Episode 54: Direct Care with Dr. Daniel Paull of Easy Orthopedics

Direct Care Orthopedics with Dr. Daniel Paull 


What you'll learn in this episode

  • How Dr. Paull started his direct care practice
  • The practice model Dr. Paull uses, which includes having office space and also offering mobile services by traveling to people's homes
  • How he builds strong relationships with his patients
  • And much more!

Here's how to connect with Dr. Paull



Dr. T 0:52
Hey there, welcome to another episode. This one is really exciting for me to share with you. I interviewed an orthopedic surgeon who is doing direct care, and he's mobile. And I got to ask him all the questions about how to start up your direct care practice, some of the fears, some of the issues with the insurance based practices, some of the tips and pearls, all of the things, and I crammed it all in this one episode in 30 minutes, it really has invigorated my perception about where the direction of medicine is going. And it motivates me to keep talking about it and sharing that information with you. Because Him and I are here to rescue our friends or physician colleagues from the toxicity of the insurance based practices. And you may not see that now. But as he said, in his own words, there are two guarantees in medicine right now, Number One Insurance based reimbursements are going to decline. And number two, you're going to stay miserable if you stay in the insurance based practice. So I'm really looking forward to hearing your feedback on this conversation I have with Dr. Daniel Paul, please leave me a message of this. If you enjoyed this talk. I can't wait for you to hear what else he has to say. So here it is.


Dr. T 2:10
Well, welcome to another episode. I am so excited to share my space with you. I have Dr. Daniel Paull. Dr. Dan. He's an orthopedic surgeon, a disrupter. A family man, CEO of EZ orthopedics. What did I miss? What else is going on with you?


Dr. Daniel Paull 2:28
Dr. T, thanks for having me on your podcast. I don't know. You know, you have some people you introduced. It's like the resume is like a firewall. I think what you said is fine.


Dr. T 2:38
Yeah, if you don't me, I'm pretty concise. I like to get straight to the point. And what I really love about you, you know, this is not my first podcast. When I first started the podcast, I was going for a monologue, I wanted people to tell their story and you volunteered for that monologue. And you told me exactly everything I wanted to know about direct care for orthopedics. But I'm going to have you share that experience again. But this time around, I wanted to make it more conversational, because I think a lot of people, even myself are really curious as to how an orthopedic surgeon is creating a cash practice that works for you and works for your patient. So let's start with why did you opt out of insurance?


Dr. Daniel Paull 3:23
Oh, man, so it was kind of like an existential sort of problem at the time. And it's not like one of those sort of things. That's super like when I thought I thought everything through and made a list of pros and cons. And like just went with it. It was more just kind of gut existential dread, you know, creating a big negative ball of energy and just cause it to happen. But the short story is this. A five year orthopedic surgery residency, I started to fellowship and hand surgery, it wasn't a positive educational experience. I was also looking for a job at the time out in Colorado, where my wife is from, and I couldn't really find one. And so it was kind of like, well, what am I doing? You know, I interviewed for a job out near where I live. I grew up in Connecticut. And it's, I mean, I've said it's just as old, bitter senior partner, just tell me how much money you made the 90s. And she's just so bitter. And it was this kind of moment where I'm like, what, like, what am I doing? And no, it was kind of like, well, you know, you grind away for so long and med school and residency and then it's like, Am I just gonna keep grinding like this for forever, you know, because these people don't seem happy. And I had a friend who started a house called business down in South Florida University, went to University of Miami with me, and like, Man, this guy's happy, you know? And like he's doing better financially than anybody I know. So I thought, You know what, I think there's something here so that was kind of like the impetus to start, quit my fellowship moved out to Colorado. And I just kind of started it in and it's been about four years now. And it's grown slowly and organically, which is nice. But I've had to kind of figure out, I knew that I couldn't take insurance because if I did, I would fail. You know, I can't afford all those coders and billers nor do I want to. And like it, just the more I kind of got a bird's eye view of it, it just seemed like, yeah, why was I ever doing this in the first place? I mean, yes, during training, but it just seems like the really the wrong way to go about things. So, you know, I think we need a change in our healthcare system. And I've also needed to, I've also been pioneering what direct orthopedic care looks like, and just been kind of figuring that out as I go.


