The Power of Personalized Care: An Insight into Direct Primary Care with Dr. Vasanth Kainkaryam

Parker Condit: 0:01

Hi everyone, welcome to Exploring Health Macro to Micro. I'm your host, parker Condit. In the show, I interview health and wellness experts around topics like sleep, exercise, nutrition, stress management, mental health and so much more. By the end of each episode you'll have concrete, tangible advice that you can start implementing today to start living a healthier life, either for yourself or for your loved ones. And that's the micro side of the show. The macro side of the show is discussing and having conversations around larger systemic issues that contribute to health outcomes here in the US. An example of that is exploring alternative medical models such as direct primary care, and, as the name implies, that involves a direct relationship between the patient and the doctor, removing the middle man of the insurance company, and this is what we discussed throughout today's episode. By the way, direct primary care is often abbreviated to DPC, so if you hear that abbreviation, that's what we're referring to in today's episode. My guest today is Dr Vasanth Kainkaryam. Dr Kainkaryam is a triple board certified physician in internal medicine, pediatrics and obesity medicine. He's the founder of four elements direct primary care and wellness space in Connecticut and is the chief medical officer for Bastion Health. If we look the macro, micro spectrum of this show. This episode is more on the macro side. Almost the entire show is going into the nuances of direct primary care. We discussed what it is, how it's different from insurance based medical practice, how it's different from concierge medicine, why there are better doctor patient relationships in this model, what are the associated costs and how can it be paid for sort of. You'll see when we get to that point and how DPC may be one of the tools that's used to help address social determinants of health. We go over quite a bit. So this is a. If you're interested in direct primary care or alternative models like this, this is a great episode for you. I thought this topic deserved its own whole episode because it is still such an unknown medical model for many and in my opinion, this is one of the more promising ones for the future of primary care. So, without further delay, please enjoy my conversation with Dr Kinkuriam. Dr Vasanth Kinkuriam, thanks so much for being on. I think a lot of this conversation is going to be based around direct primary care and I think those three words people are going to be familiar with, but maybe not so much as a medical model. So I think the easiest place to start is just giving everyone an understanding of what the direct primary care model is, and then we can dig into a little bit of your background as well.

Dr. Kainkaryam: 2:33

Yeah, so the way I like to describe direct primary care. I say think of the doctor from 70 years ago in a modern either gym or Amazon prime subscription model, right, and that's really the essence of direct primary care, where you're paying for the relationship with the person. So, like a gym membership, you pay for access to the gym. You don't get, you know, double charged if you go on the treadmill, say, an extra 15 minutes or if you decide to use another piece of equipment. So by giving access to the medical care itself, it actually makes it a lot easier and is a lot more flexible. So, to really simplify it, that's the way I think of it.

Parker Condit: 3:14

Yeah, that's a great way to explain it. I've actually never heard of it kind of using that sort of analogy where the gym is very good because there's so much equipment in there. Are my getting charged for this, of which you're probably not even going to be told you're going to get charged for? You'll just get a bill in the mail later. So can you kind of go into what some of the benefits are of this model from, I guess, like the patient side of things? Just to? I want to be able to paint the experience for patients to understand what it's like normally working with a physician who's billing through insurance versus this sort of subscription model.

Dr. Kainkaryam: 3:45

So the very first question I always say is who is your doctor working for? That is question number one. So if your doctor is working for anyone other than you, the way they deliver care is going to be influenced. So let's say your doctor is working for a large health system, right, and then they can only do what are part of the practices or the groups, policies and procedures. They don't have as much autonomy in making those decisions as to being able to flex their time. Their scheduling processes are very limited to what that looks like. But if your doctor is working for you right, in a sense direct primary care is that right. You are paying the monthly subscription fee for your doctor to be, in a way, on retainer to be able to help you with the care that you need in a model that is going to work for you. So from a patient standpoint, it allows longer appointment times because their doctors are not limited by what their organization dictates. Number two you can even flex the way in which you do appointments. So you're not because you're not waiting on an insurance company to reimburse you for every service. You can go for a walk with your doctor and do your appointment while you're walking. You can go to the gym with your doctor, you can sit outside in the sun. I mean, it's interesting because I think as a society we've made all these rules for ourselves to say. Well, who said a medical visit has to be in an office? It doesn't have to be in an office, right? So it gives you freedom in the method in which the visit is delivered, the duration in which the visit is delivered, but it also gives more freedom to incorporate other modalities. So I do acupuncture, sometimes for stress and anxiety. Some patients are here. I'm like hey, you know what you seem. You know that you could benefit from it. Do you want to do it? So the entire structure shifts to saying what does this person need? Who's here in front of me? How do I help them in a way that works for them, as opposed to me thinking what is going to get me paid or what is my employer allowing me to do so? As long as it is allowed by law, as long as it is part of a good standard of care, as long as the patient needs it and as long as I'm willing to do it, those are the only things that really matter.

Parker Condit: 6:15

Yeah, those are all great points that you brought up. Can you speak to the average patient panel size for a direct primary care physician versus somebody working with insurance? Just an approximation is fine.

Dr. Kainkaryam: 6:26

Yeah, I think a lot of. It just depends on how many patients you want to see, right. So I know of direct primary care docs who say they work 20 hours a week and they've got a panel size of 300. You've got direct primary care docs who say I want to work 40 hours a week and I'm going to have a panel size of 400. So I think you'll find most people are in between that 200 to 400 range. But because you're not being paid by encounter, it also allows you flexibility with your life, right? So you can say I'm booking by appointment only and so therefore you create your hours whatever works for you or your patient. So for the doctor, all of a sudden you have freedom to go to your kids' activities. You've got freedom to really just kind of create this balance of life that you want and yet be there for your patients when they need you.

