Why I Chose Direct Primary Care With Dr. Kenneth Qiu

“We don't have a healthcare system, we have a health insurance system. Everything is built inside and around health insurance. In order for us to actually have a healthcare system, it has to be built on a foundation of primary care. That needs to be completely separated out from insurance.”

Dr. Kenneth Qiu is a family medicine physician and the founder of EuDoc, a direct primary care practice in Virginia. Kenneth brings a fresh perspective, having taken the bold step of starting his own practice right out of residency.

On this episode of How I Doctor, Offcall co-founder Dr. Graham Walker talks with Kenneth about the state of primary care and why he believes a direct care model has advantages over insurance-based care. Kenneth also discusses launching and marketing his practice, the specific challenges of family medicine, and the importance of having humility as a physician. This short episode delivers a lot — from big ideas about systemic change to tactical tips for entrepreneurial doctors.

Here are four takeaways from Graham and Kenneth’s conversation:

1. With a brand-new practice, marketing is key

“You're just trying to get your name out there however you can.”

After launching his practice, Kenneth spent a year learning how to market it. There was no other direct primary care practice in his area, so he and his team went out into the community to spread the word. They showed up to farmers markets, for instance. When you open a new practice, and especially when you’re offering a new model of care, Kenneth recommends devising an advertising strategy.

2. A direct care model helps PCPs get to know their patients

“I think a lot of doctors in primary care are moving to direct primary care because they want to establish the patient relationships.”

In medical school, the more Kenneth learned about the healthcare system, the less fixable it seemed — until someone turned him onto direct primary care. One big differentiator, Kenneth says, is that direct primary care enables physicians to build long-lasting patient relationships. (As a refresher: In direct primary care, patients pay a subscription fee (out of pocket) for access to personalized, comprehensive care. In a traditional insurance-based model, patients use insurance to pay for individual services.)

3. Kenneth prepared to launch his own practice by learning as much as possible about direct care

“Stepping outside of the system helps you look at the system in a different light. Actually making it work is a proof of concept.”

Kenneth has never worked in the fee-for-service world, since the first thing he did after residency was open his own direct care practice. But, by that point, he’d already spent years learning everything he could about this model of care. His self-education included talking to at least 100 different practices around the country and visiting several dozen in person. He engaged in high-level conversations about what primary care is and should be, and also asked about nitty-gritty things, like where practices buy their supplies.

4. “Live like a resident” is a strategy for long-term success

“Lifestyle creep happens, and it happens very quickly."

Financially, Kenneth is focused on long-term goals. He could be making a lot more money as a fee-for-service urgent care physician, but he believes that investing in his business now will generate greater returns down the line. In order to prioritize business growth, he’s cautious about spending. Once you start being loose with money, it’s hard to go back.

Connect further with Kenneth on LinkedIn here. Learn more about his practice here.

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Transcript

Kenneth Qiu:

We don't have a healthcare system, we have a health insurance system. Everything is built inside and around health insurance. In order for us to actually have a healthcare system, it has to be built on a foundation of primary care. That needs to be completely separated out from insurance.

Graham Walker:

I am so excited to share with you this conversation with my guest Dr. Kenneth Qiu. He is the embodiment of an incredible physician. He's a board certified family physician and founder of his own direct primary care practice. Not only did he found his own practice, he did something that personally me and probably many of you would be terrified of. He did it right out of residency.

Dr. Qiu, thank you so much for joining me today. What made you decide to go into family medicine?

KQ:

Yeah. I actually went into family medicine late. I had decided by third year that I wanted to do emergency medicine, which is what you did.

GW:

Yeah!

Kenneth doubted the healthcare system could be fixed

KQ:

Yeah. Now I defected. I actually set up my whole fourth year with emergency medicine, AI electives and all that stuff, and then changed into family medicine.

I've always been interested in policy in the healthcare system. I just spent a lot of the time during med school, in addition to learning medicine, learning about the healthcare system. The more I learn, the worse it was. Because I had all these interests in the healthcare system, someone turned me onto direct primary care. I was like, "This is it." Everything up to this point about the healthcare system just got worse and worse. I was like, "There's no fixing this." But then I learned about direct care, I was like, "Okay, maybe there's something here."

GW:

I feel like primary care is even scarier to me. Maybe I have too much of an emergency mindset where I think everyone's having a dissection. But I think one of the things we like about emergency medicine is that we can always go back and ask patient extra questions, or just order a CT scan if we're nervous. Versus with family, or with most of outpatient medicine, once the patient's left the room, it's too late. Do you ever think of things from that perspective?

