The Missed Opportunity Nobody in Primary Care Is Talking About

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Michael Tetreault: um, also coming at it from the fact of Look, I'm the last Canadian on the planet to think that things like subscription based healthcare delivery, direct primary care, concierge medicine, all these things, these are great pathways for doctors, but they're not meant for every doctor. And nor do I believe that, you know, one particular model is the saving grace of every doctor's profession because we it's just not everybody's different, as my dad likes to say. Well, son, if everybody was the same, the world wouldn't be very interesting. So with that in mind, we're going to talk about the third pathway for doctors. What every doctor Needs to know about Direct Primary Care before they decide.

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Michael Tetreault: If you have ever been in a room, probably with other doctors lately, you've probably heard this phrase, especially among the DPC community. Cash only Direct primary care, or DPC as it's uh, abbreviated is the future of primary care. Now maybe like you, you know, and like me, maybe we've nodded and a little bit of skepticism and uncertainty, but wholeheartedly trying to agree. But maybe something in us or you quietly thought, is that the whole story? Well, in this episode we're going to take a long, full, honest, evidence based look at uh, direct primary care. What it is, what it isn't, where it actually came from, who it serves beautifully and where its structural limitations are. Where is it putting a lid on the organization? Where are these doctors putting a lid on their organization or their practice? And uh, we're also going to explore something that doesn't get enough airtime. The remarkable opportunity that the direct care model may hold for nurse practitioners, physician assistants, employer based DPC is a wonderful thing, uh, for so many patients these days and advanced practice clinicians. And we're going to look at, at the question of why the dpc, you know, some in the DPC community seem to have more organizations than agreements these days and what that tells us about where we think that the model might be heading just based on what has happened in other spaces, other specialties and um, even though direct primary care is not a specialty, it's a business model. Again, this is a podcast today that's not a critique or criticism of DPC physicians. The conviction driving this community is, is incredible and it's genuine and it's admirable and important for the future of primary care. But I'm not a believer that as a patient that is for every doctor either. And when you sit down face to face, you know, kneecap to kneecap with some physicians out there who are doing DPC like I have over the years and I've been doing this a long time, been observing this space. I've had a seat on the bus for a very long time. What we want to offer today in this podcast is just some education, something every physician deserves to go into before and consider before they are making a career decision. It's not an argument for or against. It's just a full picture grounded in some evidence delivered with incredible admiration and respect for doctors. Because as we say around here a lot, it is no longer about being the best doctor in the world anymore. It's about being the best doctor for the world, for your patients and for your local community. And all right, with all of that being said, uh, here, let's just, just get into it. All right, so direct primary care, first of all, let's get this thing and let, let's, let's get the wheels on the, on the, the wheels on the bus. I got three kids. Let's get the wheels on the road, you know, all four of them. Okay, so before anything else, let's establish one thing clearly because uh, this, this single, one single point, if we get this wrong, we don't clarify it up front, it muddies everything else we're about to talk about today. First, direct primary care and concierge medicine, they are not the same thing. DPC is not a more affordable version of concierge medicine, despite what you might read on physician websites or hear about out uh, there. And it's not an evolution of concierge medicine. It's not a replacement for it, it's not insurance. They all share surface level features, I.e. concierge medicine and direct primary care. They share surface level features like flat fees, smaller patient panels, direct relationship between physician and patient. And those similarities have created a lot of genuine confusion, particularly from the marketing perspective and the business perspective, the service and features and benefits perspective in the media, in, in physician communities especially, and in the minds of doctors and patients who are trying to figure out what path and features and services they should offer and uh, which pathway, which business model fits their goals. DPC is its own thing. I like to refer to it as a third or a fourth pathway for doctors. It's got its own origin story. I look at it sometimes. I've described it to media as, look, it's like a cousin of concierge medicine. It's in the same family under the umbrella of membership medicine or subscription based healthcare delivery today. But it has its own origin story, its own patient demographic, its own economic logic and its own set of opportunities and challenges. So with a little uh, starting with a little context, because context matters when we're making a significant career decision, right? We both, we all want to move into something well informed so that we can reduce the amount of risk that we take. Right. Right now we estimate that there's probably the data showing us out there from our uh, various sources that there's between a thousand and fifteen hundred DPC practices operating in the United States. Some would say that there's probably more, some might say that there might be less. The broader concierge medicine and membership medicine market includes what is estimated to be by other sources as well, between 8,000 and 12,000 practices with a second generation personalized care model, kind of a hybrid model, representing a large majority of those numbers. Now DPC is a smaller community under the umbrella of membership medicine. Its advocates are active, they're vocal, they're genuinely, um, visible, which is genuinely a strength of that movement. But knowing the actual size of the landscape also helps you and I inform others about, okay, it helps me make a more informed decision. It helps me also evaluate the conversations that I'm hearing. So where did it come from and what healthcare's history? What can it teach us? Well, here's something that rarely comes up in a lot of DPC conversations, and I think it's one as I've had with many DPC physicians over the years, as well as experts in this space as well. And I think it's one of those most, one of the most genuinely useful pieces of context for anyone exploring this path. Because before we talk about where DPC is going, I want to spend a few minutes on something broader. Healthcare has a long and humbling history of quote, unquote movements that were evangelized as transformative. Now with that, those have all had real conviction behind them, real amount of physician enthusiasm and real patient demand. Nobody's neglecting or negating the influence of those. However, those trajectories turned out to be more complicated than early momentum suggested. That's not pessimism, that's pattern recognition. And it's worth sitting with before you make a career decision. So let me give you a few examples of this pattern recognition. The micro practice movement. Now, the purist DPC model has a structural predecessor that most people in the DPC community, uh, may have never heard about. It's called the micro practice and sometimes the ideal medical practice or the solo micro practice model is what it's been termed, as I remember sitting next to, um, one of these imps or a micro practice position, uh, in Las Vegas several years ago. Gosh, it's been almost two decades and it was the most fascinating model. And this was way even kind of before direct primary care was kind of being talked about, but kind of not. It didn't really even have its name at that time because this was at a, uh, at an interesting