Episode Summary
- Dr. Umair Malik explains how direct primary care let him trade rushed 15-minute insurance visits for 60-minute appointments, getting to the root of patient problems instead of just handing out prescriptions.
- By cutting out the middleman and working directly for patients, his practice delivers transparent cash pricing, faster care (a $1,000 cash MRI scheduled in two days), and even refunds, which are virtually unheard of in traditional healthcare.
- He argues the broken insurance system may not be fixable and that a parallel cash-based ecosystem of DPC doctors, imaging centers, and specialists is already emerging, accelerated by tech and price transparency.
Full Episode Transcript
Dan
Welcome to another episode of Uninsured by Choice, a podcast where we help you navigate the healthcare system without insurance. I’m your host, Dan. We are brought to you by our sponsor, Zion HealthShare, a nonprofit medical cost sharing community. Today, I’m joined by Dr. Umair Malik, who is a board certified family physician and the founder of Blues Bruce Health. A leader in the direct primary care movement, he spent over a decade in Vermont declaring independence from insurance to provide unhurried relationship-based medicine that puts patients first. So, Dr. Malik, welcome to the show.
Umair Malik
Thank you for having me, Dan.
Dan
Yeah, absolutely. So I think everyone would just love to know, I always love to hear these stories, what your background in medicine and practice looks like and what kind of got you into the DPC movement and part of that and just hear your experience there.
Umair Malik
Yeah, thank you, Dan. I worked for probably about seven, eight years in traditional hospital-based primary care. So I was being probably what everyone considers the regular family doctor, you know, the 15 minute to 20 minute visits, full packed schedule, and not much time to call folks back or really do the relational care. So I did that for many, many years before I sort of had this moment, which I think a lot of people had a moment around the pandemic. It was a time for reflection. A lot of downtime too that lets you kind of really reconsider what you’re doing. So right around that time, I decided was the right moment for a change. Decided to go off on my own and do primary care, but do it the way I’d always envisioned doing it when I was growing up. As a young child thinking about what family medicine was and what it would be. The only way I could sort of see that was doing direct primary care, which was basically much more relational. It’s cutting out any middleman working for my patient and having a one-on-one relationship. Been doing that for about five years. Blue Spurs Health has been open for five years in Newport, done fairly well. We’ve built our own little following, we like to say. And we are looking to the future by expanding and opening a couple of new offices to spread the word about DPC.
Dan
That is so cool. I love to hear that, people are able to just you I always envisioned things going a little differently. The story you say about, you know, being a child growing up, thinking about being a doctor reminds me of my oldest. She’s not a little child anymore, but when she was little, her favorite show was Doc McStuffins. But you know, when she was playing doctor and putting on the stethoscope and doing all the, all the things. She never went and sat down at a computer and said, time to figure out how I’m going to bill my toys and deal with the insurance nightmare, right? She just took care of in this case. But I think a lot of people, know, doctors, one of those things that a lot of kids say growing up, I want to be a doctor. And I think that’s how you envision it. I want to take care of people, not take care of paperwork. And I think the DPC movement that a lot of people maybe don’t understand is that you are
Umair Malik
Yeah.
Dan
making it so it’s much easier for you as a doctor to take care of people. Can you walk us through the differences between what you were doing before versus as a DPC doctor, how is that different now and how are you able to better take care of your patients?
