0:00:02 - Mark Henderson Leary

Welcome to Practice Freedom. What if you could hang out with owners and founders from all sorts of healthcare private practices, having rich conversations about their successes and their failures, and then take an insight or two to inspire your own growth? Each week on Practice Freedom, we take an in-depth look at how to get the most out of both the clinical side and the business side of the practice, get the most out of your people and, most of all, how to live the healthy life that you deserve. I'm Mark Henderson Leary. I'm a business coach and an entrepreneurial operating system implementer. I have a passion that everyone should feel in control of their life, and so what I do is I help you get control of your business. Part of how I do that is by letting you listen in on these conversations in order to make the biggest impact in your practice and, ultimately, live your best life. Let's get started. Welcome back practice leaders. It's me. 

Mark Got an interesting conversation, so it spoke with Dr David Donahue and he is the chief medical officer for Progressive Health of Delaware as well as chief executive officer of Poplar Care and sort of this interview doesn't dig into. Well, I steered the conversation intentionally around how does purpose, how does differentiation like lifestyle, because lifestyle is this thing, so lifestyle medicine, which is really about changing your whole lifestyle to be more healthier, and so that's really both sides of that. His business models that he's working with is really around establishing the patient, the primary care patient relationship around lifestyle, but it's also this ACO model and how to add more. The popular care side of what he's doing is really around creating processes and really plans and ways to provide complete care to people who, for lifestyle purposes that fit into the ACO model. It's really innovative stuff. We don't really dig into the mechanics of that, though. That's not the point. The point was really you have to go to market with this. You have to get out of the academic mindset of we know better, people are better off if they live healthier lives. Well, duh, but people don't. How do you turn this into a business? And so, where this manifests we talked a lot about, you know how do we manage profitability in the form of productivity in the healthcare providers? Who are those healthcare providers? What kind of things are on your mind when you're worried about being a profitable practice, when you've got a mission? 

That's important, and I think, ultimately, this is just an opportunity to listen to somebody who is thinking as a leader, and I think it's just a good example of when we talk about the leadership choices, the role choices of the physician founder or anything that's sort of the analog physician founder, healthcare for whoever sort of founds the organization. There's three places to go with your mind, and one is I'm gonna be an individual healer that I was started as a doctor or whatever, and that's where I gotta take care of patients, which is a linear contribution, one patient at a time. Then there's like but this is a business, so I got to have somebody in the organization who's going to understand the mechanics of the business and that might be me in the early days and then who's going to be the visionary leader of the organization. Where is it going? Who is the person who thinks about? Well, I'm not just taking care of one patient at a time, I'm creating a culture in an organization that's mission driven. They could serve thousands or tens of thousands of patients over time and we've got to make a big impact. 

And I think if you listen to this interview, you'll hear where, most of the time, you know he's in the mindset of that visionary leader. And so this is the narrative of the things that people think of in that capacity. So I hope you find this useful. Listen to how he's staffing and how he's thinking about how the people fit into this and how you message the value proposition and give us some feedback. Now, of course, don't forget if you're stuck, please reach out. If you're envisioning an amazing practice where everybody's on the same page with the vision, everybody's accountable and disciplined, everybody's part of this healthy, functional team, but you don't know where to start, or if you don't know what the next step is, please don't stay stuck. Reach out and get some time with me and we'll talk about what a next step or a first step could look like for you at practicefreedomcom slash schedule. So, without further ado, dr David Donahue. 

0:04:21 - Dr. Dave Donohue

Well, good morning David. How are you, sir? I am doing well, mark. 

0:04:24 - Mark Henderson Leary

How are you today? 

I'm well, it's a context switch to jump from different world to different world and trying to get my mind around an interview as opposed to coaching people and sort of the mind shift. 

So I'm eager to have this conversation to kind of get your perspective on what you're doing, leading and running the business, because a lot of times I'm coaching and this is not that conversation. I'm very curious. You and I haven't talked a lot, so this interview is going to be a lot of innocent questions and so you know, just to kind of reframe it, this podcast, this format, this community, while it's focused on private practice healthcare, which is the business of healing people, what I'm trying to cultivate is not about the science of healing people. It's more about the business, the leadership, the management, the systems, the tools, the marketing, the marketability, the economics and things of that broad healthcare all the way from. You know chiro, optometry, all the way through. You know pain management, anesthesia, plastic surgery and everything in between. So I'm super curious about how you've come to feel this passion around serving through lifestyle medicine, meaning there's a business there, there's people who want to buy lifestyle medicine. How did you decide you wanted to serve that community? 

