View From The Top: What Great Things Would You Attempt If You Knew You Could Not Fail?
What Great Things Would You Attempt If You Knew You Could Not Fail?
Company: Primary Health Partners
CEO Physicians: Robert Lockwood, Kyle Rickner and Catrina Bourne
It all started about 15 years ago when two medical residents, Robert Lockwood and Kyle Rickner, met during residency. This chance meeting blossomed into a friendship and eventual partnership that will surely change the face of medicine in their home state. In the last 18-months they have established a successful family medicine practice based on Direct Primary Care (DPC). The DPC model gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging patients a monthly retainer that covers all or most primary care services.
These physicians exemplify leadership by focusing on all of their stakeholders – their patients, staff, vendors and community. The great news is that they have also accomplished two things that most start-ups struggle with - profitability and growth. Within three months of finishing the construction of their building and opening their doors, they were profitable. Additionally, this summer, they welcomed Dr. Catrina Bourne into their practice after searching for a special individual who closely aligns with their vision for the practice.
After participating in a lunchtime yoga session offered to their patients, all four of us sat down last week to talk about their bold moves in a relatively traditional field. This is an edited transcript:
CF: Why did you decide to start an independent practice utilizing the DPC medical model?
ROBERT: It was really a big decision, but the reason I did it was because I didn’t feel I was able to do what I wanted to do with the patients. That was a big issue for me. Between our system, the federal government, and insurers, most of the time spent with the patient was doing things that were required by a third party in the room and not directly related to the patients themselves. It was difficult to only have six or seven minutes of true face-to-face time with the patients. On top of that, trying to run in and out to answer emails, complete paperwork, develop employees and handle leadership responsibilities was just an enormous pressure on me. Then I would head home only to have to work in the evening and get up early in the morning to get things done before I went back to work. During that time I kept thinking about the old adage, “It’s crazy to do that same thing over and over, hoping to get a different result.” Of course, the different result never happened. One day I realized I’d been doing it for eight years.
Around that time I went to a national meeting for The American Academy of Family Practice and learned about Direct Primary Care. The thought of having the patient as the focus of care without all of the distractions was so appealing to me. By the end of that, I had decided that this was the direction I needed to take. Kyle was with me at the meeting and was in full agreement. I had a renewed vigor about medicine again after that. We spent the next 14 months learning all we could about Direct Primary Care – how to do it, visiting practices around the country, and figuring out how to model this as a business for us. What I hoped it would do, and has done, is that it has bought me more time with the patients. The time I now spend with each patient during a visit is approximately 45 minutes. I feel like I do a much better job of taking care of them. In return, the patients also have more access to me than they’ve ever had in my career.
CF: What is the difference between Concierge Medicine and Direct Primary Care?
KYLE: From our perspective, there is a big difference. The first is cost. Concierge Medicine is uniformly more expensive. On the concierge side, the average $500 monthly fee can get very expensive. The national average for DPC is $77 per month. The second difference is the number of patients that we take care of. Concierge Medicine is designed to take care of very few patients and really cater to them. Concierge Medicine can be very self-serving for the physician. We view DPC as more patient focused – trying to take care of more people and in more of a community responsibility mode. The third difference is that many concierge practices will bill third-party insurances for their services in addition to the fees, while we don’t do that in DPC. The reason we don’t do that is because Concierge Medicine does absolutely nothing to affect the cost curve of medicine. DPC has a mission to change that curve. We are cost advocates for our patients. We do not view our patients as revenue sources. We realize that the cost of healthcare is affecting every area of society. We like to think that we are now part of the solution and not part of the problem
CF: So you are starting to talk a little bit about your mission statement. Can you speak to that in your practice? What really drives what you all do?
KYLE: It’s getting back what has been lost. A lot has been taken from us as providers and as patients by a system that is grinding along. Our mission is to return to the essence of healthcare, which is the doctor-patient relationship. We get back time and energy. A patient recently described us in a way that goes along with our mission – “We’re like old-school docs in a new world.” We’ve had some of our older patients say that this reminds them of the Marcus Welby-type doctor with the black bag visiting his patients. I think that speaks to the heart of what we are doing. Before we started down this path, there were so many thought processes that we had to have when we were in the room with the patient. Whether that was checking a quality box, making sure we filled out the form right for coding or billing…it was constantly on our minds and wasn’t related to patient care. We have none of those thoughts now. It does give us clarity and time with our patients. All of us have experienced having previous patients of seven or eight years that have decided to join our DPC practice and we learn something that was impactful to their health that we didn’t know. Before we didn’t have the time or give them the environment to feel free to share it. Given more time, we can give better care.