The biggest challenge in family medicine is the risk of “missing stuff”

KQ:

Yeah. That thing we learn early third year of sick, not sick, I think applies to both of our professions. To your point, I don't have the donut of truth in my back room, so I can't just send people through CTs when I'm nervous. But that same rule, if somebody comes in and they don't look well, we still have access to EMS and all that stuff.

I think where the higher risk comes in for family medicine is missing stuff. Because we have to sift through so much normal that ends up being nothing that we need to stay vigilant enough to catch that maybe .1% that does end up being something. Most of the time, it's not going to be like a heart attack or a dissection, those are a little more obvious but can be missed. But it's the cancers, it's the lingering infections that get worse. Maybe it is something like an undiagnosed A-fib that we mistook for a reflux, or something like that. I think that's where the risk is.

When you establish a relationship with a patient, you get to know them better. Why I think a lot of doctors in primary care are moving to direct primary care because they want to establish the relationship. It helps with that sick, not sick. That's where, if primary care is doing right, there's a beauty and art to it.

GW:

That's what I try to convince them of, is the value of primary care is your PCP getting to know you well enough that they can both talk you down from a ledge when you're just very anxious about something, versus they actually can tell, "Whoa, something's actually up with Graham." It's building that relationship. I think that's probably one of the things that you guys can do in direct primary care that's probably a larger challenge for primary care in other settings.

I want to ask you some nuts-and-bolts questions about direct primary. You started your own direct primary care practice right out of residency, is that correct?

Kenneth heavily researched direct primary care before launching his practice

KQ:

All throughout residency, I must have talked to at least 100 different direct primary care practices and visited several dozen across the country. Just asking them how to do things, how they structured this, where they go their supplies from, so on and so forth. That built up a lot of just knowledge going into it.

It's been a great opportunity for me to engage some really interesting people and have some good conversation around what primary care is, how it should work, how it does work. I think if I started in a fee-for-service world, all I would think about is coding, billing, how to make it more sufficient, how to convince Medicare to reimburse more, and all that stuff. Well, when I get rid of all of that, now I start to think, "How can I do better patient care? How can I do it more efficiently? Who pays for primary care and how is it currently paid for? Why does that not make sense, and how can we do it better?" Stepping outside of the system helps you look at the system in a different light. Actually making it work is a proof-of-concept.

GW:

Kenneth, this might be a little bit of a controversial question. Do you think that primary care physicians are paid enough?

KQ:

I think both yes and no. Really the answer is how do we match up the value of what the primary care doc is doing to their reimbursement.

The importance of marketing a new practice

GW:

How long has EuDoc been in existence?

KQ:

We celebrated three years last Friday.

GW:

Oh, wow. Congratulations.

KQ:

Yeah, thanks.

GW:

What's changed in the past three years?

KQ:

When I started, it was all marketing. You're learning how to market. We sponsored random stuff, showed up to things like farmer's markets, which worked really well for some of my friends and colleagues in other localities. It was not a big success for us.

GW:

Because you're trying to drum up business essentially?

KQ:

Yeah.

GW:

You're trying to grow your panel, essentially.

KQ:

That's right. Year one, new docs in a new location with a new practice model, because there was none in my county. You're just trying to get your name out there however you can. You have to have some sort of advertising strategy. Onboarding, just learning how the process works, how to make it more streamline, how labs work. It's little things.

GW:

How big is your practice, Kenneth?

KQ:

I'll be vulnerable and throw it out there. It took us a whole 18 months to get to our first 100. But then it only took 10 months to hit our second 100. We're about to do our third 100 in eight months. The time gets smaller and smaller. I imagine that's only going to get faster.

GW:

You mentioned a little bit about, in medical school and I think in residency, how the healthcare system disturbed you. What did you find the most disturbing about the American healthcare system?

KQ:

What I think is the biggest problem right now about healthcare in general is the fact that we've tied everything to an insurance-based system. We don't have a healthcare system, we have a health insurance system. Everything is built inside and around health insurance. In order for us to actually have a healthcare system, it has to be built on a foundation of primary care. That needs to be completely separated out from insurance. There are ways where we can separate out primary care so that it doesn't fall under the umbrella of insurance, and go through the same hoops, and risk adjustment, and all that stuff that insurance does.

GW:

In our last few minutes here, Kenneth, I've got some rapid-fire questions. What's the number one thing you wish patients knew about you?

KQ:

How much I care about them not being taken advantage by the system. What I'm trying to do, not just for them medically, but also a lot of the care navigation that I'm doing on the background. There's just so many things that I think, as a primary care physician, I can protect them from and guide them through.

GW:

What's the number one thing you wish your patients knew about your specialty?

KQ:

I think probably the potential, what we're trained to do. Basically that we can take care of babies all the way through the elderly. That we can do a lot of care navigation, and that we do like to have continuity rather than just in-and-out.

