102 - Replay: Breaking Free From Insurance & Physician Burnout — The Rise of Direct Primary Care (DPC) and How YOU Can Thrive Today

Tired of the endless coding, paperwork, and burnout from the traditional healthcare grind? Ever wondered what it would be like to practice medicine on your terms — without third-party interference?

In this inspiring replay episode, Coach JPMD reveals a revolutionary model that’s helping physicians ditch the rat race and reclaim the joy of patient care. You’ll explore a blueprint for sustainable medical practice that’s disrupting corporate healthcare, slashing costs, and putting autonomy back into doctors’ hands — all through the power of Direct Primary Care (DPC).

By tuning in, you’ll uncover:

• How to dramatically reduce overhead and increase profitability without seeing more patients
• The surprising truth about how DPC practices are thriving — even in underserved rural communities
• Real-world strategies for building a cash-based practice that improves outcomes and brings back physician-patient trust

Hit play now and get re-energized about what’s possible for your future in medicine — no insurance approval required.

Know a physician who needs this? Share this episode and help them join the movement toward freedom.

Discover how medical graduates, junior doctors, and young physicians can navigate residency training programs, surgical residency, and locum tenens to increase income, enjoy independent practice, decrease stress, achieve financial freedom, and retire early, while maintaining patient satisfaction and exploring physician side gigs to tackle medical school loans.

Transcript

Coach JPMD (00:00.482)
By the end of this episode, you will understand how you can practice medicine on your own terms without accepting a dime from an insurance company. Welcome to the Independent Physicians Blueprint with your host, Coach JPMD, and that's me, where we help younger physicians decrease stress and increase income by transitioning from corporate to independent practices, even without any business experience. In this episode, you'll discover

how to dramatically reduce your practice overhead and increase profitability without seeing more patients. You'll also learn the surprising truth about how your own DPC practice can thrive even in underserved rural communities. You'll also discover real world strategies for building a cash-based practice that improves outcomes and brings back physician-patient trust. Dr. Gross is with us from Northport. It's a little bit north of Fort Myers, I think.

right down the road on I-75. Dr. Gross is the founder of Epiphany Health Physicians and is family physician, also a national speaker for the direct primary care. Is it a coalition or a direct primary care group?

Just the movement in general.

Okay. And you've also testified in the US Senate as well, which is really impressive. So I'll let you continue that introduction and tell us about direct primary care and what that is, because some of our listeners don't know. And I'd love for you to help us understand what you do.

Lee Gross, MD (01:27.598)
Absolutely. So I am a family physician by training originally from the general, the greater Cleveland area, graduated from Case Western Reserve University and did my training at University Hospitals of Cleveland. And in 2002, decided to look at what our options were in terms of practicing in family medicine. And in the Cleveland market at the time, back in 2002, you had basically two options. You had a market that was dominated by two massive organizations, the Cleveland Clinic Foundation and University Hospitals of Cleveland.

And those organizations were essentially consuming and gobbling up the entire market of physicians and ambulatory surgery centers and everything so that they controlled everything. So basically you either worked for one of those two organizations or you didn't practice as a physician in the Cleveland area. And that was not something that I really was interested in. So I sort of looked outside of the Cleveland market and found Southwest Florida to be a very attractive place to practice primary care. So I joined a group in...

Southwest Florida in 2002. I was a multi-specialty group. And after a couple of years, bought my practice from the group and took it solo. So in 2004, became a solo primary care physician. And interestingly, I was just like most other primary care physician at the time. I was completely insurance-based practice. I contracted with Medicare. I took Medicaid. I contracted with all the commercial carriers. And I was on a rat race for trying to figure out how to keep my practice afloat.

And every time I found a way to generate more revenue from my practice to keep free and coming in the insurance companies or the federal government or Medicare would change the rules and make that an unviable source. So for example, we used to do stress tests. You know, as a primary care doctor, you would think that the number one cause of death in the country being heart disease, you would try to diagnose that before the heart attack. And so we were doing stress tests. Well, Medicare basically banned the arrangement that we were doing to do stress tests. And so.

We started doing it another way, Medicare outlawed that or changed the rules on that. And eventually we had to sell our treadmill. We were early adopters of electronic medical records because they made phenomenal sense for our practice. They were excellent for our workflow. They made us more efficient. They automated tons of tasks that we were doing until they made it mandatory. And then when they made it mandatory and require meaningful use, EMR that we were using them to perfect for our practice was no longer a certified EMR. So we started a...

