Pioneering Direct Primary Care: Kelly Botta's Journey of Resilience and Innovation in Family Medicine

When you're at the crossroads of your career, sometimes the road less traveled leads to the most fulfilling destinations. Kelly Botta, a Physician Assistant with a fire for change, invites us into her world where she transformed her professional trajectory from the confines of traditional medicine to the boundless horizons of her own direct primary care practice, Smarty Pants Medicine. Through her candid recount, we hear of a journey marked by burnout and bravery, as she navigates from a structured group setting to her leap into the entrepreneurial waters of healthcare during the thick of COVID-19, all while balancing the acts of patient care and motherhood.

Step into the intimate spaces of house calls and the strategic expansion to a physical clinic with Kelly's personal stories that resonate with heart and healing. Her practice isn't just a medical endeavor; it's a testament to the strength of human connections and the significance of safety, particularly in these peculiar times. From the driver's seat of her car to the welcoming doors of her clinic, Kelly's experience sheds light on the pivotal role of telehealth, and the profound impact of direct primary care on both provider and patient well-being.

With a blend of entrepreneurial savvy and medical expertise, Kelly unveils the behind-the-scenes of running a direct primary care practice. From the decision to manage a smaller patient panel for a sustainable lifestyle, to adopting cloud-based EMR systems like Atlas MD for seamless patient interaction and management, Kelly's narrative is rich with insights. She shares how this model proposes a unique compensation structure, challenges the norms of healthcare, and fosters a space where physicians can practice medicine aligned with their personal values—a revolution in family medicine that's as smart as it is compassionate.

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Transcript

Speaker 1: 0:06

Welcome to the DPCNP. I'm your host, amanda Price, family nurse practitioner with two decades of experience, including 16 years as a business owner. Hey everybody, welcome to the DPCNP. And today I have a special guest for us and it is Kelly Bada, and she is a physician assistant, Kelly welcome to the show, thank you, thank you for having me, amanda.

Speaker 2: 0:29

I'm excited to be here.

Speaker 1: 0:30

I'm excited too, because you have a unique clinic that I can't wait to hear all about, and maybe somebody will be inspired by it. I hope so.

Speaker 2: 0:37

Yeah.

Speaker 1: 0:38

So tell me, first of all, your journey to get to the point where you became a physician assistant.

Speaker 2: 0:44

Sure. So that's going way back to just becoming a PA or to be starting the DPC. Just to clarify.

Speaker 1: 0:49

Just go back to when you became a.

Speaker 2: 0:51

PA.

Speaker 2: 0:52

Okay, so I always knew since high school I was really kind of a nerd and I was interested in anatomy and medicine, and so I thought, going through undergrad, that I was going to be going to be a physician and I thought maybe I would end up in orthopedic surgery.

Speaker 2: 1:06

And then, as I went through school, I learned about this profession called physician assistant and I thought that this would fit a lot better with the lifestyle that I wanted long term, because it got me through school faster. I always wanted to be a mom, and so getting through school was a big deal to be able to balance that, and then also the fact that it was shorter and more affordable was appealing, and I loved that. We could also, as PAs, change fields of study, and as a physician you have to get certified in just one spot, and so that kind of fits my personality. I always like to try new things and do new things, and I thought that really sounded like a good option for me. So I stopped going down the med school track when I learned about our profession, and the rest is history.

Speaker 1: 1:43

I saw that you went to Shenandoah University.

Speaker 2: 1:46

I did yeah, and I still live in the same town where I graduated, so I've really stuck to the mission of the school, which is primary care for our local community.

Speaker 1: 1:53

So how did you become an entrepreneur? Did you work for somebody first, and then you learned all your experience and then move on to opening your own practice?

Speaker 2: 2:04

I did. I grew up, you know, I've always kind of been around entrepreneurs. My father owns his own business and is in small business and so it's just kind of in our DNA. But I never thought in medicine that I would own my own practice or even be interested in doing that. So that was really not on my radar until, you know, six months before I decided to take the leap. So, yeah, straight out of school I practiced internal medicine with a private multi-physician group and they were really incredible physicians. There was a PA there as well, so I had lots of colleagues to learn from and it was a great environment and I was there for years and years, loved that. I did a few years in the ER the first female PA in our ER here and that was an interesting experience. And then I really missed primary care. So I went back to internal medicine and I've been in that field since. So when I decided to take the leap I had my second daughter and ours.

Speaker 2: 2:55

We. You know our small private company had been bought out by a large health system and so the whole vibe and management and clinic and the way we ran the practice really shifted over that 11 years. You know that I was practicing in that setting and I didn't know it then because this was pre COVID, but the term would be burnout that we are all very familiar with now, but that was not commonly spoken about. As you are aware, in our field, in healthcare, we don't talk about burnout, and so I didn't know what I was feeling. I just knew I didn't feel like I could sustain what I was doing anymore. I wasn't feeling like myself. I had a small infant and I was trying to work, you know, 10 to 12 hour days with extra charting, and we realized this was not sustainable for the life that I wanted to build for my family and so I decided to resign and I really didn't have a plan other than I was going to do some per diem work because I love my job and I love being a PA and I love my patients. And I cried when I left but I knew something was off for me and we had to figure that out. And luckily I have an incredibly supportive husband and he just said you know what? Just just resign, take a break and we'll figure it out. And I'm really grateful for that and I'm it's not lost on me that that's a really privileged thing to be able to do, and so I'm just, I'm really grateful I was able to step away and deal with what I now know was burnout in a healthy way.