Parker Condit: 7:15

Yeah, I think the numbers will vary, but I think for many family physicians or internists, let's say family physicians- I think, they're typical panel sizes between 1500 and 2000. Just to give people perspective on what that 200 to 400 or 200 to 500 looks like in the direct primary care model, you said something there which I've never actually thought of before, which is that in the DPC model you have more flexibility to sort of live your life as a physician. Do you think that offers you more perspective and empathy because you're not just so wrapped up and being swamped with work all the time and you can kind of connect with your patients more? Because doctors go through such a rigorous training through med school and then through residency, it seems like you can lose touch with what the rest of the people in the world are sort of experiencing. Have you found that there's? I'm very clumsily trying to get to a question, but do you kind of understand what I'm getting to here?

Dr. Kainkaryam: 8:22

Yeah, I mean, does it make you more human? Is that it?

Parker Condit: 8:25

Yeah, Thank you for saying that in five seconds what took me a minute to stumble through.

Dr. Kainkaryam: 8:31

I think. So there's a couple of ways to think about this. So number one if you look at physician burnout statistics, and so we see anywhere between 40% to 60% physician burnout in the past several years, so then if you really think about it and you say, wait, the people who are supposed to be keeping us healthy, they themselves are burnt out and are not feeling healthy, right? So number one, number two among all the professions, physicians have the highest suicide rate. So all of a sudden, now that the very people who are supposed to be keeping people healthy are exhausted, are burnt out, are depressed, and so this doesn't make any sense. So if you're in the system long enough, some way and a lot of the term that a lot of people use is moral injury, right, you do enough things that you know are not in the best interest of the patient, but are what the corporation requires you to do, or we know what someone else requires you to do, and so you get jaded. So I think. And then there was a really interesting article a few years ago, as one of the ways to combat burnout for physicians was find a side gig, right? And so now, like, well, that sounds great, but now you're saying well, you working this much isn't enough. Now find another avenue to work more to keep yourself happy. So, if you really think back, I think models like DPC are fantastic. Many physicians every day are leaving their practices and saying I'm going to start a DPC practice, right, and so it's not easy to do. But I think, from a burnout standpoint, you have control, right, as long as it works for your family, as long as financially you can make the numbers work, you can choose what you want to practice, how you want to practice, as long as there's a market for it, right? I mean, there's no point in building a practice that you're not going to get patients for, but as long as there's a market for it, you're going to get patients for it. You have the freedom. And I think I tell all my patients right, I work a ton, but I always go home every day and my cup feels full, and that to me, is very important because my kids see it, my family sees it, and you find that meaning for what you're trying to do. You're finding that icky guy, and so that's that. I think that's the best way I can just describe how I feel is. That is the way this model fundamentally changes your thinking to once again say I can actually have all of these things and these choices that, as a doc, I didn't think I could have.

Parker Condit: 11:06

I bet your patients feel that too and it's like one of those things that you probably can't quantify and it's not going to show up in any sort of like metrics. But I think you feeling like your cup is full doing what you're doing and not feeling burnout. That has to translate to the relationship with your patients.

Dr. Kainkaryam: 11:22

It absolutely does. And it's funny because one of my patients walked in a couple of weeks ago and they actually met another patient on their way out. And they walk in here and they're like Dr K, your patients are all weird, like what does that mean? She's like everyone leaves here smiling and happy, and you know, and I was like, look, I think part of it's what you put out there, right, you, if you put out, you know, if you put out frustration and your mind is already on the next patient, because that's where you got to go and you're still half reflecting on the previous patient. You didn't have transition time. People feel it. But when you, when you sit down and you say, all right, my attention's on you, I'm talking to you, nothing else in this world matters right now. It is very palpable and patients feel it and I think part of it's also Because we invest so much in getting to know them as people. The dynamic of the relationship is changing. I'm not cheating to look at their chart when they come in here to say who's this person? Again, it's oh, I know you went on a cruise. I know you just went on a trip. I know how you got these many kids right, and so what takes, people Say, four or five years to develop? In this traditional model that relationship is compressed, it's almost like a speed date and within a few months you get to know your patients really well.

Parker Condit: 12:36

Generally in this model it's like unlimited visits, right, and most people probably aren't coming in once a month, but it's you have much more access to to physician visits. Is that correct?

Dr. Kainkaryam: 12:46

Yeah, I wouldn't say unlimited, unlimited as a Legal buzzword that you sort of want to be very cautious about. So so there typically is a finite number of visits, right? So some DPC docs, advertisers, unlimited, but you get into whole state statutes and stuff, so we'll save that for another conversation. Let's say there's ample visits to get the care that you need and Typically people don't Once again, right? So if you have multiple modalities of giving visits, right. If you have a rash, like I tell my patients, send me a text message first, why are you going to spend time to try to call and do all you know? Send me a picture. That's really what I need to see. So when you have these various modalities in which you can deliver care, the way you think about appointments themselves is different, because what you really need is not an appointment. What you need is advice, and the way in which that advice is given really doesn't matter, as long as you get the appropriate advice for that care. In the past, we thought of appointments because that was the only method by which we could give advice to patients, but we live in a different world now. So as long as the patient can get timely medical advice, the way you think of appointments changes. It takes patients a while to sort of go through that retraining of their brain process of oh, not everything is an appointment.

Parker Condit: 14:11

Yeah, no, that's why I think these conversations are so important, because I'm not sure if you know who Ron Barshop is. He runs a podcast that's called primary care cures huge advocate for direct primary care. Yeah, so I'm not sure if you've heard of it, but anyone else listening it's a great resource. But he estimates that there's 25 to 30 million people that are currently being served by direct primary care, which is not. It's a bigger number than being that's being advertised, because a lot of it's run through employers, but a lot of people just never heard of this and, like you said, they've been conditioned To this and just how things have always been. But, like you said, not everything is an appointment, not everything has to be run through insurance. There are these alternative models, which does seem to be very encouraging.