Lee Gross, MD (03:49.57)
brewing Medicare penalties because we weren't using a certified EMR. We were just using what worked for our practice. So we converted over to the certified EMR that was compliant, but the compliant EMR didn't do anything we needed it to do. That just stopped the penalties. So now we had to run parallel systems, one that did the job and one that kept us from getting penalties. And we were on this hamster wheel of playing whack-a-mole with the carriers and with the government and the insurers that we just said, you know what, we weren't happy.

Patients want happy. were having to funnel tons of people through the office trying to find multitude of things to do to them to generate revenue because a level three visit needed to become a level four visit and a level four visit needed to become a level five visit and it was exhausting. And I was unhappy and the patients weren't happy. So the name of my practice now, and this is a long-winded introduction, but it's relevant, especially to the people that have not been through what we have been through in private practice 20 years ago. The name of my practice is Epiphany Health right now.

And that's a really strange name for a practice, but we had an epiphany and the epiphany was in that background to say, why are we insuring primary care? Why are we inserting so many obstacles and barriers between doctors and patients and then filing a claim for every single basic interaction between doctor and patient? And then we're upset because it's expensive, it's impersonal, it's cumbersome, we get surprise bills in the mail. And so our epiphany moment came when a small business owner came up to us and said, doc, my insurance premiums for my employees are skyrocketing.

and they all see you as their primary care doctor. I know what I pay the insurance companies and I see what they pay you. And I'll tell you what, we're getting screwed. And he said, why don't I just hire you directly to take care of my employees and I'll take out a major medical plan against them for major catastrophes. And that was our epiphany moment is, you we don't need to insure this. We can work directly with our patients and with small businesses. And so we created a business model in 2009.

That was a subscription based model, kind of like Netflix is today, where we charge a flat monthly fee for unlimited medical care. And it turned out that that was one of the earliest direct primary care practices in the country. So anything that we can do in our office was included in that membership fee. So no copays, no deductibles. We don't bill any third parties. So I'm sorry to keep on going, but I promise I will give you a word in here. In January 1st, 2010, we flipped the switch and turned down this crazy idea. And

Coach JPMD (06:08.14)
No, no, this is great.

Lee Gross, MD (06:15.182)
interesting thing happened is that we started seeing uninsured patients come to our practice in Southwest Florida, all over Florida. We started seeing patients from Miami, patients from Orlando, patients from Naples, and they would drive two or three hours away because they could afford what we were charging. At the time, we were charging $89 a month for an adult, and we were charging about $49 a month for a child, for unlimited care. By the way, fast forward to 2023, so 13 years later, my price for an adult is now $85 a month.

The skyrocketing cost of healthcare has caused us to keep our prices flat now for 13 years. And the children are as low as $15 a month now, again, skyrocketing cost of healthcare. So the cost of coverage has massively exploded at 15 % per year. Our prices have been flat for over a decade. But it created an interesting problem for us because now we got a massive uninsured population that we now had to find ways to provide affordable care for them outside of our office because we're just priming our care.

But we need labs, we need imaging, we need physical therapy, and now we need some maybe specialty care. So we created an entire cash-based network of independent laboratories, independent imaging centers. And it turns out that when we did this, the prices for cash were cheaper than most patients' copays when they had insurance. And so our cash price for blood work or everything was $45. And we seeing 95 % discounts off of $2,000 worth of blood work we can get for $80.

Our CAT scans are $175. Our MRIs are $225. Our x-rays are $30. And so what are we ensuring when using the insurance actually blocks people's access and drives up the cost out of pocket for these services? So here we are 13 years later, still alive and slow. have four physicians in two locations. We started up a nonprofit foundation, and Docs for Patient Care Foundation, through the work of our foundation and federal and state advocacy.

We've helped nearly 2000 physicians across the country start up DVC practices through our training programs.

Coach JPMD (08:17.848)
You said so much and keep going in so many different directions here, but would you be considered a concierge practice or what's the difference between concierge and direct prior care? Before we even get into the details of what you said, because there's so much in there.

Yeah, so I think there's a lot of overlap in the terminology. Some of it's intentional. I would say that concierge is sort of where the direct power care model probably initiated, started. The analogy I like to use is that airbags, when they first came out, they were only on high-end luxury automobiles, but now they're standard on every single entry-level car. And so when concierge came out and was sort of elitist, it was a high price for the wealthy, the worried well with concierge level executive physicals and sort of things.

And now it's being done at a price point where if you can afford a cell phone, you can afford a direct card care doctor.

And that model that you're describing is less than one would pay. I look at the statistics, I pulled up the statistic. Actually, I want to share this with the audience. So this is the annual expenditure of all consumer units in the United States in 2021 by Statista. And healthcare expenditure is about $450 a month that the consumer pays for healthcare in this country. You're saying your model is much less than that.

