Episode 121: Unified Endocrine & Diabetes Care with Dr. Chhaya Makhija

Direct Specialty Care in Diabetes, Endocrine and Metabolism, and Lifestyle Medicine with Dr. Chhaya Makhija


What you'll learn in this episode

  • How Dr. Makhija started and grows her direct care practice
  • Challenges in transitioning from traditional private practice to direct primary care, focusing on patient outcomes and education
  • How to balance academia and private practice as a physician
  • And so much more!


Here's how to connect with Dr. Makhija



Dr. Tea 0:52
Today I have Dr. Chhaya Makhija who is a board certified physician in diabetes, endocrine and metabolism and lifestyle medicine. She is the founder of the first direct specialty care in endocrine and lifestyle medicine and state of California, Unified Endocrine and Diabetes Care. Her main office is in Fresno in central California. And she also provides her expertise to patients throughout California via telemedicine and in person consultations in the East Bay. Welcome to the podcast.

Dr. Makhija 1:25
Thank you, Dr. Tea. Thanks for having me. It's a pleasure.

Dr. Tea 1:29
Yeah, you're you're I think you're four hours from me, Santa Cruz, two or four hours, I forget

Dr. Makhija 1:36
Two and a half hours. Yeah, not too far off.

Dr. Tea 1:43
So we're not far. And we do things that are similar, we take care of people who are pretty sick, diabetic, pre diabetic, hardcore, diabetic. And stage, you know, this is, this is a topic I truly care most about. Because it pertains to the lower extremity. By the time they get to me, the damage has been irreversible, in a sense. We're talking about nerve damage, like amputation, stuff like that. But I think as we start to get into direct specialty care, we can do a lot more prevention, because we're allowed to have more time with patients compared to sick based care or what we know it as insurance based care. So why don't you tell us the listeners, what your background is, and how you decided to pivot into a direct care model?

Dr. Makhija 2:33
Sure, thank you. So definitely, like 100% agree with what you just mentioned, prevention and direct care just go hand in hand. But I was practicing traditional, you know, private practice for almost eight to nine years in Central California. And as many of the direct care specialists have experienced, you know, it was something similar to me that there was a big void, a big void where you are managing patients, trying to treat them, but forgetting about prevention. And the second one was, you know, the systems based care where you were forced to see more volume. And man, you know, the delayed forgotten care compromising time for direct patient care, and focusing more on how do we, you know, how do we charge? And how do we make it possible so that the company or the business or the private practice gets more reimbursement for the insurances. So eight years was enough of an experience that I had to shift, I had to focus on what I really went to medical school for. And my research for private practice, like setting up my own started, I think it was around 2018 2019. But I realized that I wouldn't be able to, you know, by myself find a similar insurance base model and still make it holistic or focus on prevention. And that's when I learned about direct care. The first time I learned about it was from Dr. Granita, she was doing a random zoom session and 2021 about EHRs under our care, and I just stumbled upon it. It was just three of us in a zoom session and it just you know, that was the lightbulb moment.

Dr. Tea 4:26
Are you currently fully in direct care? Do you build any insurance? How do you handle a super bill?

