more please join us on the website, "PRP-Now.com" and click on the FREE Masterclass. Also, don't forget to "Subscribe" to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.