Umair Malik
Yeah, this might be a bit of a tangent, but it makes me really think about my inspiration for actually becoming a doctor, which all of my youth growing up, my father, who was an immigrant to the country, came from a different background. And basically his idea of medicine was what you would consider the old school, a doctor coming out to the house and sitting with a family and looking over somebody while they’re in their bed. And there was a point really where My father was really proud for me becoming a doctor. He’d ask me all the time, he’s like, oh, are you doing good work? Taking care of people? High on the idea that I’d become a doctor and just accomplished all on high for a while. That I sort of lost the idea of what it really was. I was working, you know, this nine to five job, which really wasn’t nine to five. You know, you got to come in early and you got to leave really late because you’re doing a lot of the charting and documentation. It really was that 15 minutes, 20 minutes, you got to hurry. The next person’s already waiting in the next You’ve got more charting to do than you do actually have face to face I was leaving a lot. on the table, meaning I’d leave a room saying, I don’t think I got to the root of that. I don’t think I really got to talk to that person about what’s really going Why is their blood pressure really high? At 15 minutes, you can’t really get to the bottom of came a point where I sort of had to ask myself, every time my father would ask me, you know, with pride in his eyes, it’s like, are you a good doctor? Are you taking care of people? There was a moment where I had to say, I’m not sure I am, you know, I’m not sure I’m fulfilling that vision of what a physician is. And so really, I think to get back to the root of I had to stop, I had to slow down. And now, you know, we have 60 minute visits. you know, 30 minutes or 60 minutes and really the patient gets to decide. So they get to book their own appointments. So if they want 60 minutes, we can sit and we can chat. We can have those conversations to say, well, you know, your blood pressure is up because you’ve been drinking a little more lately. Have a talk about that. You know, instead of here’s your prescription and see me back in a month to see if it we get to really get to the root of problems and that’s really what I want to do. because I want to get to the solution, I want to get to the root of the just hand out a slip that just says, here’s your pill come back if it’s not it was transformation to change from being in a rope system, what I factory medicine, the treadmill, with the conveyor belts coming, you can’t push stop on the conveyor keep going. sometimes that piece has already moved on and you haven’t really quite finished it, you know, and the next one’s already I get to think I get to even pause the conveyor belt and sometimes hey, we’re not moving We’re gonna take some extra time here to talk about this that’s really meant that I feel more fulfilled and The cheat code here is that the patients feel more fulfilled, too So we’re all happier in this system.
Dan
And that’s really the magic of it. When you think about it, there’s articles always coming the lack of primary care doctors or that there’s a shortage of providers people leaving the industry by switching to DPC, both the doctor or the provider is improving their own mental health and their own fulfillment at work, but it’s also better for the patients. It’s. It’s a win-win for people to make that switch. And I’ve actually talked to several doctors. I was at the DPC Summit in July last year, and there was a lot of people in residency or a lot of current primary care doctors thinking of making the switch. And I think it’s interesting that you have now for five years got a successful practice up and going in what most people would probably Vermont as more rural, I would say. But now you’ve also put up a practice in Burlington, which is going to be more city that others might be thinking about. What’s been the difference in your what I’ve heard from a lot of doctors is, well, I’m in kind of more of a rural area. I don’t think there’s enough people for this to work. This will only work in a big city, but you are kind of pushing back on that. So what’s your experience regard?
Umair Malik
I think that it’s been absolutely foundational to who we are that we did start in a rural setting in a small town. This is the kind of town where everything is built on relationships. There’s a lot of trust. Your reputation can go a long way. So there’s a lot of word of mouth here. So basically, I would say that our practice opened and we did really well very quickly because of that. word of mouth. When people hear that something good is going on, mean, that’s friends like wildfire. So that really did help us take off. Think the community sort of sharing were getting good care, that this was definitely different. It was hard at first because direct primary care is sort of novel in this part of the country. This has been much more popular in the South and on the West Coast or in the Midwest. but in the Northeast, it’s been a little slow on the a lot of people, we had to educate what is this system? And this is real and it’s not just some hokey thing. And that this is actually as good, if not better care than they’re getting from other institutions. Actually moving into the more urban setting now in a city that’s a little more populated. it’s a bit of a different approach to get people to kind of see On the one hand, they’re much more tech savvy and they get it. They understand that, hey, if I’m looking for healthcare that’s convenient, this system makes sense. It is a little different in that word of mouth spread, you know?
Dan
Yeah, that makes total sense. I think it’s pretty cool though that in either situation you can thrive. Mean, there are DPC practices from rural to urban and suburban and anything in between where they’re doing just fine. So that’s, there’s not some sort of in. Have to check these boxes for this to work for You really it like for me, I’m testicular cancer survivor and about two years out, pretty much all the symptoms of low T basically, and somewhat common in my situation. And I went to the doctor my annual check, he asked the same questions. Did the blood test, came back and I was, over whatever minimum of normal was, like just barely. And in my case, the spread was like 400 to 1200 or some large.
