Key Considerations For Building A Successful Practice In The COVID Era

Dr. Tom Blue

Well, thanks for having me.

Cheng-Huai Ruan, M.D.

Yeah, so we’re in such a crazy time. You know, when I scheduled the summit, I assumed that COVID was gonna be over, and this was, you know, six months ago, but obviously that’s not happening, but so what impact on for a lot of practices, there’s really two categories, right? There’s the practices that made it and the practices that didn’t make it. And then there’s probably a third category, is the practices that scaled because of it, right.

Dr. Tom Blue

Right.

Cheng-Huai Ruan, M.D.

And I would love to talk about what are the components of each, does that make sense?

Dr. Tom Blue

Sure, sure.

Cheng-Huai Ruan, M.D.

So let’s talk about the practices that didn’t quite make it. What do you think was it about this whole event that created enough stress on the system that there was some sort of collapse?

Dr. Tom Blue

Well, you know, this is, you know, as you probably remember, last year through Virtual Practices, we did a big, a big survey that, that we had the good fortune of fielding, right kind of on the heels of the Physicians Foundation slash Merritt Hawkins survey on sort of the state of practices in the, you know, right sort of in the throws of COVID. So it was almost a year ago right now. And, and at that time, it was when you sort of backed into the math that Merritt Hawkins had done the, you know, the pandemic had really wrought a lot of havoc on independent practices in particular, not surprising, you know, they’re a bit more fragile and the independent primary care practice closure rate was something in the vicinity of about 14%, which was temporary or permanent closure, which was really quite staggering. And so, and so we sort of, with that as the backdrop, we fielded a survey to a responder audience of almost an equivalent size, about 3,500 respondents. 

And, but our audience was a little bit different. It was, we were, we were really circulating the survey amongst kind of broadly defined root cause medicine practitioners. So in the functional, integrative sort of root cause focused practice domain, and we found right out of the gate, that the closure rates among the physician practices was considerably less. And, the, you know, as you certainly know, in the root cause medicine arena, the great majority of the practice, the physician practices, that really apply this, tend to be small independent practices or for many of the insurance reimbursement reasons these are the guys and gals that have the latitude to, you know, to kind of play around with their business model a bit and be a bit more and therefore apply that type of training. And so what we found was across across the board that among the MDs and DOs, the closure rate was more about 2%, which still obviously is not great, but it’s a heck of a lot less than, you know, than was the case with the average, which then led us down the path of investigating, you know, kind of what were, why, A, why was that? And what were the differentiating characteristics of the practices that did the best and the worst. 

And what we found was just as you said, in your opening that in fact there was a really real continuum from those practices that were, that were temporarily or permanently closed and all the way to those that were doing better than ever. And, and so it was, it was really interesting then to dig more deeply in and say, okay, well, what was it about these practices that, you know, that might’ve caused them to do better? And what were the characteristics of those that did the very best? And what we found was, I mean, first and foremost, given the, you know, the difference in the way this audience performed as compared to their, you know, random peers, we, you know, we had to dig into what it meant to be a root cause medicine practice. 

And we’d asked a number of questions about, you know, sort of the different services that people were offering and that kind of thing, looking for, you know, what they all may have, have had in common. And really the one thing that all, that almost all had in common. And I mean, I’m talking like 98 and a half percent had in common, is the use of sort of food and nutrients as medicine. And so, you know, there was, you know, that was sort of the hallmark in the mind of the consumer, that would probably indicate that a practice is a root cause oriented practice. And, and then below that we had, there were practices that offered a whole variety of different, of different types of services that would sort of fit you might think of associated with functional and integrative root cause medicine. But first and foremost, it was that nutrients and food as medicine kind of attributes. So when we then dug deeper to say, okay, well, what did the best performing practices do? You know, in the early part of the pandemic, there was a lot of rush to convert to, you know, to virtual practice. And, what we found was interestingly enough, that the, that the sweet spot, wasn’t actually a complete conversion away from all your brick and mortar presence to nothing but virtual, but that the best performing practices were running about 35 or 40% of their visits virtually really in the height of the pandemic and the kind of the lockdown. And so at no point really did, you know, did the best performers take away the option for a face-to-face visit, nor at any point, did they see even the majority of patients opting for virtual visits. 