Dr. T 5:36
I am so inspired by you, just knowing in the middle of fellowship that this wasn't going to be the end of it for you. And you know, I did my fellowship in 2015, as well. And that was really intense. Those are some intense time all crammed into a year. And it was never really even entered my mind not picking insurance. So do you think seeing somebody else haven't you send your friend in Florida had a non insurance practice? Is that what kind of put you over? Or was it just an accumulation of everybody's misery? It sounds like,


Dr. Daniel Paull 6:10
yeah, it was the combination of me not being able to really live where I want to live and find a job that was suitable or not, you know, let's face it, not abusive. And just this kind of, like existential moment of like, realization of like, Oh, my God, it's just like the future. This is like, I got a view of the future, like, get a glimpse, and I was like, This is really bad. And it was just mostly, you know, it was mostly pure desperation. I'll be honest with you. I mean, Desperation can be a really powerful motivator if you can harness it. Because it's like, I've got to figure something out like something. I never thought that during residency, I wouldn't be ever run into practice like this. But here I am. And like, you know, thank God I am. I mean, it's been really good. But yeah, certainly a lot to figure out, you know, learn.


Dr. T 6:59
How did you figure it out? Did you have like a coach or a mentor or a Google? Like, what was your process?


Dr. Daniel Paull 7:06
So I add, I talked to my friend down in South Florida, his practice is totally different than mine isn't like internal medicine. He does some holistic medicine as well. And like, he kind of gave me like a generalized outline. But really, I had to sort of build it up myself. I mean, you start with the very basics, right? Like, okay, I need a business, I needed to make a company. So you make an LLC, and pick your business name, and alright, and you get a business bank account for that. And then like, I need to get a tax number. And then like, okay, now I need to get malpractice. Now I need to get supplies, and then you set up a website, and I create a business card. And that all sounds daunting. But honestly, if once you started, it's really not so bad. And you figure all that out. And that allows you to kind of get started. I mean, the hard part is actually getting business and like getting going, especially with a new concept like mine. But those are the starting points, and then it is just trial and error, find out what works, what doesn't work, we still change our system practices as we go. When we feel that something doesn't make sense anymore.


Dr. T 8:06
So your current model, you have an office space, but you also do mobile, like you traveled to people's homes.


Dr. Daniel Paull 8:13
So um, well, I actually. So I have various offices I use, but none of them are mine. I don't pay for any of them. So basically, it's other physicians, or as our chiropractors or people, providers of health care in the community, who say, Hey, can you see this patient who's got shoulder pain at my office? And I'm mobile? So sure. So whether I go to an office, or I go to someone's house, it's like, I'm still mobile. Even though maybe in an office, they're like, I always carry a bag with me have all my stuff in it. So it's not like I'm ever set up anywhere. But yeah, so it's still fully mobile. And what that does is it keeps my overhead down and allows me to see many less patients and still do well,


Dr. T 8:51
that looks like you created a really great relationship to for a doctor to just say, Hey, can you come over and check this out?


Dr. Daniel Paull 8:59
Yeah, I mean, you know, you got to kind of find those people in your community, that share similar value systems to you, right? So my goals are, I want to see somebody I want to get them better, as efficiently and humanely as possible. And the people I work with tend to also want to do the same thing. Whether that be drug primary care doctors or chiropractors or physical therapists. And people I don't tend to work well with are those that say, Hey, how can I maximize my profit? And patient care is not like a number one priority for them? With those sorts of people, you know, you share different value systems and over time, they tend to wear down and you end up not working with them. I mean, so it kind of like weeds itself out.


Dr. T 9:42
We were just talking about how there are some people we need to like block out of our mental space energy, like how long did it take you to realize you had the power to just shut it out because there's going to be a lot of people attacking the direct care model because they don't get it. They're drinking the juice. They think you know what we're doing During a selfish, it's greedy, taking money from patients like how did you process basically weeding people out or just blocking them out?