healthcare conference, but none, nonetheless, it gained real traction in the early 2000s, about a decade before DPC truly kind of emerged into what it is today. The concept was developed most prominently by Dr. Gordon Moore, a family physician who published influential work in family medicine and health affairs. The idea was elegant. One physician, minimal overhead, minimal staff, lean tech technology, and a direct relationship with patients at the center of everything. We've sourced this in, um, our white paper related to this topic. You can go to conciergemedicineforum.com and search in the our educational resources or shop and download that white paper there. Nonetheless. Sound familiar? The AAFP even embraced it. Built toolkits, case studies. In fact, their Transform Med initiative specifically promoted small, low overhead solo practices as a genuine and desirable alternative to high volume group medicine. This was in 2006 by the AFP transfer med initiative. Now this all parallels to DPC. You can see that the DPC, the parallels to DPC here are structural. They're not superficial but centered. Direct physician patient relation. But both center around direct physician patient relationships. Try saying that five times fast. But both reduce or eliminate billing infrastructure as a core value. Both generate genuine evangelical energy from, from their practitioner, uh, communities. And both navigate the same fundamental economic reality when revenue is tied directly to how many patients one physician personally sees at a deliberately low flat fee. And the model, by design limits both panel size and fee level growth, has a natural ceiling. We talked a little bit about that earlier business, um, consultants outside of healthcare and inside of healthcare too, talk about the things that we do as owners and business owners and managers of a business or medical practice. For example, there are things that we are doing that, whether we recognize it or not, we're putting a lid on the growth of our organization or our, uh, business. And I don't want that to happen to any physician out there. Why? Because your words carry weight, right? Like that's it. Your five words from my doctor are, uh, probably one of the top five or ten most influential voices in my life, so behind my wife and kids. But I digress. All right, getting back on topic, the AFP's own research from the Transformed initiative, published in the Annals of family medicine in 2010, found that physician satisfaction was genuinely high inside of these micro practice or ideal medical practice, um, models. But sustainability was a consistent challenge. Solo physicians absorbed more administrative weight, uh, than anticipated. And as panels aged and lives grew more complex, many practices that started on a micro practice principle or principles gradually added staff, added services, and evolved towards something that looked more like DPC or concierge medicine according to the Angels of family medicine in 2010. Now, uh, the model served a specific population very well. It became a respected niche, and that history is now worth knowing. Don't you feel smarter? I know I do. All right, so let's talk a little bit about price transparency in healthcare as well as a pattern recognition. Here's another example that's closer in time and that I think physicians will find particularly more, uh, relevant and resonant. You might even even remember this for years, genuinely years, physicians and patient advocates. You don't have to Travel far on LinkedIn to see it or on the Internet. But physician and patient advocates argued so passionately that if patients just had access to real, transparent pricing information, the whole dynamic of American healthcare would change. That advocacy was earnest. It was admirable, and the logic was sound and the conviction. It was real. But then we got it. The CMS Hospital Price Transparency Rule went into effect in January of 2021. The transparency and coverage regulation followed in July 2022. And for the first time, hospitals and insurers were required to publicly disclose prices at the level that was comprehensive and unprecedented. And this was in the West Health Institute, Gallup and PMC in 2024 by Pathic and Molestein. And so what happened? Well, a Gallup survey conducted in partnership with the West Health Institute, covering more than 5,000 adults from across 50 states, found that public awareness and actual use of price transparency tools remained surprisingly limited even after the mandates took place. Effect. Have you ever tried to go to those charge masters and look, try to understand? It's like reading another language. I remember interviewing, uh, a couple of different physicians and other healthcare consultants about that over the past several years. But a systematic review published in Science Direct in 2025 found that while price transparency improved after the mandates, actual consumer behavior using that information to choose lower cost providers was modest at best. And that was according to ScienceDirect 2025. And we've included a lot of the citations and sources we're mentioning today in the white paper. All right, so the research from the University of Minnesota also found that some patients, um, used price transparency tools, but most did not change their provider selection based on the information available. This was according to parent 2023 and inquiry. All right, the advocacy was right about the need here for price transparency in healthcare and the information. It was genuinely somewhat helpful and valuable to some. However, the assumption that access to information would automatically change behavior, especially at scale, well, it turned out to be a lot more complicated than the movement anticipated. Now, I'm not sharing this to diminish the price transparency advocacy and the work that's been done as a patient. Great. Did it change my life? Absolutely not. Did it make my life in some ways a little bit more complicated? A little, yeah, actually, kind of a lot. In some ways, healthcare is complicated. I get it. The work that people did on the price transparency advocacy. I know some of them. The work matters. I'm not sharing all of this information because it illustrates something. I'm sharing this information, because I think that it illustrates something important, that in healthcare, the distance between a compelling idea and a scaled behavioral change is almost always longer than the early enthusiasm suggests. Now let's look at another pattern that happened as a movement where it is today. Retail healthcare. I know some of you are rolling your eyes and shaking your heads, but the rise in the reality check here is real. One more example, and this is instructive because it did scale, despite what you might read about it out there. Right? Just not in the way anyone really predicted that it would scale. You see, in the mid-2000s, retail clinics were positioned as the great democratizer of American healthcare. They were convenient, affordable, staffed by nurse practitioners and physician assistants located where people already shopped. Cvs, Walgreens, Walmart, et cetera. And all of them moved aggressively into the space. I remember going into the grocery store, grocery store and using one of the, I think it was called a take care clinic. At the time, analysts projected thousands of new clinics physicians, they worried about competition and the movement had genuine momentum and scale. And retail clinics, they did scale. But the business reality was harder than the concept. Margins were pretty thin, patient utilization was pretty seasonal. And a study cited by Drug channels found that 58% of retail visits represented new utilization rather than substitution for existing care, which meant they were adding the to the healthcare spending, not redirecting it. This was according to drug channels. In 2017, Walgreens eventually closed most of its in store clinics. Village MD, the Walgreens primary care venture recorded a $6 billion loss, according to CNBC in 20 in healthcare finance news in 2023, Walmart closed all of its health clinics in 24, according to CNBC in 24. CVS's MinuteClinic, which survived and grew, did so largely by pivoting away from the original transactional visit model toward chronic disease management and partnership with health