Lee Gross, MD (09:44.386)
includes access to the negotiated cash prices that we have. So we have transparent cash prices. We don't bundle in MRIs and CAT scans and those sorts of things. I have nine different imaging centers in three counties that I work with that provide cash prices. Now we have cash price surgeries. We have a cash-based hospital that we're working with. If you have no insurance, then the prices for these things are affordable for most people's budgets for services. Things that people think...

they had to have insurance for are actually more affordable for most people. And in fact, a lot of times people are paying so much for their insurance and their deductibles are so high that they actually can't afford their insurance and the services they need. So they end up picking just the insurance and skipping their health care.

Yeah, that's very interesting. So is this similar to the Christian Health Network? I heard this advertised online or in radio stations where they're creating a membership model for a group of people. Would that be something similar to what you're doing?

think what you're referring to are the health sharing ministries, which there are many varieties of, and those pair up very nicely with what we're doing. The way I kind of remember that was I grew up in Northeastern Ohio, so we had a very large Amish community that they had no health, they don't use health insurance for their medical care. And so one of the members of their community gets sick, they pass around a hat, they go from home to home and collect money to pay medical bills. So the sharing ministries are same general concept where

whether it's faith-based and oftentimes it is faith-based where they pool together their resources to pay each other's medical bills. And now that insurance is getting so expensive, this concept of pooling money to cover each other's healthcare costs is becoming more more popular in the health share world. But those are, again, uninsured patients' share in costs. So they are all cash-based consumers trying to shop at a store, which is our crazy healthcare system that has no prices on it. So we go through that store, we put prices...

Lee Gross, MD (11:41.972)
And so we provide the primary care services and create cash-based services. And we've gone well beyond that now, and now we're contracting with self-insured employers and self-funded health plans and so forth.

So going back to the original model of that employer that came to you, that one of their members or their employees to come to you for care, you said that they purchased a catastrophic plan. So you have this group of patients who get regular primary care and they do their blood work or cholesterol or diabetes screening, but then they get cancer. That catastrophic plan would cover the cancer treatment or how would your model help in treating patients who are going for cancer treatment?

where medicines are costing $10,000 a month, $20,000 a month.

I think pretty much every model of care is always complicated when you're dealing with high cost long-term issues. I think most of them handle a one-time major cancer about fairly well. It's that ongoing product condition that's high cost that may last 10, 20 years. A high cost catastrophic insurance may have a $10,000 deductible, but once you hit that, 100 % of your costs are covered by the insurance plan. That's very helpful if you needed...

You know, you had a heart attack, you need to bypass surgery, your out-of-pocket costs are capped. And $10,000 sounds like a lot of money, but honestly, on the Affordable Care Act exchange, the average deductible nowadays is about $10,000 to $12,000. So, you know, at the time, the $12,000 seemed ridiculous, but now that's actually the norm. Every plan out there is a high deductible plan and every pace of now is essentially a cash paying consumer.

Coach JPMD (13:18.254)
And I'm one of those patients, right? Because I have a high deductible plan. I think my deductible is between five and $10,000, depending on the procedure. And what I did, my wife actually found a functional medicine doctor who took her off her thyroid medicines and did some specific blood work that aided her in guiding her through supplements and physical activity, things that has helped, but it costs us a lot of money on top of what we're already paying for insurance. So what you're saying is...

those consumers would not have insurance by their employers at all? Or how do they get a catastrophic plan if it's employed?

So it's tricky now. I will tell you that when we started this, it was very easy because those plans were widely available. Those plans would cost $50 a month. The Affordable Care Act outlawed those plans. They're illegal to buy now. so you can't buy, unless you're under the age of 35, you can't buy a catastrophic only plan that's compliant. So nobody really sells them. They're trying to make a comeback, but they're ripped again. That's just a fight over that you can't have junk insurance policies because they need to cover everything.

Turns out when you cover everything, the policies get extremely expensive and most people can't afford them. Same with subsidies. So interestingly, to your point about you and your wife and the functional medicine and coming off of medications, when I'm an insurance-based doc, and I have got to see 40 patients a day to pay the bills, then I have seven-minute office business and five of those seven minutes have to be spent clicking the boxes to make sure I meet the metrics to get paid by the insurance company. So five of those minutes, my face is in the computer with my back to the patient.