Although the ability to choose a virtual visit seemed to be really critical to kind of maintaining relationships with, you know, with the bulk of patients. So that was a big deal. We found that the biggest characteristic of the top performers were the application of what we were calling value-based payment models. And so what that meant was that that either, either, you know, it, you know, strictly, or in addition to their, you know, their fee for service billing, they had some element of a value based model, either selling a membership of some sort, like a concierge type practice or direct primary care, or they were selling bundled programs packaged up as a, you know, a six months reverse your diabetes program or whatever. And, patients were engaged in a, you know, in a care path that they had made a decision to engage in and purchase ahead of time. 

And so, and so the thing that we, that began to make sense when we really looked at why the, why business model would have been such a, such an important predictor was, I mean, if you think about it, we’re in the throws of a pandemic, and that’s not a common sense time to say, well, I’m terminating my relationship with the doctor. I mean, you know, common sense would say in a pandemic, you would be more inclined to, you know, to value your, your access to the doctor. But what we saw was is that patients that were accessing the doctor on a strictly fee for service basis, the pandemic hits, the news says, don’t go to the doctor’s office, stay away from, you know, from, you know, from anybody who could get you infected. 

You know, the question on people’s mind was, well, geez, you know, and under circumstances like this, how long can I go without seeing the doctor? Whereas the people that were in the membership programs and in the bundle programs gave their doctors time to say, okay, well, what’s my doctor gonna do to, you know, to continue to earn the monthly revenue or the monthly membership fee that I’m paying. And lo and behold, it was just, you know, those that were in those types of programs chose not to terminate the relationships with their doctor, and we saw this, we actually pulled some extra data from Hint Health, which is a very large membership payment processing company that services probably the majority of the concierge and DPC industry and across the board, there was no, you can’t really like when you look at a graph of their, you know, their patient growth rates, you really can’t tell the pandemic occurred. I mean, it was, you know, net net, there wasn’t a single month where there was a net loss of membership patients. And it tended to grow around, I don’t know, you know, two or 3% a month kind of thing. It was, you know, it continued to steadily steadily grow, so I’ll pause and let you react. And I can go deeper on any of that, if you like.

Cheng-Huai Ruan, M.D.

No, that’s makes really good. It makes really good sense. You know, I think that, a couple of other things is that this is a bit of a selection bias, because I think that the doctors that tend to practice that type already are kind of thinking a little bit outside the box of the risk tolerance, which was far different. Right, and then the other thing is the fixed costs. So doctors that run leaner practices, more on those models, tend to run leaner on a fixed cost and the biggest risk cause is employees, right. And overhead, well, first it’s taxes and then it’s employees, right. And then the other thing is that I think these practices are able to, like you said, bundle the value delivery. 

So there’s more predictable operating cash flow in a time sequence. And because this practice is, you know, you’re not burning through, you’re not burning through money on a weekly basis, the payroll and stuff like that. And then, and then the last part is like, you know, for my practice, you know, we’re very, very traditional just, bill to insurance and Medicare and stuff like that. Even though we are an integrative health center, you have to deal with the fixed costs of something that you’ve already made an entire system for, which is a medical billing, and revenue cycle management. Right, and at that time, you have all these crazy changes in CPT codes and stuff like that with CMS. 

So I think that alone was really enough stressor for some of the other docs to say, Hey, I’m just going to hit pause for a second. And the other thing is like, I’ll, I think a lot of these docs who, who hit pause is because you have to hit pause in order to stop the bleeding of the actual money from the fixed cost. So, and it really speaks to how stupid expensive running a medical practice is, conventionally speaking, right. And the idea that, that we can’t make some of these more scalable or cheaper, I think we’re trying to flip that mindset because, I mean, we did it, you know, we’re, even though yes, we’re an insurance based practice. We actually came out on top by very key decisions as a very counter intuitive, you know, so we decided to get rid of a majority of our fixed costs. So we have three locations and we ended up shutting down all three and moving to even smaller one because we switched from 5% Tele-med to 86% Tele-med.

Dr. Tom Blue

Wow.

Cheng-Huai Ruan, M.D.

And then we started building online courses that are free for our patients. So we actually retain the value there. So I do think there’s there’s ways to retain that, but it does take a really little bit of an innovative technique to, to actually do it because I think, I mean, Tom, nothing’s going to be the same anymore.

Dr. Tom Blue

Right, right.

Cheng-Huai Ruan, M.D.

After Coronavirus, right? So that’s sort of my thoughts behind that.