Dr. Daniel Paull 10:08
Well, I mean, the first thing is like, there's a lot of misconceptions that need to be dispelled. So, I mean, there's a whole host of people, as you know, that don't have insurance or have a high deductible, and you are me, in a direct care world, we're actually the most economical option, these people are not served well by the system. And so like they don't the people who think that we're just greedy and taking money, they simply just like seek rich people all day and charging an arm and a leg. And that's really not what we're doing. So I mean, the first thing to do is understand that you're really doing the right thing. We're really putting the patients first, like, do we want to make a living? Yes, but I mean, we value our own autonomy and being able to deliver good care, you know, you know, above a lot of other things. So how do I block these people out? Well, you know, I like to one of my main platforms is on LinkedIn. And what I found is that it's a professional platform, I like it. So I'm trying to get this word out by kind of posting pretty regularly. And most of the time, the posts are very reasonable. And sometimes people disagree with me, and that's totally fine. You know, you can have a professional conversation, but when someone just kind of starts antagonizing you, if it's in social media, especially something like LinkedIn, it cannot possibly be easier. You just block them. And then they they cease they cease to be right. In your in your world, like they they disappear from existence. So that's easy. And then in an actual life. I mean, it has to go with your gut. I mean, I can tell pretty quickly when I meet someone, whether they value what I do, or they don't. And if they do, we continue conversations. And if they don't, I try to just I just don't, I don't work with them, really. I mean, it's not usually an active thing, although sometimes it is i There are certain individuals who if I really don't like them, I just won't work with them. And I'll tell them that, you know, we're not talking patients, we're talking other you know, purveyors of medicines. Yeah, they're professionals of sorts. So, I mean, you have to do that. If you really don't want to surround yourself with all this negativity, you want to surround yourself with positivity. And if somebody has criticism, you got to make sure that it's at least constructive. But there's a whole host of people and want to give you deconstructive criticism, it doesn't help you. They're not, they're not looking to help you, they don't have your best interests in mind. They want to cause damage, and those people you really have to remove.


Dr. T 12:27
You know, this took me a long time to figure out that there are people who are just not supportive of doctors who put patients first like they think that there's an ulterior motive. And it becomes the more we have these conversations, the clearer it is, you know, who gets it and who, who doesn't. So I think you're totally right, early on, just create the environment that supports you, first of all, and then you can create those ripple effects. So now that you've had your direct care practice, what surprised you the most would you say about your business?


Dr. Daniel Paull 12:58
Um, you know, I don't really know. I mean, I have a lot of free time, I guess that's sort of surprising, right? Because we're so used to the insurance system grind. And that's so ingrained in us that when you get out of that you realize, like, what an abundance of free time you actually have. So that's kind of surprising. And it's a completely wonderful thing. But you know, I'm still getting used to it, where, if I have nothing going on, even though the business is doing well, and things are good, you know, sometimes I get a little antsy, because like, I was trained to just be busy all the time. But it's kind of surprising how you can have sort of a very normal existence that you never probably experienced, or you haven't experienced in a long time. So yeah, I guess kind of the buttons are free time. And somewhat surprising.


Dr. T 13:43
I have to agree tremendously with that. Because you're right, we're used to seeing a lot of volume for very little. And in that model, when I had the insurance based practice, I could not think I had no room for creative thinking, I had no room to think beyond the walls of my clinic. And then when I started to opt out, I was able to charge more, but see less. And I was like, Oh, I have time to like, work out. I have time to write a little article, I have time to meet people socially outside the clinic. And so I think that's something we need to emphasize. Like, if you want to live record, it's gonna give it to you. Right?


