[INTRODUCTION]
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[EPISODE]
Christopher Habig
Hi, everybody. Welcome to Healthcare Americana. I am your host, Christopher Habig, the CEO of Freedom Healthworks. Today, we are diving into a specialized area of direct care, a model that's transforming not just primary care, but as you will learn, many specialties across the entire medical practice spectrum. Joining us is Dr. Beth Goldstein, a leading dermatologist from Modern Ritual, who has embraced the direct care model in her practice.
Dr. Goldstein, welcome to Healthcare Americana. Welcome to the show.
Dr. Beth Goldstein
Thank you for having me.
Christopher Habig
It's rare treat where we get to venture outside of the world of the direct primary care, which is where obviously we spend a lot of time and I spent the vast majority of my career.
within Freedom Healthworks. And so anytime we come across a physician who is practicing in a non-primary care specialty, our ears kind of perk up saying, yes, it is possible. Yes, there are people outside of this. And so you have inserted a direct care model into the practice of dermatology.
Dr. Beth Goldstein
Yes, it is interesting in that with the primary care component, I am married to a family physician and that we have worked our whole careers together with about dermatology and primary care and have seen issues with access that have just gotten worse and worse. And that this model of direct primary care and how we can support that collaborative model where patients get the best care possible.
and that we know a lot of dermatology happens in primary care. And how do we marry that up? How do we create a model that's a win-win for the providers and for the patients? And I'll say also for the specialists.
Christopher Habig
Yeah, absolutely. And you're hitting all the tenants that we hear about from physicians who are in the primary cares, which, you know, just as a refresher for the audience, there's pediatrics, family medicine, or general practitioners, and internal medicine. So people who already have relationships and really lifelong or even multi-generational relationships with their patients. I've always thought that dermatology was one of those, you know, that sit outside of what we define as primary care.
that would fit very well with this model. So kind of give us, well, I mean, take us through the weeds of this. Like, how does a direct care dermatology practice differ from a dermatology practice that accepts insurance and is reliant upon third-party payers?
Dr. Beth Goldstein
We have two different avenues here. One is where we work collaboratively with the direct primary care clinicians, where they are able to consult with us without having a whole separate visit with a whole nother doctor. So we find that the direct primary care clinicians are very bright and are handling an awful lot of dermatology already. And that where we want to come in is where
that lesion you're not sure if it's normal or cancer, kind of those in between lesions and to help figure those out. And does it need a biopsy? Does it need a removal? And if so, what kind? Does it need a shave or a punch or an excisional removal? So whether or not we're supporting the direct primary care clinician to stay in charge of that patient's care and when do they need to actually be seen by bricks and mortar dermatologist.
And that has worked really well with our direct primary care clinician. So that is an e-consult model. And then there's a more traditional teledermatology where it's a cash pay. The patient just pays us cash and we have asynchronous usually visit with the patient where they upload their photos and provide history and then we connect directly back with the patient.
Dr. Beth Goldstein
It varies state by state. In some states, we need to do a video visit to be compliant with the medical board. Where we can, we try to do the asynchronous visits. We have physicians licensed in every state so that we can provide care and collaborative care easily in every state.
Christopher Habig
So two different sides of the coin there, which is funny because when we first met, you hit me a business card with two different sides on it, two different practices because you are an actively practicing dermatologist, but you're also involved in modern ritual, which is providing virtual dermatology services. So let's start with the e-consult side of it. How effective is that partnering with primary care physicians on the virtual side of it?
Is there anything where you say, wow, I do need the brick-and-mortar location, do you need to see it hands on approach? Or is the virtual aspect of it able to satisfy a very large, large portion of items that come your way?
Dr. Beth Goldstein
85 to 90 % can be handled virtually or with support of the primary care clinician. If the primary care clinician does not do any biopsies or any procedures, that is when we need to do collaborative care with a bricks and mortar dermatology office. And we do have relationships across the United States so that we can help patients be seen.
What I've heard so many times is the direct primary care clinicians have a relationship with the dermatologist. Usually it's a friend of theirs and they say, you know, I've got a call, I've got a call in a favor. And with using us to support them with the e-consult, they know, okay, this is one that really needs to get in and needs to get in quickly. And I think it improves the relationship, but it avoids, you know,
the primary care clinician have to spend time, quote unquote, calling in a favor when I think it really should just be collaborative care. Because they don't want them to wait months and months to be seen, which is kind of the big problem we're trying to solve.
