Episode 106: Direct Care with Dr. Andrea George Hill Country Endocrinology

Direct Endocrine Care with Dr. Andrea George 


What you'll learn in this episode

  • What it takes to operate a successful direct care practice for specialists
  • The primary challenge of effectively communicating the direct care message to prospective clients
  • Dr. Faris's biggest win so far
  • Plus, a whole lot more!

Here's how to connect with Dr. George


Dr. Tea 0:52
I have a lovely guest today. She's an endocrinologist, Dr. Andrea George, welcome to our show today.

Dr. George 0:59
Thank you for having me on.

Dr. Tea 1:01
I'm going to ask you to introduce yourself, tell us where you practice, how long you've been in practice, and why you chose direct care.

Dr. George 1:08
So Andrea George, triple board certified and technology, internal medicine and obesity medicine. I currently practice in cedar park, Texas, which is outside of Austin, a suburb of Boston. And, about two years ago, we moved from Omaha, Nebraska. And I was in an academic center in Omaha, Nebraska, Texas, we were two little kiddos at that time. And just the idea of signing up for a corporate job 8 to 5 and a Friday with two little kids was overwhelming. And so I was trying to figure out what other opportunities or what other things I could potentially do. At that time, I thought, okay, well, let's open my own practice. I started learning about reimbursement. And I said, Okay, well, that's going to be seeing a lot of patients and over to just make overhead me, you know. And so I learned a lot about direct primary care. And I said, "Well, why can't we do this for endocrinology?" And so I opened the first direct endocrine clinic in Austin, Texas. So it was exciting. That was two years ago. And I said, Well, if it doesn't go, Well, I could always enroll in insurance. That was kind of my backup plan.

Dr. Tea 2:25
So you had gone out to create your own practice, straight up all cash.

Dr. George 2:30
So I didn't opt out of Medicare, just because it was a scary thought process to say, Okay, I'm not going to be able to see any Medicare or not have a locum opportunity. So I've never opted out of Medicare, and I still haven't opted out of Medicare. But for the rest of the patients it is cash pay,

Dr. Tea 2:51
What percentage of patients do you have as Medicare?

Dr. George 2:55
I have very few numbers like maybe 2 to 5%. I don't necessarily advertise the Medicare portion. It was if anybody calls and they do have it, then I'll just take them on. But my focus is still kept doubling my cash pay practice.

Dr. Tea 3:14
So you opened your practice two years ago, and you have a very small, almost negligible percentage of Medicare still? What's holding you back from opting out completely? Or is that even a plan for you?

Dr. George 3:29
You know, so I do traumatic brain injury consultations for another clinic, which I've always done. I also do expert witnessing depositions for that clinic and I really enjoy doing that. And for that reason, I haven't opted out. And it's something that I have, you know, it's just like, something over my head, like, what if I ever need to go back and work at a practice? And I think that's something that I haven't gotten over yet. And I don't know if I foresee myself ever opting out, to be honest. I know some people are just like, opt out, you don't need it. And it's not like that it brings in financial income, or it holds over my overhead at all, but I think it's just a mental hold on me.

Dr. Tea 4:17
Do you ever have fear or concerns about Medicare coming after you and auditing you or taking money back like Does that ever cross your mind? Or has it ever happened?

Dr. George 4:29
It hasn't happened. I mean, I've heard the horror stories. Obviously, I think we all have at this point. It's not a fear because like I said, it's a very small percentage of patients that I see. So I don't feel like it's going to make a difference. And I really do provide the same standard of care for those patients.

Dr. Tea 4:47
So let's talk about the makeup of your practice. I heard you say you are triple board certified. What is the focus of your direct specialty care practice?

Dr. George 4:56
Endocrinology is my general endocrinology and endocrinology does focus on obesity medicine in of itself, but I did do obesity medicine training. It gives you a lot more information because I think in fellowship, we're not trained or focused a lot on obesity medicine. So I do both and Endocrinology and obesity medicine

Dr. Tea 5:18
How do you patients find you everywhere?

Dr. George 5:20
So Facebook is a big one for me through physicians searches like social media or other things, Instagram, and then Google SEO, Google searches. And then word of mouth. So the current patients that I'm seeing, like I had a patient this morning, and she was telling me at the end of the visit, like I just want to let you know, I said to my patients your way, and they absolutely loved you. And I was like, Oh, well, thank you. Like I didn't even realize that came through her as a referral. So the word of mouth that definitely picks up after I think the first year,

Dr. Tea 5:30
Do you have a membership fee for service? Or is it both?