Speaker 2: 4:08

And then, you know, I was really COVID happened within two months. So then I was forced to be stuck in my house after working you know a lot out of the house. So that was a big, a big shifter, but it gave me a lot of time to think and I wanted to practice and I couldn't because there was no positions open at that time. I was per diem at a lot of different places, waiting for hours, waiting for hours, and there was just there wasn't any work. And so I figured you know I really miss medicine and I want to practice primary care. Like I love the longitudinal nature of it, that we get to know our patients and their families often, I just really missed it.

Speaker 2: 4:41

And so I thought there's got to be other people in the United States who've burned out from medicine and they want to practice more sustainably. Certainly I'm not the first person who's trying to figure out a better way, and so when I started really digging into that, that's when I learned about direct primary care and, to be truthful, I didn't want to start my own. I wanted to work for somebody else, but in our town we're very rural and so the closest DPCs to us were an hour and a half away and that didn't solve my problem. That would still be a 10 to 11 hour day. So, after I talked to a lot of owners, I just cold called you know some practices and the providers were incredibly gracious and spoke with me and I realized this was a real thing that people are actually doing and it works. And it had better balance, like I was reading, and so I talked with my husband and he just suggested why don't you start one? And there we go.

Speaker 1: 5:28

Wow. So were you just Googling stuff and you fell upon DPC as an option and you started reading about it, or did you already know about it?

Speaker 2: 5:36

I had no clue what DPC was. I actually think I found it through concierge medicine when I was looking like more sustainable ways. Yeah, I was looking like more sustainable ways. Yeah, I was googling more sustainable ways to practice medicine, you know lower patient volumes, you know and I was just good, I was Google trying to figure out how can I fix this, and it led me to concierge medicine. And then there was articles comparing and contrasting the differences between direct primary care and concierge medicine, which I had never heard of. So, yeah, it was somewhat serendipitous and somewhat just doing the research.

Speaker 1: 6:03

I can't help but focus on the fact that you had that period of time where you felt like you were burned out, and I felt that way too. I honestly wanted to leave the whole career and try to figure out something else to do. Did you have a moment where you thought maybe you had gone into the profession prematurely and maybe it wasn't meant for you?

Speaker 2: 6:23

That's so interesting and I'm sorry you. You went through that Also. I think it's so much more common than any of us talk about or realize. Luckily, that conversation is opened up quite a bit with COVID, but I still think it's not not really widely accepted. We don't have good support. So I'm glad you've been able to find your way forward. Also, you know, I really didn't, I really didn't ever want to walk away from medicine. I really feel like it's in my DNA and I love it and I'm just one of those people who feels like I'm wired for it.

Speaker 2: 6:51

Now that doesn't mean I wasn't trying to figure out a way that maybe I didn't want to do patient care right. Maybe I wanted to be in medicine as in a different role for a little while. I thought maybe it was just, you know, oh, I have small kids. Maybe it's just too much when you have small kids, you know, and that triggered a whole bunch of other stuff internally that I didn't want to identify with. Like you know, maybe you're not tough enough to do it or maybe, you know, maybe motherhood is not cut out with medicine, even though these other people are doing it.

Speaker 2: 7:13

You know, maybe I'm somehow broken that I can't figure it out, and so that whole processing to be in patient care, but I didn't want to be doing high volume and I didn't want to be doing so many days or hours, and I tried doing urgent care for a while, which I think a lot of us kind of end up in as our transition period, and it just didn't bring me the same personal satisfaction that primary care did, and so I knew that would be a great temporary solution. But I didn't want to do that for years and years, and also I was concerned that I would lose my edge. You know, with clinical medicine there's a lot changing and there's a lot of medications we use, and when you're not using them regularly, you do lose them, and so I think that's really what spurred on my research was I didn't want to be out of the field for very long and lose my competitive edge.

Speaker 1: 8:02

So from the time that you stopped working at the big, huge clinic and then COVID hit, how much time passed before you opened your clinic?

Speaker 2: 8:11

Yeah, man, that's a great. I don't know if I've ever calculated it. So let's see I resigned in December 2019 and COVID happened in March, and then I started officially in October 2020. So less than a year and that means I actually didn't learn about DPC till COVID was kind of happening In under six months I had I learned about it and started.

Speaker 1: 8:31

Well, you were given this opportunity to sit and be still and have time to do this research at home and be like, oh my gosh, I think I just found an answer that is going to solve all my problems.