Christopher Habig
Yeah, and one of the frustrations that we hear from patients all the time is that, you know, I love my doctor, like, this is amazing. But when I have to go outside of these four walls, I'm back in the system and I now realize how miserable it is. And so, again, going back to my original point, it's like whenever we have anybody or come across the trail, so to speak, of a physician who's practicing and doing things like you're doing, it's like, oh, my gosh, all right. How can we how can we
help be a resource to help you grow and help you be really the shining example for other dermatologists out there. In your mind, is there a lot of confusion or a lot of pushback with your colleagues that are practicing dermatology that say that direct care thing, that cash paid medicine thing, that's not going to go anywhere?
Dr. Beth Goldstein
There certainly is this issue with in-person dermatology where we do a lot of procedures. And as we all know in the current system of fee-for-service that certainly the reimbursement is higher when you see people in person and do procedures. And that if you are able to do the teledermatology visits for those patients who don't need procedures and there's a long wait time,
for patients to be seen who knew, who need procedures, then it's really a win-win. As far as outside of the insurance model, that is harder for some people, but we do always have a cash pay option for those people, but it is certainly very cost effective for them to have, if at all possible, a tele dermatology visit. From the dermatologist standpoint, you know, the overhead is so much lower to just need your computer and not,
what we have in our office, which is an awful lot of support. Like primary care, our overhead for bricks and mortar is quite high, traditionally.
Christopher Habig
Right, right. It's a problem that is up and down.
all specialties across the entire industry for sure. And I like that you delineate, you know, things that I need to put hands on a patient versus the things that can be handled from a consultative, really kind of a peace of mind or doing videos or doing pictures. I think so much of that, those bad habits are tied to reimbursement models from insurance companies and really the government where they didn't have a reimbursement model for a phone call or a
picture or video until about four years ago. So once COVID hit, then they all pat themselves on the back for being able to charge patients for virtual visits and the technology had been around for decades. Different story entirely.
What do you think it takes to get those doctors sitting on the sideline who say, yeah, there needs to be a split of these services. What do you think it takes to get them off the sidelines and doing practices that are very similar to what you are doing and how you're practicing and how you are billing your patients?
Dr. Beth Goldstein
My preference would be for e-consults to be reimbursed appropriately so that when the patient is staying within their primary care, that it's a win-win for the patient and for the dermatologist or any specialist to give that care. And I'm speaking of within an insurance model, which is probably not the question necessarily to answer.
Christopher Habig
It's all kind of connected, right? So you can't have one without the other at this point in time. We're kind of chicken or the egg, you know?
Dr. Beth Goldstein
It's interesting. Yeah. It's interesting to me, the dermatologist who really have embraced this the most. And it's all over the place from, I know in my practice during COVID, we did a lot of telehealth in the insurance space in my bricks and mortar. And as we came out of that, the pent up demand and the continued demand for in-person services made it so that nobody wanted to do telehealth at all
in our bricks and mortar practice. And now we're kind of circling back to doing that. What I think really does need to be seen in person are high risk people having total body skin checks. And I think of so many times over the years where people come in and go, I have this spot on my shoulder and you go, oh, that one's fine. But that one on your back, now that's the melanoma. And that's happened so many times. So these high risk people,
if they're just showing you one spot and that's the only interaction they ever have with the dermatologist, that's not really delivering the appropriate standard of care, I don't believe. So those patients, I think, do need to come in person. It's interesting, there certainly is getting more and more technology where you use AI to do a total body scan from certainly an office or even from your home that technology is coming. So that's very exciting.
But the AI is only supportive. It's not instead of an in-person. So that, I think, is the key place when you need to be in person.
Christopher Habig
Another great distinction that you make there, all too often people look at virtual care as a replacement for the actual physical physician who's highly trained, highly experienced. And then you add in the AI component and they're like, oh, just the robots will figure everything out because you know, you see headlines of them passing tests or AI them. Well, the AI systems passing tests, all this kind of stuff. And it's like, well, that's great. But me, Christopher here is not a standardized test. So there's a lot of
of different things that go into finding the right answer. I want to talk a little bit about your start into Modern Ritual because you have your dermatology practice but then Modern Ritual is where you're plugging in, you're helping primary care, you're doing these virtual visits, more cash-based, cash-friendly.