0:05:45 - Dr. Dave Donohue

Yeah, so, mark, my focus and my perspective is primary care. So I'm a primary care-minded physician and the reason that I'm really focused on primary care is because that's really the way that we improve public health. There's lots of research that says that more primary care physicians in a region means lower cost and better outcomes, whereas that's not the case for a lot of other healthcare professionals. Like, more specialists means higher costs and, by some studies, worse outcomes. So as we approach people in a primary care setting, we're trying to solve the problems that people have in their day to day life. We're trying to solve their medical problems that they've accumulated. 

0:06:27 - Mark Henderson Leary

I love, I love. I want to stop you because my curiosity is sort of burst into flames the. I think one of the big pulls and one of the challenges in serving in healthcare is there is a purpose there and maybe even data that says if we do this, good things happen, if we do this, bad things happen. And that's a data, informed reality. Then there is I got to go sell that, but no one's buying it. For example, like low sugar, low carbohydrate, lower in processed food diet, better outcomes no one buys that. That's not true, obviously. But so I was thinking about, like we've got a poll to solve some problems here. You're in the business as an entrepreneur. You got to go sell that. Are people buying that? And how are you approaching this idea that, like we got to help these people? 

0:07:12 - Dr. Dave Donohue

Yeah well, more people are buying it than you might think. So a lot of people come to us in a primary care setting with a list of problems that they've accumulated and their body's starting to break down and they're getting insulin resistance or type 2 diabetes and they're getting heart disease and they're getting chronic kidney, chronic liver. The list goes on and on. Memory problems as we get older, up above age 80, it becomes rampant to start to have dementia, especially for women. So more and more people have these long lists of chronic diseases. So more and more people have these chronic, long lists of chronic diseases. They come to us and they would love to find a solution and they're often not all that eager to go the medication route. 

0:07:53 - Mark Henderson Leary

How do they find you? They've researched independently one of their friends another doctor. 

0:08:03 - Dr. Dave Donohue

Well, in a lot of cases it's people who just need good primary care and they come to us as primary care patients. But our approach in primary care is the lifestyle medicine direction. So that's where we bring in. We want to bring in whatever the best evidence-based medicine and research has discovered to help people to prevent diseases, to reverse diseases. And it turns out that medications are often not the answer to at least treating the root cause of disease. So often medications can lead to a little bit better outcomes. They can treat symptoms and medications are definitely warranted to use. But you can often achieve much greater results with lifestyle change. So the research is pretty clear there. 

So that on one hand it's a little bit hard sell to tell people to totally change the way they eat, the way they live their lives. I love it, yeah, all right, all right. But on the other hand a lot of people come to me and say I don't want to take a pill the rest of my life. What else can I do? I don't want to have hypertension, I don't want to have heart disease and diet and disease or have an amputation like my uncle. So in lifestyle medicine we have a real answer. We say, well, ok, we have a lot of science that says that if we change our diet in certain ways and we start moving more, you have enormous agency, enormous power over these diseases. So in a lot of ways this is an exciting message to portray to patients. So word gets out, people want to come to your practice. We certainly advertise ourselves as lifestyle medicine based as well, so we get some people who travel relatively long distances to see us. But it's a strong value proposition and people do seek us out. 

0:09:38 - Mark Henderson Leary

So I want to dig into patient journey a little bit in a second, but I don't want to move off of sort of that initial finding just yet, so forgive me beating the dead horse second. But I don't want to move off of sort of that initial finding just yet, so forgive me beating the dead horse, because I think the reason I want to dig into this is that traditionally, healthcare has not had to market. It is, you know, you're credentialed. There's a fixed demand or somewhat perception, like we just got to hang a shingle I need a doctor, I find a doctor, all doctors are the same, and that was the old way. Now that's not the case and now, as doctors are in any kind of healthcare is finding that they're looking to more cash pay options and they're looking to more retail things and there's this blend of covered services. And then we're trying to. We're realizing that we've got really unique psychographics, that we got to go find them and if we just wait for people to show up at their door, we get the wrong people. How do we get the right people here? So the disciplines of marketing and be creating awareness and creating demand are becoming more and more important and it's something that's a very weak muscle across all healthcare. So I'm imagining you have this purpose and you want to attract this type of patient. 

But I'm seeing from your description three types of patients that show up One that says I've been looking and you came up and I'm happy to be here because I want somebody like you. You've got another person who said I wasn't looking for this, I just need somebody. But I'm excited to hear that you have a different message. I'm glad I accidentally found you, and there's probably this third one. It's like oh, that's what you do. Message I'm glad I accidentally found you, and there's probably this third one. It's like oh, that's what you do. 

0:11:12 - Dr. Dave Donohue

I just wanted a pill man. So are you seeing those three cohorts and is that crazy? No, I think you hit the nail on the head. Yeah, it's absolutely three kind of categories of people we see and yeah, we work with whoever. We meet people where they are. So if some people aren't ready for lifestyle, sure, we'll do the medication route and some people want to blend. In some cases the blend is probably the best. 