Dr. Kainkaryam: 14:54

I Want to go back to what I say though, if you don't mind, is. I think there's a lot of people who, the moment they begin to hear, they're like, oh, that's concierge medicine, right. I think I want to draw a great point Between DPC and concierge medicine, right? So concierge medicine, historically, I think, was the first step in sort of thinking through this what this doctor-patient relationship could be. However, I think number one most concierge practices bill a third-party payer and Charge a high retainer fee on top of it, which could be anywhere from two grand to ten grand a year. Which means, if you have a high deductible health plan right which a lot of people do, right, as we see insurance shifting, more and more people have high deductible health plans you have to pay through your deductible plus your concierge retainer fee, and it doesn't save the doctor from the billing and coding and all the other stuff, because that's how they still have to get Reversed by the insurance companies. So so concierge medicine by default ends up turning to people who have a higher Wealth because they are able to pay their deductible, what number one they have. They have their insurance Premiums and their deductible and their concierge fee. Dpc is a lot more accessible to a lot more people because it is purely the monthly membership fee. There could be other concierge like services that are add-ons, which they can choose to make available if they want to, but they don't have to, so it levels a playing field for a lot more people. So I wanted to just call that out because oftentimes when you know, when I've begun to talk about DPC, they're like oh, I've heard that that's concierge. I'm like no, it's not concierge, totally different.

Parker Condit: 16:30

Yeah, I'm really glad you brought that up, because I've I've kind of been talking about this for so many years now I forget like I've made the distinction so many times. I'm like I've already said that, but it's important to always bring it up. Yet, direct primary care is very different from a financial perspective. Usually then concierge and yeah, you made a great point concierge is usually billing a third party as well and generally more expensive. I Do you want to go back to something you said which is a key guy? Can you explain what that is?

Dr. Kainkaryam: 16:56

Yeah, so icky guy is is a Japanese concept where Four things come together right, so what you're good at, what you love, what the world needs and what you can be paid for. So these four things when it's your, your passion, your mission, your profession and your vocation, right? And so when they all come together, they mesh in this center, which is the icky guy, which is a Japanese loosely translated as your purpose or your reason for being right, because oftentimes we go through things in life and you're like, well, I like this job, but I don't feel fulfilled, or I feel great about this, but it's not going to put food on the table. So, icky guy is this balance where all this stuff comes together and you truly find meaning in what you do, and so it's a really cool Japanese concept. And and, yeah, so it's it's. It's it because, before I start my practice, I stared at the diagram for about like three months and I was like what am I, what should I be doing with my life? Right, what is going to? And? And you stare at it long enough and you just you find answers.

Parker Condit: 18:02

Were you working in a traditional model before or did you kind of come out of residency and go right into this DPC model? I?

Dr. Kainkaryam: 18:10

Have worked in probably all the different types of models you can work at. So I I worked in a hospital-owned health system, I've worked in corrections Moonlight at the VA, I've worked in a venture-backed startup company, I've worked in a private practice, so you name it. I've done it right and I think I was. You know the community health center world, so so what I do now, which is the coolest piece, is I take all the best practices I've learned from all the places I've done stuff at and and I bring it together.

Parker Condit: 18:42

Yeah, that's great. Can you so? Did icky guy help influence your, like, the naming of your practice, which is four elements? Can you just share a little bit about the story behind the naming and what those four elements are?

Dr. Kainkaryam: 18:58

Yeah, so the the name four elements came out of. So, years ago, when I was doing my certification as a physician executive, we had to give a capstone project on our philosophy of leadership, and so the philosophy of leadership that I had created had the four elements in there, right? So it was the engage, educate, empower and encourage. And so, and as I and that came from looking at the, as we talk about motivation and coaching and we go through, you know what we call pre contemplative, contemplative, the action state, and so that is really these four elements. Right, you got to engage with people. So that's you, you build that connection. The second step is Educate, because the foundation of everything is knowledge. The third is empowerment, where you begin to help people say, hey, I can actually do this. Self-care, motivation. And then the last is encouragement, where they're on this path and your role is stepping back now and helping them continue. So you know it, the four elements. You know that the name came with a conversation with my wife and it's just like what would you call it? Four elements? And I think there was. You know, the other piece to this philosophy is bringing a nod to integrative medicine and the ways of thinking of yes, we are made of earth, fire, wind and water. And these elements and and how do we name something that has this Multiple meaning? Right? And the other four elements are looking at the health system with the four major players. Right, microscopic and Macroscopic is doctor, patient and that becomes at the microscope of the macroscopic level as the system, health system in society. So four elements has multiple meanings depending on on how you look at it. But it started with those Four ease, which are the, the core values in which we work with people.

Parker Condit: 20:46

Yeah, I appreciate sharing that. Uh, so can you kind of go into, I guess, a bit more of your medical philosophy or your philosophy around health, because I know within your practice you offer iovating medicine and there's a bit of that In you from your, like, indian background. Um, so can you share some of the other aspects of it? You mentioned integrative, so I'd love to just get a feel for, like, how you think about health as a whole and how you practice medicine.