Dr. Tom Blue

Yeah, well, you know, it’s interesting, the timing of COVID was, you know, was in some ways, some ways fortunate, I think it would have been way, way worse had this happened even even a few years earlier before the dawn of such accessible tele-health tools. And like, for example, I can remember I dealt with a practice up in Boston that had gotten quite large on a, you know, on a fee for service basis that, that remember a few years back, there was a huge blizzard that kind of shut Boston down for a really long time. And, to your exact point in that little market with, you know, everything kind of having ground to a halt because of that huge blizzard, practices that were really kind of on the, you know, on the edge cost-wise, you know, had to, you know, had to push pause or all close down, just because of, you know, about six weeks of massively reduced patient throughput, you know, was more than they could, more than they could weather. 

So, you know, so COVID with, I mean, with the ability to so quickly utilize Zoom, or, you know, the multitude of various tools that are, you know, very affordable, very easy to use and stand up, I think turned out to be a big help. One other thing that we saw was that the practices that, you know, that were making use of nutritional supplements, and in particular, we’re able to, we’re utilizing a virtual dispensary. So patients didn’t have to physically show up to get their supplements. It was a great tip because of course, supplements sales, you know, you know, across the board, you know, shot up and, you know, not only in the consumer channel, but practitioner as well. And so if those practices that had that in place, I think that turned out to be a really nice sustaining revenue stream, as people became much more sensitive to their, particularly immune support supplements.

Cheng-Huai Ruan, M.D.

Right, and it doesn’t cost a whole lot and fixed costs or even variable costs, for that matter, to actually run these things. And that’s what we really have to leverage with technology. I think you’re absolutely right. I mean, the amount of tele-health platforms now compared to maybe 2016, it was like night and day. It’s vastly different. And I think that even from now on, there’s even more that pops up and now there’s, you know, remote patient monitoring, all sorts of different things that are there. And so it brings more competition which actually drives down costs which is really good. And so I think that if we learn from the practices that actually, you know, sustain and actually did well, is that it’s all about, it’s all about how do you optimize different profit centers within your practice and not have it be rely on one, which is now a risky situation, right? Before it wasn’t so risky. 

And now it’s a very much risky situation. And the other thing is a lot of practices don’t do this. Doesn’t matter what type of practice it is, is I think we need to figure out what the patient wants. So literally reaching out there and asking patients, hey, what do you prefer? Do you want to come in? Do you want to do telemedicine? Do you want phone calls? Because in insurance, we can get reimbursed for phone calls as well. Like, what is it that you want? And they using those statistics to say, hey, I’m gonna formulate my provider’s day in doing X, Y, and Z based on the statistics what our patients actually want. That’s what we ended up doing. That’s how we got 86% telemedicine. You know, there’s not a, it’s not a random number.

Dr. Tom Blue

Right, right.

Cheng-Huai Ruan, M.D.

It’s what the patient wanted, right. And so I think that once you’re able to make that and then, and then always listen to what the patient wants. Then we have an understanding of what’s going on or like, you know, supplements. Do you want to come to the office or do you want to ship it? Most people want to ship it. You know, we changed up our SOPs to allow for that. And then we doubled down on our virtual staff. We have overseas staff from Zimbabwe and in the Philippines. So we have overseas staff. Now we have overseas virtual system that becomes like virtual medical assistants and those decreased fixed costs as well. I think all of these are pretty congruent, no matter what type of practice you have, but we just have to assume that we’re going to have a shutdown again sometime soon, it’s inevitable, and that we’re gonna have to, you know, pivot again, if you will. 

And, but what about, let me, let me ask you this, what about sort of the mentality of these practitioners, because, you know, burnout is just stupid high, astronomically high, you know, even before the pandemic, burnout was at 46% and afterwards, I forget what the new number is. It’s a little under double, right. And so let’s talk about that for a second, because you have a lot of practitioners that temporarily shut down and they’re super burnt out. And then you have also a lot of people who remain even more burnt out just trying to work through the process, but, and ended up on top of afterwards, you know, you know, you run VirtualPractices.org. so I’m sure you see a lot of practitioners, you know, come through those programs and trying to make new changes, so that things work. What is your feedback overall do you think, what are the doctors really saying when they’re going through this?