Medicine is work in parallel on lifestyle while we're also treating with drugs that we know from very good evidence will reduce your risk of adverse outcomes. As far as marketing side, you know, in primary care and a lot of medicine we don't tend to market that much because we've got more demand than we can meet out there. So there's not a financial driver. We do market in the sense that we're sort of mission driven to promote a healthy lifestyle. In the sense that we're sort of mission-driven to promote a healthy lifestyle, I'm involved with some volunteer initiatives to try to promote a healthy blue zone style or we call it a green zone style transformation of our community, because we just want to get the message out to people. 

But we also do create some services that are a little bit higher end that we do market. So one of them would be an intensive cardiac rehab. We're standing up a intensive cardiac rehab program in our region of Wilmington, delaware, and so that's exciting because there's no other such program. We're working in conjunction with the Pritikin intensive cardiac rehab program, but there's no other such program anywhere in our region or Philadelphia or Baltimore or anywhere close to us, and the value proposition is huge. I mean, this program is covered by insurance and it has the power of really reversing heart disease and extending life expectancy dramatically. So this is an exciting new offering that we're putting together. 

0:13:03 - Mark Henderson Leary

So that's interesting because I think that you're in a nice sweet spot. I think that primary care still is a tip of spear and when somebody's not feeling great they go searching. And that's really the tip of the value chain of healthcare. Like, once they have that trusted relationship, you kind of can steer the rest of their journey If you build trust and you take care of them, and so then combination, we're differentiated, it's lifestyle, we're accountable, care oriented, which then opens the door to basically we're covered by insurance, so we don't have to run this whole retail play thing, how to figure out how to price our stuff. So that's an interesting sort of Venn diagram of differentiation, lots of opportunity. But I do think it creates Well. So I guess it's, I guess I'd call it out. 

That's not everybody enjoys that right. A lot of people are like you feel like man, we're getting really our reimbursements are going down. We got to sell more stuff off the shelf. I got to create a retail site. I got to create an aesthetics practice, I got to do something to make some money over here. But so what do you when you all that with an organization who knows who their best patient is, but they've got more demand than supply. The discipline to say, hey, thanks for your interest, but we're not the right shop for you, is the hardest thing to do. How are you handling like we're set up for this and that's what we do, and I know you want something different, but like you're's? 

0:14:33 - Dr. Dave Donohue

the wrong place. 

Yeah, oh yeah, we have to. 

We have to communicate that sometimes, and you know we would try to match everybody to the right resource because there's so, as you say, there's such a diversity of resources out there. 

No doubt, yeah, and I think you made a good point that primary care is kind of the perfect place for this kind of lifestyle or preventive medicine. So, and because it's not something people like you say, people don't want to go and seek out and pay extra money necessarily for some specialty provider who's going to talk lifestyle and tell them to stop eating junk food, whereas when their PCP is using that as their primary tool for treating hypertension and high cholesterol and all the other risk factors and all the other diseases, that becomes a very different prospect for people and they're a lot more willing to make some of those changes because it's medicine. We're using lifestyle as medicine, so it's a powerful value proposition. And some people yeah, some people that's going to rub the wrong way. They're annoyed at us and they're going to move on to somebody else who's not going to do that, because most of the players in our healthcare system are not going to talk lifestyle as medicine at all. 

0:15:45 - Mark Henderson Leary

They're playing the traditional medical I had the light bulb moment I guess light bulb moment from my perspective a couple years ago. The primary care is just the absolute missed opportunity for all of healthcare. It is totally complacency driven. It is rinse and repeat. I heard something the other day on the radio that was probably not validated. You could probably have the actual number. Something like 80% of primary care doctors will not tell their obese patients to adjust their lifestyle. It will not comment to them about their obesity. They just accept it and move on. And only 20% will say hey, by the way, we got to make a plan here, because they're just kind of stuck in the rut and anytime you've got a differentiated offering in this space anything lifestyle, anything fitness-oriented, anything where it's sort of like, hey, it's different, you want a specific outcome. It's just so exciting to me that there's actual value here. It's not just give you antibiotics and pretend you're okay for another year on your glucose levels. It's actually we're gonna do something, oh yeah. 

0:16:45 - Dr. Dave Donohue

And you also touched on the financial challenges that a lot of people in healthcare are facing, especially people who are trying to peddle this message of healthy lifestyle, because it's not the most lucrative way of practicing medicine. 

So people diversifying and finding other ways that are going to drive revenue aesthetics or what have you and so the Intensive Cardiac Rehab Program is one of our initiatives in that direction and we have a few others. 

