Lessons From Forest DPC

Lessons I Learned from Farrago: Be Generous; Be Wise

After a grueling, multi-phase interview process, I purchased Forest Direct Primary Care from Dr.
Doug farrago in October 2020. In the month before that transition, Doug was kind enough to
“show me the ropes”. He had set up several systems and policies that yielded success for his
practice of six years at the time. As I have been mentoring resident physicians, medical
students, and pre-med students, I find myself sharing these pearls and tidbits often. I offer
them up for the DPC community.

This month we celebrate Thanksgiving. We’re heading into the Holiday season where end-of-
the-year giving is often at its all-time high for charities. One of the conditions of my purchase of
the practice was that I would continue to offer free care to the few dozen folks that had crossed
Doug’s path that needed help and couldn’t afford even a reasonable, low monthly membership
for themselves or their families. Well, while Doug was generous, he was also wise.

One of the best pieces of advice that he gave me was that when someone comes in need, be
generous with offering free care, but be sure it is time limited, and that there’s a plan to circle
back to see if that need remains. When I took over the practice in the first full year of the Covid
pandemic, I had approximately a dozen different individuals and families that lost their jobs.
They would call the clinic to cancel their membership because they didn’t have any income for
the foreseeable future. It was always fantastic to be able to offer them free care without having
to go through bureaucratic red tape and administrative hassle. Remembering Doug’s
recommendation, I would always put a date of one month, three months, etc. to check in to see
how they’re doing. I was pleasantly surprised to find patients would call back when they found
employment and asked to be put back on the membership role, often before that date. Not
only is it just the right thing to do for someone who’s in a tough spot, the good will it garners,
and the word of mouth just keeps rippling.

The “ba-hum-bug’s” among us will be skeptical and worry about folks taking advantage of free
care. That’s the beauty of following up. Twice I found individuals who decided to get insurance
and shared with me that they would be leaving the practice. The follow up keeps them from
lingering on the books in perpetuity. Sometimes the offer for free care would be intentionally
connected with improving health. This is back to the idea of implementing wisdom while doing
well. There was a patient who was smoking and getting free care. My agreement was to
continue to provide free care if she would stop smoking. I would offer support, prescriptions,
and accountability by checking the cotinine level every three months. She embraced the offer
enthusiastically. Unfortunately, she never quit smoking. She decided to leave the practice
because she didn’t want to pay for care, and she didn’t want to quit smoking. One other couple
comes to mind that needed to stop using drugs so that they could afford some very important
pharmaceuticals to help their significant chronic medical conditions. I had jumped through a lot
of hoops to help them get these at affordable prices. With follow-up testing, it was clear they preferred to continue using, despite my best efforts to help. Nonetheless, these examples are
quite rare. In my experience, about 10% of folks will try to take advantage of you, but the
wisdom with the circle back dates and testing keeps the accountability and makes it all work.
About a year into owning the practice, I was attending the annual fundraiser banquet for a local
nonprofit. It only dawned on me that in the same way I don’t need to ask anyone else to give
free care to an individual or family, I could give free care to a nonprofit to help their bottom line
so they could pursue their mission. What a joy it was to see the look on the Executor Director’s
face when I offered to provide free care for all the nonprofit employees and their families. Over
time I’ve done the same for another nonprofit.

Doug had shared that he usually shot for about 10% of patients receiving free care. I do just
that. The numbers work out both from a patient access standpoint, as well as a revenue
standpoint. One of the hallmarks of direct primary care is physician autonomy. In the fee for
service world we just don’t realize how much that has been taken from us. As I write this, I am
shocked that it took me months to years to recognize the freedom I had to help whomever God
put in front of me. It has been a blessing. The vast majority of DPC doctors that I know provide
free care to a percentage of their patients. If you’re not doing this, please give it serious
consideration this Thanksgiving season. As Doug would say, “Be generous, but be wise!”