Dr. Makhija 4:33
So you know, 2021 the beginning of the year I gave my resignation. I knew I would start something myself but I wasn't sure how and where and you know the tools or I didn't even know how to make create an incorporation. So the next part of the year went into designing it, and it was after the research learning from the DPC doc's, I decided that I will not sign up for any insurances completely direct, no hybrid model. So I opted out of Medicare also, at the same time. And, you know, initially I had the plan or because I deal with a lot of chronic conditions, which is, you know, diabetes, even thyroid, autoimmune disorders, osteoporosis and a lot to do with, you know, high cholesterol, hypertension, that all falls into endocrine umbrella. So initially, when I started, that was October of 2021, when I had my lease, everything set up, I had this either membership or pay per visit model. My prices were very low, similar to DPC, our direct primary care physicians. And the first six months were a bummer. Because it was, it was hard to sell the concept of direct care, you know, mind you, I don't have any direct primary care in our 200 mile radius to the entire Central Valley, you know, direct primary care, we didn't have anyone. So the concept was brand new, and there was a lot of opposition from other physicians also. But eventually, six months, I realized that, you know, you have to focus on what your core specialty is, and also speak about, you know, your patient healthcare outcomes, and speak about, you know, what, what, actually, what are the healthcare benefits, in terms of reducing their healthcare costs by focusing on prevention, and that's where I started honing on, you know, actually, you could call it as marketing, but it was sharing the real patient stories, their outcomes, as well as just redesigning my model into into a higher priced membership model for anyone who's looking for a reversal of disease remain remission for diseases, chronic diseases, per se, and, and also creating it into a more holistic approach where I had my lifestyle medicine. I have a dietitian, a diabetes educator. So all that was, was included in that membership program, with unlimited visits, unlimited care, and, and, of course, time and access. Were the two main keys for this membership model. Yeah, so from the start, I was completely direct. If that answers the question.

Dr. Tea 7:27
I have so many more questions, hang on. So you just breeze through it, like, Oh, this is just how it is. But you know, there are doctors listening, and they're like, What have you first of all, when in your first month, it sounds like you went through some serious challenges, because you're having to learn how to speak to people in a way that they find your stuff irresistible, that they actually want to pay for it. Because we're dealing with people who are used to just relying on their insurance to pay for stuff. And you mentioned that you had a lot of physicians who opposed what you were trying to do. Why did you speak to those doctors? Or did you know they were going to oppose? Or what were you doing to even engage in that kind of conversation? Were you going to them to validate what you wanted to do? Were you trying to market to them? How did that look?

Dr. Makhija 8:18
So if I didn't break it down, you know, I went into the assumption that all I have was, you know, wholesale 4000 patients from the previous traditional private practice. And they will just follow me. So the first thing I did was just assumed, which was completely wrong notion for you know, for especially for direct care, and the space and this publish an Ad and here, you know, I'm going to be here the local newspaper ads, and that was a complete disaster, I got more calls, but Oh, you don't take insurance? You know, most of them have hung up, or they were, you know, just trying to ask questions as to why what's the reasoning behind it? And within like I said, few months, I realized that the education part of it or just the awareness or someone showing the pros and cons of two systems, right, we are humans, if we get into a habit, it's just a notion that okay, this is what it is, this is how things are done the way so I had to, you know, start my own Instagram account, which I did not have until 2021. And I teach at a medical school, which is a deal School, which is a brand new one in central California. That's the first one in central California. And, and you know, they just got a credit so it was founded with them. And what I learned was by speaking to this big crowd of medical students or faculty of professors, people want people wanting to learn, I was doing these community events with them. And that's where I was meeting physicians. shins are a healthcare providers community. And that's all I used to do is talk about what is prevention? You know, what is lifestyle medicine? And what is the data showing evidence based trials? That is if you focus with, with a medical expert, right, who knows what they're doing. And truly, if you're motivated, you know, things are accomplishable, something is possible. So I had to focus on that aspect rather than just telling them or selling them what is direct care if that makes sense. So it was their pain point, it was what they were suffering from. Physicians hated to take care of patients with diabetes, physicians hated prior authorizations, physicians hated teaching diabetes technology. So that's what I started offering, I said, you know, you take care of your patients, it doesn't matter, I'm not going to steal your patients by any means. But what you're lacking, I can fill that void.

Dr. Tea 10:57
So you took it as you are solving a problem that's missing in your community. And instead of telling people what direct care is, you said, you told them the end result that they can achieve through you, they didn't care about the process. And so this is a concept that I like to talk about, where we're not selling them the dumbbells to get stronger, we're just selling them the membership as to all the tools are there for them to use. But the end result is to be fit and to be healthy. And we do this in the vehicle as a medical care lifestyle function. So you demonstrated that so well. And you're totally right, because I was in the same boat where I felt I was selling direct care. But that's not what people wanted to buy. People just wanted to offload their patients as in the doctors who worked with them, they didn't want to consume 30-60 minutes of their time taking care of the patient, they'd rather send that off to somebody and that's what we can do for them. And from the patient's perspective, the patient's wanted the end result of a healthy lifestyle, too, but they didn't necessarily want a bunch of pills either. So from the patient's perspective, I imagine that their buy-in was because you were able to hone down key things that were bothering them that couldn't be solved in traditional medicine. So how did you sell your, what it sounds like a high ticket offer now, to your patient