Speaker 2: 8:44

I'm not sure what your listeners or your own, you know faith beliefs is, but I believe in God and I believe in providence and I really felt like now, looking back, I even see that I needed to get to that point to walk away from traditional care, where because I'm built to be loyal and I don't think I would have ever walked away if it didn't get so bad to where I felt like my family was being impacted by it, and that was the tipping point for me. So I even see the good coming out of that, because it forced me to find a solution.

Speaker 1: 9:14

And you have quality of life now.

Speaker 2: 9:16

So that's huge yes, yes Okay.

Speaker 1: 9:19

So along comes smarty pants medicine. I need to know where did that name come from. So cute.

Speaker 2: 9:27

Oh, thank you. Yeah, I wanted to have a memorable name A lot of the offices and practices in our area. We're like a big time apple growing area. We supply apples to like the whole nation. Everything is like apple blossom, this or Winchester family, you know practice and just kind of all names locally. And so I thought what I'm doing isn't like anything that anyone else is doing and I don't want to be afraid to do something different and to have a different name, and so that let me just start thinking creatively.

Speaker 2: 9:55

And when I heard about direct primary care, I thought this is brilliant. This truly solves the healthcare problem, at least in the primary care outpatient world setting. This system is widely broken, as we all know, and it doesn't fix it across the spectrum, but in my particular lane it does solve the problem. And so I just thought this is brilliant, this is smart. And then I got the idea of this is smart healthcare. And then Smarty Pants. Medicine is something that I call my kids Smarty Pants all the time, and I've always said it, even through PA school. When I started the practice I had one of my former classmates message me and say you always said smarty pants, even back in school and I didn't actually realize that, but I think it's just part of my vernacular and it kind of came out and I thought, hey, that'll probably be good for marketing to. You know, people might remember it. And that has proven to be true.

Speaker 1: 10:45

Oh, they'll definitely remember, because when I was emailing you I didn't have to think what was her email like, I just remembered it, of course.

Speaker 2: 10:51

So it feels. I mean, it still feels risky to me sometimes, but it's okay because DPC is different and it's good different and it's okay to be different and we want to be different because what we have in the current system is broken for everyone involved, and so I'm excited about it. I'm excited about the future.

Speaker 1: 11:09

Yes, so let's talk about the uniqueness of Smarty Pants Medicine. You don't have a brick and mortar yet, so you've been operating out of your car, so talk to everybody about what does that look like, how did you come up with that was going to be your business model and how you know? How does what does it look like? Yeah, sure.

Speaker 2: 11:31

So, of course, you know, starting up during COVID and I was kind of a scary thing scary time to start a business because you do have to make some investments and the whole world was upside down. And so I thought I would be crazy to take on space during that time when people aren't even leaving their houses. You know, how am I going to build a practice where people are coming to me? And so I just started researching if it was possible to do house calls for medicine. You know, this is direct primary care is very personal, and to me it really models a lot off of the way healthcare started in the beginning, whenever physicians made health calls and it was relational and it was personal and they paid directly to the physician when this started, right before we had health insurance. And so I thought, well, okay, maybe I can do that. Is that legal, is that possible? And so I did the homework on all of that and I saw that there were you know, you are able to do that and a lot of concierge practices are built that way, in fact, and so I just thought this seems like a good way to go. It keeps my overhead low. It'll give me an idea if there's a market for this in my area and it also keeps me at home, which is where I wanted to be. You know, most of the time I can do telehealth from home, I can answer emails from home. Of course, I still have help here, but I'm at my house and when I have little kids I'm accessible if they need it, and so it just seemed to fit with where I was at my season of life and the whole thing was just a big, grand experiment and it's been proven that it works. So house calling has been great and I'll tell you, patients love it because they're not wasting time driving, sitting. You know it. Just it gives them back time. It puts that on us as the provider, and so it's actually been really fun for me.

Speaker 2: 13:06

I get to know my patients in a different way. When they're hosting you in their home right, and so it is it's very personal. I know their families, they know my family, and so it's a different way to practice. I was scared of it at first. There's concerns as a female doing that, I'm sure as a male as well, but just it's unknown, and then you know the safety side of it and just wondering how it would go. But it has been awesome and I think when things are built off of mutual respect and there's clear boundaries and you know there's things that we do take in precaution for safety stuff, it's been a total non-issue and a really enjoyable way to practice. And also it's shown me my parts of my area that I live in that I never knew existed, and so that's been kind of fun it's. It's almost like a little adventure when I go somewhere new and so that's kind of nice and very different from being in white walls with fluorescent lights and I've loved it.

Speaker 1: 13:53

What precautions do you take in order to make sure that you're safe when you go to someone's house?