We have some group disease reversal programs and precision medicine, longevity programs, and so we have a number of different lifestyle group programs that we offer that are all science-based and trying to give people skills from the evidence of ways of changing their lifestyle, connecting with superfoods that have almost medicinal qualities in terms of their ability to reduce inflammation and improve, potentially, cognition and things of that nature. So there's a lot of exciting messages as you dig deep into the science, and it's not something that most people are very up on because we're not trained in it in a traditional medical setting, but there's something like over 100,000 research articles come out every year in just nutrition science. So there's all this massive trove of insights out there that are getting communicated to people. So in lifestyle medicine we try to use that as our secret weapon that's going to drive more revenue, but we still have to be pretty creative to really make the dollars flow properly. It's very easy to go out of business doing anything in primary care, including especially including lifestyle management. 

0:18:22 - Mark Henderson Leary

Well, I'm going to ask a what seems like a non sequitur question, but hopefully I'll bring it back to feel like this is sequentially logical. When you think of yourself as your role in the, in your role of the organization, do you think of yourself as a visionary leader, or it doesn't even visionaries of a leader, a business leader, a person with a who has to carry this mission forward? Or are you thinking of yourself in this individual healer capacity? I'm working with a patient and I got to really take care of them, or do you? Or how do you think about those two roles in particular? 

0:18:53 - Dr. Dave Donohue

Well, I think you got to do both. You got to keep your hand in the game or else you become disconnected from what it's like to have that one-on-one with patients. So at least maintain some. But yeah, that does occupy the minority of my time and so mostly it's more of a leader and strategic kind of role, just trying to find ways of making this whole thing work. It doesn't work out of the box and you have to be creative, you have to be entrepreneurial, you have to think marketing, you have to think from the perspective of the patient, customer. How am I going to drive? How am I going to get my message out? How am I going to connect to people who need to hear this message and and achieve real clinical results for people? 

0:19:37 - Mark Henderson Leary

well, that was exactly. That's exactly where I was going in that, because I worry about, like, the academic mindset of this is what you're supposed to do. You're just supposed to do that. That's the right thing. It's like, well, how are you going to get this to manifest? 

And there's an economics to this that we have to create a positive feedback loop of people experiencing it and telling their friends and coming back for more. And there's a pragmatism to this. And so you know, I get the health case, for this is super strong. And well, I say that the passion for people who believe this and I'm not taking one side or the other, I'm just I think there's lots of different opinions, of approaches to this. And we say we, we, you know, we got a solid case. We feel this is, this is doing right in the world. Then there's gotta be a business pragmatic side. You know how do you look at this as a leader and say are we monetizing this? Well, do we have to adjust our margins? Do we have to market differently? Do we have to change prices? Does the economic model just naturally fall in place for you? What is your business mind responding to when you're going to market with it? 

0:20:40 - Dr. Dave Donohue

Yeah, I like to build a lot of pro formas, that kind of map out what the next six to 12 months are going to look like if we stand up this new initiative or that new initiative and you have to stay closely connected with your billing manager or somebody who knows the billing system well to find out if we're recouping the revenue that we thought we would Pivot. As much as you can find new billing opportunities, new codes, new market opportunities for which you can charge a fee and implement these new programs. Meanwhile, trying to keep the engine running by keeping your personnel happy and keeping your office staffed and, as you grow in a setting of difficulty, employing people in healthcare, you've got to have a constant pipeline of bringing people on board, talented people who are willing to stay with you for a time. So there's challenges in every direction. All those different things that I just mentioned can be daunting and challenging. Yeah, so far we're keeping the ship together, but it's through a lot of energy and underpaid work on behalf of the owners of our practice. 

0:21:58 - Mark Henderson Leary

That's a whole other thing. I might dig into that in a second. But thinking about, like, those critical factors you've got to get new patients, you've got to get them to come back. You've got a staff, you've got to do all kinds of things which are the ones that worry you the most in terms of like we, which are the ones that worry you the most in terms of like, we just need to get more patients up a tighter schedule. We got to have a more densely packed schedule or new patients, or return visits, or pre-appointments, or staffing what are the things that just go like? This is the one thing that will kill us if we can't get it right. There's so many threats. 

0:22:28 - Dr. Dave Donohue

The prospect of regulatory issues, somebody coming along and saying, hey, you were doing this wrong the whole time and you didn't document this, and that you know there's so many requirements laid on us and changing requirements from the insurance payers, new rules, new legislation coming along all the time. So there's HIPAA is a theoretical risk. There's the prospect of any of our 15 PCPs leaving suddenly and then we have to sort of scramble and backfill for that person. So all these things equate to sleepless nights for those of us who have to write the check, the payroll checks every week. 

0:23:06 - Mark Henderson Leary

Those PCPs are those like sort of agents or those associates in the organization that join your payroll. 