systems. This was according to uh, undocumented in Health Care Finance News in 2023. Now, the model that worked wasn't the original concept. It was the evolved concept, the version that found its structural fit within the healthcare system rather than standing apart from it. Here is why all three of these examples matter when we're talking about and trying to understand direct primary care. They share a pattern, a genuinely good idea, real physician or patient conviction, compelling early advocacy, and then a longer, more complicated story about what happens when that idea meets the economic realities. Intention of healthcare delivery at scale. So what has all of this, what has actually scaled in healthcare reform? Well, this is important to know because I don't Want to leave you only with cautionary tales and associate it with direct primary care. There are healthcare practice models that have scaled and they teach us something worth knowing. Urgent care. Urgent care scaled from a handful of walk in clinics in the 1980s to more than 10,000 centers across the United States today. Urgent care claims grew 70% in a five year period tracked by Definitive Healthcare and documented in med City News 2023 and reported there. The model scaled because it found a structural fit. It worked with insurance, it embedded itself in a gap the existing system wasn't filling and it diversified its revenue. Let's also look at the PCM style. The pcm, or what I call the personal care um, model style in concierge medicine scaled from a handful of practices in the late 1990s to an estimated 8 to 12,000 practices today. Kind of more of a hybrid concierge medicine model. It's hard to track those numbers when you talk to the industry experts, but those are the numbers that they have landed on according to our sources. And it scaled because it maintained insurance integration alongside membership fees. Now balk at that. You know, say what you want about that, but it also diversified its revenue base. It didn't put all of its, um, eggs in one basket, as you say. And it found a clear patient demographic, middle class and upper middle class patients willing to make uh, an investment in their health care. Now here is where we also get into what I'm kind of excited about, which is the employer integrated DPC model, which is scaling in December 2025. Study from Johns Hopkins found that concierge and DPC practices grew 83.1% between 2018 and 2023. This was reported in Johns Hopkins in December of 25 and Med City News in 2026. The National alliance of Healthcare Purchaser Coalitions. That's another mouthful. Documents employers reporting 12 to 20% cost reductions through employer integrated DPC arrangements according to the national alliance of Healthcare practitioners coalitions or NAPC in 2021. So what does all this say? That capital is moving into that space. Employers are starting to take it seriously. It's not just a direct to consumer physician to consumer product or service offering in health care anymore. The common thread in every model that has scaled. Let me say that again, the common thread in every model that has scaled, whether in health care or outside of it, is the structural fit, not ideological purity, not evangelism. A structural fit with economic environment, the patient population and the regulatory landscape. So the purist DPC model, it's growing too, from an estimated 100 practices or so in 2009 to over, you know, sometimes we're hearing 1300, 1500, 20, 100 by 2023, according to research published in the Journal of General internal medicine in 2024. All of that, regardless of whatever the number might be actually today, I don't know if anybody actually really knows because I don't know if we're tracking closures as well, or retirements or sell buyouts. That is all real and meaningful growth in the purest DPC model. But the growth has been concentrated. Typically it's concentrated geographically, demographically and among a specific type of physician at a specific stage of their career. A Mid City News analysis from March 2026 put it plainly. This is no longer a fringe movement. But growth without structural discipline creates risk. See how we're tying all of this together? Again, all of this is not a criticism. It's an honest observation, a pattern recognition of a market, an analyst from watching a, uh, genuinely promising model navigate the gap between concept and sustainable scale. I share all of this. Not to throw water or throw a wet blanket onto your enthusiasm for dpc, but the, the physician satisfaction data, it is real. The patient relationships are also real. And the clinical value is real, too. I share all of this today because the physicians who build lasting practices are the ones who understand the full picture. They get the understand. They also understand the full landscape before they commit. Those are the ones that I think are going to last well into the future and have a promising career in this space. So it's not just the inspiring parts that keep you in business. Right. All right, so let's look a little bit at the history, the what it is and what it isn't. Direct primary care emerged in the late 2000s. Now, some would like to say, oh, it started way before that. Oh, it started after that. Well, we're just going to say it started in the late 2000s. That's when I remember it, uh, because I was around then and it kind of did and didn't really have a name. And I remember having those conversations with doctors. They're like, what are we going to call this? Well, a group of physicians, many of whom proudly call themselves the rebels of American healthcare, were genuinely fed up with insurance bureaucracy, with seeing 25 patients, if not more per day, with spending more time on documentation charting at the middle of the night than on actually caring for people. One said, I become a better typist than I have a physician. And their frustration was completely legitimate. The model they built was elegant, it was pure, and it was Simple. Patients pay a flat monthly fee directly to their physician. They get unlimited or near unlimited primary care access. No CO pays, no insurance billing, no per visit charges. Usually the membership fee per member per month was under, uh, $99. I've even seen prices as low as 8. So it went from the more affordable, um, price tag to appeal to more people. And we could talk a little bit about pricing and, you know, some of, um, advantages and strategies and disadvantages as well in the next, uh, few minutes. But patients pay a flat monthly fee directly to their physician. They get unlimited or near unlimited primary care access. No CO pays, no insurance billing. It's kind of a lean type of startup, right? It's kind of a lean type of office. Not a lot of frills. Some had more than others. You know, I would hear people say, especially in the physician community and the dpc, say, well, if you've seen one, you've seen one. There's no visit per visit charges. There's no Medicare participation, typically. And again, this is not always because it's a, it's a little bit fluid. Like there's. You seen one, you've seen one. And I totally understand that. It was direct, it was clean, the physician patient relationship unmediated. It was originally called fee for care. Now, that label didn't stick. I kind of like that label, actually. Years ago, I remember having a conversation at length, said, uh, for a couple of years about that, and that label didn't really stick. But I thought it was a better label because it didn't put a lid on the brand. Right. It's been known by a few other names over the years, but DPC or direct primary care, it kind of landed. Well, the appeal makes complete sense. In a 2018 study by JAMA Internal Medicine, Singh and colleagues found that administrative costs associated with insurance billing consume 25 to 30% of total practice revenue in traditional primary care or traditional plan reimbursed settings. Removing that overhead restores time, it restores the relationship. And I understand the appeal deeply. And to give you the full picture of the size today, approximately 1000 to 1500. Uh, 15,000. Approximately 1000 to 1500 practices DPC practices in the United States against a concierge medicine and membership market that's more of a hybrid model that has a few more thousand than that.