Dr. Tom Blue

Well, I mean, it’s a scary time. I mean, especially last year with all of the uncertainty and, you know, as to what, you know, what the future might hold. It was an incredibly scary time. We, you know, we saw a lot of people actually, interestingly enough, and I, you know, I made note of how many nurse practitioners we saw starting up new practices. Their hours had been cut back wherever they were working. And they were actually sort of going out on their own as independent practitioners for the first time, which was, you know, which was sort of a mix of exciting and scary, I’m sure at the same time. So, you know, it’ll be interesting to see this go round. You know, the, my hunch is that the uncertainty and fear factor will be, won’t be quite as great as it was.

 ‘Cause, you know, we’ve sort of done a rehearsal of this show already and, you know, and we know that, you know, that in fact there are some winning strategies and the tools are not that hard to access. And a lot of the cost cutting measures probably took place last year. And, you know, and haven’t, are still somewhat in place this year. So my hope would be that it will be easier for practices to weather, kind of whatever the fall and winter holds for us this year than it would have been, than it would have been last. I will say this, it has been, it’s been interesting to watch the, you know, the, I guess I’ll call it sort of root cause medicine education landscape in the, you know, in the COVID era. So, so when the pandemic hit, all the live conferences are, you know, are now going virtual and, you know, and the question certainly arose for me is to, you know, I wonder what this is gonna mean for, you know, the likes of the Institute For Functional Medicine and A Forum and others. And what’s been fascinating to see as best I can tell is, is that it’s actually created a surge of demand. And so there’s a lot of this, I mean, I mean, literally, you know, I know for IFM, the programs have been more, way more full than ever before.

Cheng-Huai Ruan, M.D.

Oh really?

Dr. Tom Blue

And so, yeah, like, like not a little either, I mean, like way, way more full. And part of that, I’m sure, is that in a way moving to a virtual conference, it’s, the prices aren’t discounted, but in a sense, they are, you know, you’re not buying a plane ticket, you’re not booking a hotel room. And so it’s, you know, the content’s more accessible, but I do think that a lot of people have taken some of this, this downtime last year to embark on reinventing themselves, which actually brings me to something that you just said that I think is really remarkable and something that I hope that folks will take note of, which is, you were saying that you were evolving the practice in the way, in response to consumer preferences and what you were hearing as sort of the voice of the customer. And that is, you might hear some people thing like that in the, you know, in the private pay arena, but, what’s exciting for me to hear is you run an insurance-based practice. 

And I presume that we’re probably speaking to a majority of providers that are, that are in insurance-based practices. That is the days of thinking of yourself because you live in the payer system, is somehow being kind of disconnected from, you know, the reality of a consumer marketplace I think are over. And you just sort of demonstrated it. In your insurance-based practice, you listened to what the consumer wants. They’re now enough tools in the toolkit to reinvent a practice while staying on that, on that, you know, that revenue model chassis, you know, to do some really dramatic and exciting things. And, I think it’s, it’s incredibly important to listen to, you know, not only just, not only the service delivery aspect of what the consumer wants and how they want to receive services, but the nature of those services. 

And, and certainly the pandemic, if anything, has awakened consumers to the difference between, you know, managing a chronic condition and actually putting in the effort to reverse that chronic condition and looking at how, you know, how COVID is able to see quickly past the fact that it’s well-managed and you know, it’s, I think it’s really sparked a motivation among, among patients to be more participatory in their, you know, in their care. And so, and so sort of seeking to reinvent the practice, to align with that evolving consumer health value, you know, is to me a great idea. And I think a lot of people have instinctively, you know, either out of personal interest or maybe strategic intentionality, like you did it, have embarked on that.

Cheng-Huai Ruan, M.D.

Yeah, so you’re right. I think the days of, you know, me being kind of stuck within the insurance system, or, you know, I don’t consider myself stuck but some people do, is really coming to an end because there’s actually a lot more billable events now than there ever worse, especially in 2021, oh my gosh. In 2022 CPT codes came out in July and I’m like, okay, they pretty much, you know, CMS kind of doubled down on this and say, we should be reimbursing for virtual. We should be reimbursing for phone calls, secure messages, text messages, emails. We should be reimbursing for behavioral change modification outside of psychiatry and social work in psychology, right? So they made a lot of the behavioral change and mental health codes available to be billed by everyone else. And the idea is to incentivize the practices, to reach out to the patients. 