Speaker 2: 14:00

Yeah, so I probably won't tell you all of those, just for safety reasons, sure, but one of the things that if other people are thinking about starting these, I would suggest you consider has worked out really well for us is we always do our new patient visits as a telehealth visit, so on video, and that way we have a chance to talk through you know medical history and we get a chance to meet each other and, even though it's not in person and healthcare, we are trained to read people and so you can kind of get a sense of if it's a situation in a patient provider relationship that you feel okay with and comfortable with, and so that is something that I'm really thankful that I do as a screening and, honestly, it's never been a deterrent for me. Thankfully, you know, I haven't had to walk away because of that, but there do have to be certain things in place, and that's one of them that I would strongly recommend. It's not the best idea to just show up blind at a location you don't know. So telehealth gives us that opportunity.

Speaker 1: 14:51

I'm sure it's similar to a home health nurse having to make her calls as well.

Speaker 2: 14:55

So exactly, and that did take my anxiety down some, because physical therapy has been doing this for years, home health has been doing this for years, occupational health, you know, and so this is an accepted thing in our industry. It's just something that as providers we're not usually as comfortable with. There are a couple of physicians when I first started practicing that made house calls to their older housebound patients, but it was very, you know, one-off here and there. So it's been, it's been really enjoyable.

Speaker 1: 15:26

Is there a certain mile radius that is the limit of which you'll go, and what if one of your patients lives beyond that?

Speaker 2: 15:30

Yeah, great question. So we do, I. We serve a 30 minute radius from the center of Winchester, and so that's how we figure that out in a equitable way. And then we do travel up to 45 minutes and there's a travel fee if you live in that further distance and so decide you know to do that or not outside of 45 minutes, and there's a travel fee if you live in that further distance and so people decide, you know to do that or not. Outside of 45 minutes, we don't go. I usually try and refer to one of the other practices, but in a couple months we're going to also be offering a brick and mortar location and so people will have that option then to drive to us.

Speaker 1: 15:59

I was going. That's a good segue into what made you decide to start a brick and mortar. If it's going well and you love what you're doing, where did the transition to have an actual place come into play?

Speaker 2: 16:14

Yes. So there was a couple different things that just kind of unfolded as the practice has grown that have shown me that we need to have a location. One of those is my patient panel is full and so I don't have the capacity to take on, you know, any more patients for now. So that meant I was looking at hiring and so I was thinking as an employer it's gonna be a lot bigger of an ask for me to ask somebody to go do house calls than to put them in a environment that they're already used to. The model that we're practicing is already very, very, very different for people to wrap their minds around, including providers, and so to me that felt like one thing I could bridge the gap, you know, for the difference for them. The other thing is it's just more time, efficient, you know, to have patients come to us and we can keep the costs lower for them because we're not spending so much time of our time as providers driving to and from at a reasonable cost where every day people can afford this type of care, and we don't have to have it in a higher bracket that excludes some people in the community. So that's appealing. And then I do do procedures in home and EKGs in home you know that are appropriate for that setting. That's hauling a lot of stuff to the patient's house and it takes a fair amount of time to set up Not that that's an issue for me, but it's much more efficient if we already have an environment where that stuff is set up and the patient can come in, get their service done and leave and they're not waiting for me to set all of these things up, do their procedure, clean all of it up and pack it out. So from an efficiency standpoint I think that'll be a really nice perk that people will have a choice on.

Speaker 2: 17:43

And then the last thing was we worked with some small employers, local small businesses, and where we're situated in Virginia is kind of unique. We're right at the very top northern part of Virginia. We 30 minutes are in West Virginia, We'll just say it that way. Across state lines gets tricky for medical license and being able to house call and physically practice medicine in another state is like a whole nother thing. And so some of our employers have employees from multiple states and so right now we provide care on site at their business.

Speaker 2: 18:12

So right now we provide care on site at their business and as we grow and we get multiple businesses, that's going to become harder and harder to provide the level of care that we want to. So by having a location, then we can kind of draw from, you know, the different states, the different areas and people who are driving away for jobs in a more efficient manner. So I'm really excited about it. I think there's, you know, we're still going to stay a house call practice. That's one of the unique things that we do in our area that nobody else does. Patients love it and, like I said, I enjoy it. So we're not going to get rid of it. But this will just be another facet to the practice.

Speaker 1: 18:42

So it looks like on your website you've already hired another PA. Is that true? I just did in January. Yeah, awesome she's, since you haven't technically opened up your brick and mortar, so she's willing to do the house calls and things like that. So what is her opinion on it? Do you know? I do.

Speaker 2: 19:00

Yeah, I just hit the lottery with Jesse. She is a brilliant PA. She graduated from my same university and actually has a few years senior to me. She's been practicing a bit longer and she was looking for the same thing just better balance with her life and interestingly, it's not a very fast process to get a brick and mortar place, you know, up and running, and so it's taken a little bit longer than we wanted. But she was already doing a per diem job where she was going into homes and doing these evaluations for a medical company and she was going into just a lot of different home settings that we don't find ourselves in. She was very comfortable doing that. When the process of getting the office open stalled out a little bit, she was more than willing to do that because she was missing practicing, you know as well, and so this has been a great way for us to be able to provide both services.