Narrator: Well,

Michael Tetreault: that kind of gives you a bigger picture. All right, so as we continue to, you know, explore what this model is, there's two models inside of dpc. And why is knowing the difference between those two models, those two pathways you know, the fork in the road that some physicians are making when they build their medical, um, their DPC practice. It's worth noting that these two pathways or these two models exist under the DPC umbrella. There isn't just one DPC model in you. Some would say that there's three, four, some would say that there's only two. And some would say, of course there's only one. Depends, I guess, on who wants the numbers. Right? That's a conversation for another day. Well, they operate under a very different economical logic or economic logic. They serve different patients, they carry different sustainability profiles and different regulatory considerations. And right now they share a brand name, which makes it a little bit muddy. The water a little bit muddy. And understanding which one you're actually building or considering I think changes the whole conversation. So the first one, I refer to it as the purist model. This is the model associated most commonly with dpc. When people think about pure DPC or DPC in general, they think about usually this model. They usually don't think about the employer direct primary care integrated model. These doctors have traditionally leave insurance network or they've opted out. They've opted out of Medicare and they have a panel. I m think the numbers are a little bit estimated, but they usually need to serve a panel of 400 to 800, if not a thousand patients. Especially when you're looking at the math on the. And please don't do napkin math. That's terrible. Like I've seen physicians do this. Well, just back into the numbers and figure out how much you want to charge and how many patients you want to see. Oh my gosh. Like, that's not how you build a practice. That's not how you build a sustainable model that you eventually, you know, will love. That's going to be one that maybe you're going to love to regret. However, these practices are charging 55 to 85 on average per member per adult, annual fees, uh, between maybe 600 and 1200 per patient. All revenue comes from the membership fees. Let's look at the numbers together here because understanding them helps you plan and make a more informed, educated decision. 600 patients at $70 a month generates 504,000 in gross annual revenue. Subtract overhead, which would be your rent, your staff, your malpractice, your technology, your supplies, your benefits. In most markets, that runs 40 to 60% of your revenue. What remains then before taxes is in the range of 200 to 300,000. Now that's a great number. Like a lot of physicians, they'll happily take that. They'll happily sign on to that model because it doesn't have the golden handcuffs attached like in some health systems. In 2023 Medscape Physician compensation report shows that comparable to and in some markets similar to what a well run traditional primary care practice generates. I want to be clear, for many physicians the trade is absolutely worth it. I've even seen them take less than those figures. But less administrative burden and more meaningful work, more actual patient position, relationship time spent. That joy comes with its own real reward and that is real. And it matters. How do I know? Because I'm a patient. I sit on the other side of these people uh, sometimes. So what I want for every physician considering this path and uh, being informed about this path is to go in with open eyes, eyes wide open, knowing both that there's opportunity and a uh, realistic financial picture to consider. In fact, a 2019 survey of DPC physicians published in Family Medicine Doane and colleagues found physician satisfaction was genuinely high. Financial sustainability was one of the most important considerations practitioners were flagging, particularly solo practitioners. Does that sound familiar? Back to micro practice models again, particularly solo practitioners and those in lower income markets. Now that's useful information because honest useful information from here about from DPC positions themselves I think is super helpful. Now the model has also natural growth tension because when you raise your fees it can work against the accessible positioning or the affordable positioning that makes DPC distinctive. Expanding panels can work against the access quality that makes the membership meaningful. This is a business decision. This is a practical decision and understanding this tension upfront I think helps all of us plan around it and for it. Now let's talk about pathway number two. This is probably my favorite DPC model because it's called the employer integrated model. Well it's gone by different names but I like this one because I think that it has real legs and the data supports it and I think that it has real lasting impact compared to local communities and businesses and patients and families compared to the more purist, evangelical, not religious but evangelistic, you know, touted purist model. Now this pathway, the Employer Integrated DPC model, this pathway operates under a fundamentally different economic structure and it's one that deserves a lot more attention than it typically is getting because it's sometimes because the brand identification is associated with the purist model. In this model the physician contracts directly with employers, typically small to mid sized businesses, to provide primary care as a workforce benefit. The employer pays a per member per month fee on behalf of employees. Revenue is spread across multiple employer contracts rather than concentrated in individual memberships. And a 2020 study from SPANN and colleagues in the Journal of Occupational Environmental Medicine found employer sponsored DPC program produced significant reductions in specialist visits, emergency room use and total claims cost. That's awesome. The national alliance of Healthcare Purchaser Coalitions. There we go again. Found that employers implementing DPC as a benefit strategy reported average healthcare cost reductions of 12 to 20% over three to five years. This is a more financially diversified DPC model for your consideration. The employer integrated DPC model, that's if you like working with employers kind of in, it kind of has a little bit of a managed care kind of flavor to it. Whereas you know, I remember, you know, I've, I've interviewed um, some experts and folks in the space and asked them, okay, so when the, the three year contract is up, are you finding similar to what happened in managed care, that these rates are getting ratcheted down and right now they're not. But again that was just one person's perspective that represents a group of physicians. So again the national health, uh, the national alliance of Healthcare Purchaser Coalitions found that employers implementing DPC as a benefit strategy reported an ah, average healthcare cost reduction of 12 to 20% over three to five years. This is a more financially diversified model. That employer integrated model. It doesn't put all your eggs in one basket like individual. You're not selling over and over and over to individuals. You kind of can sign a contract with an employer and maybe get 12 patients over here, 30 over here, whatever it might be. And there's people out there who are helping to do this. This is a more, as we said, financially diversified model. Not because of the clinical philosophy differs from the purist approach, but because the revenue structure is m embedded in an employer benefit rather than dependent on those individual consumer decisions that they're making year to year, month to month or quarter to quarter. Again, both pathways into dpc, they have real merit. They have, they just have different profiles, different set of risks and different ideal physician and patient candidates. Knowing which pathway works for your situation, that's the question that you should be asking yourself. Which are you more comfortable with? All right, so let's look at uh, who DPC serves beautifully and where other models may be a better fit. One of the most useful things you can do when evaluating any particular practice model is to get specific about who it serves exceptionally well from a marketing perspective. Um, and any marketer will tell you whether they're working with large organizations like ah, Procter and Gamble or Market Advisors from other areas, whether it's in healthcare, not in healthcare. If you're selling something as a service provider, usually 80% of your audience is going to be 10 plus or minus years of whatever you are. So if you're a 45 year old female physician, you're going to typically attract 8 out of every 10 of your patients are going to be within 35 to 55 years old. That's not always the case, but that's typically the pattern that has been recognized from service offerings. And again, who might be better