Dr. Kainkaryam: 21:15

So I think one of the things that I always ask my patients the very first is that, as I always ask them their journey in health and what life events may define the way they think of health and wellness, because at the end of the day, it's not what I think of health and wellness, it's what the person in front of me thinks of health and wellness, and so my role is to give them some structure to that. So I think there's, as I may have shared before I'm an MD, I'm an allopathically trained doctor, but I incorporate elements of functional medicine, integrative medicine, precision, which is really sort of that genetic based medicine lifestyle, and so I think that all of these things have a role. We live in a world where oftentimes it's very polarized I'm an anti-vax or I'm pro-vax, or I'm anti-meds and pro-supplements or anti-separate and the reality is that there is a place for everything, and the question is how do we blend all that stuff together? And so I find myself I refer to naturopathic doctors, I refer to chiropractors, because I think everyone's got a role the question begins to say, when someone says mine is the only path, is where I begin to see problems. So we take a very blended approach, I think, and it depends on my patient. I have some patients who tell me directly hey, doc, if it's not from a double-blinded, placebo-controlled, randomized trial, I don't want to hear about it, cool. I have other patients who are like give me everything before you give me a pill. Cool. I think as a doctor it makes it harder because I don't know everything. And then you say, all right, how do I bring in these other people who have these banks of knowledge to be able to help our patients? So I think it's really that very broad look at what are our practice beliefs fundamentally about health and wellness, and really this blended, holistic, integrative approach to things, and then what are our patients' beliefs and at the end of the day, can I give this patient what they're looking for, whether it's an integrator approach or, if they want, straight up, sort of an allopathic approach. Every patient has a place here and that's sort of the way I approach it. I'm not here to judge your value systems. I'm here to help you think through your values, with what solutions there could be and risks and benefits of each of these, and oftentimes, with certain things I'll tell them. Look, there might not be a lot of clinical data on this. But that's not always a bad thing. Because if we look at, let's say, someone wants to have a continuous glucose monitor, is there evidence to put a CGM on every single person? No, if someone's willing to pay for it on their own and let's say it's outside of insurance, they're willing to pay 70 bucks for a 10-day CGM. But putting that on makes them more mindful, makes them aware, helps them change their habits. If those habits now impact their risk of disease long-term, then that is not a bad thing. That is a good thing. But when we look at this purely from a financial model, you may say, well, it's too expensive. But if it's coming from the patient, for the patient and that could be altering their disease pathway, that's not a bad thing. There's not clinical research to do that on everybody, but for the right person. As long as you have that conversation, but you know what you're looking for at the end, there could be tremendous value.

Parker Condit: 24:48

Yeah, I think you just bring up such a good point about the nuance that's required because, just to circle back to something else you mentioned, which is that everything is so polarized right now where there's a lot of companies who I mean their entire financial incentive is to get a CGM on everyone because they're getting very good markups on it for these technology companies. I think there's a time and place for it, like you said. And then there's other people who are very staunchly. People who have a normal glucose level or who are not necessarily diagnosed with type 2 diabetes shouldn't be wearing a CGM. And I think both of those things can be right under the certain circumstances, as you were saying, like if it's the right person but you can probably tell because you have that relationship with the person Like, does this person not have a very stable relationship with food? Getting extra data on them about food probably not a great thing to do, but, like, probably want to focus elsewhere. But because you have the extra time with these people and you can build those relationships, you can make those much more nuanced decisions where it's not just we're going to CGM everyone or only type 2 diabetics should have a CGM.

Dr. Kainkaryam: 25:57

Yeah, and I think what's important to also understand right so clinical guidelines are made as a population health tool. They are a starting point, right so? You can't, when you go from population to individual, you have to begin to customize it and you have to begin to say does this guideline apply to my patient? I think oftentimes where we get so hung up on guidelines and you say, we just got to check all these boxes because that's how insurance is going to pay for these visits, but the question is always does this guideline apply to this person in front of me, or do I deviate from this guideline intentionally because I have a clinical rationale for doing so? I think guidelines have also almost become very firm without us remembering what was a population that was studied to make those guidelines. Are they all comers? Are there subpopulations that we need to deviate from those guidelines? And how do we individualize medicine? We are in this world, I think, of there's a fundamental conflict of individualized medicine and standardized medicine. And so when we look at a lot of these quality improvements and stuff, they want standardized because they want everyone to get the same treatment, no matter where they go to, whatever facility. But people want to be treated as an individual. They want their care plan to be different than the person next to them because they are an individual. So you have this mass market medicine, pushing this agenda, and then you have people asking for I don't want to be another number, but if you're going with mass market medicine, you are a number because that's the way the system is designed. So we are entering this world of conflict and people are being a lot more vocal about I don't want to be a number. I want someone who treats me as a person, which means that things have to be flexed to you as an individual.

Parker Condit: 27:55

Yeah, that's a great point. Are you worried about consolidation within the healthcare industry?

Dr. Kainkaryam: 28:01

You know, I think at some point it's going to implode. I think that, yeah, I think that there's a. So why does consolidation happen? So let's just kind of go back right. Number one medical schools do not teach business. Medical schools teach you how to be a doctor and they say go out in the world, save lives, and then let someone else tell you what to do. So that's mistake number one. Mistake number two is because that doesn't happen. Doctors who have decided to go out on their own do not have a retirement plan, so for many people their retirement plan is well, who wants to buy my practice? The only people that are raising their hands are these large healthcare systems and they, of course they want to do it because for every doctor that's in their primary care side, the hospital system is going to generate over millions of dollars later in referrals and procedures and stuff. So of course it makes business sense for them. So there's this system where you've got people being bought up by healthcare systems because it works for them. They need an exit strategy. Medical schools do not teach you how to run a practice, so that is beginning to shift where there was this great book I read a while back by Hamon Feneja called Unscaled, and it was all about healthcare systems and how actually it was about businesses in general, rather, I should say and how they went from large brick and mortar scaling businesses to niche based, smaller nimble businesses, and DPC is one of those smaller nimble businesses. So am I worried? I think that there's going to be some degree of consolidation. Then you've got this massive doctors are burnt out. They're like I'm not going to do this anymore. Then you're going to have this other well, who else is going to be filling the gap? So how can we get doctors to replace nurse practitioners, pas, and how do we fill these roles that were traditionally occupied by doctors? And at some point you're going to want, in certain places, these people who have the expertise right, who went through residency and who had this knowledge and this training, and they're going to be harder to find. And once they gain these knowledge of businesses and sort of compliance and rules and tech, they're going to want to start on their own. And we're seeing that happen across the board, with more and more doctors saying I'm fed up, I'm doing my own thing, and so I think that consolidation will happen, but patients need to begin to ask the question who do you want your care from?