Dr. George 5:58
It's both. So to be honest, I've played with these numbers a lot, because I was trying to make it work. Initially, I had the option for everyone to kind of pick and choose what they wanted to do. Like you want to enroll in your membership, you can enroll in membership, you want to pay per visit, you can pay per visit. But it was becoming difficult, because some patients would pay per visit, but still expect, you know, the in between visit conversations and text messaging access. And so recently, I've changed it to paying for your initial consultation. But if you have more than two visits a year, it's a requirement to enroll in membership.

Dr. Tea 6:41
I've not heard of that. That sounds really great.

Dr. George 6:43
Yeah, I think it helped me kind of separate the needs, because I feel like if you need more than two visits a year, you're now requiring more attention and more of my time. And you probably do have more questions, right? You're not necessarily a stable endocrine patient, which is okay. And I want to give you my time, but for those patients, I do require that they enroll in a membership.

Dr. Tea 7:11
Do you have an ideal client avatar that you target? Is there something you think about when it goes to building your practice?

Dr. George 7:20
I think the ideal client is the one that's been in the traditional system, and understands the deficiencies there. And then when they come to me, they're like, oh, wow, this, this is what we were looking for, this is what we need, we needed this access, we needed the time we needed, just the speed or you know, the individualized care. Because if they don't, if they haven't been in the traditional systems, as a patient, you won't value what we're doing. Because then you're like, they're like, Well, why am I paying for this service? Like, every other doctor does the same? And you're like, well, not necessarily, because their systems prevent them from being able to do what I do for you.

Dr. Tea 8:05
I have to agree. At first, I thought it was just that we were here to serve everybody. And then you would get people asking, well, doesn't my insurance just pay for this? Why do I have to pay and those can be really frustrating experiences, because they don't yet value what we do. So in a way, they also have to recognize what's wrong, maybe get burned, even to then start valuing what we offer and be willing to pay out of pocket. So that's a really great point in regards to who fits your clinic.

Dr. George 8:38
Right. And the general wait times around here in Austin for endocrine is anywhere from three to six months. And you know, it doesn't necessarily mean you'll see a physician each time you go in to see someone. So there's definitely different levels of care. And I've never blamed the physicians, I feel like all the physicians are just great at what they do. But the systems, right the insurance does not allow for them to spend the time or when they have the paperwork and the volume of patients to even recall what's going on or what they did the last time they saw that patient. So it's definitely a limiting factor.

Dr. Tea 9:23
What has been your biggest struggle when you were opening our practice?

Dr. George 9:28
I would say It's just learning how to get the direct care message across. So as I mentioned, I'm the only endocrinologist in Austin doing this right now. And so even when I reached out to physicians, they were like, they were like, well, this is great that we have another endocrinologist. You should take all insurances, your practice will be fallen two months. And I was like, okay, but that's not what I'm trying to build. I don't want to go take insurance, right? And so just getting that message across to physicians to patients, I think was the hardest part and then feeling a little letdown when like if a patient initially would call and say, Oh, this doesn't make sense, or why would I pay cash or I'd rather go see a primary care, like, you know, someone in network. And that was, you know, hard initially. But I've come a long way. And even patients that are in my practice, if they say, you know, things are stable for me now, I think I'm gonna use my insurance. I'm more than happy to say that I understand. You know, that's totally fine. I wish you luck. And I hope you get the care you deserve. Because I'm confident that they're going to come back even as a stable patient, just the response time, or getting your schedule like, if you can, you can call our office and get scheduled within 24 to 48 hours. You're not going to get that anywhere else, right. Like I had a patient this week who called us and wanted to get scheduled to see us. And she said she had a follow up visit with her endocrinologist. And she was sick. So she called the endocrinologist and said, Hey, could you make it a telemedicine visit? They said, No, we can't. They're like, Okay, well, could you give me can I reschedule? I'm sick, I don't want to get you guys sick. And he's like, Well, the next appointment is going to be three to four months out. So that's for a follow up visit. No telemedicine, you know, because obviously telemedicine probably gets reimbursed more. And so they weren't willing to switch out to telemedicine. And so these are the kinds of things that I don't have to worry about. In my practice, you can get scheduled within 24 or 48 hours. Are you sick? Okay, let's make it a phone call visit, let's make it a telemedicine visit. There's just so many different options, because I don't have to deal with the bureaucracies of insurance, right? It's just me and what works for your schedule. And yeah, so even when patients now say, maybe I'll use my insurance, I feel a lot more confident because I know what value I bring into, you know, the health care system.