served by a different option? Well, every great business model has a sweet spot. Being clear about that isn't a, uh, criticism. It's smart, it's helpful. So let's look at the purist DPC model as where it's a genuinely excellent fit. Well, younger, healthier patients, typically 25 to 45 years old with lower chronic disease burdens, who use primary care episodically rather than intensively. Research in Health affairs by Eskew and Klink in 2015 confirmed this demographic profile. Clearly among early DPC adopters, households earning roughly $40,000 to $80,000 annually, enough to comfortably manage a 70 per $70 monthly membership fee alongside a high deductible plan for major events. People who want a physician they genuinely reach without navigating insurance paperwork for routine concerns for that patient in that income range in good health. This model, this purist model, it works beautifully. And where other models may serve patients better, let's look at Medicare eligible patients 65 and older. Well, if a physician opts out of Medicare, there are real implications for how their Medicare eligible patients can interact with with the practice. CMS has specific guidance on uh, opt out affidavits and the details matter. For Most patients over 65, a concierge practice, for example, that accepts Medicare, approximately 75% DO per AAPP data, may be a, uh, more straightforward fit for their coverage situation. Patients managing multiple complex chronic conditions. Roughly 60% of American adults live with two or more chronic conditions, according to research by the Johns Hopkins Bloomberg School of Public Health. Patients managing cardiovascular disease alongside diabetes or COPD with an autoimmune condition typically need regular specialist coordination, imaging and hospital level services. DPC provides excellent primary care. I remember one physician, he said, you know, we can handle about 85% of the human condition here in our DPC practice. For patients who need an additional layer of coordination, a model with insurance integration, it may serve them more completely. Now balk at that all you will. And I know that there are a few who will but some of you, the majority I believe, who are listening probably are nodding your head. I understand. This isn't about one model being better. It's not about insurance is, you know, this or insurance is that. It's about matching the right model to the right patient population with the right physician. Which is exactly what a thoughtful physicians and smart physicians do. Patients in households below 35,000 annually. Let's talk about them. The DPC community has a genuine and admirable aspiration to serve lower income populations. A 2019 Doan, uh, study in family medicine found that in lower income markets, panel recruitment and financial sustainability were more challenging and that patients facing financial pressure found it harder to maintain a monthly membership fee along with their other obligations without a subsidy mechanism like employer contribution reaching this population consistently. Therein lies the word consistently is still a real challenge. That's worth thinking through honestly. Now let's talk about the employer integrated DPC model because again, this is one more my favorites just because I think it can scale better and it has longer legs to make it work in the decades and years ahead. Working adults at small to mid sized businesses. Again, I'm not giving any legal, financial accounting or other advice. You do what you want to do. This is up, uh, this is, this decision is up to you. And maybe it's, maybe it's philosophical, maybe it's ideological for you, maybe it's practical for you. You got to make your own decision. I'm not responsible. All right, so let's talk about working adults at small mid sized businesses. I'm just giving you education. People typically 25 to 55 years old. Kaiser Family foundation data from 2023 shows employees at businesses with 50 to 500 staff face some um, of the steepest insurance cost burdens relative to income of any group. For them, employer sponsored DPC can be genuinely meaningful. And that model shows the strongest results with employees managing moderate chronic conditions enough to benefit significantly from consistent primary care access without requiring the intensive specialist coordination that goes beyond what a primary care model provides. All right, I want to spend some time next on talking about the opportunity. Um, if you need to take a break, now would be a good time. However, hit the pause button or if you're ready to keep on rolling through this. So let's talk about the opportunity worth um, mentioning here. And that is, I would be remiss to talk about direct care models if I didn't talk about, I think is a real opportunity for MPs, PAs, RNs, et cetera in this model. Um, so I want to spend Some time on something I think deserves a much bigger conversation in this space and unfortunately it hasn't had enough traction. I've interviewed folks who are practicing in these specialties or these, uh, these care models and again, they're some of the great, greatest people on, on the planet. But when you look at the DPC landscape, the major advocacy organizations, the conference programming, the startup resources, the online communities, the ideological framing, the framework is almost entirely physician centered. The conversation is almost entirely run, you know, by these physicians or. And the physician is the practitioner. I get that nobody's saying, nobody's diminishing your role, but the physician defines what the model is and who delivers it. And I want to genuinely raise a question. What about nurse practitioners? What about physician assistants? What about advanced practice clinicians? Because the evidence of NP and PA led primary care, it is genuinely strong. What am I talking here? A 2019 study in the New England Journal of Medicine, Laurent and colleagues found that care delivered by nurse practitioners in primary care settings produced outcomes equivalent to physician delivered care for common conditions with comparable patient satisfaction. I'm probably going to get some negative reviews just by stating the uh, facts alone from the New England Journal of Medicine because you don't philosophically agree with that. Oh, you haven't seen this data. A foundational 2010 paper in health affairs by Naylor and Kurtzman made the case for NPs as essential architects a, uh, primary care redesign, citing outcomes, evidence and the critical role advanced practice clinicians play, particularly in communities with limited physician access. Furthermore, I'm not done yet. The National Academy of Medicine's 2021 Future of Nursing report specifically called for removing scope of of practice barriers that prevent MPs from practicing to the full extent of their training, especially in primary care where the need is greatest. You can go to nationalacademies.org search 2021 NAM National M Academy of Medicine's Future of Nursing report. And here is the scale reality underneath all of this. Okay, for the, for those listening that haven't already, you know, wrote me a nasty email. The AAMC projects a shortage of between 17,000 848,000 primary care physicians in the United States by 2034. Now, those numbers used to sound a long way off. It's 2026. We're not very far from 2034 right now. Now the shortage is coming. I, uh, like what one of my physician guests, she said, you know, the calvary is not coming. The calvary is here. What are we doing now to prepare and leave healthcare better than how we Found it. The shortage is not going to be addressed by any physician only model alone that safeguards and criticizes anybody who criticizes its own model. Advanced practice clinicians represent one of the most significant near term capacities to expand access to primary care I think in the United States, and I'm a Canadian, so I kind of know something about shortage. And many of them are motivated by exactly the same things that drew DPC physicians out of traditional practice. Autonomy, direct patient relationships, more time with my patients, less administrative burden. Right. What I want to do, work that feels meaningful. The direct care model, the subscription based relationship centered reduced patient panel model is a, uh, genuinely, I think, excellent fit for NP and PA who wants to build an independent practice. The fee level works, the panel sizes are manageable, the clinical scope is appropriate to their training and licensure in most states. But here's what we're observing, and this isn't an accusation of anything, just an observation over the years is that the organizational infrastructure of the DPC community has been built primarily for physicians. MPs and PAs who want to build direct care models largely have to adopt physician designed resources to their own situations or build their own infrastructure from the ground up with very little help. That's a gap. And if you're an MP and a PA listening, that's a gap, that