Top DPC mistakes physicians can learn from Brian Forrest, MD

It has been 15 years since Brian Forrest, MD, a family medicine physician in Apex, North Carolina founded Access Healthcare, which is considered one of the earliest Direct Primary Care (DPC) practices in the U.S.

In this podcast, Forrest highlights the failures he has experienced over the years since starting a DPC practice, and explains how other physicians can learn from his mistakes.

Brian Forrest: I would say that one of the things that I’ve seen as that you have to figure out where your patients are and sometimes that takes a little adjusting, figuring out what patients want, what they desire in the medical practice.  Also finding out what they can afford because part of our goal as a practice is to make healthcare affordable for everybody.  You sort of have to experiment around with that and know different patient types to figure out what’s going to work for everybody. 

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You also have to set up some policies in this model since you’re not billing insurance to make sure that you do get paid.  You know our collections have been really, really high and that’s gotten a little better every year but it’s probably around 98% to 99% and the reason for that is we keep it very simple.  We use an automated system, a type of software that you know originally the company that developed it used it for those Gold’s Gym memberships.  They do a lot of the membership processing for Gold’s Gym.  So, we just adapted that to work for our model and it makes the collections pretty seamless.  Before we had that in place, I think one of the bigger mistakes was we used things like PayPal and other ways to do monthly billing and we just weren’t reliably getting collections. 

Now in terms of mistakes that I’ve seen others make because you know over the years we’ve helped a lot of physicians, but we’ve also seen a lot of physicians sort of do this the wrong way.  And unfortunately, sometimes a doctor might read one article, or they might go to a conference and feel like ‘okay I know how to do this’ and then set out on their own without any guidance or mentorship to try to do it and they tweak something this way or that way and it really doesn’t work for them.  So, I’ve seen failures where physicians decided to charge too much.  Maybe they charged twice the average level as direct primary care.  I’ve seen physicians who set up in really, really affluent areas which is actually not good.  If you set up in a direct primary care practice in an affluent area, what happens is none of those patients find you because they’re all really well insured, they go to look in their insurance manual and you’re not there. 

Next: "Those have been the two key mistakes that I’ve seen people make"

And so some of the biggest failures, there haven’t been that many in direct primary care.  I can only think of maybe about five practices nationally that I personally know of.  But they’ve been either one of two things: either they set up in too affluent of an area or they set up in an area where there weren’t any patients.  And this works really well in rural and underserved areas.  I just got back recently from the University of Alabama where they’re considering setting up a rural residency track in a direct primary care model and I was consulting with them on how to do that.  And you know for rural medicine it really works well in general.  However, you’ve got to have enough people within ten or fifteen miles of the practice to create a panel of patients.  And so the other failures that I’ve seen have been where physicians just went out literally somewhere where there might only be a hundred or two hundred people within 20 square miles and hang a shingle.  And that doesn’t work because you know you’re not volume dependent in direct primary care but you are panel dependent.  You have to have patients. 

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And so those have been the two key mistakes that I’ve seen people make. And along with that is the idea that people don’t get out and beat the pavement and educate their communities about what it is and how it’s different and what the advantages are.  And there have been physicians who sort of just hung their nameplate up and assumed patients would find them and not been proactive about getting out in their community and letting people know about what they’re doing because you know inevitably when physicians go out in the community and let businesses, especially small businesses and different groups know about what they’re doing, people really want this.  It’s not infrequent to go out and tell people about something like this at a Chamber of Commerce event or a Rotary Club or something like that and by the end of that a bunch of people want to be patients or they want to sign up all their employees.  So, I think that’s very. very important is that people don’t just open a practice and then not go out and educate their community about what this is.

You can’t anywhere if you don’t push through the challenges and continue to innovate.  You may come up with an idea that’s a bad idea.  Direct primary care wasn’t a bad idea but there’s definitely been you know subtle things we’ve done or policies we had or ways we did things that weren’t good ideas and you have to know when to sort of scrap those and move on. 

But the key is, is that you’re persistent about the ultimate goal and the ultimate vision of where you want to go and where you want to do for people and patients.  And if you’re persistent and you ignore those barriers, or you innovate around those barriers I think you can accomplish change for healthcare.