Dr. Tea 12:15
I didn't need to get myself to build that confidence.

Dr. George 12:21
It took time. I think patient feedback was big for me, because as I start seeing patients and I hear the stories of kind of like how the healthcare system failed them. Myself dealing with the healthcare system for things like when my kids get sick, or when I have to deal with insurance based physicians and I want to like I've been saying I can't wait for another director endocrinologist because I have endocrine needs. And I'm like, I wish I can go see a direct care endocrinologist. I think those things really helped. It took time because and then trying to learn what I wanted out of this practice, because I realized really quickly. My goal is not to bring in everybody who needs an endocrinologist. It's the right fit like they have. And the biggest one for me now is they respect me and I respect them. And that's just so important because we talk about burnout, you know, traditional systems, but I really think burnout can creep into direct care practices, too. And so it's important, not just about boundaries, like we talked about hard boundaries, but just talking about kindness and respect and having a really good relationship with your patients where they value your time as much as they value theirs. And my patients are really good but that right now because they text me and they would like Dr. George I know you're out there kids right now this does not need to be answered. You can wait till tomorrow and so it's just so nice that you don't feel anxious like Oh, I got a text to respond to this right now. It must be something important. And so I think that's what came with time and with the right patients.

Dr. Tea 14:12
So you didn't start your practice fully confident knowing you would happen, you had to grow a little bit.

Dr. George 14:19
Oh, yeah, I didn't even know if this whole idea was you know, that would it make sense for endocrine there aren't well now more and more endocrinologists started doing this. But there weren't a lot then and there still aren't a lot that are doing it right now. So I didn't know how it would translate like we have a lot of successful direct primary care physicians in Austin. I didn't know how it would translate into a sub specialty. And so it definitely took time.

Dr. Tea 14:48
Do you have models, role models, mentors that you look to to gain a little bit of confidence to star or when were you predominantly looking at the DPC structure are

Dr. George 15:00
Predominantly at the DPC structure, because there weren't a lot of like, endocrinologists that were doing it at that time. Like I said, at that time, like two years ago. Within Austin, there were a lot of direct primary care physicians, so I was able to meet with them and, you know, kind of learn their model. And I think that's what I based mainly off of,

Dr. Tea 15:22
What would you say to residents who are looking for a job about direct care,

Dr. George 15:29
I think, you know, coming out of medical school, or like, if you're thinking about what you want to do, as a doctor, I think direct care is the way to go. It's exactly what it should be, we get to practice medicine, without the big systems without the restrictions with more autonomy. And that autonomy is what's going to keep you going for the long term. Regardless, you're gonna see patients, you know, in both systems, but you actually get to sit and think about each of their care and their needs. And just have that flexibility, which is so important. So I would, sometimes it's hard to start your own direct care practice right out of residency, I mean, I definitely valued the years of experience, I had post fellowship, because fellowship is great, but I think having those couple of years of just working in the traditional system, where you're seeing a lot of patients and you're making a lot of decisions, helps boost that clinical confidence in you. I know there are direct primary care physicians that have done it right out of residency. So not to say you can't do that. But just to know that this option is out there. And to just go talk to people people are very open to, you know, giving you advice on to do is to not learn from mistakes, like I've listened to all the podcasts that I can, you know, I've read all the forums and or all the articles, forums, I've just done it all and you learn a lot from those.

Dr. Tea 17:02
What do you think it takes to run a successful dry care practice for specialists?

Dr. George 17:07
I think it takes a lot of patience. Sometimes, you know, when we go on Facebook, we see a lot of likes, the success stories, the super successful ones, like I opened my practice, and I had 300 patients the next day, and you're just like, wow, this is amazing, right? Like, but I don't know if that's reality for everybody. It takes a lot of work, and you're gonna get discouraged, you're gonna be like, Oh, my God, why did I do this, I could have been making good money working at a big system. So patience, and to know that it will work, but it takes time,

Dr. Tea 17:42
What has been your biggest win in the last two years, you've had your direct care practice?