CATRINA: I have an example of a recent patient that I’ve been able to spend an extensive amount of time helping out. The one I am thinking of is a lady that had a significant stroke. It required a prolonged hospitalization, a peg tube and a tracheostomy. She went to a long-term care facility for a while and finally went home. She came in to see me and had several issues going on after the stroke including getting off of her trach, speech therapy, learning to swallow again, physical therapy and home health. When she came for the first time to this practice I spent at least an hour with her. She became anxious during that time and needed to suction her trach. We took a break and suctioned her trach. So instead of me feeling like, “I’m sorry, but I have to keep moving here,” I was able to do that with her. Since then I’ve been on the phone formulating a plan with her ENT doctor about helping her get off her trach. We were able to set goals. She can come in more often and not have to worry about the co-pay each time. This is what I’m here for. In fact, her husband sent texts almost daily with updates and questions when she was in the hospital. I was accessible by phone, text, and emails, and I even went to see her one or two times while she was inpatient. It is important that she knows how her care is going and where they will go when she gets out.
CF: Was it risky for all of you to launch into a practice such as this?
CATRINA: This was a very risky deal in my eyes. I learned about Direct Primary Care just over a year ago. I had been struggling for quite a while in the traditional practice or rat-race of squeezing people in every 15 minutes, and charting for hours at home. It was to the point that we were starting to see some issues in my older child at home. Kyle came up to me one day, and he said, “There’s hope! I’ll tell you more about it sometime, but just know there is hope.” He got my interest, and then they told me a little more. I really wanted to do it, but I was anxious. I’m the sole breadwinner for my family. I worried about screwing this up! It’s not just my life, but I have three other people that are depending on me. Can I really make this work? What if I fail? Am I going to be able to feed my family? I was scared. I don’t know how many times Robert had to come and pat me on shoulder while telling me, “It’s going to be okay. You can do this”.
ROBERT: Think about that from the perspective of starting a business from the ground up! Of course, it was helpful for Kyle and me to plow a way for Catrina, but we’re not struggling. We are fine and growing. What’s amazing is that physicians look at this as such a risky venture, yet those same physicians will go invest $100,000 in risky business ventures all the time in the blink of an eye! They don’t believe enough to invest in themselves. I think there’s a little something self-deprecating of “I’m really not that important.” Realistically, we all have an extremely sought-after skill set. I don’t think that physicians realize that. The skills and years that it took to learn what we do are why people come to us. If you go out there and do things for a fair price while you treat them well, you are going to be fine. You may get to what you were making before in two months, but more importantly two years down the road you’ll look back and say, “My life is so much better, and my patients’ lives are so much better. Why isn’t everybody doing this?”
CF: As the CEOs and leaders of this practice, how would you describe the culture you are trying to create?
KYLE: Robert and I spent a lot of time talking about this. We wanted to provide something that people could belong to, feel a part of – the idea of this being their medical home. It’s a safe, comfortable place. We wanted patients to feel that when they were here. We wanted them to feel some ownership. We wanted that to translate over to our staff too. We were fortunate, because we got to handpick people that we knew. Ladies that worked for us before came voluntarily. They asked us; we didn’t have to ask them. The very idea of catering to the patient is similar to being in a country club. People pay a certain amount of money to belong to a community of people and the culture that is created there. In a way, we are trying to do that for our members in terms of giving them something to belong to. When I told Catrina there was hope, I say that to patients too. It doesn’t have to be the way you are used to it being. We can get rid of most of the things that frustrated you.
Another aspect of the culture is a establishing a culture of quality. We do what we do and we do it well. We do things that are evidence-based. We are providing services that are the best available. A culture of quality with good outcomes is very important to us.