Dr. Makhija 12:19
I actually started increasing my prices to what I felt it was, it was a you know, it would justify the hard work and the service and, you know, giving you're more than 100% best as a physician. So you know, just to give you a layout, because this is more for even physicians who are planning to, you know, think about their care is, you know, I had a membership of $99 per month, and rarely anyone bought it. Except for people who really knew me well, like the, you know, physicians around the community, or our friends in California who really were seeking this kind of care. But as I realized, like, within three months, I realized that I was just unfair to myself and to my education and, and, and to the business itself, right to what, what you're trying to provide. So then I just started, I made two tiers, which was $199 per month, paid annually versus $299 per month with a three month commitment. The reason being that, you know, we I had to be very clear and very specific, that you know, we do harm to our bodies unintentionally, or sometimes intentionally with anything that we are getting exposed to be it food, be it lack of physical activity mindset, you know, it just doesn't change or reverse in few weeks or a month. If you're stuck with a chronic disease, you have to give it time you have to know, you have to mention about ability and that it takes time. So that helped me to sell the three month commitment with the higher ticket price for a membership and the annual commitment, which is actually a high salary. People love the annual commitment and knowing that they will have access to me anytime and take the privilege of reaching out because they themselves are motivated. And of course, same thing with the consultations. I was at $250 for a 60 minutes consultation, but I was spending two hours with them. So that jumped up to $450 and I ended up signing more patients than I ever imagined. Yeah, so it was just valuing yourself and your service because you ended up you know, having complete faith and confidence. And that translated into people believing you.

Dr. Tea 14:38
So I bet you people are thinking oh, you probably just serve rich people. Is that a true statement? (No) we're not like this. So Fresno was not like the Beverly Hills that people are thinking right. Like Santa Cruz hills.

Dr. Makhija 14:52
Yeah. It's the people who need you. You know people who are who are really suffering Are they seeking out second opinion, or they're actually seeking out just the right physician, you know, how many times have you or many of us experience that you're referring your patient to a specialty center, and they're being seen by a mid level like it and and you know, the PA expecting that I will get superior high quality care, because my primary care physician is not able to resolve it or is does not have enough expertise for that particular field. But I am seeing a mid level provider who has less expertise in my primary care physician. So that was, you know, one of the key ones that physicians I mean, the patient's like they reach out is self referral with patients that don't need a referral to see me. And that was, that was one of the main, you know, I would say, an inviting feature, that you will be seeing a physician, you will be spending hour and a half or two hours with the physician, you will only be exchanging conversations or dialogues with the physician, there's no person in the in like the middleman, whether we talk about, but there is nothing in between us. So I felt like I was back into that sacred relationship, what we learned in med school, or, you know, the oath that we had taken. So that was one major aspect. And even for physicians, like I don't get too many referrals from physicians, but there is just a group of physicians that will really believe in you and your care. And that's enough, you know, five physicians, they're seeing, you know, 2000-3000 patients each. And even if you're getting three or five referrals from each one of them, you're good. And that's what they trusted on that, you know, when I refer this patient to this particular physician, endocrinologist, they will not just get endocrinology care, it will be completely holistic. And I could sit back and not worry about that problem anymore. Patients who have medical insurance, we don't have we don't have health insurance? I have, I would say the, you know, whatever, though, how are America United States, Has the income criteria based on that? Its middle income, most of them are annual members. And then upper? I would say most of them are, yeah, most of them are employed nurses. I have few doctors, but few doctors, meaning I would say 10% 15% of my patient population are physicians. But they Yeah, they're all professionals, or there'll be ones who are, you know, Fresno Central Valley, it's AG, but they appreciate that one on one care. And of course, I have a staff member who also helps me with Spanish translation. So that invites more of these individuals on so and they just pay per visit, they don't necessarily have to be a part of the membership.