Dr. Daniel Paull 14:21
Yeah, it certainly will. And I mean, if you look back to way before Medicare times, a lot of doctors did house calls, you know, they'd see less people and I think, you know, you certainly can work a lot. But you're you're getting off the hamster wheel when you're going into direct care and the care I think we deliver is a lot better. In a certain sense not because we're better doctors or anything, but because the business model deliveries better when you book an hour with somebody. I mean, which is what I do or you book a long time, and you know, as compared to seven minute visits, 15 minute visits, you're just gonna do a better job. I mean, you have more time to take care of more problems and actually develop a relationship with the patient is relationship based, which I think is much more powerful than this kind of transactional model that we have. So, I mean, yeah, I think that the patient's really noticed the difference, as well.


Dr. T 15:15
Yeah. Did. Did you have a like, what was your biggest fear? Starting your practice? Because you didn't go into insurance and opt out, right? You just opened your business decided to be cash. And that was it? What was your biggest fear in starting your business?


Dr. Daniel Paull 15:31
Oh, man. I mean, I guess at that time, when I started, I was living in my in laws basement, I have my own house now. So things have done well, but I'm actually in my own basement right now, which is a big step up. But I guess that it would fail. I mean, but I didn't know if it was gonna fail. I didn't think it was gonna fail. But I just didn't even really think about that. And like I said, when you're powered by pure desperation, you just kind of go, and then you get a little bit here, you get a little bit there. And then they start adding up, and then all of a sudden, like, it's good. But I couldn't, you know, under different circumstances, I don't know if I would have started this practice. But I'm really glad that I had those circumstances to start it. Because I mean, I think its activation energy is relatively high, at least at this point in time.


Dr. T 16:20
When did you open your practice?


Dr. Daniel Paull 16:22
I opened it almost four years ago. So April 2019.


Dr. T 16:27
What do you know, now that you wish you knew, then,


Dr. Daniel Paull 16:30
I mean, if I could go back in time, I think I would just be much more efficient. You can spend a lot of time trying to talk people in or talking with people to give you referrals. But ultimately, there's those that value, and there's those that maybe value, but don't have patience for you, and those that don't. So I mean, you need to really find the ones that have value and also have patience for you, and really focus your efforts on procuring those relationships. Because, yeah, I don't know about you, but like some, you know, like St. Let's take direct direct primary care, which in my opinion, is the best primary care, you can get, you know, some of those providers in my, where I live, will send me their orthopedic stuff, some won't send me anything, which makes me question what are you doing with it? Right, because I'm like, the only direct ortho guy around. So I mean, I learned to not focus on the one people who are just not going to, you know, see the value what I do, that's fine. I'm not going to spend time, you know, meeting with them. I mean, obviously, I'll talk to them Be friendly, but I'm going to spend more time and efforts focused on the people who are referring to me and then over time, you get sort of feel like, who will generally probably refer to you and who won't?


Dr. T 17:35
How do patients find you? How did you develop your marketing strategy? Was it just word of mouth? Or do you also do other things?


Dr. Daniel Paull 17:43
So I have pretty good search engine optimization. Despite all the salesy emails I get every day telling me my website's horrible, we'll really do find me on it. And then also, yeah, word of mouth, by knowing people in the community that refer to me, I really don't spend any money on marketing. So word of mouth marketing is like, it's free. And it's the most powerful marketing you can get. But it also takes the longest so, you know, it just depends how you want to do it. But for me, that's what I've done.


Dr. T 18:11
So word of mouth, SEO, you do your own. You said, SEO? Yeah, I do. That's incredible, because I burned so much money on marketing, you know, throwing money away, thinking that they would just magically show up. And you're saying that doesn't work?


Dr. Daniel Paull 18:27
Well, I tried very, very, very small bounce of it, like $100 to $200. They're like Facebook ads, or whatever, Google ads and like, it never got anything. So I have made it pretty quickly. The SEO has gotten real results. It's not really, you know, I don't know. I'm sure SEO people will be screaming at me, but it's not super complicated to do. It's just very tedious and nuanced. So I paid someone initially to help me do it. Then after I kind of learned what they were doing, I just sort of copied it on my own. You know, you really don't need to pay someone $2,000 $3,000 a month to do all your SEO. Yeah.