So

Lee Gross, MD (14:49.806)
And I got two minutes basically now to manage your diabetes. So either I'm going to refer you out to somebody or I'm going to write you a prescription is what I'm going to do. But it takes time to get somebody off medications. So it takes about two or three minutes to write a prescription, but it takes 30 minutes to not write a prescription. And so that's the beauty of what we do in the direct primary care model. And again, similar to the concierge model, we have the time because we're not fighting your insurance company. My staff is not behind the scenes fighting with your insurance company for authorizations that

approvals. We hire clinical staff to do clinical tasks, not insurance-based and billers and coders. We don't have billers and coders in our projects. We have nurses and medical assistants doing patient care. So I have 30-minute office visits so I can explain to you what you need to do to come off of your diabetes medicines. And I can write you a $600 insulin pen, or I can spend a half an hour teaching you the lifestyle choices and then see you back at frequent intervals or hop on a video chat.

to reinforce what we've talked about to get you off your meds and keep you off your meds. And that's how the system ends up saving money.

You're absolutely right. And I saw a patient yesterday, actually, she came in and she's trying to lose weight. She's struggling with it. And I hadn't seen her in probably eight months. And we spent a good 10, 15 minutes talking about what she needed to do. And husband is kind of echoing what I'm saying. And at the end of the visit, she says, doc, can I see you sooner than six months? Because I felt like she knew that if we had more frequent visits, we'd be able to further solidify the things that we talked on the visit and

I said, yeah, I would love to do that because it's easier for me to prescribe a medication. Really. I could have prescribed those bake or all these other medicines that, you know, they're looking to prescribe to lose weight. But once you stop the medicine, if you're not changing the mindset, then they're going to gain the weight again and we will be back to square zero. It's very interesting that you're saying that. So you have a primary care model. They, you have a membership B that members pay. Do you have a specific number of patients that you need to treat to cover the overhead expenses? Because.

Coach JPMD (16:51.602)
I would imagine that you have clinical staff, not coding staff. You got to pay facility fees and what are your overhead costs and how do you know how much, how many patients to have that you need in the membership model to cover your expenses.

I think you probably in your introduction to the question answered the question is it really depends on what your overhead costs are and how much money you need to take home at the end of the day, which is how your fee structure is going to have to work and how many patients you need to make that happen and what your community can bear. So what works in Manhattan may not work in Arcadia, Florida. Different price points, different populations, different needs. So what I would say is that a typical overhead

cost in a primary care practice because primary care is very overhead intense. It's a lot of human labor, a lot of touches, and it's very heavily office based. So, typical primary care runs 50 to 60 % overhead. The direct primary care practices run closer to 30 % overhead. Some of them run a little leaner than that. Some run a little heavier than that, but 30 is probably about the national average from what I've seen. Most practices run between 600 and 700 patients on a full level.

I, that, you know, typical primary care doctor can make as much as a primary care doc on the treadmill.

Yeah, running from place to place and doing the things that we continue to do and not be informed of these things, these practices.

Lee Gross, MD (18:18.354)
And it's not headache free. I mean, it's still challenging. It's still complicated. This isn't country club medicine. We're not treating the worried well. In fact, what we attract are some of the sickest of the sick patients that need the extra time. And so oftentimes we get accused of sort of cherry picking the healthy people and leaving the sick for the system to take care of. And in fact, it's usually the opposite. It's the sick that have heavy needs that highlights the failures of our broken system.

that causes them to seek out docs like us that have the time and the ability to provide the intense.

Are they willing to pay? those sicker patients, have multiple medical problems. Some of them have psychosocial problems, poor living situations. Are they seeing the value in paying that $85 a month?

Yeah, and if they don't, they don't renew the membership. That's the beauty of sort of market forces is that if we're not providing a valuable service to them and they don't perceive the value, then they won't come back. They won't renew it. I mean, they have the option to cancel if they choose to. Our retention rate is fairly high.

And for those that are leaving, you find that they're a risk for the practice? If they're leaving the practice and they're not paying the membership fee anymore and they perceive it as not something that is valuable to them, how do you see that as a risk to your practice?

Lee Gross, MD (19:33.102)
Yeah, I mean, think we have sort of a constant churn level of new patients to patients leaving out of our practice. It's probably about 1 % per month that cancel memberships. The most common thing I might hear is, have new insurance now and I'm going to go find a doctor that takes my insurance. And quite honestly, they come back, they experience what it's like to you know, wait two months for an appointment and oh, by the way, when you're sick, can...