The third part of culture is to be a patient advocate. In this model, this practice, you quit looking at patients as revenue centers. We have purposely set it up where the only revenue that comes in here from our patients is their monthly membership, which is obviously completely transparent. We don’t do other things to our patients to make revenue. In the doctor-patient relationship, there is some inherent vulnerability because they trust implicitly what we know and they don’t know. Any types of services that are meant to generate significant revenue leverage that relationship of trust that has vulnerability put into it. I have an ethical issue with that. We’re not here to turn a profit on the backs of our patients.
CF: What has been your biggest leadership challenge overall?
KYLE: I’m a pretty passionate person. My biggest challenge has been a lack of patience for lack of action, complacency, or people that are not willing to sacrifice something for the team or the whole picture. In every arena where I’ve been a part in a leadership sense, selfishness has been the biggest enemy. My biggest challenge is in dealing with that kind of “me” culture. I can be a very passionate person with intensity. In the right arena, I will display that. That’s not always the most productive way, so that’s always a challenge for me to keep my head about me and keep emotion out of it when I do address it. When I see unmotivated people that are being self-serving, I just don’t have patience for that.
CATRINA: The challenge for me is that I try to make everybody happy, and you can’t always make everybody perfectly happy. I also have to make sure my emotional side is kept at bay. I can get emotionally tied up in situations.
ROBERT: Since I’m the numbers nerd here between the three of us, my biggest challenge is letting go and allowing our organization to evolve in a way that’s not my preconceived perception of the way that it needs to go. They are both going to push it in certain directions that I’m going to need to let happen. I don’t want to squelch initiative and innovation. That is something that I want to be very careful about. If I can help my partners make those money decisions from a perspective of not discouraging them, but rather “That’s a great idea! Let’s wait six months, and then we’ll have the money to make that happen.” I want to be careful about how that part of me comes out. I think Kyle and I fit very well together because of that. He’s very innovative and imaginative. I’ll rein him in when I need to, and he’ll pull me along when he needs to.
CF: How do you keep this partnership healthy? What do you do?
ROBERT: We are friends and do things together.
KYLE: The real foundation is that we are doctors with a strong faith. We know where our true hope and trust lies. We know each other’s hearts with regard to that. The selfishness that occurs in many leadership positions…it’s not here. I think that allows us to be partners and friends. Many partnerships are not friendships. Each of us is humble enough in our own way that we defer to the other. We know each other’s strengths. For example, I give Robert veto power on deciding if we can afford it or not. I don’t argue with him about that. I have put that decision making in his hands, and he tries not to hinder me from making new inroads and relationships for our business that could benefit us. The way we operationally run things is one of Robert’s strengths, and we try to blend that with a clear vision and strong culture and see how those things come together. I think we all really compliment one another and that’s why it works.
CF: What is one piece of advice you’d pass on to a young, upcoming CEO and leaders?
ROBERT: Not to worry about the incidental things too much. They usually resolve themselves in a positive way, but if not, they impact you so little that you’ll be fine. Take time to breathe. Do you best to not let your career dominate you. Relationships are way more important than anything you do.
CATRINA: Start off with prayer. Have faith. Trust God. You can do it.
KYLE: We can let what feels urgent distract us from what feels important. Losing sight of what’s important is a big pitfall that needs to be avoided.
CF: Any final thoughts?
KYLE: When I went into medicine, I dreamed of working for myself. I also dreamed of leading people. I’m now doing that! I can’t encourage people enough to dream big versus staying safe. About six or seven years ago, I heard a speech based on a book called “Crazy Love” by Francis Chan. The image I remember was a man standing on stage on a balance beam speaking. He was using the balance beam as an analogy for life. He was traversing it, saying “Wow! This is fun, but it feels a little dicey and, at times, a little uncomfortable. So we decide to sit down and feel a little more comfortable. Then if we learn forward a little more and wrap or arms and legs around it, we feel really safe. Dismounting in front of the judges though...our score might not be very good.” At some point in our lives we may get like that. We may talk about safety above all else and choose a stable career, and choose to live in a gated community and put our children in helmets when they leave the house. We all have to understand that living as safe as possible is not a noble pursuit. We have to get uncomfortable to make a difference. I feel that what we’ve done with our practice represents doing a few tricks on the” traditional medical practice” beam and then sticking our landing!
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