Speaker 1: 19:46

Are you willing to share with us how you came up with a salary for her, or how do you compensate her when you you know she hasn't brought on? Clearly, she doesn't come into your clinic with a full panel, so how did you work that out so that it worked for you and it worked for her? Financially?

Speaker 2: 20:07

Yeah, that is the question right, and so that is what makes this such a hard leap, because as pas, we don't usually carry our own panel. Some of us do. But when we switch models, even if you had your own panel, you know that percentage that follows you is not that large from what most of the providers say who've done it that way. And so, the way you know, there's multiple different ways that you can choose to do reimbursement, but what we've decided to do is model our reimbursement more to match how the physician owners, you know, model theirs, which is the more people you have. You take a percentage of your panel, and so we we based it that way and the understanding you know, with the understanding that that means a much lower income upfront for her, but that has basically an uncapped potential based on how much work she wants, which is also very different from a standard salary.

Speaker 2: 20:55

And so there's upside there that's mitigated by the initial lower start rate and I think for those of us who have the ability to take that risk, it is a risk but it's also a solution, because we're no longer willing to practice in the setting that's been offered to us. Like I said, I just feel like she's been a gift and she was in the right season of her life and financially stable enough to be able to take a lower income as we grow her panel. And then, you know, it takes a special person to do DPC because we do have to be in the community and get our name out there and you know, explain what this, the way we practice medicine, and so it takes effort. You know people don't just show up on your schedule the way they do in traditional care and so I think finding the right person who thinks that's fun and has that entrepreneurial spirit, it has to be that kind of person I think to fit with this model, because it takes significant effort to grow our patient panels.

Speaker 1: 21:46

I completely agree, because you're only going to grow your panel with your customer service, your personality. You're not going to grow it if you're not a personable person.

Speaker 2: 21:57

Yes, yes and I. That made me really uncomfortable at first because it was totally new. People always just showed up on our schedules. What a luxury, right. Little did we know that that was one of the upsides of working for a larger company, so that was. That was scary at first. But once you change your mindset and you understand the value of what we're offering and how incredibly streamlined, convenient and personal the care is that we give, it doesn't feel like a sales pitch. It feels like I'm educating you about this incredible opportunity to get care a different way. And if you don't want it, that's totally fine, but it does exist and most people simply don't know that it exists.

Speaker 1: 22:35

Yes, exactly, and it is, I think, revolutionary for family medicine for sure, because you can actually get to, you know the root cause of people's problems. You're not just putting you know, dishing them in and out, just trying to find a pill that's going to just pacify their complaint and then just come back in for a whole. Nother waste of your time for another eight minutes of something else If that doesn't work. I like the fact that DPC allows us to spend enough time with the patient that we can actually ask all the questions that we need to ask in order to get to a very logical reasoning behind what the problem is.

Speaker 2: 23:13

I totally agree. It's been revolutionary for the way we're able to do especially chronic disease management. Is you just you have the time that you need. And the other nice thing is if we need to do follow up, we have the time to do it. Our schedules are not booked out for two to three months to where if we need to do a blood pressure follow up we don't have to push people out so far or give them to a colleague. We have the space in our schedule to be able to take care of, to really take care of our people, and patients really appreciate that and it's just a better way to practice. And I think it's, like I said, it kind of harkens back to the way medicine was before. We got pushed for high volume when the big system began, so it's been very fulfilling. I think you know when the big system began, so it's been very fulfilling.

Speaker 2: 23:55

I think you know there's some talk in this community about like ethical and moral burnout also, not just like the physical rush of it, but feeling good about the way we're able to practice and knowing that we're doing a great job. That's really important to the personalities, for people who go into medicine and want to help, when we feel like the system is no longer crippling us, to practice the way we want to practice, and so that has been one of the biggest upsides of starting. My own thing is I'm really proud of the way I practice. I'm very proud of the care I provide. I know it's good care and I know you're not going to get it anywhere else, and so that does something, for some days are even long, or some days you know they don't go exactly as you were hoping as an entrepreneur, but feeling really good about the work we do is invaluable.

Speaker 1: 24:35

How large is your panel and how large is your other PA's panel?

Speaker 2: 24:39

Just for context. I don't know if people know you know patient panel sizes but in traditional practice usually it's two to 3000 people. If you're working full time In direct primary care it's typically between 450 and 650. Somewhere in there is considered a full panel. I have no intention of working full time. I don't want to work full time. I think you know there's beauty and having a better balance. So, that being said, I've kept my panel around 150. And that way you know that's lower than most. But when you're house calling you're almost tripling the time, you know that you're spending.

Speaker 2: 25:09

So that seems to be a sweet spot for me. When I get over that, I feel like I'm doing a little bit too much, and so I've kind of sat there and that's been working. And Jesse's panel right now is growing, so she's still under 100. She just started in January but she's growing steadily every week, so we're anticipating that she's going to be there for sure within the year, which is very exciting.

Speaker 1: 25:30

Do you anticipate that you'll have to increase your panel size when you start paying rent on?

