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“Our children are not OK. Our pediatricians are not OK. Please, let us not further ignore and jeopardize the future health of our society. Pediatrics needs a transformational change to direct primary care and other models that transition from transactional care to relational care. Encourage your employer to embrace direct primary care for children. The future health of our children is at stake.”
Andrew Hertz and Keili Mistovich are pediatricians.
They share their stories and discuss the KevinMD article, “Kids are not OK: Health care is failing them.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.
Today on the show we have Drew Hertz and Keili Mistovich. Both are pediatricians, and they wrote the KevinMD article “Kids are not OK: Health care is failing them.” Drew and Keili, welcome to the show.
Andrew Hertz: Thank you.
Kevin Pho: So Drew, let’s start with you, and I’m going to ask both of you the same question: Just share your story and journey to where you are.
Andrew Hertz: Thank you for the opportunity. I’m a general pediatrician, and for a long time I was with a large academic health system, and I most recently ran their extensive outpatient pediatric inventory network. About a year ago, I decided to leave that job, and I started my own consulting group. As I dove into the problems with pediatric care, because our children are getting sicker all the time, I learned about direct primary care. Actually, I learned that from Keili, and she’ll explain that story. I realized that the concept of direct primary care really could be a solution to all the woes, both for our patients and for our doctors. So I’ll let Keili explain a little bit about her journey, because that’ll help us understand how everything came together for the article.
Kevin Pho: Sure. Keili, go ahead and share your story and journey to where you are today.
Keili Mistovich: Absolutely. So for many years, I was working in a traditional fee-for-service, insurance-based model that all of us know very well. It was quite the challenge to maintain being able to do what we want to do as pediatricians and as doctors, having a 3,000-patient panel and seeing over 25, 30 patients a day. You really feel the moral injury of not being able to do what you want to do as a doctor day in and day out. You feel as though you’re never quite doing enough for your patients, despite going above and beyond everything that you can do.
So we really put some thought into this and said, “How can we do this better?” As Drew mentioned, our kids are getting sicker. There are so many chronic illnesses that we are unable to adequately care for them with the time constraints and the abilities within a traditional office. And so our answer to how we can do this better was to open a direct primary care office. My partner and I opened the first pediatric direct primary care office in Cleveland.
In comparison to what we were doing previously, we are limiting our panel sizes to about 300 patients apiece, as opposed to 3,000, which is a very different number when you’re taking care of children. It really allows us to focus on the relationships that we have with our patients, and it’s not about just moving kids through like a mill in this practice. Our patients have direct access to us. They are able to call me and text me whenever they need anything, and we have really extended and prolonged appointment times, so I can spend an hour with a patient as opposed to 10 or 15 minutes, which is all we were able to do previously.
We also do home visits. So during those early months particularly, when families are really vulnerable, we come to parents’ homes, we see them where they are and meet them where they are, and we’re able to care for them in the best way. So that’s my traditional path through: starting in the fee-for-service world and ending up in what I truly feel is the best way to be able to take care of children now.
Kevin Pho: And Keili, just for those listeners who aren’t familiar with the direct primary care model, can you just briefly describe exactly what that is?
Keili Mistovich: Sure. Direct primary care is a model in which patients are able to be cared for by their physicians outside of a traditional insurance model. What that means is that instead of billing all of our appointments through an insurance company, we set them up with a membership that allows them full access to their doctors. So in fact, we are what we call a non-insurance-based model, and I do not bill insurance for anything, which truly gives me the freedom to see and take care of my patients in any way that I see fit.
Kevin Pho: All right. And you’re going to talk about more in your KevinMD article titled “Kids are not OK: Health care is failing them.” Drew, I’m going to ask you to walk my audience through it for those who didn’t get a chance to read that article, and maybe share the story of why you and Keili decided to write it.
Andrew Hertz: Sure. The article outlines how children are having more and more chronic diseases. The estimate is really that about 25 percent of children have some type of chronic disease. Mental health is a major problem across children, and the pandemic has just made this worse. At the same time, doctors feel moral injury. As Keili mentioned, doctors want to provide total patient care, but you just can’t do it when you’re seeing 25 patients a day. The average well visit is 16 minutes, and you’re supposed to assess development, you’re supposed to assess nutrition and sleep, and then all the medical conditions, and then the family has more questions. You just can’t do it. And then after the meeting, you still have to document your notes extensively to meet all the needs of the insurance company. So we outline all that argument in the article.
Then we propose that direct primary care, a membership base that’s really a capitated payment, allows the doctors to do a much better job. If you think about direct primary care, it eliminates the administrative burden associated with processing your insurance claims. It eliminates the administrative burden of having a high-volume, high-throughput office. Once you eliminate those expenses, you dramatically decrease your overhead, so the doctor can see fewer patients, spend longer time with each patient, and provide increased care. The article outlines this as an argument and asks people just to be more aware of direct primary care and to even talk to their employers about supporting direct primary care. Many employers will support direct primary care for adults, but there really aren’t any employers that support it for children yet.