Parker Condit: 30:31

Yeah, I think it's largely. It can largely be unknown as well, because, like primary care offices, I mean, they will have to send out a notice when they get bought up by a private equity company or they become part of a health system. But that's not explicitly understood by a lot of patients. They're not nuanced or they're not trained in the language of the healthcare industry, which, to be fair, is very complicated. So they might still have the same doctor, but they're no longer understanding that it's no longer an independent physician, they're now employees of a hospital system. Are there? Do you have any resources for people? Because I think, kind of speaking, to the idea where people may not. People don't know what they don't know. So if they are in a health system and they need to get a CT scan, for example, somewhere, can they shop that Because they're going to get referred within the health system because their doctors incentivize to do so. The health system is incentivized to keep people in their system. But are there services that are shoppable for people?

Dr. Kainkaryam: 31:37

You can definitely shop around, right. So I think, number one people are not aware that by law, any place they get service or are thinking of getting service, has to give them a transparent, cash-based price. They have to by law. They have to, right. They may say we don't know how to do it, but they got to figure out a way. Number two there are plenty of services, right, and this is sort of another boom that we're beginning to see. We're saying, hey, here's direct pay, cash-based services, right. So I've got relationships here in Connecticut where I can get my patients' CAT scans for $350, mris for $450, and in other places you can get them cheaper. So a lot of this is depending on your doctor's knowledge. And I tell my patients I say, number one, I'm your doctor, but number two, I'm your guide in using the health care system. So use me, don't go spending stuff without talking to me. But colonoscopies, right. So I can get a patient to colonoscopy for all inclusive rate of $1,200, $1,300 if they are willing to drive an hour. The issue is a lot of doctors themselves don't know about this, because this is not what you're trained for. You're just trained to decide what they need. You're not trained to help them think through the social determinants of health, right? So we know that finances are a big determinant. So if you're recommending something that you think the patient's not going to do because of finances, how do you empower yourself with the knowledge? Unfortunately, there's not a whole lot of good resources out there to put it all in one place for, like a consumer shop market. But even if you just Google, like cash pay surgeries right, I mean, I did an episode on my podcast about a year ago with a company that it's all direct pay surgeries right, you can use your HSA, fsa, you can fund them. But by doing direct pay surgeries you're maybe paying a quarter of the cost of what the surgery might be, maybe a little bit more, a little bit less, but you know what the cost is going to be. So I think the biggest takeaways of course you can shop for your surgery, just number. You got to make sure they're coming from a reputable place. And that's typically where doctors like myself get involved with our patients to say, hey, does this look legit? Are they? What are their credentials? Who's doing these surgeries? And that obviously opens up to the whole concept of medical tourism. Medical tourism historically was international. You go for. You might go to Turkey for your hair transplant, you might go wherever Now that is happening within the United States, because you're saying well, why am I going to pay more to go here when I could go to New York, get my colonoscopy, stay in a hotel on Times Square, grab a Broadway show and have all of that still be cheaper than my colonoscopy.

Parker Condit: 34:23

Yeah, the point I was trying to get to was that a lot of people they think, oh, if I'm just using insurance, that has to be cheaper than cash pay, when in reality, oftentimes, if you shop around, cash pay is going to be significantly cheaper. You see that from surgeries to prescriptions as well. It's such a weird market where if you're trying to use insurance, oftentimes not always but it is going to be more expensive, which is a very strange phenomenon.

Dr. Kainkaryam: 34:51

If anyone has ever used a good RX, they know that it was cheaper not using their insurance. They just didn't connect the dots.

Parker Condit: 34:58

Yeah, yeah. So that's why I think these conversations are so important. But I want to go back to something you said about. You were talking about how you are able to integrate so many things from these different types of models that you worked in, also drawing from different, I guess, philosophies of medicine. I read an Instagram post and I'm going to poorly paraphrase it, but I think it comes from working in pediatrics. You said looking at a child's health without understanding the parent's health is not a comprehensive approach to treating the child. Can you unpack that a little bit more, and is that a common thought amongst, I guess, medical professionals?

Dr. Kainkaryam: 35:40

I would say it depends on your training. I think being trained both as an internist who works with adults and a pediatrician who works with children. The reason I chose to do what I do is because of that very philosophy. I think when we talk about health broadly, we talk about things like social determinants of health, and so those are who's at home, who's working, what are the job stressors, who's childcare, all these things that have a big determinant. I think that we do lip service in the traditional healthcare model where you ask these questions you say, well, let's ask you about all these things. Oftentimes it's not your doctor asking you, it's someone else who's checking a box because some insurance company needs that box checked to say you give high value care. But who really needs to know that information is the person who is helping you make decisions about your healthcare. So, as a doctor, when I work with entire families, I have couples who are getting divorced where I take care of both sides and their kids. I have families that are completely intact. But all of those pieces of information help me think about what is good for that person who's sitting there in front of me and I know I'm not taking sides, I don't judge, I'm not getting involved in why their personal life is what it is, but I need to know what it is so that I can see how it's impacting their health, and so those are all key things. For example, if someone's bringing their kid into the office all the time, is there something going on with the parents? Or the other question is I have actually a patient of mine who is very sick, a pediatric patient, who is here very frequently, and part of it is the parents are not my patients in this particular scenario, but every so often I'm like how are you doing? Because I cannot imagine what it is like as a parent to be going through this with your child, and I don't know if their own doctors know what's going on and so. But I see them, and I see them defeated and deflated and there's a part of me that I wish I could do something for these people, and besides just giving them genuine concern, I can't. But if they are my patient now, all of a sudden I can bring up topics that they may not bring up, because I know what happens in the dynamic that I'm observing. That's the myth. I think that is that special sauce of this old school doc who used to take care of the whole families and stuff. You draw the threads from all these generations and you begin to say this is the dynamic of this family and so how do I work within that dynamic? How do I help the people, because that's such a big part of who they are. We lose that by creating these fragments today.