Speaker 2: 25:37

a space. Yeah, so you know, navigating as an entrepreneur in a small business is you got to be savvy. You definitely need to have some good financial predictives, and I'm not planning on increasing my panel size. I've actually not been taking a very large salary on purpose for the last couple of years since we started, because I wanted to have the flexibility to grow and bring somebody on and not have to take out a lot of loans for that, and so that was the way I approached it. You certainly can approach it differently, and most people would take out a business loan. I just personally didn't want to unless I had to, and so the practice is financially healthy right now, and so we're in a way that I'm going to be able to carry that with what we already have. So I'm very happy about that, and so as long you know, as long as we grow, we'll be all good, that's great.

Speaker 1: 26:20

I would love to just have 150, but my business was a fee-for-service for 16 years and it took on a lot of debt over those years, so I had to take that into consideration. So that's a blessing that you do not have all that incurred debt, because it's terrible to have that, because you are stretched a little bit thinner than what you were hoping. But I also see the light at the end of the tunnel and someday I'm going to have all that paid off and then I can actually figure out what it looks like after.

Speaker 2: 26:52

Reset. Yeah yeah, how big is your panel, amanda?

Speaker 1: 26:56

540. Yeah, I know, but it's actually. It's very manageable because I have an office manager that works three days a week, I have a receptionist that works the other two days a week when my office manager isn't there, and I have a nurse that does all the prior authorizations. She does all the shots, she does all the lab work, she does all the things. I don't have to do anything except just communicate with my patients and put them on my schedule and things like that. So she's helpful. But it requires more patience when you're hiring staff like that, when you have that ancillary staff?

Speaker 2: 27:33

Absolutely yeah, and I actually am looking to hire an administrative assistant just because I think it will position us for growth well. So again, that will be something that I take on financially. You know prospecting out to the future, so hopefully that will pay off. It's all a big risk, you know. Owning your own thing is not low pressure, it is hyper, and we are betting on ourselves and we are putting our money where our mouth is and it's a big deal. So we will see. You'll have to have me on in a year or two.

Speaker 1: 27:59

Yes, we'll do a follow up.

Speaker 2: 28:01

We'll see how the experiment goes. But you know, I think, keeping everything in perspective and approaching it, you know I would never recommend people to start this straight out of school. It would take you too long to put all the pieces together and you, quite frankly, I don't think you'd be able to provide the quality of care that you would want to. But if you get to a point where you're financially able to take a risk on yourself, why would we not take a risk on ourselves? You know, we've proven to ourselves through all of our schooling and all of these years that we are competent and able. And so, you know, as long as we have a good business plan, we have good mentors and we have coaching and we have it mapped out, and it's a risk but it's a reasonable risk.

Speaker 2: 28:35

And then the other piece of that is financial. So if you know that it's not going to crush you to fail it's going to set you back but it's not going to crush you you know that's a risk worth taking. Everyone has different risk tolerance, but to me, when we get a location almost does feel like we're starting a whole nother business and so hopefully that one will pay off. But if it doesn't? You know, we'll peel back to house calls and we'll pivot and we'll do what entrepreneurs do and we make it work. Yes, absolutely.

Speaker 1: 29:03

You are always waxing and waning, through all of the different things that life throws at you, but you keep it alive and it keeps paying you, and so it's successful, no matter how it looks. Yes, well, I wanted to ask you I haven't had a chance to get into this but what EMR did you choose, and why did you choose that one Sure?

Speaker 2: 29:22

So this is going to be funny, but when I first started I was a health school practice and I didn't have an EMR. So it is possible. If you don't want to pay for that upfront, you can get by. You have to have, you know, e-prescribing and some of the services, but you can do records in a secured way. That's not in a fancy platform, I guess, and that was kind of nice to know.

Speaker 2: 29:40

Knowing what I know now, I would have paid for one upfront because migrating all of those charts and all of those records into an EMR was very time intensive. So I would suggest that would have been a better spend up front and I would suggest people to do that hindsight, but it is possible. So, that being said, I ended up with Atlas MD. Oh yeah, and so they're a DPC out of Kansas, a brilliant family, and they have a platform that was built by a DPC physician. It's very simple. It works really well. I did look at several others, including Serbo, the owner of that, as a DPC owner out in Northern Virginia, which is close to me, has been a very great support to me as well. So there's a lot of really good options, but that's where I landed.

Speaker 1: 30:19

Awesome. I've interviewed a lot of people that are already using Atlas MD, so we're looking to change. I'm using eClinicalWorks, but eClinicalWorks was perfect for my fee-for-service practice.