So, you know, we have health coaches in my practice, the perfect time for health coaches to come in and take over the one missing piece in medicine, which is SDOH, which stands for social determinants of health, where that’s, what really makes the patient, you know, either not comply or not do very well, you know, where do they live, who they’re living with? Socio-economic status and stuff like that. So there’s now systems that’s already set up to collect this data. You’re giving patient value that’s far beyond sort of the traditional doctor, patient relationship and a prescription. And then you kind of tap into those resources. I think that, you know, as we, as we go on and as these new sort of CPT codes kind of come out and stuff like that, there’s not necessarily an easy way to consume that information. In fact, the way I did at the very first is actually go to your website, VirtualPractices.org, and take a look at, what those CPT codes, this is earlier in 2020, last year when it first launched. 

And I was amazed at really what really there was out there. And now there’s even more. I think that the, I think that from a, from a mindset, just from a business mindset and perspective is that there are things in medicine that was never designed to scale. You know, doctors are kind of the widgets and we kind of make these, where we’re widget makers, right? And so, and now it’s different because outside of the one-on-one physicians, you also have your staff, your clinical staff versus your administrative staff, and they fall into other buckets like remote patient monitoring and chronic care management. So I think what we’re learning right now is that if we think about things a little bit outside the box, we realize that we were never outside the box to begin with. We’re just going into the new box that we really should be in, you know, moving forward into, into the future, right?

Dr. Tom Blue

You are so right. I got to tell you, this is, 2021 is my 20th year, since, since creating the first concierge practice in the state of Virginia. So I’ve been doing this, you know, alternative business models for a very long time now. And, I can’t tell you, I mean, the main reason for these business models prior to 2021 has been essentially to modify the, you know, the financial relationship between the doctor and the patient in such a way as to allow for, you know, the delivery of the kind of comprehensive care that everybody kind of would want to do anyway and knows is needed. And all of a sudden this year, you no longer have to alter your fundamental revenue model in order to do this. It’s, I mean, what you just said with, I mean, think about the behavior change aspect, you know, being reimbursable, the monitoring, the education. 

I mean, it is an unbelievably exciting time, and it’s really strange, I think that, you know, what I’ve heard is that, I mean, even through the folks at medical economics, is that people just aren’t aware of the, of the significance of these changes. And I think probably because the majority of doctors don’t look at their schedule and say, boy, I’ve got a bunch of uncompensated time as is the case in the kind of root cause medicine world. It’s like, you know, that the leakage of time that’s uncompensated has been a huge problem for practitioners that are trying to practice that way. But for the most part, doctors just work faster and faster. But, you know, the work that they’re doing has, is billable. And as a result, the, you know, these changes haven’t risen to their, you know, to their consciousness in the way that I wish that they would, because it’s an invitation to reinvent your practice, in a way, by the way, that I would submit would largely prevent the burnout that so many people feel from an unsatisfying practice model. So it’s exciting that the, you know, that this summit you’re putting on in this conversation right now, hopefully will, will bring to the attention of many, many, many more people that this, you know, the invitation to reinvent a practice.

Cheng-Huai Ruan, M.D.

Yeah, so, and, you know, part of it, part of the lack of an ability for a lot of doctors to move into that space is because, you know, none of this is really taught, you know, in residency or medical school. And in fact, you know, my sister’s a fourth year medical student right now in Columbia, you know, it’s really hard to shift away from a large institution like that, what you’ve been doing for such a long time. And I think a lot of people, a lot of doctors are just waiting for things to get back to normal. It ain’t gonna be normal, you know, so, you know, and for private practices, it’s easier to do that, if there’s a good and documented system, because, you know, coronavirus basically revealed all the weaknesses within practices to the practice owner or the physician, whoever it is. 

And now everything’s just kind of glaring at you, right? And so our ability to change and pivot from that, none of this is taught, you know, it’s not like we went to business school, got an MBA and really learned about this. And all we learn is how to take care of patients. Now, we think about it from a subconscious perspective. So we go to college and medical school and residency and fellowship, and then you finish your attending. So we have a very structured process. In all the years that we go through this process, we’re taught to never go outside of the line, right. And then there’s a hierarchy to it, right. You have your attending, you’re a fellow, and et cetera, et cetera, moving down the line, right. And so the fundamental concept is, if you don’t go outside the line, you’ll be fine. 