GW:

What is something you didn't learn in med school but is crucial to your daily practice as an attending?

KQ:

I don't want to frame it as risk reduction, but it's just learning how to communicate with patients, and then learning how to have full discussions without harm. Because people are coming in with various opinions, various social media influences, and you have to help navigate that. I think a lot of doctors, they get really, really frustrated because a patient comes with a complaint that they've seen on a test.

I think that's something that a lot of docs miss and they don't develop that skill of, okay, let's try to understand where the patient is coming from. I don't know that that's inherently teachable in med school, but that's definitely street smarts that I think every doctor needs to develop in the real world.

Being frugal now can help you reach financial goals later

GW:

What do you think the best financial advice you've received is?

KQ:

The advice is always live like a resident because lifestyle creep happens and it happens very Qiuckly. But just understand what your goals are. I could be making so much more money in fee-for-service doing urgent care, but this is something that I'm investing in myself. By being a little cheaper right now in my life, and focusing on the business, and doing a lot of things through the business, you have more returns later. Hopefully. It's going the right way so far.

Yeah. One, understanding what you want to do longterm, making sure you have the runway to do it. And then not letting lifestyle creep get the best of you.

GW:

Do you have a piece of really good advice you got from an attending that you still think back on, or something they said or how they interacted with patients still to this day resonates with you or you've stolen from them?

Humility is an important quality in a physician

KQ:

One attending says, what is it? "We treat and God heals." Sometimes you just watch and there's only so much we can do. That's one. It's a little bit of humility, like we can only do so much. Two, being mindful of how nature works. Some things just get better and some things get worse, regardless of what we do.

The second one was something during residency. I did a rotation with a DPC mentor of mine. Just watching him see patients, he was just very confident. Watching him, he was just like, "This is the truth, this is how it works." Just how to present yourself makes such a big difference. I notice my patient satisfaction scores in residency change drastically after I started taking that approach.

GW:

Do you recall the most ridiculous thing that you've been dinged for?

KQ:

One of the things that I still remember that's still really frustrating is one of my first patients in residency, back when we still had an hour per patient, you got two per half-day. They were here for an annual physical, the free thing that insurance gives you. I just went through, and I didn't know any better because I was a new grad, and I just adjusted all her medicines, got all the labs. Talked about each different issue. Basically, a tune-up.

I got to my attending. I'm like, "Yeah, they're here for a physical. I did this, this, and this." The attending is like, "Oh, great. We can split bill her." I'm like, "What is split billing?" They're like, "Well, you made adjustments, didn't you?" I was like, "Yeah, it's a physical. What's the point of a physical if you're not helping the patient get tuned up?" They're like, "No, no, no. The physical is just to look. Then if they have any issues, then you get to bill them." I'm like, "That sucks. I hate that so much with a passion."

GW:

If you could design a new medical specialty, what would it focus on and why?

KQ:

I think there should be a fellowship in care navigation. Understanding the healthcare system, cost, quality metrics, that kind of thing. There should be one that is fellowship and team-based.

I think a lot of the frustration between scope of practice, this NP, PA, MD debate, is because nobody actually knows how to work with them. We're never taught. We're forced into the same space and sometimes replaced by administrators who just don't know anything about our training. Then it just creates this natural friction.

GW:

Give me one medical myth that you wish would disappear forever.

KQ:

I don't know that it's a myth, but a culture that things can just be fixed Quickly. This leads through into a lot of downstream myths. Everybody just wants to feel better now. Not enough people understand that sometimes things take time. Even the people who are chasing this longevity stuff who are drinking all the powders, and pills, and getting all the advanced scans and test, and whatever, they just want things right now. Sometimes you get older and sometimes things don't heal as fast as you want to. It would dispel a lot of the snake oil salesmen that are out there.

GW:

Kenneth, where can listeners find you and your practice? How can they support the work that you're doing in direct primary care and your advocacy work?

KQ:

I'm looking for anyone interested in primary care innovation, people who are policy-minded or business-minded to try to make this work. Because I think those are the two areas where we can do the most good is figuring out a business model that works, and then convincing the right government agencies to do it the right way.

GW:

Great. Well, Dr. Kenneth Qiu, thank you so much for being with us today on How I Doctor. Look forward to connecting with you more on LinkedIn.

KQ:

Yeah. Thanks for having me, Graham.

GW:

Thanks for joining me today. For interviews with physicians creating meaningful change, check out offcall.com/podcast. Make an account on Offcall to confidentially share your details about your work, and sign up for our newsletter where you can hear more about the latest trends we're seeing in physician pay. You can find How I Doctor on Apple, Spotify, or wherever you listen to podcasts. We'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well, stay inspired, and practice with purpose.