Speaker 1: 30:32

But, when I switched over I still had like two years left on the contract with eClinicalWorks. So now I was just talking to my office manager before I got on with you and she's been talking to them about how we could reduce our costs, because we want to change over to Atlas MD, because I'm just impressed with the tutorials and stuff that I've already listened to, and I'm still having to pay for eClinicalWorks until May of next year. So, anyway, just navigating through that. But eClinicalWorks isn't set up for DPC, it is set up for insurance-based practice. So there is no section for membership management. There is no section for dispensary management and I have a dispensary in my office now and I have IV hydration therapy and sometimes I give Botox to my patients, and so it would be nice if there was all these little pockets of places within my EMR where I could manage all that, but there isn't. So my office manager manually manages the memberships through her Excel spreadsheets.

Speaker 2: 31:38

Yes, and I started out that way initially, with Excel spreadsheets as well, and it is. I will tell you, it's nice to have a billing platform. I was wondering if you partnered with something like with a hint platform for your billing or something like that. I have not explored that, but I know a lot of other people use their platform. That was actually one of the things that was appealing to me about Atlas was it had the billing internal, and so it's just not another system.

Speaker 2: 31:59

There's so many pieces that we're pulling together as small business owners and there's, you know, you've got to have a fax that integrates, and there's just a lot of backend systems and platforms. One less is always really nice, and so I'm really glad that they pulled that in and because of the size of that now that that also financially helps us, because some of the rates for credit card processing are lower with them, because we just we have that negotiating power of volume, and so that's also nice. The bigger you get, the more important that is, so that would be even better for you all.

Speaker 2: 32:27

But yeah that's been great, and I would say that probably the best thing about it is I love that I can run it off my phone. I'm a house call practice, so I have to be able to connected wherever I am. I'm in the car a lot. I often am pulled over in a parking lot somewhere doing a quick telehealth visit to manage something you know, to see if we need an in-person visit, and so having access to patient information is really brilliant. To have a cloud-based service Most are, but theirs is actually easy to use on your mobile, and that is not the case with all of them and their support staff. I cannot praise them enough for their customer service. So again, as small business owners, we don't have the capacity to hire a tech person, and so when you have good support, it's just absolutely valuable.

Speaker 1: 33:06

Does Atlas MD also manage your communications with patients, your text and your video calls, or do you have a whole separate communication?

Speaker 2: 33:15

software. It's built in. Oh yes, some practices do. They prefer some of the fancier features of external companies. I haven't found that to be necessary. It has been sufficient. It documents, it syncs with their chart, all of that communication, and so that saves us, as providers, time with that documenting. They do have a video platform within their EHR as well. I actually use an external one for that, just because I was used to it from my last practice, but it's built in should you want it. And sometimes, like we experienced earlier today ourselves, technology doesn't always work and so you need a secondary platform, and so it's been awesome that way.

Speaker 1: 33:48

That was my fault, people. By the way, we fixed it, though, we fixed it though we fixed it.

Speaker 1: 33:54

So what I'm hearing you say I'm sitting here, I'm so goofy sometimes, but what I'm hearing you say is if a patient because these patients do this to me they will send me pictures of their grandchildren or their puppies doing something funny through my DPC phone that I use to communicate, that's going in their chart. Is that what you just said? That is what I just said. Oh, that's going to be wonderful. It just shows the personable side of DPC. It's like you're going through this person's chart and like why are all these pictures of this puppy?

Speaker 2: 34:31

Yeah, so I do educate them. You know, everything you send me is part of your medical chart. Of course, we can always, you know, delete it out if we want pictures of their puppies in there. You know, to clean up, it is all there, which is. It's honestly just such a saver on time, though. That's nice, I'd rather have it than not have it. I guess is what?

Speaker 1: 34:48

I'm saying, yeah, well, that's great. So your EMR manages your memberships for you, so you're not having to track down your patients if their credit card doesn't process, or something like that.

Speaker 2: 34:59

We still do have to manage the failed payments right. It's built in as automatic billing so it automatically drops. You know their charges and whatever day we pick, which is nice for you know cashflow management of your practice, but you still do have to go through and review all of the invoices. You know making sure that it's it's automated, but it requires oversight, so I always do that. You know, a couple of days before it drops, review everybody's stuff and make sure was their membership turned on or is it off? And you know everyone who onboarded it set right and everybody who had to leave the practice for whatever reason has been turned off. And so it does still require oversight.

Speaker 2: 35:32

But switching from me manually doing that, I was even. You know I was doing that through PayPal just to be open when I initially started, and that was just so much work. It cut down on hours of my life, so much easier to manage. And then, if their system fails, there's a there's a built-in kind of way for us to ask to put a new payment source on file, and so it's easy as sending a text.

Speaker 1: 35:53

So that's good.

Speaker 2: 35:54

Yeah, you do still have to manage. Unfortunately, fraud is a big deal and most of the time it's oh yeah, that card was compromised and I didn't remember you were one of the subscriptions. I didn't remember and so typically that's more the issue, but I think you're gonna have that in any business.

Speaker 1: 36:07

Is it awkward for you when you're wanting to divide being the medical provider from being the billing person? Is it awkward to have to have that conversation Like hey friend, your payment didn't go, yeah.