0:23:11 - Dr. Dave Donohue

So we mostly employ the folks who work with us, and they're mostly physician, assistant or nurse practitioners. We live in an era where it's pretty hard to attract MD and DOs into primary care, at least in our region. Fortunately, we've been able to find, so there's a few things that have lined up for us. The stars have lined up, like the fact that PAs and nurse practitioners are more willing to come and work in a primary care setting and work in a setting like our practice and are so talented. There's so much talent there and we can train these folks to practice a very thorough brand of primary care and lifestyle medicine and the results speak for themselves. We get very thorough care and very happy customers for themselves. We get very thorough care and very happy customers. So it's through the existence of PAs and nurse practitioners that we've been able to stay in business and grow our model. 

0:24:00 - Mark Henderson Leary

So I love that, because that kind of brings me to another question I wanted to ask you about. Leadership of healthcare providers is something that people struggle with, particularly the really prestigious research and reputation-oriented disciplines, where it's like, hey, there's only five in the country that are good with this and you bring somebody in the organization managing the culture to say like, hey, we have a culture here, these are the rules we live and die by and if you break those rules you're fired. It's very hard to hold stance when you're like oh, this is the number one in the country. So you said that. Like, if we don't have the right number of PCPs, we can't do the throughput. 

The whole model doesn't work if we don't have enough people to see patients. Does that create challenges for you in saying we hold accountability here and I know you've got a great reputation and you're very important in the organization but we have a standard of excellence of accountability. And if you don't play by the rules, but we have a standard of excellence of accountability, and if you don't play by the rules, if you don't play, let me rephrase that we have a mission, we have a structure, we have process. It's all patient oriented and it's business oriented, and if we don't play by the same rules, it doesn't work. You don't get to make up your rules, and if you wanna make up your own rules, you should be somewhere else. 

0:25:19 - Dr. Dave Donohue

Do you have any trouble with that accountability and the leadership and what do you think about that whole concept? Yeah, I mean, one of the challenges is productivity. So we don't want to be an organization who has to track RVUs, but a lot of healthcare systems find themselves moving in that direction. What we've tried to do is get the best of both worlds by standing up an incentive-based system that tracks RVUs and if you exceed a certain threshold that you get a bonus. We're meantime looking at admin. We give more admin time in my practice than anybody else I know of. 

I guess we're believers in not burning people out and not doing the pajama time thing more than can be avoided. So we have a lot of resources that try to make our PCPs happy, and the other thing is, with a great resignation. You've got to keep your workforce happy or else they will vote with their feet and move on, so we sort of bend over backwards, but just to the point of not being profitable. So it's a very fine line to strike, a fine balance to strike, and you've got to approach it with some creativity is what we've found, and I'm sure there's better creativity is what we've found, and I'm sure there's better ways than what we're doing. We were always experimenting to find a better way, but right now, yeah, we're barely profitable, like most primary care practices. 

0:26:23 - Mark Henderson Leary

Yeah, and that's a good one to talk to and I do want to go into that. But I do think it's worth highlighting this idea of the social contract going both ways, the old healthcare mindset of like, hey, it just sucks, you work really hard and if you don't work hard, you should be doing a different industry. People who graduate with healthcare degrees and certifications and licenses these days less likely. I'm hearing from all the people I know who seem to be people who would know less likely to want to just burn hot. They're happy to go home at the end of the day and they do want a flexible lifestyle and they do want to understand exactly what their job is and where it used to not be that well-defined which plays both ways because you okay, now I got something to offer you. This is not a burnout institution that's valuable to you At the same. By the same token, like social contract goes both ways, this is what you're expected to do, exactly nothing less than this, and if you can do that and you want that, then we have a deal. 

I've seen where a lot where, like we've hired doctors, hired associates, and it's like I need more productivity. So, in a dark room, with my leadership team. We designed this amazing incentive program so you can work lots more and get paid lots more. We designed this amazing incentive program so you can work lots more and get paid lots more. And what they find after the fact is, hey, I didn't actually want to work more and or make more money. I was fine in the lower productivity world with the old money, and now I feel like I'm underperforming. And now we've got this sort of like awkwardness, like you're telling me. I suck and I feel like it was better before and we didn't. We should have had the conversation early on. That said, this is what we do, productivity looks like this and this is how much work we're going to be doing, and if that's for you, we're in business, and if it's not for you, then maybe another place is for you. So do you feel like you've been able to have that good, clear conversation of like hey? 