If you learn to take care of your patients, you’ll be fine. And then, so that was kind of a promise. And a lot of that promise wasn’t necessarily, you know, true during the pandemic era. So now there’s like this mad dash and scramble. And so if we think about it, that there’s the subconscious mind saying, I’m not supposed to go outside the box. I’m not supposed to do this for medical malpractice, and therefore must stick within the line. Then what does that do to a culture of, of a medical practice? What it does is that now you’re, this doctor is forcing all your employees to do the same thing within the box, and the employees are subconsciously trained not to innovate as well because the employees feel like they don’t necessarily have a voice. And that’s how medicine is. That’s the very typical medical practice, you know, unfortunately. And so now it’s like, we have sort of this holy shit moment, where we’re like, well, we kind of have to reinvent things. 

So how are you, a doctor, going to be a leader for the people that you’re leading within your practice to change, but not only that, but to motivate them to want to do more things? And all of a sudden when that happens, boom turnover, you have employee turnover, they’re just like massively, right? And so employee turnover during the pandemic was absolutely just astronomically large because you have now not just unemployment, but you have government census, right? And then you have all these different things that are a little layer there for the protection. And I think that that creates a massive amount of burnout. And I think to combat this, that’s why we have, that’s why I run the summit is to, we have to think about things differently. You know, I have whole days dedicated to the leadership of humans in general. And so I think from a leadership perspective, moving forward, no matter what practice model we are is the only way, not just to survive, but really thrive. And that brings to the third category that we talked about earlier is who is going to scale during this, during this pandemic, you know?

Dr. Tom Blue

Right, right. I completely completely agree with you. Yeah, it, you know, it, well, I mean, I can, it’s thinking about, about the transition that I’ve watched hundreds of practices make to, you know, to more private pay revenue models and the difficulty in retaining and kind of growing the existing staff to, you know, to live in a different, in a different world of customer service and customer expectations and sort of the expansion of what used to be a very cut and dry job description is very, very real. And that’s, you know, that’s before government incentives making it so hard to actually, actually, you know, get new employees these days, but, but it’s, it is a, it’s very real, and a meaningful issue from a leadership standpoint that you just raised.

Cheng-Huai Ruan, M.D.

Yeah, yeah, absolutely. And so, you know, not to belay their point anymore, but let’s, I want to actually dive into VirtualPractices.org. We’ve been talking about it, but we haven’t told people what it was yet. So can you kind of introduce VirtualPractices.org and what it’s supposed to be?

Dr. Tom Blue

Yeah, so we, I, and two colleagues, that are former IFM colleagues, Lori Hoffman, and Andy Crosby, created it at, you know, right at the beginning of the pandemic. And it was interesting, what we were really noticing at that time, as you might remember, was there was a, you know, there was a huge difficulty in accessing PPE and testing after the PPE kind of crisis, you know, you know, sorta began to subside, then it was all about accessing testing. And, of course it was pretty clear that this was gonna be problematic for independent practices. And so we decided that we would try and create a resource to help people sort of to expedite the process in the mind of independent practices, that particularly that had a root cause orientation, to sort of see a path forward to where this might actually spell opportunity rather than disaster. 

And, then along the way we were attempting to, you know, to facilitate through, you know, through just a little bit more of a bulk, a bulk representation of practices, maybe access to, you know, to testing earlier than practices would have had access to it, which we, what we learned was in the, you know, in the course of that was, you know, and even to this day, you know, the, I don’t know that that many practices are all that excited about COVID related services. Although I will say, I think that long COVID is going to represent a really interesting and meaningful and meaningful opportunity for particularly a root cause medicine type practitioners, but, you know, but we shall see how people choose to attack that opportunity. 

But it’s, I think that’s going to be a very real issue, for a long time to come. So along the way, then, you know, we, we were, you know, we were, you know, sort of inviting people into a thought process of reinvention, of implementing virtual technologies, and accessing, you know, these sorts of tools using really just using COVID as an example of a condition that you could build services around, but that would be equally applicable to hormone replacement therapy or cardiovascular health or whatever. 

We then did the research, which turned out to be a really, you know, surprisingly eyeopening, and fascinating to see the, you know, to see those performance differentials and to see how, you know, frankly certain, you know, certain care paths. I mean, speaking of hormone replacement, that was, that proved to be an unbelievably robust and resilient. I mean, that care path was really, was not hardly interrupted at all. People didn’t want to unplug from their, you know, from their hormone replacement regimen and practices that did a significant amount of that business were, you know, found themselves, you know, really, really uneffected. But, but anyway, then when 2021 came around, yeah, it was shock. 