Speaker 2: 36:23

I mean, in a way I think it is, but in a way I think it it makes me appreciate my patients and the fact that they're spending money, you know, to be a part of the practice and, of course, being mindful of the tone you know it's usually it's through a text or an email, but just being mindful of how it's worded, that piece was kind of tricky but I haven't had any complaints about it, which is good. And, like I said, I almost feel like sometimes they're they're mostly apologetic, like oh my gosh, I'm so sorry, you know. So it almost builds trust if it's handled correctly. But yeah, sometimes initially sending that text, you're like okay, hope you didn't shut that off on purpose. You know it's like leaves a question mark out there. But I think we get used to managing that awkward stuff as business owners. You know a lot of these conversations are hard and even as healthcare providers we're used to dealing with awkward stuff. So it's just a little bump in the road. Yes, I think one thing that I'm proud of that I didn't anticipate but it's just kind of who the practice has attracted. So I only see adults. So I don't know if we said that, but we're an internal medicine practice, so we're 18 and up.

Speaker 2: 37:23

It's been really neat for me to see the patients that have found the practice, and most of them the numbers right now are between 70 and 75% of them have insurance and they're fully insured and they choose to add DPC because it's a better care for them.

Speaker 2: 37:38

But that leaves, you know, 30% of the practice that is not insured, and so I'm really proud of that, because these are people who have fallen through the cracks with our current system that's so heavily insurance based, and so these are hardworking people making plenty of money, but maybe self-employed or maybe realtors, or maybe they work in a profession that doesn't offer, you know, insurance, and so this just solves a problem for the community that I feel like was being.

Speaker 2: 38:04

There's just a gap, and so I feel really proud of that, and I, like I said, the satisfaction of the work that you do matters.

Speaker 2: 38:11

Once you've been doing your job long enough, the job itself is not the excitement anymore. It's how you make other people feel and how the reward that it gives you you know intrinsically, and so that's one thing I'm really proud about with our practice is it doesn't force anybody out because of cost, and I'm hoping that as we grow and I bring an admin on and I can free up some time in my schedule that I'm able to go to some of the other smaller employers in the area that I know aren't able to offer health insurance because it's cost prohibitive and just make them aware that this is a solution for their employees. I believe that most owners want to take care of their people and it's smart for them to take care of their people because replacing people is expensive. So I'm just excited about bringing DPC to our community and I'm proud that we can serve across the spectrum of the health insurance or no health insurance.

Speaker 1: 38:55

How many employers do you have that signed up?

Speaker 2: 38:58

their employees Right now we have five small employers. We have a nonprofit we're working with now also as one of the businesses, so it's been really rewarding Awesome.

Speaker 1: 39:08

How did you advertise to the local businesses that this would be something that would be a good alternative to them? Purchasing insurance for their employees is to do DPC.

Speaker 2: 39:21

Yeah, it's a great question. So I've used social media a lot and it's a very effective way to communicate. Obviously in our culture and so some people have seen my post on there about this is an option for small business owners, and probably the biggest piece is just local networking. So I joined our chamber of commerce locally and I attend a lot of those events, and so I'm able to communicate with other owners and other people who are just in the business sector. It's pretty rare that you see healthcare people at a chamber of commerce event. Right, that's just not something we do in our sphere, and so I think that speaks volumes that we're trying to relate and solve problems for business owners, because healthcare is one of their biggest costs as business owners, and so that has proven to be very effective. It's just really getting out there and meeting people, and the network of your local community network is you have to be a part of it to be successful.

Speaker 1: 40:13

That's awesome. Well, this has been an excellent interview, kelly. It has been such a pleasure getting to know you. Thank you so much for having me, amanda. You've got a unique practice and it sounds like it's really going places, and you're getting ready to blow it up now with your brick and mortar. So, who knows, you might be looking at hiring another provider soon because so many people are going to be like I want to go to Smarty Pants.

Speaker 2: 40:36

Yes, speak it out. I'm really hopeful for that. One of my goals with starting this was that it wouldn't just be a solution for me, but that it would be a solution for other providers like me who are looking at leaving medicine. Some of my friends have walked away from medicine because it's not a lifestyle that they feel like they want to sustain, and that's devastating when we're already in such a pinch and for primary care providers. That's devastating for our community to lose a good provider. So I hope in the future that I'll be able to be an option for people looking for a solution. Sure.

Speaker 1: 41:07

Well, I wish you all the best, thank you so much.

Speaker 1: 41:14

Thank you so much for joining us today on the DPCNP. We hope you found our conversation insightful and informational. If you enjoyed today's episode, please consider subscribing to our podcast so that you do not miss an update, and don't forget to leave us a review. Your feedback means the world to us and it helps others discover our show. We love hearing from our listeners and it helps others discover our show. We love hearing from our listeners. Feel free to connect on our social media, share your thoughts, your suggestions and even topic ideas for future episodes. As we wrap up today, we are so grateful that you chose to spend a part of your life with us. Until next time, take care. This is Amanda Price signing off. See you on the next episode, thank you.