0:28:19 - Dr. Dave Donohue

yeah, we're working for you, and this is this other side of the social contract. Yeah, it's something we're always working on. We're looking over people's shoulders to see how busy they're staying and making sure that they're fulfilling those standards that social contract that you speak to but it's never going to. I think the challenge is find something that people are willing to do, like you say, and you're absolutely right A lot of people do not want to work that much harder. So the old model of the doc who works incredibly long hours and sees every last patient who wants to be seen every day is a rarity now, except maybe the few owners who are remaining who are all? 

0:28:54 - Mark Henderson Leary

aging in primary care who are still willing to do that Well, and it turns out to be kind of a plus or a minus depending. Because if you want a high performance culture and you're hiring people and you're like, why are these people not motivated? It's disappointing to you. You want super ambitious people, but the flip side is you're the entrepreneurial leader and you have a small number of aggressive partners. Do you want a bunch of people who want to also be partners? Maybe not. 

Maybe you want to just have your utility players who just check out, don't need a voice in the direction of where we're going, just want to know they're in a great organization, that's mission driven, that they want to know their role and they don't want that stress and accountability into the weekends for profitability overall for the organization. They just want to know what their number is and know what their patient outcomes need to look like, to feel like they're contributing and that's it. And so it gives you a lot. I think it gives you a lot more chess moves to be able to say like you're ambitious, you're not ambitious. I know exactly what to do with non-ambitious people. 

0:29:59 - Dr. Dave Donohue

And it's a very good building block to be able to have to rely on. Well, I have a question for you, mark, is for the practice and this is a pretty common scenario is a established primary care practice led by people who are getting into their 50s, 60s and even 70s and looking to what is the next step for this practice? Do I close it down, or how do I find somebody to hand it off to Like? What is the approach that a practice like mine should follow. 

0:30:19 - Mark Henderson Leary

Great question, and the number one thing is start early, because that's where I mean. This is a whole other topic, but I'll try to summarize it. Private equity has a bad reputation in healthcare and really almost any industry, and the reason, in my opinion, is that too many people run a practice unintentionally, find themselves late in the game and say what's my exit? And they don't have an intentional culture, they weren't doing something very specific and their only options are to sell to somebody who will buy it at commodity price and get out of there. And so all too often it's just like in the last two or three years of the practice we're trying to make it profitable and you don't do well on that and it leaves man those roll-ups just eat that stuff up. That's how they grow and that's how they make money. 

The best organizations understand really on in the process that, like they're, they're led by a human being with a very specific set of values and purpose and can create a healthy organization filled full of people who are grateful to help and contribute and be part of that vision, even if it's a modest vision, like I love working with organizations who want to take over the world and transform. But that's not the only amazing vision. Lots of organizations they just hey look, I just care about people eating better, you know, I just I just want let's have fruits and vegetables in the office and let's make sure everybody understands that I just, we just want to make it, make sure everybody could eat a lot better. And the culture kind of galvanizes around that. And now we can. We can deliver something that is valuable and communicable that's a weird word, I probably didn't use it right Communicatable to someone who's like you know what? I want to carry that forward. 

Now that could be a lifestyle-oriented private equity organization who understands value proposition and understands a creative culture and will carry that forward, which they exist. Or you sell it to the next generation. You sell it to somebody who there's something of purpose and substance and it's it's. It's not that rare that it's there. 

It's just people vastly underestimate the time it takes to articulate that vision, to clear out the kind of confusing messages like I talked about early on in this interview. Like we've been taking 14 different types of patients for 15 years. Like what would have happened if 10 years ago we just were a little choosier and we just it just took like 10% less and all of our patients were now friends and saw each other like when they're running, and we had communities and and everybody, just the reputation for the firm and the organization. Our practice was just we're this type of organization and those are the small changes that take some time, that allow that value to be passed on Running it like a business, understanding that it has value, abundance, mindset. Like I said, this could be a whole other podcast. I don't even know if I've answered your question at this stage. 

0:33:11 - Dr. Dave Donohue

Well, I'm kind of thinking in terms of there needs to be somebody we're handing things off to and who's going to do that, like we're not seeing those folks very readily. They come up once every five years. It will be somebody who seems like they might want to come in and put in a little extra effort and kind of get a little bit of and earn a little bit of ownership over time, and somebody to whom we transition the business to as we move into retirement mode in 5, 10, 15 years. 

0:33:43 - Mark Henderson Leary

So those are private equity options. If you find the right ones and you do the searching, it is up and coming doctors, you got to kiss a lot of frogs and that's a cultural intentionality Finding like. I mean even how I met you. I met you through Ben and Ben sees you as I believe is somebody who's going to lead in the charge. He wants to be like you, so like if you, if you're growing your practice and you're thinking you know like what's what's been, what's his future look like, maybe it's exactly that. 