Dr. Tea 17:55
Do you feel like your practice at this time is self sustaining? Or do you continue to market to get more people? There's the idea of you cap off the number of patients when you once you hit that number? Have you reached that? Is that a moving target? What does that look like for you?

Dr. Makhija 18:11
Sure, it is a moving target. Because, you know, I end up seeing consultations that they will just come in for a second opinion, even though they're seeing another endocrinologist. And that usually suffices for a lot of patients with osteoporosis or you know, other pick up adrenal disorders. And that would be just one time, so I don't need to have a cap on those numbers. There's always room for them. My practice started meeting, we started meeting our overhead expenses, I would say after seven or eight months, but you know, indirect care, you keep your overhead quite low. So I have a 1400 square feet space office. And I did not hire anyone in person until it was a year and a half into the practice. So I had a virtual assistant. And that's about it. So that helped me to keep my overhead quite low. Second year, or Yeah, 2023. That was last year, which was a good year where I was able to, you know, even pay my part time diabetes educator who's a nurse practitioner, but purely diabetes education, a dietician and a staff in the office. In terms of paying me, that's where I am not there yet. So I have a lot of room in terms of expanding, and that's where the marketing comes. But it's all become educational marketing, rather than like I said, selling that this is a direct care or this is a specific type of practice, but just the patient outcomes have helped me to add on to the marketing piece of it. The expansion in East Bay or that's where I have another sublease space and that has been one of the major keys in expanding through California where I have patients from the Bay Area, which are around 25% of them in my patient population, and that's mostly telemedicine, or seeing them in person, you know, once a month or once every two months.

Dr. Tea 20:19
So are these people who you pay, like their wages or salary? Or are they independent contractors?

Dr. Makhija 20:25
Wages, they're all on salary. They're all employees of the practice. Yes. So you know, that's where, you know, you learn medicine, you don't learn to become an entrepreneur. And I put in, you know, they were, there's no doubt you're not talking about challenges here. But it was, you know, it was hitting the wall several times with lots of closed doors. But, you know, I would just focus on that faith and confidence what I had on my expertise, and what I could give to the people and learning a lot about business, learning a lot about leadership about entrepreneurial skills. And rather than having independent contractors, you know, having part time employees made sense to me, because I, you know, I wouldn't be able to afford a full time, because technically, you know, as you're starting your direct care, I wasn't even paying myself for the first year. And these individuals came to me, and that's where the networking and marketing piece comes along. The community wins, you know, seeing more patients, the Google reviews, so my diabetes educator is, you know, as a school nurse in one of the school districts, and she had this diabetes education certification, and she wanted to use those skills. So she came to me that, hey, I've seen your events, and I would love to be a part of it. And I would want part time, I can't be full time because I already have a full time job. So bingo, so I knew her community because we exchanged, you know, a few different volunteer activities together. The diabetes educator and the dietician is the spouse of one of my patients. And, you know, she was from Loma Linda, and she already has a full time job. And she was trying to cut back but she says My husband was so impressed that he says, You got to work here. So she sent me a beautiful handwritten letter saying that I can just work, I can't afford working so many days, you know, a week or a month, but I can do this. I was like, fine. You're more than. So I feel like engaging in community, right? Because people see you. People hear you. It's easy to, you know, write about yourself. It's easy to, you know, have someone else mark it for you. But if you're out there, I think that connection is a big piece of the trust.

Dr. Tea 22:52
So you've gone a long way since where you were when you first thought about direct care to where you're at today.

Dr. Makhija 22:59
Absolutely. Yeah, yeah, I envision something like this, but I never imagined that it would, you know, it would be even more beautiful than what I had envisioned. Yeah. In terms of the collaboration.

Dr. Tea 23:12
Oh my gosh, so what was your life? Like, before direct care? And what is your life like now?