Parker Condit: 38:43

Yeah, there's lots of pieces of information that are probably not going to show up directly on a medical history or even if they do, it's understanding the dynamics of that relationship, like you're saying, that can be so important and influential on a person's health overall. I'd like to shift gears to social determinants, because you brought that up a few times. Can you describe a little bit more about what social determinants are and then we can dig into that a little bit more?

Dr. Kainkaryam: 39:08

Yeah, I think. Broadly speaking, I think social determinants are really looking at things that determine your health that are outside this pure medical model but that are directly impacted by your environment. So, do you have a place to live? Do you have access to healthy food? Do you have transportation, Caregiver status? Do you All these different things? That may be influenced by culture. They may be influenced by yourself. Socioeconomic status it may be influenced by where you live. These are very subtle influences to health that are oftentimes not paid much attention to because they weren't like a medical problem, but oftentimes have direct correlations to specific incidents of medical problems or conditions.

Parker Condit: 40:00

Yeah, so I've seen varying numbers on this, but it can be. I'll just throw out a rough number and feel free to correct me if I'm wrong. But if you were to look at a population's health for a community, for example, you can attribute up to 50% of the health outcomes for that population on these social determinants. And an example of that is it's easy to tell people to walk more, spend time outside and eat healthy food right. But if they don't have access to get healthy food and they don't live in an area where it's safe to walk outside and there's not green spaces that are safe for people to hang out in, it's going to be very hard to do that. It's such a big problem because it's not. This is a community level problem. This is a local government problem. This is a national government problem. I don't even know where to begin the conversation on how to address this, and there's so many people trying to address it and it feels so challenging to really move the needle on this. So I'm just curious if you have any thoughts on where should it begin. Should it begin with community involvement? Should it begin with local politics? I don't even know where to start. Is it just raising money for parks or city infrastructure, like creating sidewalks and green spaces. I have no idea where to begin with this stuff.

Dr. Kainkaryam: 41:20

So I think the way I think about this let's think about this at the microscopic and then the macroscopic level right? So as a doctor at the microscopic level is you need to know your patient's environment before you give them advice. If you say, well, great, go exercise. Well, that's lovely. How do you know if they live in a safe neighborhood or not, or whatever that might be? But you begin to get creative. Do you have stairs in the home? Great. Now can we come up with something where you go up and down those stairs and you create what works for them in the world they have? So let's talk about changing that world second. So the first is you need to learn their world. You need to say what do you have access to? What resources do you have? Where do you work, do you work? And so all these things will help come up with that. And so we have, as part of our team, our nurse who is also a personal trainer, and so with many of our patients, he does personal training, and so, whether it's a virtual, or they come to the office and we teach them in a micro gym what you can do and exercise without needing a whole lot of space. You know it's giving them that idea generation with saying, okay, you're dealt with this hand of cards, let's play well with them. That's part one. Part two is let's change your deck of cards in the first place, right, and that's where you talk about creating these systems and infrastructure. I think one of the best stories I've seen I don't know if you saw the Netflix series that came out on the Blue Zones. It was really interesting on how they tried to replicate what they learned in all these places around the world, in the US, in these tiny, small, you know, and so I think you know, sometimes, if the community is so big and established, it is really hard to change. When the communities are smaller and nimble, those are a lot easier to change because every single person there has a larger voice than the larger communities. So, you know, when it comes to the macroscopic level, I'm not sure that the change will be fast enough in today's society to see a significant difference unless enough people in the community are on board. At the microscopic level is, I think, really where you begin to help people, think out of the box and really say what can I do with what you have and how do I help you with what you have, or how can I help you get really affordable resources that you can then use for what you have? And that's the way I think we've begun to think about it here in our practice is, you know, we're actually in the process of buying this space where we want to create this whole vitality institute, and that is an outdoor walking pathway, community garden and creating the saying well, all right, you don't have resources, and at least during your medical visit, let's go for a walk and let's show you simple ways, right? And people often think exercise, I need a gym. No, exercise is a method of doing things that can be done a wide variety of ways, and you can even just do it with your body. Right, but do you have someone to teach you how to do it? The issue with a lot of places, especially in healthcare, is that, say, personal training, right. Why isn't personal training integrated with your medical primary care doctor? Right? Because if your primary care doctor is just saying, well, eat healthy, workout more, sleep better, well, that's great, but how? So our healthcare infrastructure is built on just giving advice but not giving the person the tool, saying now go over across the hall, go talk to Paul and walk away with at least three concrete changes that you can make today with what you have. That's that next step where we empower people to say I can do this with what I have. That's what's missing.

