Healthcare Rebel Alliance: Q&A with Dr. Maryal Concepcion, Big Trees MD

‍Nick Soman, Decent

You've been focused on rural medicine throughout your career, and now you're a tremendous advocate for DPC through your My DPC Story podcast. What first appealed to you about the DPC model, in general and for rural communities?

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Maryal Concepcion, Big Trees MD

First, the environment in which I grew up. I’m an only child in an extremely large and loud Filipino family. I have always been drawn to communities where people are encouraged to be themselves, but also loved for their individuality. My medical school, Creighton Medical School in Omaha, Nebraska was a perfect fit, because I experienced this homey environment there as well. I was able to train and be mentored by fellow Creighton alumni who were full scope family physicians, doing procedures from colonoscopies to deliveries of babies to everyday procedures in the clinic, and offering amazing personalized care in their communities.

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When I moved onto residency, I continued nourishing skills that would allow me to practice full scope family medicine in a rural environment. Initially, when I took my first job out of residency, I was able to do this because I was on salary, and I wasn’t paid by number of heads seen per day. This absolutely changed when the model was compensation by relative value units (RVUs) or number of heads seen per day. After this change , I was unable to focus on how to care best for my patients, and I was constantly thinking about how I would get more codes in a day to make the amount of money that I was earning in my salary. To any person, whether they are in medicine or not, this is completely bonkers, and completely incompatible with how to value a physician and value their training and value what they bring to the table to be able to provide full scope care.

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I truly feel that it is in rural America that you really get to be a full scope physician, which is what I value. I did not know about Direct Primary Care when choosing to move to rural America. I see now that even if a person wanted to stay in a less rural environment, they could potentially practice full scope family medicine as well. Our healthcare system is so broken, but with the autonomy that Direct Primary Care brings, people are truly able to craft the way that they want to practice with their patients every day because they’re not pressured by things like number of heads per day, and that gives a person the time to develop or learn new skills to be able to be more full scope in their practice if they wish to do so.

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A big challenge in rural America that remains, though, is lack of resources. My training in rural medicine hasreally helped, but also, making sure that I created a good network of attendings and resources while I was in residency has continued to help in my journey as a physician. And now, with the entire world of Direct Primary Care, those resources have Increased immensely so I don’t feel as resource deficient as I was prior to being a Direct Primary Care physician.

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‍Nick Soman, Decent

You've been lobbying recently for the Primary Care Enhancement Act (H.R.3029) and the Medicaid Primary Care Improvement Act (H.R.3836). What should people know about these bills?

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Maryal Concepcion, Big Trees MD

First of all, and most importantly, everybody needs to read these bills. The one that recently passed unanimously on the house floor, the Medicaid Primary Care Improvement Cct, is less than three pages long in really big font. The Primary Care Enhancement Act is speaking to the millions of people in this country, as well as their employers, who want to provide a high deductible health plan with an employer-funded HSA to be able to increase the value of their healthcare dollar spend, as well as create savings that could be reinvested in their companies, their employees, their employees' futures or all of the above. 

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I am interviewing people who were lobbying with me and trying to report fairly all of the quotes and experiences I am hearing, but in general, there is not a single independent Direct Primary Care physician who is wanting to enter into any fee service system like the one we have all left. And in order to protect our autonomy, and the way that we are doing medicine, we have to be present at the table, whether that be on the national scene or on the state level. It is very important for physicians to not lose their voice any longer, because that has contributed to the state we are in now.

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‍Nick Soman, Decent‍

What are the best and worst things about practicing DPC?

Maryal Concepcion, Big Trees MD

The best thing about DPC is that it’s yours. It is merely a model under which a person can  practice as a physician in the way they want to practice. When you have a system that encourages autonomy, that environment creates innovation and, with the direct contracting with patients, rather than a third-party payer, it truly realigns the direct connection between the doctor and their patient. This is the care that was so loved in this country at one point by Americans who could pick up the phone and call their family doctor. We now have people who are experiencing this and it’s wonderful.

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And I would say one of the most challenging things about Direct Primary Care is the business aspect of things. Clearly, people are successful all over this country, being a physician as well as a business owner, but it is because we have a community that is so supportive of this movement, so we see success. Having gone into business ownership without formal business training or an MBA can be challenging at times, but it’s not the worst thing about DPC, because it is through these challenges that we become better business owners and better DPC physicians. 

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‍Nick Soman, Decent

What misconceptions about DPC would you like to clear up?

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Maryal Concepcion, Big Trees MD

The biggest misconception about DPC that I always like clarifying with people is that Direct Primary Care is not for rich people and Direct Primary Care is not a model built to cherry pick patients and to not choose patients who are chronically ill. In many clinics the Direct Primary Care patient is driven to have a personal physician because they cannot get the time of day with the physician or physicians that they have in their network of covered physicians. As a family physician myself, I’m able to see the piecemeal workups by different specialists, and potentially find threads where there are places of overlap. And I am able to zoom out to take an overall look at what’s going on, to try to get to diagnoses or solutions faster than in piecemeal care that our system encourages with unnecessary referrals that are happening because physicians don’t have the time in primary care to spend with their patients to provide care that could’ve been done without a referral. 

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‍Nick Soman, Decent

Who else in healthcare inspires you, and why?

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Maryal Concepcion, Big Trees MD

The over 160 physicians I've interviewed for my My DPC Story podcast who are doing Direct Primary Care.