Dr. Makhija 23:19
Completely opposite, I wouldn't be doing direct care.

Dr. Tea 23:24
Oh my gosh, I'm so happy that you're here to share with us what you've gone through because I know, it's not easy. But when I say it's worth it, hey, you're, you know, another person who puts the stick in the ground and says, yeah, it's worth it.

Dr. Makhija 23:37
Yeah, I know, you know, you had started your own direct care to and trust me, you were one of those that I had stumbled upon and you know, you used to post in, in the DSC, the group had just started in on Facebook in 2021. And you were adding on Tuesday, I feel like I literally learn from every single person with you know, I won't be able to count them on my fingers or in my head but I literally learn from everyone. So you know, I would include you in it too. You know, I was talking about medical school. So that's my big piece. Now, I was never foolish, I can tell you that in terms of you know, my husband is like the financial support. We had made sure that I don't have any loans from my end. I did not have any personal investment in the practice. Everything was just, you know, it was just recycled from the practice itself. And while I was working, I'm still working as like an professional assistant professor at the Medical School. And that's become a networking event. It's nothing, everything or events. It's nothing to do with that. Okay, I'm getting a salary from there. But it is a great platform. Because as you know, the new physicians are learning from you, the to be physicians and at the same time, you'll be surprised that how much of the spread of word happens when you are engaged with them. And when they see what you're doing, and that I feel that inspiration circulates around, the only reason to hold on to education was because I loved it. And I didn't want to leave it and patient education has become a part. You will be surprised, like I just held an event, my first event for like endocrine health and wellness event, where again, this was also a marketing aspect. But I used all our patient healthcare outcomes, we published a few case reports on the patient, hell out healthcare outcomes with the medical students, and I presented that in my office. So I didn't have to, you know, I didn't have to create a CME or a conference or request someone to, you know, to justify that these are the cases and these are good cases, it was just by yourself. And that brought in a lot of patient referrals to

Dr. Tea 26:00
Being an educator being so you're a professor, you're an educator, it seems like a really natural progression to just have a direct care practice, because you already spend so much time educating your patients like it's an actual skill you've developed professionally. So it seems almost like it couldn't happen, because I come from an academic background too. And it's almost like, I don't know if it was like this for you. But back in the day, when in academia, people saw private practice as like greedy, money hungry doctors, who, you know, they're only in it for the money. But now I'm seeing this is a natural progression, because we want to educate, we want to help people, we truly want to see outcomes, we're not just digging into their pockets, we are making transformations. And that is worth $1 value. So you're showing us that you can have both academics, and a private practice that works harmoniously with each other. And I think that's just so beautiful.

Dr. Makhija 26:55
Yeah, absolutely. Yes. I always this is what I envisioned. You know, because when I graduated from University of Nebraska, in Omaha, this was 2012 to 2014, when I was asked that, what do you want to do? Should you stay in academics? I was like, I can't do that. I need both. I need both. They said that does not exist. (Yeah) So I had made a pact that I will figure out how to make it exist, you know, and be very much true to my patient care. Right? We're taking the greed out. Because that's, like you're saying with private practice that's always attached. And at the same time being involved in academia, without peer pressure. So it took a while though, it's, you know, I graduated. Yeah, it's 10 years from my endocrine boards. So it's been 10 years. It took a while, because you know, you have to learn from your experiences, you want to you need to know what you don't want. And I was very clear about that.

Dr. Tea 28:01
That's incredible. Oh, my gosh, I can't wait to re-listen to this episode. Not gonna lie. Okay, so there's a doctor listening. And they're like, I hate insurance. But what do I do? It feels totally unsafe. Maybe they're in academia, but they're like, is private practice real for them? What would you say to that doctor?