Parker Condit: 45:08

Yeah, that's a great point. So, like you probably don't know this I used to be a personal trainer and then I would end up trying to coordinate with their primary care physicians. But it's such a siloed universe, essentially, that I was so frustrated. That's why I ended up co-founding the last business I did, which was trying to help put patients at the center and help them sort of draw in all these different providers as they needed. But yeah, it's such a good point that it's very advice-driven. There's like the lack of practical application without the knowledge for people. But yeah, I used to give people who didn't have access to gyms and couldn't afford it kitchen workouts, squats, lunges and push-ups on the sink. There's so much you can do in a small space that is accessible. But yeah, it's the larger macro things that are very challenging and it's like, like you said, I don't know that there's a big enough shift that's going to happen to make things really move the needle quickly. Dpc does give me some hope because, on the employer side because usually employee benefits in the form of health insurance is one of the biggest expenditures outside of salaries, but DPC is actually generally a one-to-one cost in the first year, so the employers are not going to be losing money on it. And then if people are. The other thing with doctors' offices is like how long is it going to take to get in there and how far? How inconvenient is the location for me? So a lot of DPCs via employers will be on site, being in the building or near site where it's like an industrial complex, and they'll end up putting a clinic in between four or five office buildings, for example. So that's one of those things where I'm like there's possibly hope there. But now we're moving to more of a distributed employment model where people are remote. So I don't know how that could solve with DPC, but it is one of those attractive models that I'm very encouraged about. But I do want to ask you are there people who should not be participating in direct primary care? Is there any population where I'm like this is a bad model for them?

Dr. Kainkaryam: 47:17

So I think the answer for that is a little hard because I think every direct primary care practice is a little different. So I think that the model itself is scalable in so many ways. So years ago with IORRA we started a DPC practice for employees of Hartford Health Care in Connecticut. So it works for employers, it works for insurance companies because you have less claims going through, cost of care is going down, patients are happy, employers are happy like it actually works for everybody. I think a particular DPC practice may not be right for everybody and I think that's where, just as patients are individuals, the DPC practices are individuals because for a lot of us these are extensions of who we are as people and as our practice philosophies, which makes the scalability a little bit challenging. And let's say you decide to scale and you say I'm going to use a private equity funded or venture backed funded model DPC. Then all of a sudden you're shifting this relationship based model into something more corporate again and your doctor is once again an employee. They're more dispensable. So you now you might not be as bad of a monster as compared to some other models, but it's still nevertheless heading in that direction. And it's so easy because look at the end let's be frank private equity they want money at the end of the day. Right, they're putting this in there. Yes, some people have a social mission, I get it, but for the vast majority it's I want in and I want returns. And so, as someone getting care in those models and as a physician in those models, there's always that bit of how much am I valued in this because at the end of the day, it's someone else's money and someone else's going out. And so those of us who are private DPC oftentimes are taking years of not getting paid anything because we are building from scratch. Now. The downside is not everyone has a luxury of doing that. Right, I'm married to an anesthesiologist. I'm lucky that she gave me the opportunity to do that because she said I'll support you, I'll hold the fort. So I think the challenge with DPC is number one. Not every doctor can be a DPC doctor. Number two For some people and like well, it's better than the other alternative. So I'm going to go with the employed DPC model as a patient. It's always important to know that because you need to know what you're getting into right as a one doc shop right now, like I get hit by a bus and my practice is done and they lost a doctor right and or as a corporate model yeah, it can be corporate at some point and someone else may cross cover who doesn't know you, or they can be bought out and then booth, like you know, the whole thing is like different for you. So there's risks and benefits to both. It's knowing what you want and what the risks are. So, but in terms of complexity, look, we've got patients who in our practice or have no insurance. We have patients who are undocumented. We have patients who are on Medicare, medicaid, commercial high deductible who have you know or who are sitting on millions of dollars of life insurance money, and we have patients who are, hey, I'll see you once a year when I need you and I know you're there. And we have patients who have had double, triple transplants, have multiple comorbidities and we are playing a much high touch role. So everyone has value, I think, in this model, depending on who is paying for it. Number one and number two depending on is that particular practice and that doctor the right fit for them?

Parker Condit: 50:53

Yeah, I appreciate the nuanced answer. I want to go back to finance a little bit and the members should be paid for with HSA or FSA.

Dr. Kainkaryam: 51:03

So the official answer I'm going to give is it depends, and the continuous answer I'm going to give is it depends on who you ask. So a few years ago, my understanding is that there was an executive order issued by the Trump administration to clarify something in the IRS tax language that basically allows HSA money to be paid for toward a DPC membership. Now there's some nuance of is it considered another health plan? So can you have another health plan with an HSA, and blah, blah, blah. There's sort of some legal issues there. So some lawyers will say absolutely, you can. Others lawyers will say talk to your accountant because ultimately you're responsible for your HSA funds being used appropriately. The reality is do I know for a fact? There's thousands of patients who are paying DPC memberships with their HSAs across the country from other docs. I know that to be fact. Do has it ever been litigated? Not, to my knowledge. Does the responsibility of an HSA spend ultimately lie with the consumer? Absolutely. So that is the best answer I can give you.

Parker Condit: 52:20

I have no idea why people are frustrated with healthcare in this country. It's so easy, it's so simple to navigate. There you go, there you go. It's so wild, but so additional services. So typically within a membership there's going to be a set number of services, whether it's, however many visits, an annual physical, certain labs that are included. If there are things that are cash pay outside of that list, can those things be used generally for an HSA?

Dr. Kainkaryam: 52:46

Yeah, generally. Yes, also, like your lab tests, anything that is medications, labs like those are. The issue with the DPC is you're paying for the membership as opposed to paying for an episode of care. It's all in this nuance. But medications, labs, all things that you would be able to use your HSA for anywhere, you can use them in the DPC world.

Parker Condit: 53:13

All this nuance is thanks to the lawyers in this country, so thank you for that. Would you recommend people have some sort of additional coverage beyond DPC? So I've had a variety of DPC plans over the years, paying anywhere from just to give people an idea of what this costs per month, I've paid $75 a month up to $150 a month and I think that's around the average. But I've also always had a catastrophic not a catastrophic plan, a stop-loss plan, on top of that. So anything that you would recommend or again, it's just dependent on the individual- so people typically fall under four buckets.