Umair Malik
Oh yeah.
Dan
if I’m at oh, fine. Thought, well, but I don’t always really feel fine. I am a member of a here and have a doctor here who takes more time to say, well, let’s look habits or these lifestyle factors you are normal range, but you’re on that lower end. Let’s see what we can was able to help a lot. that arena and that’s just one example of what I’m sure are many from people all across the country of taking that time really works. You have similar kind of experiences without violating HIPAA of course? Examples where that’s worked better for people?
Umair Malik
Well. Yeah, I mean, I’ll give you my spiel now, which is essentially the thing I think I say the most. And I love saying this to people when someone comes in, a patient comes in, I love telling them, I work for you, means that I’m not paid by insurance, I’m not paid by a corporation, I’m not paid by a government. I’m paid by you, the patient, and therefore I work for you. That means that if you’re coming in and saying, look, my testosterone level is considered normal, but I don’t like how low it is. Then that’s now become my priority too, your priority is my I’m not beholden to some other inevitably when I was working in the traditional system, I was focusing my own encounter on how can I make this fit within the rubric of what insurance is going to cover. And is this a diagnosis or not? Well, because the numbers in the it doesn’t really fit in a diagnosis. And so how do I get insurance to come along? But now I don’t work for insurance. You know, I work for my So there’s, I mean, I can give you a lot of examples where this has kind of become the cornerstone of what’s changed things for people. But I think the really take home message that I really want everybody to understand is that who does your provider work for really? They can say anything, but it’s whoever’s paying them, So if the patient is paying and it’s a direct transaction, then it’s a very clear relationship. There’s no middlemen there.
Dan
Yeah. And to that point too, with the way consolidation has happened in healthcare, the provider might not even know who they work for. They, are in a facility that’s owned by a hospital that’s owned by insurance carrier who also owns the pharmacy and PBM and blah, blah, blah, blah. It’s consolidation where who, who even works for who who’s paying who here. And I think that’s why think the stat is something like 30 cents of every dollar spent on healthcare actually goes to.
Umair Malik
Right.
Dan
providing of care and the rest is this administrative bloat because no one knows who’s paying who and there’s all these people taking something out. I love that direct care and direct pay really yield those kind of results and I’m sure you’re seeing those results every day, right?
Umair Malik
Yeah, and kind of to your point here, there’s the hurdles as well. Give you the example a 20-something-year-old gentleman who came in not too long ago, had been playing basketball, he injured his knee, and he came in with what is basically a cookie-cutter story to a of a meniscal injury, which is a tear of one of those supporting structures in your knee. So he basically gave the textbook example story of how he fell and injured his knee. And of course he met all the criteria on an exam. So we’re checking him out. We say, hey, this is a pretty open shut case. But again, he had insurance. And so we’re trying to navigate his insurance. We knew he needed an MRI. The MRI was gonna be declined because insurance needed to see an X-ray. They needed. six weeks of physical therapy. So when we first pushed through the MRI, that was the response we got is send him to physical therapy, an x-ray. Well, even the patient knew an x-ray wasn’t gonna show anything. He was well educated enough to know that, I didn’t break anything, I didn’t break a bone. Then the physical therapy, he’s like, do you think I’m gonna do exercise on this? And I was like, absolutely not. I don’t want you doing exercise on In any case, his insurance had thrown up these hurdles and ultimately, when we actually did a little bit of math for him, so we were helping him navigate the healthcare system at this point, we said, you’re deductible is actually about $2,000, which means that even if you get the MRI, you’re gonna be paying $2,000. The end of the day, we called a facility that we knew well just said, hey, what if we pay cash? He ended up getting the MRI for his knee for $1,000, which was half of what he would have paid. We didn’t have to do any of those hurdles or hoops. We didn’t have to clear it through insurance. He paid cash. And even better, he got that MRI within two days. Scheduled it at his convenience. He got the MRI done and got it done on a Saturday. And by Monday morning, we were already calling the orthopedic surgeon to arrange his procedure. everything was lined up without any kind of six-week delay of therapy that he then fails and then trying to get the MRI scheduled and then trying to get the orthopedic scheduled. And he had this moment where he was I don’t think my insurance really helped me in this situation. Know, everything we did in that case was out of pocket.