Dr. Makhija 28:22
Do you have to believe in it. You know, that's the first thing you know, when we private practice, or traditional practice or you're employed, you have to believe in what service you're providing to the patient, because that is what's going to sell no matter where you go. Like, that's your attribute. And that's your, you know, that's why you're a physician. That's what you're a doctor. So that faith, the belief comes first. And the second thing is, you know, you have to give yourself time. Like, you have to be wise enough. And I think many of us will realize that there has to be some safety net, which I had. And it was more of a planned approach. So that I don't have stressors, financial stress, and specifically where I'm trying to juggle and not plan or not envision or forget about my vision. So that's very much needed for direct care, because it will take time to grow. You know, you're putting in the seed, it's not going to happen instantly. It's not going to happen within a year either. I'm in my, you know, two and a half years close to 30 in October. I still have long ways to go. I cannot say that I'm completely financially independent, to pay myself. Right. But it is growing. I see the growth, I see the expansion, I see the potential. And if you look down I would say give it four to five years. You know, people who are more experienced than me probably don't have something similar. But then there is no no limit, no limit to you. or quality of service, no limit to I think there'll be more improved patient outcomes. absolutely believe in that reduced healthcare costs, you know, diabetes complications that you're witnessing, we will just be doing preventive care. And that would be so amazing, which, you know, which as the United States of America, as the American healthcare system, we forget about it. You know, that's what we are trained for, as physicians that you treat, you manage, you resolve complications, you, you add medications, and, and then deal with, what's the word I'm missing out on Polly pharmacy, and that's about it and finish your protocols, the meaningful use. So that all will eventually eventually not be as important as your patient care. So time is going to be the key and you have to have this you know, I don't have any boundaries, no inhibitions anymore. Like before, direct care, shy person, Intro word, no networking, no social connections, except for you know, friends and family. And I did not know anything about business. Nothing whatsoever. Like my husband is in finance, I thought he would take care of the business. But surprisingly, it's only me. So you have to, you know, the growth is immense. But you have to be open to growth, you have to be open to speaking, you have to learn new, new ways of transforming yourself. That's direct care. You know, private practice, traditional private practice, you may not see the transformation in yourself, but you will see that in yourself in direct care,

Dr. Tea 31:49
What would you say to the younger version of yourself about what life looks like in medicine?

Dr. Makhija 31:53
It's complex. It's not complicated. It's so complex. That, you know, yeah, it's very complex. It's, you know, you don't realize that it's so much gender bias, I faced a lot while working with, you know, white men in the field. I'm five three petite Brown, very much existing the, you know, the, the racial biases. Your experience if you're a new graduate versus a five year experienced endocrinologist versus a tenure experience, endocrinologist a lot of biases, especially in private practice. And, you know, it is complex. So other thinking that, okay, I've honed my skills, and I could practice it's not it's not that medicine is not that. And of course, with the systems and how the design and the layout of medicine is, it's not serving the physicians or the patients. So that complex situation was never told in med school or residency or fellowship. So I would just say it's complex. But you know, in the end, you know, you need to know what you want to do. You'll find your way.

Dr. Tea 33:11
I have a five year old, so I'm always thinking about like, I can prepare her for a future, but I don't think I think you have to go through the lessons to really learn them.

Dr. Makhija 33:21
Absolutely. Yeah, absolutely. You know, we have to make our own convictions. Yeah. Yeah. When it comes with our experiences, and yeah, what we have, what we are, what environment we are in, and how we process things. So just adding on to the goodness of life. I think that helps us to make the right decisions.

Dr. Tea 33:41
Well, thank you so much for your wisdom, your time for sharing your personal story with us. Do you want to leave the listeners with any last words?

Dr. Makhija 33:50
Go direct care, it is one of the most revolutionizing ways to treat your patients. And if you're a physician, you know, is the greatest support you can have is from all of us reach out. But it's very much possible and there is no other way that you could be getting that professional fulfillment as much as in direct care.

Dr. Tea 34:13
Oh, I agree. Awesome. That's two for direct care today.

Dr. Makhija 34:18

Dr. Tea 34:20
Well, thanks again for your time. I'll put your information down in the show notes in case doctors want to reach out to you to learn more about you and your practice. And I want to thank everybody for listening into this awesome interview. I look forward to catching you all next week. Take care everybody.