It's not always founder physicians, it's not always those. There's a lot of people who have a lot of leadership background. They're like I would love to run this practice, I would really love to do something big with this, even though I'm not a doctor, and they're absolutely out there. The teams I work with the passion for the vision at all ages when we articulate it well, is absolutely there. So I don't see in any of the organizations I work with I'm trying to think the smaller they are, the harder it is, but that's part of it. Like so, once you build a sense of growth in the organization, it becomes a lot easier. A very small mom and pop shop is going to have a much harder time than a small regional organization or a multi-site, multi-million dollar practice. They're just going to have a much harder time than a small regional organization or a multi-site, multi-million dollar practice. They're just going to have a lot more attractiveness because the upside is big, the mission is bigger, but there's definite attraction there. I know we're kind of hitting on time. I know we had a kind of a tight time frame to fit into. 

Let's talk about profitability, because I do think that is. I don't even really know where this is going to go, because I know from my perspective, healthcare enjoys the most abundant value proposition of any industry I've ever worked with, and that is to say the least valuable healthcare organization I've ever worked with on their worst day is in the business of healing people, and so that's a good gig. And I do think a lot of organizations lose sight of that and understand why regulation and, of course, insurance makes it hard to feel like you're this valuable service. But it's true and if we really hold it to heart, we can do that. At the same time, I do see some organizations who struggle with it because of lots of reasons and I have my theories, but you know what are the things that you think make it hard for healthcare organizations to be profitable. 

0:35:53 - Dr. Dave Donohue

Well, it's the struggles of keeping a happy workforce and preventing people from leaving your organization and giving them these huge signing bonuses to get people to come and join you. So that's always a challenge. And then the fact that healthcare is a little bit stacked against you, especially if you're doing primary care and certain kinds of specialties. But other kinds of specialties that do procedures are going to do better financially. So I think some of it's a little bit systemic. 

I think a lot of folks who are trying to run a successful primary care practice are going to need to find other sources of revenue outside of just fee for service, and so those can come from value-based care, value-based payments through well such as accountable care organizations, medicare Shared Savings Program, for example, which ends up being a very strong value proposition for a lot of practices, the main source of net profit that they're earning. Then you have other ancillary kinds of services like fee-based things, aesthetics, concierge. I've stood up a concierge practice for myself, actually recently around precision medicine, longevity medicine to deliver a better product than is commonly available to try to help extend people's life expectancy. So once you've been established and you've got a good reputation and you've got a larger practice to draw from. You can do something like that. And then I mentioned intensive cardiac rehab. So there's some of these entrepreneurial opportunities and it seems like those kinds of icing on the cake operations can end up being the main source of net revenue, profit that you can generate. 

0:37:31 - Mark Henderson Leary

Yeah, I see a lot of interesting things. You know, at one end of the spectrum, this is strategy and that is you know, what do we sell in the marketplace and do we need to add more ancillary services? Do we need to do specialty services? And I see, like in optometry for example, there's a lot of profitability in new specialty eye care services and there's a lot of reticence to move into it. And my perspective is that it's very different. They're used to. They evolved the industry to go from pure eye care to like now it's retail play and they're selling glasses and selling things and that's their highest margin, and now they're moving back into the eye care experience itself, potentially being a very high margin thing, and it's a new skills set. They need to learn and it's just like it's kind of grinding gears. They don't exactly know how to shift back into that mindset and so I do. 

I like what you're saying about experimentation, but then that has to flow back into. Well, how do we really make this efficient? Because I think, like patient flow, you have to own that as a management science, like how many patients do we need to see? And then we have, and which goes into the philosophy, I see a lot of organizations these days and I'm sure you were kind of touching on this we are not at our max profitability, at max throughput. We there is a sweet spot between wasting time and way too fast, where we're like, this is the right amount of thought, the right amount of care, the right amount of care that really creates the best outcomes for the best reputation for the best everything. And that is some hard, difficult stuff to sort of. You know, it's easy to kind of like, well, just go faster or go slower. It is, you know, figuring out the sweet spot of no, it's not 15 minute visits and it's not three hour visits, it's like a 90 minute visit for this type of patient, because this is what we do and that takes a lot of iteration and I think that's the kind of good and bad of what we've got to work with. 

There's so much opportunity, particularly in primary care, but there's so much of this stuff that's undiscovered, like you can't go model this, you can't go figure out who's figured this out and copy that, and you have to do a lot of experimentation, which is all of this is in strategy, which is the whole idea of when, in the pillars of a free practice. You have to build the lab Metaphorically. You have to learn how to experiment and figure out what works. But to summarize this whole thing, the one thing that I have found that this trumps all of this is you got to have the right people and you got to start with the right person in the right seat. You got to get crystal clear on the job. Is your job front office coordination? Is your job, therefore, to have a schedule optimized and do I have the person who understands how to do that and loves doing that? And if I don't, I got a serious problem. 