I mean, it became kind of, you know, we sort of put COVID in our rear view mirror a little bit and shifted our attention to, you know, to the magnificent changes that have occurred to the payer system. You know, that now make the, you know, like I said, are this open invitation to reinvent your practice without feeling like you’re taking the risk of divorcing the only way you know of making money. And, and so, and so, you know, to be able to do this type of more holistic care without having to, you know, without having to get wildly creative with the revenue model and to do it right inside the payer system is just such a big deal. And so, as you saw, we, you know, we began to, you know, to unpack a series of programs on exactly how to, you know, how to do the kind of medicine you want to do without, you know, without jumping off a cliff of radically altering your payment model, which to me has been incredibly significant work. 

And I’m excited for, you know, for that to continue on, into 2022. And I frankly, can’t wait to see, you know, what, and start to catalog the, you know, the changes, particularly around remote monitoring and possibly, I don’t know if you’ve been following, you know, the emergence of remote therapeutic monitoring, but it seems like that also, that along with the behavior change stuff is going to be really, really interesting to look at, you know, when it finally shakes out, I’m kind of, do you have any early read on the remote therapeutic monitoring?

Cheng-Huai Ruan, M.D.

Yeah, so for those of you who don’t know what we’re talking about, there are reimbursable structures within CMS that reimburse for monitoring vital signs and other metrics over time, therapeutic monitoring is a different designation. And so the first version of therapeutic monitoring is actually doctors monitoring how patients are doing on their C-PAP compliance for sleep apnea. That was probably the very first version. Now there’s technology to look at everything, right? And so, for example, there’s, you can look at therapeutic monitoring of vitals when you prescribe some one a cardiovascular medication or diabetes medication. And then there’s also now a remote neurofeedback, which actually looking at brainwave patterns by neurologists over time, and they can do neurofeedback at home. 

So the technology there has just expanded. There’s new CPT codes that are really related to that portion as well. It’s actually industry, it’s very much industry focused, but originally there were limitations to, it was 2022 that pretty much took away all the limitations. When I say limitations, I mean like billing frequency, how much you’re monitoring. I think the push right now is to do virtual. The push is for that technology. The remote therapeutic monitoring is one of the things. And then there’s also principle care management and transitional care management. So which most doctors have been avoiding because according to CMS, not many people will actually bill for it, but it actually exists. So a transitional care management is let’s say, if someone gets COVID and they come back to your office. 

So within seven days is one code, within 14 days is another code. And they actually have really high reimbursement just to get patients into the actual office as well. So people aren’t really taking advantage of that as much, but they should be. And then the principal care management is a little different because we have chronic care management requires two chronic diseases. Principal care management is one chronic disease, and has its own set of codes as well. So I think the variability in understanding this has to rest on the education of physicians, because honestly like billers and billing companies, even they’re really behind on this, I know because a lot of them want to consult me to figure out what’s the new changes are as well, for even the larger billing companies as well. So I think that from engineering standpoint of how to engineer your practice, you know, from a, if you’re in private practice, you can’t just rely on the office manager, rely on your medical assists. You got to go in and restructure what it is that you think medicine should be. What are your core values and kind of design around that. 

So what I love about VirtualPractices.org is that a lot of that conversation kind of started there, you know, what are these CPT codes and what could you possibly do, but also what does it like to evolve into a telemedicine program? What is it like to package different things? For example, Cleveland clinic, they’re on another segment of the summit, they’re doing the recover program. So recovery from COVID, the Recover program, in shared medical visits, it’s billed to insurance when multiple, multiple groups, which has actually taken off tremendously. You have Spectrum Health, who I interviewed on another segment, doing the virtual culinary medicine program. Literally I have a virtual kitchen and they’re, and the dudes in the masks. And they do that to the Medicaid population, you know, and so in all of this is the payers actually covering as well. So I think that the time to scale on medicine when it comes to like numbers, that part of the secret is the shared medical visit. But other part of secret is just kind of knowing and navigating around the CPT codes and also knowing navigating if you’re in a cash practice or DPC practice, knowing navigating about leadership, how to get your team to go from point A to point B, how do you talk to your patients? How do you get patient feedback? 