Dan
I think. lot of people find themselves in that situation. I love what you brought up though, is that DPC is gaining a lot of traction. There’s thousands of DPC doctors opening their clinics across the country. Like you mentioned, what about an independent imaging center or an independent surgical Are you seeing other practices follow suit in that sort of direct care, direct pay independent of this whole system? Is that getting more popular?
Umair Malik
Yeah, I think the imaging centers are a little quicker on the uptake here. We’re seeing some places open up where they’re offering x-rays that could be $100 in comparison to several hundred dollars or even $50. So there’s a lot of these folks that are beginning to realize that it’s actually way cheaper to get a simple thing more than that, I’m starting to hear from specialists too. I can tell you the number of, I’m approached probably every month by a specialist becomes familiar with what I’m doing and they’re calling me and saying, hey, how can I do this too? A neurologist or a rheumatologist who’s saying, I’m fed up with this system. I can’t really do this any longer. And they’re saying, I’ll be willing to create a cash I just wanna see patients. I just wanna help we’re seeing that shift starting to spread outside of primary care as well. And I think that, you know, probably it won’t be very long before we’re going to start to see bigger and bigger movements and more and more places around the country where that’s easily I think there’s already some surgical centers that are doing phenomenal work. Have transparent pricing and people are willing to travel for that kind of thing.
Dan
I saw a documentary, I think it’s called, it’s nothing personal, it’s just healthcare or something along those And interviewed the founder of a surgical center. I want to say it’s in Oklahoma, an independent surgical pioneering this whole this direct care and direct pay. And it’s just so cool to see just starting. And so I guess the big question is, is this sort of ecosystem that’s being built, is this fixing? Are we seeing a fix to the system? Separate system? What’s happening here?
Umair Malik
Yeah. so this is actually another thing I love to say, which is that, you know, the healthcare system is broken. I think everyone is in agreement with that. There’s, you know, it doesn’t matter what party you affiliate with or where you grew up in the United States, everyone will agree that the healthcare system is broken. My personal take on it is that not a system that we can fix. and it’s broken and we actually may need to let it break and die completely. I’m seeing a lot of this, the cash-based system is circumventing. We’re bypassing that system and bypassing that system, building something And ultimately, the broken system doesn’t have to die, but at least people are seeing that there’s choice. And with the choice they’re getting to choose, they say, well, I can go this route or I can go that route. At the end of the day, that’s what I think a free market should be, what a free market is. And what healthcare was always based on, is choice,
Dan
Yeah, it’s a, say, there’s always been choice. No, there’s not. You’ve, you could just pick from one bad insurance option or the other. That’s not really
Umair Malik
Well, you know, there’s healthcare systems that love to say, we take this and this and this and this insurance. At the end of the day, a direct primary care is the only system that can take anybody. Because a healthcare system that only takes certain insurances can’t take uninsured. But we take uninsured, we take undocumented, we take anybody at any time for a very fair cash rate, transparent from the outset.
Dan
Yeah. And that’s the big thing too. I know there was a law that was passed. Can’t remember when, and the name was something along the lines of healthcare price transparency. And the idea was everyone needs to provide transparency and pricing. Good idea, right? That should work. All of them tried to circumvent that Hey, we’ll just post the pricing in some sort of file type that no one can open on the normal computer or we’ll make these files, know, 20 gigabytes and take forever to download. So no one can, can see them. They’re technically. compliant with the law, but not really. And you just see this over and over again in the traditional system of how can we keep things as and expensive as possible? So doing something to, like you said, circumvent that system and just build essentially a separate system, right?