has an opportunity. And if you're an MP or PA listening to this, the evidence supports your outcomes. The demand for this kind of care is real. And whoever builds the right infrastructure for advanced practice clinician led direct care practices is going to, to own a very significant and underserved part of this market. Again, you have to make these decisions on your own. You take all the risk. I'm just giving you the information and telling you, not giving any kind of business, uh, consulting advice. This is not what that is. This is just a statement of the facts and what's out there and putting them all together to give you a bigger picture. I genuinely believe that this is one of the most meaningful opportunities in the subscription based healthcare delivery, uh, marketplace right now. Pretty neat, huh? Huh? All right, so we're not done yet. In fact we're only probably maybe halfway or 60% of the way through. Let's talk about the organizational landscape and what it tells us. I told you, you were in for a long ride here. Let me describe something I think is worth understanding. Clearly not to be critical, but because it has practical implications for doctors. Choosing where to affiliate and how to plan. If you spend time mapping the DPC community's organizational landscape, you'll find a number of overlapping organizations, coalitions, alliances, advocacy groups, each doing valuable work in their own right and each representing some version of of their members in the DPC vision. Some are national, some are state level, some are conference communities, some focus on legislation, and they don't always align on the details that sometimes matter most to individual practitioners. Little organizational diversity is healthy for any movement. We learned that from what we studied from our history earlier in this podcast in different voices, different entry points. That's genuine pluralism. What's worth paying attention to is this pattern across most of these organizations. The message, as my observation, is the message of physician freedom and direct care values is strong and consistent. The agreement on deeper operational and regulatory specifics, employer integration, scope of practice, insurance frameworks, it's less unified. In fact, research on physician professional organizations is clear about the practical consequence of these patterns. TJ Hoff, in Practice Under Pressure, documented that fragmented advocacy communities, even those with compelling shared values, tend to achieve less durable legislative results than the unified ones. Not um, because their goals are wrong, but because speaking with many different voices on the regulatory details makes it harder to move the needle in a single, consistent direction. Again, that was from Rutgers University Press by TJ Hoff, in practice under pressure in 2010. Now, DPC, uh, has gotten some great accomplishments from the political side. I'm not negating that those things have many, many benefits, particularly for those um utilizing HSAs. And we've gone into that in other podcasts and other places and spaces over the years. But for physicians considering dpc, the practical takeaway is simply this. When you affiliate with a DPC organization, regardless of whatever, who or the name that it is, understand specifically what that organization represents, its legislative priorities, its statewide priorities, its position on employer integration, its evangelistic approach to the scope of practice, its integration with insurance or not insurance. It's ideological and philosophical, uh, beliefs. And it's. I think all of this just take a look, you know, like, it's your position, it's your decision, because DPC can genuinely mean different things in different rooms. So do your homework. What this community, I think, consistently and beautifully agrees on at its core conviction, however, is that physicians deserve the freedom to practice medicine in a, um, meaningful, unmediated relationship with their patients. And I think that this is valuable and I think that it has created some real, meaningful momentum for alternative practice models across the entire primary care landscape. It's branching out into pediatrics, which is great. It's branching out into other, a few other specialties that have chronic UM needs but operational Clarity alongside conviction is what helps all of us as individuals actually thrive if we're considering a long lasting career in the healthcare marketplace. All right, so let's talk about um, what history has gently suggested and uh, the one brand, two directions, um, and what uh, what we've learned from this. Okay, so I want to share an observation here, one that I think is genuinely important for doctors doing long term planning. The DPC brand from, I come from a marketing background. That's where I got a lot of my training is holding together two communities. And I don't know how much longer that I think that that'll stay, but that's just my opinion. The DPC brand today is currently holding together two communities that are in meaningful ways moving in two different directions. Again, my opinion, the purist DPC physician is building toward complete independence from insurance structures. No third party involvement, clean, direct, affordable, ideologically consistent. The regulatory priority is protecting the right to practice entirely outside of insurance and networks. The employer integrated DPC physician is working with ERISA and ACA compliance frameworks, contracting with HR departments, building scalable infrastructure that can uh, work alongside insurance structures. Their priority is making the direct care model in its own um, employer integrated way and that model accessible through employer benefit systems. Both are motivated by the same core values, but they need different things from the environment out there. They serve different patient populations. Yeah, of course there's Venn diagram overlap but they also have different long term economic trajectories. I was talking with one technology um, expert in the space. He's been, I've been around for a long time and he said, you know, you almost kind of got a pay your dues, you know, if you're going to be, serve employers, um, and be a DPC physician, if you're going to be, you got, you got to have kind of paid your dues, going individual to individual to individual because it takes a certain type of position to do a DPC employer integrated model. So again I say all of that to say that medicine has navigated this kind of, of internal divergence before. This is not anything new. And there's something I think instructive in how it's all played out. You see, when managed care arrived in American medicine, regardless of your thoughts on it and your cuss words on it or however you want to say it, it created a genuine divide within the physician community. Some physicians worked within HMO structures and found ways to make it work. Others opposed it on principle. Both groups remained part of the same professional organizations for years, but their interests became increasingly difficult to represent with a single voice. So over time, rather than a dramatic rupture, what happened was a gradual drifting apart. This is according to Wolinsky and Bruhn in the Serpent on the staff in 1994. Right. Osteopathic medicine navigated a similar internal conversation about its identity and integration for decades, ultimately finding a path that acknowledged the genuine philosophical differences within the community through parallel structures that gave both groups room to be fully themselves. This was, according to Gevitz, the Dos Johns Hopkins University Press in 2004. Family medicine became its own board certified specialty in 1969. Not as a rejection of anything, but as a recognition that a community with a distinct philosophy and a distinct patient focus was better served by its professional home. This is according to Stevens in the Journal of family practice in 1989. Why do I share all of this? Well, well, the pattern across. Again, it's about pattern recognition and learning from our history, but also planning for the future, making a more informed decision. You gotta m. You take all the risk here. Again, I'm not giving you advice. You gotta make the decision for yourself. The pattern across these examples isn't rupture. It's just a gradual clarification of priorities. Maybe communities that hold genuine, different, genuinely different visions eventually find structures that give each vision room to be fully expressed. Research on organizational identity suggests that when diversity within a shared brand exceeds what that brand can coherently represent, the long term outcome tends to be toward clearer differentiation. Not because anyone fails, but because clarity serves everyone better. This is according to institutions and organizations sage 2008 as well as professionalism, the third logic from University of Chicago Press in 2001. Now, I'm not predicting what this means for DPC specifically. That's