You know, also looking forward to negative feedback, not just suppressing negative feedback. And those are the two things that I think are the characteristics of this practice that’s really able to kind of scale for the now in the future. And I really want to thank actually VirtualPractices.org, to really kindle my mind at the very beginning of the pandemic. And so if you guys want to go to the website, it’s literally VirtualPractices.org, just go to the website and check it out for yourself. But, you know, I really want to thank you for creating that. I think a lot of work has gone to that. I’ve been on your newsletter since the very, very beginning. So I recognize a lot of the faces that have spoken in there. I think that, you know that from, if you take a practice and you have revenue cycle and billing, you have marketing, you have operations, and you have legal, and then you have a leadership. I think, I think VirtualPractices.org kind of touches on a bit of everything, it kind of ties it together.

Dr. Tom Blue

Yep, yep, you’re right. Well, thank you so much.

Cheng-Huai Ruan, M.D.

Yeah, no problem. And so last question, before we jump off, what, then I asked a lot of the summit speakers this, what have you learned recently that you wish you knew maybe before the pandemic? Maybe, two years ago.

Dr. Tom Blue

Gosh, you know, the, I guess, I guess the first thing that I would say that I’ve learned is how real the consumer appetite for healthcare done differently is, and how quickly and easily consumers were able to not only adjust, but I think probably get a much more satisfying version of healthcare out of the, out of the creativity that emerged from, you know, from COVID and you know, how willing older people are to use virtual technologies. A lot of the beliefs that we had about the friction that would occur in making this transition, you know, I think COVID resolved for us, you know, by forcing it, on everybody, we realized holy smoke, you know, it’s just not, you know, it wasn’t a cliff we were jumping off of, it was like a curb, you know, down to it, you know, it was not nearly as scary as, and I think without COVID Lord does how long it would have taken us to, you know, to realize these things. 

But, you know, and then of course the, you know, the, you know, kind of the, that coinciding with all of the changes to the payer system, I mean, I wish we’d known it was coming, but yeah, but it was such an unbelievably pleasant surprise to see how the payer system kind of morphed to, you know, to accommodate so much more creativity. And my sincere hope is is that if people do what you’re saying, and it is, and I mean, I can certainly acknowledge that learning about codes and business models, and it’s not the things that get most doctors really excited. And, I mean, practice implementation stuff is never the first thing that people want to sign up for. But I will say if you can suck it up, and do some learning on this, you really will find that there’s a pathway into a much more satisfying way of practicing that lives right on the other side of this education, which is not that hard of a learning curve to, you know, to summit. So anyway, I guess those are the big things that I’ve kind of come away with.

Cheng-Huai Ruan, M.D.

Yeah, I totally agree with you. I think that the, the physician community has been really loud, loud as it’s ever been in history on a lot of that deal with the pandemic, right. And so I think that the adoption rate of something like this about pivoting is going to be very, very high, you know, and I just want everyone to know there’s no such thing as the right business model. There’s such a thing as a right business model for you. So, you know, you were, for example, you know, you really have to understand what your core values are. So during the pandemic, we actually took away some service line and narrowed on the things that really were part of our core values and got rid of the things that were expensive at the same time. No one’s super passionate about it. And so once we were focused on that, our value delivery systems for our patient was much better. 

So for each doctor, that could be a completely different thing, you know? And so we recently got rid of all hormone, hormone replacement therapy, and now we work with our other integrative health practitioners in the community and funnel them, all those patients. And we had about 2,200 patients within that, that we decided to just kind of leave off, not because we didn’t value them, but because we wanted to focus on a lot of what our core values are. And, you know, and I, I get to focus on my favorite thing which was actually it’s neurology and neurodegenerative diseases. So I think that that healthcare could be engineered once you kinda know what to really, really track, but yeah, I think you’re absolutely right. The adoption rate’s just gonna be really high. And so, Tom, I really wanna thank you for being on and just having a very candid conversation like this. It’s not very open. It’s really nice because I think that as we move on into the, into the near future and as 2022 shows up a lot more cards in the payer system, what we’re gonna find is that, you know, there’s not necessarily an end to the pandemic era of medicine. This is how it’s always gonna be, and we just have to recognize it, right.

Dr. Tom Blue

Yeah, totally agree with you. Totally agree.

Cheng-Huai Ruan, M.D.

All right, thanks everyone for attending, Tom. Thanks for being on.

Dr. Tom Blue

My pleasure.