What was really that impetus and that kind of motivation to go out there and get involved with modern ritual and say, I want to be a resource in really this new healthcare economy that we are building?
Dr. Beth Goldstein
The story is that my daughter who is the co-founder and the CEO of Modern Ritual and I were looking to make an impact and do something about skin cancer and skin health. And we started with a product. It was a sunscreen, particularly for men. And one of the ways we were promoting it was on social media. And I say the bad word, TikTok. And...
it was really fun because people are learning about skin cancer and signs and symptoms. But over and over I saw on social media, the same thing I saw in my practice where people like, I'm worried about the spot I can't get in. My primary care provider thinks this might be skin cancer. And they tried to get me in and just the long wait times. And we're like, well, maybe this is what we should be solving for. Not necessarily a great sunscreen that gets men to actually.
take care of their skin, that's the modern ritual. And we pivoted to become a teledermatology company because we said, you know, nobody out here is really addressing this in a robust way. And we know we can do better. And the conventional systems don't seem to be changing. They're not going to be more dermatologists trained. The only way dermatology has really been addressing it is by training advanced practitioners, of which I have excellent ones in my practice.
And in no way am I saying they're not excellent, but it's really not solving the access problem in a robust longevity type of approach, sustainable approach. And working with my husband in primary care, we collaborate all the time, both ways, but having this ability
to really try to do that comprehensive care for patients because people should have a strong primary care provider. And if you see a specialist, having them in the loop, I think is the most robust way to do it. So that was our desire was to really work with people's primary care clinicians. I mean, you can go, you know, telederm or teledoc and you can just do a virtual visit and that is, that works, that's fine. We're happy to see people directly.
But it's really the best care when you're collaborating with your primary care clinician.
Christopher Habig
We're talking with Dr. Beth Goldstein, dermatologist with Modern Ritual. Dr. Goldstein, I completely agree. We always say that we need a primary care doctor to really be the quarterback of healthcare because they can see the whole field. Now, they also need to know when to throw the ball down the field to a great dermatologist like yourself on certain issues, but that's the role that they should be playing and that our nation really and our society needs them to be playing. I want to talk about more on the business
side, you're talking about collaborating with primary care physicians. Give us an insight into really the uptake in your services that you see from primary care physicians. Is it patients saying, hey doc, you really need to talk to these people, or are primary care physicians finding you as a resource for their patients?
Dr. Beth Goldstein
The primary care clinicians predominantly are finding us and the people who use us robustly really enjoy it. Like once people, once clinicians start using us and see the value, because we do a lot of teaching and it's just a win-win for everyone when we do it that way. I think just doing teledermatology for most dermatologists, this virtual,
is an adjunct to what they're already doing. So it's not full time only this way. One of our contracted physicians does have a direct dermatology practice. She's 100 % cash based, both bricks and mortar and virtual teledermatology. But it goes both ways, but the larger groups, once kind of the word gets out there, we appreciate the word of mouth.
And we are also now starting to work into health systems where they do have dermatology, but they can't get their patients in or where there's no dermatology and we can help. We think of ourselves kind of like the TSA pre-check. You know, we'll get you seen sooner, you know, but if you have a bad vasculitis, if you have a really difficult issue where I feel like we need to operate at the top of our licenses as dermatologists, we need to be able to see those people.
don't need them to be waiting. And I know you keep leaning more towards the business side and it is most cost effective for groups who use us more robustly and how they pass this onto their subscribers or people in their panel varies widely, whether or not they just upcharged and give them the option to have dermatology visits and they pay a little bit more per month.
Or you have so many visits with a dermatologist per year or a poor use, or they say, this is just something I offer with my model. So I hope that's helpful to say there's different ways that people, practices have positioned this.
Christopher Habig
Absolutely, absolutely. And it is, going back to what you said about, you know, there's the primary care doctor and then they can use you as that kind of quick reaction saying, hey, I need some quick eyes on this one. And then you're able to say, well, yes, we can do this or no, let's get this person into somebody local where, you know, they can be seen. That's the type of collaboration I believe that patients really want and they demand and they desire these days.