not the point. The point for a doctor or for a physician doing some serious long term planning is simply to know which version of DPC you're actually going to build. Because those two versions may increasingly find their own distinct homes, communities and advocacy voices over time. Build that, build with that kind of clarity and I think that it's going to serve you well. All right, so let's talk a little bit about the tax and structure in question and what you need to know. Again, I'm not giving tax, financial, medical, legal, accounting or other type of advice here on this program. We've very clear about that. But this is one quick and genuinely important topic because it affects every physician in this space. So I'm just going to tell you about what some folks have shared and you take that for what it's worth and do your own due diligence. Until recently, neither concierge medicine nor direct primary care membership fees qualified as a medical expense eligible for HSAs, FSAs or HRAs. That meant patients on HSA eligible high deductible plans, one of the fastest growing insurance categories in the country, couldn't use their pre tax healthcare dollars for DPC membership fees even when DPC was their primary source of care. California attorney James Eichen, with over 32 years in healthcare and business law, offers practical guidance on this for physicians. Your practice label doesn't determine your patient's tax benefits. The structure of your membership agreement does, he said. The IRS responds to structure, not brand names. According to Jim Eichen, uh,

Narrator: attorney, um,

Michael Tetreault: in California in 2025 and here is genuinely good news from 2026. The 2025 one big beautiful bill act changed this meaningfully. Federal law now explicitly allows HSA funds for qualifying DPC memberships fees. Fixed fee arrangements covering core primary care services with monthly fees under approximately 150 per individual or 300 per family can qualify according to DLA Piper 2025 and the IRS Notice 26. Oh, this is all real progress, meaningful progress for patients and for practices. The important thing to know is that qualifying is doing real work. In that sentence. The structure of your agreement matters, the services you cover matter, the fee level matters. Before making any representations to patients about HSA eligibility, connect with your own healthcare attorney or your own experts who specifically know this area and can help you navigate it. Because it is navigable, it just requires the right guidance. Sorry, I've got my wife telling me it's time to go. My son. Nonetheless, we're coming in for a landing here. And here is um, another topic for today and I know this has been a long one, so thanks for sticking with us. Let's talk about concierge medicine for a moment because it deserves its own word. I want to say something clearly because I care about this being a balanced conversation. This episode is an argument against dpc. It's genuinely not. I think you understand my heart and you understand where I'm at on all of this. I'm just trying to give you the right information according to the facts and the numbers and the data that are out there and then let you make a decision that's right for you. DPC is a legitimate, growing evidence supported primary care pathway. The employer integrated version has a very compelling financial case and meaningful outcomes data behind it. The purist model, in my opinion, it serves patients genuinely well and the physicians who have built those Practices who had the courage to opt out of insurance networks early and build something from scratch because they believed in it. That is so admirable and amazing, but full stop. What I want to genuinely push back on is one specific framing that sometimes enters the conversation here, and that is the idea that DPC is the future and concierge medicine is somehow this expensive elitist model or somehow in the past, because the data tells us a different story. Concierge medicine, particularly the second generation, what I call the more hybrid or pcm, personalized care model, is not, it's not in uh, again no one company or uh, that I believe I've understood takes ownership of that. But it's not retreating. This model of concierge medicine, this more, you know, hybrid approach, it's not retreating, it's not going away. In fact, Grandview Research projects the concierge medicine market growing more than 10% annually through 2030. Where they got their numbers, I'm not sure, but precedence Research reported as well. The US market grew from 6.6 billion in 2023 to 6.9 in 2024, and the global market is projected to surpass 34 billion by 2032. 2032, just like 2034, it is not that far away now, especially since this is being recorded in 26 now. This is all growing market, it's not a shrinking one. How they define membership medicine, concierge medicine, dpc, maybe we'll never know. But clinically I think the evidence for these concierge, uh, medicine models, all of these subscription based healthcare delivery models, it is substantial and it is deep. In fact, MDVIP affiliated peer review studies have documented significant reductions in hospitalizations, ER visits and outpatient costs for enrolled patients. One study documented 300 million in savings, attributable to a tribute to DeBolt. Well, getting my tongue tied today to increased physician contact time in membership based practices. Both models are growing. Both serve real patients well. They serve different patients though, and at different price points, with different business models and different structures and different features and services. And that diversity is good for doctors and good for patients. The right question isn't which model is winning or wins in the end. The right question is which model fits your patients, your market, your goals and your life. So for the physician considering this path, this part is for you. If you're considering a direct care practice, if you're thinking about direct care care or DPC in some form, or concierge medicine, either the purist path, the employer integrated path, the concierge medicine model, if you're even a nurse practitioner or physician assistant wondering if a subscription based direct care practice model could be the right next chapter for you. Well, this next couple of minutes is for you because I want you to know that the impulse that's bringing you to this conversation, the desire to practice medicine in a way that actually feels like medicine again, that impulse is good. It's worth pulling that thread because the frustration with the traditional system is real. The weight of bureaucracy that follows physicians through their days is real. The longing for a practice where you actually know your patients, where you have time to think, to listen, to show up fully. That longing comes from the right place. I've been in this space reporting, uh, these business models now for more than 20 years. And I've talked with thousands of physicians who made this transition. And the ones who still have joy in the work that they do in these models at, uh, year 15, year 20, those are the ones that, whose patients tell stories about them that make you want to be their patient. And those physicians share something in common. They made their decision with a full amount of information. They understood what the model they chose does well and what it doesn't do well. And they understood its honest limitations. They followed their entrepreneurial tendencies. They knew their market. They did the homework. They sought the right experts and surrounded themselves with essentially a, uh, board of advisors to help them make the right decisions before they moved into this and while they moved into this and even now while they're still growing this. In fact, I was just talking with a DPC doctor the other day and he said, you know, I love that I took the advice of my mentors and some of the stuff that I've read here and listened to here on this podcast and this, that I kind of went back and got an unofficial MBA or I got kind of this unofficial doctorate of learning. And I surrounded myself with people who saw my blind spots and I have a great practice now. I, in fact, I'm planning for my exit soon. And he's in his, he's in a, he's pretty seasoned. But they all made the model. They all understood that what the model does well and they understood its honest limitations. They knew their market. They got good legal and financial and business counsel. They built their patient base around the demographic the model genuinely serves. They asked the hard questions before they launched, not just the inspiring ones. That's not a caution for caution's sake. That's how you build something that lasts. And the practice that lasts is what your patients deserve from you. Now, if you're genuinely Considering before you decide, here are some questions you might want to wrestle with. Because it's genuinely considering. If you're considering one of these