Dr. George 17:48
Biggest win, I think, like, my initial goal was like, when I, I interviewed at different places, traditional systems here. I had this number in my head that I got offered, right? People were like, Okay, this is how much it is to work part time or, and so I had like this initial cash pay goal, were like, Okay, well, if I hit this goal, which I didn't get offered a lot of money, like it was similar to a mid level. So full time salary, I won't say the numbers, but that's about it. Um, and so my initial goal is like, well, I guess all I have to do is make that money. And then I've hit that initial goal. And I was able to do that within my first year. So that was nice. And I think, you know, when I got to hired on just virtual assistants, that just helped me see my growth. That was like another nice one, but just every little, it's not about like, the big wins. I think, for me, it's about the small wins, like, Oh, nice, like, I started really small, and like this one location where it wasn't within a clinic, it was just a freestanding, one room that I subleased. And every time someone came in, they were a little confused, like, where are you? You know, and I felt that was, that was just my start. I wanted to keep my overhead really low. And so I recently moved into still subleasing, but into a clinic, but it just feels nice. It was a small way, but still another small one. So I'm really over the last two years, like I'm learning to be just intentional about the small wins, and not just the big ones. I mean, the big one is that I'm still open. I'm still here. I'm still excited about my practice. But I've had a lot of small wins.

Dr. Tea 19:34
That's really fun to hear. Because I do think we overlook the little things and I'm in the same situation. I have a 500 square foot space, I do surgery in my little office. Everything's sterile and people come in and they feel that level of intimacy. They know when they walk in. It's going to be different. They're not going to be tousled around in the waiting room overlooked and things like that. They know as soon as they walk in, they're going to see the doctor. But I think that's just so special about what we do.

Dr. George 20:03
And it's so funny because the new patients, they'll come in with like a book or, you know, like work to do in the waiting room, and I just go out, and they're like, Oh, you didn't give me enough time to finish my chapters. I'm like, we don't wait here. You know, I mean, Thursday's occasion would be like the previous patient had warmer or needed my extra time. But yeah, it's definitely different.

Dr. Tea 20:27
So moving forward into your practice? Where do you see you taking yourself? Are you completely where you want to be? Do you see yourself expanding? What is the future look like for your practice?

Dr. George 20:38
This is a really good question. And I constantly think about this, because I think like, I'm at a good goal financially is where I'd like to be. But of course, I think when you think of business, you're always thinking growth, right? I think, you know, I, I've had a lot of endocrinologist recently, locally, reach out to me, just about maybe even joining my practice, or learning about direct care, and I give them both options, like you go out and do it on your own, like, it's gonna be a great adventure. But you know, that's one thought that I've had. But another thought I've had in my practice or growth is I've a great list of patients now. And just to say, have a primary care physician. Come on, and have more of a multi specialty direct care practice, which would be so great, because a lot of my patients are like, Dr. George. Could you find us, you know, our direct primary care doctor just like you? Or could you do it, I'm like, I don't want to do primary care. I love endocrinology. So that's been a big kind of conversation that I've been having, even with my patients, there's a need there. And then there's just the different aspects of growth, like adding nutrition, or a personal trainer to the practice, and just different alternative things, just overall wellbeing of my patients, because I haven't realized that, you know, health care isn't as simple as just fix one thing, like, even when patients come in to me, I'm not just looking at their diabetes, I'm talking to them about their stress levels, and, you know, their sleep and everything else. And it being so comprehensive, I think it'd be nice for patients to have access to different things like whether it's, you know, just medical or even alternative. So, these are some things that I've thought about from my practice. And, you know, over the years that I think what I would love to just have one center with different kinds of medical services available to them.

Dr. Tea 22:50
Would you encourage your children to go into medicine, knowing what you know, now?

Dr. George 22:56
Ah, this is a hard question. So, you know, this is a hard question for me. I think it's hard because of the mid level care, right? There's so much like, even in endocrinology, that's one of the big problems, a lot of big facilities have mid levels. I think I won't discourage them from going to a medicine. I think if they really love medicine, there's still a place for it. And you could still do it the way you want to. But I do think the future, I mean, there's a big movement, but it has to be stronger. Like, it has to be more of us doing this. And there are still a lot of physicians that I talked to that seen that don't see it, that don't see the problem within the big systems, or even the mid level creep. And so I don't know, I'm still on the fence about encouraging medicine, I think that it could potentially change with this movement. But it's got to be stronger, we need more numbers.