We just don't see as much of an education level that patients know that this type of a service is even a thing that's even out there. We have so many bad habits from a consumer standpoint where they think, oh, this little insurance card on my wallet is healthcare. And if I get sick, I just call a number on it and somehow they'll take care of me.
Dr. Beth Goldstein
A few years ago, when there became a lot more expansion of insurance, I think a lot of people experienced this, yes, you have insurance, but do you know you're deductible? Do you know your copay? And there were a lot of surprises where people said, well, I've got this card. It's like, yeah, but you've got a high deductible and it's going to be cash.
And I think it was quite a rude awakening. I think people are more aware of that now.
Christopher Habig
I hope they are.
There's still a lot of people out there that you ask those basic questions to. And it's either, I have good insurance or I have no insurance and there's nothing in between. And it's hard to have a conversation around that and kind of show them that, hey, just because you have health insurance does not mean you have healthcare. When you're sick, who are you going to call? It's not Ghostbusters by any means, but who is the actual physician that is going to care for you to get you back into good working order?
Dr. Beth Goldstein
And I think the more that we can do with patients through their primary care, the better. It's just better care and that it's not so disconnected and fragmented.
Christopher Habig
Absolutely. Let me ask you this. When you're facing practice startup, when you said, I know you said your daughter was the co-founder, CEO of Modern Ritual. When she came to you and said, hey mom, I'm doing this. I want you to be a part of it. And we're going to go do this telehealth thing and we're going to charge people just good old fashioned US dollars. What was your reaction? Was it scary at all?
Dr. Beth Goldstein
I think the overhead is not as scary because having had a bricks and mortar practice and so many employees over the years, I thought, well, you know, this is just time. This takes time. Now the marketing and spreading the word and increasing utilization is I would say the biggest investment for us is how do we get more people to do this? I did kind of go, oh my gosh, you know, there's so much
regulation to the practice of medicine and state by state and with the virtual healthcare changing after COVID and it's still changing and that you have to do a lot of legal wrangling to know state by state to be compliant. I say that that is what gave me, I would say the biggest hiccup here on that.
But to Eliana's credit, she really organized and helped to figure out a way, and we did a lot of learning to make this opportunity possible, whether you have one clinician in your practice or 10 or 20, that we can provide this. And it's not a huge cost or undertaking. It's very simple. Our onboarding is 30 minutes at most.
The equipment is very inexpensive and a lot of primary care clinicians already have a dermatoscope. And if not, we have, we have those where we can help. And so starting it is for the primary care is not hard. There's not a lot of commitment to just kind of dipping your toe. From a dermatology standpoint, we are heavy in our home state, which is North Carolina. We are in about 18 states now.
But that is what I would say has been the biggest work, is the legal and being compliant and getting licenses in all these states.
Christopher Habig
Dr. Goldstein, I want to thank you for joining us here today and sharing your expertise. And thank you to our listeners for tuning in to Healthcare Americana. Dr. Goldstein, before we adjourn, any last words of wisdom for our listeners out there and the direct care medical industry at large?
Dr. Beth Goldstein
Absolutely. I do believe e-consults are the way to go. I think if you have a patient who you know what it is, but the first treatment hasn't worked and you need any support, we're here for that. We're just not what is it? We're here actually as a practice partner with you to help deliver care for your patients. It's much more of a partnership than just a one-off question about one rash or one spot.
Christopher Habig
Physicians working together and patients working to educate themselves to learn that there is a better way to access expert medical professionals. It's a very beautiful concept that is not just smoke and mirrors. It's not just an imagination. It's real. It's happening. So once again, Dr. Beth Goldstein with Modern Ritual. Dr. Goldstein, thanks for joining us.
Dr. Beth Goldstein
Thank you so much for having me.
Christopher Habig
And again, thank you for all of our listeners for tuning in to Healthcare Americana. We hope you have found today's episode enlightening and inspiring you to think about the possibilities of direct care in your own health journey. Remember, there's great physicians out there doing this all over the country. And remember again, changing healthcare starts with changing how we think about patient care. I'm Christopher Habig, signing off until next time. Thanks for listening.
[OUTRO]
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