You know, see me in three weeks, you can see my nurse practitioner next week, or you can go to the emergency room or urgent care now, and they don't get messages returned. And so that's sort of our best marketing is to have people sort of go out and experience what it's like in some of these large corporate practices that are all about filing as many patients through as possible, waiting two hours to be seen in the waiting room and then getting two minutes with the doctor. That gets frustrating quick. So those patients do end up coming back. So that's actually good marketing for us.

talk a little bit about some of the work that we're doing in rural healthcare too, because this is something that doesn't just work in North Port, Florida, which by the way is one of the fastest growing cities in the state of Florida, if not in the country. But we also have an arrangement in Arcadia, Florida. It's DeSoto County, second poorest county in the state of Florida. And we have a relationship with DeSoto Memorial Hospital. It's a 49 bed rural hospital. And if you're following the plight of rural hospitals across the country, they are desperately seeking life support and COVID was miserable to them.

And so we've probably in the last three years lost over a hundred rural hospitals and once they go, they don't come back. So we partnered with a rural hospital and if any of their employees sign up with our direct crime or care practice, the hospital pays for their membership for them. And then they restructured their employee health plan around our practice and said, okay, if any of these employees that are seeing Dr. Gross and his practice have any services done, they're a hundred percent automatically covered.

and we'll waive all copays and all deductibles. So they've given us free rein and eliminated all step edits, prior authorizations, and anything whatsoever, as long as it's done in the hospital. Any service that's done through us is free to the employee and paid for by the hospital. And we're now four and a half years into that arrangement. We've saved by eliminating deductibles, eliminating copays, providing access to free primary care with no copays, no deductibles.

Lee Gross, MD (21:51.49)
We've saved that hospital's employee health plan 55%. The employee's premiums have been reduced 30 % and have not increased one penny in almost five years. This hospital, while most hospitals are sucking wind, has had some of its best financial years in its history because we've taken their number two line item expense behind human labor, which is their employee health plan costs, have reduced it by 55 % and frozen it for five years. That is something that is unheard of if...

that were done in a Medicare population that would be front page of the New York Times above the full. And yet we're doing it in one of the most vulnerable populations and providing better care and better access.

So why wouldn't at least the Florida government look at that?

Everybody's looking at it. We're speaking with governments from Utah and Montana and Texas and Wyoming. And yes, people are definitely paying attention to what we're doing in central Florida.

I think that's amazing because I think it gives hope to those physicians that are coming out that may not understand what you just said. And maybe we should go back and listen and research this. And maybe if you have any articles, I'd love to post some articles about these numbers that you're showing. Because if we can slowly tell physicians, show physicians that this model is possible, and then go and take it to other rural communities, because I live in somewhat of a rural community in this area, and the hospital costs are insane.

Coach JPMD (23:15.726)
CAT scans of the abdomen and chest costing $18,000 even though they have insurance and they're Medicare Advantage insurance. So they're fleecing the Medicare system just because they have insurance because they went as an outpatient versus an inpatient because they didn't go to an independent diagnostics center. It's just a mess. But if you're seeing that you have a model that works like this and hospitals can make more money, I'm not sure why they wouldn't do it.

So in 2019, the rural accountable care organizations, the rural ACOs saved $63 per beneficiary. And in our first year, we saved them $2,000 per beneficiary. So it's not even a fair fight in terms of sort of practice design and structure. The other thing that we did with this hospital is we created cash-based surgical bundles for uninsured patients. So we created a draw for medical tourism into this rural hospital. So while most rural hospitals see patients leaving the community for care,

we've created a demand for community or for services to come into this community for elective colonoscopies, elective hip replacements, elective knee replacements. And so because of the quality and drive that we've done, we've turned a hospital that basically didn't have enough volume to even have a single CMS star. It's now one of the few five CMS star hospitals in the state of Florida.

amazing and it needs to be broadcast all over. I hope that you're Yeah. That's, that's you're practicing impossible. That, is exactly what we do here. So I know that you've got a hard stop coming and I'd love to continue the conversation, but there's so many questions I have and I'm sure my audience have similar questions and if they want to get ahold of you is hear what you have to say. What's the best way to contact you?

hate him.

Lee Gross, MD (24:59.04)
So they can go to my practice website. It's epiphany.health. that's where you can read about our practice and the practice model and the structure. We also have a nonprofit foundation. It's called Docs for Patient Care Foundation. That's D the number four, PCfoundation.org. And every year we put on a direct primary care conferences, grant supported where we teach physicians how to structure their practices and give them details on how to make this successful for themselves.

So what you learned today is that you don't have to see more patients to make more money. DPC practices are on the rise and can help you decrease your stress and you can improve patient outcomes if patient centered incentives are aligned in the right direction. Thank you so much for listening to the podcast. If you'd like to hear more, subscribe, follow on your favorite podcast app so you'll never miss an episode.