pathways. Dpc, the employer integrated model. Here's eight questions worth answering honestly for yourself before you commit. Not because they're meant to discourage you, but because physicians who can answer them I've seen have clearly built practices that are thriving today. First question, which model are you actually building? The purist or the employer integrated? They require different infrastructure, different marketing, different legal structuring, different planning horizons. Getting specific early makes everything easier later. Number two, have you run the realistic revenue math? Have you put everything on paper for your specific marketplace? Your 600 patients at $70 a month is $504,000 growth gross. What does your overhead actually look like? Get clear on your numbers. If you aren't clear on your numbers or you don't know your numbers right now, now maybe that's a good place to start by getting some help there. You can't ignore your numbers. What does overhead actually look like where you practice? What remains before taxes? Is that number aligned with your household needs and long term goals? Number three, what does your actual patient community look like? Is it going to be able to sustain and support this type of practice model regardless of what you choose? Does it match the profile that DPC genuinely serves? Serves best? Younger, healthier patients, 40 to 80,000 household income willing to carry wraparound coverage. Being honest about your market is one of the most valuable important things that you can do. So do your homework, get some help. Number four, how does your model serve Medicare eligible or complex chronic disease patients in your community? Is there a plan for that population or a referral path that serves them well? Where's the gap in your market? Number five, have you connected with a healthcare attorney specifically for structuring? For specifically about structuring for legal compliance agreements, HSA eligibility under the, uh, current IRS rules, this type of conversation is worth having before you do anything, not after. Number six, if you're considering the employer integrated pathway, do you have employer relationships in your market? Or do you have a resource that you can lean on, not just another physician who got the same business credit hours that you did in medical school to take advice from or a clear plan to develop them? What's realistic timeline to have some revenue diversification? Is that something you want? Number seven, what does the financial Runway look like for you right now? If the practice grows more slowly and projected in year than projected in year one, year two and year three? Because I can tell you what other physicians have told me I had a big dream and it took a lot more time and uh, a lot more money than I thought it would. So having clear answers to these questions gives you the confidence, not just caution number eight, and this one is specifically for MPs and PAs. Have you researched the scope of practice laws in your state for independent practice? Have you identified resources designed specifically for advanced practice clinician led models? This opportunity or the opportunity is genuinely real. The organizational infrastructure isn't fully built for you yet in this space. Maybe concierge medicine will start to do that, which means your due diligence upfront needs to be a little bit deeper, get some people to help you that's worth knowing. And we put some of those resources that can help you. Those attorneys that are in this space, we don't make recommendations or endorsements, but we have put some of those@, uh, conciergemedicineforum.com uh, you can check some of those out in the concierge medicine who are also familiar with these models in direct care as well. Again, these are questions that are not meant to slow you down, down, they're not meant to pump the brakes, they're meant to make you faster in, but in the right direction. So as we come in for a close here, I want with something larger than any model we've discussed today, underneath all of the economic analysis and the historical parallels and the demographic breakdowns that we've talked today, there's one question that I hear from physicians and clinicians everywhere. How do I practice the way I believe healthcare should be practiced and still build something that lasts? Is it even possible? This question, those questions, they're legitimate and they're urgent and it is being asked by a lot of great people. The fact is that thousands of physicians and clinicians are asking it loudly enough right now and acting on it boldly. The DPC and concierge medicine and other subscription based healthcare, um, delivery models, they have become a real growing data supported sector of our American healthcare marketplace. And that is something we're celebrating, not worth dividing over. That is a, that these are great things that I'm proud to write about, proud to cover, proud to interview, happy to interview. Because I think that things like this we need to be honest about. We need to have supportive voices alongside the inspiring ones. We need to have some, you know, maybe want to ask some questions, people who care enough about the individual physician, the individual practitioner, not just the movement to say, hey, here's the full picture, here's what we know, here's what the evidence shows, here's what the facts show over the years. Here's a little bit of history, too. And here's what the physicians who built lasting practices understood before they even started. These are not meant. This conversation today is not meant to slow you down, but it's to help you go farther. DPC is not the only path, I believe, to practicing correctly or differently. Concierge medicine in all of its forms, membership medicine, all of its forms, urgent care, PA and MP led programs, they've all been leading somewhere and they've all given physicians, patients, NPs, PAs, they've all given you back some time, some relationship, some dignity and some purpose for like three decades now. And the direct care model in particular, in whatever form it takes and under whatever name or brand you eventually carries, represents, I think, a genuine and growing opportunity for doctors and MPS, PAs and clinicians who are willing to lead and ask the right questions and surround themselves with the right people and advice. The practitioner who builds something lasting is the one who matched the right model to the right reality. That's our philosophy here at the doctorpreneur Leadership Podcast in concierge medicine today. And that's what this community of physicians and membership medicine at large are all about. Out. So I hope today's conversation has given you a little bit more of what you need to find and help you find the right path. As I kind of sometimes describe, it's finding our websites, running these, these events, and talking to some of your peers out there is like you're trying to cross this foggy bridge and you just kind of need somebody to hold your hand and maybe walk in front of you sometimes, walk beside you, maybe walk behind you sometimes. So I want to thank you for listening and if today's episode has been helpful, I'd love it if you'd share it with one physician or a clinician who, you know, is navigating this decision right now. Not to point them toward any particular model, not to evangelize, just to give them a bit of a, um, more of a full picture. Because all of the sources and citations from today's conversation are available at conciergemedicinetoday.net learn, learn. And every claim is backed by published, verifiable research. And that's always been our standard and it always will be. The Concierge Medicine Forum, our annual gathering, uh, industry's annual medical conference, is for physicians and innovators and care providers and clinicians in the concierge medicine and membership medicine space. And we invite dpc, Curious to come as well. It's October here in Atlanta every year, and it's the room where physicians, legal experts, operational leaders, and industry thinkers who are actually building these practices all come together. And I'd love to see you there. Details go to conciergemedicineforum.com thank you for being here today. Genuinely, the fact that you're doing this work that you're investing in yourself, investing time into yourself, time into your practice, it's worth it. Because you didn't sign up for easy, you signed up for worthwhile. The patients in your community are fortunate to have a physician like you in their corner. I'll see you next time. I started Ornod in 2013 and we make bike apparel. The best part of Shopify for me is our ability to run the business as essentially non technical people. We're able to admin everything on the back end, front end and sell things online easily. If Shopify were a bunch of bike accessory, I think it would actually be the bicycle. It's the thing that you do the thing on. We run the business on Shopify. Start your free trial on shopify.com.