And I found, unfortunately and I said this a bunch and I always feel like I'm being kind of negative, but there's nobody who hires worse on average than healthcare. Legal is second close second, but it's like I don't know exactly. I have theories as to why, but like I go to the plumber down the street on average gonna hire better than a typical healthcare organization in terms of like who they think they need to hire other than doctors, and even then they're hiring doctors who graduated medical school or whatever healthcare license level they're at, but they do a terrible job hiring on culture and personal ambition and alignment for that, and so it's really, after all, the strategy, and I love the strategy conversation. I just want to caution the listener on this. Like the strategy is great, you right person, right seat will undermine all that. You're the wrong person in the wrong seat, everything falls apart. 

0:40:56 - Dr. Dave Donohue

Oh yeah, you've got to build operational excellence, so that's kind of a foundation. 

0:41:00 - Mark Henderson Leary

But it's sort of. 

0:41:01 - Dr. Dave Donohue

Maslow's hierarchy of needs like a practice, needs at its foundation, like a purpose, like a mission. And then you need good people on top of that, and so the people have to work with the mission, and that mission has to involve something along the lines of we need excellence in customer care. We can't be yelling at our patients and getting in arguments with our patients or you're out. We need the ability to fire and fire to get that. And then you need operational excellence and then, on top of that, you need to start building some of that icing on the cake, those other tools that are going to drive revenue in my opinion. So this is my own model of how we're doing it, but I couldn't agree more. I mean, you've got to get the right team. You've got to get the fundamentals in place, first and foremost, before you go off in a million other directions. Yeah, super awesome. 

0:41:46 - Mark Henderson Leary

Totally agree. We're kind of out of time, so I want to wrap this up for you so you can get on with your day. Is there anything we didn't cover? Anything we missed? 

0:41:59 - Dr. Dave Donohue

Well, there's the small matter that I'm a CEO of a lifestyle medicine-based accountable care organization. We work with 10 primary care practices throughout the country. We're called Poplar Care, so I'm basically trying to take the show on the road as far as building successful practices that are going to perform well in a value base, but that's probably a topic for a whole nother discussion, perhaps because there's a lot more stuff we could talk about For sure, for sure. 

0:42:19 - Mark Henderson Leary

So, given that I mean I'm certainly going to recap this in the intro, I'll make sure I highlight kind of the context of this conversation, but somebody listening to this will have been briefed by my little intro. What's your passionate plea to entrepreneurial healthcare leaders right now? 

0:42:35 - Dr. Dave Donohue

Well, we are fighting the good fight, so we have the opportunity to connect people with knowledge, skills and science that literally has the ability. It's a life and death kind of implication as far as determining whether somebody's going to live a life with suffering, with chronic disease and end up with dementia in their 70s or not. So lifestyle plays a big role in that. Social determinants of health play a big role in that People getting the right care that they need at the right time with the right medications plays a big role in that. So there's real opportunity for operational excellence and to get paid for delivering that operational excellence and to be saving lives and making very big impact in the quality of people's lives along the way. 

0:43:21 - Mark Henderson Leary

Yeah, I couldn't agree more. I love all that because my simple formula that I try to drive and beat the drum on is no greater value proposition than healing people. How do you know if you're delivering value? Profit follows value, so people pay for good service and good value. And let's just, let's leverage capitalism as our measure, for is this working or not and becoming efficient, and all that so great stuff, I think. How does somebody keep up with you and continue the conversation? What's the simple? We'll put some stuff in the show notes, but simple ways to find you, or what or what would we tell? 

0:43:56 - Dr. Dave Donohue

them. My practice is progressivehealth you can go to progressivehealth and my accountable care organization is popularcare P-O-P-L-A-RC-A-R-E, so those two. I tend to post stuff. I've got a YouTube channel through my medical practice where I post for free all my resources my successful aging program and my heal, my eye blood pressure program. It's all out on the web for free, actually through mainly through popularcare. 

0:44:24 - Mark Henderson Leary

So probably, I care, is probably the best place to check you out. Ongoing. Yeah, I think so. Okay, well, super helpful, man, I appreciate taking the time and we can revisit this if we want to go into more subjects down the line. Just a lot to cover in a short amount of time. So I appreciate your patience and there's questions I wanted to ask. I wanted to ask about your IT background. I wanted to ask about some other stuff, but interesting, interesting things there. I'm grateful for the time. I learned some things and I'm hopeful that other people will as well. And that's our time for today. So if you give us some feedback, we'd love it. Share this with your friends and people who you think might find this useful. If this helpful information is not helpful, if no one hears about it. But please give us the feedback and if you got comments, hit them to us in the voice recorder, in the link, in the show notes, and we'll see you next time on Practice Freedom with me, mark Henderson Leary.