Umair Malik
I’ll take it one step further, Dan. It’s been always a pain point for me that when I was working traditional primary care I referred somebody out to a specialist and they came back to me and I’d say, well, what said, well, he walked in five minutes. I was there. I drove two hours to go see the specialist. It was a five minute visit and they never really addressed the issue I was there for and boy, I’m pretty while the patient may not understand the whole context of it as the referring physician, I understood it and I said, this really wasn’t good there’s no recourse nothing that they can really do other than maybe file a back to price transparency, to me, direct primary care goes way above that. In our practice, at our prices are transparent, but whenever somebody is really kind of making the case that they’re unhappy or something wasn’t to their or there’s a misunderstanding about what care they were receiving. We can issue a refund. Doesn’t exist in healthcare. It almost never happens here because most people are inevitably happy with the care they But there have been times where we say, know, this situation wasn’t really the way it, it didn’t turn out the way we wanted it to turn And you paid this amount and we’re gonna, we’re gonna honor the transaction we’re gonna refund you what we think that was worth. that’s going just to me beyond price transparency, it’s accountability I don’t know anywhere in healthcare that you can do that.
Dan
In fact, it can be the opposite because my experience, again, as a cancer survivor, I was on surveillance, an annual CT scan. Just two weeks ago was anniversary. So two places in town that’ll do that. One’s the hospital $3,500. There’s this other smaller facility that does it for about So I went in there time I was very clear. I am cash they had no idea what to do I was checking in. Go sit down. Wait a minute. And so it took them about 10 minutes. So they called me back up and said, okay, we need you to sign this. If you pay today, right now in full, it’s a thousand something. If you want us to bill you at the cash period, it’s 1500 something. Said, great, I’ll pay right now. And I did and went and everything was great. Well, yesterday, guess what comes in the mail.
Umair Malik
Mm-hmm. Mm-hmm.
Dan
a bill for $1,500 says I’ve got $1,000 credit, but I still owe 500 more. And now I have to go dispute the bill because they just don’t know how to navigate this idea of someone showing up without insurance. And so you just need to find these facilities and these providers that understand how to work directly with you legacy facilities, just are confused by it. Like you said, you can’t work within the system to fix it. You just need to let it die.
Umair Malik
Hmm. it’s the most basic thing, right? That you’re paying for a service. I’m selling something, I should make very easy for you to be able to pay never create any hurdles between you and me in that regard.
Dan
Yeah, basic marketing, right? You don’t want obstacles between your potential customer, you know, and paying for the transaction, but that just seems to be what happens left and right because no one understands the transactional nature of this traditional system because who gets it? You pay it. No, you pay it. No, you get this and you get that. And it’s just a mess. And it’s so refreshing to see this direct primary care movement really ramping up. How have you seen it change just in the time? I mean, about five years, I think you said you’ve been.
Umair Malik
Yeah.
Dan
in this space, what’s it looking like today compared to then?
Umair Malik
I mean, it’s just, just in the five years alone, five years ago, I really had to do quite a bit of education to say, this is what this is, and this is why we bill. I had to spend a lot of time explaining to people why I don’t bill insurance for my was one of those things that was just, it really came across weird, Today, very few people are really raising an eyebrow at that. They’re understanding. They understand. Saying, yeah, we get it. Insurance is a nightmare for everyone, including the patient who’s trying to use it. Already that space has changed so much in that there’s so much more acceptance and understanding. People are jumping ship, jumping off of insurance. So this year alone with the increase in premiums, I’ve had so many people call up our office saying, I was on insurance. I’m letting go of that now because it’s just untenable. It’s too choosing to be previously five years ago, it was usually the person who said, look, I just can’t make insurance work and I’m struggling. So I make too much from Medicaid, but don’t have a job that can get me insurance. Today, I’m getting calls from people that are saying, you know, I did the math. I sat down and I… made a conscientious decision to abandon my insurance. It’s a very different type of So in the five years, this has become much more popular, it’s become much more of a choice. People are starting to have an awareness, they’re being more savvy about understanding that, hey, I know that I can get the surgery, I may have to travel a little bit, but it’s one third the price. and it’s just as good quality, if not better sometimes, because the follow-ups are really extended and you get a lot more doctor to patient face time. Can’t get that anywhere really optimistic. Mean, again, I think that awareness, that knowledge that’s spreading, there’s more and more providers opting in too. There’s more and more facilities that… when they hear about what we do, they get it and they’re saying, okay, we were gonna carve out a cash pay rate for your before it was just not anything they were willing to talk about.
