Direct Orthopedic Care

In today’s podcast, we’re going to be talking about direct orthopedic care, brought to you by One Touch Telehealth. Our guest today is Dr. Daniel Paull.

Dr. Daniel Paull, orthopedic surgeon and founder of Easy Orthopedics, the first fully direct orthopedic care practice in America. He does house calls and offers transparent cash pricing. Self-described as a rogue.

In our show today, we’ll learn the ins and outs of direct orthopedic care. Many providers in primary care have moved to direct care, virtual care, and telehealth models but it’s seen as rarer in specialty medicine.

How did you get into direct orthopedic care?

I’ll just say that when I was going through training that’s not something I ever thought about ever. It was not like I was a primary care doctor, I think direct-to-patient care seems good. It didn’t exist. I had a couple of crises occur at the same time. I started a fellowship in hand surgery, which in orthopedic surgery is another five years and that’s after four years of medical school. Then you can do an optional extra year of training to subspecialize. So that’s what I was doing, enhanced surgery. I do generally now, but at the time it was just going to be hand surgery. I was looking for a job right and I couldn’t find one close to where my wife was from in Colorado.

I would best describe these interviews as abusive in the sense that either they lowball you, want to give you a short guarantee or they want you to take taking call for their entire practice, like nonstop. These aren’t good jobs.

I just quit my fellowship, broke my lease, and moved out to Colorado. I had a colleague who does house calls down to South Florida. Not only was he happier than anybody I knew but he was doing better financially.

The Current Health System

It’s more attractive to just go in and jump right in the system, guns blazing? As the ecosystem exists, running your practice is extremely difficult. If you take insurance your overhead requirements are tremendous. You’re talking five people for every one doctor. Over time, your reimbursements go down and your overhead goes up. It becomes a really difficult game to keep playing. That’s why you see the only people who are still being able to play this insurance game are these hospital systems or your very large private practice groups.

For most providers, the only option is to join these large private practice groups or hospital systems because you need the paycheck and student debt is so high. Then 5, 10 years from now, they realize that they’re pretty miserable and they’ve got paycheck addiction.

How did the pandemic change virtual care, telehealth and house calls staffing ratios?

If a typical model is a 5:1. For every provider that means they need five administrative staff plus nurses, but over the pandemic, virtual care reduced that model from 5:1 to 1:1.

Carrie asks Dr. Paull, what is the staff ratio in direct orthopedic care?  Dr. Paull says, “it’s max 1:1.” It’s probably less as it removes all the middlemen. There are a bunch of people in the system that they don’t add anything to the patient relationship, or doctor/patient relationship. They’re just strictly for billing and coding and that sort of stuff. And you essentially removal them. They’re not necessary when you don’t take insurance. If you take insurance, you have to have someone checking insurance coming in, you have to go into the room to basically, pre-build your electronic medical record. Now you have an expensive EMR because it’s meant for billing.

So they’re asking questions that have no real relevance most of the time. And they build that you spend 5-10 minutes. Are you delivering good care? I don’t think so. Even if you’re a good doctor, because I don’t think you can compress these visits down for that long. I mean, and I think patients realize and they hate going to the doctor. Nobody listens to me, or they’re taking care of something that I don’t even care about. All that stuff detracts patient value by forcing you into this system.

In direct orthopedic care, you remove all that, it looks different for different specialties, and it’s just bare-bones basic. So you don’t need anybody else. In my practice, it’s me and my wife, and she helps coordinate it. And before her, it was just me. So it’s not uncommon to see these who are solo, like no other office staff.

What’s the difference between direct care vs. concierge medicine?

When people think about direct care, they think, it’s concierge medicine. And it’s very similar. How is what you’re doing indirect orthopedic care? I mean, you don’t consider yourself a concierge medicine guy, right?

I think that’s kind of a very common misconception. The difference between direct care and concierge care is concierge doctors usually take insurance. So they double-dip. They not only take insurance, but they also bill on top of it. So basically what they’re saying is my panel is getting too large. I’m going to decrease in, spend more time with patients. I’m going to bill your insurance, but to make up for all that junk, you have to pay this high premium. The cost of concierge care is usually much higher, but I don’t think the care is any better because they’re still dealing with insurance systems. With direct orthopedic care, there’s none of that. The cost ends up being lower, and I think the care is slightly better.

What is the patient population for direct care?

People think it’s just for rich people, but that’s just not what I do. That does that happen. However,  there were also people who, workers who don’t have insurance, and I ended up being sort of a cost-containment vehicle for them. I look at their situation and determine, no they need to go to the emergency room or they don’t need this MRI. Let’s try this treatment. Here are some home exercises. It ends up being cost-effective rather than, just me going to some rich person’s house and riding the elevator up with them.

  • I get all sorts of people, even people with insurance that don’t want to wait two months for this appointment. And they’ve had a bad experience. They’re willing to go out of pocket just for the convenience of it.
  • I’m seeing more and more self-insured employers doing this direct care model where they may have an employee and the cash price is so much less than having to run through all the hospitals. They fly them somewhere, give them off work or take their family out there because the full cost is less than going to the hospital or outpatient surgery. That just shows you how crazy things are. So little fly the person and their whole family down in Mexico with the doctor from the United States down to Mexico and all that is less than doing it down the street. And read out the run, the surgery center space, or whenever they have to do down there.

Dr. Paull, says he was able to fix a guy’s wrist for about $6,500 all in including implants. The local hospital quoted in $27,000 plus facility plus the anesthesia. It would have been a $50,000 surgery. Employers are paying over $20,000 per employee per year for health issue coverage. It’s becoming one of my biggest line items, so they are trying to figure out what they can do about it?

What is your mix of house calls, in-person, and telehealth?

When I started, I was 100% house calls and then I found that as I would travel around, meet people in the community. Now I’m probably 50% house calls, 50% office visits just depend on the week. I’ll do some medical work as far as telehealth. I was doing that before the pandemic, in the sense that if I had a patient I already saw, I would call them to follow up with them to see how they were doing. And if they were doing well, then I don’t need to see them again. But if they weren’t, then I would see them again. I always found utility in orthopedic telehealth.

Now I’ve kind of expanded my orthopedic telehealth as just a completely separate visit. Now I screened those meaning that for most people is pretty appropriate, but sometimes if it’s something that I need to do a physical exam, then I won’t do it. And I’ve also found that there are about a dozen or so other states that recognize my license for telehealth. So I’ve started to expand into those areas as well with the goal being, that if a telehealth visit can maybe save a patient in Pennsylvania from sending someone into the orthopedic ward, to get unnecessary surgery it helps.

Where do you see the future of direct care, orthopedic telehealth in the future post-pandemic?

Do you think that pandemic has changed people for being more accepting to coming into the house or telehealth, vs going into a physical office? People still don’t want to go sit there and wait for 20 minutes looking at each other, like, are you vaccinated? Are you vaccinated? Where do you see this progressing?

Yeah. You know you don’t want to be sitting in the office, especially that guy, that’s not wearing a mask, you know, he’s not vaccinated, right. There’s no way. But I think that the pandemic pushed telehealth ahead by a lot, probably years as it kind of came into a necessity. If you’re sick, you can do essentially almost everything through telehealth. And then I found as I did appointments, I could add a lot of value. So someone’s got an MRI. They want to talk about it before they see their local surgeon get a second opinion or a first opinion. Well, I can do that for them with orthopedic telehealth consults.

To learn more about Easy Orthopedics or Dr. Paull.

To watch our on-demand webinar, “Best Practices in Telehealth Patient Handoff Workflows”.