Clinicians seeking to develop holistic practices often do so by gradually adding things like nutrition counseling, stress management or herbal medicine as side-dishes to their main menus of conventional allopathic services.
Erin Martin, DO, founder of the TrueMed Institute, in Hood River, OR, took the opposite route. She made lifestyle-based functional medicine the core of her new practice, and as it grows, she’s gradually adding conventional primary care services.
After years of frustration trying to practice holistically in a variety of conventional settings–an odyssey chronicled in the excellent documentary, Escape Fire: The Fight to Rescue American 
Healthcare–Dr. Martin knew she was going to have to either create her own practice or leave medicine.
It’s a crossroad an increasing number of clinicians are reaching.
A featured speaker at HPC’s upcoming Heal Thy Practice conference in Long Beach, Dr. Martin will reflect on the lessons learned on her journey from frustration to fulfillment. She’ll offer insights on how she assessed various options for practice transformation before arriving at her current practice model.
The key, she says, is to start by being very clear about what you want, and what you’re willing to accept.
Weighing the Options
Dr. Martin evaluated a number of different models– insurance-based vs non insurance, primary care vs integrative “specialist,” concierge vs direct pay–before realizing that what she needed to do was start from scratch and create a model that gave her the maximum flexibility to provide lifestyle-focused medicine that could truly transform patients’ lives, not just offer disease management.
That, basically, ruled out an insurance-based model.
“Many of the things I want to do are not covered by insurance. I simply couldn’t see how I could provide them while still accepting insurance. In order for me to do this right, I couldn’t accept insurance, so the first decision was pretty easy,” she told Holistic Primary Care. Her years in mainstream care settings left Dr. Martin highly critical of insurance plans—a view she voiced without hesitation on CNN earlier this year, to the chagrin of UnitedHealth Group’s chief medical officer, Reed Tuckson.
She did consider a concierge or membership model, but felt that it carries “a big stigma of “wealth-care.” It seemed too exclusive. I come from working in community health centers. Helping people that need help shouldn’t depend on their having a lot of money.”
Further, most concierge models are built around primary care services, and Dr. Martin had come to the realization that she didn’t want to function as a primary care physician, but rather as a “specialist” focused on functional medicine and lifestyle change.
She and her husband, Casey Weeks, a health coach, ultimately decided on a direct-pay model, with a full-time focus on holistic medicine. Their TrueMed institute, which just celebrated its first birthday, offers a wide range of functional medicine services, including nutrition education, intensive fitness coaching, and detoxification programs. “We have an on-site teaching kitchen where patients can learn what we’re calling “culinary health.””
The direct-pay model enables Dr. Martin to offer sliding-scale fees for people with limited means, while ensuring that the clinic is established on a firm financial footing.
Disengage the Hassles
TrueMed does provide superbills, and in almost all cases, patients have been able to obtain at least partial reimbursement for the services they receive at the clinic as out-of-network benefits.
By ensuring that patients are paying the clinic directly, Dr. Martin has been able to disengage from the hassles, payment delays and overhead associate with insurance-based practice. With the exception of occasional pre-authorization conversations for advanced tests or imaging, she has almost nothing to do with insurers—a big relief after a decade wrangling with utilization reviewers when she worked in community clinics.
Going cash-pay in a small town during a prolonged recession was definitely a calculated risk, but so far TrueMed is off to a very strong start. Dr. Martin says the clinic went from zero to 250 paying patients in the first year. She works just 3 days, by choice. The patient volume is growing quickly, and she hopes to add other clinicians and support staff in the near future.
Though the practice is open to children, she says the majority of patients so far are adults in their 30s to 50s. Most have complex, chronic conditions for which they have been to multiple conventional physicians without getting real answers. Majority are people who have conditions that are not getting well and not gotten answers from conventional practitioners. “They come in with multiple complaints and long lists of tests they’ve had, and modalities they’ve tried.”
She estimates that about 10% of her patients are healthy, but seeking ways to preserve their health as they age. The practice has also attracted quite a few athletes looking for ways to optimize their performance.
So far, the Hood River community has been welcoming of Dr. Martin’s approach. “A lot of people have said they’ve been searching for years to try to find a practice like ours.”
Cost Transparency
TrueMed operates on a very transparent cost basis, and the community has been accepting of the direct-pay model. “I put my fees on our website. When people call to make appointments, in most cases they’ve already understood that we’re a cash practice, and what the visits will cost. They’ve considered it and they’re OK with it. It takes out the intermediary veil between physicians and their patients. People begin to understand what things really cost, and where the money goes.”
She says direct pay re-engenders a sense of value–not just for the clinician’s time, knowledge and skill, but also for the patient’s own health and wellbeing.
“It weeds out people not willing to make a real investment for their health. If they’re not willing, then we may not be the right people to work with them. If you don’t even value yourself, it will be very hard for us to work with you.”
This, she says, is a very different relationship than the one created by insurance based practice, in which patients showing up to their “assigned” primary care “provider.”
“That’s what I love about this–the people that come to me have already made that investment in health, and that’s half the battle. Once they’re here, the rest is not all that hard. They don’t have
to come to me…I’m not their primary care doc. They come because they want the help I can provide. Where I worked in the past, most of the time the people I was trying to help were just there to get meds refilled. Now, people seek me out because they want to be here.”
Patient demands are slowly pushing Dr. Martin to consider bringing in some standard primary care services to the TrueMed menu.
“People are saying, “Why can’t I just come to you for my physical? Why do I have to go to someone else for my Pap smears.” And they have a point. So we may start to add some routine primary care. Because people want and need a primary care doctor who really listens to them and really looks at what’s going on.”
A Far Better Place
In effect, Dr. Martin is reverse-engineering the standard models of care. Rather than trying to cram “holistic” services into a conventional primary care model, she’s created a thriving holistic specialty model with the option to add routine primary care elements as she sees fit.
She’s also exploring ways to bundle sets of non-covered services focused on specific conditions that can be offered for fixed fees. “I’m always thinking about how can we offer more value, and do more to help more people but still keep things financially viable.
She said TrueMed has already made forays into group visits focused on things like weight loss, diabetes, and detox. She’s been pleasantly surprised at the overwhelmingly positive response. “They’re always filled to capacity. It’s been very, very popular. People really like to have the social support for things that are hard.”
Like any start-up, TrueMed definitely has its challenges. But Dr. Martin says she’s in a far better place than she was at the end of Escape Fire.
“It’s definitely been a learning curve, but it’s working out really well. We have a 3-5 year plan, but things are growing so fast for us—much faster than we thought they were going to go. So we have to continously recalibrate.”
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