Kevin Pho: And Drew, you mentioned as part of your biography that you worked for a large integrated health care system for 20-plus years. Tell me about some of the obstacles you faced when you tried to change the system from within and tried to overcome some of the difficulties that you described.
Andrew Hertz: It is very difficult because it’s all based on insurance claims. And you know, what’s the definition of insanity? Doing the same thing over and over again and expecting different results. But our children are not doing any better, so we need to change it. It’s very difficult in a big health system because it’s so focused on fee-for-service. A lot of health systems lose money on primary care; they make money on the downstream revenue. So they really don’t have any incentive to change the model for primary care too much, because they’re already losing money on it. But I think if we could really be innovative, it could work.
It’s actually rather amusing, because I first met Keili because she and her partner approached this academic health system to support them in starting the first DPC model. We were very excited about this, and we made them an offer, and then, brilliantly, Keili and her partner refused it. It’s because they realized they wouldn’t have the nimbleness in the health system that’s needed to quickly evaluate and transform your care delivery model. So Keili does home visits; that’s probably going to be frowned upon by compliance departments or legal. Their patients sign a HIPAA waiver so that if they just want to have a quick video chat with their patients, see what’s going on with the kid, they send a picture, look at a rash. It really is about access and being nimble, and that’s very hard in a large health system.
Kevin Pho: And Keili, I’ve had physicians in a direct primary care model, but as Drew said, there’s not too many in the pediatric arena. So walk me through a typical day of a direct primary care pediatrician and the type of cases that you’ll see.
Keili Mistovich: Absolutely. As Drew mentioned, our patients have full access to us, which means that they have my cell phone number, and they’re able to call me or text me whenever they need anything. So generally speaking, I’ll start my days, and I’d like to add into this that one of the nice parts of being a pediatrician and a mom in the direct primary care model is that I can be more of a mom, and I can be more present in what I’m doing. So my day actually starts with getting my daughter ready and getting her to school, and then I’m able to decide independently when I’m going to start seeing patients in the office, as opposed to being told what time that is going to be. So it takes a lot of stress just out of our lives in general.
In the morning, I’ll generally start getting a few text messages from my patients, just “So-and-so woke up with a cough,” or “a runny nose,” or “They have a fever,” and they’re asking for some general guidance on what to do with that situation, or “Should I keep them home from school?” Any of those kinds of things. Then over the course of the day, I will generally see an average of three to four patients, each one for anywhere from an hour-and-a-half appointment, if I’m seeing a nine-month-old for an infant visit, or it might be a five-minute appointment if it’s a family where I said, “You know what, let’s bring them into the office,” because they were having ear pain last night. I’ve already heard the story from them because I’ve been talking to the family over text in the morning, and I can see them truly for five minutes in the office, do a quick exam, check their ear, and then send them on their way.
So not only does this save the families a massive amount of time, because they’re not coming into the office, they’re not waiting for the child to get roomed, they’re not waiting for the doctor to come in. I truly meet them at the door, I walk them down the hallway to my office, I see them, and then they’re done and on their way to school or to work or whatever it is that they need to do, without having a huge time lost in their day. Not to mention that in a traditional office, you would call the office, you talk to the front-desk person, then you get transferred to nurse triage, and then they might call you back two hours later, and then they’ll give you some advice, and then they have to talk to your doctor, and then maybe your doctor will call them back, or maybe they’ll get scheduled for an appointment, and then it’s six hours later and nobody has been able to, the kid has been suffering, and they’re not being cared for.
So in my day, I’m able to remove all of that administrative burden, and I just see the kid and see the family and take care of things and allow them to go on their way. So that’s a typical day. I’m usually able to wrap things up generally around the time school is ending for my daughter. I can go and pick her up, we come home, and we do our normal family activities. I may get a couple of additional text messages or a phone call in the evenings, and that’s pretty much what a day is. I love that.
I also have so much time. When you’re seeing three or four patients, there’s a lot of extra time left over, which means that I can read, I can actually look up things and study again, and do some CME, and actually dive into the questions that families are talking to me about on a much deeper level, which I would never have had time to do before unless I was doing it at 11 p.m., when I should be asleep.
Kevin Pho: And Keili, how difficult was it to find a sustainable group of families willing to pay a membership fee to financially sustain your practice?
Keili Mistovich: That’s a great question, and certainly in the beginning of starting this up, it was one where we weren’t really sure exactly how that was going to go. My partner and I had been practicing in the area for five or six years prior to that, and certainly we had developed some very strong relationships with some of our families, so those families were quick to move and to follow us to our new endeavor.
Since that time, in the beginning, it was a little bit of a slower growth, and part of that is because the direct primary care model for pediatrics is so new, and families just don’t know what it is. They have difficulty wrapping their brain around, “Why would I pay for this when I already have insurance?” And so it took a little bit of time to help people understand the model and what they were getting for their membership with the practice. That being said, about a year into us being open, approximately, we’ve gotten to the point where word of mouth has truly taken over, and now we are having more patients reaching out to us than we can almost manage to take on in the course of a month. So initially slow, but certainly once the word of mouth got out there, we really have grown much more quickly.