Dr. T 18:59
What's what's motivating you to not just talk about it, but to continue your business in this way? Well,


Dr. Daniel Paull 19:06
I mean, first off, I can't go back. So like, I think once you've tasted direct care how good it is, and how much better you feel about taking care of patients and how much better your life is, and how much you were controlled by hospital systems and, you know, administrators and stuff in the past, like once you've tasted that, like you can't go back, like I can't go back into this system. I can't go get a normal orthopedic surgery job I'd be I'd be miserable. So that part of that as part of the motivation to keep going. The second is that I really want to disrupt, I really want to grow the value network of direct care and disrupt this old system. The only way to do that is by keeping working and growing and building my practice. So people eventually hopefully will realize and some already do that, hey, I don't need to use my insurance to do all this junk we were doing. I could just pay cash and get great care. 


Dr. T 19:53
 Do you think patients did they get it like when when they were looking for orthopedic surgeons in their area in your area? Are you? What made them choose to pay out of pocket versus their insurance?


Dr. Daniel Paull 20:04
Well, some are cash paid, they don't have insurance. So that's, you know, they're looking for someone who understands cache. And if you go to the other insurance space models, they ask them how much it's going to be, I gotta give you an example, I gave a lady a few steroid injections like a week ago. And she said at the hospital, they're going to charge her like $3,500. For one steroid injection. I'm a fraction of that. So there's this fear of, you know, cash paying patients, I'm going to use those systems, and also those with high deductibles as well. They say, I'm not going to be my deductible. I don't want to mess around with it. You know, those, those patients seem to kind of to get it, you know, because they're looking for that. Yeah, I mean, occasionally, we get someone who calls and say, Oh, this sounds great. But I want to use my insurance. The other thing is the speed at which I can see somebody, so I can get somebody the same day, next day, I do house calls. And you know, in the insurance based world, they may be backed up for three weeks or months. So sometimes people just don't want to wait. So that's another we'll I'll see people just because I can get to them quicker.


Dr. T 21:01
How do you work with patients who need surgery? What are you taking them to the surgery center? Are you doing it in house.


Dr. Daniel Paull 21:08
So I mean, I do surgery center, and then there's a procedure room, I'm trying lately to move more things to proceed to the procedure room, where you can do what's called an MPO, melt, which kind of an oral sedation, and then local anesthesia, and we can do a lot of things that way. So I'm trying to stick more towards things that can be done in a procedure room, because I think it's just technically much, much easier. But if it does need to get done, that's sort of the way I do it. Everything with a surgery centers, you know, it's I have to get a quote, each time I'm fighting with them the quotes variable, then you need the implants X ray get really expensive, real fast. And if somebody's cache kind of prices them all out. So it's kind of been redefining, like, Where does the market live for that? And like, what makes sense to do? You know, because I have to be able to pay off anesthesia and I have to be able to pay off the surgery center and the implants, and everybody has some somebody has to, you know, I tried to get the number as low as I can reasonably get it. But sometimes it's just the numbers still work?


Dr. T 22:07
Yeah. What do you think the future would be like in surgery, because I'm very interested to see surgery centers move towards a cash friendlier option. And I think we only have two in existence that are talking about cash pay surgeries, what are your thoughts about the future for that?


Dr. Daniel Paull 22:26
I think that they're largely going to ignore it. Because, you know, they're looking for like spine surgery or joints. And while there are cash pay for those, they're coming from businesses. And they're kind of few and far between. So they're so focused on the insurance world, they've so many resources built for the insurance world, that like I think for cash, they just tend to ignore it, they see it as more of self pay, where people who can't pay, the ones who are more forward thinking have actually developed cash pay rates of bundle prices, which are binding, and they'll attract some cash pay pay patients. But I think these ACs are basically still going to burden themselves with insurances for very long periods of time. I think as far as surgery and the direct care world, and maybe surgery, in general, you may see more of a push to do things like minimally invasive procedure room, like even somewhat less than an ASC. As long as it's safe to do so. And everything's still sterile in the procedure room, you know, everything's still safe. It's just a little bit like, it's like going from hospital to ASC and I'm like ASC to procedure. As reimbursements get cut, I wouldn't be surprised if we see more pushes to go towards that, you know, like no tourniquet surgery. Patients are wide awake, local anesthesia type stuff.