Dr. Kainkaryam: 53:54

First bucket is pay doc, this is all I can take out of my paycheck and I just don't have anything else to pay toward anything else. That's number one. Number two are people who say okay, so the 25 grand I paid toward my insurance premiums I'm going to put into a rainy day investment fund, knowing in the back of my mind, I'm going to pull that out if I need it for health expenses, but that's my plan. Number three patients say all right, I'm going to keep some type of catastrophic coverage or minimal coverage, just so that my risk tolerance is met and I can sleep well at night in case something bad happens. And then number four are the groups of people who say I'm going to explore health shares or medical cost sharing as a health insurance alternative. And this is gaining a lot more popularity because it's their nonprofit organization, so their CEOs are not getting the millions of dollars that they are getting into traditional companies. They're benevolent funds and so when there's a need from the community, it gets pulled out through sort of the formal process. So I find that people typically do one of these four things. I tell everybody very clearly that what I do is, does not provide hospital care. There's gaps, but at the end, like insurance in general, for a lot of us it's risk tolerance. So if you go buy an iPhone, are you going to buy insurance on it in case something happens? You may, you may not. Are you the traveler who's going to say I'm going to ensure every trip by paying another one quarter of the cost of my trip with travel insurance? You may, you may not. So it really depends on that risk tolerance. I don't tell people what to do in that end. I tell them to think of their risk tolerance and at least know that these four options are typically what I see people do and they choose what's best for them. Oftentimes people don't know about the cost sharing, which is probably the fourth bucket. That requires a lot more education for people.

Parker Condit: 55:54

Yeah, I appreciate sharing that, because I've had this conversation with so many people and I never really have a good answer for them. But kind of breaking it down into those four buckets is very helpful. At least now I have sort of a list of options I can give them and just instead of just saying here's what I've done. So that's very helpful. I want to be respectful of your time, so is there anything else you wanted to share before we start closing things out?

Dr. Kainkaryam: 56:19

I mean, I think the DPC model is in so many ways, great for so many people. I think everyone wins. I think the one thing I tell all consumers is just really learn. There's so many resources out there. Ask your doctors, learn their style. At the end of the day, I believe in the power of choice. I believe that as a patient, you should choose the way in which you get care and what you're paying for. As a physician, I have a choice in the way I wish to practice medicine and who and how I wish to create my life that I want to sort of work in. And if there's synergy, that's great. If not, that's okay too, because there are other choices, right, maybe concierge medicine is better for you, maybe a different DPC practice is better for you, but all these are okay options. I think people walk in with a very, sometimes a very closed approach to healthcare and I think one of the hardest parts about learning is knowing that your assumptions may have been wrong. And I think for people to be like, of course, I need to use my insurance and pay $1,200 for a CAT scan and if all of a sudden, I'm like, actually no, you didn't need to do that, you could have gotten away for like one third of the cost. There's an element of I feel really stupid and no one likes to feel stupid and I think that healthcare has made so many people across the country just have blinders on and not know that, yes, you are entitled to cash pay rates, not know that you're entitled to self pay, not know that you have all these choices, and I think there might be some degree of intentionally, you know, not promoting that education and that's why we take opportunities like this to say learn about it, but don't feel dumb if you didn't know something, because we all felt that way, even as doctors going through healthcare. I'm like I didn't know I could do all this, and so if the people who are in it don't know it, as a consumer, don't feel bad. So those are my two big things. I'd say is learn and don't feel bad.

Parker Condit: 58:24

Yeah, that's very important and I can attest to that as well, kind of coming from the personal training world. Then, over the past four years, having to learn healthcare Also, during that time I'm trying to be kinder to myself. But gosh, so many times trying to learn the healthcare industry, I'm like this industry makes me feel so dumb and trying not to beat myself up over it. But yeah, it's a very complicated industry. So for people who are it's crazy to have worked in this industry and now, like look at it from a patient's perspective, I'm like how are people whose job it is not to understand this, how are they navigating this industry? It seems so challenging. So, yeah, it's a very good point to be kind to yourself. Yeah, don't beat yourself up too much about it. Do you have a positive message you want to close with for our listeners before I let you go?

Dr. Kainkaryam: 59:20

You know, I think you know. I would say if you are in question, let's say you're a doctor, you're listening to this, or if you're a patient, you know, look at, look at number one. If you're a doctor, look at that Iki guy diagram really hard. Stare at it. Know that you have a choice. Know that there's other people out there who are doing it. Ask for help. A lot of us are so willing to share our journey so that you can learn the lessons that we are learning later, earlier, so that that can change your course as a consumer of healthcare. You know, similar to what I said, don't beat yourself up. There's great podcasts like this one. I've got my own podcast that we look at healthcare too as well, and so take every opportunity to learn. Ask lots and lots of questions, Follow people on social media who are innovating in healthcare, and even if they might not be able to give you the solution that you need, chances are they probably know someone who can and leverage that network of people in the health innovation space to get you the answers that you need for yourself.

Parker Condit: 1:00:32

That's a great way to close things up. Yeah, so I'll just end it there. We will definitely link to your podcast. We're going to link to your practice. We'll link to all your socials as well. People will definitely be able to get in touch with you if they're interested and we will link to any of the resources we mentioned in the show. But, D r. Vasanth, thank you so much for joining us today. It was a real pleasure to talk to you.

Dr. Kainkaryam: 1:00:53

Awesome. Thanks for having me.

Parker Condit: 1:00:55

Well, to those of you still here, that's all for today's show. I want to thank you so much for listening. I really hope you enjoyed today's conversation. If you want to learn more about today's guests, please visit our website exploringhealthpodcastcom. There you can find show notes for today's episode, links to the guests and our full episode archives. If you enjoyed today's show and you want to hear more, make sure to subscribe on your favorite podcast platform. I really appreciate each and every one of you listening Until next time.