Dan
a lot of progress in just those five years. What do you think the next five years hold? What do you think the healthcare system looks like five years from now? Is it kind of the same or change?
Umair Malik
Yeah, well, we just came back from a conference that kind of highlighted a lot of the upcoming trends, the tech, the software that’s in in healthcare. Know, I think insurance thrived off the obscurity of things. And you mentioned opaque earlier, you know, everything was just so nebulous and hard to navigate. But we’re living in a world where software and tech is making things so streamlined and you know, it’s pulling the veil up and it’s basically exposing what we’re seeing is that things are so much more streamlined and efficient that I would have said it’s gonna take 10 years for things to shift and for traditional insurance to break down and fizzle out or die completely. But I think it’s actually shorter than I think the timeframe is probably within five years, we’re gonna see a major shift and either there’s major reform on the insurance side to make it more tenable or it dissipates it’s really amazing what’s coming up now and what’s making direct relationships so much simpler and easier. Mean, telehealth is an example, right? It just makes sense that you can get care over a phone now, but traditional insurance doesn’t generally support that, And more and more people get that. Mom who calls me up and says, I’ve got three kids and they’re sick. Do I really need to bundle them all up? I need to get in the car, my husband’s at work. I gotta figure out all of this to get them over to the office to get checked out. She can show me some pictures. I could see a rash. I could see a stuffy nose. I can hear about how the breathing is going. And I know that family. I can take care of them five minutes over the digital communication, a text photo, or even moms who will record the breathing or the cough. And I hear that cough and I say, boy, he’s really wheezing. That’s pretty clear to me. His asthma’s flared up. I know this don’t have to drag him in. I’ll take care of that mom who just God, are screaming, one’s gotta get buckled she couldn’t even put a value on what that is, what that relief means to her.
Dan
Yeah. If you look at tech just in the last five years, boy, how far have we come five years ago to today? And like telehealth is a good example. I remember scrolling through my LinkedIn and I saw someone post and say, there’s big news. And insurance carriers are going to start using AI to aggressively up the bill and figure out how they can you more. And right below it was, I don’t remember who it was. It was DPC Dodger or some healthcare advocate saying, you can start putting your bills in AI and bring them down. And I thought, well, now the AI tech wars are going to start one’s trying to up bill and one’s trying to bring it down and AI is going to fight it goes back to the opacity of, of insurance. It’s what are all these codes? What do they mean? Breaking down. And that’s where insurance has thrived is on that lack of transparency. And with it.
Umair Malik
Yeah.
Dan
becoming more transparent. Don’t know how much longer insurance can thrive in that.
Umair Malik
They had a great line at the hint summit that the conference I just went to, which was care over codes. That mom that had those three kids, weren’t a code. They were, there was care. It was a situation for a family and it had nothing to do with codes. Know, that whole encounter was done over the phone. Yeah, it’s tough when you have to reduce that down to a billing. widget and trying to make that fit into the system.
Dan
Yeah, absolutely. Well, appreciate your time today, Dr. Malik. This has been an awesome conversation. Anyone listening though, if they wanted to reach out, connect in any way, what’s the best way for someone to find you online?
Umair Malik
Yeah, check us out. Our website is bluesprus.care. Blue like the color, spruce like the tree, and dot care because that’s what we do.
Dan
That’s perfect. Love it. Thanks for your time. You joining us. Listening, keep in mind you can always subscribe on YouTube, Apple or Spotify and we’ll see you next time.