Dr. Tea 24:05
So we need you, those of us are listening. Just jump on in, we have to do it together. And I totally agree. That's the reason why I love speaking to doctors like you is because I can see how much we all love medicine, we just don't like the structure, the infrastructure is a mess. But if we can carve our paths for our respective specialties, and maybe interweave our different disciplines to create this holistic wellness type of movement, we will draw in more people. So my ultimate goal is to reach at least 10,000 specialists. I don't know if that's going to happen, but I want to make sure that people see that the pathway is there and we really do have to do this together.

Dr. George 24:48
Right, right now that's exactly what I think. I think there's more numbers. So I opened up a Facebook group for direct specialty care of endocrinologists. So there's a group of 250ish now, and, as of last, you know, obviously, it's biased because it's only what whoever's in the Facebook group. But by the end of 2023, we will have 20, to about 22, direct care, specialty, endocrinologist, and all of the US. So we're gonna see how that number goes up every year. But I've already had a couple of people announce that they're opening one up this year. So that's still not a big number. That's a very, very small number. And as you probably already know, endocrinologists, like most specialists, right, there's such a need for us, like, there is wait times in the six month mark for most endocrinologists in the traditional system. So this is the way I hope things change as an endocrinologist, more people want to go into endocrinology, right to say, Okay, there's other ways than just the traditional system to do it. And, yeah, for us to serve the community better, rather than, I'm gonna see you every six months, your diabetes is not so well controlled. I'll make a small change. I'll see you in six months again, oh, well, nothing really happened? Well, of course not. Right. Like where I can see you every month, I can see you every two weeks, get your diabetes under control, actually have movement in your house.

Dr. Tea 26:17
Oh, I love that. So there's a doctor listening right now who is on the fence very concerned about opting out of insurance or hopping into their direct care practice? What would you say to them about direct care?

Dr. George 26:29
I would say I think hard work and dedication. And I take it it will happen. And not to give up easily. Like I gave myself a two year timeframe, not a two month timeframe, right. I think sometimes people go in and within three months are just like, oh my god, this is not working. I don't have any patients coming in. No business looks like that. Right? You have to give yourself a good timeframe, before you can actually assess whether it's been successful, or whether it will be successful or not. So give yourself time. It's not an easy path by any means. And I never thought any of the endocrinologists that reached out to me that because and not because I'm trying to scare them at all. It's just so you know what's coming. But once you're in it, you won't want to practice medicine any other way. So it has its pros. And and you know, like any business, it has its cons, but it gives me autonomy. Like, that's something I'll never get in any other practice. Like, I don't start my clinic till 9am. Why? Because I have two kids drop offs today. So I dropped off my kids, my last patient is a tip because I get to pick up my kids and bring them up, and then I'll see telemedicine after that is one of the kids sick, let's switch it all to tell him that today. Do I need to go to a doctor's appointment? All right, let's block that schedule. Like nothing can put a price on that autonomy. And it doesn't matter how much you get paid, you're not gonna get that level of autonomy in a big system. They're gonna expect you to work the hours that they've told you to work. And so really, you have to figure out what your why is, why do you want to do it? Is it for the money that may be hit or miss? But is it for you do just learn to love how to practice medicine again, and have that autonomy in your life and maintain your quality of life than this is for you

Dr. Tea 28:28
Do you have any last minute words that you want to share with the listeners,

Dr. George 28:32
You know, if you're on the fence, go for it. You won't know until you try and talk to other direct care specialist primary care physicians. Everyone's willing to talk. So if you're not doing well right now, and you have already started, reach out to people and just get tips because there's always something else that can be done. So yeah, that's it.

Dr. Tea 28:56
Congratulations on your two year anniversary. Thank you so much for sharing your story. Dr. George, if people want to connect with you, how can they do so

Dr. George 29:05
My email address and then I'm very active on my Facebook groups. And if you're an endocrinologist do join our specialty endocrinology group. There's a whole bunch of us doing that right now. And yeah, and Instagram, I'm on Instagram too. So any of those methods, please do reach out. I'd love to talk to you guys.