Dr. T 23:45
Yeah, in my office, I do minimally invasive surgery for like hammertoe bunion correction. We do it old school, all in our local I have floor on things like that. And when I was insurance based, the insurance the I think it was a private insurance actually paid a percentage more if you did procedures in the office, because you're saving them money. We're not utilizing a surgery center. So I would love to see more doctors look into direct care, especially specialist in proceduralist. In California, we don't have the option of like a mobile anesthesia service to come to the office. Is that the same for Colorado?


Dr. Daniel Paull 24:22
No, you the anesthesiologist travel around. So that's a luxury that we don't have. Is that because of is that because of legal legal issue?


Dr. T 24:29
Yeah, I think it's a legal restriction. And it was like really complicated for me to even look into like, I'm a very simple person, I want people just to get better. And if there's a convoluted way to get there, I'm not going to do it. And that's what traveling anesthesia is for us here. So I have access to a surgery center. And we also have CRNAs and stuff, but they have to be at a designated site for airway reasons, you know, and my office isn't set up for that.


Dr. Daniel Paull 24:55
Yeah, I mean, you so you're kind of learning like I am in a direct care A world like your surgical practice just looks a lot different.


Dr. T 25:02
Yeah. And it's fun. And I can understand why a lot more. Even direct care, doctors, DPC are leaning into the aesthetic world because that is a procedurally based thing that people pay cash for anyway, lucrative and it's easy access. So I don't see myself doing that. But I could understand why people are doing that.


Dr. Daniel Paull 25:23
Yeah, me neither. I mean, ultimately, it comes down to cash basis. So there's different ways to do it. You have direct care, cash paying patients, but then if you're doing a service that needs this necessarily covered by insurance, like aesthetics, then that's a cash based businesses. Well, I mean, there's medical legal work, there's personal injury work, you know, there's a lot of different ones, you just need to find the ones that sort of fit you that don't violate your moral compass, and that you feel like you're qualified to do like, I'm not going to do aesthetic. See, they're like, Could I legally like, yes, but like, I don't want it?


Dr. T 25:54
Yeah, well, I take that back. I do take foot filler, that weed they use in the face into the foot, because there's a functional purpose for that, but nobody really cares what the foot looks like, as far as most people are concerned in that type of aesthetic way. Yeah. The gray zone. Yeah, there's always a gray zone for for us to move about. So let's say you're, you know, people are listening. And they're on the fence. They're like, this sounds really gravy. But I'm not really sure. I want to start opting out, what would you say to that person?


Dr. Daniel Paull 26:25
I would say that if you continue doing what you're doing and staying in the insurance world, like, you know, for two things for perfect one is you'll be miserable. Because you probably are now so that that's a fact. And the fact is that you will likely see decreasing income as the years move on. As they decrease your position reimbursements. That's also essentially effect. So if you're okay with those two things, then you don't need to do anything. But if you're not, you might want to think about even if you don't start your own direct care practice, at least opting into the insurances that give you the hardest time that are there that are not worth your time, and starting to at least make an avenue for cash pay patients or some sort of cash pay revenue, to just augment your stability.


Dr. T 27:05
That's incredible. I'm so grateful that you're here. I look forward to future conversations with you in person. Hopefully, we get to meet at a conference or something. Yeah. Where can people find you if they want to connect?


Dr. Daniel Paull 27:17
I think I'm on LinkedIn, Daniel, Paul and D. We've website easy orthopaedics.com. And then actually, the YouTube channel is more informational. Like how do I know if I broke my finger? It's youtube.com/apt orthopedics. I was really early and I got that. I got it. I got just at orthopedics. That's incredible. jumped on that. So


Dr. T 27:39
Wow. So you get to monopolize that. I'm gonna look that up because I have all kinds of problems.


Dr. Daniel Paull 27:46
Hopefully nothing too bad.