Andrew Hertz: And Kevin, you have to remember that a lot of people now have high-deductible health plans anyhow. So it’s about helping them understand how a membership fee improves your access and improves your care but doesn’t necessarily mean that you’re spending more total money.
Kevin Pho: Andrew, you worked for this large integrated health care system for 20-plus years. So take me through the decision points as you were about to make this transition into direct primary care. Tell me some of the questions you had, some of the apprehensions you had, and then finally, what tipped you over into making this career transition?
Andrew Hertz: Another great question. I love it. It took me a long time to decide to make a change. I just wanted new challenges, and I wanted to learn new things, and so I started health care consulting. As I had mentioned, I had met Keili and her partner earlier, while I was still at the health system, and so I stopped by their office in one of my first weeks and started talking to them. I was so proud of what they had done, and we talked. I gave some suggestions; I was helping them out. And then Keili said, “You know, let’s think about building a network of this. There are no pediatric networks.” And I said, “No, thank you. I really want to continue consulting and doing population health and this and that.”
But as I dove into the problems with primary care and learned more about direct primary care, I realized that this really could be a solution. It’s not going to be the only solution to change how we deliver care, but it certainly is a great one. And so Keili and her partner sold me on the concept. It took about three months, I think, Keili. Now I’m devoting most of my time to working to set up this pediatric direct primary care network, and that’s what it’s all about. We think it’s going to make a big difference in the lives of children, and it’ll make doctors happier, parents happier, and hopefully kids healthier.
Kevin Pho: We’re talking to Drew Hertz and Keili Mistovich. Both are pediatricians, and they wrote the KevinMD article “Kids are not OK: Health care is failing them.” Keili, one of the criticisms I hear about direct primary care is, of course, access. If every physician decreases their panel from 3,000 to, say, 300, then that’s going to severely limit the access that patients have. So what’s your response to a criticism like that?
Keili Mistovich: I think it is a fair criticism. I mean, purely on the number of spaces, that absolutely makes sense. I think that one of the challenges of primary care is that it is difficult to convince new medical students and residents that that is the pathway that they should take. Part of it is, when you look at what life looks like as a traditional fee-for-service doctor, where you are running nonstop throughout the course of your day, that’s not a very appealing lifestyle for anyone. Not to mention that primary care doctors are paid less than the vast majority of subspecialists out there. And so combining those two things makes it a less-than-desirable field. So I think that if residents and medical students know that direct primary care is an option, we will potentially end up moving more people into this space, and so the number of total primary care pediatricians and adult internal medicine doctors would go up to eventually offset the difference in that.
Kevin Pho: And Keili, I just want to follow up on that. If a resident is interested in a direct primary care practice, certainly that’s less turnkey than just plugging them into some type of large integrated health care system that already has a patient panel. So tell me some of the challenges and thought processes they have to go through if they do want to consider going straight into a direct primary care world.
Keili Mistovich: Certainly. And absolutely, in starting our office, that was one of the biggest challenges: learning, having been in a practice which essentially took care of everything for you, and needing to then figure all of that out by ourselves. That was truly one of our largest obstacles in initially setting up our practice: learning all of it, learning all of the policies, learning all the business, learning everything that there is to know, which is very overwhelming for any doctor, especially considering that most doctors receive zero education on anything related to the business of medicine.
So honestly, I think that what this network is actually trying to do is alleviate a huge obstacle for new doctors to be able to do that. The goal of our network is to actually set up these practices for physicians and give them essentially a turnkey option that they can walk into, and they can start practicing medicine immediately and taking care of patients immediately, and then our job is to take care of everything on the back side.
Kevin Pho: And I’m going to ask each of you the same last question, just your take-home messages, pieces of wisdom, and advice to my clinician audience. Drew, why don’t we start with you?
Andrew Hertz: Thank you. I think the take-home message is what I already mentioned about insanity. We can’t continue to do the same thing over and over and over and expect different results. Our children are not OK. Our doctors are not OK. And doctors need to realize that there is another option, and there is a way to become the doctor you always dreamed of becoming in medical school, and direct primary care is one of those options. But we need to stop doing the same thing. It’s not working for our patients. It’s not working for our doctors.
Kevin Pho: And Keili, what are some of your take-home messages?
Keili Mistovich: I think that the important thing, similar to what Drew said, is that there really is another option. When I speak to new doctors who are considering this option, one of the things that I often say to them is, “I would never go back to a fee-for-service model.” Not only do I love being a pediatrician, which was always true, but I also love my job. I love going to work every day, and I would bet that not a lot of pediatricians out there who are doing a traditional job currently can say that.
Kevin Pho: Drew and Keili, thank you so much for sharing your time and insight. Thanks again for being on the show.
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